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A View of Specialization within Veterinary Practice
Br. vet. J. (1976), 132, 346
A VIEW OF SPECIALIZATION WITHIN VETERINARY PRACTICE BY
F. R.
BELL
Department of Medicine, Royal Veterinary College, London, N. W. 1 Discussion of the possibility of specialization in veterinary practice has only emerged in the last decade. Specialization was not even considered 25 years ago when mention of veterinary practice meant mixed practice with domesticated agricultural animals the dominant aspect of the general mix. There were few practices at that time which dealt exclusively with either small animal or equine medicine, attention to these species usually being delegated to a cadet member of the general practice. Even in large cities practices were of the mixed variety having evolved to serve the dairy herds and horse transport established in such areas. At that time the total number of registered veterinary surgeons was less than 3000, although many non-qualified persons also made a living by attending animals of all kinds. Following a period of stuttering development in the thirties, the whole veterinary panorama was transformed by the findings of the Loveday Committee which produced the Veterinary Surgeons Act, 1948. This act produced two significant events, firstly veterinary education was brought within the ambit of the universities and consequent stability of finance, and secondly, the veterinary profession was closed except to those qualified to be registered by the Royal College of Veterinary Surgeons. These changes, combined with the surge produced by the new pharmacodynamics and a rise in human living standards, brought great benefit to veterinary education, veterinary science and to the standing of the profession. The new power developed in veterinary science and veterinary practice in the last ten years has destroyed the old 'jack-of-all-trades' outlook. Veterinary practices have splintered from the general to the particular so that veterinary surgeons engaged in agricultural medicine are now in a minority. The veterinary profession, however, still remains responsible for a wide field of activity and because ofthe increase in diagnostic and therapeutic knowledge available to the veterinary graduate he can select his own avenue of endeavour so that many practitioners now seek knowledge of a particular subject in depth (e.g. ophthalmology, avian diseases, dermatology, equine medicine). As a result of this particularization the R.C.V.S. attempted to set up a special vocational register but the attempt failed mainly because of a lack of common standards of the kind which have evolved in human medicine. Furthermore, at about the same time the R.C.V.S. initiated two diplomas
SPECIALIZATION WITHIN VETERINARY PRACTICE
347
whereby accreditation of veterinary radiologists and veterinary anaesthetists could be established. The disparity between the formal education for these accrediting diplomas appears to be much wider than the accrediting diplomas of the Royal Colleges and Faculties. The desire to produce superior service by the profession is very laudable but whether 'specialization' is the best way to achieve this end requires rigorous scrutiny and objective examination. Probably the greatest retarding influence in the progress of development in veterinary medicine towards specialization is the numerical smallness of the profession; it is estimated that even by the year 2000 the total number will only be 8-10 ooo persons of whom about half may be in clinical practice. Because of this numerical restriction it will be difficult for more than a few specialists to find a good enough market to buy their services. Another difficulty is the schizophrenia shown whenever the veterinary profession discusses its modern role, the point of cleavage being whether agricultural practice shall continue to dominate .and the other spheres where the profession serves the general community, remain secondary. It must be recognized that the veterinary activities of the profession are always tangible and dependant upon economic forces so that prosperity within the profession has shown short and long cycle rhythms which emphasize its vulnerability. Many other professions, by contrast, have built-in supportive mechanisms, the medical profession is protected by the sanctity of life, the legal profession by the intricacies of the law and the engineers by public demand for safety. The veterinary profession has no such solid protection nor is it ever likely to develop this exclusiveness, unless perhaps the public demands that its food supply is protected by veterinary inspection to a high level of quality and hygiene. WHAT IS A SPECIALIST?
