Spectrum-of-care: Busting common myths

Mike Greenberg, DVM: While an SOC approach is sometimes conflated with discounting services, they aren’t synonymous.

A SOC approach is not about the price of services. Rather, it’s about how a plan is developed/offered while considering not just the pet and their particular condition, but the family’s means and circumstances. It’s about choosing treatments that ameliorate suffering and diagnostics that get you answers, while simultaneously considering the finances and other constraints of the pet’s people.

It’s about asking yourself questions: Do I really need a CBC to make a treatment decision or will a PCV/TS and a blood smear do? Do I really need a long-acting injectable antibiotic or can I offer a less expensive oral option? Do we really need all of these diagnostics right away, or can we do them incrementally while seeing how the patient responds to treatment?

A spectrum-of-care approach could—in turn—be called a “common sense” approach to medicine.

Emily McCobb, DVM, MS, DACVAA: Not at all! There are many strategies that can be incorporated into any practice without changing any of your prices.

For example, one strategy to make your practice more financially friendly is to make your prices more transparent. Consider listing prices for common services on your website or having sample estimates prepared. (For more information on making your practice financially friendly, see Open Door Veterinary Collective.) Another strategy being widely used is to ask your client if there is a budget that you need to keep in mind when making treatment recommendations.

The bottom line is that the SOC approach is one way to increase access to care. It means offering your client an array of options and then working with the client to make the best decision for them. Ultimately the client makes the decision, and they are the ones that know their budget and all of the other factors that might impact the decisions. It is our job to support the client with their decision.

Elizabeth Alvarez, DVM, DABVP (Canine and Feline), DFNAP: Through my work at both a state-of-the-art veterinary teaching hospital and an access to care clinic, I have determined that, hands down, the most important machines we possess as veterinary diagnosticians are our brains. Carefully considering the basics—your signalment, history and physical exam, as well as determining the goals and abilities of the family caring for each patient—will get you most of the way to a favorable outcome.

Practicing with a spectrum of care means you are critically evaluating your minimum database (and “minimum” doesn’t always mean collecting a full CBC, chemistry, urinalysis, imaging, etc. on every case). Instead, carefully consider a stepwise approach (or incremental care), utilizing a more broad or specifically (limited) scope of testing, depending on the case. Ask yourself: Is this test going to change what you do? Are there diagnostics that can wait? Are there dangerous differentials that must be ruled out? Do you absolutely need a definitive diagnosis in this situation, or would starting with supportive therapy be reasonable? Which treatments are safe given what you know? Are there cheaper medications available with similar efficacy? Can some treatments wait until the next paycheck? What are your goals and what are the family’s goals? Are you trying to palliate, manage, or cure?

By thinking about the answers to these questions and carefully balancing both patient care and the family’s resources, you will be successfully practicing SOC without discounting services. The most important aspect to this is clearly communicating the risks and benefits of pursuing (or not pursuing) additional diagnostics during that visit.

Alvarez: To begin, I prefer considering the basic definition of “standard of care” as a legal term referring to the level of care a reasonable person would exercise in a given situation; in other words, the level of care accepted by peers/experts as proper treatment.

Spending the last (almost) 20 years in academia, I witness students who transition into general practice perceiving that they are failing as doctors if they cannot provide the exclusively advanced level of care they were taught by specialists. This misperception can negatively impact new graduates’ wellbeing as they navigate the realities of the general practice context, and this moral distress can be associated with decreased job satisfaction as they may be trying to model the skills and actions of the veterinary specialist while working in general practice.

In practice, the clients’ specific situation and resources (whether financial, physical, mental/emotional, time, their values and beliefs, etc.) all must be considered as we develop the best treatment options for a particular pet and [their] family on that day. Providing care by using sound medical knowledge and considering both experience and what the family in front of you can agree to and accomplish is all we can ask of our profession to practice high quality medicine.

A high standard of care does not necessarily correlate with more and more testing and/or more and more advanced treatments in every situation. By understanding that there are multiple appropriate answers to a problem, and that the best course of action depends on the unique circumstances of each case, we can develop resilience as we navigate the many contextual challenges associated with providing care in general practice.

