Ethics quiz results: Accountability should rank high

Question 1: What is the most important determinant in your decision to advise referral of a patient for overnight care?

Importance ranking

1. The medical condition of the patient.

2. The clients' degree of advocacy for their pet.

3. My opinion of the care at the emergency clinic.

4. The clients' ability to pay the additional fees.

5. Availability/distance to the overnight hospital.

6. My personal/financial relationship with the emergency clinic.

Commentary by Kathy Yerger, hospital administrator, Animal Care Center of Sonoma, Rohnert Park, Calif., a large 24-hourreferral facility.

What the client is expecting for their pet during the overnight care should be what is considered. I think that if most clients knew that their pet was left alone in a clinic overnight without supervision they would prefer to be referred to a hospital that has staffing throughout the night.

Most clinics have signs informing clients that no one is on site, but I don't think emotional clients notice them or truly understand that their pet will be unattended when the doctor goes home.

Question 2: What is the most important factor involved in your decision to refer a patient to a specialist?

Importance ranking

1. The medical condition of the pet.

2. The patient is likely to die if I don't refer.

3. Do I have the time to care for the patient properly?

4. The client's level of advocacy

5. The client's ability to pay

6. My personal relationship with the client.

7. My personal relationship with the specialist.

Commentary by Kathy Yerger, hospital administrator, Animal Care Center of Sonoma, in Rohnert Park, Calif.

What is in the best interest of the patient is the question that should be answered. And most family veterinarians refer for that reason. Historically veterinarians have been preoccupied by the financial aspect and let that interfere with referring the patient. They tend to decide for their client. They believe that their client will decline referral because of the expense and that is simply not my experience. Many families want that level of care and expertise and are very willing to pay for it, especially when the option to finance the services is available.

One of the ways to enhance the referral relationship is to have a trusting relationship with a specialist. It is important that the family veterinarian is kept informed about the patient and is able to reassure their client that their pet is getting the care it needs.

Legal status

Veterinarians have long been able to minimize the costs of professional liability as the law has seen pets as little more than property. Lately, this is changing as numerous jurisdictions have changed the legal status of pet owners to "guardians", and emotional damages have been awarded for negligence to pet animals. Despite our profession's support of the human-animal bond, there has been a collective outcry over the specter of pets as having emotional value.

Question 3: Does your apprehension regarding this issue arise from: Importance ranking

1. Concern for rising liability expenses.

2. Anticipated costs to my clients for practicing defensive medicine.

3. Financial repercussions if I were found liable for my actions.

4. The need for improved medical records and client consent strategies.

5. The potential need to refer more cases to specialists.

Commentary by Robert Newman, attorney; Irvine, Calif., who represents pet owners pursuing claims against veterinarians.

He also counsels veterinarians on how to avoid these liabilities.

• #1 answer: Concern for rising liability expenses.

The problem with this answer as the most popular is that it illustrates a real misunderstanding of how liability will work. Veterinary malpractice insurers are currently paying out virtually nothing on claims. While allowing emotional distress damages for the loss of a companion animal may increase insurance premiums in the short term, they should not increase dramatically, and will taper off as the profession adjusts.

• #2 answer: Anticipated cost to clients for practicing defensive medicine.

In an age where veterinary medicine continues to improve and greater and more complex treatments are made available on an almost daily basis, practicing defensive medicine is something that every veterinarian in this country should already be doing.

• #3 answer: Financial repercussions if I were found liable for my actions.

Perhaps the most frightening of all the choices comes in as the third most popular response. It is very disheartening to see this as the third most popular response in that this answer illustrates that many veterinarians responding are still of the mindset that for some reason their profession should have a lower level of accountability than other professionals. The more important question here may well be, "Why shouldn't veterinarians be held accountable for their actions?"

• #4 answer: The need for improved medical records and client consent strategies.

I am glad that this response did not score higher, in that every veterinarian can benefit from complete and understandable chart notes and client consent forms. Again, this is an area every veterinarian could and should constantly strive to improve, as it is the first line of defense in a veterinary malpractice action.

• #5 answer: The potential need to refer more cases to specialists.

I'm glad to see this answer causes the least apprehension among respondents. If need be, and the case is something you are not comfortable handling, by all means, refer, refer, refer.