I n the world at large the title 'specialist' is conferred readily and widely by the public, both within and without the professions. Wheel-balancing specialist and beauty specialist come to mind but our argument must be restricted to the level of the learned professions. A great difficulty in using the designation 'specialist' is the widely varying use of the term within the professions. It is the general public who, usually through awe or snobbishness, hang the appellation ~specialist' to a member of a profession and thus by advertising confer upon him some higher ranking than his peers. On the other hand it is generally accepted, usually by manifestation of superior skill, that a 'specialist' has somewhat more than the basic professional expertise. Sometimes it may not be by a display of superior skill but by histrionic ability that the specialist convinces the public of his special ability. Specialization within a profession can occur at any time after the attainment of the basic degree. This usually means that some special postgraduate training schedule must be fulfilled and commonly a postgraduate accreditation made through a degree or diploma. In human medicine this has been the situation
BRITISH VETERINARY JOURNAL, 132, 4
for some time, the appropriate Royal College being the examining body for the postgraduate accreditation. It has always been accepted by the medical profession that accreditation of postgraduate degrees is a formal qualification which allows the recipient to proceed with a further course of clinical training by preceptorship in the designated speciality. In medicine when the postgraduate is accredited he seeks a junior appointment and gradually over the years passes through his special training gaining experience and responsibility in a unit or sub-department of a hospital. Eventually, after a period of up to ten years he can then be appointed as a clinical consultant in the narrow field of his speciality. The term medical specialist is used synonymously with clinical consultant and it becomes clear that both terms imply the acquisition of knowledge by experience as well as taught courses. In some other professions, however, consultant status has been arrived at without further postgraduate accreditation. This is the case in the law and in engineering where consultants emerge from long experience in the profession. In engineering and architecture the consultant is usually a senior member of an established firm and he may combine this post with a senior appointment in a university department. In both divisions of law, in a similar way, a consultant is a senior in a law firm who has specialized for some time and derived special knowledge of some narrowly defined aspect of law. It is probable that the R.C.V.S. in introducing the D.V.R. and D.V.A. hoped to confer the idea of specialists on these diplomates without any other training or the acquisition of experience. If this is the case then the result must be self-defeating for the gap between the holder of the first-degree and the diplomate is too narrow to indicate clearly a distinction between the two levels of knowledge; the element of experience is missing. It is only by experience derived by the examination of a narrowed special aspect of the professional field in depth, that eventually confers sufficient expertise that an individual stands out to be sought after as the obvious choice for professional consultation. IS THERE A NEED FOR VETERINARY SPECIALIST CONSULTANTS?
The wide division between the various forms of veterinary practice, where at least six distinctive species are catered for, generates a need for a wide range of special services. These difficulties are further compounded in veterinary practice because many practitioners are concerned on the one hand with very large groups of healthy animals reared to produce food products for human consumption while on the other hand they must cater for small numbers of animals within the large group which develop diseases. The importance of maintaining positive health in the national herds and flocks to feed the population and to control zoonoses is the responsibility of the Agriculture Departments. This work is one arm of the agricultural industry for which the veterinary profession provides a service, veterinary practice fulfilling a limited part-time role helping a wholetime field and diagnostic
SPECIALIZATION WITHIN VETERINARY PRACTICE
349
service manned by veterinary government officials. This extensive function of veterinary practice has no specialist function and could readily be absorbed into some bureaucratic organization designed to maintain or raise home produced food supplies. The veterinary practitioner also plays a part in maintaining the health of non-agricultural animals which impinge on the daily lives particularly of urban populations. This is an important aspect of social medicine as the companionship provided by pet animals often either substitutes for human companionship or adds to the happiness of the family circle. Animals are often associated with the recreational pursuits of man, for example the thoroughbred horse, where a very small number of selected animals raised for a few restricted owners, provide an important focus for a vast number of people. The veterinary practitioner provides a service which maintains the racing horse and the racing dog to provide maximum performance, and once the animal becomes ill then exemplary diagnosis must be provided so that the animal can be restored to perfect health and performance or be eliminated. There is even a small moiety of veterinary patients that compare directly with human patients, usually the small animal companions of families or especially of individuals, providing intimate relationships nearly equal to that of a human being. The owners of these animals demand the highest attention by the veterinary practitioner and an attitude similar to the relationship of doctor to patient so that every effort is made to restore normal health whatever the disease condition might be, together with the arduous endeavour towards diagnosis, nursing and therapy. The spectrum of activity expected of veterinary practitioners in the clinical field is seen therefore to be very wide, much wider even than that asked of medical practitioners. This breadth of purpose has recently caused the development of pressures to provide specialists over the whole range of professional activity and extended to veterinary education which is charged today with the training of both general practitioners and specialist consultants. AGRICULTURAL VETERINARY MEDICINE
The need for consultants in agricultural veterinary medicine is more difficult to establish than for the companion animals. This difficulty is because the rural practitioner is concerned mainly with the positive health of herds and flocks often kept under intensive or semi-intensive conditions. To achieve this end the special knowledge of the veterinary practitioner is directed towards maximizing the profit of the animal owner by systems of preventive medicine and disease control. The farmer is concerned with the entity of his animals not with the single animal so that the practitioner becomes a species specialist. Very often diagnosis of disease is made following post-mortem examination by a nonclinical specialist rather than the practitioner. The demand by the agricultural industry for a 'fire brigade' service for dystokia and diseases associated with parturition, for lameness and for other individual conditions do not require specialists.
