Impact of a Spectrum of Care Elective Course on Third-Year Veterinary Students’ Self-Reported Knowledge, Attitudes, and Competencies
Publication: Journal of Veterinary Medical Education
Volume 50, Number 5
Abstract
Veterinary services’ rising cost is an increasing barrier to pet care. Spectrum of care (SpOC) refers to evidence-based veterinary medicine options along the socioeconomic spectrum. To meet growing pet owner financial constraints and pet care needs, training to equip veterinarians with competencies to provide SpOC as Day One graduates is argued to be added as part of the veterinary curriculum. Objectives of our prospective pre- and post-survey study were to (a) determine baseline self-reported knowledge, attitudes, and competencies (KACs) surrounding SpOC in third-year DVM students; (b) develop and assess impact of a SpOC course on student self-reported SpOC KACs; and (c) obtain student feedback on the course and future SpOC training. Enrolled students (n = 35) completed the pre-survey (n = 35) and post-survey (n = 33). Results indicated that students were aware of the need for SpOC training within the veterinary curriculum, and positive changes occurred in self-reported KACs from pre- to post-survey. Students tended (p = .08) to predict better outcomes in SpOC cost-barrier scenarios from pre- (34%) to post-survey (76%), such as reduced perceived likelihood of euthanasia (63%–39%) and unsuccessful outcomes (40%–27%). Most students (31/33, 94%) predicted the course would benefit them in clinical practice and had preferred future training preferences (online modules [70%], seminars [60%], webinars [58%]). Data indicate benefits in student self-reported KACs following the SpOC course, warranting formal course inclusion, with tracking of students into clinical practice to document objective KAC impacts and perhaps similar course rollout to other institutions.
Introduction
Increasing veterinary costs over the last decade have led to a rise in clients’ decision not to seek veterinary care, citing cost as the main barrier.1–3 Unfortunately, the COVID-19 pandemic may have worsened this already dire situation, with statistics indicating an increase in pet ownership in those living at or below poverty level in the US.4 Further, the current approach to veterinary training has established a culture and methodology in which there is a perception that gold standard care (typically translated to mean advanced diagnostics and therapy, i.e., frequently high-cost and/or intensive) and services are the only means to deliver quality medicine.5 However, an increasing proportion of pet owners, particularly those belonging to certain demographics or regions, cannot afford such services, nor are these services necessarily superior to alternative (less expensive) options.1–3,6–8 Consequently, there is a strong and immediate need to ensure Day One veterinarians are competent to assess, deliver, and communicate approaches to clients and their pets that include health care options along a spectrum (lower to higher cost, resource intensity, etc.), currently defined as spectrum of care (SpOC).9 Additionally, students must be equipped to evaluate these options, including the gold standard option, from an evidence-based veterinary medicine (EBVM) approach.10
The concept of SpOC in companion animal practice appears to be gaining increased attention.2,9,11 One such commentary proposed four key initiatives to improve access to care and overcome barriers that prevent veterinary practice across a wide spectrum of pet health care needs.9 A summary of these initiatives pertinent to the veterinary curriculum and training of veterinary students includes the following9:
•
raise student awareness of the concept of SpOC;
•
ensure student exposure to (and education in) specific care options and the clinical guidelines available for common health conditions;
•
give students the ability to obtain training in the practice of SpOC skills; and
•
build student competency to quickly evaluate the existing evidence for approaches along this spectrum (evidence-based practices).
SpOC, also referred to as incremental care or contextualized care, is recognized and has been incorporated, to some extent, within the human health care field (e.g., Choosing Wisely12). However, the critical need for training (and support) in SpOC appears unique to veterinary medicine for numerous reasons, among them out-of-pocket cost, lack of infrastructure, and veterinary professional burnout.9,11,13,14,15
In 2020, one of the authors (ME) was successful in obtaining approval to offer an elective (1-credit) course in the third-year, second-semester DVM curriculum at the Atlantic Veterinary College (AVC), University of Prince Edward Island (UPEI). The Spectrum of Care in Small Animal General Practice course was developed (see Appendix 1 for course syllabus), with the following course outcomes:
•
hone general practice skills in order to recognize SpOC needs and provide these options to clients and patients;
•
recall specific examples of diagnostic and treatment options along the SpOC for common canine health issues;
•
identify and further develop the skills necessary to determine the likely success (level of evidence) for these options; and
•
develop the skills, competency, and comfort to communicate in this area with clients and peers.
To promote active learning and provide students with the opportunity to put theory into practice, a combination of didactic, case-based, and team-based teaching approaches were used. These techniques were used to attempt to ensure that students developed the knowledge, skills, and competence necessary to address the pet health needs of an economically diverse clientele. Specific clinical examples discussed in lectures highlighted common day-to-day conditions for general practitioners, such as canine parvovirus enteritis, otitis, canine lameness (cruciate rupture), and preventive care (e.g., ecto- and endoparasite prevention, vaccination).
