The Equine Veterinary Workforce Crisis: Why the Missing Middle Matters

Every equine veterinarian has attended their first colic. Every experienced practitioner once questioned whether they were good enough. Somewhere between those two moments lies the future of equine veterinary medicine.

It Starts With a Phone Call

It’s 5:45 on a Friday afternoon. The consult room has finally fallen quiet. Most of the paperwork is finished, and after a long week, home is finally in sight. Then the receptionist walks in.

“There’s a horse with colic about twenty minutes away.”

The new graduate looks up from their notes. They know colic. They’ve spent years studying the physiology, learning treatment protocols, and watching experienced clinicians manage countless cases during veterinary school and externships.

But this time is different.

There isn’t a senior clinician standing beside them. There isn’t a teaching hospital down the hallway. There isn’t someone else making the decisions.

There is only a truck, a worried owner and a horse waiting for them. For just a moment, they hesitate.

Not because they don’t care. Not because they aren’t intelligent. But because they aren’t yet certain they are ready. Every equine veterinarian remembers a moment like this.

Perhaps it wasn’t colic. Perhaps it was a septic joint, a dystocia, a complicated laceration or the first lame horse you were expected to investigate on your own. 

Whatever the case, there comes a moment when theory meets reality and you realise that graduating from veterinary school and feeling confident enough to manage patients independently are two very different things.

That moment is only starting to appear in workforce reports or industry surveys.

Yet it may be one of the defining moments in an equine veterinarian’s career, because what happens next often shapes the rest of it. It determines whether that veterinarian says “yes” to the next horse, or gradually begins saying “no.”

We’ve Been Asking the Wrong Question

For years, our profession has been focused on one important question:

How do we solve the shortage of equine veterinarians?

It’s a legitimate concern.

Across the United States, the American Association of Equine Practitioners (AAEP) has highlighted growing workforce shortages, particularly in rural communities. Approximately 1.3% of veterinary graduates enter equine practice directly each year, while another 4.5% undertake equine internships. Of those who do enter equine practice, around half leave equine practice, or veterinary medicine altogether, within five years.

The United Kingdom tells a similar story. Research from the British Equine Veterinary Association has identified long working hours, perceived understaffing, increasing burnout and significant numbers of veterinarians considering leaving equine practice.

These are genuine challenges. Long hours, emergency duty, comparatively lower salaries, and the difficulty of maintaining a healthy work-life balance all contribute to the problem. No amount of training can compensate for poor leadership, chronic understaffing, or unsustainable on-call systems.

But perhaps there is another question we haven’t spent enough time asking.

What if the problem isn’t simply that we don’t have enough equine veterinarians?
What if we don’t have enough veterinarians who feel confident managing common equine cases?

Those are not the same problem.

And they require very different solutions.

The False Choice

Spend enough time talking with veterinary students or recent graduates and a familiar pattern begins to emerge. Many feel as though there are only two possible career paths.

The first is to avoid horses altogether and choose small animal practice instead.

The second is to become an equine specialist by completing internships, progressing into residencies, working in referral hospitals, publishing research, and building an academic career.

Anything less can feel like falling short. Of course, nobody explicitly teaches this. But it’s remarkably easy to absorb.

Veterinary conferences naturally showcase remarkable specialists performing advanced surgery, interpreting complex diagnostic imaging and managing some of the most challenging cases in equine medicine. Referral hospitals represent the highest levels of clinical expertise. Universities often expose students to the most complicated cases because they provide outstanding teaching opportunities.

These experiences are invaluable. However, they can also unintentionally create a distorted picture of what successful equine practice actually looks like.

Because the vast majority of horses never require referral-level medicine.

Most horses simply need a veterinarian who is willing to answer the phone, perform a thorough clinical examination, recognise what is routine and what is potentially life-threatening, begin appropriate treatment when it’s safe to do so, and recognise when referral offers the horse the greatest chance of success.

That veterinarian doesn’t need to know everything. They simply need to know enough.

The Missing Middle

Modern human healthcare systems are not built entirely on specialists. Human medicine depends upon family physicians, emergency physicians, general practitioners, urgent care, and community hospitals. Only a relatively small proportion of patients ever require referral to tertiary centres.

