Sunday, February 19, 2012

Truth or Consequences

A veterinarian of my acquaintance related the story of a new client visit. Middle aged male owner with a dog. The tech who had led the client to the room and performed the usual temperature, respiration, pulse count met the doctor in the hall as she headed toward the exam room.

“The pulse and respiratory rate are up, but he won’t tell me anything. No history. No nothing. I’m sorry. That’s all I have.”

“Well….he’s a big help. OK, thanks. Not your fault. Hang close while I talk with this guy.”

The doctor enters the room, the client standing next to the exam table, the mixed breed thirty pound dog in repose upon it.

“Good afternoon Mr. Quiet. I’m Dr. VBB. Pleased to meet you. So, what’s up with Friskie today?”

“You tell me.”

“Excuse me?”

“You tell me. Show me how smart you are.”

A moment’s pause as the doctor regrouped. 

“OK, Mr. Q…Is Friskie sick, or do you think he has been injured?”

“You tell me.”

“Excuse me for a moment, please.”

The doctor leaves the room and wanders over to the receptionist’s desk.

“Mr. Quiet…Did he give you any reason why he brought his dog in today?”

"Nope, not a clue."

Dr. VBB walks to her office and then back to the exam room. She re- enters the room and Mr. Q is standing there, arms folded across his chest. She plops the old snow globe onto the exam table next to Friskie. There is no water in the globe. The large crack in the glass is obvious.

“See….it’s broken. My crystal ball is broken. So you have to help me a little here, Mr. Q. Why did you bring in Friskie today?”

“You are the second vet I seen today. The last guy couldn’t tell me anything neither. You people have a lot of nerve charging us for the nothin’ you do.”

“The best doctor in the world is the veterinarian. He can’t ask his patients what is the matter-he’s just got to know.” 


“Will Rogers said that. Smart man, Will Rogers. But he had that one wrong. We don’t ‘just gotta know’. We need a little information to help us figure out what’s wrong with our patients. We are not psychic. And we don’t have a crystal ball. Now, if you won’t give me any information about Friskie, I’ll just thank you for wasting my time and move on to my next patient.”

“I think Friskie has cancer.”

“OK, what is Friskie doing that makes you think he has cancer?”

Mr. Quiet finally rattled off the list of things Friskie was or was not doing that suggested he wasn’t quite right. Dr. VBB asked a few questions, which Mr. Q answered. Then the doctor did her physical exam, noting that the poor dog’s gums were pale and his pulses were in fact too rapid. The doctor got permission to run some blood tests and take an abdominal radiograph. Mr. Q took a seat. 

The blood count showed anemia, and the odd cells present suggested a hemolytic anemia. And the spleen was enlarged on the xray. Friskie had immune mediated hemolytic anemia. Very serious, but treatable. After treatment, Friskie is doing much better now. 

Veterinarians are quite skilled at reaching a diagnosis when a patient like Friskie shows up in our office ill. We utilize three sources of information. We take a careful history of the problem from the owner, perform a thorough physical exam, and reap the answers that our tests can yield. These three sources of information feed into our brains and generally a diagnosis flows out.

If we get bad information, if the owner for instance, gives us bad information, we get sent down the wrong path, and that does not help. What we need from owners are their observations, but not their conclusions. Pardon the ego, but we are better equipped to form conclusions once we have the three sources of information, than the pet owner armed only with their knowledge. That’s what all those years of training, and retraining, and experience nets us. But the real skill we acquire over the years is the ability to coax observations out of a client who only wants to give us their conclusions. 

One of my oldest friends, and most difficult client, is a retired physician I’ll call Dr. R.  He was a skilled physician, but through all the decades I’ve known him, he has never noticed that his knowledge of human medicine doesn’t always translate well into veterinary medicine. Each and every time he has brought an animal to me with a problem, he has already reached a conclusion about the cause of the problem, and of course, already laid out his preferred treatment. And over all these years, and all those pets of his, he has yet to be correct. And no, this has not altered his style one lick.

Many years ago, Dr. R brought in a kitten he had found. The little tyke was not doing well, and he had that all figured out. He had even picked out the antibiotic he wanted to use. All he needed from me was to be the source of the drug he wanted. I of course, wanted to do an actual physical exam after he told me how the kitten was acting. The heart murmur surprised me, for I had never heard such in a kitten. I was convinced the poor thing had a birth defect, a heart problem called a PDA. I had heard the classic sound of a machinery murmur.  Dr. R didn’t believe me, and off he went with his kitten. 

The phone call came a few days later. The kitten had died with classic signs of congestive heart failure. Dr. R thought it was pneumonia, and he was going to show me the error of my ways. Would I be willing to do an autopsy? Meet me at the clinic.

Tiny thing on that big table, with the big light shining down. Dr. R standing beside me as I opened the chest. The lungs were severely congested. And right there, at the top of the heart, that extra blood vessel that is a patent ductus arteriosus, and it kills by causing lung congestion. Dr. R wasn’t convinced, but there it was.

Years later he called. He thought his old poodle had suffered a stroke. Bring it on down, and I’ll take a look. 

“So, why do you think FIFI has had a stroke?”

“Well, it’s obvious. She has been eliminating in the closet for a week. She won’t go outside to poop or pee, but does it in the closet.  She clearly isn’t acting right. She must have had a stroke.”

My physical exam was normal. All the blood tests were fine too. I gave him call and asked a few more questions. Turned out FIFI didn’t want to go through the doggie door to the back yard. And so she was pooping and peeing in the closet. 

“Anything happen to FIFI in the back yard recently? Could she have been spooked by a raccoon or a coyote? Did she get injured by the doggie door?”

“No, of course not.”

“What happens when you let her out the front door?”

“Haven’t tried that. What’s the use; she’s had a stroke.”

“Let me know what happens when you let her out the front door.”

Turns out, FIFI was just fine in the front yard, and this continues to this day. Don’t know what spooked her out of the back yard, but I doubt it was a stroke.


  1. One day at a veterinary clinic I heard one technician say to another that it was okay to send in a biopsy without any history because that would help the pathologist be "unbiased" when they made their conclusions.

    I explained that this would be similar to a client doing exactly what you described in your first story. Knowing the history and what diseases we suspect helps the pathologist look for subtle but importance signs of disease on the slides.

    Just a little plug on behalf of our pathologists to make sure we don't ask them to be psychic either.

  2. I get that crap, too. Patients who don't want to give a history because they think I'm supposed to figure it out. If they don't start talking I just show them the door.

  3. I am tempted to go buy a snow globe and break it just so I can use the crystal ball line.

    1. I was thinking that, too! I have actually told clients I don't have a magic wand or crystal ball, but maybe a show-and-tell object would enhance the experience!

  4. In situations like this.....

    I've been tempted to say my crystal ball is broken & Clark Kent is unavailable. :)

  5. You all are too nice and creative. If I can't get someone to talk, first I'd be surprised since I usually sit down and chat so I'd make up a nice big estimate for the basic diagnostics + some and tell the owner they might be able to help me better plan my diagnostics and save them some money.
    But I rarely can't get my clients to talk to me.
    I do have to get them to clarify how long is 'for some time' or how many times is 'a number of times', etc.

  6. "What we need from owners are their observations, but not their conclusions." Amen.