Merging differing minds

THE PROBLEM

In managing a case that involves both me and another veterinarian, our assessments and plans sometimes differ. When the pet owner asks me, “Why didn’t the other vet tell me that?”, the awkward dance begins. How can I support my protocol without undermining my colleague or confusing our mutual client?

Photo: Charlie's/Adobe Stock

THE SOLUTION

If you ask 10 different veterinarians how they would handle a case, you will likely get 10 different answers. Although these differences may be more nuanced than substantive, clients tend to notice every little variation. Our profession has standards of practice, but inconsistencies in medical advice do happen. “This occurs quite often,” Mia Cary, DVM, CEO of Cary Consulting in Greensboro, North Carolina, said. “It’s not only GP [general practitioner] to GP, but it can also occur when clients are going back and forth between a GP and a specialist for a specific issue.”

Disagreeing doctors might work together at the same hospital or may be housed at competing practices. Whichever the case, she added, “Lead with empathy and humility—empathy for the client and for the other medical professional.”

Health care disagreements permeate human medicine too. Results from a recent study of human hospitals found that the way individual medical personnel assess and prioritize harms and benefits and how they interpret moral rules and obligations can vary greatly and confound medical decision-making.¹

The patient stands to lose. Research at a human teaching hospital in Switzerland found that 4 in 10 such conflict scenarios affect patient care.²

On occasion, the conflict is not even real, according to Barbara Bower, VMD, associate veterinarian at South Bay Veterinary Group in Boston, Massachusetts. The client might recite another veterinarian’s diagnostic impressions or treatment protocol that does not line up with yours. However, she cautioned, owners can be dubious raconteurs. “Sometimes the client has it all wrong,” she said.

The owner might not have understood the other veterinarian’s explanation. Or maybe the emotions of dealing with a sick pet had distorted their interpretation of it.

True distinctions in medical approach can boil down to personal style. When Bower anticipates stylistic variations in her patients’ future care, she heads off client confusion at the outset by explaining that there is often more than 1 correct strategy.

In new puppy visits, for instance, she prepares her clients for this. “I say, ‘One vet might tell you to keep your puppy away from other dogs until his vaccine series is complete. Another vet might say it’s more important to go ahead and socialize him early on.’ Sometimes the real answer is no one knows,” she said.

In a study of ethical conflict and moral distress among 889 North American veterinarians, a majority reported feeling conflicted over what care is appropriate for a given patient.³ Whether it is a question of ethics or of straight science, the gray areas can produce discord among veterinarians. But most experts agree on one thing: Never badmouth another veterinarian, particularly to a client. It is unprofessional. It is presumptive. And if the other veterinarian is a coworker in your hospital, it can create a toxic working environment. “You wouldn’t want someone making an assumption about how you handled a case without knowing all the facts,” Paige Andersen, DVM, owner of TimberCreek Veterinary Hospital in Manhattan, Kansas, said.

Andersen, who is also a member of the board of directors of the American Animal Hospital Association, considers such instances ideal opportunities for collaboration. She suggests asking the client for permission to reach out to the other veterinarian to discuss the case and then following through. “Often, there are additional details you’ll find in talking to the other vet,” she noted.

There are valuable nuggets in the pet’s history that the client may not have disclosed to you. These include diagnostic exclusions already performed, prior treatments that had not worked, owner adherence issues, declined services, and even priceless snapshots of how an animal looked in the past week, past month, or past year before arriving at your office.

John Lewis, VMD, DAVDC, FF-OMFS, co-owner of Veterinary Dentistry Specialists in Chadds Ford, Pennsylvania, recalls Soupy, a Siamese cat referred to him for a nonhealing extraction site. When the site dehisced, Soupy’s veterinarian went back in and closed it with a larger flap. But then it dehisced a second time.

The veterinarian referred the patient to Lewis, who determined by the large hole that had now formed that this was not normal tissue. Lewis performed a biopsy on it and found it to be a salivary adenocarcinoma. “The owner asked, ‘Why didn’t my primary vet biopsy it?’” Lewis explained that the tissue had remolded over time, which gave him, but not the previous doctor, the luxury of visualizing a tissue gap that was bigger than it should be.

Whenever small animal veterinarian Amelia Knight, VMD, is asked why earlier veterinary advice differs from hers, she tries to bring harmony to discord. She will often tell the owner, “That’s music to my ears that you’re remembering the previous recommendation. I can’t speak to what your other vet saw before or based their decision on, but I can see how disconcerting it is to hear one thing from me and something else from another doctor.”

Knight, who also runs the veterinary consulting firm Life Boost with Amelia in Charlotte, North Carolina, then redirects the client to the here and now, the shared common goal, and the need to move forward. And do not be afraid to continue an ongoing protocol instituted by an earlier veterinarian—even if it would not have been your first choice—if it is working well enough or if the client is comfortable with it; sometimes the benign status quo is the way to go.

Keeping mindful of the distinction between a disagreement and a mistake, you might consider speaking directly to another veterinarian whom you believe has erred in one of your cases. For those rare instances of medical malpractice, there are protocols for reporting. Always maintain a professional stance.

When Lewis is called on to repair iatrogenic jaw fractures in patients who are referred to him, he is careful to save face for his colleagues. He shares with owners his own experience of accidentally fracturing a jaw during a tooth extraction years ago while working in general practice. And he explains to them that jaw fractures are an inherent risk when extracting firmly rooted teeth. Whenever an owner challenges him on why their regular veterinarian tried to pull that tightly bound tooth in the first place, he said, “I explain to them that their vet must have brushed up on their veterinary dentistry, because some firmly rooted teeth need to come out.”

Healthy discourse—and dissent—can promote individual clinical growth as well as progress in our profession. But it must be done with care, Andersen cautioned. “Always acknowledge your client’s concerns, but also be supportive of the other veterinarian,” she advised.

REFERENCES

1. 1. Gert B, Culver CM, Clouser KD. Bioethics: A Systematic Approach. 2nd ed. Oxford University Press; 2006.
2. 2. Cullati S, Bochatay N, Maître F, et al. When team conflicts threaten quality of care: a study of health care professionals’ experience and perceptions. Mayo Clin Proc Innov Qual Outcomes. 2019;3(1):43-51. doi:10.1016/j.mayocpiqo.2018.11.003
3. 3. Moses L, Malowney MJ, Boyd JW. Ethical conflict and moral distress in veterinary practice: a survey of North American veterinarians. J Vet Intern Med. 2018;32(6):2115-2122. doi:10.1111/jvim.15315