For practical SpOC, the unique aspects of a specific patient and client, as well as client values, must be considered. Further, these needs must be examined in concert with the evaluation of (and accounting for) the various forms of existing evidence (and critical assessment in the strength of evidence) to proceed to clinical decision making for a specific client, patient, and scenario. EBVM, defined as “the use of the best relevant evidence in conjunction with clinical expertise to make the best possible decision about a veterinary patient,” is an important component of effective delivery of SpOC.10 As such, an emphasis on (and incorporation of) EBVM was utilized throughout the course, including incorporation into a final group assignment. This was undertaken to assist in building student competencies in evaluating health care options along the SpOC and aid in assessment of best options from an EBVM approach.
Considering the recognized need for SpOC training and our course design for provision of this to veterinary students, the objectives of our prospective pre- and post-survey-based study were the following: (a) to determine baseline self-reported knowledge, attitudes, and competencies (KACs) surrounding SpOC in third-year DVM students; (b) to develop and assess impact of a SpOC course on student self-reported SpOC KACs; and (c) to obtain student feedback on the course and future training opportunities. We hypothesized that (a) students would have limited knowledge of the term SpOC, discomfort with client and pet SpOC needs, and an existing awareness of the need for SpOC; (b) students would have an increase in self-reported KACs surrounding SpOC post-course; and (c) varied feedback responses would be received about the course and future training on SpOC. Our research contributes to the scholarship of course design/curricula in this topic area and, to our knowledge, is the first course of this type and subsequent study on veterinary school curricular delivery of SpOC training.
Materials and Methods
This study was an observational, prospective, pre- and post-survey-based study intended to assess the impact of a SpOC course on student self-reported KACs surrounding SpOC in companion animal medicine. Third-year students from the AVC UPEI enrolled in the elective Spectrum of Care in Small Animal General Practice course were surveyed. Students were informed that survey responses were anonymous and would not affect their grade in the course. Both surveys were in English, and program evaluation by UPEI Research Ethics Board deemed the study exempt from further review.
Format of the Questionnaire
Two surveys (pre- and post-course) were designed by the study team and tested on five second-year veterinary students who were not eligible to take the course and three members of the public who had a limited background in veterinary medicine. Anonymous links to the online surveys (Qualtricsa) were posted on the course webpage to enrolled students immediately before and at the conclusion of the course.
Questions consisted of closed-ended (e.g., multiple-choice) and rating formats (e.g., move the marker between 0 and 10 to indicate how strongly you feel, where 0 indicates the lowest level of agreement and 10 the highest level of agreement). Both surveys were estimated to take approximately 10 minutes to complete. A subset of the pre-course survey questions was included in the post-course survey. Surveys are available from the primary author (ME) on reasonable request.
Study Design
Surveys were compulsory but did not affect the grading of the course. Students were given dedicated class time to complete the surveys. All responses were anonymous and confidential, and surveys were closed 24 hours after recipients opened them.
The pre-course survey was intended to establish self-reported baseline KACs of DVM students in their third year of training and consisted of demographic questions, KACs of SpOC, and a section assessing student opinion of training on SpOC in their curriculum to date.
The post-course survey aimed to identify any changes in student self-reported KACs after undertaking the Spectrum of Care in Small Animal General Practice elective course. This survey consisted of an identical KACs section to the pre-course survey and an expanded section to allow student feedback on the course and future training opportunities.
The Spectrum of Care Course
DVM students in their third year of study at the AVC are offered a variety of elective courses in the winter semester. These courses range from 0.5 to 1.5 credits, and students are required to complete a minimum of 16 credits divided over three 5-week blocks. No maximum credit limit is imposed, but scheduling conflicts (e.g., class timing) may limit a student’s elective options. Spectrum of Care in Small Animal General Practice was offered as a 1-credit elective course for the first time in the winter semester (February–March 2020). The course was offered at the end-of-day timeslot during February–March and was open to all third-year DVM students (n = 62). The course consisted primarily of case-based lectures introducing the concept of SpOC to the students through discussion of different diagnostic and treatment plans for a specific disease or group of diseases likely to be encountered in general practice (e.g., common dermatologic disease; see Appendix 1). Throughout the course, students were encouraged to employ the EBVM process introduced during the second-year core curriculum, that is, formulate a clinical question using a PICO(T) (population, intervention, comparison, outcome [time]) format, and seek and critically evaluate literature to support their clinical practice.16
Most of the course grade (60%) was based on a group team-based assignment, whereby small groups (3–4 students) chose a common general practice topic (e.g., dental disease) of their choice and then formulated a specific PICO(T) question with respect to that topic (e.g., treatment, etc.). The assignment consisted of a written portion and a video portion. For the written portion, groups utilized the EBVM process to evaluate literature and develop three tiered (< $100, $100–$500, > $500) SpOC cost-based diagnostic and/or treatment plans, complete with risks and benefits of each plan, based on their literature searches and using available price guidelines from a local veterinary or regulatory association of their choice (e.g., the Prince Edward Island Veterinary Medical Association). For the video portion of the assignment, groups used communication strategies taught and modeled in class to role-play discussion of each plan with a mock client (another student in the group). Rubrics were created for evaluation of the written and video portions of the assignment. Rubrics and further information on course design are available from the author (ME) upon reasonable request.
