Y2S1 Week 13: Covelo Clinic, Prop 129, and AI in Veterinary Medicine
This week started off with our endocrinology final followed by a lecture on the histological features of the male reproductive tract. I then had a little break and got some things done around the house before going to update my headshot. Every year the business club hosts a complementary headshot session for their members, so I make sure to take advantage of the opportunity! I then made my way to the undergraduate campus to teach the Knight’s Landing course. This week we focused on communication skills and did a few little skits to demonstrate the components of effective communication. Communication is one of the pillars of veterinary medicine so creating good habits early on is crucial. The rest of the night was spent reviewing some lectures with Churro.
Tuesday morning started off with a nice hot yoga session followed by lectures on puberty/seasonality, fertility, and pathology of the male reproductive tract. That afternoon we had a little break before heading back to campus for a lab on comparative male anatomy. This lab was exactly what the title suggested, a lab full of different male reproductive anatomy (if you are using your imagination you are probably picturing exactly what we saw).
Wednesday started off with a quick run with Churro followed by a hot yoga session and little swim. We then had our last male-centric lecture on infertility and then jumped into the anatomy of the female reproductive tract. Although reproduction is not something that I am inherently interested in, it is important to understand the major role that the reproductive system plays in the lives of our patients and the issues that can arise when things do not go as planned.
During lunch we had the opportunity to learn more about Colorado’s Prop. 129 which, as of this past week, has officially passed. This proposition authorizes veterinary professional associates to work in the state under the supervision of a licensed veterinarian. That may not sound like a huge deal but here is a little breakdown so that you can understand what this proposition means and how it could impact the future of veterinary medicine.
Colorado and Florida have been pushing to create a midlevel veterinary practitioner; a role that is comparable to that of a nurse partitioner or physician assistant in human medicine. Colorado State University has created a master’s program to produce this "midlevel practitioner" and those that go through the curriculum would become a “registered veterinary professional associate” (VPA). VPAs would have a scope of practice that encompasses duties and tasks once restricted to veterinarians such as diagnosing conditions, providing prognoses, and surgically sterilizing patients through spaying and neutering. The master’s program at CSU involves 5 semesters, three of which are completely online and the other two are in-person followed by a 6-month internship. The role of VPAs is currently focused solely on building expertise in routine veterinary visits and procedures limited to dogs and cats (CSU).
I thought that it was interesting to learn that this bill and ballot initiative are part of a coordinated effort by animal welfare groups that are also backing moves in both states to relax in-person exam requirements for veterinary telemedicine providers. These supporters believe that these measures will allow veterinarians to provide a broader spectrum of care to their clientele and attract new patients who may not have access / the ability to seek traditional veterinary care.
It's important to note that this proposition has been met with a significant amount of resistance from the American Veterinary Medical Association and several state Veterinary Medical Associations including Colorado’s. A recent survey of Colorado’s veterinary professionals also showed some hesitation to this proposed position.
Here are the results of the study(CSU)
46% of Colorado’s veterinary professionals indicated that a VPA would positively benefit the profession
41% reported that a VPA would benefit their practice
51% agreed that the development of a VPA position would increase access to veterinary care for underserved populations
While not everyone is opposed, these numbers are fairly split and there appears to be a lot of hesitation regarding this new role in veterinary medicine. It should also be noted that the veterinary associations are not the only ones opposed to this new position, results from the AVMA’s 2023 National Pet Owner Survey indicate that 79% of pet owners want a licensed veterinarian, not a midlevel employee, to oversee their pets care (AVMA).
In order for a VPA to practice, a veterinarian must be on site. This does not mean that the veterinarian is directly supervising this person, it just means that they are on the same property. It should also be noted that proponents of this proposition want to make the supervising veterinarian legally responsible for all of the acts and omissions of a midlevel practitioner. This significant liability is something that a majority of veterinarians are not willing to take on. Many veterinarians do not utilize their technicians to their full capability so I find it hard to believe that they would be willing to let VPAs do surgery and diagnose patients. The addition of VPAs would also further exacerbate our veterinary technician shortage increasing the strain on practicing veterinarians.
I personally do not support the development of this position for a multitude of reasons. I do not believe that five semesters of training (three completely online) and a 6-month internship is sufficient for the level of responsibility that these professionals have. The curriculum focused on “routine veterinary visits” which are not extremely common in this profession. Even if something starts out as routine, such as a spay or a neuter, things can quickly escalate into a life-threatening emergency which is when the years (not semesters) of medical training come in handy. A veterinarian has the ability to change from a surgeon into a criticalist in the face of a surgical (or medical) emergency, which is something that VPAs don’t learn in their condensed curriculum. It is also common for appointments to be more complex than what the owner initially explained to the receptionist over the phone. If a VPA is given a “simple” ear infection patient but later finds out that there are a plethora of other issues going on, they may not have the capacity to treat the animal and that would lead to additional work for the practicing veterinarian who is likely already fully booked for the day and likely the rest of that week or month. I think that it is great that VPAs are learning the routine aspect of animal health, but it is critical to understand that very rarely is something “routine” in veterinary medicine, especially if you are thorough with your physical exam. Animals don’t always read the textbook and like any other biological system, they tend to do wacky things.
