The tone of this post has bothered me for a while. When using e-mail it can be easy to sound harsh or callous when a post is not meant that way. Apologies if any of my posts did sound like that.
Reading back over mine, Boston’s and Meghan’s comments all of us stated we always did our best to explain to our client of all the options, that we did not “assume” what the client could / could not afford, and that we used the highest protocol available in conjunction with the clients wishes. No body has indicated they tell the client what to and expect them to blindly obey, that has been completely misconstrued. As has the “fact” that unsterile equipment is often used, and that “all” vets are condescending.
I’ve agreed with everything Dr Khuly has said on this topic, although she’s probably phrased it a lot better than I have.

Lis - You seem to have taken every opportunity possible to twist people’s words and make personal attacks and assumptions, which is a shame as some things you say are very lucid.
I truly think you are projecting from some bad experiences you have obviously had with vets in the past (like your Sunday), where your vet did appear negligent & obviously didn’t listen.
Please appreciate that vets also sometimes have clients like this.
Do I think that all clients are like that? Of course not. Do you think that all vets are like that? Of course not.
Everybody sees life through the eyes of their own experience. I am foremost a human being, secondly a vet. Don’t deny me my experiences, and I won’t deny you yours.


Hi Barbara – this was a comment you made in the early discussions in this blog

” Dr. Khuly---I LOVE this type of post!! We learn something & appreciate WHAT we learn! And thank you for your candidness, as Stefani was so astute to notice. That's the "most" of what we are afraid of : the pretty 'front office' and 'dirty back room' !(in more ways than one--)”


I thought it was a great comment. I wish vets did get more of an opportunity to be candid about the realities of the job. I believe this would be beneficial to both vets and clients – for instance, after reading this blog, as a client putting a pet in for surgery, I would always ask your surgeon if fluids are going to be used, what pain meds, and what was their protocol for monitoring anaesthesia? I love it when those types of questions are client-initiated. These are the main standards that tend to differ between clinics in my experience, and are completely reasonable things to clarify and request.

Its also refreshing as a vet to see that a lot of people here do care about high standards of animal care during surgery. Please ask. Please demand high standards. Please be prepared to pay for it.

Meghan RAHT, thank you so much for summing up *exactly* what I was trying to say in my posts. Thank you, thank you. You sound like a terrific asset to the profession. {{}}

Just to clarify:
I have never said I am a veterinarian. I work at a vet clinic as an assistant (unlicensed!) 1-2 days a week.
I have never "demanded blind obedience" to every whim of anyone's vet.
I have never said that I "know everything and owners know nothing."

I lurked on this blog for the longest time before I decided to jump in. I loved the relatively polite discourses, the "backroom view" of vet medicine that we usually don't get to see. I loved hearing about the issues I'd never thought about before. This blog is such a special gift--we get to hear about the good and the bad, from a fantastic, caring vet who takes the time to post every day. I'd always thought that disagreement was pretty well handled here, as long as the poster was polite and could back up his/her statements. Sure, there are a few one-issue posters, but sometimes I felt that they introduced a new angle to an old issue. This blog is a coming-together of two sides of the vet industry, the people who work in it, and the consumers who use it. There's bound to be conflict. But it doesn't have to get personal.

Lis, I hope you can wipe the froth and spittle from your monitor and see that your (completely perplexing) personal attacks have changed the tone of this website. Please, step back and take a deep breath. If you feel attacked by something, please, calmly ask about it. The sense of nuance and tone is completely lacking in the written world and sometimes things can be misinterpreted. I know I have done that often and I have to remind myself it's just words.

This will be my last post here, so you don't have to worry about me anymore. Just please, don't let this blog lose its beauty, its value, and its sense of honesty. I thank you, Dr. Khuly, for having had the chance to participate on your website.

"The story of the Hypo/hyperthyroid cat was one that he/she had heard of. It was not him/her that made the decision to give the pet the thyroxine. The moral of that story was that vets should not give in to an owners every whim, even if they have already consulted Dr. Google. I assume (having been on the vet-end of these types of situations) that the owner did not want tests, and only wanted meds. I don't think any veterinarian would refuse to send blood on a skinny 18 year old cat. I would also assume that some attempt was made to educate the client. In this case the pet owner was making the wrong decision for their pet. Should she have been allowed to do that?"

And what about my poor Sunday's bladder cancer? Should my mother have been "allowed" to demand x-rays the vet "knew" were unnecessary? After all, not only did she have no medical education, she didn't even go to college! So she must have been wrong in contradicting the vet and demanding x-rays, right?

Thing is, she wasn't freaking _stupid_ and she knew what was happening with Sunday wasn't right, and wasn't just "recurring infections."

A few years later, with a different vet, when our cocker spaniel and this _stuff_ on her ears, and the vet said "it's just allergies," we weren't nearly as slow to twig to the fact that he just wasn't bothering. When the first couple of rounds of "it's allergies--->do his treatment--->doesn't work----"it's just allergies"----try treatment again, didn't show some signs of progress or relief, we called around and got referred to another vet.

Who took one look and said, "Let me test for mange." And life started getting better for Brandy and for us.

You're reading into "Anonymous's" story medical steps that certainly ought to have been taken, but "Anonymous" doesn't claim that they were. The story "Anonymous" actually tells is the story of a vet who couldn't be bothered to actually listen to the client, treat her with respect, and recommend the correct tests.

Just like the vet who told my mother, "It's just a recurring bladder infection." Or the one who told us, "It's just allergies!"

My hostility and contempt is not for vets or vet techs in general. It's for the ones like you and Anonymous, who are convinced you know everything and the owners know nothing, and can have no reason for not doing exactly what you say without question, except that they don't really care about their pets and will just "replace them."

I showed this comment thread to my vet. Who was appalled. And no, not by the idea of clients questioning vets.

Megan, That is too easily stated. Licensed professionals don't wear little name tags coded for "I'm a good guy, or I'm a scammer" If accountability was enforced by government resources in place, consumer/clients wouldn't have to be paranoid.

And on your second statement, I ask myself all the time: why would a clinic that had my business for 14 years with 8 dogs and 2 cats, that obviously garnered a lot of money and knew me very well, perpretrate such a cruel money-making scam? Why would four veterinarians conspire and sell their integrity and souls to harm two humans and a dog? Why didn't they "sever" the client/patient relationship? It is unfathomable and beyond reason.

Lis

You have abviously misread Bostons posts.

He/she is not a veterinarian.

The story of the Hypo/hyperthyroid cat was one that he/she had heard of. It was not him/her that made the decision to give the pet the thyroxine. The moral of that story was that vets should not give in to an owners every whim, even if they have already consulted Dr. Google. I assume (having been on the vet-end of these types of situations) that the owner did not want tests, and only wanted meds. I don't think any veterinarian would refuse to send blood on a skinny 18 year old cat. I would also assume that some attempt was made to educate the client. In this case the pet owner was making the wrong decision for their pet. Should she have been allowed to do that?

I also get the impression that any contempt and hostility contained in bostons posts was directed at YOUR hostility towards the profession.

As a fellow veterinary employee I understand his/her frustration, not with ALL clients, just the paranoid, hostile ones. Bottom line, if you don't trust your vet- get a new one. And veterinarians reserve the right to do the same, a veterinary/client/patient relationship is not valid if there is a lack of trust on one or both sides.

Barbara, the sad thing is, I sympathize to some degree with the vets' fear that making the status of pet animals too much like that of people will simply raise the cost of good vet care for them, thus actually doing harm.

But SOMETHING has to be done. Surely there is a status somewhere between "toaster" and "exactly the same as a human being, with all the complications that entails" ? And maybe vets could help us find it, instead of steadfastly defending the "toaster" status quo, despite the fact that their business depends on the fact that we do NOT regard pets as toasters?

THANK YOU Lis & Dr. Khuly! That is ALL we are asking: respect, courtesy, honesty, information---in exchange you get loyalty, trust, compliments & referrals, and prompt happy payment of services rendered.

Lis, my gut told me you had a 'memory' Re: poor vet care; and some how you may have thought that this was a thing of the past. Pocket's Story of 2006, illustrates how far away that is. I implore people like you, to actively support and advocate legislation to "raise the bar". Massachusetts has such a proposal currently, to allow for non-economic damages for abuse and malpractice. We need to 're-classify' that a pet is no longer a toaster.

Lis: As to your question on how I feel about my vet industry posters? They are entitled to their hard-earned opinions, just as you are. Am I dismayed at the polarization displayed here? Yes. Do I begrudge them their frustration? Not at all. I absolutely understand where they're coming from.