Statistics
All data were analyzed with descriptive statistics using commercially available software (StataCorp 17b). Discrete (integer) data were reported as mean, range, median, and upper and lower quartiles. Categorical data were reported as counts and proportions. When comparisons were made for question responses between pre- and post-course surveys, the two-sample Wilcoxon rank-sum test (Mann–Whitney; exact method) was used for discrete data, while Pearson’s Chi-square test (or Fisher’s exact test when greater than 20% of cells had expected frequencies < 5) was used for categorical data. Due to confidentiality concerns, no student-level identifiers were included in the surveys; therefore, pairwise analyses (pre–post linked at the student level) were not possible. For all analyses, p < .05 was considered statistically significant.
Results
AVC UPEI third-year students enrolled in the SpOC course elective were surveyed, and these results reflect a subset of the survey questions. Most students in the third-year DVM class (39/62, 63%) registered to take the elective course, with four electing to drop the course prior to the start date due to conflict with other scheduled courses (1) and citing the end-of-day timeslot (3). Final student enrollment consisted of the majority (35/62, 57%) of the DVM class. All enrolled students completed the pre-survey (n = 35), while two students were not able to complete the post-survey (n = 33). Student demographics were similar to those for the overall third-year class. The majority of enrolled students were between 25 and 30 years of age (71%), with 23% younger than 25 years of age. Most students reported that they were from Canada (66%) and the US (31%).
Most students (66%) reported tracking exclusively small animal practice. The remaining students (34%) reported tracking mixed animal practice (23%) and other (11%). All students reported prior small animal general practice experience as working (or volunteering) in a companion animal clinic. Few students (17%) had heard of the SpOC term prior to the course, with the majority (71%) reporting they had not or were unsure (11%).
Students’ Responses to KACs Rating Questions Surrounding SpOC before and after the Course
An increase in post- as compared with pre-survey response was observed for students who responded to the following questions (Table 1): “Do you feel that clients who cannot afford the cost of veterinary care should still have a pet?” (pre-survey M = 5.3, post-survey M = 7.2; p < .001) and “What is your level of agreement with this statement? ‘I feel able to recommend treatment approaches to a case when an owner has limited finances.’” (pre-survey M = 4.9, post-survey M = 7.4; p < .001).
| Question | Pre-course | Post-course | p* | ||
|---|---|---|---|---|---|
| n | Mean (range) Median (Q1, Q3) | n | Mean (range) Median (Q1, Q3) | ||
| Do you feel that clients who cannot afford the cost of veterinary care should still have a pet? | 34 | 5.3 (2–10) 5 (4, 7) | 33 | 7.2 (1–10) 8 (6, 8) | < .001 |
| What is your level of agreement with this statement? “I feel able to recommend treatment approaches to a case when an owner has limited finances.” | 35 | 4.9 (1–9) 5 (4, 6) | 33 | 7.4 (3–10) 8 (7, 8) | < .001 |
| Do you feel that there is a need for spectrum of care options (i.e., reduced cost options that may vary from a more expensive option in their likely effectiveness) in situations where clients have limited finances? | 35 | 9.1 (5–10) 9 (8, 10) | 33 | 9.8 (7–10) 10 (10, 10) | .001 |
| Do you feel that education on spectrum of care should be included in the core veterinary curriculum? | 35 | 8.8 (2–10) 9 (8, 10) | 33 | 9.5 (5–10) 10 (9, 10) | .02 |
Q1 = first quartile; Q3 = third quartile
Note: Instructions were as follows: “Please move the marker between 0 and 10 to indicate how strongly you feel, where 0 indicates the lowest level of agreement and 10 the highest level of agreement.”
*
p value for two-sample Wilcoxon rank-sum (Mann–Whitney) test, exact method
Students reported a high initial perceived need for SpOC options (Table 1), which significantly increased by the end of the course: “Do you feel that there is a need for spectrum of care options (i.e., reduced cost options that may vary from a more expensive option in their likely effectiveness) in situations where clients have limited finances?” (pre-survey M = 9.1, post-survey M = 9.8; p = .001).
