Proper treatment and client funding ethics

[HorseyVet]

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Greg, if what you are saying is true, should clinicians receive training as doctors at all? Your statement seems to suggest that all clinicians need to do is interpret symptoms and test results without understanding any of the underlying causes or mechanisms of disease. Why not go one step further and completely replace clinicians with a computer program? Symptoms could be checked off, scans and blood work could be loaded, and the computer could make the diagnosis and write a treatment based on programmed algorithms.

Only their critical thinking, rooted in a deep knowledge of physiology (dependant on biochemistry) enables doctors to perform their duties better than a lesser trained individual.

There is an idea held by many that medicine is a trade profession. I agree that to an extent it is. How much one subscribes to this philosophy will likely, and in my experience does, reflect how one views undergraduate courses and admissions evaluation criteria.

Vet med in general is much more problem-solving oriented on a daily level b/c the patients cannot speak and b/c of the diffculty in treating patients that cannot be compliant to many treatment and diagnostic desires. Also, b/c cost is a much greater delima in vet med, veterinarians must really know how to get the diagnostic bang for the buck, which requires an additional layer of problem-solving and observational acutity of the patient. I don't even know how many times I've seen a patient where one says "well I wished I had blood work and xrays, but since I don't/can't this is what we'll do." There is a very real, "by the seat of your pants" medical knowledge needed in vet med.
Human medicine is a little more restrained to the trade functionality, in large part b/c of liability concerns. If one does something novel, even though it may make practical sense, they may be considered in malpractice if the Tx is not the accepted norm.

Don't flame me. Both professions are hard and there are exceptions to what I have said in both fields, however, I do think that the general trends are true.

 

[julieDVM]

There is an idea held by many that medicine is a trade profession. I agree that to an extent it is. How much one subscribes to this philosophy will likely, and in my experience does, reflect how one views undergraduate courses and admissions evaluation criteria.

Vet med in general is much more problem-solving oriented on a daily level b/c the patients cannot speak and b/c of the diffculty in treating patients that cannot be compliant to many treatment and diagnostic desires. Also, b/c cost is a much greater delima in vet med, veterinarians must really know how to get the diagnostic bang for the buck, which requires an additional layer of problem-solving and observational acutity of the patient. I don't even know how many times I've seen a patient where one says "well I wished I had blood work and xrays, but since I don't/can't this is what we'll do." There is a very real, "by the seat of your pants" medical knowledge needed in vet med.
Human medicine is a little more restrained to the trade functionality, in large part b/c of liability concerns. If one does something novel, even though it may make practical sense, they may be considered in malpractice if the Tx is not the accepted norm.

Don't flame me. Both professions are hard and there are exceptions to what I have said in both fields, however, I do think that the general trends are true.

they way you describe veterinary medicine is outrageous! to treat conditions by "the seat of your pants" is outright malpractice, and ANY veterinarian that does this opens themselves to litigation (and rightfully so).

This style of archaic medicine is no longer acceptable among practitioners anywhere. They surely dont teach you this in vet school (at least i dont teach my students this) - and i will have words with the professors that do!

Granted our patients cant talk - but we are trained to get around that. I would seriously caution you with this attitude - especially these days. there's nothing wrong with employing an experimental treatment for a condition that doesn't respond to conventional medicine - but you sure as hell have to make sure that you exhausted all diagnostic techniques, and have informed consent from the owner - in triplicate!

This is dangerous thinking.

 

[HorseyVet]

they way you describe veterinary medicine is outrageous! to treat conditions by "the seat of your pants" is outright malpractice, and ANY veterinarian that does this opens themselves to litigation (and rightfully so).

This style of archaic medicine is no longer acceptable among practitioners anywhere. They surely dont teach you this in vet school (at least i dont teach my students this) - and i will have words with the professors that do!

Granted our patients cant talk - but we are trained to get around that. I would seriously caution you with this attitude - especially these days. there's nothing wrong with employing an experimental treatment for a condition that doesn't respond to conventional medicine - but you sure as hell have to make sure that you exhausted all diagnostic techniques, and have informed consent from the owner - in triplicate!

This is dangerous thinking.

Hang on....I said that you need to be able to think and treat that way, but not that this is how one operates all the time.

Funding is a concern. If the cilents can't pay for the full spectrum of diagnostics, then you need to be able to talior treatment to meet what they can afford such that it maximally benefits the patient.

