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Monday, February 7, 2011

Professional Disagreement

I'm often faced with clients transferring to our clinic from other vets, and this can be quite a challenge, especially if they're seeking a second opinion. There is the very human temptation to say that the other person is wrong and promote your own opinion.  But I am very strongly of the opinion that this is the wrong thing to do for numerous reasons.

Intentionally or not, clients often misrepresent what another vet says.  Maybe they misunderstood, maybe the vet didn't communicate well enough, or maybe the client just didn't personally like that vet and wants to bad-mouth them.  I've seen clients take a statement such as "I believe..." or "In my opinion..." and translate that as the gospel truth.  So as much as it may be hard for clients to understand, many veterinarians take a client's statements with a healthy grain of salt, realizing that it may not be exactly what a previous vet had intended.  I've heard clients who took my statements completely wrong, ending up telling another vet something completely different than what I had said and recommended.

I also think that even if I believe that a vet is completely wrong and off the mark, there needs to be a degree of professional courtesy.  Criticizing another doctor is a sure way to breed bad feelings among colleagues, and can often come around to bite you back.  If I was not directly involved with a case or otherwise have first-hand knowledge of it I'll generally decline to comment about the actions of another vet.  There may be details I'm not aware of that would change my opinion, and it's not a good idea to go off half-cocked to later regret it.

If I'm placed in a situation where a client is coming to me for another opinion and I agree with the previous vet, I make a point to tell the client this and support my colleague.  If I disagree with the other vet, I'm careful to talk about things only from my viewpoint and use statements like "Based on my training...", "In my opinion...", "According to lectures and articles that I've seen..." and so on.  By focusing on my own education and opinions I hopefully avoid being antagonistic towards another vet.

Why do I bring this up?  In recent discussions in the comments of this blog other vets and I have had disagreements.  This actually happens commonly, even among specialists. Ideally we should all be professional and mature enough to realize that as valid as we believe our opinions to be, they are not the only viewpoint out there.  Science actually thrives on differences, as by disagreeing with convention we explore possibilities that may not be otherwise considered.  Even in established professions (most vets aren't performing research) new therapies can come from discussions of contrary opinions.  The key is to keep it civil.  I believe that it is okay to say "I disagree" and provide your reasons.  But I don't think it's acceptable to deride someone for having a different point of view.

Thankfully, I have to say that my colleagues who comment on this blog have been such professionals.

8 comments:

  1. I sometimes tell clients: "I didn't see the patient last week. Had I had opportunity to examine him last week, I might have come to the same conclusion as Dr. A."

    That statement happens to be true, and thus defuses a lot of tension, unless the client is spoiling for a fight.

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  2. Good point, I'm glad that they are emphasizing this more in vet school now, we actually had a week long orientation where we did team building activities and learned this concept that we are now all in this profession together. I also agree that everyone has their own opinions and should be able to discuss them openly and honestly without hurting anyone's feelings. I love Science!

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  3. An interesting and important post...but my question is this...where is the line between professional courtesy and turning a blind eye to malpractice?

    I'm not talking about taking a client's word for what the veterinarian said, I'm talking about holding records in your hand, seeing what the veterinarian did or didn't do, and knowing that malpractice occurred.

    It is too easy to judge when you weren't there and don't know the circumstances, but I also think that we in the medical field use that as an excuse to not have to take action when we know wrongs have occurred.

    Sometimes, I fear we are so worried about protecting ourselves and other veterinarians that we fail to protect our patients first.

    To make the distinction, I'm not talking about cases such as using butorphanol for pain control versus more up-to-date pain control like hydromorphone or morphine or using or not using steroids in head trauma and HBCs. Those are matters of difference in graduation year and teaching and are still open to debate.

    Just curious as to what your thoughts were on the subject. I agree that professional courtesy is very important, and it's an important reminder that I give myself every day. I tend to think I know everything, so when I practice differently than my colleagues, I get on my mental high horse. This is likely due to being recently in the Ivory Tower, and it's something I have to combat every day. I'm still working on it, so thanks for the reminder!

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  4. >>I'm talking about holding records in your hand, seeing what the veterinarian did or didn't do, and knowing that malpractice occurred.>>

    Well, all malpractice is not the same. There is...

    1. Consistent malpractice. This is fortunately limited to one veterinarian in my area who is no stranger to the board of registration. It's not a secret, but he's charming and reassuring, so clients think he's merely misunderstood. I direct any irate clients to the board of registration, or small claims. Those who aren't irate I'll never again, because they called only because Dr. Danger "accidentally" turned off his pager. Again.

    2. Consistent substandard care and occasionally missing the boat entirely: I see this from veterinarians who have failed to keep up with CE, as well as from predominantly small animal veterinarians who see horses 1 or 2 days a week. Sorta okay, but sloppy medicine with the occasional disaster. Clients like these veterinarians, too. I tread carefully.

    3. Not really malpractice, but an arrogant internal voice telling me: "I'd have known the diagnosis and/or it would have gotten better with the treatment protocol I like to use." This constitutes the majority of "professional disagreements" I see. The longer I practice, the more I see, and the more I realize I have no way of knowing what the heck the original veterinarian(s) saw. I regularly see weirdness that was not taught in any veterinary school class I attended. If I did not regularly discuss cases with colleagues, seek second opinions and receive confirmation from other veterinarians, I wouldn't believe me.