Respondents reported a high perceived need for SpOC curricular inclusion (Table 1), and there was a small significant increase in post-survey student response to the question “Do you feel that education on spectrum of care should be included in the core veterinary curriculum?” (pre-survey M = 8.8, post-survey M = 9.5; p = .02).
Students’ Responses to Closed-Ended Multiple-Choice Questions before and after the Course
Over the course, there was variation (approaching significance) in student-reported expected outcomes with clients who cannot afford their recommendations (p = .08). This variation (Table 2) included a positive change (increase) in student prediction of successful treatment outcomes (34% pre-survey to 76% post-survey), negative change (decrease) in predicted euthanasia outcomes (64%–40%), and unsuccessful treatments (40%–27%).
| Question | Pre-course (%) | Post-course (%) | p |
|---|---|---|---|
| When you are in practice and a client cannot afford your recommendations, what do you think will be the most common outcome? Please choose the TWO reasons you feel are most common from the list below. | |||
| Euthanasia | 22 (62.9) | 13 (39.4) | .08* |
| Unsuccessful treatment | 14 (40.0) | 9 (27.3) | |
| Successful treatment based on lower-cost options | 12 (34.3) | 25 (75.8) | |
| Unknown outcome (i.e., client leaves and there is no follow-up) | 21 (60.0) | 17 (51.5) | |
| Other (please specify) | 1 (2.9) | 1 (3.0) | |
| If you are in practice and have a client who cannot afford your recommendations, what is the source you will consult to assist your decision making for lower-cost options? Please choose the TWO you feel you are most likely to consult from the list below. | |||
| Another veterinarian in the practice | 32 (91.4) | 26 (78.8) | .002* |
| A consulting veterinarian (e.g., IDEXX, VIN, pet food company) | 14 (40.0) | 9 (27.3) | |
| The Internet (e.g., database search, Google search, VIN) | 14 (40.0) | 4 (12.1) | |
| Veterinary association guidelines or consensus statements | 9 (26.7) | 22 (67.7) | |
| I wouldn’t consult with any resources | 0 (0.0) | 0 (0.0) | |
| Other (please specify) | 0 (0.0) | 4 (12.1) | |
| In general, the price clients pay for veterinary care is reasonable. | |||
| Agree | 32 (91.4) | 29 (87.9) | .8† |
| Neutral | 2 (5.7) | 3 (9.1) | |
| Disagree | 1 (2.9) | 1 (3.0) | |
| I feel comfortable charging clients the full price when I know they have limited finances. | |||
| Agree | 10 (29.4) | 11 (33.3) | .9* |
| Neutral | 6 (17.7) | 6 (18.2) | |
| Disagree | 18 (52.9) | 16 (48.5) | |
| Clients understand that the cost of veterinary care is reasonable. | |||
| Agree | 1 (2.9) | 0 (0.0) | .5† |
| Neutral | 2 (5.9) | 4 (12.1) | |
| Disagree | 31 (91.2) | 29 (87.9) | |
| I would like my practice to adopt a spectrum of care plan. | |||
| Agree | 31 (96.9) | 32 (97.0) | 1.0† |
| Neutral | 1 (3.1) | 1 (3.0) | |
| Disagree | 0 (0.0) | 0 (0.0) | |
| How important do you feel training in spectrum of care is when compared to other topics in your veterinary curriculum? | |||
| More important | 11 (31.4) | 8 (24.2) | .3† |
| The same importance | 22 (62.9) | 25 (75.8) | |
| Less important | 2 (5.7) | 0 (0.0) | |
| How would you quantify your training on cost of veterinary care thus far in your veterinary curriculum? | |||
| More than enough | 0 (0.0) | 0 (0.0) | .001* |
| The right amount | 0 (0.0) | 0 (0.0) | |
| Could use more | 7 (20.0) | 18 (54.5) | |
| Could use a lot more | 15 (42.9) | 14 (42.2) | |
| None or minimal | 13 (37.1) | 1 (3.0) | |
VIN = veterinarian information network
*
p value for Pearson’s Chi-square test
†
p value for Fisher’s exact test
Note: Multiple responses were permitted by respondents for each question; therefore, percentages may sum to greater than 100% for each question.
A significant student self-reported change in types of resources predicted to be utilized for decision making was observed over the course (p = .002), with use of veterinary association guidelines or consensus statements reported by 27% pre-survey to 68% post-survey (Table 2).