For example, just the other day a dog came in who had not had a BM in like a week, nausea, vomitting etc. The dog has a history of eating and passing socks and other misc items. My vet was at least the second person the patient had seen. The owners did not want to do a barium, blood work, or xrays. Chances where that the dog had eaten something, was impacted and would need exploratory surgery to get whatever out. If diagnostics confirmed this then the dog would need exploratory anyway and the owner would have an extra hundred or so to their bill. The same diagnostics could also indicate another problem and therefore another treatment course....however not finding anything on the exploratory would also indicate that something else was a problem. So the owners decided to just do the exploratory and then go from there b/c it was the least expensive route. True, if the impaction was not the source, then the surgery would be a much more invasive way to deduce it, however the client was unwilling to take the steps to determine the cause. Something obviously needed to be done.

This is what I'm talking about by saying "seat of your pants." One needs to know what to do even if they do not have all of the tools available to make a totally informed descision.

I hope that makes the point I was going for more clear.

 

[julieDVM]

Hang on....I said that you need to be able to think and treat that way, but not that this is how one operates all the time.

Funding is a concern. If the cilents can't pay for the full spectrum of diagnostics, then you need to be able to talior treatment to meet what they can afford such that it maximally benefits the patient.

For example, just the other day a dog came in who had not had a BM in like a week, nausea, vomitting etc. The dog has a history of eating and passing socks and other misc items. My vet was at least the second person the patient had seen. The owners did not want to do a barium, blood work, or xrays. Chances where that the dog had eaten something, was impacted and would need exploratory surgery to get whatever out. If diagnostics confirmed this then the dog would need exploratory anyway and the owner would have an extra hundred or so to their bill. The same diagnostics could also indicate another problem and therefore another treatment course....however not finding anything on the exploratory would also indicate that something else was a problem. So the owners decided to just do the exploratory and then go from there b/c it was the least expensive route. True, if the impaction was not the source, then the surgery would be a much more invasive way to deduce it, however the client was unwilling to take the steps to determine the cause. Something obviously needed to be done.

This is what I'm talking about by saying "seat of your pants." One needs to know what to do even if they do not have all of the tools available to make a totally informed descision.

I hope that makes the point I was going for more clear.

What if this patient was anemic, or lacked clotting factors, and you failed to do the proper pre-Sx blood work, and it bled out on the table and died. Then where would you be? Would that have maximally benefited the patient? Dogs have a lot of intestines, who knows where the blockage could have been? If you ask me, you got lucky on this case.

I do not approve of this approach, nor do i approve of the idea that you can substitute guess work and cutting diagnostic corners for the sake of saving a buck. Most clients will pay for diagnostics if you explain the risks of not doing pre-op blood work etc.

I assure you, you wont be taught to treat patients this way in school.

 

[HorseyVet]

What if this patient was anemic, or lacked clotting factors, and you failed to do the proper pre-Sx blood work, and it bled out on the table and died. Then where would you be? Would that have maximally benefited the patient? Dogs have a lot of intestines, who knows where the blockage could have been? If you ask me, you got lucky on this case.

At this point for that animal, the owners had already turned down doing diagnostics at least one other practice. The dog had been very ill for over a week and they had no intentions of opting for diagnostics. If what was done in this case was wrong, then what would you do? The only other options I see are: (1) allowing the dog to continue to be ill and hope that it improves on its own and (2) euthanizing the dog.

Personally, I think it would have been unethical at that point to just "wait and see." The majority of the potential problems it could have had would have resulted in eventual and painful death. I think it is far better to do something which could help, than do nothing which you know won't help. The clients were well informed about the risks of the surgery and the value of the diagnostics and they choose the surgery option. They did not want to euthanize. It seems you would not have even considered surgery an option, which again leads me to wonder, what would you do then?

I do not approve of this approach, nor do i approve of the idea that you can substitute guess work and cutting diagnostic corners for the sake of saving a buck. Most clients will pay for diagnostics if you explain the risks of not doing pre-op blood work etc.

I am not sure of what your experiences are, but if you are at referral type hospital then your clients essentially have already been screened according to what they are or are not willing to pay for. In my experience, it is very common for clients to be unwilling to pay for diagnostics. Those clients have already made the descision to pay for advanced services are seen at referral clincs. The clients that didn't had their animal either already treated using less expensive services or euthanized at the would-be referring hospital.

No one takes their horse to a university or referral clinic for colic treatment, gets there, and then says "boy this is expensive, just euthanize him." The descision to have (or not have) the surgery was already made at the farm.