Michael Blackwell, DVM, MPH: Practicing the SOC is not a compromise, but a significant enhancement to your ability to provide meaningful care within the context of your patients’ and clients’ realities. It allows you to offer viable alternatives that meet the needs of both the patient and the client, thereby preventing nontreatment or euthanasia.

The ultimate goal of veterinary medicine is to safeguard the quality of life of our patients while honoring the bond between them and their families. In many cases, providing incremental care prevents nontreatment or euthanasia by offering viable alternatives that meet the needs of both the patient and the client.

Veterinarians are ethically bound to make decisions that protect and enhance the wellbeing of their patients. Practicing SOC means that rather than offering a single “gold standard” treatment, you work collaboratively with clients to find the best option that aligns with their financial, emotional, and logistical realities. Doing this does not mean compromising your veterinary knowledge or skill, but adapting care to ensure that a patient receives treatment, even if it’s not the most advanced or expensive intervention available.

McCobb: No, you should always offer all the options that you think are valid and viable. You should also let the clients know if there are other options they could pursue elsewhere.

If you believe that an option is ill advised or would be detrimental, then you can explain that to the client as well. If there is no option that you think would be acceptable for what the client can afford to spend, then you need provide options for where else the client could go and to let them know what could happen with their animal if they choose not to pursue care. Euthanasia is always on the table in veterinary medicine and should be discussed, particularly if the animal could suffer as a result of not pursuing a recommended treatment plan.

It’s also important to keep in mind that there are many reasons client may not wish to follow a recommended treatment plan—and they are not all financial. For example, clients may have different beliefs about pain management or end of life than we do. It is our job to explain our perspective, advocate for the welfare of the animal, and help the client make an informed decision that will work for their family.

McCobb: Access to veterinary care is not a problem that can be solved by any individual practitioner but requires us each to do our part. We need to radically reshape our profession to make sure that we have service delivery models that can work for all pet owners.

Reach out to colleagues to find out what they do and whom they aim to serve. Let them know about the things that are working well in your practice and the kinds of patients and clients that you can best work with. Working together across a community is the best way to ensure that more pet owners have access and we are not overburdening practitioners who are already overworked.

If you are taking new clients, let the shelters in your area know, and maybe offer a free first exam. That’s a great way to meet a new family and the animal will usually have a jump start.

Reach out to your local ER and urgent care clinics if you can take follow up for chronic conditions, and meanwhile, maybe they can offer after-hours care to your clients.

These are just a few examples, but the bottom line is that, by increasing the number of providers in an area, we will all be able to make more of an impact.

Blackwell: A critically important role of veterinary medicine is safeguarding community health by preventing and controlling zoonotic diseases. As more families are unable to access veterinary care, the risks of zoonotic diseases in the community increase.

Being overbooked is a real challenge as a veterinarian, and the demand for your time can feel overwhelming. However, ensuring access to care doesn’t mean adding more work to an already packed schedule—it’s about supporting systems that make care more accessible to those who need it, which benefits individual patients, clients, and the broader community.

By promoting access to care through partnerships, community resources, or incremental care options, we help prevent more significant issues from arising, such as untreated diseases that can spread and cause public health risks, including zoonotic diseases. This approach recognizes that while your time is limited, your role as a veterinarian extends beyond the individual exam room, contributing to a healthier and safer community for animals and humans.

In this way, access to care isn’t just an additional burden—it’s about sharing responsibility across the veterinary system to ensure that all animals, regardless of their owner’s circumstances, can receive the care they need.

Alvarez: In a large 2017 Access to Veterinary Care Coalition (AVCC) survey, 95% of veterinarians either agreed or strongly agreed with the statement, “All pets deserve some level of veterinary care.” As a profession, we believe all pets deserve care—and we must also charge for our services to stay in business.

However, the whole practice suffers when we have to turn families in need away. When we can help and our cases end up with good outcomes, we feel joy, satisfaction and a healthy pride. But, when we are faced with situations where we are unable to help, we are often left with feelings of sadness, frustration, guilt, and even overwhelm.

Fortunately, we don’t have to choose between our own wellbeing and the wellbeing of others. It is the opposite. Kindness is a “win-win”! Being a benefit to others obviously benefits others, but it also benefits the giver (just as much—perhaps even more). Studies have found that after receiving an act of kindness, one is 300% more likely to then perform an act of kindness! We are built to cooperate, share, and to care for one another.

