Nat Whitley on becoming a specialist in small animal internal medicine
Why become a specialist?
In my case, having spent the summer vacation before my final year at an emergency and referral centre in Calgary, Canada, I realised that the amount of information imparted in the clinical years at vet school was only a fraction of what was known. I also recognised that a career in general practice often involved a lot of compromise in terms of what was possible, because of the level of knowledge/training, the level of equipment and variable owner expectations.
At the time I went to Calgary, veterinary procedures and care, including emergency facilities, were acknowledged to be much more advanced in North America compared with the UK, and postgraduate training opportunities were much better developed in the USA. This gap is now closing as the UK rapidly catches up. I loved North America, and knew that the training programmes and resultant qualifications there were highly regarded in the UK, so I decided to take the first step and apply for small animal internships in the USA.
My time as a small animal intern at the University of Pennsylvania was an incredibly intense and rewarding year in a high-profile hothouse of academia. It opened up all sorts of opportunities – so much so that I was initially overwhelmed by my choices. I knew I wasn't a natural surgeon (‘glacial’, I think, was the adjective applied), but I loved both the logic of cardiology and the apparently endless layers of complexity in medicine cases – there seemed so much to learn and so much that was still unknown.
"I loved both the logic of cardiology and the apparently endless layers of complexity in medicine cases"
Getting to where I am now has been a combination of talking to people, keeping my eyes and ears open, gaining an early understanding of the system and different career options, being prepared to travel and relocate, and serious hard graft. I had a couple of lucky breaks, but often paths in life hinge on chance meetings and events.
Looking back, it was probably just one case – a dog that was seizuring because of an insulin overdose – that propelled me into a career in internal medicine; I didn't know why the dog had been so difficult to stabilise, and neither did my mentors. That niggled at me. I wanted to understand what had happened. I was quite tenacious, I did some reading, talked to some more medics and compiled a retrospective study. My approach impressed a couple of people sufficiently to get me good references for an internal medicine residency application, and the rest is history. A few years later, a similar level of intrigue and frustration with very sick immunology cases led me to undertake a PhD in immunology.
Difference between first-opinion and referral practice
In a referral practice, as well as trying to diagnose and manage the patient, you have two sets of clients to keep happy – the pet's owner and the vet who referred the case. Most of the time the owners understand the need for referral, but sometimes they are already pointing fingers when they arrive or have unrealistic expectations of what can be achieved. It is a daily exercise in diplomacy to keep all parties happy and talking to each other.
Specialists seeing a new referral are in the privileged position of starting with a clean sheet – the clients are often well-off or well-insured and consultation times are much longer to allow detailed examination and to explore the subtleties of the patient's history. The initial consultation usually narrows down the list of possible diagnoses considerably. I also spend a lot of time on the phone discussing cases with other vets.
In a large referral centre, there is plenty of support – we have a great nursing team and facilities at DVS and, when a complex case comes in, although one specialist may not be able to manage all aspects of it, there is a good chance that a team approach between different disciplines will result in a good outcome. For example, a diabetic dog with cataracts and also with Cushing's disease caused by an adrenal tumour may start off with an internist (internal medicine specialist) and could subsequently involve specialist diagnostic imagers, anaesthetists, soft tissue surgeons and ophthalmologists!
Highs and lows
The highs are when you know that the buck stops with you and you are able to deliver and rescue a critical or desperate case or find a new solution to an old problem – that's very rewarding. I chat to many different people every week, including first-opinion vets and other specialists, and get involved with lecturing, publishing and organisations such as the British Small Animal Veterinary Association and the European College of Veterinary Internal Medicine. I feel much more connected to the rest of the profession than I did during brief periods in general practice, which can easily feel quite isolating.
In terms of lows, the path to specialist status is not without significant sacrifice: years of hard work, low wages in training positions, and endless evenings and weekends either on call or studying. That can take its toll on your personal life. These days, full-time specialist work usually involves significantly more on call and out-of-hours than many first-opinion jobs entail. Urgent referrals tend to increase as the weekend approaches!
"The RCVS specialist recognition scheme offers the public and referring vet assurance of the competency of the clinician"
The term ‘specialist’ gets thrown around very loosely, and that can be frustrating. There is an assumption by many pet owners that any vet they are directed to from a first-opinion practice, who has a special interest or postgraduate qualification, must be a specialist. In comparative terms, a RCVS specialist is the equivalent of a consultant in the NHS. The RCVS specialist recognition scheme offers the public and referring vet assurance of the competency of the clinician, but awareness of this scheme is too low.
I feel very lucky – becoming a specialist is not a guarantee that you will be happy in your work, but I really like my job and work with a great team of people. Owners and other vets put enormous trust in you, and I try not to take any of this for granted.
My time is quite thinly spread between work, my young family and renovating an old house, but I would like to do more lecturing and have more involvement in clinical research – we have a great caseload and years of medical records archived at DVS that could yield a lot of useful information.
Staying on the list
To retain RCVS specialist status you have to show that you have spent, and continue to spend, most of your time actively contributing to your discipline, through seeing cases, being available for referrals, training residents, lecturing, attending conferences, publishing, examining, serving on professional bodies and generally promoting your specialty.
After initial approval, RCVS specialists must apply for renewal of their specialist status every five years, showing that they continue to remain active and at the forefront of their field.