AVMA, the ultimate gatekeepers and their disdain for veterinary technician advancement

On July 14th the AVMA put out a convention daily news article that rattled the already abusive and contentious relationship between veterinary technicians and their organizations, and veterinarians and their representative organizations. This was not dissimilar to the opinion piece I wrote after the AVMA’s last piece on the same topic that can be found HERE.

Fortunately, I am not alone this time in writing an open opposition piece about the most recent AVMA clash. The Academy of Internal Medicine for Veterinary Technicians (AIMVT) put out a fantastic open letter to the AVMA. They also emailed it directly to the new AVMA president.

But first I wanted to address something that is getting a little murky. That is the difference between creating a “mid-level professional” or “Veterinary Professional Associate” and increasing the scope of practice for Veterinary Technician Specialists (VTS). A MPL/VPA and VTS are similar but two different things.

“Mid-level Professionals (MLP)” or “Veterinary Professional Associates (VPA)”: This role is centered around a Masters degree. Lincoln Memorial University has initiated an ONLINE pilot program already that is not accredited by AVMA. While these first classes are not guaranteeing an increased scope of practice, we have heard enough from LMU advisor Mark Cushing (a non-veterinary professional and lobbyist) and from conversations with students enrolled in the program to see the intent and goals of the program. Interestingly the first program director has recently left. In conversations with them I never got the feeling of real buy in for the program… Unfortunately, many of my colleagues and I have seen/heard of how conversations in the program amongst students try to discredit the VTS credential and share other misinformation about the VTS process- despite being taught by VTSes in the program (sidenote: VTSes should boycott teaching for this program as it is actively undermining the VTS. But that’s a different Op Ed.). Colorado State University (CSU), again with the help of Mark Cushing, is also looking into a pilot program with similar goals. Goals for a MLP/VPA include INDEPENDENT diagnosis, prognosis, treatment plans and surgery. Prescriptive authority is still unresolved.

Veterinary Technician Specialists: I have written on VTSes before which can be found HERE. In short to become a VTS, at minimum an individual must be a credentialed veterinary technician (CrVT) or nurse. They must have also worked a minimum of three years fulltime in their specialty, provide evidence of more than average continuing education, prove mastery- not basic competency- of skills singed off by a DVM (preferably a DVM or CrVT Specialist), provide professionally written case logs and reports, and pass a validated exam that may or may not have a wet lab associated with it. Most applicants for a VTS per the most recent data from Norkus et al. 2013, have been practicing for 11–15 years! Goals for increased scope of practice for VTSes includes a collaborative approach to diagnosis, prognosis, treatment plans and +/- limited surgical interventions with the DVM retaining full control over the case.

In an informational video put on by CSU the MPL/VPA curriculum developer Dr. Wayne Jensen stated:

“The Masters program makes it easier, its a package thing…it would be easier [than the VTS process]”

While I do agree with this statement it also elucidates the frustration and misconceptions between the two pathways to increased scope of practice for non veterinarians. For the MPL/VPA we have individuals that may or may not be CrVTs receiving 2–3 years of education and variable but minimal required clinical experience- with the LMU program being all online- getting to do more compared to a VTS. Meanwhile to be a VTS, one must be a CrVT with at the very minimum 6 years of clinical, hands-on experience with proven mastery of knowledge and skill, among the other requirements to apply for a particular VTS Academy. It’s almost offensive to compare the two.

The MPL/VPA appear extremely premature and unnecesary at this point in time. What has caused my and other VTSes out there frustration about the AVMA article and in another recent publication by the California Veterinary Medical Association (CVMA) is the mischaracterizeation of a now active law in Arkansas and a proposal in CA.

“Earlier this year, Arkansas adopted a law that will expand veterinary technician specialists’ (VTS) scope of practice. It allows these individuals to establish — on a temporary basis — a VCPR on behalf of the veterinarian and then diagnose and develop a treatment plan.” — From the AVMA article

“In the afternoon sessions the BOG conducted its regular quarterly meeting addressing various items of business, while the HOD heard a legislative proposal from Stephen Cital, RVT, SRA, CVPP, VTS-LAM (Res. Anesthesia). The proposal, slated for the 2024 California legislative session, would permit RVTs who hold specialty certification to diagnose injuries and illnesses, prescribe medications, and perform select surgeries by obtaining on-the-job training while working under the oversight of a veterinarian pursuant to a written agreement.” — From California Veterinarian, a CVMA publication.

These both are oversimplified and mischaracterize the actual language of the legislative text. So here we are.