Practicing along a SOC may help improve veterinarian wellbeing by providing care to animals who otherwise would not receive it, as well as building relationships with team members and social networks within the broader community. Such positive feelings of meaningful work can be protective against burnout.

By increasing access to care can through scheduling brief, straightforward preventative visits (providing basic veterinary medical and behavioral education as well as vaccines, spays and neuters, etc. to pets who would otherwise not receive it), we can possibly prevent clients waiting until their animal is very ill and bringing them in when there are fewer favorable options or outcomes, such as prolonged recovery, premature death, or relinquishment. Being able to offer a range of care options can help address issues surrounding access to care, thus improving veterinarian mental health and job satisfaction.

Blackwell: Offering a range of treatment options—such as A, B, and C plans—is precisely what the SOC embodies. You’re already practicing one of its fundamental principles: providing clients with choices that fit their needs and realities. The next step is to fine-tune your approach by considering how to make these options even more accessible, flexible, and aligned with each family’s situation.

So, acknowledge what you’re doing right! Providing tiered treatment plans is the essence of spectrum of care clinical practice. You’re already ensuring clients have options ranging from the ideal or “gold standard” to more incremental approaches that still protect the patient’s welfare. Offering options is a crucial aspect of providing family-centric, contextualized care. By offering a spectrum of treatment choices, you’re helping clients make informed decisions that balance medical needs with their practical limitations, which is the core philosophy of the spectrum of care.

But there is still more you can do. While you may already offer several options, you can deepen your practice by focusing on how those plans address specific barriers that clients face—whether it’s cost, logistics, or follow-through. You might also consider:

• Communicating the value of incremental care: Ensure clients understand that lower-cost or less-invasive treatments are still effective and compassionate solutions when the “gold standard” is out of reach. Such communication can empower clients to make decisions without guilt or fear of judgment.

• Incorporating preventive care: Emphasize the importance of preventive care as part of your spectrum of care approach. By providing affordable, accessible preventive options (such as vaccines, parasite control, or nutrition advice), you help clients avoid more complex and costly issues later on.

• Adapting care based on follow-up: The SOC is not a one-size-fits-all approach—it’s about ongoing communication and adjusting plans as needed. For example, if a client initially chooses an incremental treatment plan, you might offer reevaluations and adjustments that allow them to move toward more advanced care if their situation improves.

Alvarez: The easiest step that every member of the veterinary team can do to improve access to care is to change any negative perceptions they may be harboring around pet owners who may be in life situations where their resources are limited or carry beliefs about their pets that may be different than ours.

Working to build cultural humility in ourselves and our team—the ability to consider others’ lived experiences and where all clients are coming from—may help our profession embark on these potentially stressful situations with empathy, curiosity and possible solutions rather than frustration and anger. Open, compassionate, and nonjudgmental communication is the number one tool veterinarians have.

Regardless of what one might assume about a client or situation, continue to always communicate all options for care, and bring the client along on your medical process while you work together to decide which tests to do. It is also important to use informed consent and signed estimates to add an additional layer of clarity for the family and the veterinary team.

Take time to learn about and review what resources are available beyond your clinic. Are there local low-cost surgical options? What does your local animal shelter provide? Do food pantries in your area carry pet food? Are there grants or programs that cover any medical care? What alternative transportation services are there in your area? Are there clinics that are open during less typical hours? Are there sheltering options for people experiencing domestic abuse?

Finally, work hard to set boundaries (for you and your team) about how much you can take on as a clinic. Ensure the team is involved in the discussion about what could be offered pro bono, what could be discounted, or any plans to collect donations. Ideally, having these discussions early and often will decrease tensions between staff members and practice owners who are working hard to balance profitability and service.

McCobb: We know that most practitioners are practicing using SOC principles every day. What we are trying to change is the way we talk to students about it and to recenter the pet owner and the partnership for care.

No one has to be all things to all patients, but we want to acknowledge this approach and support those pragmatic and effective strategies that in many cases work really well. That’s one reason I call SOC “back to the future,” because it was more common before technology helped drive up the cost of care.