Change in Students’ Responses to Agreement-Type Questions Surrounding Cost of Veterinary Care, Comfort Charging Clients, Client Understanding of Care Cost, and Future Practice Having Spectrum of Care
Before and after the course, most students reported that the cost of veterinary care was reasonable (91% pre-, 88% post-), that they were not comfortable charging clients with financial limitations (53%, 49%), and that clients do not understand the cost of veterinary care (91%, 88%) (Table 2). Little change was noted in these responses between pre- and post-survey, respectively (all p ≥ .5).
Nearly all students (97% pre- and post-course) wanted the practice where they would be working in the future to adopt SpOC.
Change in Students’ Responses to Veterinary Curriculum Questions
On both pre- and post-course surveys, the majority of students reported that SpOC was of the same importance as other veterinary curriculum content (63% pre-, 76% post-). There was a significant change in respondents’ response on whether curricular content on cost of veterinary care was needed (p = .001), with the could use more / could use a lot more responses increasing from 63% to 97% from the pre- to post-surveys.
Students’ Responses to Post-Course Evaluation Questions
Most students reported that they would recommend the course (88%) and felt it complemented other DVM courses (88%) (Table 3). Most students (76%) reported feeling confident in their competence to choose the best approach for SpOC cases, and nearly all (94%) believed the course would benefit them in clinical practice (Table 3).
| Question | Count (%) |
|---|---|
| Would you recommend the class to another student as valuable? | |
| Yes | 29 (87.9) |
| Might or might not | 3 (9.1) |
| No | 1 (3.0) |
| Do you feel this course worked well with (complemented) your previous veterinary courses? | |
| Yes | 29 (87.9) |
| Might or might not | 2 (6.1) |
| No | 2 (6.1) |
| Do you feel confident choosing the best approaches to cases when owners are on a budget and cannot afford referral? | |
| Yes | 25 (75.8) |
| Might or might not | 7 (21.2) |
| No | 1 (3.0) |
| Do you feel the spectrum of care course will be beneficial to you in clinical practice? | |
| Yes | 31 (93.9) |
| Might or might not | 1 (3.0) |
| No | 1 (3.0) |
| Which of the following most improved your ability to apply spectrum of care practices? | |
| Class discussion on lower-cost options | 26 (78.8) |
| Creation of alternative treatment protocols | 24 (72.7) |
| Group work assignments | 15 (45.5) |
| Lecturers | 11 (33.3) |
| Evidence-based assessment of current veterinary guidelines | 9 (27.3) |
| Other | 0 (0.0) |
| What types of continuing education support formats would you find useful (i.e., after this class) to learn more about spectrum of care? | |
| Online modules | 23 (69.7) |
| Seminars or lectures at conferences | 20 (60.1) |
| Seminars in my practice | 20 (60.1) |
| Webinars | 19 (57.6) |
| Other | 2 (6.1) |
| None | 1 (3.0) |
Note: Multiple responses were permitted by respondents for each question; therefore, percentages may sum to greater than 100% for each question.
Most students felt that class discussion (79%) and creation of SpOC plans (73%) were most beneficial to learning, with about half (46%) reporting this for the group work assignment (Table 3).
Students selected online modules (70%); seminars (60%), either within practice or external; and webinars (58%) as preferred routes to receive additional training in SpOC (Table 3).
Discussion
Overall, our study results indicated veterinary students’ clear understanding of the need for training in provision of options along the SpOC and cost communication within the veterinary curriculum. Further, our work demonstrated a positive change in the self-reported KACs of this group of students related to SpOC course training, with responses to several survey questions showing a significant change on completion of the elective course.
Veterinary students’ level of knowledge about and awareness of a need for client cost options in our study is unsurprising, despite their reported lack of familiarity with the SpOC term. This awareness is consistent with recent work indicating that most US veterinarians reported that “all pets deserve some level of care” and that many use strategies to improve access to care.1(p.vii) Participants in our study also reported a need for curricular discussion of cost and payment options, and this acknowledgment rose between pre- and post-course surveys, indicating further awareness of this concern and need in clinical practice after course completion. Students rarely receive specific training in cost communication within many veterinary curricula, and most have low levels of awareness of medical care programs, payment plans, and specialist consultation availability, much less specific knowledge of the cost of diagnostics, treatment, and services in general.11,13 Additionally, aside from institutions that use a distributed teaching model to provide students exposure to primary care, students do not often encounter general practice pricing and clientele SpOC needs.
