Hello everybody. My name is John Ray. I'm gonna talk to you about why the art of good referral helps pets and cements good client relationships.

Just by way of an introduction, I'm a, a referral specialist at Dick White Referrals in, in Cambridgeshire, in the United Kingdom for, for, for those of you that are outside the UK, and I'm a, a specialist in small animal medicine. I've, been seeing. Referrals in internal medicine and cardiology and interventional radiology for the last 23 years after starting off my practising career as a, a general practitioner in mixed animal practise.

I'm giving this webinar primarily to, to, to just try and talk through what makes good referral and how that's helpful, because, it, it, from a, a referral specialist perspective, there's a noticeable difference between when referral works well, and, and, and clients and their vets are more strongly bonded by that, and experienced vets will often use referral to enhance the way in which their practise works and to, to add value to their relationship with their clients in a very, very effective way. Sometimes, unfortunately, it doesn't go so well, and that can have the opposite effect and clients can seek to change practise, often through through problems that arise that are very preventable and and actually boil down usually to communication or very predictable, avoidable things that that that I I'd like to try and and help avoid if if possible. So by way of a plan, I'm going to talk a little bit about what referral is, and, and what it isn't.

I referral the right decision? And to spend some time talking about the partnership between, a first opinion practise, the specialist or person that's seeing a a referral and the pet owner, and how that develops into a hopefully a win win win win situation where everything is, is working well and referral really has been the best decision all around. I'm gonna finish off talking about some situations if, if referral isn't possible, and then mention some troubleshooting things that can, can, be avoided in terms of pitfalls that can, lead to referral not being the, the, the, qualified success, it should, should generally be there.

So, so what is referral? Well, simply put, referral is, is the transfer of a case to a colleague who's got specific expertise in that area. And that may be for a diagnosis, for a form of procedure or treatment that isn't readily available outside the hands of someone with, with, with expertise in that, that, that one area.

But essentially it's temporary transfer of a case for the enhancement of that animal's welfare and and to look after that client's needs. And then that that patient is returned to the care of the the primary veterinary surgeon, the, the referral practitioner shouldn't be taking over the case. Entirely, and neither should the referring practitioner seek to divest themselves of all responsibility for that that case.

The referral occurs after discussion with the client, and it's important that it's established that referral is what the client wants. Without that basic step, and it sounds like a very obvious thing to say, but unless The client actually wants referral and it suits their needs, it's not going to be successful. It's not going to, to, to have an outcome that is satisfactory to that client.

What isn't referral? Well, just simply seeking the view of another veterinary surgeon, which may be a very important part of case, case management and case strategy, is a second opinion. That's not not referral.

And there may be circumstances in which that's a very useful thing to do. For example, Where a client may require ratification of one vet's decision or or or or discussion or diagnosis, or where it may benefit for a fresh pair of eyes to to to be cast upon a case. That's a 2nd, 2nd opinion.

That's not a a referral. Similarly, transfer of case responsibility out of normal working hours for ongoing care. Is within the domains of a first opinion out of hours clinic or provision of emergency care at an out of hours emergency provider.

That's not a referral, OK, that's, that's, that's provision of, of, of continuation of care out of out of hours. And referral definitely isn't divesting responsibility for a difficult client, and aggressive patient, or even worse a bad debt. Those are all examples of essentially trying to make one's own problems someone else's to get rid of it.

That's, that's not professional activity. There may be circumstances in which the reason why a client is difficult could be a saged by discussion with and potentially referral to a specialist, but that should always be discussed with a specialist 1st 1st of all. Those are all examples of, of essentially trying to get rid of problems, and that's not a a referral at all.

One thing to try and avoid. It is always the impression or practical consideration that referral is being performed as a unilateral decision. It should always be a partnership.

Referral should always be something that's undertaken in collaboration with our clients and understand that that's that's what would suit their needs. So when's referral most appropriate? Well, there may be a number of clinical factors why referral is an appropriate thing to consider.

For instance, a case may be of a complexity or a confusing nature that may fall outside one's own level of skill or experience. It may be that a form of Treatments necessary that is outside the scope of of first opinion practise or what facilities one can offer. Maybe that particular diagnostic expertise may be needed.

