Playing the odds, balancing the quality of care with the need to get paid could prove a costly gamble

I suppose there are a few of us out there who practice veterinary medicine without financial constraints, such as some specialists, a number of big-city general practitioners, and of course the occasional zoo veterinarian or poultry practitioner.

The rest of us spend a lot of our time engaging in what I like to refer to as gift-certificate medicine. That's where the pet owner comes to you with a sick Schnauzer and tells you to go crazy with diagnostics and treatment modalities as long as you don't go over $100.

Less vocal clients, evidenced by a blank stare when discussing treatment options, silently demand that doctors find an inexpensive solution without sacrificing the quality of medicine.

It is not particularly comforting that the civil and administrative law of all 50 states supports this assumption by the owner. The law, in a nutshell, tells us we must do all our work at a minimum level of care regardless of our ability or inclination to collect a fair fee. The law provides for an equal-opportunity mandate to healthcare providers of virtually all categories: Do first-class work, and then do the best you can to get the money.

There would be no problem, legally or otherwise, with this mandate except for that ubiquitous, nagging necessity for veterinarians to pay their mortgages, educate their children and buy food and shelter. If we weren't constantly trying to do those sorts of things, we could devote all of our personal time and resources to caring for animals at the Johns Hopkins level of care with a Salvation Army level of remuneration.

The problem is that while there is no legal authority requiring a veterinarian to maintain a reasonable lifestyle, there usually is a legal authority requiring that when medical and surgical treatment are undertaken, they be done at a fairly high minimum level of skill and competency combined with the appropriate equipment and product availability.

What then, are we allowed to do legally to reconcile these apparently conflicting demands on our time and practice resources?

There is a one school of thought among practice management consultants that says the mere decision to attempt to reconcile the opposing forces of economics and standard of care is erroneous. The position goes something along the lines of: "Bring your fees and your standards higher, and the marginal clients will fall to the wayside; it is a loser's game to chase them anyway."

That might be good advice for those focused primarily on the financial side of the equation. Nonetheless, people who are short on money continue to adopt pets and for those of us in some economically challenged parts of the country, culling this group from our client base would spark the relocating of our practices.

Obviously, there are some veterinarians who might choose to take another approach. These doctors could dramatically curtail the time and/or inventory commitment that they are willing to make to clients who are not expected to pay the established rate for acceptable-quality care. This approach to diagnostics and treatment is ordinarily chosen without significant disclosure to, or input by, the client.

The decision to follow this route, legally speaking, amounts to a bet. The practitioner is wagering that one of the following events will intervene in the legal favor of the doctor:

1. The animal has good recuperative powers and will improve regardless of the use of the second-best or third-best diagnostic and treatment alternatives selected. (This is where the doctor suspects mandibular osteomyelitis but sends home the lowest therapeutic dose of penicillin because it might do the job and fits within what he perceives to be the client's price range.)

2. If the animal's condition should deteriorate or if the pet should expire, the owner will not be overly disappointed. (This is the result the doctor might get if he has already explained that "Fluffy is really, really sick ..." Or the owner was doubtful that much could be done in the first place.)

Remarkably, the vast majority of veterinarians who take this approach to reconciling the conflicting demands for quality care and reasonable remuneration actually win the bet. And not infrequently, the winning streak is a full career in duration. But many of us still don't feel comfortable with the odds, and the following example illustrates the reason:

Imagine that on Monday, Dr. Bettor sees an appointment in which Lou Zer stops in with his cat. Typically, Lou comes in every three years with his dogs. Today, though, his cat Plug hasn't been feeling well and hasn't left the litter box since Sunday afternoon.

Bettor can't just send Plug away, so he tells Lou that the cat is really, really sick (no lie). Lou explains that his unemployment checks just ran out, but "do whatever it takes, doc, I can't live without my Plug ..." Lou leaves a deposit of $37 and a six-pack of empty Sierra Mist bottles.

Doc now has choices. Make Mrs. Gold and her Pomeranian wait impatiently while he immediately relieves Plug, or see her while the volume of the problem expands.

Bettor must chose whether to do an ECG in tandem with the catheterization or perform only the procedures the practice might actually get paid for. What'll it be? Should he place an indwelling urinary catheter in anticipation of days of uncompensated hospitalization or just flush the kitty and ship him by 5 p.m.?

Doctor B has been watching much more World Poker Championship than either Animal Planet or Nancy Grace, so he waits a couple hours, pops Plug with IM ketamine and ships him home with Lou before closing time.

Plug dies at 9:12 p.m., even though Lou made sure the marginally conscious feline got his first amoxicillin pill.

Even Gomer Pyle couldn't have been more surprised when a process server accosted Dr. Bettor the following week. Not only was our veterinarian friend shocked that a client with a sixth-grade education was suing him, he was also pretty wide-eyed to discover that the cat was worth $1,000.

Who could have predicted that Lou would be so distressed by Plug's untimely demise that he would need to start six months of intensive psychotherapy? And guess what? Lou's so distraught that he may never be able to go back to work.

Next time: What decisions could and should Dr. Bettor have made to appropriately reconcile a reasonable standard of care with the need to receive adequate payment for the care that he provides? Stay tuned. And now, here's a word from the good-hands people at the Professional Liability Insurance Trust.

Dr. Allen is president of the Associates in Veterinary Law P.C., which provides legal and consulting services exclusively to veterinarians. He may be contacted at (607) 754-1510 or info@veterinarylaw.com