Thursday, May 1, 2014

Unneeded tests

I have recently been reading some reviews about veterinary hospitals and doctors. For one clinic, the majority of reviews were great - ones that I would love to have and, well, lucky for me I do have that type also. But there were a few, a small percentage, that complained. Some of them actually gave 4 of 5 stars, but their comments were not so flattering. 

In those cases nearly all of them mentioned money. A few mentioned that the doctor would not allow services to be paid for later. Unfortunately for way to many veterinarians we know later never comes. Many people that do not have their finances figured out today will not have them figured out tomorrow. That is my personal bias. I said many, not all. Believe me, all veterinarians wish their clients were financially sound. 

One thing that struck a chord for me was an unhappy reviewer noted that unneeded tests were done on her sick pet. So, I’m trying to figure out what IS an unneeded test. I have a whole book of tests that can be completed by the lab. I went to school to help determine which tests should be completed in a logical order. In particular my instructors made me describe why I wanted to complete a test before it could be authorized. Even in just casual discussion with my peers we regularly may ask each other about the logic for running any particular test. 

When the unhappy reviewer clearly stated they took their pet in because it was sick how did they know a test was unneeded? Why would they authorize a test they think is unneeded? I suspect in retrospect they really are suggesting that the test results turned out to be ‘within normal limits’ which is very different than ‘not needed’. 

When veterinarians are faced with a sick patient we need to figure out what is normal and what is abnormal. Knowing what is normal has as much value to medical professionals as what is abnormal. Some patients will have multiple systems affected by their condition. If we only tested until we got a single abnormal result we may miss the most important problem. We need to sort out a variety of problems so we can diagnose a condition and rule out other conditions. It helps us determine the need for treatment as well as the treatment choices indicated. We also need to know what is normal because some medications and fluids must be used with respect to certain organs functioning properly as those organs will metabolize the drugs.

One common diagnostic test is a ‘general’ panel. It is done on blood and gives us basic information about the kidneys, liver, gall bladder, blood proteins, electrolytes and pancreas. If my dog is sick and I run a panel on her I am THRILLED that her ‘general’ panel is normal. I then know that her kidneys, liver, gall bladder, blood proteins, electrolytes and pancreas are normal (or near normal). I would not be happier if the panel revealed renal failure, liver disease, pancreatitis, etc. 

I get clients that ask me at times if a test is needed. I tell them that I would not recommend a test if it was not indicated. Need is not really taken into account when a diagnostic plan is formed.

16 comments:

  1. Start of thought process:

    Q. Do I love my dog? A. Yes.
    Q. Am I willing to do/pay whatever it takes to keep him healthy? A. Yes
    Q. Do I trust my vet? A. Yes

    End of thought process.

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  2. Yes....what the good Officer said.

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  3. If I knew which test results would reveal the diagnosis, why would I need to run any tests in the first place?

    Deep sigh...

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    1. Exactly. I had someone bring in a generically ADR budgie. When I asked to get some cytologies/blood, the response was "we don't know what's wrong with him, so we bring him to you. Why don't YOU know what's wrong with him? Why do you need tests??" Apparently vet school provides us with x-ray eyes and I-stat fingertips in the minds of the public.

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  4. Everyone has those days when the patient looks like a duck, talks like a duck, but the tests show it's a mongoose.

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  5. Have people come into the ER all the time wanting to know what's wrong with their pet before any tests are done. I am tempted to tell them my X-ray vision is on the blink & Clark Kent is unavailable. At other times I want to say my crystal ball is in the shop. Of course, management frowns on this sort of rhetoric from the DVM.

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  6. I'm a new(ish) graduate who has only been able to work in shelter/low-cost situations so far. I >wish< I could do some "unneeded" tests. The first place I worked at a ca. 1964 x-ray machine & a functional microscope. The current place has neither of those two luxuries. If I can't diagnose it with my eyes, hands, and ears, I have to tell me people and make and educated guess. It's intensely frustrating and I feel like a syringe mechanic.

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    1. Gareth, have you been unable to find a better job? Are you still in CA? It is sad that there are still places around like that, and while it's not a crime to not invest in ridiculously expensive equipment, it sure does make life easier and improve your medicine. Good luck, if you're looking for something better! Shoot us a message if we can help.