And then there are a number of client factors, but it has to be undertaken in the setting that it's what clients want to occur, and that the practical costs involved are something that is that that is suitable for them, and that costs must always be discussed. And that it may well be the clients are specifically driving referral that they even might demand referral. Sometimes it may be that a particular client need is identified, and that includes sometimes, when clients don't accept a vet's diagnosis or or management or treatment, advice, and that it is desired to, to, to ratify that, that it would help that client to and their relationship with their vet to essentially hear the same thing from a, from another source, and perhaps one that is.

Held in greater regard by the, the, the, the client in terms of their level of qualification. And that can be a very, very useful and important part of referral. But if that's the reason for a referral, that should always be discussed really between vets, to, to discuss with the specialist that may be seeing that, that, that client, that that's what you're, you're desiring, that, that, that essentially you, you're pretty certain of the diagnosis, but the client will benefit from hearing it from someone else as well, and that's, that's useful both to ratify your own findings, and to discuss that with the, with the, the, the specialist.

When considering to whom one is referring a case, there are a number of factors to to bear in mind. There are a number of, of potential sources of referral services, and they may include those veterinary surgeons who have qualifications that they've undertaken. On a postgraduate basis that are essentially self-taught qualifications, that are sort of, accessible from, from practise, such as, postgraduate certificates and, and then application to be included on a list of advanced practitioners.

That has advantage of a, a, a more widespread accessibility. A lot of people that undertake these qualifications will concentrate on that, that, that area alongside some of their their other work. They are essentially though not supervised their self-taught qualifications, and they are not specialist qualifications.

And remember that the term specialist is a protected term. It is breaking the professional code of conduct from the RCVS to describe someone as a specialist who isn't. And my specialist, we mean some that's accredited by the RCVS as a specialist.

They have undertaken specialism qualifications which involve usually a rotating internship and then a 3 year apprenticeship training programme or residency. In which postgraduate training is supervised and dedicated to one subject with the input of a very large caseload, it's undertaken to the exclusion of all other all other forms of veterinary work, with the aim of then sitting specialist examinations and then application to be a specialist. Specialists have to be reaccredited, and one of the checks and balances involved in being a specialist is that that reaccreditation process has to occur regularly to ensure that one is active in the field, one is up to date and and is continually available to accept referrals.

These aren't equivalent qualifications. It's like comparing apples and oranges, and they're they're very, very different in terms of the level of expertise involved and the experience involved as well. There's also a decision to be made as to whether a case is referred to either a single or standalone discipline where either a practitioner or a practise focuses on one area alone, and they may be very highly skilled in that pursuit and very commonly, for instance, in orthopaedic surgery, orthopaedic surgeons have the, the, the, the luxury that they don't have to rely a great deal on on other specialists in my.

Particular field in internal medicine, I have to rely on a lot of other people's expertise as well. And orthopaedics isn't isn't like that, and orthopaedics works very well as a standalone subject. But cases referred that may fall outside that area, then may need to be discussed to to to to refer elsewhere there to someone with more appropriate skills.

There are a number of, of specialists or people with further qualifications that may offer. Peripatetic services and visiting practises, that has advantages in, in, in being convenient for clients and keeping work within the house. It's important to, to, to bear in mind and establish what happens if there is a a problem outside their attendance or outside normal working hours.

Are they contacting in emergency, what contingencies are there there? And conversely, multidisciplinary referral centres may have the advantage that there can be assessment and inputs from multiple departments with with a great breadth of knowledge. But the, the disadvantage can be that if a patient is referred and it's sent to the sort of wrong discipline.

That then there, there, there may have to be sort of a delay whilst an appointment is made for another discipline. So if you think that in advance of making a referral, the input of more than one specialism may be needed, always communicate that. In advance and discuss that in advance.

If you're unsure, always ask or referral centre very happy to to to say, well, we think that this would be more suited to seeing a soft tissue surgeon than an internal medicine specialist. And and and that's something that we'll we'll always be able to answer. Now, when discussing referral, always discuss client wishes and expectations.

