Standards of care: Apply them evenly to all patients

There tends to be a fairly ascertainable medical standard that must be met, regardless of the client's capacity or inclination to pay for treatment that meets that standard.

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Unless a veterinary practitioner is willing to accept some degree of risk in patient treatment, she must institute and carry through the same level of medicine and surgery for clients who are likely to be so-called "bad-pay" risks as she would have provided for a routine client.

Leaving aside the political and moral arguments as to whether people with minimal resources should or should not own pets, let us explore the important legal considerations facing veterinarians as they "walk the tightrope" between personally subsidizing quality veterinary care for indigent clients and exposing themselves to liability for lowering their personal bar in diagnosing and treating certain individual patients.

Initially, let us face the precise nature of the problem. Human physicians and human hospitals know that the question of standard of care is virtually non-negotiable for legal purposes. Under the law, physicians are working on patients with an infinite value and consequently, nothing short of an acceptable standard of care is sufficient. They are not mechanics performing tune-ups; they can't install a cheap set of spark plugs in a used Hyundai while tapping original equipment for a Mercedes.

Food animal veterinarians, on the other hand, are working on property. If a Holstein gets sick and the resulting surgery is done improperly, then either Doc comes back to fix it or insurance pays the dairy for the price of the cow. Case closed.

Companion animal veterinarians are stuck between the moon and New York City. Increasingly, they are being held to the medical care standards of those practicing on beings of, if not infinite, at least immediately unascertainable value. ("Members of the family whose people might suffer emotionally as a result of the patient's death?").

On the other hand, the veterinarian is faced with fee constraints established by both pet owners and the marketplace. At times, it is hard not to feel as if we are mechanics who are required to use premium parts to repair used vehicles with the owner looking over our shoulder murmuring, "I don't want to put a lot of money into this ..."

What then are the guidelines for reconciling these two inconsistent demands placed on us almost every day in small animal clinical practice? Here are a few that might be helpful:

• Abandon the concept of using living collateral for your fee.

I formerly worked with a veterinarian who would never, ever let a pet out of the hospital until the full bill was paid. That actually worked pretty well 20 or 30 years ago. Nowadays, however, the public and the law see companion animals as having a much higher financial and emotional value. And although it might seem counterintuitive, it is more likely than ever that a high veterinary bill will result in abandonment of the patient and the inability of the doctor to receive his or her fee. At the same time, the regulations concerning an animal hospital's ability to have such pets declared "abandoned" are becoming increasingly strict.

The upshot is that a veterinarian is obligated to provide quality ongoing care. However, they are also generally entitled to require an initial deposit, followed by additional payments on account as a medical case moves forward. While it may be an uncomfortable thing to have to do, veterinarians should request additional deposit amounts as a hospitalization episode moves forward. We are obligated to provide quality treatment when we provide care, but we don't have to carry that treatment out indefinitely with only a guess as to whether payment will eventually be rendered.

• Explain the most-costly scenario to clients at the outset.

You probably don't need to take the time to outline your entire recommended protocol to all clients. Those who have paid in the past and have learned to trust you know that you will try to do the right thing. Also, they can rely on you to check with them before performing costly or unanticipated tests and procedures.

The clients who must get the full explanation are the ones who you probably are least inclined to fully advise: These pet owners are those who:

1) you least want to engage in conversation because they seem obnoxious or dense; and

2) are least likely to be able to afford the work you are detailing. Why do these folks need every detail? There are several reasons:

The obnoxious ones will likely later claim you never told them exactly what you were going to do, so therefore they shouldn't have to pay for it.

The dense ones will nod with understanding and later refuse to pay because they didn't get an understandable assessment of the potential cost.

The "bad-pay" folks know that they will insist that you do anything and everything for their pets. These people don't want to be bored with details. "Just take the cat in and get started. Doc, we'll pay whatever it costs ..."

By being advised of the details of what would constitute the "best practice" in the care of their pet, these questionable clients are placed in the position where they have to make a decision. The client can:

1) Establish the financial limitations that they want you to respect, thereby taking the "infinite" patient value out of the equation and pushing the case further into the "property" category; cost-cutting measures then can be discussed with full disclosure and acquiescence on the part of the owner.

2) Acknowledge that they understand their obligation to pay you for the full scope of appropriate care and, by inference, their obligation to release you from the obligation to perform continuing care in the event that they fail to continue to pay or make satisfactory payment arrangements.

3) Elect to pursue treatment elsewhere. Depending on the circumstances, this decision might need to be deferred until after life-saving critical care is undertaken.

As always, it is critical to document as fully as possible both the details of your explanation and the specifics of the client's responses. As students are told in veterinary school, "If it isn't in the record, it didn't happen." This is always true and in addition, a completely documented record will help in your efforts to collect full payment through litigation, collection or otherwise.

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.