May 18, 2024

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Is veterinary medicine ready for a midlevel practitioner? – News


Photo courtesy of JoAnn Nocito

Veterinary technicians seeking more responsibility and better pay sometimes move into human medicine, like former veterinary technician JoAnn Nocito. Now a pediatric cardiac intensive care nurse, she is working toward a nurse practitioner degree.

JoAnn Nocito hit what she called a roadblock in 2012. A credentialed veterinary technician, she was a lead supervisor at a busy emergency hospital in Arizona, where the veterinarians trusted her to work to the full extent of her training and experience, she said. She presented at national conferences and helped launch the Veterinary Nurse Initiative to unite technicians under the single title “registered veterinary nurse.” Yet, she longed for more autonomy and opportunities to hone her nursing skills. Nocito said she realized she couldn’t achieve her aspirations as a veterinary technician.

So, six years ago, she left the field that had been her lifelong passion to become a nurse in human medicine. Today, Nocito is a pediatric cardiac intensive care nurse at Duke Children’s Hospital in North Carolina and working toward a nurse practitioner degree. She said she is happy with her career change, but if an opportunity in veterinary medicine to advance her skills and elevate her role had been available, short of becoming a doctor, she “absolutely would have done it” and probably still would be in the field today.

Nocito’s experience is not unique. Driven by issues such as underutilization, poor pay, lack of respect and few opportunities for career advancement, technicians have among the highest turnover rates of any health care occupation, according to the American Veterinary Medical Association. Technician turnover is widely seen as a significant workforce challenge for the profession.

Some technicians, educators and practice owners believe establishing a midlevel role between technicians and veterinarians would help keep technicians in the field and improve efficiency on hospital teams. Even among veterinarians who once opposed the idea of creating something like a veterinary nurse practitioner are those who say they’d welcome a new category of professionals as they struggle to fill openings for veterinarians.

Now, a proposed degree — a Master of Veterinary Clinical Care — from Lincoln Memorial University College of Veterinary Medicine in Tennessee has become a new spur in discussions about creating a midlevel practitioner role.

Although there is no credential, national exam or job title associated with LMU’s new degree, it is seen by advocates as a step toward restructuring veterinary care teams. In particular, the Veterinary Innovation Council (VIC), a nonprofit industry association, touted the degree and what it describes as growing interest in a midlevel position at several national meetings this year.

Critics warn that calls for a new position are premature, an overreaction to pandemic pressures and not based on a systematic study of the veterinary workforce. Another criticism is that offering a new master’s degree for an undefined role will replay the struggles veterinary technicians have faced in achieving formal recognition and respect in the profession.

New degree: Educate first, regulate second

LMU is proposing that classes for the new degree be online, with clinical work happening in the practices where the students are employed as veterinary technicians. Veterinary school dean Dr. Stacy Anderson told the VIN News Service by email that she anticipates the master’s degree will be approved by the regional accrediting body for higher education institutions this fall. Admissions would open soon after, with a tentative program start in August 2022.

Speaking at a symposium in July sponsored by Colorado State University College of Veterinary Medicine and Biomedical Sciences and the American Association of Veterinary Medical Colleges, Anderson described the proposed curriculum as similar to that for veterinarians but “less in-depth,” with foundational courses in anatomy and physiology. It would also include high-level nursing-type training, such as advanced case management and care coordination. 

Anderson told VIN News that the Master of Veterinary Clinical Care, at least initially, would be offered only to credentialed veterinary technicians and is aimed at those who want to further their training but aren’t prepared to invest the time and money required to attend veterinary school. (“Credentialed veterinary technician” refers to technicians who have met some state or professional standards for education and experience. Standards vary widely.) Proposed tuition is $25,000 for 30 credits, which could be completed in three semesters. 

Where they go with the degree is an open question. “There hasn’t been a lot of discussion of what the extender/midlevel practitioner would look like,” Anderson said in July. Extender is a term used to convey how the position would extend what veterinarians can accomplish by taking specific tasks off their plates. “The credentialing is going to come later,” she said. “Our goal is to create an educational program.”

The VIC has taken up the cause, collaborating with LMU on its curriculum. VIC board member Dr. James Lloyd, a veterinarian and economist, joined Anderson at the July meeting to present research on the topic that he conducted with Mark Cushing, a lawyer and founding partner of the consulting firm Animal Policy Group.