    >>I also think that we in the medical field use that as an excuse to not have to take action when we know wrongs have occurred.>>

    If the client doesn't want to complain, there's little I can do other than maintain excellent records. Most clients just want me to fix the patient.

    >>Sometimes, I fear we are so worried about protecting ourselves and other veterinarians that we fail to protect our patients first.>>

    Honestly, I don't really care about protecting most of the other veterinarians practicing in my area. The problem is, their clients protect them, have no allegiance to me, and aren't afraid to damage my business.

    >>I tend to think I know everything, so when I practice differently than my colleagues, I get on my mental high horse.>>

    That's what I was like a couple of years out of school. Getting humble has been a painful process.

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  5. Not being a vet but having a little life experience I know how hard it is to keep silent on border line actions.

    I give an example. The vet I use has four vets in rotating schedual.
    So it happens that when I go I get a differnt Dr each time. That is OK by me they are all good Doctors.

    One vet though gave me what I feel is sloppy/borderline advice.

    I needed my dogs to loose weight so this vet suggested I add green beans and carrots and broccoli to their food as a filler.

    Dogs are carnivores and veggies and plant foods cause gas. I think this caused a gas pattern in one of my dogs that may have helped bloating along. I just feel using foods that create even more gas in large breasted dogs may not be the best of ideas.

    Also my dog had a rectal polyp and when I asked about that she replied oh it is OK, it doesent hurt them.( she even squeezed it to show me it does not hurt my dog) Long story short it blew up and the tissue started to degenerate. I had it removed with surgery.

    Now I tend to learn after the fact because something goes wrong.I google these things so I can find out what is going on.

    I would think the vet should have told me all the implications of a diet change and also what could occur with an anal polyp.

    I did mention it to another vet at the office and she kept whatever opinion she had to herself.

    That is the smart thing to do in a case like this. Even though we want the vet to agree with us and say it was bad advice it would backfire anyway.

    Because in reality no one likes a bad mouther even the client that is looking for that.

    But there is a code of ethics I think that is good to follow in life.
    If one really sees a person doing something that can harm another it is their duty to speak up. I cannot find any rational reason to look the other way and say that is just professional courtesy.

    By the way I found a meal plan that works really well with my dogs.
    I found it on a site for body builders. The idea is to feed several small meals. This causes the body to use the calories more efficiently and helps to reduce hunger.
    I feed four small meals a day now and my dogs have lost weight and they hunger a lot less.

    Rock dropped almost 20 pounds from 175 to 157 and Molly went from 130 to 120 lbs.

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  6. >>Dogs are carnivores and veggies and plant foods cause gas.>>

    An excellent example of "difference of opinion", because not all dogs tolerate all diets. My dogs, of various breeds and sizes, have always eaten a variety of fruits and vegetables as a regular part of their diets. No gas-related problems, not even the dog who would literally eat any vegetable I offered (bell pepper, carrot, tomato, cabbage, etc.).

    >>my dog had a rectal polyp and when I asked about that she replied oh it is OK, it doesent hurt them.( she even squeezed it to show me it does not hurt my dog) Long story short it blew up and the tissue started to degenerate. I had it removed with surgery.>>

    It blew up because she squeezed it, or it blew up at a later date?

    I usually tell people to watch lumps and bumps for any changes, at which time we re-evaluate. That's a rule that's served me well over time, and is related to: I didn't see what that lump looked like 6 months ago, when Dr. A saw your pet.

    I obviously don't know the veterinarian you saw, but this doesn't sound like "sloppy" or "borderline" medicine. It does sound like the two of you do not communicate effectively. That happens, and is one of the challenges of running a multi-veterinarian practice.

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  7. not all dogs tolerate all diets.

    I agree and this should have been stated. It is important to be thorough.

    It blew up because she squeezed it, or it blew up at a later date?

    It turned into a "califlower" at a later date of course.

    From what I read a bleeding polyp could get infected, also it could be cancerous. ( it turned out to be cancer)

    I also read that if these polyps are not treated they generally do not go away and in most cases have to be removed.
    At least that is what the owner Dr L said.

    Now how hard is it for the vet to explain this?

    As for communication, It is hard for me to ask the proper questions if I do not understand the possible problems or outcomes. I would expect the Dr to anticipate this and explain some possiple outcomes. This is not an unrealistic expectation.

    As for sloppy I did not say sloppy medicine. I said sloppy advice. I used the word sloppy because there was a lack of order.

    The consult lacked order because there were no possible outcomes explained.

    Right now I am in the IT field but whenever I plan or do any type of job I look at the different outcomes, reactions and how it affects the clients and what they need to know to be able to function. In other words I create an orderly procedure.

    I then explain everything I think can happen or what might be needed.
    I do not expect the client to project any ideas. They can but it is not an expectation.

    So no big deal they are still my vets but I do think I have a point here.

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  8. >>As for communication, It is hard for me to ask the proper questions if I do not understand the possible problems or outcomes.>>

    It is difficult for a veterinarian to determine which information a given client wishes to know, and how to explain it adequately within the confines of an appointment time.

    After reading your explanation, it sounds like you have a very different communication style and personality from the veterinarian with whom you were dissatisfied. Neither is likely to change, IME. It doesn't mean there's anything wrong with either of you, and I'm guessing she may have been just as frustrated as you were by your encounter.

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