Additionally, in this case...after the dog had been ill for so long, it is likely that its blood work would have been abnormal in at least some aspect. Again, do you just say "well he's not a good candiate for Sx, take him home to die."

This client, and many like them, continue to bounce from practice to practice untill the animal dies or they find a vet who offers a treatment course they agree with paying for. I do not think it is right to condemn this clinic for performing a treatment which could have potentially resolved the problem rather than doing nothing, and allowing the animal to suffer or become the problem of another vet.

I assure you, you wont be taught to treat patients this way in school.

Maybe not, but I think one needs to be competent and savy enough to tailor treatment when finances exclude the ideal treatment course. Part of the point of vet school is to educate you on all of the tools available to you, so that you can make descisions about what is appropriate.

I remember while touring a vet school, the person giving the tour was boasting about how they had fully switched to digital xrays. I asked if students ever gets exposure to reading the standard radiographs, because many clinics have not yet been able to incorporate digital. I foresaw a problem in being trained on very good quality images and then having issues making diagnoses on lesser quality images, once one entered a practice. You obviously can't tell the client "I can't do xrays b/c we do not have digital, and anything I tell you won't be completely informed." Part of the whole reason why many practices have not switched is b/c clients are not interested enough in the value of the digital images to pay more for them. The same can be said about many laser surgeries.

If you operate in a perfect world where client funds are limitless, then you may never need to make these descisions. The majority of individuals working in private practice, however, will need to have the smarts to make tough and educated descisions about talioring paitent care.

 

[PAThbrd]

FYI, this discussion originaly came from the Competition in pre-reqs thread.

 

[UKYWildcat]

No one takes their horse to a university or referral clinic for colic treatment, gets there, and then says "boy this is expensive, just euthanize him." The descision to have (or not have) the surgery was already made at the farm.



I remember while touring a vet school, the person giving the tour was boasting about how they had fully switched to digital xrays. I asked if students ever gets exposure to reading the standard radiographs, because many clinics have not yet been able to incorporate digital. I foresaw a problem in being trained on very good quality images and then having issues making diagnoses on lesser quality images, once one entered a practice. You obviously can't tell the client "I can't do xrays b/c we do not have digital, and anything I tell you won't be completely informed." Part of the whole reason why many practices have not switched is b/c clients are not interested enough in the value of the digital images to pay more for them. The same can be said about many laser surgeries.

Two comments -
1. About clients making their decision about colic surgery - happens all the time where they arrive, are worked up and euthanized. Could it have been done at home? You bet...but sometimes the client needs to feel like they are doing "something" for that animal, so they make the trip...by the time they've thought it through during the drive that they can't afford surgery, they'll often decide to euthanize if surgery is the only option. I'd say this happens at least 1-2 times a week in our facility.

2. About digital radiography - the technique is the same, the end product and what you can do with it is a little different. There is NO reason why a new grad should say "I can't do radiographs because I don't have digital" Position, measuring, machine setting - same, same, same. You may have to take a few more films because you can't just lighten and darken a image like you can with digital, but again, I'll say that there's no reason for a new grad to say they *can't* do radiographs.

 

[HorseyVet]

1. About clients making their decision about colic surgery - happens all the time where they arrive, are worked up and euthanized. Could it have been done at home? You bet...but sometimes the client needs to feel like they are doing "something" for that animal, so they make the trip...by the time they've thought it through during the drive that they can't afford surgery, they'll often decide to euthanize if surgery is the only option.

Hrm, I wonder what the percentages are of "mind-changing." You're right though, I have known a few of those. Basically after they've been presented with all of the financial paperwork etc. they realize that it is no longer an option for them or something they are willing to do. Additionally, sometimes there is something that makes the surgery more expensive then they expected. I've also known people that said they'd take the horse for surgery, and then change their mind and don't want to call the vet back to euthanize it so they take it to the referral center. People have also been caught lying about what happened to the animal...for example saying it died while in surgery when they just had it euthanized.

Like you said, they feel they are bad people if they don't do the surgery, so they drive it there, and then when faced with reality, decide to do soemthing else.

2. About digital radiography - the technique is the same, the end product and what you can do with it is a little different. There is NO reason why a new grad should say "I can't do radiographs because I don't have digital" Position, measuring, machine setting - same, same, same. You may have to take a few more films because you can't just lighten and darken a image like you can with digital, but again, I'll say that there's no reason for a new grad to say they *can't* do radiographs.

