The Breeders’ Cup Forum: Racing medication and its ‘shades of gray’
What began as a conversation with veterinarian Scott Palmer at the Welfare and Safety of the Racehorse Summit at Keeneland in October evolved over the next several months into the following article by the former president of the American Association of Equine Practitioners.
Palmer, an internationally known equine surgeon and director of the New Jersey Equine Clinic who has also worked as a racetrack practitioner, served on Gov. Andrew Cuomo's Task Force on Racehorse Health and Safety. The task force report, issued in September 2012, made numerous recommendations to improve the health and welfare of horses and jockeys competing in New York.
Palmer's term as chairman of the AAEP's Racing Committee recently came to an end, but he remains a member of that panel. – Ray Paulick
Horse racing is an industry in transition. It is a sport with a rich tradition but is competing for relevance in today's culture. Scrutiny from the public is greater than ever before and horse racing is struggling to redefine itself in the international gaming market.
A number of controversial racing issues – particularly injuries and medication usage – were spotlighted this year in the national media and before Congress. Racehorse medication is a flash point. While medication is often characterized by the media in black and white terms, it is in reality best understood in shades of gray. When one side of the dialogue is framed in terms of “hay, oats and water,” anything else is considered permissive medication. The reality, of course, lies somewhere in the middle.
Lack of uniformity in medication rules among racing jurisdictions continues to stifle industry progress. Multiple groups – including the AAEP – are pushing for reform of the racing business model and governance structure, but consensus has proved elusive. However, recent efforts, including The Jockey Club reformed racing medication rules and the ARCI medication proposals are on a parallel track to simplify and standardize regulation of medication. I feel confident that we are closer than ever to achieving a consensus on these issues.
Veterinarians are at the center of the medication controversy. How much medication is too much medication? This is an ill-conceived question that oversimplifies the medication discussion. Medication is not a quantitative issue. There is no correct or incorrect number to indicate “how much is too much.” The best approach to understanding and defining the appropriate use of medication in racehorses is to look at the question from a new perspective. Appropriate use of any medication should be based upon the findings of a thorough diagnostic examination in the context of a valid client-veterinarian-patient relationship. Importantly, the results of all medical treatment should be evaluated prior to entry for the race. The fundamental question of “is this horse fit to race?” should not be answered at 38 miles/hour in the company of other horses and riders.
As the intense media coverage of racing has demonstrated, the general public does not view veterinary medicine through the same lens as do veterinarians. Veterinarians who practice in the pari-mutuel environment view their role as sports medicine doctors.
This role has two components. First and foremost is to protect the health and welfare of the horse; second is to ensure that the horse is in top medical condition prior to competition. It is important to understand that these two roles are not mutually exclusive. In fact, they are often one and the same. It is our obligation as doctors of veterinary medicine to always put the health and welfare of the horse first should these two obligations come into conflict. And this certainly applies to the use of medication. Veterinarians are professionals, but as in any profession we don't always do the right thing. With that said, veterinarians must confront those difficult choices with honesty and a clarity of understanding of our role as medical professionals and stewards of the horse.
The dermorphin issue caught the industry off guard in terms of the scope of the problem and the gaps in the regulatory infrastructure to prosecute the cases and regulate the behavior of veterinarians. Everyone must be accountable, including veterinarians. Recent discussion has begun to address this issue and some have recommend action by the state licensing boards. This approach needs to be evaluated with due consideration given to the obvious distinctions between therapeutic overages, repeated violations and use of prohibited medications.
Medical records: Veterinarians practice in a culture defined by medical ethics, prescribed by the American Veterinary Medical Association. Veterinary medical records are the property of the horse owner. In general terms, veterinarians are not allowed to disclose medical records to anyone without the owner's permission. The exception to this rule is the horse participating in a pari-mutuel wagering event. In such circumstances the medical records are made available to the stewards on request. This satisfies the regulatory requirements. Disclosure of medical records to the public runs the risk of misinterpretation of the information by laymen. Bottom line; if the racing industry wants to disclose this information to the public, veterinarians will comply.