350
BRITISH VETERINARY JOURNAL, 132, 4
Unfortunately owners of flocks and herds seek information and help which is not the sole prerogative of practitioner members of the Royal Veterinary College of Veterinary Surgeons. Much of the information can be provided by civil servants, with or without a veterinary qualification, or by trained itinerant members of food marketing firms. Since much of the food may be medicated it is difficult to restrict discussion to food utilization, conversation often extends to disease control especially parasitism. It becomes difficult therefore for the agricultural practitioner to maintain his position as a species specialist especially if he is dealing with healthy animals where he has no particular role as 'the physician of the farm'. A partial answer to specialization in agricultural practice has been made by the development of experience and knowledge of a single species. This has worked well with poultry and pigs but the number of opportunities is restricted, for once the small number of personnel required has been met there is no easy entry for newcomers. With the development of a high degree of specialization the system becomes more efficient with a diminishing call for specialist advice. It is doubtful whether more than a few veterinary specialists are needed in the sheep, pig or poultry industries at any one time so that it is difficult to envisage a superstructure above the general practitioner in this sphere. To service the national herd there is a need for species specialists and it is in this area that most of the veterinarians in agriculture practice now find a niche. The high metabolic rates demanded of the cow to convert food to milk produces many disease syndromes which must remain the domain of the veterinary physician. It must be clear, however, that the problems of milk production may be related to husbandry so that quite properly the animal husbandman is asked for advice. Often health may be difficult to define clinically in high producing animals for, although impaired metabolism often reduces food conversion or growth or milk production, it is difficult to demonstrate a positive effect without an expensive investigation which may not be justified by profit margins. Such sub-clinical disease is very difficult to elucidate since the causes are often multi-factorial and to solve the equation requires a back-up by biochemical, microbiological, meteorological, pasture and other specialists. C OMPANION ANIMAL MEDICINE
There is much less difficulty in outlining the areas of specialization in the field of companion animal medicine. As in agricultural medicine there will be species specialists attending to the general ailments of a single species such as the horse or dog. These practitioners may have special aptitudes, say for orthopaedics, but under certain circumstances they will call for assistance from discipline or organ specialists. Equine practitioners who restrict their activities mainly to the thoroughbred horse, have a geographical distribution within racing centres, and will be concerned with positive health and nutrition of the horse. The greatest economic factor in the thoroughbred horse field is
SPECIALIZATION WITHIN VETERINARY PRACTICE
351
the production of viable foals. Problems of fertility, breeding, obstetrics and neonatal conditions may require the services of consultant services but usually they form part of the training of the equine specialist. The companion animal is often solitary so that it can be conveyed to a veterinary hospital for treatment. This allows the practitioner to develop special diagnostic and surgical facilities, and to have round him a group of ancillary personnel to assist him in his tasks. This is in marked contrast to agricultural species where specialists must work in the environment of the flock and herd. THE TRAINING OF CONSULTANTS FOR CLINICAL VETERINARY SCIENCE
As has been indicated above the number of veterinary clinical consultants will always be small so that extensive training courses are probably unnecessary. Like human medicine, the place to train veterinary consultants is a teaching hospital which functions both as workshop and place of study. The utilization of university veterinary schools for training of consultants is obvious for only schools established by large capital investment can provide the facilities and equipment needed. Properly staffed teaching schools should be able to provide the critical mass of people, brains and endeavour needed to further the technology, scholarship and research which could support specialist training. As in a teaching hospital, there is reciprocity between the teaching of undergraduates and postgraduate specialists, especially for animals which exist as individuals, or are housed singly, and so can readily be hospitalized. If veterinary medicine is to progress, however, there must be a marked upgrading and further equipping of veterinary hospitals in the veterinary schools. At the time of the post-Loveday expansion of the university schools the requests lodged to establish the clinical branches of the schools has proved to be woefully inadequate. Insufficient senior staff, ancillary staff and buildings were sought for, and to repair the deficiencies today will be difficult in view of the falling standard of living, the breadth of the Swann Report, and antipathy towards universities. In the case of agricultural animals, often with closed environments for disease control, it is wholly uneconomic and unrealistic to expect farm animals to be transported for hospital treatment. Food animals, including the dairy cow, must be investigated and treated in their normal environment for changes in this environment are often causally related with the onset of disease. A farm animals' practice unit, closely associated with the university teaching hospital, is an essential arm of the clinical department of the veterinary school. The introduction of undergraduates to practical problems in the field where environment and methods of husbandry exert profound influences on the health of farm animals has led to the evolution of species specialists. This type of consultant covers individual species such as cattle, sheep, pig and poultry today but will probably extend to zoo animals, laboratory animals and fish in the near future.
