Sunday 20 January 2019

Do you want bronze, silver or gold vet care?

The best possible veterinary care can be very costly.
The best possible veterinary care can be very costly.

Pete Wedderburn - Animal Doctor

One of the stressful aspects of being a vet is the fear of failure. Animal health is rarely predictable, and even with the best possible veterinary care, the outcome can sometimes be less than ideal. It's upsetting for everyone when this happens, and understandably, some owners may feel that a negative outcome is, in some way, the fault of the vet. This can lead to complaints being made to the vet clinic, and this in turn can mean internal investigations, disciplinary hearings or even civil court cases. Even when vets have done nothing wrong, the stress involved in such situations can be immense.

The fear of such incidents has led to a new phenomenon in the veterinary world: so-called CYA veterinary medicine (Cover Your Ass - a term imported from the United States). This is an approach that utilises every possible test, covering every possible angle, so that any risk of missing something is reduced to the absolute minimum.

Arguably, this is the "safest" form of veterinary medicine but the downside is that the "art of veterinary medicine", using professional judgement to prioritise the most important interventions, risks being lost. Furthermore, CYA medicine is much more expensive for owners, potentially leading to to hyper-inflationary veterinary fees, with a knock-on effect of increased pet insurance costs in the long term.

As an example, if a dog is brought to a vet with a cough, and no other signs of illness, a vet might examine the animal to rule out serious underlying issues like heart disease, then give a general treatment to cover the common causes of coughing, such as lungworm and Kennel Cough. If the cough doesn't improve, the vet would then move to the next, more intensive, stage of investigation.

On the other hand, if a vet was to take a CYA approach on the first day, they might carry out all of the investigations immediately. This could involve running blood profiles, taking x-ray pictures, carrying out an ultrasound scan of the heart, and performing an ECG. This is undoubtedly thorough, but it's also expensive, it puts the dog and owner through more stress, and the big question is: is it really necessary on the first day that the animal is examined?

For some owners, the CYA approach is fine: they want to have absolutely every base covered, minimising any risk of their pet having a serious problem. The extra cost does not worry them.

Other owners prefer the traditional approach, trusting the vet's judgement that it's safe to delay detailed investigations because of the judgement that there's a high chance that they are not necessary.

To some extent, this is a personal choice, but in the big picture, there is some concern in the veterinary profession that if a CYA approach becomes more widely adopted, there could be adverse consequences. The cost of going to the vet will rise (because so many tests are being done) and consequently, the cost of pet insurance will also go up. Eventually, the vet could become unaffordable, and people could be deterred from keeping pets due to the high costs.

It's difficult to know what the right answer is: every case is different, and every owner takes a different view. Our job as vets is to do the best for owners and for animals, and that requires sensitive judgement. You can't say "every dog needs every test on day one", but neither can you say that "no dog ever needs detailed testing on day one".

Perhaps the best approach is to offer clear options to owners, so that they can take part in the decision making process.

Sometimes, I find that it can help to offer bronze, silver and gold options.

A recent case of diabetes in a dog shows how this can work.

The bronze approach could mean giving an average amount of insulin, and teaching the owner to carry out home tests for glucose on the dog's urine at home. This is far from ideal, but it could be the only option on a very tight budget.

The silver approach could involve regular visits to the vet for blood glucose tests for the first few weeks until the diabetes had been stabalised. After that, three-monthly blood tests could be continued to ensure good long term control.

The gold (CYA) approach could mean admitting the dog to the vet clinic at once for regular blood glucose curves for the first few weeks, as well as carrying out extra tests like urine culture to rule out underlying urinary tract infections, and performing regular blood samples to monitor different aspects of the dog's general metabolism. This would be the most expensive approach.

When I explained the pros and cons of each approach, the owner chose the middle way, with a silver level of care. The dog was successfully treated, and he's now a well-balanced settled diabetic dog.

This may be the ideal approach for vets: offering the all-bells-and-whistles (CYA) level of care, while also telling owners about more economical options that are very likely to be equally effective at bringing their pets back to full health.

I'd love to live in a world of infinite resources, where every test could be carried out on every patient, with no need for any worries about the costs. But in this present day world, cost does matter: the middle way, with the silver level of care, is often the best answer for most people.

Fingal Independent