In terms of horse health and welfare, one of the major therapeutic medication concerns right now is the potential for abuse by the intra-articular injection of corticosteroids. This class of medication is appropriately used to control joint inflammation in horses. The therapeutic effect of most intra-articular corticosteroids is prolonged, measured in terms of weeks or months. Some corticosteroids are detrimental to cartilage health while others are actually protective of cartilage. The timing and selection of intra-articular corticosteroid therapy should be based upon a veterinary diagnosis and the optimal treatment of a specific clinical condition of the horse, not the entry date.
Are veterinarians divided on the issue of medication for race horses? The vast majority of veterinarians want to do what is best for the horse and for the industry. There are a few bad apples out there that give the profession a bad name. In general, veterinarians are tired of being cast as the whipping boy for what is wrong with racing.
The AAEP has a good story to tell. Over the past 10 years the AAEP has taken a hard look at racing and made recommendations that have the potential to reform the industry. The AAEP is part of the solution. The Racing Medication and Testing Consortium grew out of an AAEP Summit on medication. The AAEP has championed and helped to fund research to create science-based medication rules that are free from a political agenda. The AAEP advocates for uniform national medication rules. Practicing veterinarians have examined their own role in the medication issue and offered reforms that put the horse first. Our White Papers and Guidelines for Veterinarians practicing in a pari-mutuel environment speak for themselves. They tell a story of veterinarians trying to make a positive difference. In 2009 the AAEP pointed out the impact of purses in claiming races disproportionate to the value of the horse before any other racing entity even thought of the issue. The AAEP has been forward thinking on these issues and that needs to be a big part of the story. Change can begin if the racing industry would take such recommendations seriously, as has been done recently by Gov. Andrew Cuomo of New York.
Most veterinarians who work at the racetrack love horses. Some might even say that they feel a stronger affinity for the horses themselves than they do for the people they work with at the track. Sure, veterinarians want to make a good living, but when you consider the 24/7 responsibilities and the amount of stress and liability involved in managing the healthcare issues of these valuable horses, the money just isn't that good. It's not why we do what we do. Of course we charge for our professional services, but in most cases we are in this game for the love of the horse. The reality is that there are powerful commercial pressures felt by all the stakeholders of racing. Part of our job is to make sure that these commercial pressures do not result in unintended harm to the horse in the process. When it comes right down to it, stewardship and our oath as veterinarians trumps the money.
Is money part of the problem? Absolutely. It is naive to believe otherwise. The cost-benefit ratio of any treatment, including rest is always viewed through this lens.
You can't understand the medication issue in racing without appreciating the dynamics of the owner-trainer-veterinarian relationship.
In July of 2008 the AAEP formed a task force to define the role of the veterinarian in this process and to work with the racing industry to “put the horse first” in the process of widespread racing reforms. The AAEP task force identified a shared medication philosophy within the owner-trainer-veterinary relationship as one of the keys to achieving an appropriate use of medication in the racehorse.
In the past four years the AAEP task force, now a standing committee of the AAEP, has produced four white papers that provide recommendations for appropriate care and treatment of racehorses. Transparency of this relationship was a key focus of all of these documents. As the discussion evolved, it became apparent that a healthy owner-trainer-veterinary relationship, characterized by transparency and open communication, presented a unique opportunity to improve horse welfare, reduce the cost of veterinary services and improve the business model of racing.
In its simplest form, the owner-trainer-veterinary relationship is a hierarchical relationship with the owner at the top. The owner hires the trainer and the trainer hires the veterinarian. The veterinarian, however, usually bills the owner; occasionally with the bill being first reviewed and approved by the trainer. In this hierarchical relationship all communication between the owner and veterinarian is filtered through the trainer.
Most often there is a direct line of communication between owner and trainer and between trainer and veterinarian, but the communication between the owner and veterinarian is usually inconsistent, provoked by a serious medical condition of the horse or a large anticipated medical expense. As in any triangular relationship between three people, two of the people in the relationship are most often talking about the third, missing person. That's where the trouble starts.