352
BRITISH VETERINARY JOURNAL, 132, 4
Consultants in university veterinary hospitals should be senior people of at least ten years' experience and they should be supported by junior staff at various levels of training. There is a need for a greater body of resident housemen attached to each discipline and to any university practice. This kind of grouping could provide continuous consultant service to veterinary surgeons and animal owners as well as to education. The course of training for consultant status could be that newly qualified graduates, or graduates who have been employed in practice for one or two years, would commence a two year appointment as a houseman in the discipline of his choice. In some cases the new graduate might proceed directly to the hospital for training in certain specialities (e.g. orthopaedics). This form of entry will allow time for the individual to decide on the rightness of his choice and for the head of the unit to assess the value of the person continuing training. It is likely that many aspiring consultants will be recruited from those who have studied for an intercalated degree in basic science. After one or two years the junior houseman could commence study towards a Ph.D on a part-time basis while continuing with his clinical training. This research degree under these circumstances would require four years for completion and is essential to provide the new knowledge for the advancement of the subject. The two diplomas offered by the R .C.V.S. in anaesthesia and radiology fulfil only the early part of consultant training and it may be, that in the future the training offered at present will be incorporated in the first degree training schedules as general practitioners extend radiology as a diagnostic aid, and practice more extensive surgery depending upon modern methods of anaesthesia. On the acquisition of the basic training the junior could be appointed to a teaching post in a university teaching hospital or practice teaching unit. In this position he will continue to develop his knowledge in the discipline over a period of years by casework, research and the application of clinical science to diagnosis and treatment in general practice. Once the veterinary schools have become properly staffed with adequate numbers of seniors and juniors, then perhaps specialist practices could develop through private enterprise. At this time it might be proper for the R.C.V.S. to confer with the universities to define consultancy status. It could be that the M.A.F.F. will accept its responsibility to finance the training of general practitioners and consultants to service the agricultural industry. Today the M.A.F.F. is no longer responsible, as it was before 1948, for financial contribution to veterinary education. It does not seem unrealistic to expect that the M.A.F.F. should assist undergraduate education in veterinary science as the D.H.S.S. does for medical education. In a Rothschild situation of customer/ contract it seems reasonable to expect the M .A.F.F. to finance extra university posts and facilities in the area of farm animal medicine. Other bodies such as the Horserace Betting Levy Board and the Greyhound Racing Association might be called upon to contribute, preferably by endowment, towards the training of consultants to maintain the health of the animals for their industries. The establishment of units for clinical consultants in the veterinary schools
SPECIALIZATION WITHIN VETERINARY PRACTICE
353
would have a profound effect on undergraduate training which would elevate and strengthen the speciality of general practice. It would be much easier to arrange courses of continuing training for practitioners in the environment of the university veterinary hospital. In the field of food animals it would be reasonable to expect the Agricultural Departments to provide financial support for these courses as the D.H.S.S. does for human medicine. CONCLUSION
There is need for a cadre of veterinary clinical consultants. Some of these consultants will be expert in a single species whereas others will be expert in a discipline specialization (e.g. cardiology, dermatology, neurology, radiology, clinical pharmacology). Because of the small numbers required and the cost of training it would appear that the university veterinary hospitals must be the venue for training. The establishment of consultant units in veterinary schools will not only assist general practitioners but could make a marked contribution to the first degree curriculum and to postgraduate re-educational courses.
