I believe we can all agree that the Veterinary Client Patient Relationship (VCPR) is a foundational concept in Veterinary medicine that establishes necessary trust, communication, and accountability between veterinarians, their clients, and their animal patients.
Conventionally, the VCPR has required in-person interactions with the stated goal of ensuring suitable assessment, diagnosis, and care; however, expansion of telehealth, advancements in technology, growing challenges with access to care, and changing societal needs have prompted consideration and rising adoption of virtual VCPR models for modern, client, and patient-centric Veterinary care. Unanimity of opinion has been evasive; furthermore, the consideration of adoption of the virtual VCPR has escalated to notable discourse between groups and individuals and on the floors of state legislatures in a way that has divided our profession. Hopefully, our profession will ultimately unite to fulfill client and patient needs, while supporting ethical veterinarians and ethical companies providing telemedicine services.
What are Current Realities About the Virtual VCPR?
Are veterinarians following current rules that prohibit a virtual VCPR or are they creating a virtual VCPR based upon their own professional judgement—regardless of their opinions regarding the virtual VCPR debate? This question may sound facetious, but it is an honest and thought-provoking question that needs to be answered. I have asked many veterinarians, individually and in large groups at meetings, to raise a hand if they had never created a virtual VCPR in their practice careers. How many hands went up? Zero. Did you hear that? Every veterinarian I have ever asked, publicly or privately, has created a virtual VCPR despite laws, rules, or practice acts. Why?
I speculate that it is because they are highly trained, dedicated, compassionate veterinarians who used their best professional judgement to identify the need for care that could not be provided through conventional means. In other words, they used their own medical judgement. Sadly, each one of these veterinarians risked licensure by providing a virtual VCPR in states in which virtual VCPR is forbidden. Why should ethical veterinarians be placed in this position? The bottom line is that veterinarians should be trusted to determine when a virtual VCPR is essential and when an in person VCPR is indicated—and be supported in their choice.
In human healthcare, telemedicine has existed in the U.S. for over 60 years. Well before that in 1879, the Lancet talked about using the telephone to reduce office visits (T Nesbitt, “The Evolution of Telehealth: Where Have We Been and Where Are We Going?”, NAS, 2012). In 1925, the cover of Science and Invention showed a doctor diagnosing a patient by radio within an envisioned device that would allow video examination.
NASA has used telemedicine to monitor astronauts in space for many years. Veterinary medicine is well-positioned to draw from vast experiences in human medicine to apply what works for Veterinary healthcare. One important experience is that there is a 50-state acceptance of the virtual doctor-patient relationship. Today in Veterinary medicine, more than 120 million Americans may start a VCPR through virtual communications in Arizona, California, Florida, Idaho, New Jersey, New York, Ohio, Virginia, and Vermont—with more to follow.
Is Prohibiting the Virtual VCPR Fencing in Ethical Veterinarians or Fencing out Bad Actors?
The ethics of every licensed veterinarian in the U.S. is a requirement, as well as a presumption, of every examination and treatment regardless of whether performed in-person or via telemedicine. And the standard of care enforced by state boards is the same regardless. Telemedicine platform companies are U.S.-based and rely exclusively on veterinarians licensed in the states where the pet resides or is located. And these same veterinarians are subject to Veterinary medical boards wherever they are licensed.
We are not dealing with Sri Lanka call centers, which was the false charge against human telemedicine. The ethical veterinarians and ethical telemedicine platform companies should be fully supported and properly enabled. However, rampant in the debate are concerns about unethical veterinarians, non-veterinarians, and unethical companies that some claim would abuse the virtual VCPR, if it were allowed. However, it feels like we are fencing in these ethical veterinarians, whether in practice or within ethical telemedicine companies, who are not allowed to use their professional judgement to decide what is best for their patients and clients. Furthermore, it has long been said that “locks are for honest people.”