I agree. I wasn't saying that non-digital technology should be veiwed as useless. I was just using that as an example where you may wish you could utilize one kind of diagnostics, but that if you can't that doesn't mean that there are no more options. Maybe it was a bad example. I do however, worry about being trained on digital and then not being as great with reading standard graphs.

 

[julieDVM]

At this point for that animal, the owners had already turned down doing diagnostics at least one other practice. The dog had been very ill for over a week and they had no intentions of opting for diagnostics. If what was done in this case was wrong, then what would you do? The only other options I see are: (1) allowing the dog to continue to be ill and hope that it improves on its own and (2) euthanizing the dog.
...

If you operate in a perfect world where client funds are limitless, then you may never need to make these descisions. The majority of individuals working in private practice, however, will need to have the smarts to make tough and educated descisions about talioring paitent care.

Pre-op blood panels are part of my surgical bill - i do not cut into an animal without doing a blood test first. It's standard procedure for any anesthesia procedure - and it should be everywhere. I am at a university right now - so i fully acknowledge that the environment is artificial - however that doesn't diminish the standard operating procedures when working up a surgical case. I'm not saying that in this case the dog wasn't a surgical candidate - clearly it was. What I am saying is that doing procedures "blind" is risky business, because if things go wrong - and invariably they do - you need to cover yourself... both for the patients welfare, and for your own ass.

the point of vet school is to teach you the fundamentals - the proper way of doing things. Not to teach you to cut corners. As you begin your training, you will realize that there are strict reasons you perform basic diagnostic tests - and the attitude that you can tailor treatment without doing the basics is completely reckless.

There will be times when you cannot get clients to pay for treatments or tests, and its the most frustrating part of our jobs - but you cannot potentially compromise your quality of care because of it. Further to this, and i've said this before, you cannot do things for free. That's why when clients bring surgical patients into my hospital, there isn't a question as to whether they get a blood test - its part of the procedure and its built into the fee. The same goes for an IV catheter - its built into the fee. All our general anesthesia patients get IV catheters, and I know a lot of practices that do not place them for routine procedures... I think this is ridiculous. What if the patient crashes? The time you spend hunting for a vein in a hypotenisve patient probably means its life.

In this case, how do you know the blood work would have been abnormal? i'm sure it probably was, however, depending on what showed up, it may have been decided that a different med course was taken. Like I said before, you got lucky.

And as a matter of fact, I've dealt with a number of clients who have brought their horses into the university, decided that the procedure was too expensive, and opted to euthanize them. Sorry, but it happens.


After all of this, what I'm trying to impress upon you, and all the new (and current) vet students out there is that all the practice experience you've seen so far may not have been the "best practice." You're entering university to be taught and challenged to think critically, and you need to keep in mind that once you go out with your qualifications, you can do things better.

Now - I'm off my soap box!

 

[HorseyVet]

Pre-op blood panels are part of my surgical bill - i do not cut into an animal without doing a blood test first. It's standard procedure for any anesthesia procedure - and it should be everywhere.

There will be times when you cannot get clients to pay for treatments or tests, and its the most frustrating part of our jobs - but you cannot potentially compromise your quality of care because of it. Further to this, and i've said this before, you cannot do things for free. That's why when clients bring surgical patients into my hospital, there isn't a question as to whether they get a blood test - its part of the procedure and its built into the fee. The same goes for an IV catheter - its built into the fee.

You didn't really answer my "what would you do?" in that scenario question. Including all of the diagnostics in your fee doesn't really address the fundamental problem. Essentially your answer is to give the client an option of surgery with all of the diagnostics or euthanasia. If you tell a person they have the choice of a $400-$600 surgery or a $40 euthanasia, and they don't have much money, it pretty much forces them to choose euthanasia. If you offered a $200 surgery without diagnostics, then they may be willing and able to take that attempt to save the animal. If it dies as a result of issues which could have been adressed by the diagnostics, is irrelavent b/c for that cilent they were not an option to begin with.

It seems that for you, doing things the proper way outweighs doing what is economically pragmatic, even if that means the only treatment you can offer is death. You are essentially saying, "do things the right way, or euthanize it." I would agree that in some cases this is the only choice, but in many, especially where diagnostics are concerned, there is a lot of gray area where other options are possible if your outlook is different.

