Hands On or Off? Decision Time for California's Veterinary Rehabilitation Oversight Proposal

How would the proposed change affect horses--and non-vet professionals?
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california veterinary law hands on or hands off

So leap with joy, be blithe and gay,

Or weep my friends with sorrow.

What California is today,

The rest will be tomorrow.

— Richard Armour (poet)

The final week for comments has arrived as California considers a major change in the legal status of horse care concerning rehabilitation. Under a proposal, direct veterinary supervision would be required and only licensed animal physical therapists and registered veterinary technicians would be allowed to provide equine (and all animal) rehabilitation therapy. 

Will it pass? An open hearing planned for Thursday in Sacramento gives the public a chance to comment.

The Jurga Report investigated how the proposed change might affect horses. Also possibly affected would be hundreds of non-veterinarian service providers in California who would lose their right to work if their services are re-defined as veterinary medicine.

Is this a workable plan for horses on farms as well as small animals in clinics? We asked the question, and share the thoughts of those who are concerned about animal care, on both sides of the issue.

Background

First of all, veterinary oversight or scope of practice laws are nothing new. They crop up every now and then and often are more relevant to small animal practice than horses, so you might not read much about them. An example are the animal grooming statutes in states like California. Clipping cat claws can be a big issue in some places.

Every state has its own more or less unique Veterinary Practice Act that governs how the profession is conducted in that state; it is ratified by the state legislature, which delegates the authority of enforcing that act to a state veterinary board.

The key to this legislation is that the state either adopts the language of what is called the Model Veterinary Practice (MVP) Act, provided by the American Veterinary Medical Association, or it updates a pre-existing document that has been used in that state. The variations from state to state in both the definition of veterinary practice and how the practice is governed can be confusing. The AVMA has several helpful charts to show the variations between states on various subjects or issues.

The board is also unique. It is made up of individuals who may or may not be involved in animal health or be veterinarians themselves.

Some states give wide powers to veterinarians for complete responsibility for the health and sometimes even the care or well-being of animals. Some parts of veterinary practice acts may be open for interpretation. When board members change, or a state adopts a new practice act, perceptions may also change.

The area of most contention in most veterinary practice acts is how veterinarians interact with other professionals who are providing healthcare or husbandry services that could be called veterinary services under some definitions...or not. In most states, professionals with many backgrounds, veterinary-licensed or not, work together with a common goal of assisting animals and the non-vet professionals are keenly aware of their legal limitations.

A state may also exempt a profession from the definition of practicing veterinary medicine. In several states, this is the case with farriery, which was called horseshoeing in previous Model Practice Acts. Other professionals--especially non-vet chiropractors, acupuncturists and therapists--are working on a de facto peace agreement with veterinarians. Stepping over the line can result in a “cease and desist” order from the board, and/or criminal prosecution for the illegal practice of veterinary medicine.

With a few exceptions, there has been peace in the valley for several years. So what’s going on in California this week?

The elephant in the room

As with so many contentious issues, there’s an elephant in this room, and the elephant isn’t your veterinarian. Nor is s/he the fox or the snake that many would like to suggest.

Nor is the elephant the nice horse-friendly professional who comes out and rubs your horse just the right way after a big endurance ride or three-day event. 

The elephant is the room is you, the horse owner. And the question marks surrounding the elephant are all about what decision-making rights come with owning an animal. If you suspect your horse has an abscess, do you call your vet first or your farrier? Do you think you should have the right to worm or vaccinate your own animals? What if you owned a dairy farm? What if you owned a kennel of hounds? Do the same decisions translate evenly across all animal ownership situations?

Very often, we see horses with a degree of tunnel vision, but the law is designed to view all animals with a wide angle view. What’s good for parakeets should also be good for dogs and cats and exotic pets and dairy cows and zoo animals. But in some situations, animal ownership comes with its own politics.