Unethical individuals and companies may not follow the rules, anyway. The result? Ethical veterinarians will be placed in the position of violating the rules and risking their licenses or saying no to clients who are asking for professional help from licensed veterinarians. Clients are then put in the untenable position of seeking help from unethical sources or from outside the profession. At a time when public sentiments are generally more cynical, veterinarians continue to enjoy high public trust and appreciation. Saying no and driving clients elsewhere has the potential to tarnish our reputation of compassion and caring. Additionally, if our clients are forced to receive help from sources outside of the profession, they may not return to the Veterinary care that we know offers the highest quality and safety for patients.
What are the Consequences of Allowing the Virtual VCPR?
Simply stated, animal health and welfare would be improved through expanded access to essential care. The well-being of veterinarians would be boosted through avoidance of the mental distress of saying no to clients and animals they know they could assist, if allowed. Veterinarians, who are highly trained and tested for competence, would be permitted to execute their own professional judgement in delivering the highest quality care to their patients. They would be supported in considering the individual needs of animal owners, with no risk to their licensure. One of the most compelling consequences of virtual VCPR is its ability to increase access to care, a major contemporary issue.
Clients and their animals, challenged to get in-person care by absence of local Veterinary care, geographical distance, transportation constraints, personal health limitations, age, financial restrictions, and more, could receive prompt, quality Veterinary assistance. Telemedicine, augmented by the virtual VCPR with appropriate guardrails, could go a long way to solve the crisis shortage of Veterinary care in rural communities. Public perception of veterinarians would be enhanced as they are allowed to say yes, rather than no, to appropriate requests from clients. Clients in need would not be driven to unethical sources or outside the profession to obtain care for their animals.
Veterinarians and practices could operate more effectively and efficiently, while providing care for more animals. They could increase in-person visits and client numbers, as new clients established through virtual VCPR become loyal clients. The virtual VCPR could streamline the process for clients, reduce wait times, minimize travel requirements, provide more flexibility for scheduling, and offer more convenience for clients and veterinarians.
Virtual VCPR could enable continuity of care while prioritizing public health and protecting clients and the Veterinary health care team from unnecessary exposure. Veterinary telehealth is estimated to become a $346 million global market by 2027, attracting corporate investors (P Tanella, TVB, October 2021). It is important to guarantee that licensed veterinarians are solidly positioned within this growing Veterinary business model, as job opportunities for veterinarians are expanded through telemedicine services.
Is an In-Person Examination Really Better than a Telemedicine Examination?
This is pertinent because those who oppose virtual VCPR argue that virtual examination is insufficient. It is realistic to want to put our hands on our patients in our clinics, as has been done traditionally. But really, the quality of the examination depends.
For example, a University of California study (EC Dooley, Jan 11, 2023) showed that cats showed signs of increased stress at in-office visits and that in-home appointments better reflected the health and behavior of cats. Certainly, a lameness examination on a cat would be very difficult in a clinic setting, but a video Veterinary appointment could be very useful. New technologies are being developed with staggering speed in human healthcare and are becoming available in Veterinary health care, especially digital technologies.
Some examples include wearable monitoring devices for vital signs, wearable ECG monitors, continuous glucose monitors, pulse oximeters, behavior assessments, pain estimations, and digital stethoscopes, otoscopes, and ophthalmoscopes. TytoCare is a home use device that enables remote physical examinations by clinicians. This one device allows remote examination of the heart, lungs, throat, ear, skin, and abdomen, along with vital signs. It is AI-enabled, data-driven, and virtually delivered. It has FDA-cleared AI algorithms that provide insights and decision support for doctors.
What Is the Answer to the Virtual VCPR?
A reasonable answer is to permit veterinarians licensed in the jurisdiction in which the animal resides to create a virtual VCPR based upon their professional judgment and proper assessment of client and patient circumstances. The virtual VCPR would be created with full consent by the client as an enhancement, not as a substitute, for subsequent in-person visits. Appropriate guardrails would be instituted.
The Virtual VCPR represents a progressive step forward for Veterinary medicine, aligning with technological trends and societal expectations for accessible, efficient, and safe healthcare. By embracing virtual relationships, the Veterinary profession can trust its veterinarians, expand its reach, improve client satisfaction, and continue to provide high-quality care in an ever-evolving landscape. And the experiment has already been proven in human healthcare in all 50 states and in a growing number of states in Veterinary healthcare.