Where is the personal responsibility?

A dog limped into my office the other day and informed me that he'd avulsed his gastrocnemius tendon. Well, ok - he didn't actually SAY it with words, but it was pretty obvious from looking at him. Anyway, his person described the history:

Doctor, last night he was FINE! I let him outside, and he was out there for a while in our fenced-in yard. Nothing can get to him out there. He was out there for a while and then when he came back in, he was like this.

Pretty typical, really. So, I told this dog's person that I'd like him to see a surgeon, as I wouldn't be able to fix this here at VBB Satellite Office. She looked at me, apparently shocked beyond my expectation, and remarked "Well! Someone's going to have to pay for THAT!"

Now, I am not known in my social or professional circles for having any real degree of tact. I try to be sensitive to people's needs, but generally I say it like it is for better or for worse. So I replied "yes! Someone is going to have to pay for that, and I expect that someone will be you!." She was quick to correct me. "Oh no, this wasn't MY fault! I didn't do this to him!" and I explained that I in no way intended to confer blame on her, but simply financial responsibility for her pet. She reiterated that since she wasn't culpable, she was not going to pay, and she would be contacting the breeder because the breeder had never informed her that this type of injury could occur to a dog who was "just out playing in the yard."

I'm pleased to report that, in the end, the dog received the care that he needed. I have no idea who is paying for the care, though.

"I've already spent SO MUCH MONEY..." - guest post

Today, a guest post from Emily, who writes:

I have been working in ER/Critical Care for more than 10 years.  And wow, today I read in the news that the owner/trainer of "Uggie" who was in Artist and Water For Elephants was suffering from some mysterious shaking disease and had spent thousands of dollars on trying to figure out what it was, I got a little miffed.  Now you might think that I would be happy that they were spending money on the dog that they earn money off of, but no.  Why does the amount spent have to be at the forefront of the conversation?  Do parents always preface their quest for diagnosis on a illness in a child with a dollar amount that they are spending after insurance?  No, not really!!!!
Does spending money on your pets make the owners saints?  Some owners think so, but really come on people.  Having a pet is a responsibility wether or not the pets are for companionship, breeding, show or other.  It is very frustrating to go into a room and the first words from the client are "I've already spent 200 dollars on Fluffy and I she is not better and I really do not want to spend much more."
Well, had the owner got their pet vaccinated appropriately, you would not be here with the dreaded Parvo virus!!!  Had the owner spayed or neutered their pet they would not be here with ulcerated mammary tumors, or a testicular torsion.  Had the owner properly provided flea, tick and heart worm preventative, they would not be here for flea anemia, immune mediated joint disease or right sided heart enlargement.  Had the owner actually paid for regular grooming, or bathed and brushed their pet regularly, they would not be here for skin laceration from trying to cut matts off their pet.
I have known clients to obtain a second mortgage to pay their vet bills. Their pets were family.  I have had clients call family and friends to collect money to treat appropriately.  It can be done!!!
So, when people brag on how much they have spent on their pets for sympathy or attention, I find it repulsive and insulting.  We are doctors, we studies hard, we love medicine and prefer treating those who do not have a voice!!  Veterinarians are here to provide a voice for the patients.
The owner/trainer of Uggie certainly have it in their budget for pet health insurance as well as most others. It saves in the long run just like it does in people.  Imagine if you had to pay for your annual physical exam and blood work, mammogram or colonoscopy, or any ER visit or UTI or sinus infection.
We are doctors and not taking advantage of people or their pets.  We want to practice excellent medicine and improve quality of life for pets.  It is not amount the money. 

I tend to agree - investing in preventive care up front can save a lot down the road. Too many owners are penny-wise and pound-foolish. But then, that's not a behavior limited to pet-owners. Emily, I feel your pain. I hope the economy turns around and fewer people are put into the position of making healthcare decisions with their wallets.

Priorities

Yesterday we had to call the plumber out to our house to rooter the pipe that drains the washing machine. Apparently it was full of gunk, a.k.a. dog fur. The plumber spent about 15 or 20 minutes and charged us $350, which I didn’t have. I thought about all the things my clients have said to me over the years when presented with treatment bills for their pets:

• “If you really cared about animals you wouldn’t charge so much.”
• “You should name a wing of this hospital after me, for all the money I’ve spent.”
• “I don’t get paid until next Friday. Can you hold a check?”
• “Is that the lowest you can go?”
• “You vets are only in it for the money.”
• “I bet you drive a Porsche.”