But if pressed, I'll agree that it's sad to see pet owners treated as the enemy--especially pet owners who demand more for their pets.

Anyone wanting the best for their pets deserves to be treated to the kind of information you consider basic. They deserve to know what they're getting for their money and what practices their practitioner of choice deems basic. They deserve to know what their practitioner thinks can be omitted from this list.

Is it realistic to expect a vet to run down a list of "what we do versus what they do"? I don't think so. Most vets practice comfortably at a level they've determined works for them and their clients. Unless they're directly asked to provide this info most won't go out of their way to do so.

But should they always be willing to discuss these issues? Absolutely. Honestly, I don't think anybody here would disagree with that, much though some comments have led you to think otherwise.

Meghan, the difficulty with all that you say about your communication with clients and education efforts, is that you have explicitly expressed support for all that "Anonymous" has said--including the very direct condescension, contempt, and hostility to the veterinary clients.

In particular reread the story of the cat whose owner thought he had hypothyroidism, and what Anonymous did about that. The CORRECT thing to do about that was to run a thyroid test--not because it was likely that the cat really had hypothyroidism, or to run up the bill, but because hypERthyroidism is quite common in cats, and a concerned owner with some basic internet research skills, but no medical background, could easily make that mistake while being basically right thaqt it was the thyroid.

Plus, hyperthyroidism is really common in cats, and something that's worth checking for in a very skinny, geriatric cat.

Simply assuming that the client was dumber than rocks and not worthy of having an opinion or being taken seriously, was not the correct course of action.

Knowingly prescribing what was almost certainly the wrong treatment, was not the correct course of action. In fact, in human medicine, it would be called malpractice.

But vets are largely safe from that, because pets are "just property."

So we owners are the only protection they have. And "Anonymous" has repeatedly and vigorously rejected the idea that the client has the right to ask questions and be informed, and make the medical decisions for their pets. Any suggestion that this is the case, is reinterpreted as a demand to decide what sutures to do and the the vet check with the client if a different choice seesm advisable when doing the surgery. And you keep explicitly and without qualification endorsing _everything_ that "Anonymous" says.

I learned thirty years ago not to blindly trust the vet's judgment just because they're the vet. My first dog's last day of life (at least) was painful and scary because we had not over the preceding months questioned the vet's repeated assurances that she just had "recurring bladder infections" and demanded x-rays. On her horrible last day, when she was bleeding and couldn't stand, my mother put her foot down and insisted on the "unnecessary" x-rays, and the huge tumor in her bladder was discovered.

"Anonymous" wants blind trust in his/her/its judgment just because of that vet school degree? (Yeah, couple times has said he/she/it isn't asking for "blind" obedience, but has also made it clear that any serious questioning is disrespectful of the vet's education and status.) No, sorry, ain't gonna happen. And you keep endorsing EVERYTHING Anonymous says--so, no, sorry, you don't touch my animals, not if I know who you are.

I'm not ever going to forget, or forgive, what happened to Sunday, who trusted us to do what was right for her. Trust has to be earned; it's not something that a fancy degree entitles you to as a matter of right. And the primary message of this discussion has been that, even the things I thought we could rely on--maybe not. Maybe not. Not if the vet has already decided that I'm not willing to pay for correct care, and that I'm too stupid to understand an explanation of _why_ it is correct.

Lis

It is unfortunate that you would never knowingly allow me to touch your pet, I assure you, I am VERY good at what I do. After 6 years working in a state-of-the-art hospital with VERY high standards I have great technical skills and a very comprehensive understanding of veterinary medicine. I pride myself on my ability to communicate well with my clients and I work hard to get them all of the information they need (in laymans terms) in order to choose treatment options for their pets. I think, that if you met me and visited my clinic, you would change your mind. I think we would definately meet your needs.

I have re-read Bostons posts and, I still agree with her. The both of us do not advocate substandard care for our patients, we are just acknowledging that bare-bones, low-cost care does have a place in veterinary medicine. It is usually only reserved for those animals that would not otherwise receive care. Animals don't receive care for one of three reasons:
1 They don't have owners to provide for them.
2 Their owners are too poor to provide for them.
3 Their owners don't value them enought to provide standard (read: more expensive) care.

And, as Boston points out, animals that receive substandard care, often recover and live normal healthy lives. IME anaesthetic emergencies are rare and totally random when dealing with young healthy dogs and cats. You CERTAINLY have a better chance of avoiding and treating these events if you have appropriate monitoring, an IV and an endotracheal tube in place. It is just a fact that some people, DESPITE my attempts at education, will choose not to do these things. As Boston mentioned, if a client is concerned and wants the safer anaesthetic, the vet should (and most would) default to the higher standard of care. Of course the client must also be willing to pay more for the "extra" measures.

In the practice I am currently at, we don't give clients an option to reduce the standard of care. They must adhere to our minimal standards of IV catheter, monitoring, ET tube... even for cat neuters! So, clients that want to pay less go to another clinic. Im my area that works for us. In other areas, where there isn't as much disposible income (and i have also worked in this type of area), our clinic would likely go out of business.

Dr. Khuly, I promise I'm not posting again to annoy you. I don't think most of us mis-interpreted the original blog, but went astray on the "implications" of what we as pet owners don't know. And surely, there may be clinics operating on a shoe-string (with clients with the same limited resources)that may have to forgoe the "extras". I wondered about those $15 s/n back then (all went nicely), but envisioned long "bingo hall tables" with lots of "volunteers with needle and thread".

To liken this to another procedure, I wondered when going to my present clinic, how the dentals could be 3x price, in less than a year. I got my answer, inadvertently, and it is because techs do not perform the dentals---well, that explains it and more than justifies and satisfies me! (I just didn't know- and why would I ask?)

Shannon, I don't have this attitude towards my vets. Or towards most vets. Until this discussion, I thought that vets who thought that pet owners didn't have a right to be informed of the available options and make medical decisions for their pets were not only bad vets, but exceptions to the general rule. I am reacting with alarm and anger and some degree of grief to the indications here that that may not be true.

Dr. Khuly, you have not answered my question, about whether you find the attitudes expressed in this discussion by vets and vet techs about veterinary clients, at all disturbing. This is actually an important question to me. "Anonymous in Boston" and "Meghan RAHT" are not people I would ever knowingly allow to touch my pets, BECAUSE MY PETS ARE IMPORTANT TO ME.

Lis: With all due respect, I stated clearly in the original post and in a follow-up comment that the instrument re-use is a practice employed in stray animal medicine. I really don't understand how those comments got so misconstrued.

I think the temp on this issue needs to be dropped a degree or two. Ultimately, we all want what's best for the animals. The problem is that what's *best* for the individual animal is not always what's *best* for the pet owner or for the population.

I'm sure I could have steered this discussion a whole lot better had I redirected it to reflect this point, which I find to be one of veterinary medicine's most important issues: It's frustrating for the vets (as you've seen here), it's frustrating for those who want great medicine for their pets (as you've clearly illustrated) and it's frustrating for those who want a humane end to the animal overpopulation problem (which we could have discussed more of, I refer you to the PetConnection thread for more insight on this).

I defer to the kind comments of your "rusty" vets that failed to inform you of options and treatment for probably the most "common" diagnosis of renal failure (in both cats & dogs) . From my standpoint, "I cynically" presume that they may have presumed that you'll just "get a replacement". - Barb

*****She was rusty. The majority of the people in my area are not willing to pay for treatment of chronic medical problems. She probably did assume I would just replace him since that is what 95% of the local population would do. What I’m saying is she is still not a bad person or even a bad vet. She has just worked in this environment too long to remember that some people are willing to go the extra mile. Once she realized I was planning on giving this pup decent care, she did help to the best of her ability. But remembering what you were taught 5-10 years ago when you haven’t been given the opportunity to use that knowledge is quite difficult. Also medical treatments change quite a bit in just a few years. So she politely listened while I explained the option I had recently read about. She took the time to read the information I brought in with me. She thought about it and gave me her professional opinion which I needed. I’m intelligent and able to understand the info myself, but I was also overwrought about my sick baby and needed an unbiased point of view to help with decisions. She also showed compassion towards him. When he needed to stay at the vet for a few hours, I knew they would go the extra mile to get him to eat some lunch. I knew they would get aggravated when replacing his IV line after he chewed through it for the fifth time but I know they still stopped to pet him each time (he was sick but still a puppy and did what puppies do).