Lloyd said interest in a midlevel position reaches back at least a decade, when it was presented as an outgrowth of veterinary technology education planning at Michigan State University. Since then, several papers, including a 2021 paper whose four authors included two veterinary technicians, have identified support for a more advanced role on veterinary teams. 

The idea of an intermediate position was floated well before 2011. Vanderbilt University economist Malcolm Getz in the late 1990s proposed a degree that would take fewer years of higher education than the eight it takes most veterinarians to earn a DVM in the United States. While he was an early advocate, the now-retired professor doesn’t claim to be the idea’s originator.

Getz was responding to a very different time in the profession: Visits to veterinarians were declining, competition for jobs was stiff and graduates were burdened with high debt. Only the third condition holds today. The author of Veterinary Medicine in Economic Transition (published in 1997 and now out of print), Getz proposed an intermediate degree as a way for veterinary schools to attract students by creating more balance between starting salaries and the costs of education.

He also believed – and still believes — it would improve practice efficiency to have non-veterinarians covering more routine services, allowing veterinarians to focus on “tasks that require the specialized training of the DVM.”

Getz told VIN News that when he wrote his book, there was significant pushback to his proposal, driven mostly by financially struggling veterinarians wanting to protect their positions.

Resistance seems to have diminished since then. Lloyd said that when the VIC queried corporate practices, animal health companies and companion animal practitioners, it found support for the degree and the position, although it wasn’t unanimous.

The corporate practices and animal health companies were asked if they would be willing to fund a technician for the program knowing the clinical work would be performed in their practices. “Several were ready and willing to send associates as soon as the program was up and running,” he said.

The VIC declined to identify companies willing to underwrite degree candidates, noting that it had not been granted permission to make their names public. Doug Drew, president of Mars Veterinary Health for North America, announced today during the Banfield Pet Healthcare Industry Summit, that Mars is supporting the LMU degree.

Among reservations cited in the VIC’s research were concerns that a new position could heighten the feeling that technicians’ pay “does not match their value or their demand.” In his report on responses to the companion animal practitioners’ survey, Lloyd wrote, “Most DVMs feel a Master’s program would exacerbate this divide instead of solving for the bigger need — a larger, more experienced pool of technicians,” Lloyd said.

The research also determined, he said, that extenders would optimally have a distinct role beyond what veterinary technicians and veterinary technician specialists are trained and permitted to do. “The new individual should be independent and able to lighten the veterinarians’ workload to bring the greatest value,” he said, “and, at the end of the day, it’s most viable if the volume of visits, the client satisfaction and the overall clinic revenue increase as a result.”

These changes likely would require revising state practice acts, which restrict to veterinarians the jobs of diagnosing of illness or injury, developing a prognosis, prescribing medication and performing surgery. Creating an effective extender, in Lloyd’s view, would require carving out circumstances under which some of these duties in certain circumstances could be performed by the new practitioner. 

Veterinarians’ shifting views

Dr. Jeffrey LaHuis, the owner of a mixed animal practice in Michigan’s Upper Peninsula, told VIN News he would welcome the opportunity to hire a veterinary nurse practitioner or two.

Right now, he’s stretched to his limit, unable to find an associate and tapping his veterinary technicians to the full extent of their training and experience. What he needs, he said, is someone who could share some of the responsibilities currently restricted to veterinarians, “to free me up to do what I need to do.” Among those need-to-do duties are surgery and complex cases.

Given a chance, he said, “I’d treat them like a vet.” They’d have their own patients, and he’d be available to consult or step in as needed. In addition, he said he’d pay them the same way he pays associates — a “hefty” base salary plus production, which is based on revenue a practitioner brings to the practice.

Cushing suggested the salaries for a credentialed midlevel professional might be between $60,000 to $75,000, a range based on conversations with practice owners and managers. He has been an outspoken advocate for the degree and the extender position, and LMU and VIC are among his clients.

The median annual salary for veterinary technicians is around $36,000 and for veterinarians is $99,250, according to the U.S. Bureau of Labor Statistics. 

Dr. Matthew Edson, who owns two mixed animal practices in New Jersey, remembers when he didn’t look too fondly on the idea of an extender. “Years ago, I don’t know that I would have been very receptive to that kind of thing. I even kind of pooh-poohed that idea at one point,” he said. “We were in a very different position as a profession then. We had a lot of vets and not as many jobs.” Veterinarians worried midlevel practitioners might take some of those jobs.