Regarding the topic of “Access to Care” I do not think that adding a midlevel practitioner is going to significantly move the needle. These practitioners are likely going to seek out jobs in a veterinary hospital that will pay them significantly higher than what they would get in a shelter or resource-depleted area. In order to truly address the access to care issue, there would need to be regulations stating that VPAs are only allowed to work in areas where there is a need for accessible veterinary care such as veterinary resources deserts or shelters. I fully support providing veterinary care to those in need but think that there is a better way to address this issue.
I also think that instead of adding a new practitioner level to the veterinary world, registered veterinary technicians and technician specialists should be used to the full capacity of their license. Creating a culture that promotes retention and prevents attrition while also taking advantage of technology can positively impact the workforce efficiency without the additional liability.
Overall, I think that it is important to understand the changes that are occurring in veterinary medicine and critically think about how this may impact the future of the profession. The addition of VPAs was proposed with good intentions however I do not believe that there is a need for this level of practitioner in veterinary medicine and veterinarians who choose to use these professionals as well as clients that bring their animals to see them should be aware of the potential consequences. Links to the information above and additional information on this topic can be found at the end of this blog.
The rest of Wednesday consisted of two labs on the male reproductive tract. One was focused on the histological aspects while the other lab had gross specimens with different pathologies. It was interesting to see these conditions in real-life and it brought the lectures to life! The rest of the afternoon involved some quality time with Churro and his buddy, Clover followed by hanging out with Madeline at the clinic.
Thursday morning started off with a quick run with Churro followed by Steve’s hot Pilates class. This is always a fun, and humbling, way to kickstart the morning especially when he brings out the leg bands!! The class schedule today was completely case-based and we were presented with two different cases related to reproduction topics that had been taught in the beginning of the week. One case was large-animal focused and the other was small-animal focused. After spending some time working through the cases with our group we met as a large group and a few groups presented their findings to the class. We then had a detailed discussion and went over how the clinicians would have addressed the cases. This was a great way to work through some of the complicated topics from the beginning of the week and cement our understanding!
During lunch I had the opportunity to learn a little bit more about how artificial intelligence (AI) is being used in the world of veterinary medicine. Dr. Christie Long, a veterinarian from the Modern Animal hospital chain, spoke about machine learning and how it impacts our jobs as veterinarians.
There are three types of machine learning:
Supervised
Task driven (regression/classification)
Example: Spam detection
Unsupervised
Data driven (clustering) understanding the habits repeatable in the data
Example: Customer/marketing segmentation
Reinforcement (what freaks most people out)
Algorithm learns to react to an environment
Example: training an AI agent to play chess
Veterinary medicine is using a combination of all three of these machine learning techniques but when people think about AI in the clinic they are likely thinking about reinforcement. This is what is being used by AI radiology and clinical pathology reports, the machine develops an algorithm and learns from repetition meaning that as the data bank of radiographs and histology grows, the readings (should) become more accurate. AI is also being used to help facilitate record keeping.
While implementing AI can be beneficial and improve the efficiency of the clinic, Dr. Long also explained the potential issues such as hallucinations (basically when chat GPT provides false information), plagiarism, data privacy, and the learning curve associated with prompt engineering.
It was great to learn more about AI and understand its use and potential consequences in veterinary medicine. I think it is exciting to think about where this can take us in the future while also understanding that it is a supplement, NOT a replacement for the intense schooling that veterinarians go through.
The rest of Thursday involved some quality time with Churro and then I met up with the SVVMA board to discuss upcoming events and trends in veterinary medicine. It is always a great time learning from local professionals and hearing about what is happening in our local veterinary medical association.
Friday morning began with a fun 6-miler with Churro followed by three lectures on the female reproductive tract. We started with the basic physiology of the non-pregnant female and then transitioned into a lecture on fertility and pregnancy. The last lecture focused on breeding management in female dogs which was my favorite lecture of the week due to it’s clinical relevance! We then had a lab on comparative female anatomy which helped tie the morning lectures together.
