The High-maintenance Client

Ah, the high-maintenance client.

I’m talking about the one who needs every tiny detail explained beyond all reasonable expectation. The one who has his own list of differential diagnoses, and expects you to explain the diagnostic pathway of every single one on the spot during the appointment. At VBB Central, we have our share. I saw one last week.

This week, the dog was brought in for an acute illness which had resulted in significant dehydration, requiring hospitalization. During the office visit immediately preceding the admission, the owner not only regaled me with the details of every meal/urination/defecation/nap/wake/play/funny look the dog had in the past five days, but also insisted that this acute illness (which was most likely a viral syndrome) was in some way related to a deworming medication given to the dog the week before (even though this man had called poison control already). I told the guy I agreed with poison control that this was not likely due to the dewormer and explained what supportive care and treatment I wanted to provide. He agreed to go along with the plan, but had a list of followup questions as long as my exam table. Could this be due to Lyme disease? (Unlikely.) Could this be due to having eaten a piece of cheese last week? (Unlikely.) What if the cheese was moldy? (Was it moldy? No? Then who cares?) Is it possible this is because the vaccines were given one week after the “due date” on the postcard? (No.) Is this because of the abdominal ultrasound he had last month? (No.) How do you know? (Because that’s not a thing that happens!) Each question required not only an answer but an explanation. And then an explanation of the explanation. And you know, at some point, when you hear yourself saying things like “honestly, I’m not sure anyone has actually done a study to determine whether dogs with an isolated episode of hematuria 5 weeks prior to the onset of acute anorexia are more or less likely to have pancreatitis than a dog who presents with anorexia in the absence of a preceding episode of hematuria, but generally hematuria has nothing to do with pancreatitis and anyway we have a UA pending and if we see hematuria today we will address that,”  odds are that you are dealing with a high maintenance client.

This owner, btw, was also very interested in having me personally lay eyes on several baggies of urine and feces that had been dutifully brought in. LOVE that.

Just as I thought I could escape from the exam room and move the little dog back into the hospital ward, the owner put his hand on my arm and asked me to check the ears - because of course we should consider whether this could be related to the cotton allergy.

The what? “Oh, well, you know - after that bout of ear mites, I did some research and it turns out this breed is really prone to cotton allergy and I’m sure that’s what caused those blisters he had in his ears that time. Please mark his chart, doctor, so no q-tips or cotton gets used on him.”

You see, once in the past, this little dog had presented with a horrific inflammatory, ulcerative, blistering otitis. It turned out the dog ultimately was diagnosed with food allergies and had some secondary bacterial infection, but at the time of initial presentation, it was just terrible. The owner had tried treating the little guy at home first - with, variously, dish soap, alcohol, sweet almond oil, gentian violet, and a few other things that slip my mind at the moment - but all of the home care had failed to help his little buddy, so he presented the dog to me so I could get stronger medicine to treat the ear mites. Yes. The owner insisted that there were ear mites even after my cytology revealed that this was not the case. The owner then produced baggies of ear exudate he had allegedly been collecting at home and insisted that I look at them under the microscope. I did, and saw only cotton fibers and epithelial cells and some pollen grains. I have no idea where that stuff came from! On that day the owner agreed with (paid lip service to) everything I said, went home, and ignored all of the recommendations, which I found out when they came back in a few weeks later, having tried more harebrained home treatments that did not work. Eventually the ear problem was solved by a regimen of medication & a diet change.

So at that point, I couldn’t take any more and agreed to mark the chart. Then, when discussing the case with my colleague during our hand-off, I explained to her what had happened and why I’d done that. She said to me “oh, I can’t wait til this guy comes to pick up this dog - I mean, he was wearing jeans, right? And what kind of shirt did he have on?” I started cracking up. I mean, I hadn’t even thought of that. Plus of course the dog had been wrapped in a cotton towel when the owner carried him in. D’oh.

Anyway, this type of client can really suck the life out of me and kind of makes me hate my job.