“I think the pendulum for that has swung in a very different direction,” he said. “We’re in a bit of a hiring crisis now. Many of us need multiple doctors. [A midlevel practitioner] is something that I would have an interest in right now.”

Edson’s perspective is influenced by his experience in human medicine. Before becoming a veterinarian, he was a paramedic. He also has two nurse practitioners in the family. That, he said, has given him an appreciation for what they bring to the health care team.

The AVMA warns against allowing worries over what feels like a workforce crisis now to push prematurely for a new position. In a commentary in the Sept. 15 issue of the Journal of the American Veterinary Medical Association, the association’s chief economist, Matthew Salois, and chief veterinary officer, Dr. Gail Golab, said it’s not clear a new position is needed or would help. 

“[N]o comprehensive, quantitative analysis has looked at the extent to which such professionals are needed and whether they would be utilized appropriately,” they wrote in a section titled Avoiding Knee-Jerk Reactions. They argue that “a thorough assessment of the overall market is necessary before making any efforts to develop any new position within the veterinary profession.”

The AVMA created a working group in 2020 to study how to improve technician utilization, which means allowing veterinary technicians to perform the full array of tasks they have been trained in. The organization has also begun looking directly at the question of a midlevel professional and studying whether and where shortages may exist.

Dr. Janet Donlin, AVMA CEO and a former veterinary technician, told VIN News during an interview that the pandemic shouldn’t drive workforce policy. She would rather see efforts focus on improving job satisfaction for veterinary technicians.

“The best thing to do is to try to figure out how to leverage our great credentialed veterinary technicians to the top of their degree, so that we can pay them appropriately and hopefully keep them and attract more of them into the profession. I really want to put a lot of time and attention into that,” Donlin said. “One of the worst things we could do is not fix the leaky bucket … and put more people into an inefficient system.”

Dr. Wayne Jensen was disappointed by the AVMA commentary and what he sees as the organization’s resistance to a midlevel position. While agreeing with the importance of increasing the utilization of technicians, he believes that the needs of the profession cannot be addressed solely through this strategy. A professor and head of the Department of Clinical Sciences at CSU’s veterinary school, Jensen has been working on the concept of an advanced degree for around seven years.

According to Jensen, interest in the degree at CSU goes back at least 20 years to Dr. Franklyn Garry, a professor of livestock medicine at the college who proposed the role as a much-needed backup for rural veterinarians. CSU faculty members Drs. Sherry Stewart and Lori Kogan penned a 2009 paper proposing a veterinary professional associate modeled on a physician’s assistant in human medicine. 

They proposed the position to answer a “critical shortage of food-animal veterinarians” and a projected shortage of veterinarians in other areas, including research, education and public health.

Jensen got interested in the idea of veterinary professional associates as a way to address high education debt burdening many practitioners. 

“I looked at it as a mechanism that could free veterinarians from low-margin tasks, and allow them to focus on higher-margin activities to increase their revenue,” he said.

He envisions veterinary professional associates taking on the uncomplicated, routine tasks that right now only the veterinarian can do, such as diagnosing and prescribing treatment for a straightforward ear infection, or performing simple tooth extractions. He stressed that such team members would work under the supervision and license of a veterinarian, operating as an “extender” of not a “competitor” to the veterinarian.

This model could have the additional benefit of lowering the costs of routine care, Jensen said, which could help stem the rising cost of veterinary services.

“We have priced ourselves out of access for many pet owners,” he said. “Aren’t we obligated to find a way to serve those animals?” 

In his eyes, the midlevel professional could also help whittle away at another challenge for the profession: lack of diversity. He said individuals from underrepresented groups often look at the debt-to-income ratio in veterinary medicine and decide to forgo the profession despite their interest in the field. A master’s degree leading into an extender position could provide a more appealing entry point. 

Jensen is preparing a presentation on his degree concept for CSU’s clinical sciences faculty, which he hopes to complete by the end of the year. Their OK would be the first step toward gaining approval from the college and the university for a new master’s degree. Like the LMU program, he imagines coursework would be mostly online. Unlike LMU, clinical work would likely happen on campus. CSU has a veterinary teaching hospital, LMU does not.

