Saturday, March 22, 2014

Doing the best thing

Our basic training experience was an orientation class that we had very little interest in. But we didn't get to start veterinary school without sitting through this. So we sat through this.

Our friends endured a more significant basic training before heading out to Viet Nam, so we had little to complain about. But we complained....anyway.

I was nineteen. The oldest guy in the class was 40. We nicknamed him, “Gramps”. Five had masters degrees already. Most all already had at least one bachelors degree. Some had two. I had two years of undergrad under my belt. Five women had been admitted. The class was 71 men, and those 5 ladies. And the term “second class citizen” landed firmly on the ladies' backs. They had to prove they were up for the challenge. And they damn well better not quit to have babies, because that's what everyone expected.

It was 1968. The world was a tad bit different then.

We all wanted to become veterinarians. And the doctors teaching the orientation class intended to teach us what that meant. What we learned wasn't exactly what we expected it should be. These teachers were REALLY old, and we wondered why we must endure them.

Veterinary Medicine had been important for many years before we came along. Decades. A century. More. It had served the farmer, and the horseman. It did the best it could, which was considerable because a small number of truly dedicated, inventive, brilliant, adaptive men figured ways to keep horses sound and farm animals productive.

But there was that other side to our calling, the witchcraft and the charlatan too. Veterinarians were known as “Horse Doctors” The blue ointment worked better than the red one, when the only difference was the coloring agent. And some worked for the money while most others worked dedicated to helping the farmer and the animals.

The men who taught us were the men who during their lifetimes had dragged our profession into the modern world. These were the men who changed things, rid us of the charlatans and the quacks, elevated our passion into something that warranted the title profession. They improved the training, applied the ethics and enforced the ethics, and they were damn sure going to teach us to do the same. We were to inherit their baby, and they wanted us to appreciate it, protect it, perfect it.

We were going to be practicing medicine. We were going to behave as professionals. Our ethics would drive our behavior, not greed or pride. Look around the room....brilliant educated dedicated professionals....colleagues, not competitors. We would hold ourselves to the highest obtainable standards. And the animals and their people would benefits from this. So we all would win.

We would not disparage our colleagues to enrich ourselves.

We would be honest to a fault.

We would not advertise, self aggrandize, lie cheat or steal.

We were professionals. And if we worked hard enough, and sacrificed enough, and achieved enough, we would earn the respect that went with this claim.

And we would refer to ourselves as Veterinarians. We were not to be “Doc”. We would not be the “Vet”. Were were Veterinarians. And yes, we learned how to spell the word. Weren't gonna be no vetinaries in this group.

And through this we found ourselves joining a profession. We were proud. We even earned a degree of respect in the real world. Not like “real doctors” of course, but we did OK. People could trust us. Many did trust us. And we helped them and their animals.

Over time we became really good at this helping animals thing. In the decades of my career we changed Veterinary Medicine into something I would not have recognized at the beginning. Our training became so very much better. Our medicine got ever so much better. A set of blood tests that once yielded information a week later after we mailed them to a lab 300 miles away soon became an over night set of numbers, and then an hour's wait while the machine right there in our office spewed out the results. The x-rays got better, and then we gained access to endoscopy, ultrasound, cat scan and even MRI. Oh, we could do so much more to help.

We've conquered diseases that were the scourge of the animal world. We fix things now that were certain death 40 years ago. We have become so good at preventing some diseases that our critics claim we invented those diseases just to scare folks into spending the money they'd rather spend in casinos and bars.

A days drive to a specialist became twenty minutes across town. Anybody could get world class medicine to save their precious pet in a time of need.

If they wanted to.

My career has spanned the time that can only be described as the golden age of veterinary medicine. This profession has grown, matured, improved so very much as I have watched and participated. We've become damn good at what we do. We are so much more wonderful than when I began. We can offer so much to the animals and their people.

Problem is, we've left some folks behind. And a lot of those folks are our clients. These left behind folks don't want all that we can do to help them. They want the less exciting, less effective, less intimidating, less expensive version we used to offer. As one once told me in total honesty. He didn't want it done right. He just wanted something less done.