Alvarez: Clients who are financially burdened today may not be in the future (and vice versa).

It has been found that living paycheck to paycheck is a way of life for the majority (75%) of U.S. workers in a 2017 CareerBuilder Survey. An estimated 29 million dogs and cats live in families participating in the Supplemental Nutrition Assistance Program (SNAP, food stamps). Millions more are in financially struggling middle-class households.

According to data on pet ownership published by the AVMA in their 2017-2018 AVMA Pet Ownership and Demographics Sourcebook, at least 50% of families within this socioeconomic bracket own at least one dog or cat. These are members in our communities who may be classified as working poor in industries such as agriculture, fast food, retail, construction, and even employees in animal shelters and veterinary medicine practices!

Working to support families in your community when they are struggling is a way to play the long game. Falling on hard times is not necessarily a permanent, or lifetime condition. Only 50% of households had “stable” incomes between 2009 and 2012, said University of Tennessee Professor of Economics Don Bruce, PhD, MA, in a 2019 AlignCare Access to Veterinary Care Symposium. Additionally, he said a quarter of households experienced an income change of at least 50% between 2009 and 2012. And that was before the pandemic! Not supporting or turning clients away with minimal resources—or insisting that specific diagnostic tests must be done at an initial visit—may ultimately turn those clients away for good.

However, encounters with clients who feel respected and cared for, even if the appointment ends up consisting of a discussion built on compassion and respect about basic options available from your clinic or supplying resources from additional support in your community—will likely result in positive feelings from both your staff and the families you support. Over time, these same clients will be more likely to return (and say positive things about your practice) once they are no longer financially struggling.

Blackwell: Referring clients to community practices, shelter clinics, or low-cost spay/neuter providers may not mean losing revenue; rather, it reflects the practical reality that no single veterinary practice can be all things to all people, especially when considering the wide range of financial capabilities among families. Collaborating with other providers ensures that pets receive the care they need, while your practice can focus on delivering advanced care where your expertise and resources are most needed.

The primary goal of veterinary care is to ensure that every pet receives treatment, even when financial barriers exist. Sometimes, your practice’s services may be out of reach for specific clients due to the overhead expenses of maintaining advanced care capabilities. It’s essential to recognize that your practice’s higher pricing structure reflects the advanced equipment, specialized skills, and staff required to offer top-tier care. Referring clients to more affordable options for routine or low-cost procedures ensures that pets still receive necessary care without straining the family’s finances. This approach is not about losing business, but about meeting the needs of the pet population through a collaborative system of care.

McCobb: Studies have shown that more providers in an area actually increases business for everyone. If your practice does not offer low-cost services but maintains a list of those who do, you can offer them to your clients without fear of lost revenue—especially for the one-offs. In exchange, the shelters can refer new adopters [to you]. After all, a spay/neuter happens just once in an animal’s lifetime.

Also, if you refer clients who cannot afford your services to low-cost providers, that will free up more time for you to work with clients who are looking for the full-service approach. By not trying to be all things to all pet owners, practices can focus on the service area that makes the most sense for their own strengths.

Greenberg: This is where communication is key. While some shelters may treat publicly owned animals within their shelter clinic, more and more shelters these days have their own public-facing clinics that operate—in some ways—independently of the shelter’s “internal” clinic. In turn, these clinics can often have additional capacity despite the shelter itself being—unfortunately—over capacity.

The key here is to reach out to your local shelter and speak with them. Do they want to take on more clients? If so, are there particular types of cases they want (or don’t want)? Collaboration doesn’t have to be complicated; a simple phone call or email can go a long way in establishing a successful partnership.

McCobb: It depends on the area of the country, but if you are worried about your colleagues in shelter medicine, they would love to have your help. Reach out and see when you can volunteer.

But given how hard veterinarians already work that may not be feasible for all. The bottom line is that, if you refer a client to an animal welfare organization early on and the group can intervene with services (fund a needed procedure, low cost spay neuter, provide training or pet food or whatever is needed), then the pet is likely to be able to remain with their family.

Keeping families together by ensuring access to resources when they need them means fewer animals in shelters and less stress for everyone. Spay/neuter in particular is key to reducing shelter intake.