The Dilemma: discount care or full disclosure?

Dr. Sean Lee owns a large practice in a northeastern city. Recently, he locked horns with one of his associates over treatment approaches.

The cases

The first case involved a 7-year-old retriever mix with sudden lameness in the left rear leg. The dog was in mild distress, bearing weight on three legs and toe-touching on the affected leg. The associate advised the owner that a proper workup would involve an exam, x-rays, radiology consultation, pain management, screening blood work and possible surgery. The pet owner loved his dog but told the veterinarian he did not have the money for the suggested services. The veterinarian examined the leg, felt some instability and told the owner that the injury was most likely caused by an anterior cruciate ligament (ACL) tear but that the diagnosis could not be confirmed without the proposed diagnostic plan. When the owner asked what he could do for his dog with limited funds, the veterinarian told him to minimize the dog’s activity for 8 weeks. He also prescribed pain medications that do not require bloodwork clearance and told the very appreciative owner that the dog should do fine.

The second case that attracted Dr. Lee’s attention was that of a 4-year-old year old female boxer that was presented with sudden onset of urinary accidents in the house. The dog had a similar episode two years earlier that was cleared up with a course of antibiotics. During this visit, the doctor recommended a urinalysis, bladder x-ray to rule out any stones and, owing to the dog’s history, a culture and sensitivity if bacteria were detected. The client explained that her funds were limited and opted for the urinalysis and requested an antibiotic. The associate strongly recommended the workup to prevent what could develop into a more serious and complex urinary tract issue, but he told her he understood her budgetary restraints and agreed to prescribe only an antibiotic at this time, with the understanding that another recurrence would require the detailed workup he recommended.

The meeting

Dr. Lee scheduled a meeting with his associate about these two cases. He felt the doctor was not assertive enough in encouraging the client to work up these two patients as initially proposed. Dr. Lee said that the doctor’s shortcut and expedient treatment decisions were akin to putting a Band-Aid on an infected wound. These patients were ultimately going to return with complications that could have been avoided with the proper diagnostics.

The younger doctor respectfully disagreed. He understood the importance of the bottom line, he told Dr. Lee, his goal was to assist his patients and their owners with honesty and transparency. In the first case, he said, he was reasonably sure from the physical exam that the dog had an ACL tear and felt that honoring the client’s desire for a conservative, inexpensive approach was very reasonable. In the second case, a urinalysis followed by antibiotics would resolve the presenting signs in 80% of the cases. Once again, he believed that respecting the client’s wishes and pocketbook was a reasonable decision.

Dr. Lee told the associate that he believed veterinarians should practice the best medicine possible at all times, adding, “Don’t worry about the clients’ pocketbook, because they will worry about that enough for both of you.” His young associate understood that veterinary practice is a combination of medicine and business. However, when the priorities between medicine and business become unbalanced, the patient, client, and practice all end up suffering.

Each agreed to respect the other’s input more in the future, but neither was very happy at the end of the meeting.

Do you believe in Dr. Lee’s “medicine at all costs” approach, or do you agree with his young associate that treatment should be tailored to each client’s wishes and finances? Let us know your thoughts at dvm360news@mmhgroup.com.

Dr. Rosenberg’s response

Veterinary medicine cannot depend on third-party insurance to pay its fees. On the other hand, prescribing the most idealized treatment plan can be a financial burden for some pet owners. It is our job as responsible clinicians to offer all available treatment options, recommend the treatment of choice and allow the pet owner to make an informed decision. This decision should not be subject to pressure, guilt or judgment from the doctor or staff.

Practice owners are often influenced a bit too much by the bottom line and, conversely, associates may have no interest in the clinic profit margin. I believe that a veterinarian who is truly interested in the patient’s welfare, but considers the client’s ability to care for the animal properly, can walk the financial tightrope laid out in this dilemma. First, veterinarians should advocate for the treatment protocol and diagnostics they believe are in the best interest of the patient. Second, all financial assistance options should be made available to the pet owner after an estimate is given. Finally, when financial restrictions are severe, treatment protocols can be modified to fit the client’s pocketbook, but not to the extent that the animal’s health and welfare are placed at risk.

No one ever said practicing veterinary medicine was easy. I’ve always followed a simple motto: “When in doubt, help them out.“

Dr. Marc Rosenberg is director of the Voorhees Veterinary Center in Voorhees, New Jersey. Although many of the scenarios Dr. Rosenberg describes in his column are based on real-life events, the veterinary practices, doctors and employees described are fictional.