Friday, November 02, 2007

Vet Article

An excerpt from this column:

He also thinks "wellness exams" are all about improving the financial wellness of the provider. Busby says the best guideline for when to take your pet to the vet is when you can tell there's something wrong. But, with the same fervor displayed by the salesperson at the electronics store who encouraged me to buy the extended warranty on the clock radio, my local pet hospital has pushed me to sign up for its $440-a-year wellness plan, which will provide a full panoply of unnecessary vaccines, as well as dental cleaning, and twice yearly neurological, cardiac, pulmonary, blood, and fecal exams. Even in France, they don't do this for people.


Caleb said...

Boy, that article doesn't really live up to its title, does it? The only thing he's told us how to do is to agree to an unnecessary $440/year program. The easiest way that I know of to say no to your vet is to say "No."

I'll read the article in more depth a little later, I think I'll have a lot to say.

Dad said...

I think it, meaning the level of care of animals who have no economic value, says a lot about the accumulation and distribution of wealth in our culture. Ordinary people spend hundreds and thousands on health care for their animals. There's a lot of disposable income out there.

While I don't really approve of open heart surgery, or even echocardiograms for domestic animals, I'd disapprove even more of telling people how to spend their money. You want serial EKGs for your 12 year old dog's bundle branch block? Knock yourself out. Me, I'd make the dog comfortable until I couldn't any longer and then put him down.

I don't have any problem with vets creating or exploiting a market for this stuff, either. There's a whole lot of more useless crap we spend our money on. But I do have concerns about needlessly causing discomfort or pain in animals by the use of invasive procedures or major surgery. Be the dog. Ask yourself if you'd want to go through the pain and suffering of surgery and rehab with dim prospects for a pleasant life afterwards.

I can't imagine any circumstance where I would do CPR, or heaven forbid, defibrillation on a cardiac arrested canine. And running invasive tests on a failing 20 year old cat strikes me as inhumane.

Mom said...

I wrote a long comment on this, but then when I tried to post it, Blogger ate it. grrr. Oh well, I'll try again.

You can't really blame the veterinary staff for taking the guy with the dead dog at his word. They did ask him whether he wanted them to try to resuscitate the dog, and he did say yes. They are not mind readers, and he had brought the dog to them in the first place -- why wouldn't they think he wanted them to try to save his pet?

On the other hand, it sounds like all he really wanted from the vet was confirmation that the dog was dead. And I can see why he was reluctant to look heartless and cheap in front of a waiting room full of people all set for heroics.

So, it was a communication problem that, with the benefit of hindsight, could have been avoided if the vet staff had taken him out of the waiting room and into a private space before asking him what he wanted them to do. But they were trying to act in an emergency at a time when it may have seemed that immediate action could have saved the dog. So, it's pretty hard to criticize any of the players in this little drama, it seems to me. It certainly is ethically interesting, though.

The wellness plan is also a good little study in ethics. Obviously, vets offer such plans because some of their customers want them. I don't think it's a bad thing to respond to that market demand, even if the benefits aren't all that clear. Take a look in any pet-supply catalogue at the cost unnecessary but fun pet paraphernalia like cat play structures, or doggie sweaters, or Victorian doll-house disguises for litter boxes with carbon odor filters built in under the shingled roof with gingerbread, turrets, and a weathervane. $440/year for health absolutely pales by comparison. But there's an obvious difference between offering such a program to those who want it and using guilt to strong-arm a reluctant owner into signing up.

It does make me wonder, Caleb -- to what extent does veterinary school try, in an organized way, to prepare students for dealing with these questions? Is there an ethics curriculum? Do these issues come up for discussion in your clinical classes (to the extent that you've had any yet)? Inquiring minds want to know . . .

Caleb said...

As you've both hinted at, the underlying problem is that different clients want different things, and it can be very hard to tell who wants what. For every two clients who think their dog should be treated like a dog, there are three who want him treated as a member of the family, with the same care they'd give their children - whether they can pay for it or not. You end up with three basic client types - those who want the vet for euthanasia and maybe emergency care, those who want the vet for absolutely everything under the sun, and those who might want either option but can't pay for it. But you would be amazed at how often someone comes in with a dog on death's door, complaining that the last vet saw "wanted to euthanize my dog, can you believe that?"

There's been a sea change in the last thirty years in how people view their pets, and veterinary medicine has been responding to it. I don't like the article's use of one old curmudgeonly vet as the voice of reason. Ignoring the changes in the amount of care over the last thirty years, everything else has changed too. The quality of basic care has skyrocketed, and there was pretty much no advanced care available. It's a whole different ballgame now.

Mom, we do have ethics courses in the third year, but I think they might focus more on animal welfare topics than practice management issues. I don't really know, to be honest.

Dad, CPR is common and cheap in veterinary medicine, but I've never seen (or heard of) defribillators used. The guy in the article got lucky that he was only billed $250 for cardiac massage - one way or another they entered the dog's chest. It's a weird story, and if I were him I'd have some objections to the way it was handled, but the guy really should have just asked what it would cost. He should also have been taken into a private exam room and been asked if he wanted them to do just basic CPR or everything possible, or nothing at all. Miscommunication by both sides, I guess.

