27 Jan You asked, CVMA answered: See the answers to your questions from the mid-level practitioner town hall
Thank you to all our CVMA members and friends who took the time to attend our virtual town hall regarding the mid-level practitioner on Thursday, January 19. Due to time constraints during the town hall, we were unable to answer every question that was submitted. We have included answers to all the questions submitted below.
Looking for more information on the mid-level veterinary practitioner issue? Get more information on our website here.
Question 1: Is there an analogous credentialed position in human healthcare i.e. physician’s assistant or nurse practitioner? How was the credentialing process developed for those folks?
This is a question that often gets asked. The mid-level practitioner position gets compared frequently to a physician’s assistant. Early PA programs were created to preserve the valuable skillset of military medics returning from Vietnam. The biggest challenges to this newly created profession were curriculum development and regulation requirements. These issues were addressed through a collaboration of all affected medical professions to develop the boundaries of a PA’s functions and discuss the need for programmatic accreditation. In the case of a veterinary mid-level practitioner, there are many options available to create an opportunity to elevate veterinary technicians and veterinary technician specialists, who already have developed skillsets with minimum competency requirements and regulation.
Where our path diverges from that of the PA program development is the collaborative process involving all affected veterinary medical professions to determine the needs and where we already have overlap with veterinary technology programs and the Veterinary Technician Specialist certification process. We have barely scratched the surface on the real opportunities available to address the outdated policies and regulations that have become a barrier for veterinary medicine to serve the needs of the public.
Question 2: Who determines what is considered a “routine case?”
This is the crux of the issue, and one of CVMA’s most significant concerns regarding the mid-level proposal. You never know whether a surgery is routine until the case is complete; we all know how quickly a seemingly “basic” surgery can go south and significant complications can arise. Or what presents as a seemingly straightforward problem can go down the road into complex diagnostics and treatment protocols. Some say this is where the direct supervision of a veterinarian comes into play: That when things become more complex, the training and oversight of the veterinarian is the ultimate safeguard.
The problem comes down ultimately to the education and curriculum: How is it possible to effectively educate a potential practitioner on only the “basic” and “routine” things?
- Which diseases make the cut and which don’t?
- Which complications are “routine” complications and which are more advanced?
- What technical competencies are needed to handle routine cases, vs. those that are needed for more complex ones?
- How can a supervising veterinarian ultimately be confident in the mid-level practitioner they are supervising?
There is no foolproof way to determine which cases will actually end up being routine; it must be determined on a case-by-case basis, for each case, and also for each practitioner and each clinic. CVMA believes this issue is a major roadblock to this proposal.
Question 3: How do advocates for the mid-level practitioner position see this fixing the shortages noted in shelter and rural medicine? To help large animal practices, would this position allow them to do castrations, ultrasounds for pregnancy on the farm while the DVM is seeing patients in the clinic?
Shelter medicine and rural medicine face distinctive and somewhat parallel challenges.
Let’s talk rural medicine first — we know that rural veterinary medicine professionals have been struggling to meet the needs of their communities for quite some time. There is a complex range of issues that come into play in ensuring that Colorado has enough rural veterinarians – things like practice models, availability of staff, student debt, rural economics, geographic distance, and as we like to say the differences between “city mice and country mice”.
It is not the topic of this session, but we know that a bill has been introduced this session that will continue Colorado’s veterinary education loan repayment program. It increases the number of qualified applicants and increases the loan repayment. That is an important investment for our rural areas. That is a win for rural veterinary practice as there are 18 Colorado counties that are designated as veterinary shortage areas. So far we understand that the education for a mid-level practitioner would focus on companion animals. The actual education that mid-level practitioners would receive in large animal medicine is not clear. However, in this process, we have learned that there is a veterinary technician specialist designation in production animal internal medicine.
What CAN be done NOW in the veterinary practice act to address some of the rural practice questions is to carefully adjust the boundaries so that they better fit the needs of rural practice, such as:
- Allowing registered veterinary technicians to provide a range of standard animal husbandry support under indirect supervision after a VCPR has been established by a licensed, supervising veterinarian.