I would still offer that no matter what "name" I use, my opinion is just as valid as your opinion. Also, a differing opinion does not constitute inflammatory. - Anon

Now, see, Anonymous, this shows a failure to grasp the basics of human interaction. An actual name, even if we have no reason to believe it's real, acknowledges the normal standards of human interaction. Even an obvious "handle," like "2CatMom," is a _name_, and used consistently provides an identity. "Anonymous" is just thumbing your nose at people. – Lis

*****I agree with Lis here. Custom dictates some sort of identifier to direct my correspondence to, even if it’s not your true identity. I don’t like addressing my response to “anonymous” but perhaps that is just personal preference. I would feel cowardly having a disagreement and signing my statements that way. That is your choice so I will not mention it again. However, some of your statements were inflammatory including the cat/thyroid story and suggesting that lay persons not in the medical field shouldn’t feel comfortable discussing treatment options with their vet. Those were the statements that prompted me to write my second response.

Lis:
The vet's education is invaluable, but if they've actually mastered the material, internalized it, and mastered the use of English as a tool of communication, they ought to be able to, in most cases, convey an adequate understanding of the problem, the recommended treatment, and the potential risks and alternatives. And the more serious things are, the more important it is to do so.

any vet or vet tech like "Anonymous," who DEMANDS blind trust, should be drop-kicked six ways from Sunday, and then dumped, gagged and blindfolded, in a hospital emergency room, to experience without explanation whatever care, or, um, "care" the ER team chooses to practice that day. - Lis

*****The first statement was beautifully said. The second statement just ruins your credibility. You should probably stop and think about what you write at times. Sometimes you seem very rational and I would gladly accept your advice, but allowing yourself to stoop to the second statement, makes me think twice about admitting I agree with you on any topic. Part of healthy discussion is disagreement. Have to learn to handle those situations maturely. It shows integrity.

Are you at all disturbed by the attitudes towards veterinary clients expressed by vets and vet techs in this thread? – Lis

*****Are you disturbed by the attitude toward vets expressed in this thread?

There’s a balance between cost and standard of care. It exists. It may not be fair but there is the practical side that a clinic is a business and you cannot pay the rent with altruism. - Anon

people assume that they have to micro-manage every aspect of their pet's care because if they don't, their greedy or ignorant vet will cut corners and endanger their pet. - Anon

*****I completely understand and agree with your first statement. I’m glad I have the option of low cost neuters for the stray that wanders up but also want the option of spays with all the bells and whistles for my personal pet. I am one of the people in the second statement. I wish I didn’t have to be. I hope to one day live in an area where my vet has more than one customer willing to pay for premium care so I don’t have to constantly remind them that I want a list of treatment options even if they are outrageously expensive because my pet is not replaceable. However, even when that dreams come true, I will still ask questions and be a part of the decision making team. Luckily my vet doesn’t view me as a “problem customer” despite my questions. It’s important to keep in mind the cause of the behavior that is annoying you. Puppies don’t chew shoes/pee on the carpet to be bad dogs and irritate their owners. Likewise, many clients are not asking questions to waste your time and prove your incompetence so they don’t have to pay the bill – they are showing concern for their pet. Good trainers set puppies up for success. Good vets can easily set their customers up for success as well. To save yourself time, print out a sheet that explains things in very basic terms. Different sheets for different procedures then keep a file folder of them at the front desk. Let the client read it while they wait for your visit. Then discuss the contents together. If you can tell this client doesn’t care, gloss over it and get to business. If you can tell they are confused, then stop for a second and see if you can clarify. Do this five times and you’ll get faster.

Vets see a wide variety of clients and it is wrong to generalize. you have to treat everyone as an individual. I welcome clients like Stefani because I can usually justifly rationally what I do, or adjust to fit most clients desires, as long as it is within ethics.
It can be hard sometimes not to be cynical when you deal with clients like the one I had on Friday: Walks in, no appointment, dog is acting funny, physical exam normal, given estimate for lab/xrays, declines, at check has "no money, no checks, no credit card", client walks out. when my assistant followed him out ot get him to sign an IOU for the exam, he finds him in the next door package store buying beer. When one gets dumped on like this on a regular basis, you can easily punish Peter because you are mad at Paul. I don't do or condone it, but I understand.

Dr. Khuly, that is reassuring to read.

Do you understand how someone reading this comment thread could have gotten a different impression?

Are you at all disturbed by the attitudes towards veterinary clients expressed by vets and vet techs in this thread?

Lis: I didn't say that any practice I know of is treating paying clients with single spay packs for multiple pets. This is, however, a practice I've seen employed in some low-cost spay/neuter facilities (but thankfully I've never been forced to take part in this practice). For the record, Miami-Dade county shelters *do not* spay this way. And yes, in answer to the questioner above, it IS a disgusting practice which does have a way of spreading diseases like FeLV and FIV, among others.

Dorene: Absolutely, it must be viewed in context. It's a "practice builder." As such, clients are encouraged to spay and neuter their pets, learn to trust in their vet and not have to spend as much to do so while still competing nicely with the lower-cost spay and neuter providers out there. I think this is the situation you're alluding to. (Correct me if I'm wrong.)

It does, however, take a lot of time and effort to provide a good spay or neuter. Any procedure done on auto-pilot, as it were, is a bad idea. And I happen to be one of those providers who likes to be up front about what good pet healthcare should cost. I think that performing discounted spays and neuters sometimes does a disservice to the profession and to the owners who need to *get it* right up front that pet medicine is expensive when done right and that they need to decide *right there and then* that this is the kind of place they'd like handling their pet's healthcare.

In this light, I think my tack is not so much a business decision but one that gets down to my philosophy of practice and what kind of clients I want to serve.

Dr. K --

I'm posting this quesiton here from my comment on Pet Connection because I was a little surprised that with your MBA, I sort of thought you would put spay/neuter in business context and you instead seemed to be impliying that the procedue has to "pay for itself" as a standalone, rather than part of a larger context. i'm very interested in hearing your view as spay/neuter in the context of business flow and "marketing"

Is anyone looking at business flow in the vet profession from spay/neuter? Since this is one of the first services the owner of a new pet requires, is it worthwhile to consider spay/neuter (especially neuter because it just doesn’t take that much time and effort) a “loss leader” or “marketing expense” to establish a relationship with new clients?

After all, most spay/neuterings are done on young animals — one would think that if the relationship was good after this surgery, a client would be impressed enough to continue patronizing that vet — and a good start to a relationship that has a very good chance of continuing for 15 years should mean a resonable profit for the vet.

FWIW Anonymous, I find your posts to be a very well balanced, realistic, portrayal of veterinary medicine and I enjoy reading them. Your sentiments closely reflect my own, though I can't seem to put them quite as eloquently. Afterall, I'm one of those veterinary employees with a terrible grasp of the english language. Really, I'm barely literate. Thanks so much for verbalizing what I cannot.
Just thought you and Dr. K needed a little support out there...
Cheers!
PS: I like your online handle and really don't see how it is any more or less anonymous than anyone elses.

Pleez, don't jump all over this comment: because IT varies widely from area to area---but some of these shelters & humane societies are very well-funded with big$$$$. (and yes, MANY are dirt-poor). I can only hope that the "preferred standard of care" is utilized when the means is available. After all, some of these big, fancy buildings are in need of "importing pets" either from within the US or outside the country, just to keep them going.

And how about a maximum quota/based on instrument # of packs, etc.---after all, it isn't an emergency based issue.

I agree with Lis and Gina of course.

Anonymous, while "we" here may be a special kind of pet owner, most I believe can understand the options they are given IF you do your best to explain things accurately but in laymans terms. I believe all medical professionals who are going to interract with clients in a decision making process should have this ability.

I DO value a vets education, and experience. I KNOW I don't know everything a vet knows. There is one narrow area that I do believe I know a lot about, more than many vets (the use of insulin and diet to regulate feline diabetics in the home environment), but I don't believe that this narrow area of knowledge gained first hand and through research means my knowledge of any other veterinary topic rivals that of a trained vet.

As for the value I place on the vets education -- that is precisely why I have a reasonable expectation that things will be fully explained to me in such a way that I can make educated choices for my pet. After explaining all the possibilities, treatment options, and their risks, I welcome the vet's opinion on what he or she would do it if were his or her pet. I may in fact solicit that opinion if it is not otherwise given.

However, I believe that every vet should objectively explain everything to me to the best of his or her ability, honestly without ulterior motive (like a financial interest), and then allow me to make a decision which may or may not agree with his or her advice, and support me in that decision.

My choice.

When it comes to spay/neuter, if a discounted spay/neuter is going to also mean a lower level of care, I want a vet to disclose that.

