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Thursday, September 26, 2013

Well-Thought Complaints From a Client, And My Response

As the owner of a fairly large (4 DVMs, 35 support staff) suburban veterinary practice in the year 2013, I occasionally get complaints from disgruntled clients. Yesterday I received a well-written letter from a client which was clearly thought-through, and significantly, logical. I appreciated the feedback, and the opportunity to respond. Here is her letter, followed by my response and a comment or two.

Dear Horseshoe Lake Animal Hospital,

Thank you for the care that you provide my pet.  I appreciate the work that you have done in the past and currently, but I feel that I need to communicate my feelings as customer feedback.  When I first began bringing my pets to your clinic, I felt that the care was great and the price was also reasonable; however, in recent years I really dread bringing my pet to the clinic, because it’s difficult to leave without a $200+ bill and significant guilt for treatments may be as well.  I have several examples from my pets’ histories to call from. 
One day I brought my dog in for severe diarrhea.  She was examined and I was asked if I wanted a giardia test.  I said if you feel that the test is necessary, then give it to her.  The end result was that she was negative for giardia but she was given flagyl (Metronidazole) to take at home.  My frustration with this incident is that she was given the treatment for giardia even though she as negative.  I understand that the treatment for severe diarrhea with a protozoal or anaerobic bacterial etiology would be Metronidazole.  I do not understand why the giardia test is necessary if she is going to be given the treatment for it despite the test outcome.  It was a waste of your time and my money to do that test when she was going to receive the medicine regardless. 
Secondly, each time I visit for a well animal visit, there are many options for tests and extra vaccines that are presented to me.  Of course I want my dog to have good treatment and prevention of disease, but I feel that my pet is probably not at high risk for many of these diseases because she is indoors most of the time (example: Leptorspirosis vaccine).  I feel guilty for refusing each time I say no to a test or a treatment, but I suppose if I accepted everything that is offered or recommended, I would leave with a $300-400 bill.  This is more than I typically spend on my family of 4 per year for healthcare clinic/hospital charges. 
In addition, I feel that some of the medications are overpriced and that, since you have your own pharmacy, the option to have the meds filled elsewhere is taken away.  For example, some antibiotics and generic medications at Schnucks pharmacy and many other pharmacies are free or next to nothing in price, yet I pay a premium to have them filled by the pharmacy at the clinic.  I know some veterinary medications are not carried at standard pharmacies, but some are.  In those cases, I would appreciate your recommendation to have the script filled elsewhere.
Most recently, my pet came in with a limp.  I thought I established before the appointment that the cost of treatment is an issue for me.  Two to three weeks prior to the appointment, my dog hurt herself while chasing a rabbit (or other creature).  The injury happened acutely.  After examining my dog and feeling an effusion around the knee, the veterinarian order 2 films- one of the knee, and one of the pelvis area.  Understandably, he was trying to rule out a hip; and given the acute onset of the injury the knee was the most likely culprit.  To save cost, it seems prudent to only order 1 x-ray, and if that comes back negative, to order an additional film if necessary.  When patients don’t have insurance to help offset the cost (and even when insurance is available), prudent management of diagnostic tests and films is necessary.  Maybe ordering 2 x-ray views in this situation was the same cost of ordering 1 (I could not tell definitively from my bill); but coming away from the appointment, I felt that maybe this could have been an unnecessary cost and I find myself frustrated at myself for agreeing to x-rays at all.  At this visit, I also had to reject two of the three therapies that may help my animal based on cost and this also made me feel terrible.
Please understand, I don’t question the excellence of care given to animal at your clinic.  The veterinarians and the techs are amazing with the animals.  However, to keep coming to the clinic I need to feel that you are also considering the cost to the “parents” of the patient.  Sometimes I feel like I’m being taken advantage of by the number of tests and preventative treatments that are strongly encouraged.  I feel like there might be a money making aspect to some of the recommendations. I would just like to feel the vets are doing their best to keep the cost of care down for the “parents”.
Thank you for your consideration.
(Name Withheld By Dr Hall)

My response:

Dear (Name Withheld),

Thanks so much for your letter.  I am always appreciative when clients have the courage to voice their opinions to us, even if they are unhappy.  I would like to address your specific concerns as much as possible, and also speak to the “big-picture”.  By the way, thank you for your nice words about the care that your pets have received at Horseshoe Lake Animal Hospital.

