When dealing with suspected cancer, all parties involved face a daunting gamut of challenges. As the veterinary specialist, this diagnosis will test your knowledge, and clinical and communication skills. The path forward for the cancer patient and client will vary according to the human-animal bond, the owner’s understanding of the prognosis and treatment options, and the logistics of finances and location. The primary care veterinarian (pcVet) is at the front line, bearing the responsibility to get a diagnosis, break the news, and help counsel the pet owners about their options.

Referral algorithms are standardized and well established in human medicine—being an immediate referral to a specialist. While recommended best practices do exist in veterinary medicine,¹ referral pathways are not standardized, and access to specialty care varies regionally. Some veterinary cancer patients will be referred before a diagnosis is made; some after a diagnosis, and some may not be referred at all.

Collaborative approach

At its best, collaborative care in veterinary medicine involves multiple teams working together to provide the highest quality, most expedient and compassionate care for pets facing more complex diseases. Whether a pcVet sees value in referral varies from one practitioner to another, and may depend upon a variety of factors. This includes the medical condition, the practitioner’s comfort level with managing the disease process, their access to specialized equipment and procedures, their comfort level sharing the care of the patient with an external veterinarian, and ultimately, their perception of whether referral for a client is in the best interests of all the stakeholders.

The Collaborative Care Coalition (CCC) has the position that collaboration between pcVets and veterinary specialists is important in achieving the best medical outcomes for a patient facing a serious condition. Its interest in a better understanding of how clients perceive this collaboration during their cancer pet’s journey led to the launch of a large survey-based marketing research study during the pandemic, which was published in the Journal of the American Veterinary Medicine Association (JAVMA) in 2023. The study sought to investigate the impact various attributes and events had on clients’ perceptions of their veterinarians, and specifically, what attributes were associated with a higher or lower likelihood for a client to advocate for their veterinarian.¹

The CCC commissioned the study as a survey of pet owners who have (or had) a dog diagnosed with cancer within the last three years. A total of 890 respondents completed the 2021 survey, which asked respondents how likely they were to recommend either their pcVet or specialist on a 0-10 scale, and then followed with a series of questions regarding their veterinary journey. Statistical analysis was able to evaluate associations between aspects of the journey with advocacy scores.

Client advocacy

You may be familiar with one question surveys ask, “How likely are you to recommend our service to a friend of colleague?” from businesses, which formulate an advocacy score called a Net Promoter Score (NPS). NPS is a marketing tool that determines how customers perceive a company, and, importantly, whether they are likely to say good things about them (promote), or complain about them to friends and family (detract). It ultimately is a way of scoring client advocacy.

The findings of the study are highly impactful at multiple levels. From the perspective of a healthcare company, it provides data on best practices that might lead to better customer satisfaction and retention. From a clinician’s perspective (whether a pcVet or specialist), the study challenges us to reflect on our own referral algorithms and shore up our best practices concerning communication.

To refer or not refer?

In the study, 76 percent of the clients whose dogs had been diagnosed with cancer received specialty care following diagnosis. Particularly interesting was the breakdown of how and why they ended up with the specialist. Among the respondents, 61 percent were referred and followed through with the specialist. Sixteen percent were not referred, but still went to see a specialist, presumably of their own accord. This raises questions as to why these clients were not offered referral; and how the clients felt about that.

The client advocacy score (NPS) was not different between those who saw a specialist and those who did not. However, the NPS for those who saw a specialist without a referral was significantly lower than those who were referred (+4 vs +40, p=0.01). Unsurprisingly, a client would advocate less for a pcVet who did not give them the option of referral, leaving them to figure out referral on their own.

Concerns over whether clientele would abandon the pcVet if referred should be assuaged by the study’s finding: 83 percent of respondents continued to see their pcVet while seeing a specialist. In fact, 92 percent of dog owners said their opinion of their pcVet improved or remained unchanged while seeing a cancer specialist.

