Doing 'the right thing'

I see a geriatric dog with recent onset seizures that are not being controlled with anti-convulsant medications.

Experience tells me this patient probably has a brain tumor. I informthe client that an MRI is the only means of confirmation, but this is acostly test that will also entail the risk of general anesthesia.

I tell the client I realize she faces a difficult decision regardingher beloved companion. I don't want to seem cold or aloof, yet I don't believeI should tell my clients what's best for them and their pet. I try to finda middle ground by discussing that from experience, most clients in thesesituations make one of a few choices:

Client A feels it's inappropriate to spend more than a thousand dollarsto pursue a serious problem with no simple resolution, and entail the riskof losing their pet at the same time.

Client B does not mind the risk or expense, and feels the informationreceived will allow her to make a euthanasia decision with peace of mind.

Client C is willing to pursue radiation therapy if a tumor is discovered,so the scan must be pursued if medically appropriate.

After being presented with these options, clients seem to more easilymake a decision, and I feel I did not make value or financial judgmentson their behalf.

Balancing advocacies

How does the veterinarian balance his/her numerous advocacies in practice?

1.) Wage earner-you have a responsibility to yourself, your family, and your employees to be well compensated.

2.) The pet owner-we have earned the loyalty and trust of mostof our clients. Our opinion is so important to them, we often are asked,"What would you do if this were your pet, Doctor?"

3.) The animal-isn't this why we went to veterinary school? Didn'twe take an oath to protect animals and relieve their suffering to the bestof our ability?

CPA mantra

The mantra of the numerous CPAs who write and speak nationally has been:

1.) Explain the value in what you do to clients, and charge appropriately,commensurate with your time, training, staffing, equipment and facilities.

2.) Stop discounting services

3.) Don't judge or assume what your client is willing or ableto spend on their pet.

I agree with all of the above statements wholeheartedly. But I'm concernedthat we have received this message at the expense of the medical care ofthe pet. Implied in the urging for us to be profitable, is "know yourlimitations." We can't expect the accountants to tell us what constitutesgood medicine.

Do you consider whether you're providing an acceptable standard of carewhen making decisions about whether to purchase that ultrasound machine,or prior to performing major surgery just before closing time? I believethat you should. This is not to suggest that referral to a specialist isalways indicated or medically desirable. If you are comfortable with splenectomyand have access to blood or blood products, then performing this procedureon an anemic patient with a bleeding mass seems reasonable to me.

Alternatively, attempting your first hepatectomy on a 12-year-old anemicLabrador, by taping the surgical procedure to the wall and reading it intra-op,is not what I suspect the accountants are asking us to do to achieve profitability.

Allegiance

Allegiance to the pet owner must be important to our profession, giventhe seemingly large number of our colleagues who discount their services.

We certainly wouldn't discount to serve the medical interests of thepet or to support our families or employees! I understand why the pet ownerlooms largest in our advocacy equation; they are the decision-maker, communicatorand our financial asset.

Conflict of interest

Very often we are faced with a conflict of interest; what if the patientdies during the MRI after I played a large role in the client's decision?Will the client lose faith in my medical abilities? Might I lose the client?Will I have liability?

After 14 years in referral practice, I've come to believe that we veryoften take the easy way out when faced with these conflicts. Our allegianceto the pet owner seems paramount, even at the expense of the welfare ofthe pet. Using the above example, most pet owners do not receive the optionof referral or MRI. Although I'm aware that this procedure is probably nottenable for most of your clients, are you acting as the limiting factor/shortcircuit in the medical care of the pet?

Reasons

Possible causes for diminished animal advocacy include fear of losingthe client, poor communication skills, arrogance/ego, and financial greed.

In some cases, it appears that the veterinarian is willing to jeopardizethe health or life of the pet so as to obviate referral. It's clear to methat many of our colleagues equate referral for a second opinion, with aloss of potential revenue. Even overnight referral for emergency observationseems to fall under this umbrella.

From these recurrent observations, I am led to conclude that many ofour colleagues believe that a finite amount of income is associated witheach pet, and that referral diminishes your portion.