Here I have copied and pasted the letter with my additions:

The Academy of Internal Medicine for Veterinary Technicians (AIMVT), in an effort to fulfill our mission statement of working with veterinarians to advocate superior patient care, client education and consumer protection, offers these responses to the AVMA’s recent disheartening and damaging statements, both in regards to the organization’s opposition to Arkansas HB1182 and its recent pledge to defend against the expansion of our scope of practice.

First, in response to the comments directly regarding Arkansas HB1182, the AVMA stated:

“Concerns include patient safety, client service, food safety, public health, and recognizing and continuing to ensure the value of degrees in veterinary technology”

Patient safety, client services, food safety, and public health all stand to improve under the guidance of a Veterinary Technician Specialist (VTS). These credentialed Veterinary Technicians (CrVTs) have undergone additional training, education, application standards, and examination to obtain this designation. We doubt the AVMA would argue that a Diplomate has more knowledge and skill than a Doctor of Veterinary Medicine (DVM). The same is true of the knowledge and skill of a VTS compared to a CrVT. The requirements of each of the 16 VTS Academies vary to some degree, but all require a minimum of three years working in their area of specialty as a CrVT, with some requiring far more experience. VTS are not new technicians — they are experienced veterinary health care providers.

Based on the AVMA’s testimony in Arkansas, it appears that the organization’s stance is that achievement of VTS certification decreases the value of our veterinary technology degrees. This is especially concerning given the fact that veterinary technology programs are required to be accredited by the AVMA’s Committee on Veterinary Technician Education and Activities (CVTEA). Achieving the designation of VTS increases the value of the technician, and this is reflected in the increased salary and responsibilities afforded these individuals. We are curious how the AVMA would recommend we ensure the value of our degrees given this context.

“The new law inappropriately expands the VTS’s scope of practice beyond these professionals’ education and training”

• ● Engaging in “joint management” of the health care of patients.
• ● Establish a temporary veterinarian-client-patient relationship.
• ● Order diagnostics, provide diagnosis, establish a treatment plan.
• ● Perform minor dental and surgical procedures on animal patients.

This is an extensive issue and deserves the proper and individualized attention to each concern raised by the AVMA. Many of the bulleted points of concern are “tasks” or “duties” currently in the legal practice of veterinary technicians in some states. It is also important to remind AVMA members they are not required to utilize a CrVT’s or VTS. The overseeing veterinarian will always be able to dictate their willingness to delegate duties and tasks to other credentialed veterinary staff members.

I can’t stress enough that the use of a CrVT or a VTS in states pursuing increased scope of practice is VOLUNTARY! If you don’t like it, don’t do it!

“Joint management” of the health care of patients”:

In practices that fully utilize their CrVTs at the tops of their licenses — a goal the AVMA purports to support — there is collaboration around care for patients every day. Whether it is development and subsequent DVM approval of an anesthetic protocol, or discussions around low stress handling techniques to improve patient experiences, or monitoring of critical patients; true partnership and joint management of patient care is the epitome of the role of the fully utilized CrVT. A VTS raises this collaboration to an even higher degree, as their advanced knowledge and skill allows for a more thorough understanding of the potential risks and benefits of various pharmaceuticals, treatment modalities, and procedures. This collaboration ensures gold-standard care of patients while in the veterinary facility, and improves the potential outcomes for those patients. This stated objection does not recognize the reality of current veterinary healthcare practice.

“Establish a temporary veterinarian-client-patient relationship”:

The requirements for establishment of a veterinarian-client-patient relationship (VCPR) already vary among the 50 US states. Legislation has recently been proposed in California (with support from the California Veterinary Medical Association) allowing CrVTs to establish a VCPR for the purpose of vaccination. Additionally, also in California, legislation is advancing to allow for a VCPR to be established via telemedicine, meaning no physical examination would take place. A VTS has much deeper and more extensive knowledge of performing a complete physical examination compared to CrVTs, and certainly could adequately establish a VCPR for the purposes of identifying pathologies within their area of specialty. When record-review and other supervision requirements are in place, such as those outlined in the Arkansas law, this is a reasonable and acceptable task for a VTS. We find this objection demeaning to our experience, credentials, education, and training.

From the California Bill alluded to above, SB669, which was supported by the CVMA, though ironically the legislative director of the CVMA seems to be double speaking a bit, in that the CVMA agrees RVTs in the state have the required knowledge to perform a physical exam and determine if an animal is able to receive a vaccine (via a diagnoses of the animal being “healthy”), yet at the same time helped draft the statement piece that says,

“Accordingly, the AVMA will vigorously defend the practice of veterinary medicine — which includes the ability to diagnose, prognose, develop treatment plans, prescribe, and/or perform surgery — against scope of practice expansions by non veterinarians that threaten patient health and safety, the safety of animal products, and/or public health.”

