Saturday, December 31, 2011

The customer is sometimes wrong.

There is a woman standing at the reception desk right now. She is telling the receptionist that she just stopped by to lodge a complaint. She is very upset.

Receptionist: I'm so sorry to hear that, ma'am. What seems to be the problem?
Client: Well - you know, I made an appointment to bring in my cat. I made the appointment 2 months in advance. It was for last week.
Receptionist: OK. Was there a problem with your appointment?
Client: Yes! I made the appointment with Dr. Underground, but when I arrived, they made me see Dr. Stillalive!
Receptionist: Hmmm. You say you made this appointment recently?
Client: No! I made it two months ago!
Receptionist: Well, yes. But, relative to Dr. Underground's death, I mean, you made it recently. Dr. Underground died a few years ago. It's not possible that you made an appointment to see him since then.
Client: What? He died? Why wasn't I informed? This is terrible. Does this mean I can't reschedule to see him next week?

Are you taking your pet's meds?

Client: "I need a refill on my dog's phenobarbital."

Dr. Sarcasm:  "In order for us to continue refilling your dog's meds, we have to see him once a year for an exam and therapeutic blood levels so we can make sure his dosage doesn't need to change."

Client:  "But I don't have any money.  Oh and I've only been giving half of the dose because I'm running out of the medication."

Dr. Sarcasm:  "But you were told a year ago that we MUST do an exam and bloodwork once a year or we can't refill the meds.   The DEA doesn't like it when we fill controlled substances without the appropriate exams and bloodwork, so that is not negotiable.  Since you've only been giving a small amount instead of the prescribed dosage, your dog could have seizures and the bloodwork results will be out of range, so we will fill two weeks worth and then check the bloodwork for the refills for the rest of the year.  This is not something we will discuss further;  this is how it is.  If you can't do this, then we can't help you and your pet any longer."

Client:   "I can't believe you.  I can't believe you're gonna make me do this $100 test when you KNOW I can't afford it.  I can't believe you'd just let my dog have seizures just because I can't afford the bloodwork!  I don't want to do the blood test!  It'll be low anyway because I haven't been giving the prescribed dose because I let him run out of meds!"

Dr. Sarcasm:  "Ma'am, this is a choice you made and I cannot re-write federal law.  Cause, see, the DEA worries that people like YOU are stealing your pet's meds and taking it yourself.  Doing this little test protects your pet by checking that his dosage is correct, and protects me by proving you're actually giving the meds to your pet.  So it's not negotiable and you had a year to save up the $150 for exam and bloodwork."

Client:  "Can't you let the rules slide this ONCE?"

Dr. Sarcasm:  "Oh sure, let me lose my DEA license JUST FOR YOU AND YOUR LOUSY $150."

Dr. Sarcasm:  "Life sucks.  No.  Bring your dog in or find a quack who doesn't care about medicine or keeping his license.  Cause you're done here otherwise."


One of these is a great gift for your vet. One is not. Which is which is left as an exercise for the reader.
A box of YUM, full of phenylethylamine for her pleasure.
A barking dog clock. Because what - there aren't enough barking dogs ??

Family pets

It's funny. There's that saying, "Physician, heal thyself," yet, I'm sure most physicians agree that if there is anything seriously wrong, it's not a good idea to try to treat yourself. Similarly, it's generally considered unethical and inappropriate for physicians to treat family members for serious conditions. Percival's Medical Ethics (pub 1803) addresses the matter, proposing separation of personal and professional identities with respect to caring for family members. There are many reasons for this, loss of professional objectivity probably being the most important. So, anyway, what does this mean to me as a veterinarian? Well, there are no formal rules regarding treatment of one's own pets. It's not frowned upon by any professional societies that I know of. In the absence of a third-party payer system, in fact, most veterinarians I know do choose to either treat their own pets, or simply have an arrangement with a close colleague in their own practice in which they treat each other's pets. For me personally, it's a problem not so much with my own pets (whom I do have a colleague treat, because I find that my own loss of objectivity is so great as to interfere with providing quality care - my own pet once went apneic under my care, and while I did successfully resuscitate her, I will NEVER AGAIN put myself in that position!), as it is with family pets.

Ahhh, family. Gotta love'em, right? I am lucky enough to be surrounded by lots of loving family members, and honestly in the grand scheme of things, I have very few complaints about them. I would love to provide them all with free veterinary care, but - well - first of all, I'm not a practice-owner. There are limits to what I can give away. Information, sure. After all, information wants to be free. Medications, diagnostic tests, other sorts of things, well - those I can sometimes get at cost or cost plus something, sometimes I can't. And while some family members are really understanding about that, others I know think I'm just being mean. Sorry about that, guys. It's especially hard when I know certain family members simply don't have the money to provide the gold standard of care, as much as we would all love them to. On occasion, I've been lucky enough to have a local specialist colleague offer a family member of mine a professional discount. My profession is full of caring individuals like that, who will offer highest quality care at a deep discount, when THEY feel it is appropriate (not when Jane Random Client wants it, which is a whole separate issue). I hope that they can karmically balance out the scummy, corner-cutting Dr. Pols of the world. [And let me just take a moment here to go off on a tangent and add: Dr. Pol does NOT practice high-quality medicine. In one episode, he left a severely dehydrated puppy with hemorrhagic gastroenteritis alone in a cage dying, without even giving it any fluids. Seriously? he also doesn't seem to gown/glove up for surgery, or do any other 'standard of care' type things. OK, moving on...]