Equine veterinary medicine is no different. Yet our profession often behaves as though there are only two destinations: don’t see horses, or become a specialist.

Between those two extremes lies a much larger group that receives surprisingly little attention. The competent equine general practitioner.

This veterinarian isn’t trying to become a referral hospital, nor are they avoiding equine work because they feel overwhelmed. Instead, they occupy what may be the most strategically important position in the entire profession.

They are the first veterinarian called to assess a horse with colic. They investigate the first lameness, repair routine wounds, provide preventive healthcare, stabilise emergencies, and guide owners through difficult decisions. They know when treatment can begin locally, and just as importantly, they know when referral is in the horse’s best interests.

But What Happens When Referral Isn’t Possible?

There is, however, an important reality we need to acknowledge. Recognising that a horse would benefit from referral does not necessarily mean referral is available.

This is one of the areas where equine veterinary medicine can be very different from human healthcare. Depending on where a veterinarian is practising, the nearest referral hospital may be hours away. Transport may not be available. The owner may be unable or unwilling to pursue referral. In some regions, access to appropriate specialist care may simply be limited.

That can leave the first-opinion veterinarian in an extremely difficult position. They may recognise that a case is approaching, or has moved beyond, their usual level of competence, yet still find themselves responsible for making the best decisions they can for the horse in front of them.

We shouldn’t pretend that better referral pathways alone solve this problem.

General practitioners need the clinical judgement to recognise their limitations, but they also need access to practical continuing education, experienced colleagues, specialist advice and professional support when referral isn’t immediately possible.

The objective is never to encourage veterinarians to work beyond their competence. It is to help them become better prepared for the realities of first-opinion practice, including those occasions when the ideal clinical pathway simply isn’t available.

And that is another reason why developing the missing middle matters.

A strong profession doesn’t eliminate specialists, nor does it expect every graduate to become one. It builds a broad, confident middle of veterinarians who are comfortable managing the common conditions they encounter every week, who recognise when a case is moving beyond their capabilities, and who have access to support when referral isn’t straightforward or possible.

That isn’t “basic” veterinary medicine. It is an essential part of a functioning equine veterinary profession.

Perhaps that is the opportunity we’ve been overlooking. Not simply producing more specialists, but helping far more veterinarians develop the knowledge, judgement and confidence to care for the horses already living in their communities.

The Confidence Gap Isn’t a Knowledge Gap

If knowledge alone determined who stayed in equine practice, our profession wouldn’t have a workforce problem.

Today’s veterinary graduates enter practice with an extraordinary understanding of anatomy, physiology, pharmacology, and evidence-based medicine. They have spent years studying disease processes, interpreting diagnostic images and learning from some of the world’s leading clinicians.

Yet many still hesitate when the first horse is standing in front of them.

Why?

Because competence and confidence are not the same thing.

Knowledge tells you what a strangulating lesion might look like. Confidence allows you to walk into a stable at 10:00 pm, assess the horse under pressure, communicate clearly with an anxious owner and decide whether referral is needed immediately.

One is acquired in the lecture theatre. The other is developed through experience. That distinction matters because confidence isn’t something veterinarians either possess or lack. It is built gradually, one case at a time, through repeated exposure to real clinical situations.

The Confidence Loop

The profession often assumes confidence comes first. In reality, confidence is usually the result, not the starting point. It develops through repeated success at an appropriate level of challenge.

Imagine a veterinarian attending a straightforward wound repair. The case goes well. The next time a similar call comes in, they accept it with a little less hesitation. As they gain more experience, they become more efficient, more accurate and more decisive. Their confidence grows naturally because it is supported by successful clinical experience.

That increased confidence encourages them to accept slightly more challenging cases. Those cases generate additional experience, which develops greater competence, which in turn reinforces confidence.

The cycle continues.

We call this The Confidence Loop.

Experience → Competence → Confidence → Willingness to Take the Next Case → More Experience

Unfortunately, the opposite cycle exists as well.