From SB669:

“(3) The registered veterinary technician examines the animal patient and administers preventive or prophylactic vaccines or medications for the control or eradication of apparent or anticipated internal or external parasites in accordance with written protocols and procedures established by the veterinarian, which shall include, at a minimum, all of the following:

(A) Obtaining the animal patient’s history from the client in order to reasonably ensure that the administration of preventive or prophylactic vaccines or medications for the control or eradication of apparent or anticipated internal or external parasites is appropriate.

(B) Data that must be collected by physical examination of the animal patient in order to reasonably ensure that the administration of preventive or prophylactic vaccines or medications for the control or eradication of apparent or anticipated internal or external parasites is appropriate.

(C ) Information in the patient history or physical examination results that would preclude the administration of preventive or prophylactic vaccines or medications for the control or eradication of apparent or anticipated internal or external parasites.”

“Order diagnostics, provide diagnosis, establish a treatment plan”:

In the reality of today’s veterinary practice, fully utilized CrVTs are already anticipating the DVM’s needs and what diagnostics will be needed to aid the DVM in an appropriate and correct diagnosis. The Arkansas law does not include diagnosis within the scope of practice of the VTS — this is a task reserved for the DVM in every state veterinary practice act. However, it would be unrealistic to assume VTS are incapable of forming conclusions regarding a patient’s condition and potential disease processes, based on history, physical examination, and presentation. In fact, a VTS may have far more experience than recently graduated DVMs, and are valuable partners in assisting the DVM with the selection of appropriate diagnostic tests and treatments. This partnership is nothing new. When the CrVT and the VTS are included as full partners in the diagnostic process, as well as a patient’s treatment plan, we reduce the mental load of the DVM, who is often dealing with many patients and may not have the opportunity to provide every patient and client with hours of their time. CrVT and VTS are also the team members responsible for providing prescribed treatments, including nursing care. We often have the first opportunity to evaluate a patient’s response (or lack thereof) to prescribed treatments. This leads to a more complete picture of the patient, and ultimately better, more efficient care. This is not a new concept and is employed in veterinary facilities everywhere. To act otherwise is obtuse, and a dismissal of what we all know to be true. CrVT and VTS utilize their experience and education to suggest additional treatments and diagnostics by often knowing what a DVM wants before they are told. Many of us are also developing practice or corporation-wide protocols for common presentations. Many states are simply asking for permission to be in place (via amendments to state Veterinary Practice Acts) so that DVMs that choose to utilize their CrVT and VTS to their fullest potential may do so. None of what has been proposed in any state thus far is proscriptive: no DVM is required to hire a VTS and utilize them in the manner outlined.

My additions to this include a reminder to doctoral vet students, new grads, interns and residents of veterinary medicine. Remember when you were in the teaching hospital or in a clinical setting? Who helped you? Who caught your mistakes? Who TAUGHT you things you didn’t learn in vet school? I’d bet veterinary assistants and CrVTs did. For those of you with the luxury of working with a VTS, I know this to be true.

“Perform minor dental and surgical procedures on animal patients”:

The objection to this point again ignores the variation in Veterinary Practice Acts across the US. For example, in California RVTs may extract teeth, they may suture gingiva, they may treat and suture lacerations, and close surgical sites. For many years, CrVTs in several states were allowed to perform feline neuter procedures. Given the current lack of veterinary care available, especially in rural and shelter settings, allowing the VTS to perform procedures that do not enter a body cavity — such as scrotal neuters and skin lesion removal — will expand the access to care for more patients and clients. As we are sure the AVMA is aware, the majority of new DVMs leave veterinary school without ever having performed a complete surgical procedure. We are unclear how allowing those new DVMs to perform surgical procedures after graduation is less dangerous than allowing a highly skilled, experienced, and educated VTS to perform minor, relatively low-risk procedures.

I recently gave a presentation to the CVMA house of delegates about a Bill that would increase the scope of practice for VTSes in the state of California. When it came to the potential of surgical procedures the biggest piece of feedback wasn’t necessarily VTSes performing the very limited procedures described, but the “standardization” of training and the “what if something goes wrong” argument. There was even discussion about how inappropriate it is for people to learn from YouTube. Looking back on my presentation I wish I would have pushed back harder. I did state what the open letter says above but wish I would have emphasized that in fact I have seen countless DVM’s, old and new, watch YouTube videos on how to perform certain surgeries or skills, and certainly many of us are accustomed to pulling out Fossum’s during a surgical procedure so the DVM could read what to do next. Let us also not forget the last few years of our DVM classes learning almost everything online during COVID. I mention this not to shame anyone for doing their homework or online learning but to challenge this overzealous and hypocritical assertion that DVM’s know everything and that learning outside of a vet school setting is somehow questionable.

