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Cost vs. quality choices, veterinary responsibility and client cluelessness

Posted Jan 22 2009 4:32pm

The cost of veterinary medicine is steep—we all understand this truism from personal experience…vets included. But the cost of veterinary care can be diagrammed on a price/quality axis so that owners can access a spectrum of these choices based on their needs, their goals and their ability to pay.

But don't be confused...this post isn’t about the many ways to get better quality care for your dollar. (You can find information on this in my archives here and here.) Rather, this post is more about what happens when a relationship of trust breaks down…and how that can cost the recipient of veterinary care…and his owners...when that price/quality axis isn't so clear.

Here's the deal:

Figgie is a Maltese whose latest neighborhood escapade landed him in a neighbor’s backyard bougainvillea bush with injuries of unknown origin. Normally a sprightly, sassy guy, Figgie’s traumatized alter ego manifested as a white ball of snarling fur.

What the whopping dose of pain reliever could not relax, the titch of tranquilizer finally soothed. Figgie finally gave in to the chemical restraint with a big sigh and a lolling tongue.

His owners: “Please help him. We want to do everything possible to save him.”

Findings…fractured canine tooth…lower back pain…diagnosis…automotive trauma…lumbosacral subluxation…sacro-caudal fracture (with significant displacement)…treatment…get thee to the surgeon for tail amputation and possible lumbosacral stabilization.

The surgeon saw Figgie immediately. He suggested that radical tail amputation followed by strict cage rest would likely do the trick, but cautioned that extreme care would be required in handling the close amputation due to the possibility of permanent nerve damage to the area (potentially rendering Figgie powerless over his bowels).

Figgie’s owners agreed…then changed their minds overnight and carted him over to the nearest low-cost clinic (a not-for profit designed to help those with minimal funds afford reasonable-quality care).

Mind you, the ginormous, late model luxury SUV might have looked out of place in the low-cost’s parking lot, but I guess they decided they had to save their pennies wherever they could given that one monthly payment on that automotive beast was very nearly as high as the surgeon’s estimate.

So that’s how “we want to do everything possible” was amended by, “but only if it costs as little as possible.”

We have a saying in Spanish that goes, “lo que cuesta barato sale caro.” Translation: What comes cheaply...will cost you.

That’s what I had in mind when I heard the story second hand from another client (friend of Figgie’s family). And that was even before I learned how it would end:

After his surgery, Figgie had to be rushed after hours to the very same surgeon’s hospital for follow-up care…after his surgery very nearly exsanguinated him. (Those pesky tail vessels are hard to reach properly, encased in spinal bone as they are.)

For my part, I confess that I felt slighted by the owners’ decision. After all, I’d gone above and beyond for him, even going so far as to visit him that night at the specialists’ place to check on his progress and the surgeon’s assessment and plans.

After all my work, his owners could have at least called me for advice before venturing off into the wilds of an unknown hospital in search of the lowest price-point possible. They could at least have asked me what I would have charged, right?

But this isn’t so much about my feelings or the need for clients to solve financial problems through low-cost alternatives. Rather, this is more about what happens to our patients when that bond of trust is breached…for financial reasons.

In some ways I feel responsible. What could I have done to head off this problem? In hindsight, I realize that by not offering the client a clear alternative solution in a general practice setting, I failed to secure their trust that I could manage Figgie’s case if the surgeon proved “too costly.”

By taking the owners at their literal word (“everything possible”) I assumed they would want nothing less than the most appropriate care possible. Instead, they arguably opted for the least. Surely I could have offered something in between. But I didn’t, so consumed by my assumptions on what my long-time clients wanted for their pet.

Figgie has doubtless suffered more pain (I don’t want to think about the pain protocols that may or may not have been employed) and what’s worse, he may well lose motor control of his bowels in a week or two (which is the main reason I urged he see a boarded surgeon). This latter possibility is a scary prospect. And owners don’t often comprehend the critical nature of this euthanasia-prompting possibility.

Sure, we can all say with certainty that his owners made the wrong decision—especially if we assume his owners had the financial wherewithal to treat Figgie with the best care available (and I still do). More so if you consider that these owners would be horrified to consider the services of the cheapest lawyers, bankers or accountants. (And they don't buy their clothes at Wal-Mart, I can assure you.)

Nonetheless, in Figgie’s little tale of woe there’s a big lesson for veterinarians...one we ignore at our own peril: When we provide informed consent to our clients, we should diagram that price/quality axis (figuratively speaking, of course) so that they clearly understand where their choices lie on that continuum-of-care curve. No, we can't contriol our clients' choices. But if we fail them in this, we must accept some responsibility for the final outcome.

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