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  7. I take my cat in to the vet. I don't know what is wrong with him. The vet does not either. I get elated when a test comes back normal! I do not fret that it cost me so and so. I just go along with what my vet needs to test. I am not in the best financial position. I know that it will cost me but so does my medical tests. It is a normal process of information. Such is life! I want my cats to be healthy and normal. When they find that certain test that comes back abnormal I want to treat my cat. I do not moan and groan. My cats are my life and joy. If someones child has something going on with them do they moan that they have to pay for the test? I would say not. My cats are like my children. I have a savings account that I put money in to pay for them. People should wise up. The money they pay for their health care is on par for pets. I don't understand why people do not care for their pets as well as they do their own. It boggles the mind!

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  8. Thanks for your comments. . .sometimes the tests my vet wants to run on my dog at a normal wellness exam does seem excessive. I always have to remind myself that she and her vet technician are the professionals and I am not.

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    1. We never mind if you ask WHY we're running the test that we want to run! I'm always happy to tell clients the reasoning that I'm recommending whatever test that I'm wanting to do. Educated clients mean pets that are better taken care of.

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    2. I would recommend that all clients ask their vets why they are recommending a particular test! That way you can understand 1) what the vets are thinking about in re: a certain issue and 2) you don't feel ripped off paying for generic "bloodwork." I know the vets I work for are always happy to explain why they want to run certain blood panels (if they suspect renal disease vs. tick-borne vs. whatever) and usually the owners can understand it and go for it. When it comes to a very sick animal with owners who have no money, one vet in the practice in particular is extremely good at laying out all the options and what information she would get from each test. Then the owner decides based on cost vs. information to be gained, knowing that they may miss something by not doing all of the tests.

      I think educating owners about why a doctor feels certain tests are recommended and the giving the owner the option to opt out (documented fully in the record) is the way to go. It takes more time in appointments to lay out all of the options though, which in a practice that still has 15-minute appts can really slow things down.

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    3. We almost always use a thirty minute block of time for sick animals ... of course, that doesn't always help, especially if you do have to go step wise through test one, and then if that doesn't pinpoint an answer, then test two...

      And then after you get a diagnosis, you have to go through options for treatment, and then do said treatment.

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  9. To go one step further, I hate it when there's those bad reviews along the lines of "The vet is just in it for the money, they kept poking and prodding to do tests, and treated my animal like a lab rat" .... I hate hearing this... because the tests are usually diagnostics.... the blood is taken, the urine is taken... the tests are run in a lab and your animal is not feeling extra pain from tests being added on the request form.

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  10. I think "The Hedge" has got it right. I am a pet owner with a limited budget. I look after my bitza hound the best I can, she has premium pet food that is nutritionally ballanced for her, worming, fleas and vaccinations are kept up to date, well trained, well exercised, well socialized. However, when a visit to the vet for an ear infection (30 min consult, test of gunge in ear, medication) totals more than my weekly wage, you might understand things.... things get tight. I'm not arguing that vets don't deserve my money (hell, y'all are underpaid), it's just that, for my particular situation, if my vet is 90% sure of a diagnosis and going with that will save me a weeks rent, then I can't really have the test. Yes, some may argue that I shouldn't own pets if I can't afford the vet bill but I do what I can for my pooch. The vast majority of us are responsible to what we can afford, and I am so sorry that there are dickheads out there who flatly refuse to spend the money. I'm sorry for their pets and I'm sorry for the vets who have to deal with the consequences of their arseholery. Just please.. involve us in the process. Give us the reasons for the tests you recommend. Give us possible consequences of our choices. Educate us. Not with condescention, but with understanding. A vet who treated me as an equal partner in my pet's health? Well, I would trust them with my dog's life.

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    1. I think everyone can sympathize with an owner like you who really cares about their pet and wants to take the best care of them, but has limited funds. You have a wonderful, understanding attitude and I'm sure your vet appreciates that. Vets should involve owners in the process and most try to, but your end of the bargain is to let us know that funds are tight. Most simple ear infections will resolve with topical medication, whether I do an ear swab and microscopic exam or not. However, I have caught things I would have missed by skipping that recommended step, not to mention it gives me a comparison point if the ear does not get better. Therefore, I always recommend it and it is so common that the techs usually collect and start it before I'm in the room. Most owners don't mind the cost so it's rare that I would bring up the option of not doing such a simple test. UNLESS the owner tells me funds are limited. In which case I would inform them of the possible consequences but would be content to skip it, if the owner wanted to. In addition, most vets have their favorite ear meds but there are often cheaper options that could be tried so I might opt for a generic which is effective but maybe not as nice smelling or easy to apply because I know for this client cost is more of a concern than convenience. It's embarrassing to talk about finances, but we don't need your life story, just let us know so we can help.

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