The Equine Veterinarian: Past, Present and Prospects of a Profession
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The equine veterinarian: past, present and prospects of a profession. De paardendierenarts: verleden, heden en toekomst van een beroep. (met een samenvatting in het Nederlands) Proefschrift ter verkrijging van de graad van doctor aan de Universiteit Utrecht op gezag van de rector magnificus, prof. dr. J.C. Stoof, ingevolge het besluit van het college voor promoties in het openbaar te verdedigen op donderdag 13 november 2008 des middags te 4.15 uur. door Johannes Bernardus Antonius Loomans geboren op 10 Augustus 1959, te Amsterdam Promotoren: Prof. dr. A. Barneveld Prof. dr. P. R. van Weeren Dit proefschrift werd mede mogelijk gemaakt met financiële steun van: Hippo Zorg Paardenverzekeringen, Nysingh Advocaten-Notarissen, CenE Bankiers, AUV Dierenartsencoöperatie, Virbac Nederland B.V., Boehringer Ingelheim Animal Health, Intervet Schering-Plough Animal Health. Copyright © J.B.A. Loomans Layout by Harry Otter en Marije Brouwer Multimedia Centrum Diergeneeskunde, Henny van Delft en Joop Loomans Cover: Picasso, Pablo (1881-1973): Boy Leading a Horse, 1905-06. New York Museum of Modern Art (MoMA). Oil on canvas (220.6 x 131.26 cm). The William S. Paley Collection. © 2008. Digital image, The Museum of Modern Art, New York/Scala, Florence Chapters 3, 4, 5, 6, 7, 8, have been reproduced by kind permission of Equine Veterinary Education ISBN 978-90-39349274 Contents Chapter 1 General introduction 1 Chapter 2 The emancipation of the equine veterinary practitioner in 7 the Netherlands Chapter 3 A survey of the workload and clinical skills in current 23 equine practices in the Netherlands Chapter 4 Does equine veterinary medicine pay off? A survey on 39 revenues in current equine practices in the Netherlands Chapter 5 Quality of equine veterinary care: where can it go wrong? 57 A conceptual framework for the quality of equine healthcare, based on court cases against equine practitioners in the Netherlands Chapter 6 Quality of equine veterinary care: client satisfaction in 71 equine top sports medicine in the Netherlands Chapter 7 The use of veterinary medicinal products in equine 89 practices in the Netherlands: Balancing between the law and good veterinary practice Chapter 8 Occupational disability and job satisfaction in the equine 109 veterinary profession; How sustainable is this “tough job” in a changing world? Chapter 9 Equine veterinary practice in perspective. 135 Samenvatting 145 Curriculum vitae 157 List of publications 159 Dankwoord 161 Chapter 1 General introduction THE EQUINE VETERINARIAN The horse at heart Equitation is becoming more and more popular in western countries. Leisure horses populate former agricultural lands and the number of professional training stables, stud farms and riding schools has increased dramatically in recent years. In the Netherlands the annual turnover in the equine industry is estimated at 2 billion euros and is still growing. The horse has conquered an important position in the hearts and minds of many young girls and (to a lesser extent) boys, but also older age groups are being “infected by the equine virus”. The fascination for the horse is certainly not limited to people with an equine or agricultural background, or to specific social classes. The equine community encompasses a large fraction of the total population and consists of spectators, horse owners, riders, drivers, grooms, trainers, sponsors, professional or leisure sportsmen etc. and also includes veterinarians. Many of these veterinarians participate in equitation in one way or another and for many their love for the horse was the reason to start a veterinary career. However, love is blind and may be a bad counsellor; proper career choices should ideally have a more rational basis. Although there is the rather romantic Herriot-like perception of the equine vet by the general public on the one hand and there are anecdotal data on long working hours, occupational disability and frequent law suits on the other, little is known on the current position of the equine veterinarian with respect to his or her working conditions, the economic viability of the job and ultimately on the degree of job satisfaction. This makes a rational choice for the profession difficult and also hampers the identification of bottlenecks or targets for improvement for the professional organisations or regulatory bodies. The aim of this study was to analyse the current position of equine veterinarians in the Netherlands as a basis for the timely recognition of trends and developments that may urge a proactive stance of the profession or parts thereof in order to avoid unwanted developments and to guide the profession in the best possible way. The current position of the equine veterinarian Relations in human healthcare can be described by the so-called triangular model, which describes a series of interactions between the three main actors, being: citizens (patients), third parties (public sector and insurance agencies) and the providers (hospitals and the primary care sector) (Cristiansen 2002). In this model there are monetary flows from patients to the third parties (and to a lesser extent directly to the providers) and from the third parties to the providers, and a service flow from the providers to the patients. In equine veterinary care the relationships and interactions are more complicated since the patient, i.e. the horse, has an owner who is responsible for it and decides whether or not equine veterinary care will be provided (Figure 1). 