So anyway, all of this is really a lead-in to a story I wanted to tell. Details have been changed but the heart of the matter is completely true.

One day at 5 AM, my spouse's cell phone rings. It's a close relative on my spouse's side of the family. She found one of their cats on the floor near a "pool of dark liquid." The cat was "gasping" and when she touched it, "nothing happened." "What should we do?" she wanted to know.

It was one of those moments for me. I have them all the time. Moments when I feel like the person I'm talking to is going to be grossly unsatisfied with my response, no matter what my response is. Moments when I feel like no matter what I say, the person I'm talking to is going to come away with the idea that I'm an imposter, because surely a "real doctor" could do better than THAT.

I was in bed. It was 5 AM. The baby was nursing and I was just noticing that she was in fact running a fever again (the fever had not been present at bedtime). What was I supposed to do, get up and go over there and see that the cat was in fact agonal? Is this what they expected of me? I'd have no access to any diagnostic tools save my eyes, ears, and fingers; nor would I have what was probably the most important thing - Euthasol. Better to send them to a hospital. But which one? They won't go to the local university teaching hospital. They claim the vets there killed one of their cats. We always disagree on that, but it was a long time ago and besides, the cat is dead (ha ha)(sorry) so I can't suggest that. But the local ER sucks. The one my boss refers to - I wouldn't direct them to if they paid me. That leaves the one I almost went to work for, the one with the unreasonable non-compete clause in the contract. So I tell them:

It doesn't sound good. I can't tell what's going on, but you can't do anything at home to help him and you can't do anything at home to end his suffering. He needs to go to the hospital.

Later, I call my spouse to find out what happened. The vet said that the cat was agonal (duh) and she didn't know why. She offered supportive care and diagnostics, with the caveat that whatever they found was probably incurable, or humane euthanasia. The owner elected euthanasia, which is what I would have hoped for. But they declined a post-mortem exam, which was a total let-down for me.

We got together with this part of the family about a week after this event. They told me the whole story, in their own words. I'm sure they didn't mean to make me feel guilty, but when they said "since you couldn't come over, we went to that place you suggested," I heard "since you didn't love us enough to get out of bed, we went to that inconvenient and expensive place you suggested, which couldn't even help us anyway."

It's hard to be a veterinarian in an extended family of pet-owners, is the bottom line. Just wanted to put that out there. Thanks for listening.

Friday, December 30, 2011

I'm telling!

There are some people out there who respect other people, and there are some who do not. I am one of those people who gives everyone the benefit of the doubt. If I come to your office, in need of your professional help, guess what? You start off being held in great esteem. I do my homework, and don't go to see a professional I'm not prepared to respect and to listen to. I thought I was normal in this regard, but then I started practicing veterinary medicine, and it seems that in fact people like me are rarae aves. More common are entitled know-it-alls who want everything to go their way, and if it doesn't, they are going TO TELL ON ME

As I sat pondering this one day a while back,  couple of people called my office and - GUESS WHAT? They rejected my advice, and yelled at me for not saying what they wanted to hear. WTF?

“My dog ate Paracetamoxyfrusebendroneomycin, what do I do” was the first. I explained we could call the national animal poison control center for a fee, or I could try to see what I could find out from a human pharmacist and get back to him. But the guy really just wanted me to say “it will be fine.” He got quite hostile when I kept repeating “I’m not saying it’s fine, and I'm not saying it isn't fine. I’m saying I don’t know, and I’m explaining how we can find out, but I am not going on record saying it is fine.” He “threatened” to tell my boss. Little did he know boss-man was listening to the whole thing! Not only was the boss listening, but he picked up an extension, and informed the caller that he'd used up enough of my time, and he could either hand over a credit card number and let us call Poison Control (we need the card number for Poison Control, not for our own purposes), or he could go harass someone else. Way to have my back, BossMan! The guy blurted out a few obscenities and hung up the phone. Hopefully, Paracetamoxyfrusebendroneomycin is not toxic in dogs. Paging Dr. Justine Lee.....

