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Friday, April 6, 2012

So-Called "Sketchy" Vets

Here's an interesting and potentially controversial topic sent in by a regular reader....

You often talk about clients that cannot afford proper care for their pets.  I'd like to hear your thoughts on vets that engage in what I can only describe as irresponsible medicine, so actually end up making the problem with clients not wanting to spend money worse by offering diagnosis of hip dysplasia without x-rays and then prescribe Rimadyl for that young dog or those vets that will actually send an animal home with syringes and fluids (cat got into Ibuprofen) because the owner doesn't want to spend the money to keep the pet at the vet office overnight.  The cat owners have no medical background and have called on friends and family (that have medical backgrounds with humans) to give these fluids.  I have recently had contact with two pet owners that have experienced these situations and of course - these owners couldn't be more pleased because they didn't have to spend that much at the vet so of course the vets get glowing reviews on the Internet.  Or am I in the wrong here and what they are doing is acceptable?

There are really a several things to address in this situation, so let me start with more general thoughts.  I'll apologize in advance for such a long discussion, but I want to explore it fully.

As I'm sure most people are aware, there are normally several levels of care and service in any profession from doctors to bankers, mechanics to barbers, and pretty much anything that involves providing a service to other people.  The majority of such professionals are good, solid individuals.  Some will be truly superlative and some will be rather "sketchy", bordering or crossing the line of malpractice (or the equivalent in their given profession).  Clients/customers should not judge a profession by the actions of a few individuals carrying that title.  For example, if you see a TV report where some police officers beat a suspect, you shouldn't assume that all police are like this.  There will always be bad apples in any bunch.  And yes, that means that there are some vets who really shouldn't be practicing and should be brought up on malpractice charges.  I've known several of them.  But the vast majority of vets are good doctors, even if they may differ in opinions on treatments from each other.

Which brings up my second thought.  After 15 years practicing and a total of around 28 years in the profession, I have learned a few very important lessons.  There is usually more than one way to do the same thing correctly.  As an example, some people are very adamant that an IV catheter must be taped in place in a very specific manner.  But I've seen numerous ways of doing it, and they all work equally well.  The other important lesson is that very smart experts can have radically different opinions on some topics.  It actually can be confusing to a general practitioner when you listen to lectures by board-certified specialists and come away with different ideas on diagnosis and treatment depending on who you listen to.  So just because one person says that something should be done a certain way doesn't mean that this is necessarily true, no matter how strong their opinion on the matter.  This principle is not true in every situation, so proper judgement is needed.

A harsh reality of veterinary medicine is that we often don't get to do what we want to do and know that we should do.  Because there are few clients with insurance and lots of money, it's not uncommon to have to cut out certain diagnostics due to financial limitations.  Using the above hip dysplasia as an example, perhaps the dog is painful and we want to do x-rays, but the client can't afford it.  In a case like this we have to make our best judgement even if we know that we really should confirm it with the radiographs.  Sometimes we just send home pain medications because that's all the client can do.

But sometimes we can tell a whole lot just on an exam and by getting a good history.  Any regular reader will know that I have frequently and rather vehemently talked about the importance of the physical exam.  Let's go back to the hip situation.  I have a client who brings in their eight year old Labrador retriever.  The dog is happy but has been having problems with stiffness and soreness in the mornings or after laying down.  He isn't as active and playful as he used to be, though he's eating okay and seems okay otherwise.  Upon questioning I learn that the dog is slow on stairs and sometimes seems to sway a little in the hind end.  When I do my exam I notice a little roughness in the knees when bending, though no pain or swelling.  There is definitely some discomfort when I move and extend the right hip, less so on the left.  However, the dog walks around normally and the rest of the exam is unremarkable other than a moderate amount of dental tartar and needing to loose about five pounds.  Any vet who reads this description has likely already made their diagnosis, and 9 out of 10 times will be right.  I'd bet my next paycheck that this dog has arthritis, and likely hip dysplasia (which really is a specific type of arthritis or degenerative joint disease).  Should I do x-rays to confirm the diagnosis and see the extent of the changes?  Absolutely.  Will those x-rays change the treatment recommendations?  In this case, likely not.  I've seen many cases where the degree of changes on x-rays doesn't correlate with the degree of pain.  I've seen horrible joints where the dog isn't limping at all, and I've seen great joints that are very painful.  I would be doing the best practice by recommending x-rays.  However, I wouldn't be "sketchy" or a poor quality doctor by making an initial diagnosis and starting treatment based on these signs alone.

Let's take the situation of fluids, because that's a different discussion.  It's actually very common and considered a normal standard of practice to send clients home with fluids and needles for cases of chronic kidney disease.  Giving cats fluids under their skin several times per week can help support them when their kidneys fail, and is something most clients can learn.  In these cases we take some time to teach the client how to do it properly and allow them to continue treatment at home.  It would be cost prohibitive for the client to come in a few times per week for the rest of the cat's life in order for the vet to do it.  I've had many clients over the years who have done this.  But in a case like ibuprofen toxicity I wouldn't recommend it.  That patient really does need to be on continual IV fluids and probably 24 hour observation at an overnight facility.  Knowing that the cat is suffering from toxicity and telling the client all they need to do is give fluids at home is what I would consider poor quality medicine and could be argued as malpractice.

HOWEVER....sometimes clients don't give us the choice.  Let's say we have a good doctor who thinks the cat needs to be transferred to the local emergency clinic.  The client doesn't have the money for something that could easily reach $1000 for one night.  So the vet offers to keep the cat on fluids at her clinic overnight, with the warning that it's not the best treatment and the cat wouldn't be observed and could die.  The client either doesn't want to leave their pet or can't even afford that.  Knowing the cat likely isn't going to survive the vet recommends euthanasia.  The client says no.  What does that vet do then?  In a situation like this I would agree with the vet sending the client home with some inexpensive fluids and hoping for the best.  It's substandard care, but the client isn't really giving the doctor many options.  Now the vet does always have the choice of saying that she can't recommend other therapy and the client simply has to take the cat home and pray for a miracle.  But something small is often better than nothing at all and we hate to completely give up.  

I've been in those situations when the client won't let me do even minimal care.  And I've had to tell the client that I can't do what they want me to do and will have to take their pet home without anything at all.  It's always difficult and hard to deal with, but we can't force the client to do anything.

Okay, all of that is fine and good, but what about truly "sketchy" vets.  These are the ones who hardly keep records, throw antibiotics at everything, rarely do blood tests, and plenty of other bad things.  These are also normally the vets who are dirt-cheap and under-charge compared to the rest of their colleagues.  Of course many clients love them because it costs so little.  And unfortunately many clients keep going back because of the cheap cost and not because of the quality of medicine.  These doctors hurt the quality, reputation, and business of the profession as a whole, and most vets don't like associating with them.  However, they usually don't get malpractice claims or state board action taken against them so they continue to stay in business.  It's a bad situation but one that the rest of us have to learn to live with, similar to great mechanics having to deal with a shady and unscrupulous one in their area.

There are "standards of care" in any profession.  Sometimes these standards are well documented and even put into law.  Others are determined by a consensus of a board or of lawyers when claims are brought forward.  But many vets practice "under the radar" and avoid any problems.  I wish more clients would try to find someone who is high quality rather than simply go based on costs.  But this is human nature, and the problem will never completely go away.

3 comments:

  1. That was a great explanation of all the all too typical situations we are faced with.

    ReplyDelete
  2. I was going back over some of your posts looking for something specific and found this instead.

    I might just print it out to keep on hand when I get sick of trying to defend the profession to people I meet who make generalizations about what constitutes a "good" veterinarian.

    ReplyDelete

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