2 GENERAL INTRODUCTION Figure 1. Triangular model equine healthcare. In line with this diagram, this thesis puts the equine vet in the centre and evaluates his/her relationship with the horse, the horse owner and third parties. The reciproque interactions between third party and owners, third party and the horse and the horse and owner are left untreated, unless they are of importance for the interaction with the equine vet. The thesis starts with the historical perspective, then goes into detail in various chapters on the current position of the equine vet and ends with a synopsis from which the future perspective of the equine veterinary profession emerges. History The second chapter of this thesis describes the heyday of the former famous equine “horse masters”, who were mainly associated with the cavalry, the decline of specific equine knowledge during the era of rapid mechanisation, and the revival of the horse vet as the modern equine veterinarian and equine specialist treating leisure and sport horses. 3 THE EQUINE VETERINARIAN Supply and demand Chapter three provides more detailed information concerning the present-day demand for equine veterinary care and the actual situation of the contemporary equine vet in terms of workload, hours spent “hands on” with the horse, relative importance of the various organ systems and disciplines, and specific interventions. The role and specific activities of the registered equine veterinary specialist is given special attention. Economic viability In equine veterinary care there is no large third party as a middleman between the supply side and the demand side. Only a limited number of horses are insured for equine healthcare, which means that there is usually a direct financial relationship between the owner of the horse and the equine vet. Thus, apart from professional competence, the equine veterinary practitioner also has to have commercial qualities as an entrepreneur who has to earn a living for himself and his or her staff. Chapter four addresses the economic viability of the equine veterinary activities, thereby focussing on the large differences between the types of practices where equine vets work. Revenues obtained from equine work are expressed in various benchmarks and compared between equine and mixed practices and between the six economically best and worst performing practices. Quality of equine veterinary care The quality of healthcare, which includes the quality of communication with owners and third parties and client satisfaction, are topics of considerable current interest in both human and veterinary health care. Crucial in this discussion is a proper definition of the quality of care. Quality of equine veterinary care in this study was measured using a conceptual framework designed to describe the quality of human healthcare (Campbell et al 2000) that differentiates between the structure of the care system, the actual process of giving care, and the effect of the system on an individual (outcome). In chapter five this framework is applied to an analysis of court cases filed against equine practitioners as a yardstick for dissatisfaction with the work or attitude of the equine vet by either the owner or regulating authorities. The degree and reasons of client dissatisfaction may be a good measure to assess the quality of the care given, but it does not give information whether the offer of care meets demand in a sufficient and satisfying way. Needs and demands vary widely depending on the type of client and the horse involved and it is impossible to investigate demands and the degree to which those demands are met for all possible subpopulations of end users of equine veterinary care. Therefore in chapter six the focus is on the group that can probably be seen as the most challenging of them all, the top segment of the most important equestrian disciplines in the Netherlands. 4 GENERAL INTRODUCTION Here the same conceptual framework of quality of care is applied to equine veterinary care as perceived by three relevant parties in this top segment of equestrian activities: the riders, the national coaches and the national team vets. Legislation Practicing (equine) veterinary medicine is regulated by law, as is the use of veterinary medicinal products. There are frequent complaints from the field that the availability of equine veterinary medicinal products is insufficient and at times inappropriate. Chapter seven is a study on the actual availability and the related proper and improper use of medicinal products by the equine practitioner in the Netherlands.