I can't emphasise enough how the greatest source of, of, of probably dissatisfaction and, and, and referrals not working well is when it's something that clients aren't fully on board with their wishes and expectations haven't been fully explored there. It's vital to discuss costs in an open and transparent way. It's also an obligation under the professional, professional code of conduct, and is, is clearly a, a, a matter of professional courtesy and honesty and probity.

All all all referral centres are very happy to give estimates. All referral vets should give you an estimate of of cost based on the information they've been been provided with. And they'll, they'll further after speaking with owners and taking a history, refine that, that estimate of cost on, on, on the basis of what they, what they would propose doing.

So, There are two sides to it, to, to, to, to cost. The person making a referral should always give the client an idea of cost, and, and so should the, the, the referral practitioner as well. The owners willingness for travel, for their animals to be hospitalised, should be explored, and also their attitude to to investigation, an owner who is highly resistant to any investigation being performed.

And is unlikely to be satisfied or have any benefit from referral, and it's not practical for for clients of that nature to be referred, however much 1 may recognise the desirability of it. If the client isn't on board, then that's that's not something that is practical. So referrals are a partnership, it's a partnership between the owner or farmer or client.

And the referring vet and the the referral vet with the the patient at the centre of it, with the patient benefiting from that relationship. This relationship between colleagues, between professional colleagues based on courtesy and etiquette and and and and and communication more than anything else. But it's an important partnership that enhances relationships with clients and for the benefit of the of the patient there.

A light to that, there are certain expectations that each corner of that triangular partnership may have. From the client's perspective, and they would really like the referring vet and the referral vet to listen to their concerns, to understand their, their, their principal concerns. From the referring vet, they want to have a a collaborative discussion, which it should be decided is is referral appropriate for that client.

They should never feel that referral is something that's done to them. And one increasing source of dissatisfaction we see is when clients arrive feeling that they have been referred because their vet doesn't want to deal with a problem, rather than that it's something that that that has been a mutual decision. And that, that always leads to dissatisfaction, often leads to clients deciding that they're going to change and change practise.

They should never feel that it's something that's done to them. They should have an idea of cost. And they should have a, a, a realistic expectation that that the pertinent information about their pet has been transferred to the referral vet before their appointment, so that they, they, they, the referral vet has the information they need to look after their pet properly.

From the referral vet, they need an idea of what's involved, what any risks and rationale for investigation are, an idea of the diagnosis, the prognosis, the cost and what advice is being given, and for that to be communicated to their own vet in a timely manner, those are all important expectations. From the point of view of the, the, the vet making the referral, they have a, a, a, a, a, an expectation, a right to expect from the referral vet that they are experts in the field in which they claim to be, and people overselling their, their, their level of expertise should never be tolerated. It's it's, it's grossly unprofessional.

. Are they available for consultation in case of emergency or if there's a change in the animal's condition, is there a provision for this? If that person's away, do they have provision? Is there a colleague there that, that, that is suitably qualified to make decisions?

They, you should have an expectation that a referral vet should communicate the findings, diagnosis, prognosis, treatment plan, and any follow up to you in a timely manner. And you should feel that you have a relationship with a referral practise or referral vet where you can call for an update or if there's a change, you can, you can call. Obviously, If if investigations ongoing, you you might want to allow suitable time for investigation to be be performed before ringing for for an update there.

Sometimes we get very, very keen individuals ringing sort of an hour after patients arrived, once you know what we found, and we, we, we often need a bit of time to be able to do that, particularly with, with complex medical cases. It shouldn't be expected that, that a referral vet will see every case as an emergency, and this is an increasing pressure we, we, we, we face, and it's, it's not a realistic one that, increasingly every case we, we, we get asked to see is, is requested as an emergency, or so it seems. And, and really, unless it's a genuine emergency, we can usually see cases fairly, fairly quickly.