- This could include registered technicians doing pregnancy ultrasounds and a range of other work, including training owner’s employees to perform various animal husbandry tasks, including castrations.
This would allow a licensed veterinarian to focus on those aspects of large animal medicine that by federal requirements MUST be performed by a licensed veterinarian such as veterinary feed directives. A veterinary license is required for USDA accreditation, therefore a mid-level practitioner would not be able to perform Accredited work such as health certificates, EIA testing, Brucellosis vaccination or testing, or Tuberculosis testing. Allowing registered veterinary technicians, and encouraging Veterinary Technician Specialists in production animal internal medicine, to perform a greater range of defined work under indirect supervision could have the result of add needed veterinary personnel in rural areas.
For shelter medicine, as we understand it, the most pressing current needs are high-volume spay/neuter work that must be performed before animals are adopted, and dentals that help ensure newly adopted pets are healthy. It also seems that there is a narrow supply of veterinarians interested in shelter medicine work. Taking these needs in turn: high volume, high quality spay and neuter work capability is developed with training and practice. Such training exists and can be offered. Some believe that dental work cannot be delegated to veterinary technicians even though Colorado’s veterinary rules currently allow the delegation of dentistry, so this can be clarified. And finally, what would happen if there was an advanced education program in shelter medicine similar to the program at UC Davis that would help develop a larger pool, a pipeline of qualified shelter medicine veterinarians? Proponents of the mid-level practitioner believe this position would increase capacity in shelters by adding new professionals who can perform high-volume spays and neuters.
Proponents suggest that mid-level practitioner students may be veterinary technicians or applicants who are not accepted to veterinary schools. As far as we know, no research on either of these pools of potential candidates has been conducted. We understand that the mid-level practitioner program will admit 25 students per semester over five semesters until the annual class size is 150 students. We do not have clear information about when this program could launch or what the specific curriculum would be.
Launching a new, generalized education program for mid-level practitioners is a time-consuming process that may not yield practitioners with the education and skills to meet the need for rural large animal or shelter veterinary medicine. The most immediate increases in capacity will be realized if we train, develop, protect, retain, and advance all the members of the veterinary teams we already have.
Question 4: What protections will be put in place to avoid over-reach of scope seen currently in human medicine with nurse practitioners and PAs that have fully replaced doctors in many clinics?
This is an important question. Scope of practice is really a critical question, and it is a key issue.
In general, among the many medical professions, the legal definition of scope of practice combined with licensing and regulation governs which professional is legally permitted to perform specific tasks. In veterinary medicine, scope of practice definitions are intended to protect patients, clients, and public health by ensuring that medical providers are qualified and competent to perform specific tasks. So, the direct answer to this question is that the best protection of overreach of scope is to delineate the veterinary tasks that can be delegated under specific levels of supervision to paraprofessional staff and which veterinary tasks can only be performed by the veterinarian.
Drilling down a bit, today across the country, most veterinary practice acts allow ONLY veterinarians to do “the Big Four” diagnose, initiate treatment, prescribe or perform surgery. Colorado’s practice allows DVM students to do the “Big Four” as part of their education and under direct supervision.
So, how does this relate to the proposed mid-level professional? During the stakeholder working group meetings, we have heard several things – first, that a mid-level professional would be able to perform basic or routine tasks. These are imprecise terms that are prone to misinterpretation and confusion.
We have also heard that such professionals would be prepared to diagnose, initiate treatment, prescribe and perform surgery under supervision of a veterinarian. CVMA questions how much time someone with a minimal education and limited experience will actually free up for veterinarians, who will be required to supervise and approve all of their higher-order work efforts.
So far, the scope of practice these professionals would be expected to fill is not fully defined or adequate which invites over-reach of scope and could work against protection of consumers and animal health.
Question 5: Since any work must be done under direct supervision of a veterinarian, does it not make more sense to use an RVT to help the veterinarian with minor surgeries, etc?