More informed owners

By watching Animal Planet and surfing the Web, pet owners are becomingmore informed about the level of services and technology available for theirpets. Practitioners lose the trust of far more clients by not offering referraland proceeding forward with procedures he/she were not best equipped orqualified to perform, or by choosing a low risk option for the client andpet, that ensured a mediocre outcome.

How then, does the practitioner as businessperson attempt to reconcilethese conflicts?

I propose that the time allotted for office calls for sick pets be lengthenedto accommodate the time necessary for you to provide a more thoughtful andinformed consultation with the pet owner.

I can't envision how a physical exam and thorough discussion of whetherto perform an upper GI series, endoscopy, ultrasound, or surgery for a vomitingcat can be adequately accommodated in less than 30 minutes.

At a recent symposium I moderated, the concept of informed consent wasdiscussed. I contend we often receive consent for procedures, but do youprovide clients enough information to truly receive informed consent? Doyou discuss the rationale, risks, and expense of all available options?Are these documented in the medical record?

Palliate fears

Charging commensurate with this extended time should palliate any financialmisgivings if referral is chosen by the client, and if not, I suspect fewclients will complain about the increased fee for the 30 minutes you tookto outline available options and costs. Clients will hold you in greateresteem by taking the time to think through all the options available fortheir pet. This professional fee is what we should be emphasizing when weconsider our profit centers, rather than equipment we may not be trainedto use or interpret properly.

Our patients would be much better off if we saw half as many clientsas we do now, spent twice as much time with them, and charged twice as much.If your consultant encourages you to see sick animals in 15 minutes or less,find a new consultant.

Ethical obligation

It is our obligation ethically to offer the pet owner what we feel isin the best interests of their pet, devoid of our own financial interestsand ego.

If we could live up to this concept more often, and heed the good adviceof our CPAs, our patients would be better served, and we could have morerespect for our collective professionalism. It is myopic to do otherwise.

Example:

An 18-year-old dog with anemia (PCV=27 percent) and splenic mass hasa splenectomy performed on Monday. The dog remains in the hospital unobservedovernight on IV fluids. A few days later, the dog presents for lethargy,and after a phone call to an internist, is referred to a local 24-hour referralcenter. Brain disease is suspected, and the pet owner approves MRI and aspinal tap as needed. The owner tells me, "This dog has been a memberof our family for 18 years. I want you to do whatever he needs."

When I asked the regular veterinarian why overnight monitoring was notadvised or offered the night of the surgery, she replied, "I don'tknow; we've always done it this way with no problems. He didn't die, didhe?"

Another example

A 2-year-old female cat is referred to the local 24-hour specialty hospitalbecause the regular veterinarian could not see the pet.

A diagnosis of pyometra is made, and the client expresses she wants "thebest care" for her cat. Surgery is scheduled with the specialist surgeon,and the estimate approved. The attending clinician calls the regular veterinarianto update, and is requested to transfer the cat back to their hospital at3 p.m. so they can do the surgery there. The clinician asks the regularveterinarian where the cat will be cared for after the surgery. She saysthe cat will be transferred right back to the 24-hour hospital.

The clinician offers this option to the client, who prefers her cat toremain in one facility without moving. The clinician offers the regularveterinarian an invitation to come to the specialty hospital to performthe surgery if she desires; this is declined. Surgery is performed by thespecialist, with an uneventful recovery.

Did these pets/owners receive an acceptable level of medical advocacyfrom their regular veterinarians?

Being a true advocate for the "best" medical care of the petis not synonymous with a loss of income. In fact, my experience has beenquite the opposite; that is,the pet owner will hold you in high regard foroffering referral, when you cannot provide the care the pet requires. Whenyou offer the best care available to each pet, you, the receiving doctor,and most importantly, the pet, all benefit. It will require a major shiftin attitude from our present standards of care to accomplish this.

By Barry Kipperman,

DVM, dipl. ACVIM

Dr. Kipperman, is a diplomate of the American College of Veterinary InternalMedicine. He has practiced in a 24-hour referral practice since 1992. Heis the owner of the VetCare-24 hour referral practice in Dublin, Calif.

Dr. Kipperman is a guest lecturer at the University of California-Davisveterinary school ethics course, and has presented symposia on standardsof care and veterinary ethics at various veterinary conferences.