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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.

4 comments:

  1. You might be interested in seeing this article which has caused uproar here in the UK: http://www.dailymail.co.uk/news/article-1232217/Why-Im-ashamed-vet-shocking-expose-profession-puts-pets-painful-unnecessary-treatments-fleece-trusting-owners.html

    Fortunately the majority of readers and people that I have spoken to (both in the veterinary profession and not) have completely disagreed with the article, but that hasn't stopped massive scepticism amongst many owners who take their pets to the vets. In my opinion, the article benefits nobody, not least the animals who now have owners reluctant to treat their animals because they think the vet is just carrying out further tests etc for financial gain.

    The RCVS and BVA have published some excellent responses.

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  2. Good post. People can be so frustratring. I'm enjoying my time away from work!

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  3. Dr. Bern: I find your use of words, slightly odd on this post.

    JMO, having been through years of mutiple-UTI's (with my pets) and among co-worker's having experienced likewise, I can understand that client's frustration, but from your POV, you chose to dismiss and send her on her "merry" way. Why?

    I'm asking if another manner might have made "both" of you satisfied with the outcome?

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  4. Liz, that article is pretty damning, and I think unfairly so. I think it strongly misrepresents the veterinary profession. I'd love to see the responses to it.

    Barbara, I didn't "dismiss" the client. She wanted antibotics without any recheck or follow-up. In my opinion, this was simply not good medicine, and ignored potential risks to her pet. I can promise you that if I had simply refilled the medications and then it turned out to have been bladder stones, there would have been complaints that I had not been thorough enough. I explained all of the medical reasons why I wanted to repeat the urinalysis, and instead of understanding she chose to "dismiss" me (using your language). Obviously we were at an impasse. So I gave her the option of finding a vet that would practice the kind of medicine that she was looking for, since obviously my standards and hers did not agree.

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