In many veterinary programs, the bulk of student training occurs at tertiary referral veterinary teaching hospitals, where the emphasis is on intensive therapy and diagnostics, and there may be little opportunity to develop or gain competency in needed SpOC skills.13,17,18 This may lead to an emphasis on (and adoption of) what has been referred to as the hidden curriculum.13,19,20 This hidden curriculum has been described as the outcome of tertiary medical hospital training programs where students learn that there is only one right way or gold standard when it comes to patient care. Unfortunately, this gold standard is often invasive and frequently expensive, and it does not account for the need many clients have for SpOC options.18–21
Other work has reported a need among new veterinary graduates for increased Day One competency in cost training and client communication and suggests role play and team-based teaching as a path to achieve this.11,13,21,22 Preparation for the real world through role play and communication regarding SpOC options should be a primary veterinary curricular competency, and our work highlights student awareness of this need within the curriculum.13,21
Over our course, we observed an increase in student agreement that “clients with cost concerns should still have a pet.” It is probable that this tendency to agree occurred due to the impact of SpOC training and the resultant increase in self-reported competence and confidence to provide SpOC options, which we observed between pre- and post-course surveys. At the completion of training, students reported feeling more confident to provide SpOC in lower-cost client-need scenarios and thus likely reported a change in their prior attitude regarding pet ownership.
Students also reported feeling more competent and confident to predict successful SpOC outcomes at course conclusion, with course training leading to a reported reduction in students’ predictions of euthanasia and poor outcomes. Impactful training is strongly needed to reduce the rising rate of economic euthanasia due to client and veterinary beliefs that no other options are available; specific training may lead to avoidance of this outcome.18,21,23 Additionally, this increase in student self-reported competencies may also serve to lower burnout, compassion fatigue, and suicide rates within the veterinary profession, as feeling distressed and anxious over client financial constraints and inability to provide animal care have been cited as major factors toward these.3,18,21
Traditionally, many veterinarians practice by providing a gold standard of care, which is a vague term typically translated to mean advanced care (i.e., intensive diagnostics and therapy). It is possible that the course focus on EBVM and tailoring of diagnostic and treatment options to specific SpOC outcomes gave students more self-reported competence in their ability to achieve these upon Day One practice due to a decline in anxiety over provision of a gold standard of care or whatever this term may mean.18 Development of EBVM plans for the course evaluation assignment provided a practical resource for students and is a technique that has been used in other studies through EBVM protocols and algorithm development.12 Similarly, we anticipate that the increase in student self-reported SpOC competence we observed on course completion will positively impact Day One graduates’ comfort level with case management and clinical decision making, and increase morale, alongside patient benefits of reduced euthanasia and unsuccessful outcomes. Additionally, the course’s topic-based nature may have benefited students directly, as one study reported that clients are more likely to seek veterinary care under recognizable situations (e.g., trauma, emergency situations, etc.) than for preventive care.8,18 As such, these pet owners and their pets would probably be more in need of SpOC options due to increased medical complexity, potential ethical decision-making strain, and resultant higher costs.
Students reported value and benefit to the course and rise in their feelings of confidence and competence in SpOC skills upon course completion. Open-ended questioning, modeling, and practicing communication development were focuses of the course. Multiple veterinary schools have incorporated communication training within their curriculum, and studies indicate that this enhances therapy compliance and raises clients’ knowledge base.24,25 These communication skills are integral to SpOC as client goals, values, and needs must be incorporated into the EBVM approach. Practical application of these skills may have been the reason for the reported course value and self-reported student rise in overall competence. Veterinarians need to be able to discuss costs with their clientele, yet one study indicates that this occurs in less than a quarter of veterinary visits.24 This is unsurprising considering how little focus conversations surrounding cost receive in most veterinary curricula. Additionally, lack of trust in veterinarians is another reported barrier to care; training in SpOC communication may reduce this barrier through candid conversations and improve overall animal health.8
One interesting finding in our work was the increase in awareness of specific consensus statements and guidelines reported among participants. These resources can vary from expert opinion to strictly defined strength of evidence publications, or commonly a combination of these. Overall awareness of these resources was low pre-survey and rose by course completion. This highlights a potential need to incorporate these types of resources within the core veterinary curriculum to improve student awareness of these valuable and practical EBVM aids to SpOC.26 Regional differences may exist in the limited incorporation of existing consensus statements and guidelines in companion animal care into the veterinary curriculum, and this could be further investigated.
Our third objective was to obtain student feedback on the course and future training opportunities. Overall, students assigned the most value to in-class (didactic) SpOC discussions, along with practical topic and cost-based SpOC plans. These results are similar to those in another study, where students described the benefits of frank discussions with a veterinary internist on formal and informal topics.12 Future training opportunities students requested for SpOC education included SpOC modules, seminars, and webinars for ongoing learning.
