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Saturday, November 10, 2012

Standing Your Ground With Clients

Today I saw a seven month old kitten for a routine spay.  My associate had seen her back in June for initial vaccines and had noted a heart murmur at that time.  This is always concerning in a young pet, but especially in a cat because murmurs are much less common in that species than with dogs.  The client was told about the concerns with the murmur, and if it didn't resolve we would have to send her to a cardiologist for evaluation before doing her surgery.  The client didn't bring her back for her last set of boosters, but over four months later she comes in today, in large part because the owner was worried that she might be pregnant (it's amazing how a possibly pregnant female or a male starting to mark suddenly reminds a client that they need to spay or neuter their pet).  We always do pre-anesthetic exams on every pet, and when I did hers I immediately noted the very loud murmur.  In fact, it was louder than what my associate had noted in June.  Back then it was graded as a 3 out of 6 (the standard scale for most vets, with 1 being the mildest) and today I marked it as a 4.  

I didn't proceed any further.  Any good vet will tell you that the loudness (or grade) of the murmur doesn't necessarily coincide with the severity of the disease.  A soft murmur may be part of severe cardiac dysfunction while a loud one may not be associated with any significant change in the size or function of the heart.  But even with this in mind a murmur is significant and should be investigated, especially in a cat.  We don't want to risk a pet dying under anesthesia for an elective procedure.

I called the client and explained the situation, making sure that she remembered the conversation she had in the Summer with the other vet.  I then told her that there were significant risks for surviving anesthesia if the heart wasn't functioning properly, and the only way to be 100% certain was to have her referred for a cardiac work-up including an ultrasound of the heart (echocardiogram).  Though she knew about the problem from the earlier visits she didn't seem happy about what I was saying.  

The owner asked if we would go ahead and do the surgery if she gave us authorization to take the risk, as she was not likely to go to the referral.  Without hesitation I said no.  We would absolutely not do the surgery without having her evaluated first to make sure it would be safe.

Why not?  The client said she wouldn't hold us responsible if the pet had complications and was willing to sign papers stating this.  So since she wasn't going to sue us and needed the pet spayed, why didn't I agree to it?  We had warned her and wouldn't be to blame if the cat died.  Right?

Wrong.

These kinds of authorizations don't hold up in court. I've read far too many similar situations where the client ended up suing the vet anyway and winning, despite giving the go-ahead.  In these cases the client usually says "Well, they knew the medical situation better than I did and shouldn't have listened to me."  The courts usually side with the client's logic at this point, regardless of what the owner had said to the vet previously.  Don't believe me?  Go find reports from any medical liability insurance company and you will see it happen again and again.  Veterinary licensing boards also can easily consider this malpractice and a vet could face disciplinary action and even loss of license for proceeding in a medically inappropriate way, even with client consent.

Sorry, but I'm not willing to lose my license and livelihood over a single cat spay.

It also isn't fair to the cat and I think would be morally questionable (at best) to proceed against better medical judgement.  A spay is an elective, non-emergency procedure, so continuing a surgery that we know is very high-risk under such conditions is not warranted.  We are putting the life of the pet at risk because the owner can't or won't go for one round of noninvasive diagnostics.

This is not the first time a client has pushed me and I have refused.  I can never force a client to do a treatment or procedure against their wishes.  At the same time, they can't force me to do something against my wishes or better judgement.  I am the one with the medical knowledge and skills, and I would be immoral and committing malpractice if I violated my instincts and training merely to appease a pet owner.

That doesn't mean that I don't compromise.  Later in the day I saw a dog that had been limping and I isolated the pain to his hip.  I really, really wanted to take x-rays, but the client couldn't afford it.  So I agreed to conservative therapy with pain medicine and rest, even though I discussed why the diagnostics were needed.  That's fine.  But prescribing medications without a proper exam, giving antibiotics without evidence of an infection, or performing surgery on a pet with a severe heart murmur are not areas of compromise.

