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TOPIC: AVMA Model Veterinary Practice Act

RE:AVMA Model Veterinary Practice Act 20 Feb 2011 15:17 #241

  • mwmyersdvm
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tbloomer wrote:
This already happened well over a decade ago. Though it may help to review the history.
http://www.anvilmag.com/comment/aaepflc.htm

Most recent update for AAEP:
http://www.equipodiatry.com/news/aaep_guidelines.html

Most recent update for the Guild (Incorporated) - essentially the same as the original wording from the unincorporated GPF.
http://guildfarriers.org/ethics

In spite of this, many farriers and virtually the entire horse owning public is ignorant of the following facts:
  1. A farrier is not required to follow the vet's instructions and the vet has no authority whatsoever over a farrier's actions.
  2. A farrier is legally liable for any bad outcome which results from executing a "vet's prescription."
  3. A vet has no legal liability for giving a "bad prescription" unless they shoe the horse with their own hands.

All good points, but the only issue is while these organizations have some guidelines, they exclude the other party from organizational interaction so there is no continuity. Obviously, the AAEP guidelines are not being followed from the situations depicted here on this forum. I have been guilty on occasion and there needs to be some resolution process when the farrier and veterinarian cannot agree without putting undue pressure on the owner. There is no provision for this, only a stalemate with the owner left to decide.

This 'stalemate scenario' just occurred with a farrier friend of mine. The veterinarian asked him how he would trim the foot of laminitic horse that was in question. The ending statement from the vet was that if the farrier wished to add his knowledge and not do precisely whaat the veterinarian dictated then the veterinarian was off the case. The farrier respectfully declined to proceed. This was a referral veterinarian for the laminitic horse so he should be aware of these guidelines. He negated all of the farriers input which amounted to relieving DDFT pull, supporting the hoof caudally, keeping breakover back to relieve the dorsal wall, and aligning the pastern axis. He stated he wasn't concerned with that. The farrier felt the trim the vet mandated would have increased DDFT pull, increased breakover distance, decreased heel support, and may not have even been able to actually perform without invading live tissue. From the guidelines he did the right thing, but there seems to be a step missing here somewhere. I don't believe this horse is going to win this one.

M. W. Myers, D.V.M.
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RE:AVMA Model Veterinary Practice Act 20 Feb 2011 15:29 #242

  • Mike Ferrara
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mwmyersdvm wrote:
All good points, but the only issue is while these organizations have some guidelines, they exclude the other party from organizational interaction so there is no continuity. Obviously, the AAEP guidelines are not being followed from the situations depicted here on this forum. I have been guilty on occasion and there needs to be some resolution process when the farrier and veterinarian cannot agree without putting undue pressure on the owner. There is no provision for this, only a stalemate with the owner left to decide.

This 'stalemate scenario' just occurred with a farrier friend of mine. The veterinarian asked him how he would trim the foot of laminitic horse that was in question. The ending statement from the vet was that if the farrier wished to add his knowledge and not do precisely whaat the veterinarian dictated then the veterinarian was off the case. The farrier respectfully declined to proceed. This was a referral veterinarian for the laminitic horse so he should be aware of these guidelines. He negated all of the farriers input which amounted to relieving DDFT pull, supporting the hoof caudally, keeping breakover back to relieve the dorsal wall, and aligning the pastern axis. He stated he wasn't concerned with that. The farrier felt the trim the vet mandated would have increased DDFT pull, increased breakover distance, decreased heel support, and may not have even been able to actually perform without invading live tissue. From the guidelines he did the right thing, but there seems to be a step missing here somewhere. I don't believe this horse is going to win this one.

M. W. Myers, D.V.M.

In my experience such situations aren't all that unusual. Only a small percentage of my work involves any vet but of that portion that does, I often encourage people to just take the horse to the clinic to be shod. That way the vet can take responsibility for their prescription.

