Referral Pearl
Volume 5. Issue 3
May 2019



I’m sure most of you will agree…our job as Veterinarians is MUCH more difficult than that of a “real doctor” of human medicine.  Case in point:  my brother accidently cut his finger once and went to hand specialist – I cynically asked if he was a right hand or left hand only Specialist.  My bother replied “Neither, he works on both…but only the index fingers.”

But as general practitioners, you DO have a tough job.  In the course of a day, and on multiple species, you practice dentistry, dermatology, general surgery, nutrition, ophthalmology, and radiology…along with infectious disease control and a little psychologist (behaviorist) mixed in.
Considering this, it’s important to remember one thing – while trying to be a “jack of all trades” you risk being a “master of none.”  Despite the perfectionism streak in many of us, we can’t know everything (believe me, as a perfectionist in recovery, I’ve tried).  Hence, the rise of us Specialists.  Some of us like to repair crunchy bones or take out the bad tissue.  Others (like me) enjoy the puzzle solving aspect of internal medicine.  Still others just like to focus on one area…like the wiggly thing in the thorax or the “windows to the soul.”  But no matter our Specialty, we all worked hard to gain additional skills and experience that allow us to better serve Patients when called upon.
So, what’s keeping you from calling on us?  How can we work together for the benefit of the Patient(s) and their chauffeurs?  Here’s a few reasons to refer:

Enhanced Care AND Saving Money
Even in an area as large as the DFW Metroplex, one specialty hospital cannot do it all.  If you assemble a strong referral team, you can provide a higher standard of care, irrespective of a Patients’ unique needs. 
And, who doesn’t like to save money?  The Specialist care may cost more initially but getting an answer faster and the proper therapy initiated saves time, money and most importantly, heartache.
Finally, your operating hours or lack of expensive equipment can limit the services you provide and introducing new services may not be economical for your practice.  Working closely with Specialists (esp. those with an integrated ER like our Hospital) gives your Clients the services and after hours support they need while not adding strain to your budget.  Referring to Specialists allows you to focus on other areas of your practice…and life (remember work/life balance!).

Patient (and their Chauffers’) Retention

Who likes to return to a business for multiple visits because of the same issue?  OK, maybe my grandmother…it gives her something to do besides watch The Price is Right.  But often our Clients become upset when they return for the same problem because it wasn’t “fixed” (believe me, as an Internist I know this isn’t a realistic goal in many cases).  And, a Client may not even give you multiple chances, instead acting on the advice of a neighbor, breeder, co-worker, pet store employee, groomer, or (shudder) Dr. Google.  You likely won’t see this Client again, and you certainly won’t get additional chances if the Patient succumbs to their disease process (morbid but true).  Discussing referral sends the message that you have a Patient’s best interests at heart and not your ego or balance sheet, which will keep them coming back because they trust you.

Free Advice
None of us got into Veterinary Medicine to get rich.  My Mom still laments I didn’t become a plastic surgeon and help her get rid of her “turkey wattle.”  We Specialists are happy to help you, whether it means discussing a Patient’s situation or recommending a medication.  But don’t exploit it.  Calling me weekly to discuss several cases or sending me 145 pages of medical records to “chat” about – when the last referral you sent me was in 2009 – is disrespectful.
Speaking of learning – we Specialists can help you grow in knowledge from every referral.  Our communications keep you up to date with diagnostics, treatments and outcomes, which in turn allows you to learn and be able to diagnose issues that you would not have recognized previously.  Many Specialists provide local CE (like the excellent ones you get monthly at your CCVMA Meetings), and we also provide free continuing education in the form of “lunch and learns” for you and your Team; just contact our Referral Relations Coordinator Shelley Martin ( to schedule!

Knock knock.
Who’s there?
A wise person once told me that if you practice veterinary medicine, no matter how careful you are, you will eventually find yourself getting sued and/or reported to the state board.  I didn’t expect it to happen 6 months into my internship, but at least I got it out of the way early in my career!  If you find yourself in a legal tussle, having offered a referral may be a deciding factor.  In fact, Texas Administrative Code (Rule §573.24 – Responsibility of Veterinarian to Refer a Case) explicitly states “a veterinarian shall have a duty to a client to suggest a referral to a specialist…in any case where the care and treatment of the animal is beyond the veterinarian's capabilities.” 