I will start with the occasion that you mentioned when (name withheld) was tested for giardia, and then given Metronidazole anyway.  My guess would be that the Metronidazole was prescribed for its anti-inflammatory effects on the large and small intestine, and not anti-protozoal.  If (name withheld) would have tested positive for giardia, this would have changed things in two; and possibly three ways.  First, a follow up giardia test would have been indicated to make sure the infection was cleared.  In our experience, giardia is probably the most difficult parasite to clear from the body.  Second, giardia is potentially contagious to people.  We always have a conversation with our clients about zoonotic risk when their pets have giardia.  And lastly, Metronidazole is no longer considered the treatment of choice for giardiasis in dogs.  Had (name withheld) tested positive, the doctor probably would have prescribed fenbendazole.  I hope this explains why we would not consider the giardia test to be unnecessary.

Your second concern involved the tests and extra vaccines that are presented to you at annual wellness visits.  You specifically mentioned leptospirosis.  There is a national advisory commission that meets every few years to determine the best vaccine recommendations for companion animals.  This commission has currently determined that there are four “core” vaccines (vaccines that all patients should receive) for dogs, four “non-core” vaccines (vaccines that should be administered to at-risk patients), and numerous non-recommended vaccines.  “Lepto” is considered non-core by the commission, and therefore by us. However, lepto has become so pervasive that the Veterinary colleges at the University of Missouri and Purdue University (among many others), consider it “core”.  The fact is, just about any dog that goes outside faces some risk, and dogs that travel away from their homes (like going for runs/jogs) are at increased risk.  I hope you understand that preventable diseases such as leptospirosis can be devastating to a dog’s health, and like giardia, lepto is contagious to people.  Our focus is always going to be putting the best interest of the pet and family first. 

Having said that, we never recommend vaccines from the non-recommended list , and we do not recommend a non-core vaccine for a pet with no risk factors, but we will have the conversation to determine risk. 

You may also be referring to the “wellness testing” recommended at each annual visit.  We do believe in the value of wellness testing for our patients, and have hundreds of experiences where early disease detection has benefited them.  My personal physician orders labwork on me every year, even though I perceive myself to be healthy.  Since many patients age so much faster than humans, and they can’t talk to us, I believe that wellness testing is even more important for them.  I do understand that many pet owners cannot or choose not to spend their dollars on wellness tests, which is why these things are optional.  But we at least owe it to you to make you aware of the benefits so you can make an informed decision. 

There is a mention of writing prescriptions for our clients to take to human pharmacies in order to save money.  We do write or call in prescriptions for our patients on a daily basis.  However, there is even some concern on our part about this practice.  Dogs are not small people, and in many cases the biological activity and dosing of drugs is dramatically different between people and pets.  You may be aware of the pharmacist in Tacoma who talked this client out of giving the dosage of medication the veterinarian prescribed for her dog, telling her it could kill the dog.  The dog suffered needlessly because the owner was afraid to give the medication. 

Lastly, regarding your recent visit with (name withheld), you are correct that I suspected a problem in her knee.  But after practicing for almost 30 years and seeing some really awful things from missed diagnoses (usually pathologic fractures from undiagnosed bone tumors), I want to make sure not to miss something obvious.  I do not always order x-rays for limping dogs (although I probably should), especially if I think it’s just an arthritic issue or a soft-tissue injury based on history and physical exam.  (Name withheld)’s history of acute onset single-leg lameness with minimal improvement in over two weeks suggested something other than arthritis or soft-tissue.  