I've tried about everything else in cases involving those specific vets and I'd prefer to just do without the headache. Let the farrier working at the clinic hash it out with the vet. I've got other horses waiting that are less trouble and pay better.
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RE:AVMA Model Veterinary Practice Act 23 Feb 2011 10:15 #243

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mwmyersdvm wrote:
All good points, but the only issue is while these organizations have some guidelines, they exclude the other party from organizational interaction so there is no continuity.
Why would a farrier want to interact with an organization that promotes extending the authority of veterinarians beyond their accreditation? The situation is adversarial.
Obviously, the AAEP guidelines are not being followed from the situations depicted here on this forum.
And when they have been clearly violated, the AAEP will not allow a non-veterinarian to bring a complaint. The situation is adversarial.
I have been guilty on occasion and there needs to be some resolution process when the farrier and veterinarian cannot agree without putting undue pressure on the owner.
The farrier bears all of the liability and has the least to gain. The situation is adversarial.
There is no provision for this, only a stalemate with the owner left to decide.
I've seen owners go along with some stoopid veterinary decisions which resulted in their horses being permanently crippled. Invariably, they still think the vet walks on water. "The doc did all he could for my horse . . ." People are used to this sort of thing from the "medical establishment."
From the guidelines he did the right thing, but there seems to be a step missing here somewhere. I don't believe this horse is going to win this one.
In my sandpile there are always a hand full of farriers who are happy to follow veterinary instructions without question. Seems they do a lot of "prescription shoeing" at very reasonable rates. If you're really cheap and the vet is dictating how you shoe, you can have a full book of lame horses that never get better and very happy customers - satisfied that you're "doing all you can."
Tom Bloomer
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302-222-6404


Here's the deal. I'm trying to keep it simple.
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RE:AVMA Model Veterinary Practice Act 23 Feb 2011 22:22 #244

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tbloomer wrote:
Why would a farrier want to interact with an organization that promotes extending the authority of veterinarians beyond their accreditation? The situation is adversarial.

And when they have been clearly violated, the AAEP will not allow a non-veterinarian to bring a complaint. The situation is adversarial.

The farrier bears all of the liability and has the least to gain. The situation is adversarial.

I've seen owners go along with some stoopid veterinary decisions which resulted in their horses being permanently crippled. Invariably, they still think the vet walks on water. "The doc did all he could for my horse . . ." People are used to this sort of thing from the "medical establishment."

In my sandpile there are always a hand full of farriers who are happy to follow veterinary instructions without question. Seems they do a lot of "prescription shoeing" at very reasonable rates. If you're really cheap and the vet is dictating how you shoe, you can have a full book of lame horses that never get better and very happy customers - satisfied that you're "doing all you can."

Tom,

I wholeheartedly agree with every point you make. Got any ideas on how to create an organization or empower a current one to assist in alleviating these problems? May I bring your commentary to a few veteirnarians that may actually look at them? I believe these are excellent points. I am sure that you feel as do I that a lot of 'lip service' is being given to farrier and veterinarian cooperation, but there is not a lot of actual motion involved to rectify the situation.

M. W. Myers, D.V.M.
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RE:AVMA Model Veterinary Practice Act 23 Feb 2011 23:44 #245

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reillyshoe wrote:
A radiologist devotes years to imaging techniques. As you mentioned venograms, I will point out that I do not think there are studies assessing the repeatability of this procedure in the equine digit. Is there value in back-filling the circulation system to see what is going on? What is your experience with CT or MR evaluation of the lamintic hoof? I would suggest that preforming a venogram is not a technically challenging procedure. I would suggest that if a radiologist does not utilize this procedure, then perhaps their study of the subject supports their decision (the same argument would apply towards a DDFT tenotomy, which is a very simple surgery).

You may find this article on venography interesting. I would think Dr. Pollitt constitutes a well known and careful researcher.

http://www.vetequine.theclinics.com/article/S0749-0739(09)00101-1/abstract

Radiologists tend to use more advanced tools because they have them available and have a case referred to them for use of modalities not generally available in the field. They are not out in the field seeing these cases on a regular basis and MRI and CT are not viable modalities for this use. A good radiologists will first want a good history and diagnostic workup before proceeding with imaging.

M. W. Myers, D.V.M.
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RE:AVMA Model Veterinary Practice Act 24 Feb 2011 00:12 #246

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mwmyersdvm wrote:
Radiologists tend to use more advanced tools because they have them available and have a case referred to them for use of modalities not generally available in the field. .

For starters, this is one reason why one might consider referring a lameness to a team including a radiologist as opposed to a veterinarian with an interest in feet.
P
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RE:AVMA Model Veterinary Practice Act 24 Feb 2011 00:31 #247

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mwmyersdvm wrote:
You may find this article on venography interesting. I would think Dr. Pollitt constitutes a well known and careful researcher.

http://www.vetequine.theclinics.com/article/S0749-0739(09)00101-1/abstract

Radiologists tend to use more advanced tools because they have them available and have a case referred to them for use of modalities not generally available in the field. They are not out in the field seeing these cases on a regular basis and MRI and CT are not viable modalities for this use. A good radiologists will first want a good history and diagnostic workup before proceeding with imaging.