In short, yes. It’s important to note that proponents actually envision a mid-level practitioner working under indirect supervision in rural USDA veterinary shortage areas. However, if we’re talking about expansion of duties, we believe it makes more sense to expand the duties of our existing veterinary technicians and delegate to qualified technicians rather than creating a whole new veterinary professional.
Question 6: I am curious how this position is meant to help address staffing issues? CVTs and veterinary assistants are already in incredibly short supply, which is driving the limited working hours far more than a lack of veterinarians. How would this not put veterinarians at a further disadvantage by removing more support staff and reallocating them to supporting this new professional? The lack of adequate support staff is what is largely contributing to veterinarian burnout and driving some out of practice as well. In human medicine a PA or a nurse practitioner doesn’t need an anesthetist, someone to restrain patients, etc.
This is the challenging issue we face. We’ve been aware of the veterinary technician shortage for many, many years, and the situation has been worsened by the pandemic. According to the 2022 NAVTA Demographic Survey, veterinary technicians cite the most challenging aspects of their job as low salary, high staff turnover, and lack of title protection.
Instead of creating an entirely new professional, we must focus our efforts on instead retaining, advancing, and increasing the number of veterinary technicians. Let’s focus on fixing this problem first; instead of squeezing our technicians out of their profession by adding another professional above them, let’s work on issues of utilization and pay first. There will be legislation coming this legislative session that will help us do just that.
It is important to note that AVMA studies show 65% of veterinary practices operate at lower than 50% efficiency – that’s huge! This low efficiency rate means that these practices (whether they be general practice, shelter, or rural) are unable to see as many animals as they could. Improving efficiency is a critical piece of solving the staffing issues we face today. More people does not always mean higher efficiency. An AAHA article published this month examines the issue of making full use of credentialed technicians: “Veterinary technicians can be running around frantically trying to get work done and being overworked because they are expected and tasked to do everything. Instead, develop a process in which the procedures and tasks are delegated to the appropriately skilled individual so that everyone can focus on the work that is best tailored to their level of expertise. This is a key to efficient workflow and team.” We think this is so crucial to understand: It’s important not to confuse “busy” with “well-utilized.”
Question 7: Why not just increase the number of seats in each veterinary class by the number of proposed VPA Masters slots?
Excellent question to focus on whether the more pressing issue is the number of veterinarians. CSU has stated that the constraint is physical space in classrooms, labs, and surgical space. We also know that veterinary faculty are in short supply nationally. This does raise the question how mid-level practitioners will be adequately prepared if the infrastructure and faculty do not allow for more veterinary students, particularly when we have heard that the mid-level students would receive the same surgical training as veterinary students. We also understand that the proposed mid-level professional program would be 5 semesters long, with three semesters offered virtually. We understand that CSU is embarking on a major expansion of its classroom facilities and VTH facilities within the next 3-5 years that will allow an increase in the number of veterinary students. Nationally, three new veterinary schools are on track to graduate their first classes in 2023, 2024, and 2025, and two more colleges are under development. There were 4,505 U.S. graduates from AVMA-accredited schools in 2021, and about 77% of those provide services for pets. By 2030, it is expected that there will be more than 5,100 veterinarians entering companion animal practice each year.
Question 8: How will this position be marketed to pet owners?
The real question here is will these providers be credible to pet owners? Many pet owners don’t understand the existing roles within veterinary medicine. It would be challenging to market this position to pet owners given that there is not yet a defined curriculum or competency exam. We also struggle with how to communicate to pet owners the difference between a veterinary technician and a mid-level practitioner. We could also ask how this position will be marketed to employers? For big corporate practices, this is an easy “yes” because they have the infrastructure in place to use these people.
Question 9: What are CVMA’s solutions for the veterinary (technician and DVM) shortage?
This is a national problem, and we see several root causes for today’s challenges. For veterinary technicians, research shows that they leave the profession because they are not able to work at the top of their training, because there is no career path, and because they are not paid a living wage. We need to figure out how to retain these essential employees. For the veterinary profession, research also shows that some 65% of veterinary practices operate at under 50% efficiency. This means that a range of internal structures, processes, and communication are likely not functioning well which contributes to burnout, low wellbeing, and poor staff retention. We need to focus attention on improving practice efficiency.