Avoid “preconceived notions”
How many times have you seen a case and the diagnosis was obvious…but you or your colleague missed it previously?  We all make mistakes, and most of us learn from them.  Think of these scenarios and you’ll likely have a Patient come to mind:  lameness diagnosed as hip dysplasia but due to a torn CCL…pancreatitis vs. IBD…endocrine issues vs. atopy…IVDD vs. polyarthropathy, paraneoplastic vs. autoimmune disease…and the list goes on.
We all learn the material in vet school, but the advanced training Specialists receive give us a focused experience that comes into play with so many cases.  As Specialists, we know the advanced testing that is needed to get an answer quickly and which procedures would better serve a Patient.  Therefore, please don’t just send the case over with your requested diagnostic or procedure…send them over for a consultation and discussion. 
For example, unless you hate me, please don’t send the 200 lb aggressive Rottweiler for an abdominal ultrasound to find adrenal glands and the Clients are against sedation for religious reasons – that dog needs an abdominal CT scan.  Do your best to avoid preconceived notions and steer the Client in our direction before the wrong procedure is recommended or performed.

Patient and Client Advocacy / Support
We all know that for some Patients, treatment is not possible, or ethically even recommended.  Along with euthanasia, hospice care should be discussed.  This may only be for a short period, but it may be the time that is needed to allow the Client to process their emotions while supporting their loved one and ensuring they are pain free with an acceptable Quality of Life.  At our Hospital, we have a dedicated team of Veterinary Social Workers (VSWs) who help Clients with these complex issues, and this lessens the emotional burden on you and your team as well.  There is no charge for this service, and our VSWs also have monthly support groups that are open to your Clients, too (more information can be found at

Final thoughts…
I hope this article made you laugh and re-examine your referral (or non-referral) policies.  I also hope we can we work together for the benefit of many Patients (including the 200 lb aggressive Rottweiler), and here are a few final pointers on how to “refer better”:
  • DO fill out the referral form and PLEASE include a summary of what you have done or administered.  You like our summaries, right?  I know you’re busy, but it will only take you 5 minutes.  Just do it.
  • DO specify any questions you may have.  Remember, we want to help you grow in your knowledge.  This will only add 1 minute to your writing of the summary.
  • DO send the medical record – all copies of bloodwork, imaging and other tests.  It makes us both look silly if we don’t have the information we need. 
  • Do NOT refer Clients who have exhausted their financial resources.  This is not a win-win situation.  It makes me sad when someone says, “they never told me it would cost me money.”  Huh?
  • Do NOT give medications that may interfere with further treatment unless critical.  That includes prednisone.
  • Do NOT send this (or at least call and warn us first so we can grab the fire extinguisher and hip waders):

Keven Gulikers, DVM, MS, DACVIM (SAIM)

Dr. Gulikers received his Doctorate in Veterinary Medicine from Oklahoma State University College of Veterinary Medicine in 1998 (Go Pokes!) and completed a private practice internship in 1999 in south Florida.  In 2002 he completed a residency in Small Animal Internal Medicine and earned a Master of Science degree in Veterinary Medical Sciences at Virginia-Maryland Regional College of Veterinary Medicine.

After his residency, he worked in specialty private practice in Phoenix for several years before moving to Dallas.  Dr. Gulikers has instructed and published on various subjects in his field.  He is Board-Certified by the American College of Veterinary Internal Medicine, and his interests include gastroenteritis, liver disease, endocrinology (especially thyroid-related diseases) and diagnostic procedures such as abdominal ultrasonography, endoscopy and laparoscopy.

When not practicing, Dr. Gulikers enjoys playing soccer, traveling, SCUBA diving, and spending time with his wife and daughter.  If you have a grumpy 200 lb Rottweiler that needs a consult, he can be reached at
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