A limitation of our study, like in many observational, survey-based studies, is selection bias. An already-interested group of students enrolled in the SpOC course, and this may have biased our results. However, most of the third-year DVM class registered for (and completed) the course; this likely reflects a true recognized need and less likely a bias. Another limitation may be concern regarding external validity of the study (i.e., limited generalizability to other regions) as the course was offered to a small group of students at a Canadian-based veterinary school. As the range of student demographics (US and Canada) is in line with most North American veterinary school student compositions, (i.e., majority female, small animal track, etc.), our work can likely be applied regionally and internationally. A final limitation is the lack of student identifiers, without which analyses of change at the individual student level could not be assessed. Identifiers were not used to assure student anonymity.
The results of our study on the SpOC course indicate that veterinary students recognized the need for (and found value in) a didactic SpOC course with a team-based group assignment. Additionally, a positive impact of SpOC training was observed on student self-reported KACs, with likely future impacts on overall specific patient and client benefits and animal welfare outcomes (i.e., reduced euthanasia, more successful pet outcomes predicated). Future work might include following this group of students (or students in other programs who have received this type of training) and performing an objective assessment of their skills and competencies. Additional studies and SpOC course planning might also tap into SpOC beyond small animal practice (e.g., mixed animal and large animal practitioners), and these perspectives, insights, and experiences could be excellent to further develop studies and adapt course designs. Finally, further work may lead to developing defined outcomes like those in human medicine (i.e., patient-, family-centered care), with emphasis placed on incorporation of the patient (pet) and family (pet owners) as valued members of the health care team.27
Given the results of our study and the recognized need for SpOC to adequately equip Day One veterinarians with competencies to address these, it is the authors’ hope that veterinary faculty will commit to incorporating this type of SpOC training within curricula. Similar module- or seminar-based training opportunities are warranted for veterinarians in general practice to meet the increasing need for pet care in the face of rising pet owner financial constraints.
Acknowledgment
Funding for course development and delivery was successfully obtained by ME and provided through a Stanton Foundation Student-Focused Canine Care–Focused Student Education grant.
Footnotes
a
Qualitrics, Provo, UT, USA
b
StataCorp LLC, College Station, TX, USA
References
1Access to Veterinary Care Coalition (AVCC). Access to veterinary care: barriers, current practices, and public policy [Internet]. AVCC; 2018 [cited 2022 Jan 29]. Available from: https://pphe.utk.edu/wp-content/uploads/2020/09/avcc-report.pdf.
2LaVallee E, Mueller MK, McCobb E. A systematic review of the literature addressing veterinary care for underserved communities. J Appl Anim Welf Sci. 2017;20(4):381–94. Medline:
3Kipperman BS, Kass PH, Rishniw M. Factors that influence small animal veterinarians’ opinions and actions regarding cost of care and effects of economic limitations on patient care and outcome and professional career satisfaction and burnout. J Am Vet Med Assoc. 2017;250(7):785–94. Medline:
4American Society for Prevention of Cruelty to Animals (ASPCA). Pets and poverty statistics memorandum [Internet]. New York: ASPCA; 2020 Aug 3 [cited 2022 Jan 29]. Available from: https://aspca.app.box.com/s/411t6699aihc1a9uxb9e3w2j4ky2dvpj.
5Pantaleon L. Why measuring outcomes is important in health care. J Vet Intern Med. 2019;33(2):356–62. Medline:
6American Veterinary Medical Association (AVMA). Dog ownership and veterinary visits by income bracket [Internet]. Schaumburg (IL): AVMA; 2020 Feb 1 [cited 2022 Jan 1]. Available from: https://www.avma.org/javma-news/2020-02-01/dog-ownership-and-veterinary-visits-income-bracket.
7American Veterinary Medical Association (AVMA). U.S. pet ownership statistics [Internet]. Schaumburg (IL): AVMA; 2018 [cited 2022 Jan 29]. Available from: https://www.avma.org/resources-tools/reports-statistics/us-pet-ownership-statistics.
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10Centre for Evidence-Based Veterinary Medicine [Internet]. Nottingham, UK: University of Nottingham; [cited 2022 Jan 29]. Available from: https://www.nottingham.ac.uk/cevm/about-the-cevm/evidence-based-veterinary-medicine-(evm).aspx.
11Fingland RB, Stone LR, Read EK, Moore RM. Preparing veterinary students for excellence in general practice: building confidence and competence by focusing on spectrum of care. J Am Vet Med Assoc. 2021;259(5):463–71. Medline:
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17Vandeweerd JM, Vandeweerd S, Gustin C, Keesemaecker G, Cambier C, Clegg P, et al. Understanding veterinary practitioners’ decision-making process: implications for veterinary medical education. J Vet Med Educ. 2012;39(2):142–51. Medline:
18Quain A, Ward MP, Mullan S. What would you do? Types of ethical challenging situations depicted in vignettes published in the veterinary literature from 1990 to 2020. Vet Sci. 2021;9(1):2. Medline:
19Roder CA, May SA. The hidden curriculum of veterinary education: mediators and moderators of its effects. J Vet Med Educ. 2017;44(3):542–51. Medline:
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23Tremayne J. Economic euthanasia on the rise. Vet Pract News [Internet]. 2009 Jun 10 [cited 2022 Jan 29]. Available from: https://www.veterinarypracticenews.ca/economic-euthanasia-on-the-rise/.