I am often shocked at the level of disdain for clients expressed here and elsewhere. I went to a local animal hospital recently and the vet had cartoons on the exam room wall that portrayed clients in a very unfavorable light.

I think in spite of the fact that those in the veterinary industry deal with frustrating situations daily, you should not start assuming that every client who walks in the door is too stupid to understand when things are explained to them. They have a right t make an informed choice.

"And let's stop harping on the one pack of instruments for more than one patient. I know it's absolutely shocking--I agree--but it was brought up as part of the main point of my question (the one I posed fifty-plus comments ago), which is that paying clients and non-paying strays are two different animals (unfortunately) and that fewer strays will get services if all services require that we meet even these basic guidelines."

And what happens when the first of several cats you do with one instrument pack has FIV or FeLV? When the first dog you do with the instrument pack has parvo or distemper that's not yet symptomatic?

I can buy that some of these other things are "extras" in the context of barebones shelter speuters--but not sterile instruments. It harms everyone if deadly diseases are spread through the stray and/or adoptable population that way.

And you and others are saying that it's NOT just the strays and shelter animals; it may be the loved pets of private clients who are not getting sterile instruments. And that this is the client's fault, for not being willing to pay--even though the client isn't even being told. For one of MY pets, if it absolutely came to an either/or choice, sterile instruments during surgery, or post-op pain meds, can only have one not both--I'd pick the sterile instruments. Because there ARE other ways to manage pain, even though they're less effective, but that infection might kill her.

So, no, I'm not going to forget about that one pack of instruments used on several patients--certainly not the next time a pet of mine has to have surgery.

I don't have much to add on the spay/neuter front, but I do about patient advocacy...

I'll never forget these words from a physician who works with cystic fibrosis patients: "As doctors, our role is to first be a listener, second to be a teacher, and only last to be a healer. As patients, it is not only our right but our duty to ask questions of our doctors, because if we have no questions, we aren't truly involved in our own care."

That's the spirit with which I wish to practice someday.

Lis: I think this information goes to the heart of what I'm saying (and what Hobson was saying as well): Spays done right are usually a discounted service. You got a fair price for all that stuff. That's about what I would charge, too (for a small dog or cat). Your vet is smart--extra-smart, in fact. Showing people how much they're saving is important for two reasons--it makes people understand that you care while also accepting the reality that IF you priced your service at a fair rate you would lose a lot of clients.

And let's stop harping on the one pack of instruments for more than one patient. I know it's absolutely shocking--I agree--but it was brought up as part of the main point of my question (the one I posed fifty-plus comments ago), which is that paying clients and non-paying strays are two different animals (unfortunately) and that fewer strays will get services if all services require that we meet even these basic guidelines.

Just for the pure, bloody-minded heck of it, I dug out the invoice from Addy's spay last year.

The pre-op lab work is not here, because that's charged separately, but it was done. Here's what's on the invoice:

Preanesthetic examination
Preanesthetic sedation/Antipain injection
IV Catheterization and Fluid Therapy
Anesthetic induction and intubation
Anesthetic maintenance (Sevoflurane/Oxygen)
Anesthetic monitoring
Surgical procedure
Operating Room and Surgical Supplies
Hospital Care

5 Rimadyl 25 mg
2 Biomedical Disposal

Total charge was $286.00, after a discount of $126.00 was applied. (Because it was a spay. They encourage spays, and they actually include the information that they're not charging full freight. I assume they're not actually losing money on the deal, but I assume that the discount means they're not making any, either, or not much. My fifteen-year-old cat's dental last month was significantly more expensive, presumably because they do charge full freight for dentals.)

This was an ovariohysterectomy on a dog over the age of one year. The invoice, in addtion to the charges listed, includes the same information I received both verbally and on a separate sheet, explaining the procedure and the drugs dispensed, and proper post-surgical home care.

It seems to me that this includes explicitly a number of the things that we're being told are just too expensive for an ordinary veterinary practice to do, that require going to a major veterinary tertiary care facility and paying a minimum of $1250.00. And I have to tell you that, if I discovered they DIDN'T use sterile instruments, I would feel deeply aggrieved that they didn't just charge me an extra $50 and get that pack of sterile instruments. But, perhaps foolishly, it seems to me that to the extent that "sterile instruments" is apparently not a given for surgery, it's covered under "surgical supplies."

Perhaps someone can explain to me how it is that the practice appears to be thriving, rather than having closed its doors several years back.

>At what point does 4 years of vet school have any value when up against a client's beliefs?

What on earth gave you the idea that four years of veterinary school gives you the right to make decisions for your client, instead of using that education and expertise as it should be used, to explain the range of options so that the person who makes decisions for your patient is operating from a point of informed consent?

It's not the client's "beliefs" you should be concerning yourself with, doctor. You should be behaving in a professional manner to help that person make a decision for the animal in their care based on information that includes your expertise.

"Let's assume my mother named me Anonymous. Of course anyone could write any name in the little box, but I digress. I would still offer that no matter what "name" I use, my opinion is just as valid as your opinion. Also, a differing opinion does not constitute inflammatory. If I advocated injecting every cat in America with Metacam, that would be inflammatory."

Now, see, Anonymous, this shows a failure to grasp the basics of human interaction. An actual name, even if we have no reason to believe it's real, acknowledges the normal standards of human interaction. Even an obvious "handle," like "2CatMom," is a _name_, and used consistently provides an identity. "Anonymous" is just thumbing your nose at people.

And you didn't just express a "different opinion." You expressed the opinion that any expressed desire to be INFORMED and be able to make the major cost/risk/benefit decisions regarding our pets, constitutes complete contempt for veterinary education and is a demand to micromanaged decisions made in surgery.

And you're continuing to do that in this post even while you disclaim it.

Or else you just can't recognize the distinction when you see it, because you think that sterile instruments are an optional extra that only fuddy-duddies and ignorant old ladies would insist on.

"The problem I have is when one person's unspoken expectations ("I would assume that any decent practice would do XYZ") are translated into "This practice is bad because they don't do XYZ." It could be true if the issue is, say, reusing needles between patients, but there's also that gigantic grey area of acceptable, but not platinum-level, care. One person's absolutely required is another person's "I'm not going to pay for THAT" optional."

People don't ask for sterile instruments because that's far too basic to believe it's not just a given. No one would expect to pay "extra" for it, because it's just not imaginable that, in a private client/vet clinic relationship, CARING FOR SOMEONE'S BELOVED PET, that something as basic as sterile instruments would be omitted.

Because as YesBiscuit points out, yes, in fact, if you're usig the same pack on three cats, you're potentially infecting two healthy cats with FIV or FeLV--which will kill them. And if the two clients ever figured out what the source is, they might kill _you_

"I really am serious, do vets need to detail the type of anesthesia, the kind of suture material, the false-positive rate of their in-house bloodwork machines? "

Chinese Cresteds appear to have a relatively high rate of adverse reactions to one drug often used in anesthesia. There are other alternatives that aren't outre choices, but they are a little more expensive. And Cresteds are a relatively rare breed; many of us who have them, have vets who have never seen a Crested in the flesh before, or have seen at most one or two of them.

So vet might, in all good conscience, make a choice that they reasonably believe to be perfectly safe, but a little cheaper--and indeed believe that they are benefitting the client at zero additional risk to the pet--when in fact it has a high risk of being disastrous.

Yes, I want my vet to discuss anesthesia with me, or at least be willing to discuss it with me if I bring it up.

I want the false-positive rate on a test mentioned if there is in fact a positive result, because that's part of the process of assessing the wisdom of going forward with more tests, or treatment, or what.

"At what point does 4 years of vet school have any value when up against a client's beliefs? Obviously I am not advocating that vets forcibly treat animals against the owner's wishes, but is there any consideration that your vet just might, maybe, have a little more information on something they do frequently and routinely, than one person's experience? "

The vet's education is invaluable, but if they've actually mastered the material, internalized it, and mastered the use of English as a tool of communication, they ought to be able to, in most cases, convey an adequate understanding of the problem, the recommended treatment, and the potential risks and alternatives. And the more serious things are, the more important it is to do so.

Waving around your diploma as an excuse for not communicating, ain't going to cut it.

Lis, I haven't watched TV in so long, I FORGOT which commercial it was, thanks for reminding me!! You expressed advocation just right, illustrating the "pickle" we are in as pet-owners.

Shannon, I am thrilled to have your viewpoint, having spent a solid 5 years wrapped up in a family member's stage 111B post-diagnosis (recently deceased) and my pets' triumphs & failure. (see my name link-web site) It has been the human medical professionals (also loving pet-owners) that have been my best supporters in my state. On previous blogs, we have all hashed out how we view human/animal medical care comparisons.