A veterinarian declines their first equine emergency because they don’t feel ready. Months pass before another similar opportunity arises. Skills become rusty through lack of use, confidence declines further and the next case feels even more intimidating than the first.

Eventually, that veterinarian begins to see themselves as someone who “doesn’t really do horses.” The difference between those two careers often has very little to do with intelligence. It has everything to do with opportunity, experience and support.

The Research Supports What Experienced Veterinarians Already Know

Interestingly, the scientific literature reflects what many experienced equine practitioners have observed for years.

Research involving veterinary students in the United Kingdom found that mentoring and workplace support were among the most important factors influencing graduates’ first career choices, ranking ahead of salary for many respondents. More than half perceived significant barriers to entering equine practice, while confidence in handling horses was strongly associated with a greater intention to pursue an equine career.

Think about what that means. The profession doesn’t have a generation of graduates who have lost interest in horses. It has a generation searching for workplaces where they believe they can safely become equine veterinarians. The same pattern continues after graduation.

The American Association of Equine Practitioners reports that more than 70% of new equine graduates choose internships. Not because they lack intelligence, but because they recognise that independent clinical practice requires more than a veterinary degree. They are seeking additional experience, mentorship and structured professional development before accepting greater responsibility.

Research into mentoring tells a remarkably consistent story. Early-career veterinarians repeatedly describe experienced mentors as a clinical safety net. Having someone available to discuss difficult cases, validate decisions and provide constructive feedback reduces stress and accelerates the transition into confident, independent practice.

Perhaps the strongest evidence comes from the profession itself.

The Royal College of Veterinary Surgeons introduced the Veterinary Graduate Development Programme because graduation is recognised as the beginning of professional development, not the end of it. Structured supervision, protected learning time and progressively increasing responsibility are now considered essential elements of early-career development.

All of these initiatives point towards the same conclusion. The journey from veterinary graduate to confident equine practitioner does not happen automatically. It needs to be intentionally designed.

The Equine Competency Pyramid

If we want to strengthen equine veterinary medicine, we also need to rethink how we view career progression. Too often, success is imagined as a straight line towards specialisation. In reality, it looks much more like a pyramid.

At its foundation are veterinary students building clinical reasoning, practical horse-handling skills, and supervised experience.

Above them are new graduates, learning to apply that knowledge safely in real practice through mentoring, structured support and progressive responsibility.

The largest layer of the pyramid sits above them. The competent equine practitioner.

This is the missing middle.

These veterinarians are not trying to perform every advanced procedure, nor do they pretend to know everything. Instead, they confidently manage the cases that form the backbone of everyday equine practice: colic, lacerations, routine lameness investigations, preventive healthcare, foal examinations, dentistry appropriate to their level of training, emergency stabilisation, client communication and referral decisions.

Everything above this layer depends upon it. Advanced practitioners can then develop deeper expertise in areas such as dentistry, reproduction, sports medicine or diagnostic imaging.

Finally, at the apex sit referral specialists whose expertise is indispensable for the profession’s most challenging cases. Importantly, this pyramid is not a hierarchy of worth.

It is a hierarchy of scope. Every level is essential.

Without specialists, complex cases cannot receive advanced care. Without competent first-opinion practitioners, specialists never receive appropriate referrals. Neither group can function effectively without the other.

Every Specialist Started Somewhere

One of the unintended consequences of modern veterinary education is visibility. Students spend enormous amounts of time learning from internationally recognised experts. That is an extraordinary privilege.

However, it can also create a subtle illusion. Students see the finished product. They rarely see the journey that came before it. Professor Dennis Brooks wasn’t born one of the world’s leading equine ophthalmologists.

Dr Sue Dyson didn’t begin her career as an internationally respected authority on equine lameness.

Every respected clinician once attended their first emergency.
Every specialist once repaired their first uncomplicated wound.
Every leader in equine medicine once questioned whether they were making the right decision.

The difference wasn’t that they were fearless. The difference was that they continued saying “yes” to appropriate opportunities while learning from experienced colleagues along the way.

That is an important distinction. The goal of our profession should never be to make every veterinarian a specialist.