But it's not realistic for everything to be considered an emergency or for, for elective diagnostic investigations to be being performed outside hours unless it is clinically necessary for it to be done so. Similarly, one should never expect, when referring a case, you're deferring to someone's greater expertise in an area, and it's, it's not only very poor etiquette, but it, it leads to some, some quite serious problems to, to try and dictate what someone else is doing. Essentially telling someone else how to do their job without having the expertise oneself is, is not something that should, should, should ever be performed, of course.

And it tends to course clients that have expectations that may then be be discussed to the country by someone with greater expertise. So, so please avoid trying to paint yourself into a corner by, by saying with great certainty that a certain procedure, a certain investigation is going to be being done. And obviously, referrals should not be a means of divesting responsibility of care.

And you should expect that after referring a case, you have communications and what was done, what was found, and what the plan should be, including idea of prognosis, what treatments recommended, who's to dispense that? How's that going to be managed and for how long? What's the expected outcome?

What happens if that's not occurring? What are the contingencies? And where, when, how, what and why follow up is to be performed, and with what expectation and what contingencies are in place, what action should be taken if those expectations aren't met, and all of that should be very clearly communicated.

If it isn't, then the referral vet or referral centre is not doing everything right there. That that's something that that a referral centre should be doing. From the perspective of referral that, what we, we really need to, to, to have is, is information prior to the appointment.

So, we would expect that, that the owners want to and are committed to referral, that they've had a conversation, at which the conclusions been that that is what they, they, they want. They want referral and the costs of that are acceptable to them. And I'd emphasise we're always very, very happy to give estimates of, of, of costs.

It should go without saying that referring a client with outstanding debts is, is unethical. It should never be performed, that is, that is, that is unprofessional. It's important that all the information required is sent prior to the client arriving, that, that caused a great deal of client upset and it delays investigation.

We need the information in order to be able to help that that client's pet. We also expect that if there's any change or there's something concerning you, give us a call, always, always pick up the telephone and talk because without, and, and when we're writing referrals, we'll always emphasise that that if anything changes, let us know because we need to, we need to know that in order to try and help. Prior to referral, the information that's that's essential to receive, we need to have that animal's clinical records, but it's also really important to provide a note, it may just be a brief note, just explain the reason for referral.

That's not always clear from from just a set of clinical clinical records, particularly if they're quite brief in nature. And trying to ascertain why a patient's being referred can be quite difficult for some. So a brief note, and it doesn't have to be long, just explaining the reason why it's really important, and also mentioning any specific issues.

Obviously, as a courtesy to a professional colleague of an animal's bitten people before, please, please let someone know. That's just, just, just common manners. If there's a specific way in which you, you found that.

A client or animal is best handled, they can include that in a note or, or, or again over the telephone is very, very helpful. Any laboratory results need to be provided, all radiographs need to be provided. That's essentially, if a diagnosis be made on a, on some imaging.

Without providing that imaging, we can't really progress the case any further. So, it's important to provide all that information, not just notes that might say something like, old laboratory tests being performed and we're normal. We need to know which laboratory tests to provide all that information.

In short, all the information you can provide is essential. There are some things it's a, it's a very good idea not to do. It's a comforting fallacy, and we, we all recognise that when a referral is made, it's a, it's a little bit of a dent to one's ego to, to, to, to ask someone else to look at a patient where no progress is being made.

But to, to use the comforting fallacy of saying someone will make a diagnosis because they have access to better equipment. Is a little dishonest and tends to lead to problems, because if that specialist then says, well, actually, this is what I would recommend doing based on their increased expertise in that particular area, and it isn't using a piece of equipment that you sold heavily to an owner is going to be used and classically this occurs when people say, oh, your, your animal needs a CT scan or an MRI scan, usually a piece of equipment that, that, that the person making the referral doesn't have direct expertise in the interpretation of. It can paint one into a corner, and it can, can lead to a loss of faith from the client if that particular technique isn't performed, especially if a diagnosis can be made by you, more cost effective means or actually a different, a different technique.

So it's unwise to state confidently that a particularly diagnostic test is going to be performed, unless you have specifically discussed that with the specialist seeing the patient. Similarly, it's unwise to give unrealistic expectations, for example, trying to give a sort of overly flattering cost estimate, such as just estimating the cost of the consultation fee only, or saying that complex investigational treatments will take place in a single day in order to to Try and encourage clients to to pursue referral. That that's not realistic.