Veterinary Medicine has always adapted to the needs of our clients and their animals. Here's the best way to fix that broken leg. Well yeah doc, that's nice, but doncha have a cheaper way? Well, it's not as good, but back in the day we used to do this, and it might work. Do that doc. Sometimes this worked, despite the odds, and we were the heroes.

And when it didn't work....well that was the doctor's fault.

Veterinarians want to do the best job possible to help the animals and their people. Some people want this. Some can afford this. Others cannot, or more often simply choose not. And so we do the best we can with what people let us do.

We hold ourselves to a much higher standard than even our most strident, malicious critics. We want to offer the best. We want to be the best. We lay awake nights wondering if we have done our best. And our clients beg, bargain, connive, demand that we do something less than the best, and when we don't they hate us, and when it goes wrong they hate us. I've had clients scream at me because I will not commit overt malpractice for their convenience, or their wallet.

This is hard.

None of this is new. Read between the lines in “All Creatures Great and Small”. That was pre-war England, but it happened back then, too. Through all those decades of my experience, the Golden Years of Veterinary Medicine, it happened every day. It still does.

But this is going to change.

Law schools now offer classes in how to sue veterinarians. Veterinarians have always carried insurance against malpractice suits. That is our reality. But now the lawyers are seriously sniffing around us.

Sometimes we make mistakes. Sometimes we do the wrong thing, hoping it will somehow turn out to be the right thing. Sometimes we shrug our shoulders and do the shitty job the client demands of us. And the outcome is bad. Sometimes....we simply are not perfect.

Well hell....sue the bastard.

Everybody sues everybody in America. Win a big lawsuit and retire. Play the lawsuit lottery. Listen to the ads on afternoon TV. Sue for this injury, about that drug, because of that product. Good thing the lawyers are looking out for those folks who sit around most every afternoon watching TV. Sue the bastards.

Veterinarians exist to care for animals. But this only happens because people care enough about the animals that they will ask us to help. If people didn't care, we'd be doing something else. But now, because people care, the lawyers can smell a profit. Because if they can prove that we injured a person because the outcome for an animal was not perfect, the lawyers want to turn this into really large pieces of money, as compensation. Sure, they will take a bit of this money for their efforts, but they can dangle the lawsuit lottery in front of people who already hate veterinarians.... and this is coming soon.

Suppose the rewards from suing veterinarians reach the levels the lawyers want. What happens next?

Well, what happened when they did this to the physicians?

Remember “defensive medicine”? That's what the physicians were forced to do...are forced to do, as they try to help in a hostile environment that will bankrupt the doctor if a less than perfect outcome results. Wonder what wrecked human medicine leading to the abortion known as Obamacare? Ask a lawyer.

Ever beg your veterinarian to pass on the blood tests before she cleaned your dog's teeth because you didn't want to spend those few extra bucks?

Well, forget that ever happening again. All those things veterinarians have done to try to help the less committed animal owner, the corners we've cut, for the less wealthy animal owner, the most ignorant animal owner, the liar and cheat....well forget that. Don't even ask. All those things veterinarians have done to compromise doing their best possible job to help the animals and their people will never ever happen again, because the doctors will now have to protect themselves from the consequences of not being perfect.

Every person who has hated his veterinarian for insisting on doing things correctly, every person who had lamented the cost of doing things correctly, every jerk who has accused veterinarians of just doing things for the money..... well get used to it.

You can beg, cajole, insult, nag...to get us to cut those corners. But you will not get your wish.

We will be forced to do things correctly. We will have no choice.

We will be doing what those old guys who lectured us in our basic training class urged us to do, because it was the right thing to do, and some of you will hate it. But you know what? Get used to it, for we will no longer have the choice of choosing malpractice to keep you happy. We can't afford that luxury anymore.

Welcome to our world. Too bad it took greedy lawyers to make you all realize this. Hope you all enjoy it as much as we will.

Thank a lawyer, for if experience bears out, you sure as hell won't thank your veterinarian.