I defer to the kind comments of your "rusty" vets that failed to inform you of options and treatment for probably the most "common" diagnosis of renal failure (in both cats & dogs) . From my standpoint, "I cynically" presume that they may have presumed that you'll just "get a replacement".

Fotini (hope I spelled it right): I am truly sorry for your experience and loss. I can say with all truthfullness, I know what you are feeling, my email is on my web site

I have a comment that I've tried to post twenty times now. 90% of those attempts have just vanished into the ether. Only a couple have failed the gatekeeper.

For some reaosn these repeated failures ar not making me calmer, happier, or more disposed to consider the possibility that "Anonymous" might know a hawk from a handsaw.

If you use the same spay pack on 3 cats, aren't you possibly infecting healthy cats with FIV or FeLV or something of that ilk?

I would like to apologize for the tone of my posts yesterday. I overreacted to some of the comments and statements and as always, I need to remind myself that one cannot read tone or inflection over the 'net. I also did not express myself very clearly. I have stewed over this all day and I realize that I may have seemed to make personal attacks and that was not my intent.

"It is hard to take you seriously when you are willing to say inflammatory things and not even use your first name."

Let's assume my mother named me Anonymous. Of course anyone could write any name in the little box, but I digress. I would still offer that no matter what "name" I use, my opinion is just as valid as your opinion. Also, a differing opinion does not constitute inflammatory. If I advocated injecting every cat in America with Metacam, that would be inflammatory.

So the issue I came up with as the problem here is unspoken expectations. Some clients expect their vet to offer every treatment option possible, to use only the best and most expensive options, to give every animal IV fluids even for 2 minutes of sedation, etc. For the most part these expectations can vary wildly among individuals. Vets also have unspoken expectations too, such as that most people will not pay for "extras" when given the choice, that many clients don't really care how a procedure is done, or that someone who asks a lot of questions about every minute aspect of something is going to be a problem client. As we have seen from many posters here, previous experience GREATLY colors a person's expectations. It is impossible for every vet to satisfy every client's expectations, but that does not mean that they are practicing bad medicine. It means you need to find a vet who is able to meet your expectations on the continuum of care.

I would posit that there is a bell curve of realistic/unrealistic expectations on both sides of the issue. I think it's fair to say that a few things are generally true: a high-volume low cost S/N clinic is not going to offer as many services as a general practice; that a general practice is most likely meeting or exceeding most of the guidelines put forth in the article; that a general practice will charge more for their services than a low-cost no-frills spay factory; that most vets do not hate animals or wish to bankrupt their clients; that there is a threshold where paying more for a service does not necessarily guarantee higher quality or "better" care; and that most concerned pet owners really just want the best for their pets, as do most vets.

The problem I have is when one person's unspoken expectations ("I would assume that any decent practice would do XYZ") are translated into "This practice is bad because they don't do XYZ." It could be true if the issue is, say, reusing needles between patients, but there's also that gigantic grey area of acceptable, but not platinum-level, care. One person's absolutely required is another person's "I'm not going to pay for THAT" optional.

One of the things that bothered me in this post is that people assume that they have to micro-manage every aspect of their pet's care because if they don't, their greedy or ignorant vet will cut corners and endanger their pet. I fully support asking a lot of questions about a proposed treatment (although I also support charging a lot more for the office visit to cover the extra time needed). However, I think it is terrible business practice to detail all the stuff that you DON'T do. Why would I shop at a department store if the sales associate told me I could probably get an item a lot cheaper at Marshall's? Where do you draw the line on how much detail you give? I really am serious, do vets need to detail the type of anesthesia, the kind of suture material, the false-positive rate of their in-house bloodwork machines? And if the client demands an unnecessary, yet harmless, treatment or procedure, does the vet have to do it, even if they explain why it's unnecessary, because it's the client's decision (see Stefani's eloquent post: "NO DECISION INVOLVING MY PET IS YOURS.") ? At what point does 4 years of vet school have any value when up against a client's beliefs? Obviously I am not advocating that vets forcibly treat animals against the owner's wishes, but is there any consideration that your vet just might, maybe, have a little more information on something they do frequently and routinely, than one person's experience? (The opposite is probably true for conditions or diseases that are not seen much by the vet, as an individual owner can devote much more time to researching the issue than the vet can.)

I think everyone reading this blog is already a step or two ahead of Joe AverageOwner by the mere fact that they are taking an active role in their pet's health by reading online. IMHO this skews the arguments in many cases, as while most people here seem to say that they will pay more for more extras and extra time with the vet, the general experience with the general population is exactly the opposite. I don't think your vet should be merely a tool you use to get done whatever you want with your pet, and I don't advocate blind obedience (and I did not use those words in previous posts). But I think there's a middle ground for the majority of clients and vets.

OK my last post defended vets in general, but anonymous has said a few things with which I have to disagree.

First, the vet giving thyroxine to a cat not diagnosed with hypothyroidism was WRONG. That is negligent behavior. He should have offered to let this client pay for a full thyroid panel even though his suspicions of disease were low. Then IF the numbers were off, treat appropriately. This client was probably confused and read symptoms of hyperthyroidism which IS common in cats and though they fit her animal. If this were human medical care, he could be held liable for any bad consequences.

Second, I don’t think other posters are saying they want control over every last detail, but to be reasonably informed about the choices being made and why. Informed consent is an important part of human medicine and needs to become an important part of veterinary medicine as well. If you think that makes me a control freak, fine – I’ll find a vet that is confident in their choices and willing to explain them to me. I do appreciate the experience of my vet but that doesn’t mean I need to trust them blindly. I don’t expect that out of my own patients.

If you don’t ask your doctors questions, that is your mistake. Hopefully, you will not pay for it too dearly. In life, we are our own advocates and that of our pets. Yes it can be frustrating when people find bad info on the internet and I have to explain why my recommendation is better. But I’d rather deal with that patient than the one who takes no personal responsibility for their health. They don’t ask questions, they don’t listen to explanations, they just wander blindly through life and expect me to wave a magic wand over their head once a year to heal them. Asking questions and doing your research is part of responsible pet ownership.

When my 14 week old puppy was diagnosed with renal failure, I was given a bag of Purina NF and told maybe I’d get a few extra weeks out of him with that food. I did my research. In the end, went to a homemade low phosphorus diet, subq fluids, occasional IV flushes, meds for various symptoms and bought him several months of quality life. When his phosphorus levels were high, I started him on binders (again after my own research since no suggestions from the vet). At this point, I’d seen three different vets in town and they all still thought kidney failure diet was about protein not phosphorous. When abnormal calcium levels started showing up on the labs I was requesting, I figured out the appropriate testing for diagnosis and the appropriate dose and frequency of calcitriol to treat his secondary hyperparathyroidism. I found a good vet and stuck with her even though she was not up to date in treatment of his disease but she was willing to work with me. I was not condescending to my vet. I recognized that while she had trained properly, she hadn’t used this info in years and was rusty. She was also too busy to spend hours each day researching for my animal. I shared this info as politely as I could by bringing in printed info with the important stuff highlited (so she could skim read and not miss the important stuff). She reviewed what I brought in and gave me her opinion on the matter. We made the final decisions about what to do with his treatment together. If I wasn’t his advocate, he would have died. Yes he was in the small 1%, but he still mattered.

My parents 10 year old Yorkies need their teeth cleaned. I called around local vets asking questions. I know by the estimates that they are not providing the level of care I am looking for so I’m looking for a vet that has the other services available since we are willing to pay extra for proper care. I’m having trouble finding an office that can provide everything we need under one roof (labs, x-rays, intubation, good anesthesia protocols not masking down, and monitoring equipment for the anesthesia). If I didn’t ask, they wouldn’t have said anything. I’m not blaming them for this, but I don’t think I’m going overboard by asking what they plan to do with my animal.

It is hard to take you seriously when you are willing to say inflammatory things and not even use your first name.

If Stefani goes to vet school and opens her own practice, I'll be the first one through the door !

Dave & PB

Wow, Lis, this was perfectly said:

"There's an awful lot of condescension and contempt for the client being expressed here. We're being told that our pets in surgery are not getting some things we thought were BASIC--like sterile instruments. We're being told that the reason they're not getting them is because we're not willing to pay for them--even though we've never been asked, and WE'VE never asked because we took sterile instruments for granted. And we're being told that we can't even be told about these "choices" because we wouldn't understand the explanation, and would certainly believe that the vet was trying gouge us, and so the ONLY POSSIBLE CHOICE is to leave us in ignorance, and cut corners, and blame us for being ignorant and cheap if something goes wrong."