The article writer's guilt is his own problem. Don't blame it on the people in the waiting room, or even the hospital staff. If you don't want to feel guilty, don't. Vets see people every day who don't want to pull out all the stops for their pets, and I've never known a vet who wasn't understanding of that, even in the "yuppie," high-end hospital I worked in in Ithaca. If he's worried about how he'll look to the people in the waiting room...i don't have a lot of pity for him.

People have trouble distinguishing suggestions from "pushing." A vet is pretty much obligated to make sure you're aware of all of the options for treating your pet, from euthanasia, to waiting and watching, to invasive diagnostics and surgery. The article mentions someone whose cat had a heart murmer, and the vet recommended an echo. So? It's a recommendation of the best care available. I'd bet that the vet actually said something along the lines of "We can continue to monitor it every time you come in, and you can watch for changes at home, but here's the number of a cardiologist if you want to pursue it further." That's certainly what I've heard vets say when they hear murmers. I don't know much about heart murmers in young girls, but a murmer in a cat is almost a strong indicator of cardiomyopathy. If the vet doesn't suggest the best care and the cat dies the next day, he has to answer to the client.

There are also some exaggerations in the article that need pointing out. If there's an owner vs. guardian debate, it hasn't reached me. Everyone's an owner, unless you're one of the more unbalanced techs or clients, in which case everyone's a parent.

I don't really buy the Sabra story, probably because I tend to side with vets, and tend not to believe anecdotes from column writers. But if it did go down like that, this guy needs a new vet. That's not the way things are normally done. "Several days of rigorous testing?" It could be sorted out by drawing some blood and a couple of xrays, which would take an hour or two. Either this guy's not telling us the whole story (leaving out the part where the vet laid out all the possible options and the client agreed to the most expensive and unnecessary route), or he really did run into a pretty lousy vet. Either way, it can't really be used as an indictment of the industry. I don't believe the next anecdote either, the one with "$700 worth of tests" for kidney cancer because of a lump. Someone's lying, or confused, somewhere, and I'd put my money on the client who sought a second opinion.

There's a lot of debate about whether or not we over-vaccinate. I do know that every vaccine in the veterinarians repertoire has been extensively studied, both by its creator and independent sources, and its efficacy over time is well documented. We're not just guessing. "Never forget how often they need to be given to you or your kids. ONCE!!!" How many human vaccines can you think of that require just one shot? Seriously. Almost every human vaccine is either over a three month course or requires periodic boosters. The curmudgeonly old vet is out of touch.

He's also out of touch regarding Lyme disease and the kidneys. To my knowledge, they're pretty well linked. There's a lot of debate about the Lyme vaccine (centered here at Penn, actually). What a Penn doctor has found is that it doesn't prevent Lyme disease, but no dog that's been vaccinated has ever developed the secondary kidney disease. In-house Lyme tests are, in fact, a pretty big waste. The company that promotes them makes a mint by putting them in the same test kit as heartworm tests, which are great, so that vets have to test for both at once. And when you get a positive Lyme test you have to either ignore it (what vets usually do unless there are clinical signs), or send out for a more expensive test to the same drug company to find out if it's actually Lyme disease or just Lyme exposure. It's unfortunate.

Also don't forget that dogs age a lot faster than people. A yearly exam for a dog is
the equivalent of an exam every seven years for people. Aging changes can happen very, very quickly, and the client has to decide between paying $200 for a yearly exam and diagnostics, with a $500 bill to treat a developing disease, versus waiting until they can see signs of the disease at home - at which point its often too late to treat - and either paying a couple thousand for diagnostics and treatment, or electing euthanasia.

One last point, regarding the 440/year plan. First, if the guy didn't want it and thought it unnecessary, he should have said so and not agreed to it (this author really annoyed me, can you tell?). Secondly, there's no way they're offering "neurological, cardiac, pulmonary" exams. What they mean is, they listen to the heart and lungs and do a quick check for signs of nerve damage or deficits in the face or limbs. It's all part of the basic physical exam. But what I see here is a vet that's doing something smart to (1) keep the clients they have and (2) provide the best care for the pet. Guess what? For a dental, two exams, two fecals, two basic blood panels, and the full panoply of vaccines (some required, actually, and some debatably unnecessary), the guy's actually getting a good deal, and the vet's not making a killing. His animal is getting what is pretty much considered the ideal standard of preventitive care, and he's not getting ripped off.

Aaand I wrote my own article. I've gotta back to studying...

Dad said...

Nice work, Caleb. I didn't read the damn thing close enough the first or even second time to pick up that they did heart massage. And, this guy FOUND his dog dead on the bathroom floor. Stiff! The dog IS dead and rigor mortis was setting in and this guy rushes him off to the vet. Can you imagine the uproar if the vet did NOTHInG! "I took my dead dog to the vet and he wouldn't do anything. Wahh!!"

Hey, how come you can't make my cat/dog live forever? What kind of avet are you? And you want to make money doing it? For Shame.

Having broken many a rib doing CPR, I would think that it would happen any time you did CPR in a dog, being that compressions would be lateral. Or do you roll the mutt up on its spine and pound on its sternum?

Lotsa comments at that article. I'm gonna read them later.

I can see why you were annoyed, Caleb.

you wont touch my cat said...

i hate these people only see the money of the owner before every animal he treats, looking for a good vet is getting kindda hard