Any radiologist will tell you that when radiographing any body part, two views should always be taken.  In (name withheld)’s case, I wanted the V-D view to also include the hips (pelvis) since that could easily be incorporated into the V-D view of the knee.  This is standard procedure and gives us “more bang for our buck”.

In summary, I am truly sorry that you are frustrated with the costs involved in the care of your pets at our hospital.  I hope that this helps you understand that every decision that we make is driven by what is in the best interest of our patient.  I assure you that surgical correction of (name withheld)’s knee is reasonable therapy (and may become imperative at some point), but I felt that conservative treatment also had a good chance at helping her, and I always prefer that over surgery, when feasible.  If my recommendations are based on what makes the most money, I would have chosen to recommend surgery.

I do very much appreciate your feedback, and I hope we can do a better job of explaining your options, and why we are recommending (or just discussing) them moving forward.  It is my true and sincere hope that (name withheld)’s knee will do well, and that she will be running around normally in the future.

God Bless,

Dr. David Hall

The only thing I would add is that she mentions that she has the potential to spend more for her vet visits than on her family's healthcare in a year. This conveniently overlooks the THOUSANDS of dollars that she or her employers are spending annually on health insurance, which then pays most of their medical bills. I've seen my health insurance premiums, and I've seen the medical bills before insurance. No one can reasonably assert that veterinary care is anywhere close to the cost of human health care. I assure you, no one at my practice (including me) is getting rich. And by the way, I'm not complaining: I make a good living, and I don't mean to suggest that veterinary care should cost as much as human health care.

Wednesday, September 11, 2013

When The World Gets Crooked

It won't happen to too many pets, but if it happens to yours, it will have you thinking that it's finally time to "put her to sleep." Your dog (or cat) will suddenly (as within a few hours) become extremely disoriented - probably to the point where she is running into things and falling over. There's a good chance she'll vomit, and for sure she will refuse to eat. You may or may not notice that her head is tilted, and her eyes are doing crazy things! You will see these symptoms and fear the worst. And who can blame you? This almost always happens to older pets: the ones that we are waiting and fearing something terrible is going to happen to anyway. And this certainly is something terrible.

Except, it often isn't as bad as it looks. I just described to you the symptoms that animals with vestibular disease often present with. Vestibular disease is a generic term which simply means there is a problem with the pet's equilibrium. The problem can be located in the inner ear, or more often in the brain. What the pet is experiencing is akin to someone spinning us around at a high rate of speed and then asking us to walk across the room. We will stumble, stagger, and maybe even vomit if we were spinning fast enough.

The various causes of vestibular disease in pets are still pretty mysterious to us. The most common maladies are "old dog vestibular disease" and "feline vestibular disease." The bad news is that we don't know what causes either one of these syndromes. The current thinking is that they are some form of vascular accident (think "stroke"). The happy news is that the prognosis is usually pretty good. Usually time, antivertigo drugs, and maybe some steroids work wonders for these patients.

Vestibular symptoms can less-often be caused by inner ear infections, trauma, or tumors. The prognosis varies in these cases.

My typical workup for a dog or cat with vestibular symptoms is to check the blood pressure (hypertension makes me suspicious of a vascular accident), and thyroid levels (hypothyroid dogs seem to be at increased risk for neurologic problems). I also do a thorough physical exam with special emphasis on the ears. The typical patient will improve over the next 2-4 weeks. If there is no improvement, I will do a more complete blood workup and skull radiographs to look for changes deep in the ear canals. If these tests are normal (which they usually are) and my patient isn't improving, the prognosis is less favorable and I am sending her to a veterinary neurologist for a second opinion and possible MRI.

I am happy to say that in my personal experience, about 80% of these pets do remarkably well, and the owners are REALLY glad I talked them out of euthanasia.