34 comments:

  1. Beautiful post. As stressed as the profession is right now, I am proud to be a vet student.

    However, I don't think that the blame is ENTIRELY outside of our profession. Frankly, we do a terrible job of policing ourselves and there are some vets who probably won't retire like they need to unless they get their license revoked or get hit with a big malpractice suit. In some states, the board can't even accept a request to investigate a veterinarian unless it comes directly from the owner of an animal who was hurt. Everyone makes mistakes and they tell us at school that everyone WILL end up harming or risking harm to a patient sooner or later because we are all human. I try very hard not to judge, but the 0.2% or whatever proportion make a habit of vastly substandard care without ever offering referral to someone who can actually help the animal, even when the client is willing and able to pay. Procedures are performed that allow the owner to profit but endanger the animal in the long run, e.g., on the racetrack, and the excuse is made "if I didn't do it, someone else would, and I would go out of business." Cases are sat on for far too long before the client finally wises and seeks a second opinion; sometimes it's too late. Major surgeries are performed without any kind of analgesia. I am in no way condoning abusive lawsuits or cyberbullying, but it we cleaned up our own house, we might be more successful at defending against those who want to do it for us.

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    1. Thank you, You provide great hope for the owner client. Again, as I have said many time in the past, on many blogs for comments: honest mistakes can be forgiven , it is the egregious, the dishonest, the abusive acts, that prompt those complaints from a client.

      I had well over 35 years of veterinary care with multiple cat/dog ownership (at once--high point 8 pets), weathered numerous honest mistakes, perhaps poor diagnosis, could forgive ALL , but the ONE horridly example of sheer ABUSE and CRUELTY , all in my very face.

      I like this article, all until the last paragraphs. I hope to address this too.

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    2. Until you have endured the constant parade of clients who demand substandard care, who berate us when we offer quality, call us greedy and thieves, who whine complain post damning reviews and bad mouth us interminably, you cannot possibly understand why some of us get stuck in the trap of below standard care simply because we try to help your animals despite you. Consider just for a moment the number of animals that will receive no care whatsoever when every doctor is forced to only offer the care these people resist. Clients demanding mediocrity get what they want. Sure, every veterinarian would like to see the quality of care improved. But those animals will get left out when any compromise option we might have used in the past will be taken away by the fear of lawsuit. Not a surprise that you don't like this, but like I said...the doctors will be blamed for this too.

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    3. Dr. Bob: I most certainly DO understand your comments ---I am one that works for/with the PUBLIC, had years of work, long ago, in the medical profession, worked in the pits of dog rescue work, and witnessed crap in the vet office that was incredibly horrifying (on the part of the client)--- but I can , without FEAR, tell you that when several of your colleagues commit without the slightest FEAR, cruelty, illegal, immoral act of abuse in the very CLIENTS face to their beloved companion pet---WELL there is one heap of a problem here. When they, without a thought or blink of an eye, worry not about harm to a client and a pet, such as me and others---well there has to be some push back. And now you are just maybe becoming a "bit" worried.

      If you got rid of the bad, or imposed enough punishment to those bad---maybe none would have to worry. As it is, none of us that research, see enough change yet, perhaps just more brave clients willing to speak out.

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    4. And so how should we do that? Round them up and kill them? What standards should we use?

      Why should we only believe ONE SIDE OF THE STORY?

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  2. DVMs are now the #1 profession for suicides. Our personality type & drive to be perfect are what put us there. Hopefully, we will learn to offer the best care, but accept the limits placed on us & still enjoy our lives.

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    1. I am sorry to learn this suicide rate or the degree of mental illness and substance abuse in the profession. Yeats ago, it was reported that "dentists" had #1 and was suspected to be connected to halogen lamps (remember that??) I thought the idea was preposterous , and truly never understood the depression that could be related.

      I have a few formulated theories as an "outsider" to depression related illness among Vets, but I can be so off base. But no matter what the reasons, just as ANY other line of work, there are the best, the mediocre, and the downright abusive and bad. It is the latter that anyone should strive to see eliminated to not drag down the good people

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  3. I have spent weeks reading your entire blog, right back to the beginning, and I have decided, because of it, not to get the dog we were starting to look for.

    Why? Because we realized (in time, thank goodness) that the cost of owning a dog is not the cost of purchase + food + license.. It is purchase + food + license + exam fees + vaccines + heartworm tests + prevention + possible deworming + spay + dental care + grooming + training + emergency fund designated specifically for said dog.