Ditto and bravo.

Lis, thank you for your kind words, especially the part where I end up in the ER. I wonder why I stay anonymous.

I am NOT saying that you must blindly adhere to whatever your vet tells you.

I AM saying that your vet has a hell of a lot more experience than you do, and I do NOT think that the client should choose or not choose down to the last detail, every part of every medical treatment. What if the patient chooses one kind of suture and the vet decides, once inside the animal, that another kind of suture is needed? Are they allowed to make that decision? At what point is a vet allowed to actually practice medicine? I don't think the average owner needs to know exactly what percentage oxygen their pet will be breathing while under anesthesia.

I also fully believe that if someone thinks they can do the job better or as well as their vet, they should go to vet school. Get your ideas out there and shake up the establishment.

And where do you draw the line if your "client" demands an unnecessary treatment or medication? I know of a woman whose skinny 18 year old cat she was convinced was hypothyroid. She demanded thyroid medication. She asked why they were witholding medication from her and her cat, and that she had the money and she wanted the medication. The vets gave in and had her give a tiny dose of thyroxine once a week. Is this client right? It's her choice for her cat. Unfortunately cats are rarely hypothyroid. But she'd done her reading on the internet and she was convinced.

As for the original point of this thread, I like the new guidelines and think it's important for all clinics, shelters, and low-cost places to follow the rules. Are most places doing the basics now? I would believe so (but then again I'm brainwashed by the vet industry, right?). This article is a great wake-up call for all practices to evaluate the way they do things, break out of their complacency and routine, and decide whether or not they need to make changes. I also think that your places doing the low-cost stuff are going to continue to do it, since they are more driven by the need to stay afloat.

Barbara--Sorry! I didn't think you were disagreeing with me; I was just struck by the "an educated consumer is your best customer" line, because of the Sims ads, wihich I assumed were in the back of your mind because the phrasing was identical.

Dr. Khuly made a comment earlier about the tone of this discussion getting a little _personal_. By which she appeared to mean that I and others are saying mean things about vets. Part of what I said in my Ghost Post that failed to actually post SEVEN TIMES before I finally lost it altogether, is that she might want to try rereading this comment thread from the point of view of the client.

There's an awful lot of condescension and contempt for the client being expressed here. We're being told that our pets in surgery are not getting some things we thought were BASIC--like sterile instruments. We're being told that the reason they're not getting them is because we're not willing to pay for them--even though we've never been asked, and WE'VE never asked because we took sterile instruments for granted. And we're being told that we can't even be told about these "choices" because we wouldn't understand the explanation, and would certainly believe that the vet was trying gouge us, and so the ONLY POSSIBLE CHOICE is to leave us in ignorance, and cut corners, and blame us for being ignorant and cheap if something goes wrong.

"Anonymous in Boston" (gee, I wonder why?) says that if we DO ask questions, insist on answers, and insist on making those cost/benefit risk-balancing decisions ourselves, then we shouldn't even be bothering to go to the vet. That the only correct way to relate to the vet is the same way my grandmother related to Dr. W of revered (by some) memory: She told him what symptoms she had. He told her what prescription or other treatement would be done. She said, "Yes, Doctor," and did what she was told without any questions.

It doesn't work that way anymore. If "Anonymous" has ever received medical care, and has bothered to look around the doctor's office, or the hospital waiting room, it will have noticed the signs for Patients' Bill of Rights, patient advocacy, people to help "translate" medicalese if you don't understand what the doctor is telling you.

Humans have laws and standards committees and patient advocates and the ability to ask questions. Our pets have US, and that's all. Pets are property, and as far as medical rights go, pets have the same property status as a toaster--and veterinarians bitterly resist any effort to change that.

So the only protection that pets have in the vets' office is those owners that "Anonymous" thinks should just shut up and not ask any questions.

A GOOD relationship with a veterinarian, as with a human doctor, rests on trust. But it shouldn't be a blind trust, and there should never be a DEMAND for blind trust. The pervasive, unconscious, unexamined condescension and contempt expressed in this comment thread undermines that trust--and any vet or vet tech like "Anonymous," who DEMANDS blind trust, should be drop-kicked six ways from Sunday, and then dumped, gagged and blindfolded, in a hospital emergency room, to experience without explanation whatever care, or, um, "care" the ER team chooses to practice that day.

Anon ~

Wake up and smell the coffee. Our experiences are NOT rare. Why? Because there is no accountability and no meaningful deterrent. RARE is when a vet actually loses their license due to malpractice....and that is NOT a result from there being so many great vets. SO MANY folks are all-trusting of their vet...they believe whatever their vet tells them...after all, the vet would never lie to cover their ass, would they? The disciplinary rates of most all of the state regulatory agencies that govern veterinary medicine prove that those agencies are FAR from reliable in judging the REAL malpractice problem. It's really simple:

NO CONSEQUENCES=MORE MALPRACTICE (known AND unknown)

Anonymous in Boston:

Here is what I suggest: 1) Veterinarians provide a xeroxed copy of this surgery report and give it to the pet guardian. 2) An itemized list and price of everything that is offered by the vet. 3) LET THE CONSUMER decide what he/she wants for their pets.

My pet DIED three days after he was released from the diplomate surgeon. I am still waiting for the surgery and anesthesia reports that I asked in March. HE REFUSES to release them to me. . .
I never bargained costs, and most IMPORTANTLY, I TRUSTED HIM! The sad part of this story is that there was NOTHING WRONG with my pet! Two attending vets, a PHD internist, an emergency vet, and the surgeon all MISDIAGNOSED my pet. His wrong treatment (surgery) cost me more than $5,000.00. No specific risks were mentioned by the surgeon other than "There are always risks with any surgery but your pet is fairly healthy--will be OK" I was naive and stupid not to ask A LOT OF QUESTIONS, but his status (diplomate surgeon, dimeanor, fancy mouthing) never let me doubt the outcome of the surgery. I paid very dearly my trust to these vets.

"Do you honestly think that the situations that we experienced are RARE? I assure you it isn't---saddened as I am to say that."

I would say they are extremely rare. The sheer volume of surgeries that come out A-OK outweighs the small number of surgeries that go wrong. I have had the pleasure of working with 7 different vets and they all, to a one, work as hard as they can, and do everything they can, as safely and efficiently as they can, for your pet. I believe the number of adverse reactions at my clinic to surgery or anesthesia is about twice a year. It's usually a very small kitten or an older cat spay, or a pyometra surgery.

It sucks when you or your pet becomes part of that 1% minority that had a problem with surgery or medication. It's easier to find others like you because it is a life-changing event to lose a pet in such a way. There isn't as much interest in starting a website to discuss how well people liked the various drugs they gave their pets, and how much the dogs felt better. There just isn't the interest since things seem to be going swimmingly.

Anonymous,

I hire vets to provide their expertise, not substitute their judgement for mine. It is my expectation that risks and procedures will be thoroughly explained to me, and then I will make the choices. NOT that they will be made in my absence, UNLESS it is an emergency and I can't be contacted.

I do grill my vets . . . now. I have a good relationship with my vet, but she knows I am going to ask questions. Yes, down to surgical details. I tried to pay her extra to use sevo instead of iso but they stopped carrying it and I went ahead with the procedure but I told her I wanted them carefully monitored and I asked questions about it. She understands this. I confirmed that they would be on IVs. I confirmed that the tech monitoring would be licensed. I think it is good that she knows I care. I have never balked at the bill.

As for your attitude toward human doctors, I personally believe you place yourself at risk when you fail to ask questions. I work in an industry where I am exposed to knowledge about the medical error rate. Medical errors and quality of care issues abound in human medicine as well. More's the pity for you if you don't grill your doctors. I have also learned to do that with medical doctors, and I get 2nd-3rd opinions when something doesn't seem right. This habit saved me a totally unncessary surgery a few years ago, in the hands of an over-eager and fairly inexperienced doctor.

Both my father and grandmother were, in my opinion, victims of negligence. At 23 with no medical background, and a surgical resident and nurse in the room, I was the only one who apparently could see that my father had stopped breathing. Lotta good they were. I had to convince them that he was dying, which was apparent to me, but the medical professionals didn't want to slow down enough to really LOOK. Not until the monitors all started going haywire.

When my grandmother died, apparently after choking on her own vomit while recovering from pneumonia, they told my mother that someone had put a DNR on my grandmothers bed. WELL, no one in the family had put a DNR on my grandmother. An autopsy showed that she had been allowed to develop sepsis from a kidney infection likely due to not being kept clean in the nursing home, and her friend confided that they were both in abdominal pain constantly, but my grandmother was probably afraid to open her mouth.