My philosophy is to provide the best treatment possible given the constraints of the situation. If I am faced with doing a surgery without diagnostics, in which the animal may live but may also die, or just skipping to euthanization, I would do the surgery. At least there, there is a chance for survivial.

I am at a university right now - so i fully acknowledge that the environment is artificial - however that doesn't diminish the standard operating procedures when working up a surgical case.

In a university setting, standard operating procedures are only elevated. Additionally, because of the environment, for legal reasons, there is often little option to deviate from playing everything from the "safe" side.

What I am saying is that doing procedures "blind" is risky business, because if things go wrong - and invariably they do - you need to cover yourself... both for the patients welfare, and for your own ass.

I think that doing procedures without diagnostics, and without informing the cilent of the risks is completely unethical. If they are informed, however, it is their choice. My parents are both lawyers, as are about 5 other indivudals in my immediate family, so I am highly aware of legal matters. I would require written consent for anything that was done against medical advice.

Again, I'm all for playing it safe and doing all the diagnostics possible. However, when the *only* choice is to either take a risk or to euthanize the animal, I would take the risk.

 

[julieDVM]

You didn't really answer my "what would you do?" in that scenario question. Including all of the diagnostics in your fee doesn't really address the fundamental problem. Essentially your answer is to give the client an option of surgery with all of the diagnostics or euthanasia. If you tell a person they have the choice of a $400-$600 surgery or a $40 euthanasia, and they don't have much money, it pretty much forces them to choose euthanasia. If you offered a $200 surgery without diagnostics, then they may be willing and able to take that attempt to save the animal. If it dies as a result of issues which could have been adressed by the diagnostics, is irrelavent b/c for that cilent they were not an option to begin with.

It seems that for you, doing things the proper way outweighs doing what is economically pragmatic, even if that means the only treatment you can offer is death. You are essentially saying, "do things the right way, or euthanize it." I would agree that in some cases this is the only choice, but in many, especially where diagnostics are concerned, there is a lot of gray area where other options are possible if your outlook is different.

My philosophy is to provide the best treatment possible given the constraints of the situation. If I am faced with doing a surgery without diagnostics, in which the animal may live but may also die, or just skipping to euthanization, I would do the surgery. At least there, there is a chance for survivial.



In a university setting, standard operating procedures are only elevated. Additionally, because of the environment, for legal reasons, there is often little option to deviate from playing everything from the "safe" side.



I think that doing procedures without diagnostics, and without informing the cilent of the risks is completely unethical. If they are informed, however, it is their choice. My parents are both lawyers, as are about 5 other indivudals in my immediate family, so I am highly aware of legal matters. I would require written consent for anything that was done against medical advice.

Again, I'm all for playing it safe and doing all the diagnostics possible. However, when the *only* choice is to either take a risk or to euthanize the animal, I would take the risk.

Doing things with reckless disregard for sound medicine is definitely not my way of doing things... economic constrains be damned. And no where have I said that I would opt to euthanize the animal if the client cannot afford radiographs (or other diagnostics). Simply put, the extra 30 dollars built into the price of the surgery for a simple CBC and chem panel is not going to make or break the client in this situation (and dont even try and tell me it would). Its not like i'm ordering 1000 dollars worth of labs here! I find it impossible to defend the notion that you can forgo medically necessary tests in order to accommodate the idea that you are somehow doing the animal some good by operating without proper diagnostics. How can you decide what fluids to administer to an animal, what electrolytes to give etc. without a chemistry profile? The answer is YOU CANT - not safely anyways. Legal issues aside, this type of cowboy medicine isn't practiced in high end practices, nor should it be, anymore.

If you had a client bring in a horse to you that you believe had a large colon torsion, but wouldn't pay for the rectal exam, wouldn't pay for the blood work, but would pay for the surgery because you thought it would probably need it anyways so why pay for the diagnostics, and you went a head and opened up the horse and found an impaction that may have passed on its own while being treated medically, what the hell have you accomplished? You've opened this horse up to a world of trouble (infection, hernia, months of complicated recovery and potential loss of athletic function) all because you decided that it was life or death, and it was probably going to need the surgery anyways?! THIS is unethical.

 

[HorseyVet]

Simply put, the extra 30 dollars built into the price of the surgery for a simple CBC and chem panel is not going to make or break the client in this situation (and dont even try and tell me it would). Its not like i'm ordering 1000 dollars worth of labs here! Legal issues aside, this type of cowboy medicine isn't practiced in high end practices, nor should it be, anymore.

