Behind a consultation, bigger pictures loom

Even though the vet consult can be reduced to a customer service interaction, in complex cases, the process of negotiating the best path forward is not always obvious or easy. Both vet and owner bring their baggage: culture, religion, life experiences, and the beliefs these inform.  The better aligned our viewpoints, the greater our mutual understanding and ease of decision-making. Here will look into these bigger pictures that impact upon our consultations.

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As vet and pet owner get to know each other, maybe through the co-management of  a pet’s disease, they often establish trust and understanding. The vet begins to appreciate the nuances of  an owner’s viewpoint, bond with their pet, and financial situation; meanwhile, the owner develops trust in the vet’s opinion. This level of mutual understanding is ideal: vets can openly and honestly disclose their view, stripped of commercial self-interest or defensiveness; while owners feel comfortable disclosing their thoughts, without fear of judgment.

This is why it’s worthwhile trying to find a vet who seems to be on your ‘wavelength’, or shares similar values or ethics. Owners confident in their vet will often ask ‘What would you do if she was your cat?‘. If you don’t feel comfortable with your vet’s recommendations or perspective, don’t be shy about shopping around. We’re rarely offended and would do the same ourselves with our own doctors.

More usually, when dealing with pet owners with whom we are not so familiar, vets must pick-up on cues or directly question them regarding their views.  How successfully a vet and owner can communicate will determine how smoothly any disagreement can be reconciled. So while it’s tempting to isolate clinical decision-making from the broader context, on a daily basis vets are having to look at bigger pictures beyond just the dog, the disease, and the drug.

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Simplistically, the relationship is that of customer service, where there’s is exchange of products and services (opinion,  diagnostics, information, pharmaceutical or surgical treatment). Each party brings to the conversation, however, their self interests, beliefs surrounding animal welfare and  the practicalities of treatment, and opinion on potential outcomes.

  • Money

The most obvious issue, given the commercial context in which vets usually operate, is financial. ‘How much is each diagnostic or treatment option going to cost? Can I afford this?‘,  and rarely, the most emotionally tangled, in cases of life-threatening disease, ‘How much is my dog worth to me?’

  • Clinical risk

There’s also the matter of how vet and owner cope with uncertainty and risk: ‘How confident is the vet that the lump appears benign? How accurate or reliable is this blood test? How certain are we that the outcome of surgery will meet expectations? How likely is a side effect from this medication? Am I comfortable with this  level of uncertainty?‘

  • Practicalities

Are all of the suggestions made by your vet realistic? ‘Will I be able to pill my cat twice daily for the rest of his life? Is it physically possible to rest my young Boxer for 6 weeks while her  fracture heals?’ Can I install ramps for my crippled Dachshund?

  • Animal welfare

And finally there’s the subjective world of animal suffering, and weighing various treatment options in terms of quality and quantity of life.  ‘I watched my mother die of cancer – isn’t it more humane to euthanase my cat now, before he deteriorates? Is it cruel to leave my dog’s heart murmur untreated when she seems so happy? Is my dog’s dental treatment necessary  now when he seems to be eating just fine? Can I condemn my incontinent dog to an outdoor lifestyle? But it’s against my religion to euthanase a cow.’

Informed consent

These types of considerations are fundamental to good clinical decision-making. Previous generations expected their vets and doctors to make executive decisions, to look after the patient’s best interests. Nowadays, informed consent is sought; a variety of options are offered, their pros and cons weighed, and the owner expected to decide what’s best and affordable for them.

This is all fine for a simple problem like an ingrown toenail or infected follicle, but with complex and chronic diseases, where diagnosis may be expensive, where there exists multiple treatment options, with outcomes both variable and uncertain, providing all the information for a truly educated decision is rarely possible in a consultation.  Introduce issues of cognitive bias and conflicts of veterinary interest, and decision-making becomes even more fraught; a paradox in an era of expanding medical literacy and heightened expectations of treatment.

In some ways our human medico counterparts have it easy. With a patient who can speak and decide for himself,  who alone bears of the consequences of his choices, and a government health system willing to step-in and fund minimum standards of care, decision-making is unencumbered from many of these considerations. Although in cases of terminal disease or uncontrollable suffering, vets have on-hand a final solution to disease that we as humans do not yet enjoy. See Exit Strategies.

Most diseases and treatments are simple and, for the sake of brevity, vets often take executive control over much of the decision-making process, and many owners are grateful for being spared all the detail.  After all, that’s what you come to us for – our professional opinion. But as our understanding of diseases and treatment options become more complex, and cost escalate, we must be wary of being presumptuous.

The pet owner’s perspective

Pet owners vary markedly in character. There are those who are switched-on and interested, possibly with some medical knowledge, who crave details of how a vet arrives at their recommendation;  others who have enough on their plate already and just want it fixed; through to those who are deeply emotionally engaged with their pet with whom our stance may be more defensive.  Unfortunately in the latter group, too much detail, especially those of clinical risks, can paralyse decision-making.  In this case, making special effort to establish a level of trust, whereby these owners can accept a vets recommendation, is crucial.

Language and cognitive barriers present another unique set of hurdles. Vets will sometimes be forced into the executive decision-making role with elderly pet owners who have lost the faculties of comprehension. A non-English speaking immigrant who arrives at the vet with her lame cat, but without a bilingual relative for translation,  may have difficulty understanding that the cat’s femur, like her English, is broken. In such circumstances communication can be reduced to pictures, mime, and even black comedy.

On one occasion I had to explain to a Japanese woman that her cat, having fallen 8 floors earlier that morning, had died during emergency surgery. Gesturing to heaven didn’t work, so as last resort the slash of finger across throat bridged the communication barrier.

Failed communication

Reading transcripts of malpractice hearings by veterinary registration bodies offers salutary insights into how things can go wrong.   How failed communication can result in bad outcomes: confused, distressed, and dissatisfied owners, and vets unpaid and questioning their personal performance and career choice.

Discord is more likely when the vet and pet owner come from differing worlds.  They may have starkly contrasting perspectives on a situation, or weigh differently the often opposing considerations described above.  A relaxed rural vet, with only minimal resources and distant referral services, may find it difficult to satisfy the high expectations of emotionally charged, inner-city pet owners, when a pet falls ill on holiday.  A vet who passionately believes in animal welfare may struggle to engage with farming folk for whom carcass weight is heavier than any ethic. For more on the diversity of relationships  between human and animal see Child versus Tool.

Throughout this blog I hope to foster a greater appreciation of the difficulties vets face when making recommendations; ultimately, the more transparent the clinical decision-making process, the better vets and their clients will get on, and the less stress for us all.

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