Non-veterinary practitioners don’t have much, if any, legislation to protect them. Nor do they have unions, licenses (usually), or a leg to stand on in court without the services of a skilled attorney who is probably out of most self-employed people's price range. Many aren't even insured, certified by a recognized, independent body or even educated to the highest level in their chosen fields. Yet owners want these people to work on their animals. Just ask them.

But do they have the right to employ them? That's the question at the heart of the California law change. Animal owners would need to accept the veterinary profession's opinion of who is qualified to come to our barns, and who should keep their hands and tools off our horses.

Animal owners don’t have much legislation to protect them, either. Even the classification of animals as livestock or companion animals affects how they are governed under the law. And the concept of whether animals are “property” or have standing as beings on their own is another big quandary for legal minds to ponder.

The California proposal

Another question that is rarely black and white is where animal husbandry, or routine care, ends and veterinary care begins. But also, where does veterinary care end? Or is being under veterinary care an over-arching continual state of existence for every animal? Is it just a matter of what phase of care an animal is in at any time? Are juvenile development and geriatrics phases of life or simply phases of an animal's lifetime of veterinary care? 

One day, will a court decision mandate that a veterinarian is required to show due diligence in providing care for an animal throughout its life? Does this extend to behavior, grooming and welfare?

The answers to these questions are not easy, but California’s veterinary entity is prepared to take a stand on rehabilitation, as they define it, for now. Under this proposal to be considered by the board shortly, no non-veterinary professionals except for licensed physical therapists (PTs) and registered veterinary technicians (RVTs) could legally provide rehabilitative services. Whether a veterinarian would like another professional to work on your horse or not, the law has already removed that option, according to the California Veterinary Medical Association, which says in its bullet list of statements on illegal veterinary practice (see links at end of article) that California veterinarians are restricted for referrals and may only legally refer cases to other veterinarians. 

All vets would be limited to the services of physical therapists and licensed veterinary technicians and all vets would be required to not just delegate the service to the allied professionals, but to be physically present to supervise the therapy as well. 

All horse owners who need rehab help for their horses would need to employ a rehab vet, who would oversee his or her team of accredited physical therapists and/or registered veterinary technicians.

That’s it, in a nutshell, except for the matter of words.

Defining animal rehabilitation

Rehabilitation is a wonderful word, with an implied positive outcome. Is it technically veterinary medicine, however? That’s the decision at the heart of this matter: is the role of the veterinarian a continuous one until some point where full health is restored? Or is there a point where “treatment” ends and “recovery” begins? Is there a state of being healthy? Are both treatment and recovery phases part of the veterinary care process? And, if they are, do they require the equal attention and physical involvement of a veterinarian? What exactly is and isn't part of rehabilitation, especially since animals are likely to have multiple or overlapping health or physical problems at many times in their lives? Is rehabilitation a state of being?

Everyone has opinions in these matters. Everyone also has opinions about the ongoing needs of animals for physical support, particularly when it comes to athletic horses who are continually between competitions but not necessarily sick or injured. The very nature of their competition conditioning and recovery after an event could be described within a “rehab” framework, even if they are not injured. Horses are conditioned to peak performance, they compete, they recover from competition, and then they begin the climb back to peak performance, or enjoy a spell of turnout for mental and physical wellbeing’s sake. Is anything less than peak condition evidence of being in need of rehabilitation?

Horses also have histories of injuries that require some special considerations in their care, sometimes for the rest of their lives. Does the occasional footiness of a recovered laminitic horse mean that it is in need of lifetime rehabilitation or only when it is actually experiencing pain from laminitis that manifests as lameness? If you're helping your horse do stretches to prevent that old injury from flaring up before and after a long ride, are you practicing rehabilitation? Is it ok if you do, as the animal's owner? Is it not ok if you pay someone else to do it?

The veterinarian

Jessica H. Waldman, VMD, CVA, CCRT, a California veterinarian dedicated solely to the practice of pet rehabilitation, sent out a national press release on September 4, asking to be heard before the September 10 meeting. Dr. Waldman is Medical Director of California Animal Rehabilitation (CARE) in West Los Angeles, and has worked with horses previously. She generously answered some questions about how the proposal might work for horse owners, vets, PTs and RVTs.