Speed of referral

From an oncologist’s perspective, there is a balance to be had when making a referral. From a client’s perspective, particularly when looking in hindsight, we might expect clients to prefer to be referred sooner rather than later. In this study, speed of referral was indeed associated with advocacy. Sixty-eight percent of pets were referred within seven days of a cancer diagnosis, and 80 percent within three visits to the pcVet. Clients advocated less for their pcVet when more visits and days occurred before referral was made.

Drivers of client advocacy

The study used multivariate modelling to try to determine the top drivers of advocacy, with respect to demographics, dog factors, cost, and veterinary performance factors. The top drivers of client advocacy for pcVets among all respondents were: being responsive to questions, staying involved with your dog’s care, and willingness to work with veterinarians and specialists. These three attributes boil down to effective communication and collaboration. Clients want to be able to have their questions answered, they appreciate having their pet’s care followed up on, and they appreciate when pcVets are willing to collaborate with other veterinarians. Who would not want those experiences?

Value of services

It is not uncommon for me to talk to a pcVet about a case where they describe the client as being unlikely to afford a specialist. Yet, I never cease to be amazed by the lack of correlation between appearances and how invested a client is in their pet’s healthcare. To address the value proposition of referral, the survey asked respondents to self-report what they spent, their household income, and their impression of the value of specialty care for money spent and result. The results indicated there was a slightly higher advocacy level associated with households of higher income levels, however, even the lowest income brackets were associated with high levels of satisfaction. When asked whether they would make the same decisions again, 94 percent reported they would.

The big takeaways

This study is rather like the magic mirror of client perceptions. We do not get a lot of objective, scientific research on this subject, and seasoned veterinarians know not to put much stock in one-off client/clinic reviews. The study rigorously assesses the associations between our actions and how clients perceive them, and even more importantly, how those perceptions affect whether those clients will communicate positively or negatively to their personal networks.

Early on in their journey, clients who experienced a referral discussion were more likely to provide their pcVets with a higher advocacy score. There was a massive drop in advocacy from those clients who did not receive a referral. At all levels of income, the client felt they received value in the services they received, and the vast majority would not have done things differently. So, my recommendation for pcVets is to try to standardize referral discussions according to a disease, rather than what you think might be best for a client, to avoid biases. It is good to discuss your overall recommendation, but this study suggests clients do want to make the decision themselves.

The perception of collaboration was a driver of advocacy in this study. This could reflect whether the client perceived the pcVet and specialist working well together. It may reflect true collaboration where the patient is sent back to the pcVet for simple tumor removal, with recommendations from the specialist, or even be as simple as the client hearing from the specialist “I reviewed Dr. Kelly’s records and she’s done a great job.”

Referral collaboration is a unique dynamic between a pcVet and their local specialists. It cannot be emphasized enough the value in developing relationships between the pcVet and specialist. This is a significant source of peer-to-peer collegiality and support, and an opportunity to share more about a specific referral to prevent misunderstandings. Finally, by understanding how specialists prefer to manage their patients, pcVets have a better chance of referring at the right time, not too early and not too late, avoiding unnecessary or duplicated tests.

In conclusion, the study suggests there is much more upside to referral collaboration than not, and provides an opportunity for all of us to reflect on how we interact with our clients. While the study participants were oncology clients, the findings likely transcend to other complex disease processes; simple collaborative communication with follow-up can dramatically improve a client’s perception of the veterinarians’ service.

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Kai-Biu Shiu, BVMS, MRCVS, DACVIM (Oncology) is a veterinary oncologist with VCA VESVSC in Middleton, Wis., and serves as assistant chair of the Mars Veterinary Health’s Oncology Advisory Board. A graduate of the University of Glasgow, Scotland in 2006, Dr. Shiu received training at the Royal Veterinary College, Cornell University and University of Wisconsin-Madison before becoming a diplomate of the ACVIM in 2010.

References

1. Morello S, Maxwell E, Ness K, Minsel T, Shiu KB. “Client perceptions improve with collaborative care when managing dogs with cancer: a Collaborative Care Coalition study”. JAVMA 2023. 1-8. 10.2460/javma.23.01.0046.
2. 2013 AAHA Referral Guidelines. https:// www.aaha.org/globalassets/02-guidelines/referral/aaha-referral-guidelines-2013