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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?


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.