My job is to look out for the best interests of the pet, not the owner's wallet.  I don't gouge clients or have unnecessary charges.  But in the end I have to do what is medically best, even if that means the client and I come to an impasse.  I have had owners literally yelling at me because I wouldn't prescribe medications without at least basic testing, yet I have learned to stand my ground and keep to my principles and medical quality.

I know there are many veterinary students and new vets who read this blog, so take this as a lesson (as I taught the new graduate I'm currently mentoring).  Don't agree with a client if it goes against sound medical practice, no matter what they say or threaten.  Regardless of their words or any signed papers, in the end YOU are the only person responsible for the outcome, and you will be the one held accountable if things go bad.

And to clients who have placed their vet in such a situation, please understand that we're not being mean or trying to get money out of you.  We truly have your pet's best interests at heart, and are trying to protect their health as well as our license and quality of medicine.

8 comments:

  1. Great post, Thank You for sharing your wisdom! :)

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  2. What would you do with that cat if it was a non-elective (not emergency, but urgent) surgery and the client still refused the cardiac workup?
    Just curious of the ethics of that one.

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  3. Great question, T. It all comes down to risk analysis. Cats rarely get heart murmurs so when we hear one it makes us take notice and can indicate more of a severe problem than with a dog. Young pets rarely get heart murmurs and when they do they can be due to pretty severe heart defects. So when you have a kitten with a persistent murmur, you have an extremely high-risk patient. If the cat needed life-saving surgery, I would likely proceed with extreme caution, letting the owner know that the cat may die with or without the surgery. If it was an urgent surgery such as removing a suspected tumor, I would likely still require a cardiac evaluation due to the patient. In that situation the patient may die either way, but we may have some time to assess how we need to proceed; if the cardiologist says that surgery would kill the cat (my associate had a cardiologist say this about a patient once) we wouldn't want to go forward and would want to look at other options.

    If it was an older poodle with the same murmur I would be less concerned. So in this case it was the fact that we had such a young cat that makes it a significant problem.

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  4. Makes sense, thanks. I suppose if they refused the consult in a case like suspected tumor, they could go find some other vet to do the surgery (or not).

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  5. I once had a cat dropped or a spay and found it had a significant heart murmur. Called the owner to recommend referral and delay the surgery. She didn't answer so we didn't do the surgery. When she finally called back she was mad and said she know about the murmur, and wished we had just done it anyway because she was a nurse and know murmurs were no big deal. Seriously?

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  6. I just had a convo with a client about his 9 yr dog diagnosed with an enlarged prostate by other vets who brought it to me for neuter. No bloodwork, no rats. I had to sit him down and make sure he understood about BPH vs cancer since he thought neutering would instantly solves his pets urination and defecation problems...

    I had to postpone surgery, get records from other vets, get bloodwork, and start antibiotics for increased liver enzymes.

    We have to make sure we educate better too! That "my vet said" doesn't fly when "your vet" isn't doing the surgery, I am. You have to have principles with your medicine.

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  7. SC: When clients insist "my vet said" or "the other vet said" I call their bluff and tell them to schedule an appointment with the other veterinarian for whatever I've declined to do. It's a remarkably effective tactic.

    These are not good clients, and no amount of education will ever cause them to be good clients. It's best to provide the information and allow them to move along under their own steam.

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  8. Wow, this was really interesting. My cat who is now about 2 years old was diagnosed with a heart murmur. At the time, veterinarians who I trusted and shadowed told me nothing about the dangers of a heart murmur. She was spayed by one of the vets at the same clinic. Since then my husband and I have moved, and during an exam I asked the veterinarian if she could hear the heart murmur, and she said that she didn't. Do cats "grow out" of heart murmurs? Could she have been misdiagnosed? Could it also be possible that the heart murmur is very mild and that's why it wasn't heard by the newer vet?

    Thanks so much for your input. I'm in the process of applying to vet school, and your blog has been really interesting and helpful.

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