There are a lot of very rural and poor areas where money is a real issue. There are also practices with do charge a lot for labs. I've seen pre-surgery lab work come to well over 300 dollars.

Regardless I think your desire to pigeon-hole me as being some kind of rabid over zealous surgeon has caused you to miss my points.

The bottom line is that these descisions are made every day and they are difficult to make. Many veterinarians will encounter situations where they need to know what is the best approach when the information they have is limited.

 

[rdc]

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[HorseyVet]

Perhaps you dont fully realize how important and valuable (and cheap!) simple blood tests are (especially pre-op)- and how they can be extremely good indicators of overall health status (which is totally understandable given you haven't had that training yet - i think julie is being a little hard on you). Things like acid/base status, PCV etc are all very important - especially when putting an animal under general.

I do realize and agree that they are important.

I can see where you're coming from with respect to working within a clients budget, but what good does it do you if you fix the gastric impaction, but the animal dies from anesthesia complications simply because you failed to pick up on something on the pre-op blood work because you opted not do do it?

Again, not that I "opted not to," but rather the client.

It seems that my experiences have just exposed me much more regularly to the type of situations where clients really won't pay hardly anything for their animals care. This is why I value the knowledge and ability of how to get the most out of what one does know about the situation. I've just seen a lot of cases where something was done which did save the animal only b/c the vet was knowledgeable enough to maximize treatment. I've also seen a lot of animals euthanized b/c the clients could not pay for diagnostics.

 

[rdc]

.

 

[youthman]

I think you are coming down way too hard on HorseyVet. We all know that the majority of people will not spend on "high end" procedures for their animals. What I see built-in to most private practices is room for adjustment because they see day in and day out this very problem. I have yet to meet a vet, whether as an employee or a client, that says "do it this way or no way at all."

As far as billing - it doesn't matter whether it's built-in or not. You still have to break down the pricing for them. "Built-in" may sound good to you but to someone that wants to sue you they could call it "hidden charges."

 

[wishes]

I think you are coming down way too hard on HorseyVet. We all know that the majority of people will not spend on "high end" procedures for their animals. What I see built-in to most private practices is room for adjustment because they see day in and day out this very problem. I have yet to meet a vet, whether as an employee or a client, that says, "Do it this way or no way at all."

I have been a veterinary technician for over 5 years and I can honestly say that I have seen many dimensions of this issue. I will say that money is an problem more times than it is not and sometimes even people who can afford to treat an animal have serious qualms about investing in a procedure or treatment course that does not necessarily promise a positive outcome, especially in a middle aged or geriatric pet. I believe that this issue remains as one of the biggest limitations of veterinary medicine.
One of my first jobs was working in a community practice in rural Alaska where money was a concern for most of our clients. This clinic offered three anesthetic options for most of their procedures. Option (#1): No special anesthetic precautions, Option (#2): Pre-operative blood screening, Option (#3): Pre-operative blood screening, IVC, fluids. The veterinarians would make recommendations in the cases of patients with special risks, but ultimately it was the client who checked their preference when they signed the consent for anesthesia.
Since then I have worked for some higher end practices with the do it my way or not at all philosophy. One veterinarian I worked for would frequently start out initial appointments by describing the type of care we provided and the corresponding expenses (premium pet food, yearly laboratory screening, IVC/fluids/bloodwork for all routine procedures, Sevofluorane anesthetic, etc.). She would actually recommend clients go elsewhere if they were unwilling/unable to pay for this caliber of services. Did she lose clients? Definitely! But to her it was more important to feel comfortable with the quality of care she was providing her patients.
Right now I work for a referral only Internal Medicine specialty clinic. While many of our patients come to us for endoscopy, ultrasound, and the like, leaving with bills that frequently number into the thousands, there are still limits on what clients are willing/able to do. For example, the owners of many of our lymphoma patients opt for the shorter/cheaper remission provided with prednisone, rather than the medically advisable $8000 course of chemotherapy. Does the veterinarian refuse to help the client if they decline chemotherapy? No, the veterinarian will prescribe prednisone after explaining to the client the significance of their decision.
The point I am trying to make it that there are many sides to this discussion that are not necessarily wrong even though they might be different.

