Doing 'the right thing'
I see a geriatric dog with recent onset seizures that are not being controlled with anti-convulsant medications.
Experience tells me this patient probably has a brain tumor. I inform the client that an MRI is the only means of confirmation, but this is a costly test that will also entail the risk of general anesthesia.
I tell the client I realize she faces a difficult decision regarding her beloved companion. I don't want to seem cold or aloof, yet I don't believe I should tell my clients what's best for them and their pet. I try to find a middle ground by discussing that from experience, most clients in these situations make one of a few choices:
Client A feels it's inappropriate to spend more than a thousand dollars to pursue a serious problem with no simple resolution, and entail the risk of losing their pet at the same time.
Client B does not mind the risk or expense, and feels the information received will allow her to make a euthanasia decision with peace of mind.
Client C is willing to pursue radiation therapy if a tumor is discovered, so the scan must be pursued if medically appropriate.
After being presented with these options, clients seem to more easily make a decision, and I feel I did not make value or financial judgments on their behalf.
How does the veterinarian balance his/her numerous advocacies in practice?
1.) Wage earner-you have a responsibility to yourself, your family, and your employees to be well compensated.
2.) The pet owner-we have earned the loyalty and trust of most of our clients. Our opinion is so important to them, we often are asked, "What would you do if this were your pet, Doctor?"
3.) The animal-isn't this why we went to veterinary school? Didn't we take an oath to protect animals and relieve their suffering to the best of our ability?
The mantra of the numerous CPAs who write and speak nationally has been:
1.) Explain the value in what you do to clients, and charge appropriately, commensurate with your time, training, staffing, equipment and facilities.
2.) Stop discounting services
3.) Don't judge or assume what your client is willing or able to spend on their pet.
I agree with all of the above statements wholeheartedly. But I'm concerned that we have received this message at the expense of the medical care of the pet. Implied in the urging for us to be profitable, is "know your limitations." We can't expect the accountants to tell us what constitutes good medicine.
Do you consider whether you're providing an acceptable standard of care when making decisions about whether to purchase that ultrasound machine, or prior to performing major surgery just before closing time? I believe that you should. This is not to suggest that referral to a specialist is always indicated or medically desirable. If you are comfortable with splenectomy and have access to blood or blood products, then performing this procedure on an anemic patient with a bleeding mass seems reasonable to me.
Alternatively, attempting your first hepatectomy on a 12-year-old anemic Labrador, by taping the surgical procedure to the wall and reading it intra-op, is not what I suspect the accountants are asking us to do to achieve profitability.
Allegiance to the pet owner must be important to our profession, given the seemingly large number of our colleagues who discount their services.
We certainly wouldn't discount to serve the medical interests of the pet or to support our families or employees! I understand why the pet owner looms largest in our advocacy equation; they are the decision-maker, communicator and our financial asset.
Conflict of interest
Very often we are faced with a conflict of interest; what if the patient dies during the MRI after I played a large role in the client's decision? Will the client lose faith in my medical abilities? Might I lose the client? Will I have liability?
After 14 years in referral practice, I've come to believe that we very often take the easy way out when faced with these conflicts. Our allegiance to the pet owner seems paramount, even at the expense of the welfare of the pet. Using the above example, most pet owners do not receive the option of referral or MRI. Although I'm aware that this procedure is probably not tenable for most of your clients, are you acting as the limiting factor/short circuit in the medical care of the pet?
Possible causes for diminished animal advocacy include fear of losing the client, poor communication skills, arrogance/ego, and financial greed.
In some cases, it appears that the veterinarian is willing to jeopardize the health or life of the pet so as to obviate referral. It's clear to me that many of our colleagues equate referral for a second opinion, with a loss of potential revenue. Even overnight referral for emergency observation seems to fall under this umbrella.
From these recurrent observations, I am led to conclude that many of our colleagues believe that a finite amount of income is associated with each pet, and that referral diminishes your portion.