You need to be your own advocate, when you are dealing with human medical staff. YES, studies SHOW that you need to ask them to wash their hands before they touch you if they don't do it. MRSA is rampant.

And, we feel that we need to be advocates for our pets as well, I know I do. It's nothing personal -- but neither vets nor doctors are all conscientious, nor always at top form, etc.

Anon: Perhaps Stefani & I want to remind the readers that *trust* is huge in pet medical care, and there are not the checks & balances in place that "human" care has. For one: staff is not going to tolerate blatant incompetance, repeatedly and put their neck on the chopping block. Review boards both internal & external are never ending, and finally, in a good portion of the states, the legal system works for the patient.

And if you haven't noticed, when in the position of human caretaker---there are signs & literature everywhere regarding patient "advocacy". Yes, you do need and should ask questions. I could go on for a mile, about dozens of personal examples---both good and bad.

Why would you say a comment about "seeking care"? Because both of us have experienced the lowest form of vet care, we should no longer take care of the rest of our pets? Believe me, there was a time I considered that option---wouldn't that have placed me with the same low regard that a educated professional(s) had for both my pet and myself?

Do you honestly think that the situations that we experienced are RARE? I assure you it isn't---saddened as I am to say that. (I have to be careful, that I don't offend readers by the horrid truth I experienced, and sometimes I wonder why reading about mutilated rabbits doesn't qualify as offensive---sorry-got carried away)

Stefani: 'Don't you DARE presume that "clinicians" get to decide what level of care my pet gets.
I initiate these discussions with vets so that I know, BUT THE CHOICE IS NOT THEIRS."

Number 1 question: why do you even GO to a vet at all? Given how cynical you appear about every aspect of patient care and cost containment, how can you possibly walk into their office ever again? I think you should apply to vet school now, then start your own practice with the very rules you keep pushing everyone else to follow. I'm sure it will Edenic.

I don't telll my personal doctor what she should do when I see her for a physical or for other reasons. I don't grill her about the side effects of the new drug I'm on. If I have a side effect I call back and get a different drug after reading the CVS precautions handout. If I had to have surgery I would assume that I would be in good hands and I would not waste my time grilling the entire surgery team about how clean their face masks are. It's a boundary that shouldn't be stepped over, IMHO. They do their job, you do yours. There's so much that I don't know about human medicine that I couldn't possibly presume to direct the staff around.

How can you be comfortable requesting treatment for your pet and making decisions on what you want or do not want done on the pet, when you as a lay person have not done the reading on every procedure, you have not performed numerous surgeries youself, and you yourself are not in the medical field? Do you specify the flow rate that you want going into your pet's IV? Do you watch the surgery to point out to the vet where he or she has stitched something a little crooked? At some point you have to give up control and let your vet do his job. What is your determination when you allow them to do this?

Yikes, I'm getting LOST keeping up! Lis, I agree with YOU---am not arguing one bit. My point of the educated "consumer"---is to explain (not preach or do a lengthy dissertation) of WHY certain things are beneficial. That creates an educated consumer (ok, some are hopeless)

This POST has created education FOR ME! Allows me, to be more informed and concerned.
Yes, I was charged for the whole liter & hopefully some of the OTHER patients benefited w/o charge (hey, I'm not a cheapskate)

And I don't understand where my comment got lost on the $15 dollar spays---those were FERAL cats not my PETS----we were good doobies taking the time to catch them , bring them, etc. LONG before catch & release of ferals was a "program"--it was the VETS price, not mine!

If it isn't evident by now, it should be---I don't expect anyone to work for FREE and I spend plenty of $$$ on my pets medical care. More than MOST pet-owners. But I still can't equate the comparison to HUMAN care and view everything as a "bargain"

I'll have to reread the posts for what I forgot!! Great blog Dr. Khuly!!!!

Boston, re:

"Why would you assume this? For a 5 minute neuter, IV fluids aren’t necessary, likewise for a young healthy spay. It’s a medical decision to be made by the doctor, not the client, although of course the client should discuss their concerns with the doctor and the doctor should default to “more care” whenever it could possibly be needed. "

EXCUSE ME, THIS IS WHERE YOU ARE 100% WRONG.

NO DECISION INVOLVING MY PET IS YOURS.

Remember, you and your lobby keep arguing that my pet is my PROPERTY, every time laws are proposed to change that YOU fight them.

Don't you DARE presume that "clinicians" get to decide what level of care my pet gets.

I initiate these discussions with vets so that I know, BUT THE CHOICE IS NOT THEIRS.

This is the point I was making on the metacam debate. You do NOT substitute your judgement for mine. I deserve to be informed of the protocol to be used, AND THE RISKS. The risk-benefit calculation and consequent decision is always MINE to make, NOT yours.

PET = MY PROPERTY, NOT YOURS.

Get it into your head.

As a family physician, it is my job to explain complicated things to the patient regardless of their education level. Sometimes it takes extra effort to word things so they can understand. This is a very difficult and time-consuming task even when the patient is listening and trying hard to understand (more on this later). While money isn't everything, it is a necessity in life. A vet can’t keep providing quality care if they can’t pay the rent, employee salaries, not to mention purchase new supplies (and that selfish feeding their own family stuff). If you have a single employee spend 20-30 minutes explaining things in detail so the client gives informed consent that costs time AND money both of which are often in short supply. Not to mention the training that goes into making sure that employee understands these things well enough to explain them properly. This is a worthwhile expense but some vets forego because they’ve had too many bad experiences where clients didn’t appreciate it. And yes, I believe there are many people that just don’t care. Some aren’t even listening because they are too busy thinking about the other place they were supposed to be 15 minutes ago but the “stupid vet” is running behind because the client before them needed extra time to understand the options and now they keep blabbing about nonsense to try and get me to agree to double the cost of this spay.

In my area, people won't even spend the money on a collar/tag so I can return their animal to them when it wanders off (since they don't contain them properly) much less proper veterinary care. So the vets in my area offer limited services. Some are less than ethical (vet tech in training finishing surgeries themselves because the vet wandered off and left the animal open on the table under anesthesia). However, many are caring, ethical vets but can’t afford to offer better because not enough clients are willing to pay the additional costs. My town has 250,000+ inhabitants so it’s not a tiny rural area.

Even people that truly love their animal and want the best for them balk at paying 2-3 times what so-and-so paid for the same procedure. Sometimes they think the vet is price gouging. Sometimes they just can't afford the better care and convince themselves that the cheap vet is doing things fine so they aren't denying their animal anything by being poor. Far too often, they don't care. They got this stupid animal because the kid wanted it and they need it fixed so it doesn't run away or get pregnant. Whatever the reason, they take their business elsewhere. And the vet providing the better quality of care goes out of business.

I think these standards are important because they will help vets determine where to draw the line when cutting corners. That means, in general, animals should get better quality of care. Instead of trying to convince a client the extra money is for their pet’s own good they can pull out a copy of the printed standard and say “Yes we charge X amount more than that clinic down the street but we are following the recommended minimal standards of care to ensure your pets best interests are served”. Might help them justify their costs without the client assuming they are trying to rip them off. Client #1 described above will stick with the good vet, client #2 will be more inclined to figure out a way to swing the higher price, while client #3 will end up at the chop shop down the street. Standards won’t fix the world, but are one step and a good one IMO.

Translation: "The client is too stupid to understand our explanation (we have no obligation to learn how to explain things in layman's terms, after all), so there's no point in bothering. We just have to cut corners without telling the client, and if something goes wrong, it's the stupid, cheap client who's at fault--even though the client had no clue that we were cutting corners, or that there were any other options or something else that should be done."

PerfectWorld Retranslation: We explain the to the client the basics of the procdure (Fluffy will asleep with a tube down her throat, gas breathing for her, and she'll havea an IV in her arm in case a medication is needed. Running a full bloodwork panel ($140) and using Iv fluids during sugery ($30-$60) usually will need to be done at the time of the surgery and/or dental cleaning. We explain that the bloodwork can give a baseline incase anything happens later Then we start the warnings about the dental, that the aniamal will be anesthesized for a period of time, and teeth may need to be pulled. If teeth are extracted, the bill goes up, per tooth. Often, hidden dental problems require a much longer anesthesia event and can put the animal under much longer than a usual dental, which increases our anesthetic costs. We explain that we can't always predict how the dental (or spay/neuter, or any other surgery) ,will affect their recovery. We explain that there is always a chance that a technician might drop your pet on the way to the recovery cage, which will have warmers if needed. Also, a Yeti might walk out of the storage closet, requiring the staff to flee with the post-surgical patients to substandard accommodations outdoors.