 

[spikey]

Pre-op blood panels are part of my surgical bill - i do not cut into an animal without doing a blood test first. It's standard procedure for any anesthesia procedure - and it should be everywhere. I am at a university right now - so i fully acknowledge that the environment is artificial - however that doesn't diminish the standard operating procedures when working up a surgical case. I'm not saying that in this case the dog wasn't a surgical candidate - clearly it was. What I am saying is that doing procedures "blind" is risky business, because if things go wrong - and invariably they do - you need to cover yourself... both for the patients welfare, and for your own ass.

the point of vet school is to teach you the fundamentals - the proper way of doing things. Not to teach you to cut corners. As you begin your training, you will realize that there are strict reasons you perform basic diagnostic tests - and the attitude that you can tailor treatment without doing the basics is completely reckless.

There will be times when you cannot get clients to pay for treatments or tests, and its the most frustrating part of our jobs - but you cannot potentially compromise your quality of care because of it. Further to this, and i've said this before, you cannot do things for free. That's why when clients bring surgical patients into my hospital, there isn't a question as to whether they get a blood test - its part of the procedure and its built into the fee. The same goes for an IV catheter - its built into the fee. All our general anesthesia patients get IV catheters, and I know a lot of practices that do not place them for routine procedures... I think this is ridiculous. What if the patient crashes? The time you spend hunting for a vein in a hypotenisve patient probably means its life.

our practice does the same. pre-surgical lab work is built into the price. i believe most of ours get catheters as well, if not all of them.

when we go over an estimate, we explain to the client what we require (heart monitor and such), and what we consider optional. we also stress which options we strongly consider and why. our practice doesnt like to force on people what they cannot afford, but we try to steer them to the best route for their pet, which thankfully most go for.

if a client refuses something we consider essential (like some deny a heartworm/lyme/ehrlichia snap test), we do deny them some further treatments and note this on the chart. i dont know what the point of me telling you this is, but its just my $.02.

 

[Olddodger]

I have been a veterinary technician for over 5 years and I can honestly say that I have seen many dimensions of this issue. I will say that money is an problem more times than it is not and sometimes even people who can afford to treat an animal have serious qualms about investing in a procedure or treatment course that does not necessarily promise a positive outcome, especially in a middle aged or geriatric pet. I believe that this issue remains as one of the biggest limitations of veterinary medicine.
One of my first jobs was working in a community practice in rural Alaska where money was a concern for most of our clients. This clinic offered three anesthetic options for most of their procedures. Option (#1): No special anesthetic precautions, Option (#2): Pre-operative blood screening, Option (#3): Pre-operative blood screening, IVC, fluids. The veterinarians would make recommendations in the cases of patients with special risks, but ultimately it was the client who checked their preference when they signed the consent for anesthesia.
Since then I have worked for some higher end practices with the do it my way or not at all philosophy. One veterinarian I worked for would frequently start out initial appointments by describing the type of care we provided and the corresponding expenses (premium pet food, yearly laboratory screening, IVC/fluids/bloodwork for all routine procedures, Sevofluorane anesthetic, etc.). She would actually recommend clients go elsewhere if they were unwilling/unable to pay for this caliber of services. Did she lose clients? Definitely! But to her it was more important to feel comfortable with the quality of care she was providing her patients.
Right now I work for a referral only Internal Medicine specialty clinic. While many of our patients come to us for endoscopy, ultrasound, and the like, leaving with bills that frequently number into the thousands, there are still limits on what clients are willing/able to do. For example, the owners of many of our lymphoma patients opt for the shorter/cheaper remission provided with prednisone, rather than the medically advisable $8000 course of chemotherapy. Does the veterinarian refuse to help the client if they decline chemotherapy? No, the veterinarian will prescribe prednisone after explaining to the client the significance of their decision.
The point I am trying to make it that there are many sides to this discussion that are not necessarily wrong even though they might be different.

Hi all,

My ex used to work for a "discount" clinic. And I have to agree with the reactions that Wishes, Youthman and HorseyVet have seen.

Its one thing to cater to a certain clientele, the type that will throw endless $$$ at a problem (justified or not). It's entirely another to deal with clients who are unwilling or unable to spend a lot of money (for whatever reason).

Oldie

 

[HorseyVet]

The point I am trying to make it that there are many sides to this discussion that are not necessarily wrong even though they might be different.

I agree with wishes, but at same time disagree at some level. I guess I am frustrated that "upscale" practices refuse to offer or present other options.

Some clients are very consumeristic, and will hunt around to find a place that can do something they can afford. This of course does has its downsides, namely the bouncing client who doesn't really believe in anything any vet tells them. Simmilar to the "I heard this on the inernet, so now I'm as smart as the vet" type.