After the female reproductive anatomy lab, I had the opportunity to join roughly 50 of my fellow classmates, eight incredible professors, and a handful of eager undergraduates for a weekend access to care clinic in Covelo. Covelo is a small rural community in Northeast Mendocino County with a population of about 1,400 people. The community is part of the Round Valley Indian Reservation and is also the ancestral homeland of the Yuki People. Round Valley Indian Reservation is also comprised of Wailacki, Concow, Little Lake Pomo, Nomlacki, and Pit River people who were forced off of their homeland. That being said, being invited to Covelo and entrusted with the care of their animals is a gift. The nearest vet clinic is over an hour away and the average annual salary is less than $40,000. Covelo is considered a veterinary resource desert and three times a year, UC Davis sends a group of vet students, professors, and undergraduates to help provide care for the local animals. We run a two-day clinic out of the local community center and camp in the parking lot.
Once we arrived in Covelo Friday night, we pitched our tents and went inside the community center for some clinic training and a general overview of what to expect during the weekend. The community had cooked us dinner and had plenty of snacks available. Everyone was extremely welcoming and were incredibly grateful to have us!
Saturday morning kicked off at 7:00 with a few hours of surgery intake appointments. These appointments were to make sure that all of our surgery candidates were healthy and ready to undergo their planned procedure. My clinic partner, Rachel and I took in 8 cats and made sure they were healthy and ready to have surgery. After all of our surgeries were checked in, we transitioned into wellness appointments and saw two more cats. These kitties were super sweet and well behaved for their rabies vaccines. As you can tell, the morning was extremely feline-heavy but luckily all of the kitties were sweet and decided that they did not want to play dirty. After sending the cats to surgery, we got a beautiful shepherd mix that was a little unsure about the whole clinic atmosphere. After some love and patience, she was able to find her courage and get through the exam so that she could get loaded up on her flea, tick and heartworm preventatives!
After the morning wellness appointments were done, we swapped with the surgery team. It was super fun to practice old skills and learn different ways to do things. The best part of this clinic is that as vet students we get to take charge of our cases while having the security of having a veterinarian around at all times. We ran surgery from start to finish and were in charge of prep, induction, intubation, anesthesia, recovery, and discharges. Each surgery had a veterinarian there supervising but depending on the year that we were in, we had the opportunity to scrub in and help. This was a great way to practice in a safe environment while also helping the local community.
Our surgery case for the afternoon was a dog neuter. I had the role of the anesthesiologist and Rachel scrubbed into surgery. Everything went well and our patient was able to go home early that afternoon. The rest of the day involved some more surgery prep and wellness appointments. We finished with all of the animals around 9:30 and had a team debrief at 10:00 where we found out that as a team we did 78 surgeries and 85 wellness visits!
Sunday also started at 7:00 with the initial surgery intake appointments. This time Rachel and I were on the surgery team first and I had the opportunity to scrub in for a dog spay on a cute dachshund named Ida with Dr. Kohen! Dr. Kohen knew that I was studying reproduction, so he made sure to quiz me on all of the canine reproductive anatomy and ask clinical questions to test my understanding. I am definitely a hands-on learner so being in the abdomen of a dog and walking through things that I have already learned in lecture was the best way to commit the concepts to memory. After the surgery was over and Ida had recovered, my friend Vandana and I jumped into the wellness appointment side of things. We got to see a handful of hound dogs plus a feisty little chihuahua that gave everyone a run for their money! Before we knew it, it was 3:00 and time to start cleaning things up. After discharging the remaining surgery patients and cleaning the community center we all headed back to Davis.
Spending the weekend camping with fellow classmates and professors was such a unique experience and I loved getting to know people on a more personal level. Everyone at the clinic is extremely busy and it says a lot that they volunteered their whole weekend to help out the Covelo community. The registered veterinary technicians were the backbone of the clinic and helped significantly with surgery prep and the undergraduates helped immensely with patient recovery. Special thanks to Dr. Hopper, Dr. Mele, Dr. McCobb, Dr. Vernau, Dr. Patterson, Dr. Epstein, Dr. Kohen, Dr. Lejeune, and Dr. Barrientos for volunteering their time and expertise. This list of faculty involves multiple boarded criticalists, an oncologist, and an anesthesiologist. Their desire to help teach students while also helping the community is admirable and having such a robust team ensured that the animals received the best care possible!
The weekend absolutely flew by, and it was such an amazing thing to be a part of! Throughout the weekend the Covelo community was incredibly grateful and continued to thank us for all of our work. They cooked every single meal for us, and I learned that many of them had booked these appointments months in advance. We truly are the only access to veterinary care that they have and spending two days in their community made me realize how incredibly fortunate I am to have access to so many resources that I easily take for granted. It is such a privilege to be able to do something that makes such a difference in not only the lives of animals, but the people that own and love them. It is also such a blessing to have amazing housemates that are willing to take care of Churro while I am away!
Quote of the week: “I don’t know if we should talk about the election, or erection…” Dr. Conley before beginning the male fertility lecture on Tuesday.
Prop. 129 Sources and Additional Information
Colorado State: https://vetmedbiosci.colostate.edu/vpa/
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