The owner-trainer-veterinarian relationship can become extremely complex. For example, it is not unusual for trainers to hire more than one veterinarian to treat a given horse in the stable. The veterinarians may or may not be aware of the treatments rendered by the other doctor. In the absence of transparency, the potential perils of such an arrangement are obvious. When multiple owners are added to the owner-trainer-veterinarian relationship transparency and communication become even more challenging. Put a racing manager and assistant trainers into the mix and things can get really interesting.
During the past three years the AAEP held focus group discussions with Thoroughbred, Standardbred and Quarter Horse owners, trainers and veterinarians across the country. During these face-to-face meetings, open roundtable discussions were used to identify the concerns of each of the three groups.
Owners feel that veterinary costs are out of control, communication with their veterinarian(s) is poor, and they feel like they are working for the trainer, not the other way around.
Trainers are concerned that they are not attracting new owners to the game, that owners will move their horses to another trainer if they don't use medication to be competitive, and they feel that they must “manage” both sides of the relationship.
Veterinarians believe that accounts receivable are out of control. They are worried that trainers will fire them if they don't do what the trainer wants. They are frustrated that trainers don't want them to communicate with owners and view veterinary service as a commodity.
At the Arizona Symposium on Racing and Gaming last year, Bill Wright, a prominent Standardbred owner, emphasized the challenges of making a profit in racing and suggested that trainers need to “manage” veterinarians, not just “let them run loose.” A prominent trainer Karl Broberg indicated that reliance on veterinarians sometimes stems from losing streaks and the need to remain competitive. He suggested that “fear feeds on itself so a trainer may let a veterinarian run his barn.” In a Bloodhorse.com posting Tom LaMarra summarized the plight of racehorse owners in terms of a dysfunctional business model wherein the costs of training and racing exceed available purse money. The perceptions and concerns expressed over the past three years are just as relevant today as they were when the AAEP held the focus group discussions.
The core issues that challenge the owner-trainer-veterinary relationship are characterized by unrealistic expectations, fear of failure, loss of control and loss of income, poor communication and a focus on medication rather than professional services of veterinarians. The AAEP is recommending that veterinarians change the business model of their practices to emphasize billing for professional services while decreasing the cost of providing medication. The current business model of racetrack veterinarians is “upside down.” Veterinarians invest years in specialized medical training in a sports medicine field, then give away that training and expertise in managing the unique healthcare needs of an athlete in training and instead bill for medication. It should be the other way around.
Veterinary bills can be difficult to understand and may include expensive state-of-the-art diagnostic technology such as digital radiography. Proprietary medications such as Gastroguard, Hyaluronic Acid and Marquis can also increase “maintenance” costs of racing. We can all appreciate how frustrating it can be to get a $1,000 vet bill for what we thought was a healthy horse, particularly if there was no prior communication to indicate a need for these professional services or medications.
Remember who is the top of all of the owner-trainer-veterinary schematics. The horse owner needs to set the tone for this relationship. The owner is the “CEO” of this operation. At the start owners must decide how much involvement they want to have in this business relationship. Do they want to set a budget, do they want to be involved in the selection of the veterinarian who treats their horses. Do they want to be involved with treatment decisions and therapy options? Are they in their comfort zone in this role? Do they need education to prepare them for that responsibility? Can we provide on-line webinars or other educational programs that can fill this need?
The single most important thing an owner can do to reduce the cost of veterinary services is to hold a face-to-face meeting with his trainer and veterinarian and clearly define his expectations for professional services for his horses. The way to improve transparency and trust is through communication and client education. In many cases the “sticker shock” of a monthly veterinary bill can be softened by a simple phone call educating the owner about the need and rationale for a treatment plan that may include expensive medications. Having everyone on the same page with regard to medication improves the welfare of the horse, controls costs and helps to improve the business model of racing.