There are however clients that are completely blinded by the aura of doctor authority. These clients assume that treatment and diagnosis is the same everywhere and/or that their particular doctor is some kind of god. Obviously there are doctors out there which truely are amazing, but in general the client doesn't have the background or info to decipher what sort of doctor or even the practice environment they are taking their pets to. Very often the client just sees the vet who is the closest to their home. If these individuals where faced with only one tier of treatment or euthanasia, they'd believe that those were the only choices, and maybe forced into euthanizing.

It's fine to say "this is how we do things here," to an extent, but it bothers me that said individuals will not admit that by not presenting other options or even mentioning that other clinics may be able to provide a different treatment, they often will force the client to euthanize.

Euthanizing an animal for which there may be another option, even if you are unwilling to provide that option, is unethical to me.

 

[kate_g]

Lots of "cowboy medicine" at shelters. Lots and lots. Let's give this dog a quick shot of ketamine to drain that huge abcess on his neck, then you find a fist-sized knot of scar tissue, need to give a bump of ketamine so you can take the time to dig that out, then a bullet falls out onto the table (!), and he's gotten light again and going to need another bump... Radiographs? Pre-op bloodwork? Not a chance, we don't have an X-ray or a lab. No gas anesthesia machine, either. You can have sterile drapes if the autoclave is working, otherwise you wash them in hot water with lots of bleach, and keep the instruments in a cold pack. If you're lucky you've got a tech who can come by every once in a while to count respirations and take a heart rate. If you're really lucky he's been there overnight and somebody was organized enough not to give him breakfast so at least he's got an emtpy stomach.

Obviously there's a big difference between having *any* client to charge, and having a budget determined by $20-at-a-time private donations. For that matter, there's a HUGE difference between that shelter, where we went months unable to order any supplies because we were so behind on paying that suppliers wouldn't fill any more orders, and the large, clean, state-of-the-art, obviously incredibly well-funded ASPCA hospital that you see on "Animal Precinct".

I know I'm just begging for a flame here, but I can't help but bring up the comparison to, say, your average village clinic in equatorial Africa. There are probably people who would say it's unethical for that clinic to do the bare minimum and cut corners in the attempt to provide care for people who truly can't afford more. Then there are probably people who would say it's heroic. Depends a lot on perspective I guess.

 

[chickenboo]

I know I'm just begging for a flame here, but I can't help but bring up the comparison to, say, your average village clinic in equatorial Africa. There are probably people who would say it's unethical for that clinic to do the bare minimum and cut corners in the attempt to provide care for people who truly can't afford more. Then there are probably people who would say it's heroic. Depends a lot on perspective I guess.

The sadder thing is, the "average village clinic" in Africa which is doing the bare minimum, cutting corners is treating PEOPLE, because they don't have the money to treat themselves, let alone their animals.

 

[kate_g]

the "average village clinic" in Africa which is doing the bare minimum, cutting corners is treating PEOPLE

Yes. People. That's what I meant. (-: I just don't see Doctors Without Borders getting their asses sued for malpractice by people who walked two weeks to get to them and never had any hope of paying for best practice.

The other thing I find interesting is, just as veterinary medicine has evolved to the point that a vet who would do what they could to treat an animal within the client's financial limits unethical, so many schools are starting up classes in "shelter medicine", which they tout as "a newly emerging specialty building on the clever solutions and experience of hundreds of shelter veterinarians, technicians, rescue and foster homes, who have learned their skill in the trenches" - skills that apparently someone thinks it's good for regular vets to know about. Skills that would have cost the taxpayers millions of dollars to develop under an approved protocol at a research institution, but that cost virtually nothing to develop in the course of attempting to provide care to shelter animals. Except the lives of the animals, that is.

So does the difference between "clever solution" and "malpractice" just depend on whether the animal has an owner who can sue you? Is it right to celebrate the use of animal shelters as unregulated research labs? Then again, is it right to withold care from a shelter animal just because you can't afford to treat it the "right" way? And if you happen to learn something in the process, is it right to refuse to incorporate that knowledge into broader practice because it wasn't acquired under an approved protocol?

The point being, of course, that the whole reason the "client funding" dilemma is such a problem is that it's an extremely complicated issue, and just declaring "this is right" or "this is wrong" is clearly inadequate.

 

[chickenboo]

Sorry, kate_g!! Misread your post. 😛