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Appendix 1 Course Syllabus
Course Description
This course will assist in building the knowledge and skills necessary for Day One graduates to address the common pet health needs of economically diverse clientele. This will be accomplished by building on the knowledge and skills acquired during year-one, year-two, and first-semester year-three core courses (e.g., Medicine, Surgery, Professional Foundations, Epidemiology, Evidence-Based Veterinary Medicine).
Using this foundation, students will be introduced to the concept of spectrum of care, highlighting specific examples of using this concept for commonly encountered conditions. With an emphasis on clinical reasoning and evidence-based principles, students will identify a range of diagnostic and treatment options that span the full spectrum of care for these common small animal general practice clinical conditions, determine the likelihood of success for various options, and design client communication plans that facilitate informed shared decision making.
Course Objectives
•
Hone general practice skills to recognize spectrum of care needed and available to clients and patients;
•
Recall specific examples of diagnostic and treatment options along the spectrum of care for common pet health issues;
•
Identify and further develop the skills necessary to determine the likely success (level of evidence) for these options; and
•
Develop the skills and comfort to communicate spectrum of care with clients and peers.
Course Outcomes
1.
Apply evidence-based clinical reasoning toward diagnostic and therapeutic decision making for common pet health issues.
2.
Prepare for final-year clinical rotations through use of a problem-oriented and evidence-based approach to aid clinical decision making and reinforced through participation in case-based lectures and group assignments.
Assessment
1.
Group Assignment—presentation (video) and written: 60% Rubrics have been provided for grading of the assignment. The assignment will be discussed in class.
2.
Participation—in-class discussion and participation: 40%
Resources
1.
Instructor PowerPoint slides and supplemental materials.
2.
Freely available online:
(a)
Barriers and next steps to providing a spectrum of effective health care to companion animals. Journal of the American Veterinary Medical Association 253.11 (2018): 1386–1389
(b)
Top 5 Steps to Practice Evidence-Based Veterinary Medicine: https://www.cliniciansbrief.com/article/top-5-steps-practice-evidence-based-veterinary-medicine
(c)
BestBETs for Vets: https://bestbetsforvets.org
(d)
Veterinary Evidence: https://veterinaryevidence.org/index.php/ve/index
(e)
Never apologize for wanting to be ‘just’ a general practitioner. Journal of the American Veterinary Medical Association 255.8 (2019): 891–893
Class Format
This course will be a combination of lectures (didactic and case-based), in-class discussion, and group assignment.
Lecture Schedule
Introduction to Spectrum of Care & Concepts (survey pre-lecture) |
Common concerns and preventive needs in general practice Discussion of group assignment |
Orthopedic (lame dog): Diagnostic, therapy options, and decision making |
Cardiology (dog with a heart murmur): Diagnostic, therapy options, and decision making |
Evidence-based medicine and clinical reasoning Discussion of group assignment |
Dermatology (dog with itchy spot): Diagnostic, therapy options, and decision making |
Dentistry (dog with dental disease): Diagnostic, therapy options, and decision making |
Obesity (overweight dog): Diagnostic, therapy options, and decision making |
Yikes—there are no guidelines! Diagnostic, therapy options, and decision making |
Infectious disease & preventive care: Diagnostic, therapy options, and decision making |
Gastro-intestinal (dog with diarrhea): Diagnostic, therapy options, and decision making |
Client communication for evidence-based and shared decision making (group discussion and self-study) |
Group assignment presentations |
Group assignment presentations |
Class discussion, follow-up, & post-course survey |
Information & Authors
Information
Published In
Journal of Veterinary Medical Education
Volume 50 • Number 5 • October 2023
Pages: 590 - 598
PubMed: 36112837
Copyright
© American Association of Veterinary Medical Colleges (AAVMC), 2023. For their own personal use, users may read, download, print, search, or link to the full text. Manuscripts published in the Journal of Veterinary Medical Education are copyrighted to the American Association of Veterinary Medical Colleges. Requests for permission to reproduce this article should be made to the University of Toronto Press using the Permission Request Form: https://www.utpjournals.press/about/permissions or by email: [email protected].
History
Received: 15 January 2022
Revision received: 1 August 2022
Accepted: 3 August 2022
Published ahead of print: 16 September 2022
Published online: 1 October 2023
Published in print: October 2023
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