“Physical Therapists and Registered Veterinary Technicians working under direct supervision of a veterinarian will be beneficial for horses,” she assured. “Utilizing the medical knowledge of the veterinarians with the skills of PTs and RVTs will give animals the best care, fastest route to recovery, and long term financial savings for earlier. This includes safer and more efficient problem resolution and management. I know that these license holder pairings provide the gold standard of care to animals and I am truly looking forward to the benefits that horses will gain from this collaboration.”

But how can horse owners afford to employ multiple referral professionals, in addition to the “home” veterinarian, who also has a responsibility to follow the case? Many horse owners do not have the ability to haul horses to a clinic for treatment, so the barn call fees would mount up. Will horses suffer from lack of care?

Dr. Waldman didn’t see cost as an issue. “I believe it's cost effective for several reasons. First, because animals are diagnosed at the time of treatment, and often by a rehabilitation veterinarian, someone who will find other problems and put the whole picture together in a way others may have a hard time doing. 

“I find that having the correct initial information invaluable. Second, when a veterinarian and a PT work together there is no middle man (ie: no need to talk to regular veterinarian about the animal needing more pain medication, it would have been prescribed that day.) Next, the number of exams that would be recommended for follow up evaluations, medication alterations, confusing symptoms with the regular veterinarian are all eliminated. Overall, two brains are more efficient than one, and faster treatment means financial savings. 

“Many times I have created a different treatment plan than a previous plan from a non-veterinarian and I get immediate results.”

Best practice recommendations for referrals in veterinary medicine suggest that home veterinarians stay involved as a middle man, to protect the horse from the “too many cooks spoil the broth” syndrome. Someone needs to be keeping score, since many horses have medical veterinarians as well as performance-related veterinarians already. But this is a minor point, compared to the scope of the proposal. 

In contrast, well-known equine veterinarian Kerry Ridgeway DVM wrote to the Board and stated, “I have not, in 50 plus years of practice, seen or know of any horse that has been damaged or injured by paraprofessionals. It simply appears that the board is just trying to totally eliminate these valuable people that I have witnessed do very good work.”

The physical therapist

If you were an animal physical therapist, would you welcome this proposal or resent it? It sounds like job security. So why is there an online petition from the California Association of Animal Physical Therapists asking for signatures to defeat it?

The petition page explains, “Restricting consumer access to physical rehabilitation AND wellness-type services delivered only by a veterinarian or in a veterinarian's clinic (including for horses) would significantly increase your cost for these services, would not result in increased safety, and most importantly will take away your right to choosewho you want to treat your animals.”

An alternate proposal from the physical therapists is that they: “...provide animal physical therapy services only after a veterinary examination has been completed followed by veterinary medial clearance stating that the animal is appropriate for treatment. Physical therapists are accustomed to providing care for patients together with the primary physician through regular communication. By utilizing a similar approach with animals, clients are able to access the highest quality of care along with continued veterinary oversight to ensure patient safety.”


The sport therapist

Nicole Rombach,, APM (ITEC), MEEBW, CCBW, MSc, PhD earned her doctorate at Michigan State University College of Veterinary Medicine in 2013. The subject for her doctoral research was investigation into equine neck pain from the perspectives of pathology, neuromotor control and equine behavior associated with spinal dysfunction. She wrote a succinct letter to the California Veterinary Medical Board stating her opposition to the proposal’s definition of rehabilitation.

Dr. Rombach challenged the supposition that non-veterinarian professionals endanger a horse. “To my knowledge, there is no legal precedent of conviction for ethical or professional misconduct from a paraprofessional practitioner, that would insinuate that AR practice by practitioners outside the proposed new group is likely to put animal health or welfare at risk. ‘To deter harm to animal patients and consumers’ is thus a non-justified reason (or ‘benefit’).” She also questioned the effect of the regulations on a veterinarian’s ability to practice. “I do not know of one veterinarian who is content with passively overseeing AR, when his/her own clinical cases are waiting,” she wrote.