M. W. Myers, D.V.M.

Secondly, for those without access to the full text mentioned, this article follows serial venograms on horses with ogilofructose induced laminitis. There are changes observed in the venogram as the laminitis progresses.

While this is interesting, and possibly useful, I would suggest that it might not be totally accurate information. There has never been a study comparing a control horse assessed a different days, when the findings would presumably be the same. I am sure there is a margin or error, and this has never been established.
It is possible that, for instance, venograms are not accurate due to the normal daily occurences of vasodialation of the hoof, which we know to occur.
It is possible that back filling the circulatory system (as occurs with venograms) creates artifacts when compared to an arteriogram, which is the normal direction of circulatory flow.
It is possible that the procedure of a venogram ((30 mL) or perivenous leakage occurred due to excessive back pressure) is not repeatable as the volume of the distal limb circulatory plexus varies, thus creating artifact in the test.
It is possible that the amount of weight bearing of each limb during either the administration of contrast material or as the radiograph is taken creates artifact.
It is possible that the administration (or lack of administration) of nerve blocks and/or sedation would create artifact affecting the result.


There is no "gold standard" on which to compare the results of venograms, as well as the procedure described. Diffuse optical temography, CT scans, MR, nuclear scan fill phase all have their limitations as well as venograms.

Are venograms accurate? Are venograms repeatable? The study you referenced does not address either of these questions. As much as I admire and respect Dr. Pollitt (whom I consider to be a friend), he is not a radiologist.
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RE:AVMA Model Veterinary Practice Act 24 Feb 2011 01:19 #248

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mwmyersdvm wrote:


There are boarded radiologists that do not do and do not read venograms.

M. W. Myers, D.V.M.


I am not stating that venograms do not have value. I am stating that a radiologist, with their dedicated area of study, might be knowledgeable enough to understand the limitations of a venogram, and why they might oppose their use. They might be aware of better alternatives.
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RE:AVMA Model Veterinary Practice Act 25 Feb 2011 14:55 #249

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reillyshoe wrote:
Secondly, for those without access to the full text mentioned, this article follows serial venograms on horses with ogilofructose induced laminitis. There are changes observed in the venogram as the laminitis progresses.

While this is interesting, and possibly useful, I would suggest that it might not be totally accurate information. There has never been a study comparing a control horse assessed a different days, when the findings would presumably be the same. I am sure there is a margin or error, and this has never been established.

I am not aware of any studies of this type done on MRI either.
It is possible that, for instance, venograms are not accurate due to the normal daily occurences of vasodialation of the hoof, which we know to occur.

Again, this has not been done with many modalities, likely due to financial constraints.
It is possible that back filling the circulatory system (as occurs with venograms) creates artifacts when compared to an arteriogram, which is the normal direction of circulatory flow.

Studies were done on arteriograms and the contrast material causes arterial spasm which compromises image quality.
It is possible that the procedure of a venogram ((30 mL) or perivenous leakage occurred due to excessive back pressure) is not repeatable as the volume of the distal limb circulatory plexus varies, thus creating artifact in the test.

Perivascual leakage is easily seen with a venogram. I can make reading adjustments for venograms I do personally. I am also familiar with a number of artifacts that occur during the procedure. I find this modality useful and I do agree it has limitations.
It is possible that the amount of weight bearing of each limb during either the administration of contrast material or as the radiograph is taken creates artifact.

The lack of load on MRI may also have effects that are unknown and MRI does not allow for load evaluation.
It is possible that the administration (or lack of administration) of nerve blocks and/or sedation would create artifact affecting the result.

Agreed, but since this procedure is always done in this manner, it is consistent in methodology.

There is no "gold standard" on which to compare the results of venograms, as well as the procedure described. Diffuse optical temography, CT scans, MR, nuclear scan fill phase all have their limitations as well as venograms.

Agreed. All of the imaging modalities are complimentary and give different information. It depends on what the operator is accustomed to using and what is being searched. I simply use venography regularly and have good results from its use.
Are venograms accurate? Are venograms repeatable? The study you referenced does not address either of these questions. As much as I admire and respect Dr. Pollitt (whom I consider to be a friend), he is not a radiologist.