The goal should be to help every veterinarian become a confident, competent practitioner working within an appropriate scope of practice.

Specialisation should remain an aspiration for those who choose it. Competence should become the expectation for everyone caring for horses.

Why This Matters to Horse Owners

Horse owners rarely ask whether the veterinarian arriving at their property is a board-certified specialist.

They ask a much simpler question.

“Can you help my horse?”

Sometimes the answer will be yes.
Sometimes the answer will be, “Your horse needs referral-level care.”

Both responses represent good veterinary medicine. The real problem occurs when no one feels confident enough to attend the horse in the first place.

A horse with colic doesn’t always need immediate surgery. But every horse with colic deserves a veterinarian capable of assessing the situation, initiating appropriate treatment where indicated, recognising when referral is required and helping the owner make informed decisions.

That is the role of the missing middle.

It is not about replacing referral hospitals. It is about ensuring every horse has access to a confident first point of contact. Because accessible equine healthcare doesn’t begin at referral centres. It begins with a veterinarian answering the phone.

What This Means for Practice Owners

If we accept that the missing middle is real, then the implications extend far beyond veterinary schools and continuing education providers.

They fundamentally change the way equine practices recruit, develop, and retain their veterinarians.

For decades, many practices have searched for the same person: an experienced equine veterinarian who can immediately contribute, confidently manage emergencies and require very little supervision.

On paper, that makes perfect sense. The problem is that this veterinarian often doesn’t exist, at least not in the numbers the profession needs.

Practices compete for the same limited pool of experienced clinicians. Salaries increase, vacancies remain unfilled and existing veterinarians shoulder even greater workloads. Those heavier workloads contribute to burnout, burnout drives more veterinarians away from equine practice and the shortage becomes even more acute.

It becomes a self-perpetuating cycle.

Perhaps the more valuable question isn’t, “Where do we find an experienced equine veterinarian?”

Perhaps it’s, “Which veterinarian could become one?”

That subtle shift changes almost everything.

Instead of endlessly searching for the finished product, practices begin building capability from within. A graduate with a genuine interest in horses, a mixed practitioner wanting to expand their equine caseload or an associate who lacks confidence rather than ability suddenly becomes an investment rather than a compromise.

Success then depends less on recruitment and more on the systems a practice has in place to develop its people. Many other professions already think this way.

Airlines don’t recruit only experienced captains. They develop first officers through structured supervision, mentoring and progressively increasing responsibility.

Surgical training follows the same philosophy. Junior surgeons aren’t expected to perform complex procedures independently from their first day. They learn by observing experienced colleagues, practising under supervision, receiving feedback and gradually taking on more responsibility as their competence grows.

Equine veterinary medicine should be no different. Competence is rarely discovered. It is developed.

Building Confidence Requires More Than Clinical Training

Of course, confidence cannot be separated from the environment in which veterinarians work.

Continuing education plays an important role, but no educational program can compensate for a workplace that is fundamentally unsustainable.

A veterinarian working excessive hours, carrying an unreasonable emergency workload, receiving little mentoring and having no opportunity to discuss difficult cases will struggle regardless of how many continuing education courses they complete.

Likewise, expecting graduates to perform independently from their first week risks damaging confidence long before genuine competence has had the opportunity to develop.

The evidence consistently points towards a broader solution. Veterinarians need workplaces that encourage learning rather than simply expecting performance.

That means experienced colleagues who remain approachable after hours. It means regular case discussions where uncertainty is welcomed rather than criticised. It means protected time for professional development and referral relationships that are viewed as collaborative partnerships rather than signs of failure.

These aren’t expensive luxuries. They are long-term investments in clinical capability. Importantly, this approach also benefits experienced veterinarians.

Mentoring another clinician strengthens your own clinical reasoning, creates greater consistency across the practice and gradually reduces the burden of carrying every difficult case yourself. A stronger middle ultimately creates stronger teams.

Strengthening the Middle Strengthens Specialists

Some specialists may understandably read the concept of the missing middle with caution. Any discussion about increasing the confidence of general practitioners could be interpreted as encouraging veterinarians to work beyond their competence.