And similarly, saying that the routine investigations will be performed out of normal working hours, will only cause cause upset there. It's important to emphasise that clients arriving at a referral centre or referral vet without that person having received the information from their own vet. Usually leads to, to dissatisfaction.

Emergencies are a special case, and, and, and emergencies and the need for emergency referral is something that, that, that really places pressure on communication and increases the need for great care to be taken. The, the first consideration is, is if you're considering making an emergency referral, is, is it genuinely an emergency? We, we define an emergency as a patient that without And the the prompt attention of a specialist is likely to die within the next few hours.

We increasingly get requests to see cases as emergencies to an extent where we have to triage those cases that are genuine emergencies, that must be assessed by a veterinary surgeon on the basis of physical examination at the time, not that they've received a phone call from someone saying that they're worried, must be a clinical assessment by a vet. It's also important to distinguish whether actually it may be more appropriate that that out of hours provision is provided by an out of hours clinic rather than referral to a specialist is is necessary. Another question that should always be considered, particularly in the heat of the moment, and, and, and, and this is something that we And we'll try and help with them.

We're always available to help with this. Would that patient's clinical state be better managed by performing some sort of emergency first aid prior to any transport. And an example of that would be patients that are dissonate with pleural effusions, for example, draining of the the the the effusion and provision of oxygen therapy will make that patient so much more safe to transport.

And often in the heat of the moment and in the, in the hurry to get a patient to a specialist, we unfortunately see a number of patients coming in in transit and arriving dead that would not have done so had they, had they been properly stabilised first of all, or just had some, some, some routine care performed there. And that's something that we was very happy to to advise with and and there's always a source of information. Also emergencies, it, it's important to look at the big picture and, and to consider is the prognosis clearly poor.

Emergency referral that then immediately results in euthanasia because the outlook is hopeless is a potential welfare problem, and it's important to bear in mind that the bigger picture and identify those patients in which sadly, no amount of specialist care is going to, to, to benefit the patient. Obviously you'd seeing cases out of hours as emergencies, increases costs, and that should be discussed. Insurers will increasingly ask for justification of why an animal was seen as an emergency and increased fees were charged, and that's important to be able to justify.

As a professional courtesy and also practically, it is essential to speak to the referral vet to see if they can accept an emergency. And that is the responsibility of the veterinary surgeon making that referral. They shouldn't defer that to a member of nursing staff or receptionist.

A vet needs to discuss that with the, with the vet. They are hoping to to send the patient to. And of course that information about the patient needs to be provided before they arrive.

It will cause huge problems if patients arrive at another centre as an emergency, perhaps in an extreme state of illness, and that centre has not received any information that will always lead to problems. The best referrals, the ones that that that really enhance client relationships, is when the referring veterinary surgeon has approached referral as a collaborative process with their client and with the referral that and have taken time to discuss with owners whether it's what they want. That may involve having to make some some additional time for that.

Conversely, it's important to accept that for some owners, referral may not be appropriate for their wishes. And that may be down to cost, may be down to their wishes for their patient, and and and that can be difficult if if there's a veterinary surgeon, you you feel that referral is appropriate, but the client doesn't see the need. But unfortunately that circumstance, the the client's wishes shouldn't be be overruled or cajoled.

They, they, they will not be satisfied with the referral if it is, is not something that they are are are bought into. It's essential that the the financial implications and the practicalities of that are discussed. When referral works well, the the the referring vet has shown the care for their patient, professional courtesy to give that information that the referral vet needs prior to the appointment.

And conversely, the referral vet needs to work with the referring vet to deliver enhanced care to the patient, the owner. If all those things work well, then it, it is an incredibly useful process. It is really a win, win, win win situation.

The referring vet has the expert help they need in a difficult situation. They'll often gain information and knowledge as a result. The client will be very grateful to them, not only for their, their, their wisdom in making that decision, but also the fact that they have Being open and honest and candid in when when a situation is outside their their area of comfort or expertise, and that often enhances bonding with with clients because of that expert guidance that vet is given.