    Thank you for saving us (and the dog we would have gotten) the grief. We can't afford all that at the moment (having three small children with whom I stay home). We're going to wait a few years until we can afford all the costs associated with it.

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    1. Stef, I so applaud your decision. I am sorry it isn't going to work out for you at this time, but when it does it will be a much less stressful situation for you all.

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    2. Indeed. Good for you. You've restored a little of my faith in humanity today.

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    3. We were about to go into it with rose-coloured glasses. I'm really glad that we got more complete info in time. We're not too sad; we know that the dog we are meant to have will be with us when the time comes.

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    4. If you have room in your home for a dog but not enough money for medical expenses, you may be able to foster. A lot of rescues will pay for medical expenses, and some will even let you borrow crates and dog beds if needed. Your main cost would be food.

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  4. Document, document, document!

    I mark it in the written chart, and make note in the computer record as well, when I recommend treatment or diagnostics and it is declined or ignored.

    I've had clients tell me 'I can't afford X', and my response to them is always the same: "I understand, but my job is to give you this information." I let the owner decide what they want to do, with as much information as I can give them.

    I tell them what various things it could be, and what tests I recommend to rule diseases in or out. If they balk, I start on the road of, 'Well, without tests, I can't know for certain, but with the history and clinical signs, it may be (potential diagnosis), and we can try these treatment options. BUT if it doesn't get better in X time, or it gets worse at any time, we HAVE to pursue diagnostics!'

    If they balk at treatment options, I start going down the list. Gold standard treatment all the way to supportive home care. If it's a serious issue, and they're balking at diagnostics and treatments... that's when you tell them that euthanasia is an option if they cannot or will not provide care. (Only put in more humane terms.)

    And I document. Document. Document! So if they come after me later for NOT doing the gold standard of care, I can hopefully defend myself by pointing out that the gold standard of care was offered, and declined by the owner!

    Unfortunately, if prices go up or if it becomes a system of 'You have to do Option A or Option B, but we no longer can provide Option C or D'... we're going to see a lot more of Option Euthanasia for otherwise curable conditions. (Or possibly also Option Go Home And Die, or Option Never Seen A Vet Before And Never Will)

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  5. You wanna know what the problem is? Go read the comments under "The Not So Incredible Dr. Pol." Or the comment about Pol on Justvetdata.com. The public doesn't WANT to be held responsible for THEIR choices. They WANT Pol. They WANT Dr. Cheap. They WANT substandard care but yet they then want to have the right to sue the vet when their own poor choices go to shit. We DO try to police ourselves, and then we can't get shit done about it because the public chooses these people as the face of Vet Med. Those of us trying our damnedest to just do a good job and take care of both our patients and our clients get left in the dust, accused of exactly what Dr. Bob mentioned above, and then we lose because we struggle just to stay in business because the public wants to get everything for CHEAP if not downright FREE.

    Just last week a woman accused me of being a money grubbing, uncaring jerk because I wouldn't help her with her parvo puppy FOR FREE. She never took the dog to a vet, never bothered with any care - dog wasn't even current on a rabies vaccines (as per law) and was 10 months old. Didn't bother with routine care at all, yet I became the bad guy when I refused to help her for free (other than offering to put the poor suffering animal to sleep). She took it home to suffer and die a miserable death and then told my staff what a horrible doctor I was.

    The public doesn't want to lose their right to decline treatment, to choose substandard treatment, to neglect their animals, to be able to dump them off at the shelter just because they don't feel like taking care of them anymore. They don't want to lose their right to all of this, so they skewer the good vets who actually do a good job and put the shit doctors in the spot light, like Pol. I'm not even referring to him as a doctor any more because the stuff he does to animals is appalling. But yet, read how much the public loves him.

    This. Is. The. Problem.

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    1. This. It's a whole can of worms the public does not understand.

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  6. While I agree with you on a majority of your post, I have seen too many negligent cases get swept under the rug and vets who receive no discipline nor fines for negligent treatment.

    I worked for a short time as a front desk associate for a vet. Some of the things he got away with, some of the things other vets got away with.. it makes my skin crawl. I personally had a vet medicate my pet with out my consent. He told me was taking her out back simply to clean her up, he then proceeded to treat her and medicate her with out discussing the options with me. I never even received an apology when I found out about it and was upset.