A VIEW OF SPECIALIZATION WITHIN VETERINARY PRACTICE BY
F. R.
BELL
Department of Medicine, Royal Veterinary College, London, N. W. 1 Discussion of the possibility of specialization in veterinary practice has only emerged in the last decade. Specialization was not even considered 25 years ago when mention of veterinary practice meant mixed practice with domesticated agricultural animals the dominant aspect of the general mix. There were few practices at that time which dealt exclusively with either small animal or equine medicine, attention to these species usually being delegated to a cadet member of the general practice. Even in large cities practices were of the mixed variety having evolved to serve the dairy herds and horse transport established in such areas. At that time the total number of registered veterinary surgeons was less than 3000, although many non-qualified persons also made a living by attending animals of all kinds. Following a period of stuttering development in the thirties, the whole veterinary panorama was transformed by the findings of the Loveday Committee which produced the Veterinary Surgeons Act, 1948. This act produced two significant events, firstly veterinary education was brought within the ambit of the universities and consequent stability of finance, and secondly, the veterinary profession was closed except to those qualified to be registered by the Royal College of Veterinary Surgeons. These changes, combined with the surge produced by the new pharmacodynamics and a rise in human living standards, brought great benefit to veterinary education, veterinary science and to the standing of the profession. The new power developed in veterinary science and veterinary practice in the last ten years has destroyed the old 'jack-of-all-trades' outlook. Veterinary practices have splintered from the general to the particular so that veterinary surgeons engaged in agricultural medicine are now in a minority. The veterinary profession, however, still remains responsible for a wide field of activity and because ofthe increase in diagnostic and therapeutic knowledge available to the veterinary graduate he can select his own avenue of endeavour so that many practitioners now seek knowledge of a particular subject in depth (e.g. ophthalmology, avian diseases, dermatology, equine medicine). As a result of this particularization the R.C.V.S. attempted to set up a special vocational register but the attempt failed mainly because of a lack of common standards of the kind which have evolved in human medicine. Furthermore, at about the same time the R.C.V.S. initiated two diplomas
SPECIALIZATION WITHIN VETERINARY PRACTICE
347
whereby accreditation of veterinary radiologists and veterinary anaesthetists could be established. The disparity between the formal education for these accrediting diplomas appears to be much wider than the accrediting diplomas of the Royal Colleges and Faculties. The desire to produce superior service by the profession is very laudable but whether 'specialization' is the best way to achieve this end requires rigorous scrutiny and objective examination. Probably the greatest retarding influence in the progress of development in veterinary medicine towards specialization is the numerical smallness of the profession; it is estimated that even by the year 2000 the total number will only be 8-10 ooo persons of whom about half may be in clinical practice. Because of this numerical restriction it will be difficult for more than a few specialists to find a good enough market to buy their services. Another difficulty is the schizophrenia shown whenever the veterinary profession discusses its modern role, the point of cleavage being whether agricultural practice shall continue to dominate .and the other spheres where the profession serves the general community, remain secondary. It must be recognized that the veterinary activities of the profession are always tangible and dependant upon economic forces so that prosperity within the profession has shown short and long cycle rhythms which emphasize its vulnerability. Many other professions, by contrast, have built-in supportive mechanisms, the medical profession is protected by the sanctity of life, the legal profession by the intricacies of the law and the engineers by public demand for safety. The veterinary profession has no such solid protection nor is it ever likely to develop this exclusiveness, unless perhaps the public demands that its food supply is protected by veterinary inspection to a high level of quality and hygiene. WHAT IS A SPECIALIST?
