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Wednesday, January 6, 2010

The "Scam" of Good Medicine

I had an interesting client today.  In December I saw her dog for blood in the urine.  As is pretty standard in these cases I wanted to run a urinalysis.  That was an ordeal, as she wanted a line-item breakdown emailed to her explaining every little detail of what we wanted.  Finally she agreed, and we discovered a pretty basic urinary tract infection.  I sent the dog home on antibiotics and wanted to do a recheck in two weeks. 

That was December 18th.  Today she calls and says that there is no longer blood in the urine, but the dog is still having to urinate frequently.  Okay, no problem.  I can recheck the pet and see if the infection is cleared.  So I want to do a recheck with a repeat of the urinalysis.  She thows a fit because she looked up on the internet (always a warning sign when a client says this) and saw that one round of antibiotics wasn't enough and she just wanted a refill without the test.  At this point the client is also sounding very frustrated and saying things like we're doing a "scam" or asking me if the tests would make me "feel all warm and fuzzy".

Here's the point of doing a repeat on tests like this.  First, we don't want to use medications unnecessarilly.  If the infeciton has been resolved, then there is no reason to continue antibiotics and we need to look at another reason why the dog is urinating more frequently.  Bladder stones are a common reason for persistent or recurring urinary tract infections or urinating urge.  These don't always show many signs on a urinalysis, so if one persists we want to consider this as a distinct possibility and do abdominal x-rays or ultrasound to try and find them.  Repeating the the urinalysis allows us to see the progress of the disorder, determine if the medicaiton is working properly, and consider other possibilities if it isn't working (such as resistant bacteria necessitating a switch in medications).  For my veterinary readers, this is all pretty basic (and I'm sure you can list similar clients).  To my lay-readers, hopefully this will make sense and seem like good medical diagnostics.

To this client...not so much.  We ended up at an impasse where I told her that we wouldn't simply refill the medications without repeating the urinalysis and she refused to do so.  In the end I offered to send her a copy of her medical records so she could seek a second opinion.

Following diagnostic processes like this is not about making money, "feeling fuzzy", or trying to "scam" clients.  It's about maintaining high quality medicine.  Simply ignoring a persistence of symptoms is a good way to slip into malpractice and isn't in the best interest of the pet.  Yes, diagnostics and follow-ups cost money, and these are tough financial times.  But as doctors we can't let money concerns get in the way of medical quality.  So please understand that when a vet makes recommendations like this, we're trying to make sure we practice good medicine and keep the pets' best interests in mind.