Here in Colorado, we have about 5,000 licensed veterinarians and a similar number of veterinary technicians. Research shows that about 1.5 veterinary technicians per veterinarian is the “sweet spot”. We need to make sure all the seats are full in our nine Colorado veterinary technician programs. CVMA believes that it would be an extremely wise investment to ensure that all members of our veterinary teams can work at optimal levels of effectiveness and efficiency. Improvements that would allow veterinarians and veterinary technicians to work effectively to the highest levels of their education will take work and would improve wellbeing, and increase the number of animals that can be helped.
In the near term, CVMA envisions a two-part solution to these problems. First, we need to better define what can be delegated to which members of the veterinary team, and under what levels of supervision. Second, we need to provide targeted education and training for both veterinarians and veterinary paraprofessionals about delegation, supervision, effective practice communication, management and leadership.
CVMA would like to work in partnership with other groups to assess the needs of the veterinary profession and the demands that it faces. We would like to collaborate with others to develop advanced education for veterinary technicians and for veterinary teams. The goals would be to improve career advancement pathways and improve compensation to better retain veterinary technicians, learn how to delegate better, and for veterinary practices to become more efficient and productive.
In contrast, developing and launching a new education program for mid-level practitioners would be slow process that will take several years to launch and two more years to yield the first 25 graduates. The educational preparation and practice arenas of these mid-level practitioners is not at all clear. Will they help Colorado where help is needed? CVMA advocates for taking action now to provide Colorado’s veterinary profession with a regulatory framework that supports optimal utilization of veterinary teams. This must be coupled with education and training that inspires and prepares veterinary teams toward improving efficiency, productivity, and wellbeing to build a solid foundation for the future.
Question 10: Why didn’t you include an advocate of the mid-level practitioner on the panel?
CVMA was pleased to invite advocates of the mid-level practitioner to share information about their proposal on the CVMA website and in CVMA’s eVOICE newsletter (click here to read it ). CVMA’s town hall was designed specifically to be an opportunity for CVMA members to ask questions of CVMA leadership and to share what CVMA had learned about the issue during the stakeholder working group meetings.
Question 11: In terms of routine cases for these roles, how do you justify having a VPA do my annual exams and I focus on complex cases? Because when I am no longer doing my annual exam, I miss out on creating a relationship with the patient of knowing what is normal.
Great question! This was not something that came up during the stakeholder working group process, but it’s a good point and CVMA agrees that this is a concern. Creating a working knowledge of what is considered “normal” for a patient is important for veterinarians to be able to handle complex cases. In addition, it is important for veterinarians to build strong relationships with clients to have a good sense of their ability to follow through and comply with the veterinarian’s recommendations. Veterinarians could lose this opportunity by focusing solely on complex cases.
Question 12: How do you plan to keep the technicians as they will never get paid more when we add an entirely new role in the clinic? How are you justifying this to techs?
It is true that veterinary technicians hold an essential role on the veterinary team and that the profession can do better to retain these professionals. In the stakeholder working group, we heard a presentation about more fully utilizing technicians on revenue-generating tasks and increasing technician compensation. Research shows that technicians want to be able to fully use their skills, to earn more, and to be able to advance in their careers. Changes made to the practice act in 2022 allow more CE hours to be used on topics that will help practices become more efficient and productive.
Question 13: How do you plan to keep vets in the field when all they will then do is complex cases? All of the vets in my clinic, including myself, are happy in the field because we get those routine’ cases. They allow a balance in the position that you are trying to essentially take and give to someone else. I think you will lose more vets this way which is the opposite of what you are trying to achieve. How will you go about preventing this?
At the heart of this question are themes of balance and the meaning of veterinary medicine. We hear these themes from many veterinarians as they enter and progress through their careers. Many veterinarians go into veterinary medicine because of the human-animal bond and the opportunities to foster that bond. CVMA believes that there are many opportunities in veterinary medicine, and that balance and meaning in one’s professional is important. We encourage every veterinary professional to find professional fulfillment.