He believes there is momentum for the idea right now.

“It’s a very small snowball,” Jensen said. “But I’m confident it’s rolling downhill.”

Veterinary technicians weigh in

When you present to veterinary technicians the possibility of a role that would afford them more responsibility, better pay and more respect, such as might be embodied in a veterinary nurse practitioner, the response is enthusiastic.

“I think having this position gives us another opportunity to show our skillset and to advance in that career path,” said Julie Legred, a veterinary technician and a practice management and veterinary association consultant in Minnesota.

She likes the idea of the Master of Veterinary Clinical Care, but she voiced reservations about offering it without a serious conversation about credentialing or buy-in from state veterinary boards, which regulate the profession.

“How can you justify spending more money in a master’s program if you’re not going to get paid [more after you graduate] and if states aren’t going to recognize your skillset?” Legred asked.

Still, the absence of advancement opportunities is especially tough on technicians with many years in the profession and multiple credentials. Kenichiro Yagi, a veterinary technician with two specialties (known as VTSs) and a master’s in veterinary biomedical sciences from the University of Missouri College of Veterinary Medicine, regularly takes on gigs teaching, speaking and advocating for the profession. He is the chief veterinary nursing officer at Veterinary Emergency Group.

Many veterinary technicians hold multiple jobs. Some go into training and education or practice management to increase their earnings and grow their careers. Rising in the ranks doing the hands-on nursing that drew them to the field in the first place is harder to accomplish. It’s why Yagi wants to see an advanced practice veterinary nurse position.

Reflecting on colleagues such as Nocito, who left veterinary medicine to become a nurse practitioner, Yagi said, “We’re actually losing our people to other fields because we have a ceiling.”

In the short term, Yagi argues, the opportunity to become an advanced practice veterinary nurse might keep experienced veterinary technicians from leaving the field. In the long term, the position could make the occupation more attractive to young people aspiring to an animal health career.

Charlotte Waack, however, thinks the focus on a new position is misdirected. A certified and registered veterinary technician, Waack is director of the Veterinary Support Personnel Network, an organization of Veterinary Information Network, which is the parent of VIN News. Echoing Donlin, her feeling is: Let’s not create a new position; let’s do a better job with the one we have.

“We need to go back to that beginning step and utilize our veterinary technicians,” Waack said, “—the step we never did take that’s going to keep them in the field.”

She believes technicians with superior training and experience are already available to take on more responsibility. She’d like to see expanded responsibilities for VTSs written into practice acts. Requirements for the 16 technician specialties vary, but they include three to five years of work experience after being credentialed, case logs and reports, recommendation letters and passing an exam.

Yagi doesn’t see it as an either/or prospect. “The world just isn’t black and white in a way where we can say, ‘Here’s step one, and then we’ll move on to step two,’ ” he said. He considers the challenge of utilization today’s issue, with efforts already underway to fix it. Discussions around a midlevel practitioner role “are the issues of tomorrow that we need to start getting ahead on so that we’re not continuing the cycle of being behind.”

Looking further down the road, Legred imagines how utilization could improve with nurse practitioners drawn from the ranks of veterinary technicians. “Doctors will probably take notice, [asking], ‘Why is this nurse practitioner very efficient?’ ” Legred speculated. “Because he or she’s an actual tech who knows what the technician can do and can utilize those skills appropriately.”

Still, even proponents of this transformation concede there may be regulatory hurdles, depending on how a midlevel professional’s role is envisioned.

Cushing said during a presentation at the July symposium that legislative change wouldn’t be required if the midlevel professional does not encroach on protected veterinary tasks. For example, if a hospital wants a veterinary technician who has earned the new LMU degree to oversee and manage its care delivery system, that is OK, he said: “I’ve looked at all 50 states; there’s not one practice act that has anything to say about whether you could or couldn’t do that.”

However, in response to a question from the audience, he said that creating something like a veterinary nurse practitioner would require revising practice acts. And that, he allowed, could be challenging. “Legislatures aren’t full of vet techs and veterinarians. They are not full of people in the animal health industry,” he said. “If your reform is aimed at the legislature and practice acts, it can … be expensive and time-consuming.”

VIN News Service commentaries are opinion pieces presenting insights, personal experiences and/or perspectives on topical issues by members of the veterinary community. To submit a commentary for consideration, email [email protected].