Nothing could be further from the intention. The purpose of strengthening the middle is not to reduce referrals. It is to improve them.

Every referral clinician appreciates receiving a horse that has been appropriately assessed, stabilised where necessary, accompanied by a thorough history and referred before valuable time has been lost.

Likewise, every first-opinion practitioner values having access to specialists who are willing to discuss difficult cases, provide advice and accept referrals without judgement.

These relationships are not a hierarchy. They are partnerships centred on the needs of the horse.

The strongest healthcare systems have always depended on capable community practitioners working alongside highly skilled specialists. 

Specialists extend the depth of care available. General practitioners extend its reach. Both become stronger when the other succeeds. This perspective also removes an unnecessary source of anxiety for younger veterinarians.

The objective is not to manage every case independently. It is to develop the judgement to recognise which cases can be managed locally, which require specialist advice and which should ideally be referred immediately, while also recognising that referral is not always available or possible.

Knowing where your limits lie is one of the clearest signs of professional maturity.

Continuing Education Has a Different Role Than We Often Imagine

This perspective also changes the way we think about continuing education.

Too often, professional development is viewed as a race towards increasingly advanced knowledge. Courses become longer, techniques become more sophisticated and veterinarians accumulate information they may never have the opportunity to apply.

There is nothing wrong with advanced education. Our profession depends on it. But if our goal is to improve access to equine healthcare, perhaps the greatest opportunity lies elsewhere.

Perhaps the most valuable educational programs are not those teaching the rarest procedures.

Perhaps they are the ones that help veterinarians confidently manage the cases they are most likely to encounter next Monday morning.

That philosophy sits at the heart of The Practitioner’s Program.

Rather than attempting to transform every veterinarian into a referral specialist, the curriculum focuses on the presentations that form the backbone of everyday equine practice: colic, wounds, foals, lameness, dentistry, cardiac murmurs, client communication, fee discussions and practice management.

These are the cases that determine whether a veterinarian feels confident saying “yes” when the next horse owner calls.

It can also help practitioners feel better prepared for situations where they may find themselves clinically stretched, particularly when an experienced colleague or referral option isn’t readily available.

Ultimately, the value of any educational program should never be measured simply by the number of hours of content it provides.

It should be measured by the change it creates in clinical practice. Does the veterinarian feel better prepared to assess the next horse? Do they communicate more effectively with clients?

Are referral decisions made earlier and with greater confidence? Are more horses receiving timely veterinary care because clinicians feel supported rather than intimidated? Those are the outcomes that truly matter.

The Opportunity We Cannot Afford to Miss

The equine veterinary workforce will not be transformed by a single initiative. Better remuneration, healthier workplaces, more sustainable emergency rosters, stronger leadership and improved wellbeing will all remain essential priorities.

Universities will continue refining their curricula. Professional associations will continue advocating for the profession. Referral hospitals will continue advancing specialist care. None of these efforts should diminish.

But there is another opportunity hiding in plain sight.

Across every country are thousands of capable veterinarians who have no ambition to become internationally recognised specialists. They simply want to provide excellent care for the horses in their communities.

Many already possess the knowledge they need. What they often lack is structured support, practical experience and the confidence that develops when skills are built within a safe, encouraging environment.

If we can help build that confidence without compromising standards, we will achieve far more than supporting individual veterinarians.

We will improve access to care for horse owners.
We will reduce unnecessary pressure on referral hospitals.
We will strengthen mixed practices.
We will create more satisfying and sustainable veterinary careers.

Most importantly, we will improve the welfare of horses.

Perhaps the future of equine veterinary medicine does not depend on producing thousands more specialists.

Perhaps it depends on helping thousands more veterinarians become confident enough to competently manage the everyday cases upon which extraordinary professions are built.

Because every specialist once attended their first colic. Every respected clinician once questioned their judgement. Every confident equine veterinarian was once a graduate wondering whether they were ready.

The future of our profession will not be determined by how many specialists we produce.

It will be determined by how many veterinarians we help cross the gap between graduation and genuine clinical confidence.

That gap is the missing middle. And closing it may be one of the most important investments equine veterinary medicine makes over the next decade.