I n the world at large the title 'specialist' is conferred readily and widely by the public, both within and without the professions. Wheel-balancing specialist and beauty specialist come to mind but our argument must be restricted to the level of the learned professions. A great difficulty in using the designation 'specialist' is the widely varying use of the term within the professions. It is the general public who, usually through awe or snobbishness, hang the appellation ~specialist' to a member of a profession and thus by advertising confer upon him some higher ranking than his peers. On the other hand it is generally accepted, usually by manifestation of superior skill, that a 'specialist' has somewhat more than the basic professional expertise. Sometimes it may not be by a display of superior skill but by histrionic ability that the specialist convinces the public of his special ability. Specialization within a profession can occur at any time after the attainment of the basic degree. This usually means that some special postgraduate training schedule must be fulfilled and commonly a postgraduate accreditation made through a degree or diploma. In human medicine this has been the situation
BRITISH VETERINARY JOURNAL, 132, 4
for some time, the appropriate Royal College being the examining body for the postgraduate accreditation. It has always been accepted by the medical profession that accreditation of postgraduate degrees is a formal qualification which allows the recipient to proceed with a further course of clinical training by preceptorship in the designated speciality. In medicine when the postgraduate is accredited he seeks a junior appointment and gradually over the years passes through his special training gaining experience and responsibility in a unit or sub-department of a hospital. Eventually, after a period of up to ten years he can then be appointed as a clinical consultant in the narrow field of his speciality. The term medical specialist is used synonymously with clinical consultant and it becomes clear that both terms imply the acquisition of knowledge by experience as well as taught courses. In some other professions, however, consultant status has been arrived at without further postgraduate accreditation. This is the case in the law and in engineering where consultants emerge from long experience in the profession. In engineering and architecture the consultant is usually a senior member of an established firm and he may combine this post with a senior appointment in a university department. In both divisions of law, in a similar way, a consultant is a senior in a law firm who has specialized for some time and derived special knowledge of some narrowly defined aspect of law. It is probable that the R.C.V.S. in introducing the D.V.R. and D.V.A. hoped to confer the idea of specialists on these diplomates without any other training or the acquisition of experience. If this is the case then the result must be self-defeating for the gap between the holder of the first-degree and the diplomate is too narrow to indicate clearly a distinction between the two levels of knowledge; the element of experience is missing. It is only by experience derived by the examination of a narrowed special aspect of the professional field in depth, that eventually confers sufficient expertise that an individual stands out to be sought after as the obvious choice for professional consultation. IS THERE A NEED FOR VETERINARY SPECIALIST CONSULTANTS?
The wide division between the various forms of veterinary practice, where at least six distinctive species are catered for, generates a need for a wide range of special services. These difficulties are further compounded in veterinary practice because many practitioners are concerned on the one hand with very large groups of healthy animals reared to produce food products for human consumption while on the other hand they must cater for small numbers of animals within the large group which develop diseases. The importance of maintaining positive health in the national herds and flocks to feed the population and to control zoonoses is the responsibility of the Agriculture Departments. This work is one arm of the agricultural industry for which the veterinary profession provides a service, veterinary practice fulfilling a limited part-time role helping a wholetime field and diagnostic
SPECIALIZATION WITHIN VETERINARY PRACTICE
349
service manned by veterinary government officials. This extensive function of veterinary practice has no specialist function and could readily be absorbed into some bureaucratic organization designed to maintain or raise home produced food supplies. The veterinary practitioner also plays a part in maintaining the health of non-agricultural animals which impinge on the daily lives particularly of urban populations. This is an important aspect of social medicine as the companionship provided by pet animals often either substitutes for human companionship or adds to the happiness of the family circle. Animals are often associated with the recreational pursuits of man, for example the thoroughbred horse, where a very small number of selected animals raised for a few restricted owners, provide an important focus for a vast number of people. The veterinary practitioner provides a service which maintains the racing horse and the racing dog to provide maximum performance, and once the animal becomes ill then exemplary diagnosis must be provided so that the animal can be restored to perfect health and performance or be eliminated. There is even a small moiety of veterinary patients that compare directly with human patients, usually the small animal companions of families or especially of individuals, providing intimate relationships nearly equal to that of a human being. The owners of these animals demand the highest attention by the veterinary practitioner and an attitude similar to the relationship of doctor to patient so that every effort is made to restore normal health whatever the disease condition might be, together with the arduous endeavour towards diagnosis, nursing and therapy. The spectrum of activity expected of veterinary practitioners in the clinical field is seen therefore to be very wide, much wider even than that asked of medical practitioners. This breadth of purpose has recently caused the development of pressures to provide specialists over the whole range of professional activity and extended to veterinary education which is charged today with the training of both general practitioners and specialist consultants. AGRICULTURAL VETERINARY MEDICINE
The need for consultants in agricultural veterinary medicine is more difficult to establish than for the companion animals. This difficulty is because the rural practitioner is concerned mainly with the positive health of herds and flocks often kept under intensive or semi-intensive conditions. To achieve this end the special knowledge of the veterinary practitioner is directed towards maximizing the profit of the animal owner by systems of preventive medicine and disease control. The farmer is concerned with the entity of his animals not with the single animal so that the practitioner becomes a species specialist. Very often diagnosis of disease is made following post-mortem examination by a nonclinical specialist rather than the practitioner. The demand by the agricultural industry for a 'fire brigade' service for dystokia and diseases associated with parturition, for lameness and for other individual conditions do not require specialists.