The other question came from the owner of a dog with a probable foreign body GI obstruction. This dog is well known locally for eating tennis balls. In fact, this dog is not even permitted on the grounds of one local park which contains a tennis court, because he has upset too many people by eating their tennis balls. But anyway, she had been in and out of our office a few times in the past two weeks and the owner described some very concerning signs, so I told her to come in and I’d squeeze him in right away. He might need surgery. She wanted me to tell her exactly what time I’d see her so she “didn’t have to wait.” I couldn’t offer a time - I was fully booked - I said “well, come now, and I’ll see you as soon as I can - you might have to wait a little bit if I'm in with a scheduled visit when you get here, but I’ll squeeze you in.” Next thing I know, she runs and tells my boss she’s never coming back because I told her she had to wait for two hours. WTF? Boss-man told me she waited for five days until the dog was totally parched from constant vomiting before bringing it in originally, so I shouldn’t feel too bad. Whatever. Poor dog. I hope she got it seen SOMEWHERE. I wish I knew what I could have said to get her in the door. I really did not think I was being obnoxious on the phone. I just can’t make an appointment for an exact time when my appointment book is full!

Ha ha. As I sit here writing this, the phone on my desk is ringing. What strange wonders lurk on the other end of the line? Time will tell.

Letter to Dr. Olderguy

Dear Dr. OlderGuy,

OK, I'm no spring chicken. I'm not one of those shiny new graduates with big ideas, ready to change the world, or at least the way veterinary medicine is practiced in one small corner of it. I have my own bad habits, I'm sure. But dude - all due respect, I realize you've been in practice more years than I have been eligible to vote, and I'm sure you know how to handle lots of things that still make me pee in my pants a little - I just do NOT understand why it is SO DAMN HARD for you to:

-document things in the medical record. No, "cleaned ears, gave vax" is not an appropriate medical record entry to document an annual physical examination. Sorry, but no.

-enter controlled drug use in the controlled drug log. Even write down how much you used on a post-it and stick it onto the book for someone else to enter later. Or just TELL me. Anything except force me to go back and figure it out based on what everyone else used and what patients you saw that day (whose records have no entries in them anyway).

-order diagnostic tests when you aren't sure what's wrong, instead of trying eleventy-billion different empiric therapies.

-ask for help if you aren't sure what to do. Honestly. I do it all the time! I think it is possible some of your cases could have improved outcomes with just this one simple step.


Dr. SickOfDealingWithThisCrap

It's dog-eat-dog.

Yesterday I sat on my ass. In the middle of the afternoon, got a call from someone we hadn't seen since 2006... cat vomiting for "last two or three months," now urinating on floor of kitchen. Time to put the cat to sleep.

Nope, hasn't been anywhere else. I told my OM "Well, at the very least I'll probably end up keeping it since it was a great cat, fixing it, and finding it a home."

"Oh, no you won't. She demands to be present. She wants to witness it when you kill it. She's calling around for prices and going to the cheapest one. I'm afraid she might call back."

So here I sit... no money. Shitbag wants to kill her nice cat that is, in all likelihood, treatable. For the past ten years I would have told her to get bent... but I was prepared to do a convenience euthanasia because it was the only way I could keep the lights on.

She never called back. There's competition for convenience euthanasias now.


"Have you ever taken your dog to the vet to have his teeth cleaned?"

"No.  I just have the groomer brush them."

"How often is that?"

"Every 6 to 8 weeks.  Sometimes they do a dental when he's awake."

"Really?  So they didn't mention to you that this tooth right here that's sideways, isn't *supposed* to be sideways?"

"No, they didn't say anything about it.  I just noticed he was having some trouble chewing his food."

"Well aren't you astute.  His canine tooth is falling out.  He needs about 30 extractions and he's 12 years old with a heart murmur.  You just made my job a lot harder and with a lot more risk, and this is gonna take about 2-3 hours to complete."

"Can't you just pull the loose tooth?

"That would be negligence and malpractice on my part because the rest of your dog's mouth is a grade 4 out of 4 with severe oral disease.  He needs to have most of his teeth extracted or there is no point in doing any of it."

"You just want my money!   You don't love animals!  Or else you'd take care of my dog's mouth for free!"

"What?  I am simply telling you what needs to be done.  It is your decision if you want to do it or not."

"I can't believe you actually want to charge me money to take care of my dog.  You mean money grubbing vet!  I bet you drive a Mercedes don't you!"

"Actually, I drive a Kia."

"Whatever, I love my dog so much and you won't help me.  Just put him to sleep."

"That would be my pleasure, just so I can get him away from human slime like you."

Thursday, December 29, 2011


"My dog bit my other dog's ear off a few hours ago.  I want you to sew it back on."

"Um, I can't do that.  The part of the ear that was bitten off is dead."

"Well sew it on anyway!  Or, cut the other ear off so they will look the same!"

"Well, if I do that, then you'll be back paying me in a few days to remove the dead piece you just had me *sew* back onto the ear.  I'm not Dr. Frankenstein.  And No, I will not cut off the tip of the other ear just so her ears "will match"."

"Well can't we attach a prosthetetic ear tip so she doesn't look like she has a chunk missing out of her ear?"

"I can't do that here but if you want to see a surgeon, I'll be happy to refer you."

"No, I only want to spend $100.  Just give me some antibiotics.  No pain meds cause she's not in pain."

"I bet Evander Holyfield would disagree.  But what do I know?  I'm just a doctor with 9 years of school under my belt."