On the flip side of that, there are very few radiologists that have good familiarity with the equine digit.

Good discussion. I think we do agree that modalities do give differing data. I have simply had some poor experiences with referrals to univerity situations where all of the specialists are in place and the result was a disaster. It appeared that after the diagnostic modalities are done they simply didn't know how to correctly proceed with the case for an optimal result. They don't see these cases often enough to know I would imagine. They often often do not get to follow cases to a final conclusion and do not have the full data on how this horse did one or two years (or more) out. This is where the veterinarian with knowledge in all of these areas but not the precise total expertise in the realm of each entire area can serve as a coordinator much as a general medical practitioner can put together data on his case from the respective specialty inputs he has accumulated.

M. W. Myers, D.V.M.
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RE:AVMA Model Veterinary Practice Act 26 Feb 2011 01:49 #250

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mwmyersdvm wrote:
I am not aware of any studies of this type done on MRI either.



Again, this has not been done with many modalities, likely due to financial constraints.



Studies were done on arteriograms and the contrast material causes arterial spasm which compromises image quality.



Perivascual leakage is easily seen with a venogram. I can make reading adjustments for venograms I do personally. I am also familiar with a number of artifacts that occur during the procedure. I find this modality useful and I do agree it has limitations.



The lack of load on MRI may also have effects that are unknown and MRI does not allow for load evaluation.



Agreed, but since this procedure is always done in this manner, it is consistent in methodology.




Agreed. All of the imaging modalities are complimentary and give different information. It depends on what the operator is accustomed to using and what is being searched. I simply use venography regularly and have good results from its use.



On the flip side of that, there are very few radiologists that have good familiarity with the equine digit.

Good discussion. I think we do agree that modalities do give differing data. I have simply had some poor experiences with referrals to univerity situations where all of the specialists are in place and the result was a disaster. It appeared that after the diagnostic modalities are done they simply didn't know how to correctly proceed with the case for an optimal result. They don't see these cases often enough to know I would imagine. They often often do not get to follow cases to a final conclusion and do not have the full data on how this horse did one or two years (or more) out. This is where the veterinarian with knowledge in all of these areas but not the precise total expertise in the realm of each entire area can serve as a coordinator much as a general medical practitioner can put together data on his case from the respective specialty inputs he has accumulated.

M. W. Myers, D.V.M.

Or could it be that once the case has reached the point of referrals...to a universty and / or a clinic with MRI abilitys the case now is out of ur hands and took over be theses folks therfore the money also....doc you do know th ey now have a traveling MRI that you can have them come to ur clinic for a moth fee and the will read it and tell ya that way u can still keep the case and use the mri....small start up fee of apply the elctric needs and its a monthly fee no matter if 10 are done or none...then you can have other reffer to ur clinic...mo money..lol..all jokinm aside not a bad deal...and we have touched on th is before I just can't figure out why ur so oppose to mri and other vets are for it....but they are also for the other things u said they seem to see it as another tool I get the idea of you don't find it much use to you
Travis Reed.....


www.sporthorsefarrier.com to direct link..
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RE:AVMA Model Veterinary Practice Act 26 Feb 2011 01:55 #251

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I think the point is that I trust the radiologist to be the MOST knowledgeable person about how (or if) to image the foot- even if there is no consensus about what is "best". There are a lot of questions about the best method of shoeing a horse, or surgically managing a horse, or medically managing a horse or imaging a horse. I trust these specialists to provide the best outcome, rather than the "veterinarian with an interest in feet".
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RE:AVMA Model Veterinary Practice Act 26 Feb 2011 22:10 #252

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Travis Reed wrote:
Or could it be that once the case has reached the point of referrals...to a universty and / or a clinic with MRI abilitys the case now is out of ur hands and took over be theses folks therfore the money also....doc you do know th ey now have a traveling MRI that you can have them come to ur clinic for a moth fee and the will read it and tell ya that way u can still keep the case and use the mri....small start up fee of apply the elctric needs and its a monthly fee no matter if 10 are done or none...then you can have other reffer to ur clinic...mo money..lol..all jokinm aside not a bad deal...and we have touched on th is before I just can't figure out why ur so oppose to mri and other vets are for it....but they are also for the other things u said they seem to see it as another tool I get the idea of you don't find it much use to you

If you could direct me to those people I would be glad to discuss it with them. So far, MRI will cost between $800 and $1500 per study (ie. per foot) so it is out fo the price range of most of the clients I deal with. I refer often so money is not the issue as you seem to think. I do this because I enjoy it. I have many farrier frineds that make considerably more income than I do.