    I know pets who have died because of vet choices and it was covered up. I know of pets who were severely damaged and it was covered up. I know of vet students preforming duties that only a licensed vet should be doing in a clinic.. (that one got a slap on the wrist but it was never reported to the public so very few people know about it)

    I do not want every one to sue their vets when the outcome is not the one everyone wants or wishes for. Not even when mistakes are made - because we are all human - as long as the vet owns up to them and reports them...

    But there are cases when even you have to admit it is time that SOMETHING is done.. and sadly the legal system is sometimes the only way.

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  7. I'm a certified vet tech, and I both disagree and agree...I think this issue is multifaceted to such a degree that there is no good solution.

    My cat is 9 and has cost me over 30,000 to date...I can never be accessed of seeking lower quality care. My previous feline was diagnosed at 7 with CRF and lived to be 14. During a routine dental at a very high-end practice, they pulled his trach tube without deflating the cuff, causing a tear in the trachea. He leaked air through the tear, which collected under his skin and around his heart. After 7 years of managing his condition, that incident started a downward spiral that ended in his death.

    That was PURE human error. Even so, I would have been likely to forgive it if the vet hadn't treated me like an idiot, refused to admit their mistake, and told me as a tech, I should understand complications happen. Which I do...but a complication is something unexpected. A tracheal tear is an EXPECTED outcome from pulling a tube without deflating the cuff. Long story short, they paid his emergency room fees, but yeah, I sure as hell wouldn't have had a problem suing them, and would have felt I deserved more than a hundred bucks for my loss.

    A few years prior to his death, I took my cat for a cardiac ultrasound and was told his heart was enlarged and he would need to be on meds. That night a different vet from the same practice called and said she was suspicious the cardio vet didn't know what they were doing...ALL of their patients seemed to have enlarged hearts. She offered to refund us if we took the cat for a second opinion and helped her confirm her suspicions. We of course did so, and the cat's heart was perfectly fine.

    I briefly worked for a vet who routinely let techs do surgery on patients who were under anesthetized and moaning. No animal in that practice received pain medication....it wasn't even an option. The practice I worked at for many years had overall terrific patient care, but one vet was less skilled than the rest and gave a cat a MASSIVE overdose of dextrose, leading to the cat seizing and dying. Then the vet outright lied to the owner. The head vet was the one who called the owner back and explained the truth, and we had fluid pumps in the next day to ensure it never happened again.

    Blaming owners for poor practice is a failure to take responsibility for one's own actions. I didn't ask the vet to pull the tube, and none of the clients asked for techs to perform surgeries on their semi-conscious animals. Vets like that deserve more than a slap on the wrist.

    I can no longer be a tech due to a physical injury, but I still take my animals to the same practice I worked for. My cat just had a dental to the tune of $900...all the bells and whistles one can imagine. This same practice WILL work with owners who struggle with finances, but they will NOT compromise patient care. And they will absolutely document every choice the owner makes, and have print-outs that go over the potential consequences for turning down options like blood work, a copy of which has to be signed and placed in the chart. The idea that vets should be free of consequences for their own actions is frightening. At the same time, I DO understand that malpractice insurance could put many vets out of business. I just think you'll have a harder time pushing that concept if you also imply that vets who screw up or outright abuse their patients are only doing what the owners want.

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    1. As a vet I agree. With a reasonable cap, I would be okay with emotional damages being awarded. As vets we depend on the human-animal bond, the value that owners place on their pets as individuals. It doesn't make sense to then get upset when that bond is given a value in court, as with any other family member. Owners should not be getting hundreds of thousands of dollars for losing Fluffy, but I don't think it's an insane idea that a wronged owner be able to collect something for the suffering that a bad apple (or just a good vet having a bad day) might inflict. Obviously, this will lead to some necessary defensive actions on our side to avoid litigation but those are things most of us are already doing (document, document, document!).

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  8. It's disappointing that Barb ("Pocket's Story") has found this blog. I would assume that Stephani (Bad Vet Daily) will also post here. These two posters have made Dr. Khuly's blog unreadable and I am afraid this will happen here as well.