350
BRITISH VETERINARY JOURNAL, 132, 4
Unfortunately owners of flocks and herds seek information and help which is not the sole prerogative of practitioner members of the Royal Veterinary College of Veterinary Surgeons. Much of the information can be provided by civil servants, with or without a veterinary qualification, or by trained itinerant members of food marketing firms. Since much of the food may be medicated it is difficult to restrict discussion to food utilization, conversation often extends to disease control especially parasitism. It becomes difficult therefore for the agricultural practitioner to maintain his position as a species specialist especially if he is dealing with healthy animals where he has no particular role as 'the physician of the farm'. A partial answer to specialization in agricultural practice has been made by the development of experience and knowledge of a single species. This has worked well with poultry and pigs but the number of opportunities is restricted, for once the small number of personnel required has been met there is no easy entry for newcomers. With the development of a high degree of specialization the system becomes more efficient with a diminishing call for specialist advice. It is doubtful whether more than a few veterinary specialists are needed in the sheep, pig or poultry industries at any one time so that it is difficult to envisage a superstructure above the general practitioner in this sphere. To service the national herd there is a need for species specialists and it is in this area that most of the veterinarians in agriculture practice now find a niche. The high metabolic rates demanded of the cow to convert food to milk produces many disease syndromes which must remain the domain of the veterinary physician. It must be clear, however, that the problems of milk production may be related to husbandry so that quite properly the animal husbandman is asked for advice. Often health may be difficult to define clinically in high producing animals for, although impaired metabolism often reduces food conversion or growth or milk production, it is difficult to demonstrate a positive effect without an expensive investigation which may not be justified by profit margins. Such sub-clinical disease is very difficult to elucidate since the causes are often multi-factorial and to solve the equation requires a back-up by biochemical, microbiological, meteorological, pasture and other specialists. C OMPANION ANIMAL MEDICINE
There is much less difficulty in outlining the areas of specialization in the field of companion animal medicine. As in agricultural medicine there will be species specialists attending to the general ailments of a single species such as the horse or dog. These practitioners may have special aptitudes, say for orthopaedics, but under certain circumstances they will call for assistance from discipline or organ specialists. Equine practitioners who restrict their activities mainly to the thoroughbred horse, have a geographical distribution within racing centres, and will be concerned with positive health and nutrition of the horse. The greatest economic factor in the thoroughbred horse field is
SPECIALIZATION WITHIN VETERINARY PRACTICE
351
the production of viable foals. Problems of fertility, breeding, obstetrics and neonatal conditions may require the services of consultant services but usually they form part of the training of the equine specialist. The companion animal is often solitary so that it can be conveyed to a veterinary hospital for treatment. This allows the practitioner to develop special diagnostic and surgical facilities, and to have round him a group of ancillary personnel to assist him in his tasks. This is in marked contrast to agricultural species where specialists must work in the environment of the flock and herd. THE TRAINING OF CONSULTANTS FOR CLINICAL VETERINARY SCIENCE
As has been indicated above the number of veterinary clinical consultants will always be small so that extensive training courses are probably unnecessary. Like human medicine, the place to train veterinary consultants is a teaching hospital which functions both as workshop and place of study. The utilization of university veterinary schools for training of consultants is obvious for only schools established by large capital investment can provide the facilities and equipment needed. Properly staffed teaching schools should be able to provide the critical mass of people, brains and endeavour needed to further the technology, scholarship and research which could support specialist training. As in a teaching hospital, there is reciprocity between the teaching of undergraduates and postgraduate specialists, especially for animals which exist as individuals, or are housed singly, and so can readily be hospitalized. If veterinary medicine is to progress, however, there must be a marked upgrading and further equipping of veterinary hospitals in the veterinary schools. At the time of the post-Loveday expansion of the university schools the requests lodged to establish the clinical branches of the schools has proved to be woefully inadequate. Insufficient senior staff, ancillary staff and buildings were sought for, and to repair the deficiencies today will be difficult in view of the falling standard of living, the breadth of the Swann Report, and antipathy towards universities. In the case of agricultural animals, often with closed environments for disease control, it is wholly uneconomic and unrealistic to expect farm animals to be transported for hospital treatment. Food animals, including the dairy cow, must be investigated and treated in their normal environment for changes in this environment are often causally related with the onset of disease. A farm animals' practice unit, closely associated with the university teaching hospital, is an essential arm of the clinical department of the veterinary school. The introduction of undergraduates to practical problems in the field where environment and methods of husbandry exert profound influences on the health of farm animals has led to the evolution of species specialists. This type of consultant covers individual species such as cattle, sheep, pig and poultry today but will probably extend to zoo animals, laboratory animals and fish in the near future.