Question 14: With all this talk about the underserved areas of medicine where vets are in short supply because of low pay and high stress, including shelter med and rural communities, how would we be making sure these people would take those positions and not higher paying urban corporate small animal work?
This is a concern shared by CVMA. Adding new professionals to the field does not necessarily mean that these new professionals will end up in the areas of greatest need.
Question 15: Would there be a limit to how many of these people could be supervised by a single veterinarian? What is to stop corporations or practices from employing one doctor and 30 mid-level practitioners?
CVMA has not heard of limits being placed on businesses in terms of the ratio of mid-level practitioners to doctors, although proponents of the mid-level practitioner suggest that the Colorado State Board of Veterinary Medicine adopt any rules necessary for the practice and supervision of mid-level practitioners. Just like there are currently no restrictions on businesses in terms of how many veterinary technicians can be supervised by a single veterinarian, we imagine there would not be restrictions in terms of mid-level practitioners either, and that it would be up to the business and the supervising veterinarian to make that decision.
Question 16: Did I hear correctly that AVMA will not recognize these mid-level practitioners and that there will be no licensing exam?
AVMA accredits all veterinary and veterinary technician education programs; there is no accreditation plan in place for a mid-level practitioner educational program. There is no national or statewide licensing exam proposed currently. Proponents suggest that the Colorado State Board of Veterinary Medicine adopt any rules necessary for registration of these new professionals.
Question 17: What human PAs perform surgeries unassisted by a licensed boarded physician?
The practice of veterinary medicine is not the same as the practice of human medicine; there are many things about human medicine that do not directly translate to veterinary medicine. In Colorado, scope of practice for Pas is regulated by laws passed by the legislature and rules established by the Colorado Medical Board.
Question 18: Beyond the VPA needs within the shelter medicine realm, has there been adequate work accomplished to understand the veterinary service needs of livestock producers who reside in underserved rural areas?
No; this is an area that was not adequately addressed during the stakeholder working group meetings in 2022. At Colorado State University, under the direction of the chancellor, a task force has been established to assess the veterinary needs of rural communities. CVMA believes a full needs assessment must be completed before embarking on a solution for rural livestock producers to ensure the right solutions are created.
Question 19: I am curious about who stands to benefit the most right now from this proposal. My thought is that large corporations stand to benefit the most, offering vaccine clinics. As a relief vet, I have already been put into compromising situations with “tech appointments” where I have been “required” to provide supervision to a technician rechecking ear infections, for example, with no say on the competency of the tech. At what point would the veterinarian be protected in saying that they do not wish to have direct supervision over an individual?
Proponents of the mid-level practitioner would suggest that it is up to the individual veterinarian to determine what they wish to delegate to qualified individuals, and that if a veterinarian doesn’t feel confident supervising an individual, that they don’t need to.
Strong performing practices that have clearly-defined roles, articulated protocols, open and productive communication, good staff retention, a practice of welcoming and training new employees, and a good culture are best positioned to onboard newly-graduated veterinary professionals at all levels. CVMA encourages all practices to make improvements in these areas.
Question 20: With the AVMA’s statistics in team efficiency, can CVMA create a way to gauge efficiency as a way to measure and improve efficiency in veterinary practices? Through the NCVEI (National Commission on Veterinary Economic Issues), years ago, there was a calculation and surveys that measured, tangibly. Can these surveys be recreated and disseminated to Colorado veterinary practices?
Thanks for the suggestion! We are looking into this to see if it is something that we could bring to Colorado veterinary practices. We agree that it is important for all practices to have the tools to measure their efficiency so that they can begin to make the necessary improvements. Providing these tools is one thing; helping practices see the value in using them is another!
Question 21: Who is going to train these mid-level people? Is this going to take veterinarians away from training new vets?
Since a veterinarian would be responsible for supervising a mid-level practitioner, it is reasonable to assume that a veterinarian would need to play a prominent role in training. Outside of the educational program requirements, proponents have not outlined what training would look like for these professionals once in veterinary practices.