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  9. Something like 70,000 veterinarians in this county, thousands more around the world, dedicated educated extremely hard working professionals, and a tiny handful of bad apples scattered amongst us. Therefore...let's condemn the entire group for the failings of that tiny few. That's fair. To the haters. Too bad these persistent nags don't realize that there is professional help available to them which could help them get on with their lives.

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  10. Dr. Bob stole the words right out of my mouth. As a profession we are not perfect. But the bad eggs are few and far between. And those of you who have been wronged...or think you have been wronged (because there are many of those out there, too)...seem to have an odd obsession with pointing out the one bad seed you encountered then grouping all vets in with him or her. And most of us don't deserve it. In the meantime, I am an honest, competent vet. And today I got 2 phone calls asking me to transfer records to a less honest, less competent vet. Reason for transfer? He's cheaper. OK. I'm honestly good with that. But those of you who want to be angry can't be mad at vets for not policing ourselves when there are still enough clients who actually seek (not accidentally stumble into) half assed, cheap medicine to keep the quacks busy. Sadly for the pets out there, this is a 2 way street.

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    1. I'm with you and Dr Bob - there is a far greater number of competent honest vets compared with shonky vets. However, the trend to litigation has coloured the way many of us now practice, I manage cases and speak to clients in a much more defensive way than I used to. I document obsessively. I refer things much earlier than I would have previously, often incurring more cost to the client. Surgical procedures that we would have tackled 10 years ago we refuse to do any more and only offer specialist referral as an option.
      On one level this is positive as clients and their pets are being offered a higher level of care, but it is pricing many pet owners out of the market. Responsibe pet ownership is becoming a luxury item.
      And we are still depressed and frustrated by the owners who don't vaccinate, don't desex, don't do basic preventative health care and present their nearly moribund pet with a host of medical problems that could have been easily addressed in their early stages expecting an instant diagnosis on the table and an equally instant cure. They usually justify their stance by telling you 'he hasn't needed to go to the vet for years as he's always been healthy' as you glance as his rotting, putrifying teeth and listen to his grad 5 heart musrmur and conncurrent pulmonary oedema.
      No wonder I'm getting compassion fatigue.

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  11. The day pet owners can sue for emotional damages is the day I quit veterinary medicine.

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    1. C'mon, could be interesting.

      The day pet owners can sue for emotional damages is also the day veterinarians can report pet owners for refusing appropriate diagnostics and treatments for their animals. It's also the day courts can mandate those services for animals, ensure payment of veterinarians for said services, and gain custody of animals if the owner's lack of willingness to authorize or pay for services is deemed neglect.

      Can of worms...

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    2. Oh hell yes! The public does NOT want this, because then that will put us in a whole different ballgame with regards to their own responsibilities with their animals. Walk into my clinic with a grade 4 mouth that I can smell across the room? Um, call the police. Dump your dog at the shelter because you can't afford to take care of it any more? Um, call the police. Need that end-of-day C-section on the 9 month old Chi that you purposely let get pregnant (because you're a "breeder" after all) but don't have any money? Um, call the police.

      Yes we have bad eggs. We try to do something about and the public cries "no fair!" because the bad eggs are always so cheap. Again, take Pol for the example.

      This IS a two way street. People will eventually get what they asked for.

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    3. The interesting part is if they change the legal status of animals which so many are willing to do. Can't afford my $3000 treatment plan? Guess what? YOUR PET GETS SEIZED!!

      That will open a whole nother can of worms, which would be interesting, but definitely not worth sticking around for.

      Here's another highly competent caring veterinarian that's considering leaving the field.

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    4. Oh heck. Turn it into a government program. Free medical care for pets. It's a right. Make it free. Let somebody else pay for it. Somebody else has the responsibility. Not me. Not my fault. Everything is should be free. Certainly would improve the availability of care. As for the quality????

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  12. Put me down as another who would love to see all the negligent pet owners brought up on charges. If that threat would cause pet owners to stop & think & act, I would have a lot less to do in the ER.
    So, all those people, who want DVMs to be held more accountable for any mistake, could see themselves facing severe consequences for their own irresponsible acts.

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