The client will feel their concerns have been addressed, that their vet cares and understands when someone else may be better placed to help. The referral vet obviously receives. Business from this.

But for, for us, it's all, all, all about performing our our job properly and enhancing the relationship between vets and their clients. We, we really want to help that relationship and also our own relationship with referring practises. And the the pet, of course, gets access to care that hopefully has has helped them in their, in their time of illness.

There are some situations in which referral isn't possible and in fact it most commonly isn't down to either practicalities like costs or client wishes. But help is is available. If there is a situation where you may require the benefit of someone else's expertise, there are lots of sources of of help that can be obtained without making a physical referral from specialists working in university departments, in, in private referral centres, and, and also increasingly commercial service providers such as IDEX will offer telemedicine services which are paid for services.

Bear in mind, of course, that if you are not paying for that advice, if you are asking a specialist colleague for their time and their expertise and to, to, to give you advice free of charge, we're all happy to do that, but we're, we're also always working as you are, in a very busy working environment with, with sort of paying clients there. And for very long hours. So there, there are some things that can, can help that that process.

If you're, you're requesting advice, if you're ringing up, then if you, the person you're seeking advice from isn't available, leave them a message, but it's useful to let your own reception staff know that they will be calling back. There's nothing more frustrating than trying to give some advice, only to be told that they're they're far too busy. To receive your phone call, when there are, there are another 12 people who also want advice.

So, so please let reception staff know. Don't send huge amounts of documentation to people expecting them to spend all their time reading through that. That's essentially asking someone to perform the work of a specialist and seeing a referral without actually paying any money for it.

And so, so having an idea, just, just condensing what it is you want to ask, and having an idea of that is, is very, very helpful. Similarly, don't be too surprised if, referral sense will prioritise giving advice to, to, to those people that refer to them on a regular basis. Rather than someone at the other end of the country that's never going to, to, to, to refer a case to them.

But we're very happy to give, give advice over the phone, but just, just bear, bear in mind that people are giving, giving up time, free, free of charge for that and try and help that process as much as possible. But there are routes available for getting advice when you need it. Where can things go wrong?

Well, usually when problems arise with the referral, it's down to communication. From the client's perspective, that may arise through feelings that they're not being listened to. So, so the client that doesn't really want referral and feels referral is something that's being done to them is likely to be dissatisfied.

And that, that comes down to to an often lack of that initial conversation that not being given an expectation of cost, that, that, that is something that is, is, an absolute clear professional requirement. It's, it's, it's in black and white in our code of professional conduct, that the cost should be discussed both by the referring vet and by the referral vet in an open and honest and inclusive way. .

Problems can arise when when a client is expecting a different type of action from that that's proposed by the, the person to whom the patient is referred. And, and that very often comes down to, unfortunately, sort of over specific discussion beforehand by the person making the referral. So I would emphasise, try not to, to, to, to sort of paint into a corner by saying with confidence that a particular procedure or investigation is going to be performed.

Information not being communicated prior to referral between, between vets is a is a a very frequent cause of dissatisfaction. From the perspective of, of, of the vet making the, the, the referral, the, the referring vet. One cause of communication difficulty or, or sort of worry or upset can be that they can feel, or one can feel questioned by another vet asking some questions about a case.

That's really something that that that's necessary in triaging cases to try and ascertain the urgency of the case and also to see whether useful stabilisation could be performed prior to to transport. Questions of that nature are not meant to undermine or question the veracity of previous findings. It's to try and get some information.

In the, the specialist world, we, we, we used to ask each other questions all the time. Every decision we make is, is constantly questioned by our peers. We work in, it's certainly a multidisciplinary practise in an environment where our decision making is, is, is questioned in a, in a friendly way, all the, all the time, and we get very used to it.

But if one isn't used to having your, you, you sort of, decision. Questions raised about that, it can feel threatening in some ways, but it's not that's not the way in which it's, it's intended to triage and get some idea of the urgency so that case can be prioritised so that that equipment personnel can be be rallied to, to, to, to particular needs there and so that an order of, of planning can be performed. There can also be be be issues if, if information is not received from the referral practise and that's something that should always be communicated to the, the, the referral practise.