More informed owners
By watching Animal Planet and surfing the Web, pet owners are becoming more informed about the level of services and technology available for their pets. Practitioners lose the trust of far more clients by not offering referral and proceeding forward with procedures he/she were not best equipped or qualified to perform, or by choosing a low risk option for the client and pet, that ensured a mediocre outcome.
How then, does the practitioner as businessperson attempt to reconcile these conflicts?
I propose that the time allotted for office calls for sick pets be lengthened to accommodate the time necessary for you to provide a more thoughtful and informed consultation with the pet owner.
I can't envision how a physical exam and thorough discussion of whether to perform an upper GI series, endoscopy, ultrasound, or surgery for a vomiting cat can be adequately accommodated in less than 30 minutes.
At a recent symposium I moderated, the concept of informed consent was discussed. I contend we often receive consent for procedures, but do you provide clients enough information to truly receive informed consent? Do you discuss the rationale, risks, and expense of all available options? Are these documented in the medical record?
Charging commensurate with this extended time should palliate any financial misgivings if referral is chosen by the client, and if not, I suspect few clients will complain about the increased fee for the 30 minutes you took to outline available options and costs. Clients will hold you in greater esteem by taking the time to think through all the options available for their pet. This professional fee is what we should be emphasizing when we consider our profit centers, rather than equipment we may not be trained to use or interpret properly.
Our patients would be much better off if we saw half as many clients as we do now, spent twice as much time with them, and charged twice as much. If your consultant encourages you to see sick animals in 15 minutes or less, find a new consultant.
It is our obligation ethically to offer the pet owner what we feel is in the best interests of their pet, devoid of our own financial interests and ego.
If we could live up to this concept more often, and heed the good advice of our CPAs, our patients would be better served, and we could have more respect for our collective professionalism. It is myopic to do otherwise.
An 18-year-old dog with anemia (PCV=27 percent) and splenic mass has a splenectomy performed on Monday. The dog remains in the hospital unobserved overnight on IV fluids. A few days later, the dog presents for lethargy, and after a phone call to an internist, is referred to a local 24-hour referral center. Brain disease is suspected, and the pet owner approves MRI and a spinal tap as needed. The owner tells me, "This dog has been a member of our family for 18 years. I want you to do whatever he needs."
When I asked the regular veterinarian why overnight monitoring was not advised or offered the night of the surgery, she replied, "I don't know; we've always done it this way with no problems. He didn't die, did he?"
A 2-year-old female cat is referred to the local 24-hour specialty hospital because the regular veterinarian could not see the pet.
A diagnosis of pyometra is made, and the client expresses she wants "the best care" for her cat. Surgery is scheduled with the specialist surgeon, and the estimate approved. The attending clinician calls the regular veterinarian to update, and is requested to transfer the cat back to their hospital at 3 p.m. so they can do the surgery there. The clinician asks the regular veterinarian where the cat will be cared for after the surgery. She says the cat will be transferred right back to the 24-hour hospital.
The clinician offers this option to the client, who prefers her cat to remain in one facility without moving. The clinician offers the regular veterinarian an invitation to come to the specialty hospital to perform the surgery if she desires; this is declined. Surgery is performed by the specialist, with an uneventful recovery.
Did these pets/owners receive an acceptable level of medical advocacy from their regular veterinarians?
Being a true advocate for the "best" medical care of the pet is not synonymous with a loss of income. In fact, my experience has been quite the opposite; that is,the pet owner will hold you in high regard for offering referral, when you cannot provide the care the pet requires. When you offer the best care available to each pet, you, the receiving doctor, and most importantly, the pet, all benefit. It will require a major shift in attitude from our present standards of care to accomplish this.
By Barry Kipperman,
DVM, dipl. ACVIM
Dr. Kipperman, is a diplomate of the American College of Veterinary Internal Medicine. He has practiced in a 24-hour referral practice since 1992. He is the owner of the VetCare-24 hour referral practice in Dublin, Calif.
Dr. Kipperman is a guest lecturer at the University of California-Davis veterinary school ethics course, and has presented symposia on standards of care and veterinary ethics at various veterinary conferences.