The price of pain

MINNEAPOLIS — For 59 years, Dr. Carl Seemann practiced as northern Minnesota's surgical "spine man," a solo generalist who, at age 84, saw three clients a day until Christmas last year.

Painful realization: Charges of substandard pain control threaten Seemann's future in practice. "My clients don't give a damn what anyone says about me. They know this isn't true," he says.

Yet the sudden end of Seemann's long career was no retirement gift. It arrived via mail on Minnesota Board of Veterinary Medicine (MBVM) letterhead. On the stationary were the words "license suspension."

"They called me a threat to others," recalls Seemann, now perched in his Colo-rado mountaintop cabin with his wife, dog and pride at bay. At press time, an administrative-law judge was expected to issue a final verdict on the nearly yearlong battle regarding Seemann's case.

The board's complaint, while initially centered on allegations of an orthopedic procedure gone bad, has narrowed to one aspect of veterinary care: the postoperative management of pain.

Dig past Seemann's lack of board credentials and malpractice accusations, and what's revealed, experts say, is the nation's first test case regarding pain management in veterinary medicine.

Onward bound: Retreating to the mountains of Colorado, 84-year-old Dr. Carl Seemann says he's building a new life but promises to continue his fight to practice.

Just a decade ago, pain management was the exception, not the rule, in most pockets of the profession. But combine new research with elevated public attitudes regarding pets, and an older veterinarian failing to adopt new thinking on pain management grabs headlines.

Such standards often aren't tangible. They develop over time, slowly simmering until a general consensus is established. Peer review, continuing education and majority practice can push the evolution. But a single event often brings new standards to a head.

Last month, the American Association of Feline Practitioners (AAFP) and the American Animal Hospital Association (AAHA) released the nation's first guidelines for managing pain in companion animals (see related story). While the tide has clearly turned, veterinarians serving rural outposts might view such change as unfair.

To beat the rap, Seemann has gone to trial, hired expert witnesses and spent $85,000 defending his reputation and his standards of practice.

"City people," Seemann argues, live in a different world than rural America, where pain-management drug costs often are considered impractical. While he acknow-ledges the public's increasing tendency to anthropomorphize animals and demand a higher grade of services, he still doesn't use analgesics following spays.

"I am absolutely shocked this case has gone this far," Seemann says. "I just was trusting that this crazy thing couldn't be happening to me. I've always been a very dedicated veterinarian."

The defense

During a three-day trial in August, the Minnesota attorney general's lawyers and experts argued against that. Defense attorney Zenas Baer, who now sifts through 650-plus pages of transcripts while awaiting the judge's verdict, claims he's never witnessed a case where authorities have lambasted a licensee based on such "flimsy" regulatory evidence. The lawyer, who once sat on the Minnesota Board of Medical Practice and represents Seemann, says he's unaware of any human doctor who has ever been disciplined for inadequate pain-control measures.

So when it comes to his veterinarian client, Baer's argument is two-fold: Veterinary regulators fail to provide any published documents linking emerging pain-control protocols to standards of care, thus creating a basis for making such guidelines voluntary. What's more, animals still are considered property in all jurisdictions in the United States.

"An allegation has been made that the failure to provide prophylactic pain management just because an animal has undergone a procedure is somehow below the standard of care," he says. "This case is almost antithetical to the concept of pets being considered personal property. If you have an automobile and say 'I want the basics,' the repair shop will give you the basics. Under the law, veterinarians should still be allowed to do that."

Imminent threat

Not so, when it comes to pain management, argues Dr. John King, MBVM executive director. Appointed by the governor, the seven-member board temporarily suspended Seemann's license based on an investigation and interviews with the veterinarian, King says. He insists such action isn't the product of "unharnessed power of the bureaucracy." Out of 3,000 Minnesota licenses, authorities revoke one every couple of years.

Seemann's case marks the state's first suspension, and his alleged failure to use post-operative pain drugs is egregious, King says. At trial, the attorney general's office representing MBVM called on a University of Minnesota professor to describe the teaching hospital's modus operandi on pain control. Critics argue that such strict standards don't yet apply to practitioners in primary-care practices, especially in rural settings. Still, "this is not about failing to give pain medication for a hangnail. This is about orthopedic surgery," King states.

While King acknowledges that the state's practice act does not include pain-management rules, he argues, "Nothing in there talks about how to spay a dog, either." Lic-ensing agencies struggle with how to enforce variable benchmarks, especially when standards of care are fluid, he says. But to hint that enforcement hinges on mere personal opinion is too simplistic a view. Dr. Robin Downing, president of the International Veterinary Academy of Pain Management and an author of the recent AAHA/AAFP pain-management guidelines, insists such standards of care are part of the profession's "collective consciousness." Seemann's case, she says, represents the first time a veterinarian has been confronted with a disciplinary action solely for lack of pain control and acts as proof that a doctrine exists for pain management.

"I will tell you that we in veterinary medicine now have enough data published that it is inexcusable for any veterinarian not to have a clear understanding that it's necessary to help a patient be comfortable following surgery," she says. "If there are five practices in a community and three embrace the guidelines, they have effectively raised the standard of care in that community. Those two other practices will be judged in that context."

Considering that analogy, "it appears Dr. Seemann was asleep at the wheel," King contends. "Our bottom line is to protect the public. People shouldn't believe that if they live in Podunk the practice of medicine is anything less than in the city," he says.

Out of bounds

Yet the board's "take no prisoners" approach isn't wise or lawful, critics maintain. Despite knowing that his opinion might be unpopular among specialists, James F. Wilson, DVM, JD, testified on Seemann's behalf. Without any widely uniform, disseminated rules on pain management, the board's suspension should be ruled invalid, he contends.

"Dr. Seemann is being treated harshly by the state board and lashed by the attorney general's office," Wilson says. "If the suspension is upheld, I believe this represents a new legal precedent for the nation of primary-care veterinarians who are not yet aware of their vulnerability to this cause of disciplinary action."

Wilson hopes surveys will be conducted to determine what the standard of care really is among practices in the United States. "After all, when does a new course of treatment become the standard?" he asks.

Next phase

That could be answered in the administrative law judge's order. Although the MBVM isn't bound to accept the judicial verdict, a ruling has never been ignored, King says. If either party contests the decision, the case goes to an appeals court for consideration. The Minnesota Supreme Court is the final step in the state's system.

Attorney Baer is counting on a ruling in his client's favor. In the meantime, Seemann plans to take his story to the state Legislature.

"I want to create a setup where veterinarians can get a hold of client complaints and mediate them to avoid some of the board of veterinary medicine's crazy judgments. These people seem to be having fun destroying a veterinarian's life. I want to raise hell every way I can," he says.