Archives | Buy Photos | Subscriptions | Submissions | Advertise | Contact

Tuesday, May 21, 2013

By Michelle Gerhard Jasny V.M.D.
Published: February 26, 2009

"Mrs. Smith is on the phone." My secretary hands me a medical record. "She wants worming pills for Granny." I glance through the file. Granny is a 14-year-old cat. Although her vaccinations are up to date, I haven't seen her in almost a year. I pick up the receiver.

"So what's up with Granny?" I ask.

Seems Granny has lost weight, though eating well. "She still hunts," her mom continues. "I thought I should deworm her." I suggest an appointment. Mrs. Smith demurs. Money is tight. It's just worms.

Here's my dilemma. Sure, it could be intestinal parasites, but in a geriatric cat with this history it is more likely something serious - hyperthyroidism, diabetes, kidney failure, cancer. If I simply dispense dewormers, am I doing right by Granny? If I insist on an appointment, am I doing right by Mrs. Smith? Which scenario covers me legally and ethically? Which will truly satisfy Mrs. Smith?

Mr. Delish calls next. He wants me to vaccinate his cats, Red and Goldie. He doesn't want examinations or to pay for an office visit. "You just saw Red a few months ago when he was throwing up and Goldie had a physical last fall," he complains. I review the files. Yup, Red was in three months ago for a bout of gastroenteritis. Goldie's in the funny situation where different vaccines come due at different times. She is five years old and has never been sick. She is due for rabies vaccination, which is required by law. Red is 15, has hyperthyroidism and kidney disease, and is due for multiple vaccinations.

My dilemma this time? Any time I vaccinate an animal, it behooves me to know that animal is healthy first. It's just good medicine to assess the status of the immune system before challenging it with a vaccine. If a pet falls sick post-injection, we want to distinguish vaccine reaction from pre-existing illness. On the other hand, Goldie is a young, hearty individual. Odds are this hasn't changed since her fall visit. Do I acquiesce? Pop Goldie a shot, sans exam, sans exam fee? Mr. Delish clearly thinks I am just trying to make a buck. Do I upset him by insisting on an exam and on being paid for my expertise? What about Red? The chance that his condition has changed since last visit is far greater, and he has already skipped one recommended recheck for his hyperthyroidism.

"What now?" I ask, hand to forehead, as my secretary appears apologetically at the door. "Ms. Intosh needs a refill of Mac's heart meds." Ah. Mac saw the cardiologist once - four years ago. He's on three different drugs and has had minimal follow-up. I understand. Ms. Intosh is a single mom, struggling to stay afloat. But I haven't seen Mac in years. His vaccines, including rabies, are overdue. In the past I have refilled the medications anyway, with the caveat that I needed to see Mac ASAP. She has made appointments, then cancelled last minute or simply not shown up. "I ran out of pills last month," she confesses. "He's slowing down, but I'm sure he's okay. Can't you just refill them?"

There are two basic philosophies a veterinarian can take in these situations. The first is modeled on human medical practice and law, and is touted by much of today's veterinary profession. Rooted in a commitment to always practicing the highest quality of medicine and adhering to rigid protocols, clients must follow the rules or they don't get services. Under this model I might legally dispense dewormers for Granny after a long conversation with Mrs. Smith and copious notes advising an exam. I would probably require physicals for Gold, Red, and Mac. I might opt not to charge for Mac's exam, but how often can I afford to do that? The Delish family will undoubtedly be mad at me, which will be awkward, since our kids are friends, but at least my policy on vaccines and examinations will be consistent. Granny Smith, the only cat my protocol says I don't need to see, is actually the one that might benefit the most from an exam.

The second approach is based on the old agricultural model. Dispense the heart medications, the worming pills. Give the vaccines without the exam. Let the owners take the risk. Sounds simple. Except I know Mrs. Smith too well. She substitutes wishful thinking for accurate assessment of her cat's condition and is the type to blame me if Granny crashes. I can hear her now. "Well, if you'd told me it was so important, I would have come right in." Uh huh. Mr. Delish will now expect to only pay for one office visit per year per cat. So do all my clients now only pay for one office visit per year, no matter how often they come in, no matter when and what they come in for? The veterinary profession has strived to emphasize the importance of the physical examination over just mindlessly popping shots when a computer says they're due. In many wellness visits, I find problems worthy of attention that an owner has not noticed. If I take the old-school approach, I am at risk of invoking a complaint to the veterinary board, a malpractice suit, and criticism from veterinary colleagues who would rightfully see this as bad medicine. And I risk not doing right by the animals.

As the economy teeters, veterinarians and pet owners will find themselves in these situations more frequently. The ambiguities arise not so much from the medical protocols as from the human factor, which, for better or worse, is impossible to ignore, especially when you live in a small community like ours. Every veterinarian handles things differently. If you have an issue with your veterinarian's policies, try to remember that the decision-making process is more complex than it appears on the surface.

By the way, the cases cited about are but hypothetical conglomerates of similar situations. What would I do? Talk Mrs. Smith into an exam for Granny by educating her about the possibilities. "Pop a shot" to young Goldie Delish, after explaining my reasoning, but insist on a recheck for the elderly Red. Refill Mac's cardiac medications, with a promise from his Mom to bring him in as soon as she can swing it. Then take a deep breath and wait for the next phone call.