Pet health insurance

Do you routinely encourage all clients to obtain health insurance for their pets?

YES=24 percent; NO=76 percent

Would enhanced financial coverage reduce the frequency of "economic euthanasias"?

YES =63 percent; NO =37 percent

Is your experience with human HMOs and PPOs inhibiting your acceptance of pet health insurance?

YES=43 percent; NO=57 percent

Would greater acceptance of pet health insurance improve the overall quality of medical care pets receive?

YES=67 percent; NO=33 percent

Do you feel that advocating pet health insurance to your clients may detract from their image of you as a caring doctor?

YES=15 percent; NO=85 percent

Commentary from J. Edward Branam,

DVM, ABD Insurance Agency, Sacramento, who has extensive experience in DVM-related insurance and risk management consultation.

Many types of pet health insurance have been available to the public for more than 20 years. However, whereas historically participation in these programs has been limited, the purchase and utilization of pet insurance has increased exponentially over the past two to three years.

Take home lessons for the veterinary profession:

• 1) Pet owners are spending more money on health care for their pets.

• 2) Pet owners are looking for ways to mitigate the unexpected nature of many veterinary related expenses, i.e. illness, injury.

• 3) Pet owners are demonstrating with their pocketbook that they perceive pet health insurance as a viable solution.

Unfortunately, I find the responses in this survey to be symptomatic of the veterinary profession's often conflicting message regarding our position on the importance of promoting pet health. The responses to each question when evaluated in total appear to be contradictory to one another and often defy reasonable logic.

Specifically, while the survey indicated that three out of four veterinarians currently do not encourage clients to explore pet health insurance, two out of three indicated they also believe that greater acceptance of pet health insurance would improve the overall quality of medical care pets receive.

How does one explain this contradiction? Especially when the survey indicates that respondents also felt that advocating pet health insurance did not detract from their image as a caring doctor. Conversely, based on their responses, I would say they feel that the opposite is true. Not advocating pet health insurance would be a much better indicator of them not being a "caring doctor."

Then the obvious question becomes, why don't the respondents heavily promote pet health insurance? Is it because they don't want to promote better pet health care or are their own experiences with human health care adversely "tainting" their perspective? Only they can answer that question. But the fact remains, the answers provided in this survey seem both incompatible and disconcerting in relation to every veterinarian's responsibility to serve as an advocate for timely and appropriate pet health care.

Referral etiquette

Just as general practitioners are careful not to offend the pet owner/guardian (their "client"), specialists feel the same way toward the referring veterinarian (their "client").

Question 9: Do specialists have a moral and ethical obligation to educate referring practitioners when appropriate, even if that results in criticism? (pick one)

1 percent No, if I wanted continuing education, I'd read an article or attend a meeting.

72 percent Yes, I'd always want to know how I can do better. This would never hurt my feelings or influence my referral preferences/affect to whom I refer.

27 percent Yes, the referral letter/records from the specialist is the best means of accomplishing this.

0 percent No, my personal relationship with the specialist would make constructive criticism too awkward.

Commentary by Kathy Yerger, hospital administrator, Animal Care Center of Sonoma; Rohnert Park, Calif.

Specialists do have an ethical and moral obligation to educate general practitioners (GP's), but I'm not sure that GP's really want that. What they want is for the client and patient to be taken care of. The survey suggests that GP's do want feedback, and yet they don't invite that.

Specialists critique medical records and radiographs all the time and yet would hesitate to give direct feedback.

Commentary by Dr. Kipperman

In reviewing the responses to the questions about referrals, it's encouraging to find that the medical condition of the pet and the perceived degree of advocacy of the client ranked highest in determining the decision to refer. On the discouraging side, our assumption or perception of the client's ability to pay still clearly impacts the decision as to advising referral. This is in agreement with my own and Kathy Yerger's experiences in referral practices as well.

This paternalistic view that we must protect the client's resources is in my opinion, misguided, and is detrimental to overall patient health care. The legal consequences of this mindset have been addressed by Robert Newman; this also emphasizes the importance of supporting a third party source of financing pet health care, as Dr. Branam points out. This may help alleviate the practitioner's perceived "burden" regarding the costs of specialty care.