I am not opposed to MRI, but I work on laminitis cases and also on subtle lamenesses that need repeat imaging studies as the case progresses. At around $1000 per hoof, I don't think I can get many MRI's done to assist a case as it progresses.

The majority of vets that are really enthused about MRI are the ones that need to pay the mortgage on the equipment. They begin at a six figure price tag and the first figure is not a "1".

MRI is a good modality for certain problems, but not generally for a start point on a lameness evaluation.

M. W. Myers, D.V.M.
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RE:AVMA Model Veterinary Practice Act 26 Feb 2011 22:30 #253

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Is money an issue or not? You seem to be giving both answers here...

All I know is that most football players who injure their knee or ankle or foot seem to have an MR exam within a day or two of the injury in human medicine, where money is not the limiting factor.

I still think the question is how to spend money wisely, and that is debated among everyone involved. Is a venogram worth the money? You seem to think so, but (as you state) not every radiologist agrees. Is an MR, or CT, or nuke scan worth it? It depends on the case, as well as the modalities available to you as well as the owner's budget.
P
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RE:AVMA Model Veterinary Practice Act 26 Feb 2011 22:32 #254

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reillyshoe wrote:
I think the point is that I trust the radiologist to be the MOST knowledgeable person about how (or if) to image the foot- even if there is no consensus about what is "best". There are a lot of questions about the best method of shoeing a horse, or surgically managing a horse, or medically managing a horse or imaging a horse. I trust these specialists to provide the best outcome, rather than the "veterinarian with an interest in feet".

I would agree as long as the radiologist is familiar with the hoof anatomy and physiology. I was lucky at LSU as a student since Johhny Watters, DVM was a farrier before he was a veterinarian. Then he went on to learn radiotion physics and radiology concurrently. Very few radiologists have those credentials. Unfortunately he has succumbed to an Alheimer like condition soem years ago.

Let me give you a specific example. I referred a horse to our local center - Marion DuPont Scott Equine Center. He was a 22 year old gelding with a coffin bone sequestrum encompassing nearly 25% of the bone. I sent him with venograms I had done and suggested they remove the sequestrum and do a DDFT tenotomy before he fractured the balance of the bone. I received a call from an intern who said the surgeon and radiologist wanted to wait and let the sequestrum liquify a bit more before surgery was done and they didn;t see a need for a tenotomy. I told her the result of this decision will be the horse will shear off the end of his coffin bone in around five days ( I will admit I pulled that one out of the air...or wherever:) ). The intern called me back in five days to let me know I was right and the horse did just that and wanted to knwo how I knew that would happen. I just told her I am rather aged compared to her professors and have seen enough of these cases to assess what will be the outcome of certain actions and inactions.

Normally, I would have done this surgery in the wash rack, but with the referral hospital nearby and this not being my regular client, I felt referral should be a viable option. It wasn't. I felt it was an easily resolvable case, but needed immediate attention. This is one case of several that have been improperly done at referral facilities in my experience. If I have a surgical colic, by all means I will send it to this facility, they just are not good with hooves.

I do appreciate your position and you have great faith in your facility, but not all facilities run as well as yours. My first referral from Horseshoes was a horse that had been to the University of Minnesota for evaluation and they missed the lame leg. They worked on a right hind leg for nearly two years when the horse was lame in the left front. Correct trim and careful shoeing application got the horse from two years of lameness to second level dressage in four months. There is alot more to this story but this is the abstract version.

M. W. Myers, DVM
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RE:AVMA Model Veterinary Practice Act 26 Feb 2011 22:38 #255

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While I appreciate your faith in your own abilities, I would guarantee that nobody has a 100% success rate. Individual case reports, while incredibly important to the individuals involved, do not necessarily tell the whole story.
P
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  • DressageReine birthday is today
  • ElCamino birthday is today
  • FarrierNTexas birthday is today
  • mark_jakopak birthday is today
  • Matt McMicken birthday is today
  • Matt_McMicken birthday is today
  • docsvoodoochic birthday is in 1 day
  • Ishoem4u birthday is in 1 day
  • JessyJay birthday is in 1 day
  • min54teresa birthday is in 1 day
  • TWH-BILL birthday is in 1 day
  • flossie55 birthday is in 364 days
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