352
BRITISH VETERINARY JOURNAL, 132, 4
Consultants in university veterinary hospitals should be senior people of at least ten years' experience and they should be supported by junior staff at various levels of training. There is a need for a greater body of resident housemen attached to each discipline and to any university practice. This kind of grouping could provide continuous consultant service to veterinary surgeons and animal owners as well as to education. The course of training for consultant status could be that newly qualified graduates, or graduates who have been employed in practice for one or two years, would commence a two year appointment as a houseman in the discipline of his choice. In some cases the new graduate might proceed directly to the hospital for training in certain specialities (e.g. orthopaedics). This form of entry will allow time for the individual to decide on the rightness of his choice and for the head of the unit to assess the value of the person continuing training. It is likely that many aspiring consultants will be recruited from those who have studied for an intercalated degree in basic science. After one or two years the junior houseman could commence study towards a Ph.D on a part-time basis while continuing with his clinical training. This research degree under these circumstances would require four years for completion and is essential to provide the new knowledge for the advancement of the subject. The two diplomas offered by the R .C.V.S. in anaesthesia and radiology fulfil only the early part of consultant training and it may be, that in the future the training offered at present will be incorporated in the first degree training schedules as general practitioners extend radiology as a diagnostic aid, and practice more extensive surgery depending upon modern methods of anaesthesia. On the acquisition of the basic training the junior could be appointed to a teaching post in a university teaching hospital or practice teaching unit. In this position he will continue to develop his knowledge in the discipline over a period of years by casework, research and the application of clinical science to diagnosis and treatment in general practice. Once the veterinary schools have become properly staffed with adequate numbers of seniors and juniors, then perhaps specialist practices could develop through private enterprise. At this time it might be proper for the R.C.V.S. to confer with the universities to define consultancy status. It could be that the M.A.F.F. will accept its responsibility to finance the training of general practitioners and consultants to service the agricultural industry. Today the M.A.F.F. is no longer responsible, as it was before 1948, for financial contribution to veterinary education. It does not seem unrealistic to expect that the M.A.F.F. should assist undergraduate education in veterinary science as the D.H.S.S. does for medical education. In a Rothschild situation of customer/ contract it seems reasonable to expect the M .A.F.F. to finance extra university posts and facilities in the area of farm animal medicine. Other bodies such as the Horserace Betting Levy Board and the Greyhound Racing Association might be called upon to contribute, preferably by endowment, towards the training of consultants to maintain the health of the animals for their industries. The establishment of units for clinical consultants in the veterinary schools
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would have a profound effect on undergraduate training which would elevate and strengthen the speciality of general practice. It would be much easier to arrange courses of continuing training for practitioners in the environment of the university veterinary hospital. In the field of food animals it would be reasonable to expect the Agricultural Departments to provide financial support for these courses as the D.H.S.S. does for human medicine. CONCLUSION
There is need for a cadre of veterinary clinical consultants. Some of these consultants will be expert in a single species whereas others will be expert in a discipline specialization (e.g. cardiology, dermatology, neurology, radiology, clinical pharmacology). Because of the small numbers required and the cost of training it would appear that the university veterinary hospitals must be the venue for training. The establishment of consultant units in veterinary schools will not only assist general practitioners but could make a marked contribution to the first degree curriculum and to postgraduate re-educational courses.