Addressing the horse owner, she wrote, “The supposed main benefactor of your proposed changes, the consumer, is unlikely to afford the service they desire for their animal under your proposed scheme – it is unrealistic to pay for a veterinarian’s time to directly oversee an AR session, which is priced separately over and above the veterinarian’s fee.

“Ultimately, the consumer/owner is an advocate for his/her own animal. Surely, denying the animal access to AR services goes against the very ethos of the practice of veterinary medicine.

“If the true aim of the California Veterinary Board is to protect veterinarians, AR practitioners and the animal (who is the ultimate consumer), it is time to embrace team work, and raise industry standards from a collaborative standpoint,” she concluded.

The equine body worker

Debranne Pattillo is director of Equinology Inc, a dynamic advanced study system for equine body workers. Equinology represents 201 registered Equine Body Workers in California and more than 1000 worldwide. The group is headquartered in California and conducts courses there and in Australia and Great Britain. The group is approved to operate in California through the state’s Bureau of Private Postsecondary Education (BPPE). Her long letter points out many inconsistencies in the proposal and asks for definitions of terms that are missing from the proposal, such as the difference between therapeutic massage and massage. 

She quoted from a letter provided by Naomi Kirschenbaum, DVM, who (like many others) called for teamwork when she wrote, “This rule would essentially end physical therapy for large animals outside of expensive rehabilitation centers which many large animal owners cannot afford to use.

"Patient care is often, and should be when needed, a team effort. Restricting use and access to qualified and experienced physical therapy for our patients would be a travesty. I cannot imagine this is the intention of the veterinary medical board.”

Pattillo acknowledged that the proposal, if passed, would”likely shut our doors after...21years.”

She also issued a call to action, encouraging horse owners and horse professionals to sign petitions, write letters to the Board, attend the Sacremento hearing on September 10, and write to members of the state legislature. 

The Equinology petition had a goal of 5000 signatures. By Tuesday, September 8, it had almost 6000.

In his letter, Dr. Ridgeway makes a point. “...Owners can use these modalities and paraprofessionals with their children, but cannot do so with their horses, i.e. their property. This makes no sense. The actions you propose are likely open to legal challenge by horse owners.”

In the end, it is true that this proposal is about professionals in California. But those professionals will surely include a major group of non-veterinary practitioners if this proposal passes: professionals who practice law, and will want to craft a definition of rehabilitation on behalf of whoever has the money to hire them. Perhaps another, and the most important group, is completely left out, because our horses simply can't testify to tell the court how they really feel.

Deadline

An open hearing will be held at 9 a.m. in Sacramento on Thursday, September 10 at the VMB offices so that the public may make comments. That said, members of the VMB may or may not be present to listen. California residents are invited to speak in favor of or against the proposed change.

Letters, faxes and emails can be sent to the Board. 

To learn more, please take the time to read the following documents before making up your mind and contacting state authorities:

VMB Proposal Notice

California Veterinary Medical Association Illegal Practice Position Statement 

California Association of Animal Physical Therapists (CAAPT) petition and analysis 

California Animal Owners Right to Choose Facebook Page

Equinology petition to the California Veterinary Medical Board

California VMB Initial Statement of Reasons for proposed changes

American Association of Rehabilitation Veterinarians Model Standards for Veterinary Physical Rehabilitation Practice (updated February 2014) 

American Animal Hospital Association forum on best practices for referral services

Send letters, pro or con, to
Elizabeth Bynum, Veterinary Medical Board, 1747 N. Market Boulevard, Suite 230, Sacramento, CA 95834. The letter must arrive no later than 5:00pm on September 10th, 2015.

Send faxes by September 10 to Ms. Bynum at 916‐928‐6849.

Send email by September 10 to Ms. Bynum at elizabeth.bynum@dca.ca.gov

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