For about a tenth of a second I thought about trying out one of those lines on the plumber: “If you really cared about washers you wouldn’t charge me,” or, “Think of my poor children! They won’t have clean clothes to wear to school!” But I didn’t, because I’m a decent person. Instead, I handed over the credit card.

For most people who claim they “can’t” afford veterinary care, it’s really that they choose not to spend money on veterinary care. It’s all a matter of priorities. If your priorities are an iPhone, shiny new SUV, and cigarettes, don’t try to make me feel guilty. I feel sorry for your pet that he is stuck with you as an owner, but I don’t feel sorry for you and your poor decisions.

And for the record, I drive a ’99 Subaru with 209,000 miles on it, having upgraded from an ’88 Blazer with 180,000 miles that couldn’t turn left in the cold without stalling.

When the Cost is Too High

Virtually daily, veterinarians everywhere are faced with clients that can, or will, only afford so much for their animal. I don't like to take an owner's finances into consideration when I make a recommendation because I try to base my plan of action on what is best. As one of the clinical professors at my school always told students: don't try to x-ray your client's wallets. As he once shared, it is sometimes the old farmer in the overalls and no T-shirt that will pull out a roll of $100 bills to pay for his sheep dog's surgery. And, sometimes the person with the Coach bag, iPhone, and Lexus will decline everything and just want a single shot to "fix" their dog.

For several years, I worked at both a general practice and at an emergency clinic. I would often have cases that went back and forth between the two clinics. One of these patients was a cat named Hercules. Actually, it was Hercules II. Hercules I had died after being attacked by a dog. Hercules II was almost identical and the family kept a close eye on him. He even went outside on a leash. However, one day he got into some rat poison that the owners had forgotten about that was hiding in a kitchen cabinet.

The owners were able to get him treated in time and after a month or so on vitamin K, which is an antidote to one of the main types of rat poison, Hercules II was back in fighting form. He spent his days lounging with the owners, an older retired couple that loved him very much.

About a month after he was past the rat poison episode, Hercules escaped from the house. When he got scared, he ran out into the road where he was no match for a passing truck. By the time the owners found him, Hercules was almost dead. When he got to the day practice, the vet there initiated treatment and found that Hercules was not stable enough to be alone overnight. The owners were not wealthy, they were not even middle class. And they were retired, so they had no real income. The veterinarian, who knew these things, offered referral to the ICU overnight facility but did discuss his poor prognosis and gave an estimate of cost for the transfer. The owners wanted to go ahead, no matter the cost.

When the owners brought Hercules into see me, I recognized them. They were very sweet, but also very minimally educated. Trying to explain all of the injuries and treatments that Hercules needed to have a fighting chance took a very long time because the owners didn't really have a concept of basic anatomy or biology. Trachea was reduced to "breathing tube," and muscle was reduced to "meat." I tried repeatedly to give them an idea of his chances and the cost of care, even just beyond the initial stabilization. Hercules had to have a chest tube placed and I feared that he might have a pneumothorax caused by ruptured bullae (where the air pockets in the lungs break open and leak air from the lungs into the chest) and a ruptured trachea as well.

I knew that these folks didn't have the money but they wanted to pay with a credit card. I wasn't worried that the clinic wouldn't get paid, but I was worried that the family would have a hard time paying off the credit card company. I was also worried that Hercules would not make it and they would owe tons of money and have no cat.

The first night turned into a few days of hospitalization. Hercules developed new problems and got progressively worse. At each stage, I discussed euthanasia as an option. I knew that even with radical and expensive surgery that his chances for survival were minimal. I tried to explain it to them, but they hung on to that 10% chance of survival. I gave them an estimate for cost of care, cringing while I did it because I knew that they were going to say yes. When I openly discussed euthanasia as an option, they wouldn't consider it. I even offered to keep Hercules completely doped up while he succumbed to his injuries so he could "pass naturally."

By the morning of the surgery, Hercules had gotten considerably worse. His glucose would not remain normal and kept dropping, possibly indicating a septic infection (infection in the blood). He started having seizures and no matter how much glucose we pumped in him or how much valium he received, it kept on happening. His kidneys were failing, which also might have been contributing to the seizures. These things made him a terrible candidate for surgery.

I called the owners and told them to come out at once because I was fairly certain that Hercules would not make it much longer. When the owners got to the hospital, I rushed them back to see Hercules. He was comatose by that time, either from the drugs to control the seizures or the disease process itself. As I placed him in the owners' arms, they asked repeatedly for me to do something to help him.