Clients can appear to be critical of referring vets. It's, that's a very difficult one because referral centres and, and referral vets always accept that that they have expertise in an area purely because they've concentrated in that area and be trained in it, and they will have conversely, a lack of expertise in areas that they haven't. No criticism of a referring practise will ever be given by a a referral vet to, to a client.

It's not in anyone's interest for that to occur in a referral vet will ever do that. The clients can sometimes seek to raise questions with their, their, their referring vets as to why such and such diagnosis was not made before. And that can lead to, to, to feelings that, that maybe some criticism has occurred elsewhere.

I, I would say in 23 years, I've never, I've never seen a colleague criticise a referring practise to a client. It's not something that is ever likely to happen. So if you, you have feelings of, of that, always speak to the, the, the person to whom you've referred the case.

It's something that, that, that usually, understanding through a phone call is is something that will diffuse. And from the referral vet's perspective, often the, the, the, the problems that arise down to costs not being discussed, information not being provided, or, undue issues carrying around emergency referrals. That's a particularly common area of, of concern.

The bottom line is that that any communication issues can usually be sorted by just discussion by telephone. I can't emphasise enough how speaking between professional colleagues often helps with any areas of ambiguity, and increasingly people rely on email. Email really isn't adequate to convey, nuance and tone and discussion, .

Pick up the phone always and and speak with colleagues. We're all in this together, we're all professional colleagues together. It's accepted that that referring a case involves a certain dent to one's ego, by deferring to someone with expertise in a particular area.

It's an important decision to make, but it's often attended by, some diminution of one's own own ego. Remember that specialists aren't better vets. They're not, they're not better vets.

They don't have the, the, the breadth of skills that a general practitioner will have. They're better in one area because of longer concentrated and frequent training in that one specific area. It makes them very, very good and experienced in that, in, in that area, and that leads to an ease of diagnosis.

That isn't experienced if one sees a case of that nature, only very intermittently or, or never at all. So it's very common to have feelings of of kind of inadequacy or that you should have made a diagnosis. That's, that's not something that is a, a, a realistic self-criticism.

Don't be, don't be hard on yourself. Similarly, don't worry about being asked questions by special. We will ask each other questions all the time, and nothing's meant by it.

We're just trying to find out information. And we work in an environment where there are those checks and checks and balances. Clients being critical to their own debs is something that that specialists, the world over will bend over backwards to try and avoid.

There will certainly be no And criticism overt or implied coming from specialist centres, and we will do, we will defend any decision making and try and diffuse any problems all the time. It's in no one's best interests for any criticism to be levelled there. So, do, do be aware that it's very common to have feelings of criticism, but very often these are Are are not warranted.

They, they're things that if you have any doubts, always discuss with with the person to whom you have that referral relationship. So in summary, when, when we're making a referral, it's a, it's not a unilateral decision. There, there's some time needed to, to discuss with owners their wishes.

But that's time well spent because it fosters realistic expectations, makes sure that clients are are really on board with that, and they will appreciate that. They will have their relationship with you enhanced by that discussion. Because they, they will understand that you're making that recommendation out of regard and care and expertise and and and expert guidance to them.

And that's a very powerful thing. That's a very powerful thing for clients to understand about their vets. And remember that we, we're all in this together.

We, we're colleagues within the same profession and discussion and talking collaboration about referral is very important. No more so than in the, in the, the situation with emergencies where special care needs to be taken. And remember that that providers of referral services aren't just limited to the cases that they see, we, we can, can help in other, other ways.

Our times can be limited in those ways. So there, there, there, there are things to, to, to, to try and help that process. But there are large amounts of sources of help available, particularly over the phone.

And if in doubt pick up, pick up the phone and call, we're all very, very happy to try and help recognising that referral is not practical in all situations, or even if it's something you're considering, but don't know and want some guidance, we're again there to try and help. OK. So that's just a, a, a quick summary through through referral, but, but the way in which it's performed can, can really help your bonding with, with, with clients and, and, and make them trust you more, not less.