In addition, when working in academia or specialty medicine it is not uncommon to see surgical cases where we are repairing what a non-specialized DVM has attempted surgically that may have been best left to a boarded surgeon. It’s also important to note there is no real “standardization” within veterinary schools and certainly internship and residency programs. AVMA accreditation focuses on core knowledge and competencies but does not direct schools or posdoc training on things like how to perform a certain procedure, nor are the veterinary school models that don’t have teaching hospitals- that rely heavily on clinical rotations- vet the DVMs teaching veterinary students, sometimes poorly. There is also conversation about offering a “spectrum of care” which takes away this idea of “gold standard” medicine that certain programs strive for instead of teaching more practical, unique care that meet the animal’s healthcare needs but pays close attention to the resources and abilities of the clients.

Next, we would like to respond to the policy released by the AVMA House of Delegates on July 13th:

Animals deserve safe, efficacious, and high-quality care, and animal owners should be able to fully trust the veterinary services provided for them. Accordingly, the AVMA will vigorously defend the practice of veterinary medicine — which includes the ability to diagnose, prognose, develop treatment plans, prescribe, and/or perform surgery — against scope of practice expansions by nonveterinarians that threaten patient health and safety, the safety of animal products, and/or public health. Veterinary healthcare is enhanced through efficient utilization of each member of the team through appropriate delegation of tasks and responsibilities by the veterinarian.

This policy, and other statements in the same spirit (see the response to last year’s “camels in the tent” discussion at the HOD meeting), are of no benefit to the development of a more collaborative veterinary healthcare team. In fact, this policy only reinforces the essential need to recognize and understand the utilization of the CrVT and VTS. The continued misunderstanding of the education and skill of a CrVT or VTS is distasteful and disappointing. We as an Academy, and as industry leaders in Veterinary Technology, ask the AVMA board and its members to allow us the opportunity to work together to promote better utilization of the credentialed, experienced, educated and professional support team, which will benefit the veterinary profession, our clients, and — most especially — our patients.

Based on many reports (some are attached for your reference), including some issued by the AVMA, the current practice model employed in veterinary medicine is not adequately serving clients, patients, DVMs, or CrVTs. Turnover is rampant. Many credentialed veterinary professionals — both CrVTs and DVMs — are considering leaving the profession altogether. There is a crisis in providing care for the patients who need it. It is time for the practice of veterinary medicine to evolve and to find ways to keep more of us in the field, ensuring the health and safety of all animals in the US.

The AIMVT would like to create a true collaboration between the AVMA and the VTS Academies. The AVMA does not appear to be fully aware of the application requirements and the VTS application and testing process required by the Committee of Veterinary Technician Specialties (CVTS) of the National Association of Veterinary Technicians of America (NAVTA) for a recognized Academy of Veterinary Technician Specialists. We would be pleased to have an open conversation around our requirements. While the AVMA has recently begun focusing efforts on increasing veterinary technician utilization (via the formation of the Committee on Advancing Veterinary Technicians and Technologists [CAVTT]), the organization’s actions have not demonstrated that it truly values the CrVT or VTS. AIMVT is committed to helping to provide any information regarding skill and knowledge requirements for any of our specialties that may shed light on the abilities of the VTS members of our Academy. Attached you will find the skills and knowledge lists for each of our internal medicine specialties. Each of the 16 current VTS Academies has skill and knowledge lists that are just as extensive, covering their specific specialty. We know that few DVMs have taken the time to review this information in the past, and this lack of exposure and understanding has — we believe — led the AVMA to take an uninformed position in regards to the capabilities of a VTS.

We thank you for your time and look forward to hearing from AVMA and working with you to create a better future for the veterinary profession.

With hope for collaboration and cooperation,

Jenny Cassibry Fisher, RVT, VTS (Oncology) President, AIMVT

To say I’m disappointed but not surprised by the AVMA’s most recent pledge is fair. If you are reading this as a DVM, please look deeper into what a VTS is, follow the money behind initiatives like the mid-level practitioners as it is not necessarily technician driven.

For the technicians/nurses reading this. Be smart. Ask questions and for the love of this profession don’t get sucked into the smoke and mirrors so many are distracting us with.