Once again, I had an internal war going on. If the owners had been millionaires, I would have still given the same advice: euthanasia. But these people, who could not easily afford what we had done already, wanted to go even further. They absolutely refused to euthanize. Their daughter and son in law had come with them to visit. I pulled them out of the room to try to explain what was going on. They too only wanted to press forward, saying that cost was no object.

I left the family to visit with their pet, telling them to alert me if there was a problem. About 10 minutes later, I heard them screaming in the room and ran back. Hercules had another seizure and then started agonal breathing. At that point, I knew that nothing we could possibly offer would help him. I explained that he was dying and offered to ease the passing with some euthanasia solution. This was a last ditch effort to try to help the owners more than it was to help the patient. Hercules was beyond the need for the injection, but I thought that if the owners had some control over the situation, they might feel better. However, Hercules was gone before I was able to leave the room.

Frankly, I was torn. I felt horrible for the owners. I knew they had poured their heart, soul, and wallet into saving their kitty. I knew they felt guilty because their miracle kitty (which is what they started calling him after the rat poison incident) had escaped the house and gotten hurt. And even though the referring vet and I had been totally honest and upfront about the chances for recovery as well as the cost, I personally felt guilty.

I also felt relieved: the cat was no longer suffering and I didn't have to spend anymore of the owner's money in what I felt was a futile battle. I was relieved because I was also tired...mentally tired to trying to explain the same thing over and over again and getting no where. It sounds awful when I write it down.... I didn't resent the owners for either not being able to understand or just not being willing to understand the situation, I was just plain tired walking that line between offering the top plan and making it plain that euthanasia was an option. Looking back on it, I like to think I would have offered the same thing to a wealthy person. I might not have felt quite as guilty about them spending the money, but I would have offered the same thing. The case still haunts me and it colors every end of life discussion I have with clients.

Another reality

Like my esteemed colleague, I always wanted to be a veterinarian. I wrote an essay on the subject in first grade! I think my mom still has it, actually. Although I ended up as a companion animal doctor rather than a doctor for elephants and horses and rabbits as originally planned, I pretty much never deviated from the plan. I'm a person who makes a decision and sticks with it, pretty much. I've never been accused of waffling. Maybe I should run for president? Ha ha.

Anyhoo, I was lucky. I didn't accrue any debt during my undergraduate years, partly because of my parents' generosity and partly because I attended a cheap-ass school. I got a job before going to vet school, and unlike my esteemed colleague I kept it for the first two years of school before really NEEDING to quit (I was able to work overnights. I don't remember sleeping much really! And no, I was not using performance-enhancing drugs.) Still, I managed to accrue a sizable chunk of debt during vet school. But then - a kindly older relative found out, and paid it off for me. Who does that, right?

So, I don't have to worry about the debt. I love my profession: the animals, of course. The intellectual stimulation, the freedom to USE MY BRAIN and my clinical exam and decision-making skills - a lot of my physician friends complain that there are so many insurance-related constraints they feel like they are stuck doing cookbook medicine all the time. It's true that there's a downside or twenty, but, even with all the negative aspects I feel like veterinary medicine is a truly rewarding profession. It's just not financially rewarding, these days, especially if you start out with a crushing debt load. Intellectually and spiritually rewarding - yes. Absolutely. At least until the client with the Lexus and the 20-karat bling shows up with the $2500 designer mutt and declines every damn recommendation because it's too expensive.

I remember being shocked when some of the vets I talked to before vet school did NOT recommend the profession due to the lack of compensation. I thought we should be "above" that. I understand better now but I have to say I am just really glad I did it anyway. I wouldn't want to have to make my living at it, though.

My Reality

For as long as I can remember, I have wanted to be a veterinarian. There was never any question in my mind. While many of my playmates, and eventually friends changed their minds several times, I could not see myself doing anything else. My family went from poor to middle class throughout my childhood. My parents showed me that hard work pays off.
Public school was easy for me so I did not have to study. I worked full time as soon as it was legal for me to while in highschool. This enabled me to save money to pay for most of my undergrad. Throughout undergrad I kept a job or two to save for vet school. I even became a resident advisor to get free rent.

When I started vet school, I quickly realized that working was not going to be an option (other than making some book money stuffing fliers in mailboxes at school). So I needed to take out loans to pay for tuition and fees. In total, I have approximately $200,000 in education debt. I call this my house I will not likely ever be able to purchase. It means that at least 1/3 of my paycheck goes to pay back loans for the next 30 years. This also means I will not likely ever have children as I cannot afford to.

Do I regret my decision? I answer that question differently everyday as I deal with ups and downs. Fortunately I love my career, because I will be working to pay for my education for a long time.