A low-cost place would have to say "you'd be better off going somewhere more expensve, even though the shelter vets are very very good at S/N;" and have a list printed up to hand out of all the services they don't offer. I'm not a business major but the whole system sounds like it means fewer patients seen in a day, and people scared of the risks. I held a 17 year old intact miniature poodle iin order to draw some blood. As we put the muzzle on him, 2 of his teeth fell out into my hand. The owner said "I'm not paying to have HIS teeth cleaned. We never did that when I was growing up." That dog lived with a garbage mouth for another year. A year he could have enjoyed with less discomfort, anesthetic risks be damned.

Next, we begin the speech oh how animals wake up from the anesthesa. Some thrash, some just wait a bit and get up, some recover etxremely slowly. Once recovered, the animal is offered some water and lounges on a towel in a cage until they're picked up.

Finally, we hand out a Patient Information Sheet about every instrument that will be used (with pictures), every medication that may be necessary that may have to be used, and the horrible side effects of spays gone wrong and what to watch for.

Now imagine having to say this to even 5 people a day. Not only will it take up all of your allotted time, you also don't know if the client understands the low-level of risk and the potential benefit that comes out of it. And most people would still choose the fewer bells and whistles approach with a young, healthy dog or cat.

lis "Translation: "The client is too stupid to understand our explanation (we have no obligation to learn how to explain things in layman's terms, after all), so there's no point in bothering. We just have to cut corners without telling the client, and if something goes wrong, it's the stupid, cheap client who's at fault--even though the client had no clue that we were cutting corners, or that there were any other options or something else that should be done."

Yes,you could interpret my statement in an emotive, "poor me, the vet thought I was stupid" manner if you choose to, as you have done above. In some cases it would be true. In others not, which is why myself and a lot of vets I know always try and explain as much as we can, and use laymans terms to do it.
The point I was making was that this takes generally much more time than a vet has available to them, and most clients don't grasp the full concept not because they are stupid, as you suggest, but because these are concepts that cannot be explained adequately in 5 minutes to the average person.

Awww man, lost my comment!

I'll re-type an abbreviated version and I apologize in advance if it posts multiple times. This is going to sound jerky, but I really don't mean it that way. Tone is hard over the internet, sometimes.

Have most of the commenters here really read the guidelines, not just skimmed? I'm beginning to think not because they are really quite broad and permissive. For example, there are no requirements for:
* gowns during surgery (they're just recommended)
* monitoring equipment (this would allow the use of manual monitoring of things like jaw tone, palpebral reflex, etc)
*pre-anesthetic bloodwork
*IV catheters
*intubation (they say to weigh the risks vs the benefits, but recommend it when possible)
*withholding food from feral cats

I'm seeing a lot of comments along the lines of "Well, nobody can live up to the ideal! It would be way too expensive to use all the bells and whistles and most expensive things and intubate everyone and change your gown every time!!" But the guidelines don't even ask for that.

It's like everyone breezed through the abstract and went "Standards - yikes! I bet they're going to be really tough!" when in reality, these are broad, minimum standards intended to make clients and the veterinary community more comfortable with spay and neuter clinics. These are NOT the fancy schmancy specialty surgeon standards being referred to in some comments.

(Let's see if this one will really post, unlike my previous post that I made seven attempts with before losing it altogether)

(Second try at beating the gatekeeper)

"My girl last week or so? Well, it states a charge of a liter of fluid, but that can't be---she would have swelled to a beach ball. (this isn't a complaint being registered)"

Barbara, I be a liter is the unit it's dispensed in, and once the unit is opened for a particular pet, no matter how much or how little of it is used, the remainder can't be used for another pet. That's not something I'd question if I saw it on the bill.

"This verifies that an "educated consumer" is your BEST consumer."

Oh, Barbara, Barbara, Barbara. Was that kind? Was that fair? Now I've got an earworm of the fruity tones of Sims mari & femme, and NO ONE outside the MA/NH broadcast region has any idea what I'm complaining about! :)

The world according to Circe:
"Like I said in my previous post, this would take too long to explain, and the average client would not understand anyhow, as detailed medical knowledge is required. (Honestly, I mean as a vet student you do 5 years of physiology, anatomy, pharmacology, etc before it all comes together!!).
The average client simply will not grasp the consequences, and by and large all the “average” client sees is cost If it cost you more, then the vet is ‘ripping you off’ as a vet down the road is doing it cheaper. Sad world."

Translation: "The client is too stupid to understand our explanation (we have no obligation to learn how to explain things in layman's terms, after all), so there's no point in bothering. We just have to cut corners without telling the client, and if something goes wrong, it's the stupid, cheap client who's at fault--even though the client had no clue that we were cutting corners, or that there were any other options or something else that should be done."

Somehow or other, my vets have managed to explain an awful lot to me over the years. But then, they don't seem to assume going in that I'm stupid, uneducated, cheap, and don't care about my pets.

Circe posted while I was writing this and she said it way better than I do below. Sorry for the bloviating :)

Circe: “Clients do not realise the true costs of medicine.” I absolutely agree with this 100%. Underline underline star star star. IMHO this is the basis of the whole tension between “unrealistic” owners and the perception of vets as money-hungry and cruel. If we compare how much our own health care actually costs, it’s pretty shockingly expensive, but most people never see the bottom line and people are generally entitled to a basic level of care regardless of ability to pay, which is subsidized by the government and the state. Vets have no such social support.

Barb: “I mentioned previously of the 4 feral cats (young) we took to a completely altruistic vet in the late '80's that spayed or neutered for a flat fee of $15, including vaccines. I don't think I'm buying into the "money" thing of shortcuts or cutting corners to "cheapen" the procedure.”

Unless you yourself work for free, I find it insulting that you equate charging enough to cover the bottom line and pay your employees to selfish behavior by vets. Perhaps your vet had his/her own personal reasons for charging so little money, but I can guarantee that those ferals did not get the fluids, bloodwork, one-on-one monitoring, intubation, inhaled anesthetic, pain meds, etc etc etc that a clinic charging more could afford, at least, not a clinic that wasn’t headed for bankruptcy. Luckily they were young and presumably healthy and the procedures went well.

Stefani: “Wow, I just assumed it was standard protocol to put a surgical patient on IV fluids at any decent practice. I just assumed that all patients were monitored for anesthetic plane and vitals at any standard practice. As cynical as I've become I'm still naiive enough to be surprised.”

Why would you assume this? For a 5 minute neuter, IV fluids aren’t necessary, likewise for a young healthy spay. It’s a medical decision to be made by the doctor, not the client, although of course the client should discuss their concerns with the doctor and the doctor should default to “more care” whenever it could possibly be needed. And the definition of “monitored for anesthestic plane and vitals” can vary greatly, from a tap of the eyes every so often, a mere pulse-ox on the tongue, to a dedicated anesthesia tech. I am curious why you consider this elevated level of care to be standard? Do you have similar views on what should be standard in human medicine as well?

“I know I am preaching to the choir, but when you say you can't afford to charge your clients the "real" cost of the spay, I have to wonder: Can pet owners afford NOT to pay for these kinds of measures?
Are they AWARE of the risks when corners are cut?
Do they understand the problem created when there is not an IV line in a patient and they get into trouble?
Not intubating?
Not monitoring or monitoring with staff that aren't adequately trained? “

I find this a completely unrealistic idea. Would you expect your human doctor to explain to you that you’d be getting more care or better care if only you had private insurance and weren’t on Medicaid, and then list all the things you won’t be getting? As far as I know, most places have a written consent form stating that all surgery carries a risk of death. As the guidelines state, vets should determine which patients are too fragile (elderly, sick) or otherwise risky to have “basic” spay/neuter surgery and should advise the pet owner about IV fluids, bloodwork, etc. If the owner declines this, they document it in the chart. Most healthy animals will do fine with surgery. It’s the percentage who don’t (and this is not always predictable) who may be better off with more of the “extras,” but in general, there’s a bell curve and most animals fall into the middle section.

There should be some basic logic to the idea that a very low cost spay/neuter will not have the “nice to have but not NEED to have” extras that a $400 spay would. Unless a clinic or shelter is subsidized by a city or donations, it’s patently impossible to stay afloat on $35 alterings, even if you do 100 a day. There is risk to all surgery and even those patients with the IVs, dedicated techs, intubations/gas, warming blankets, etc can still have exactly the same complications that the $15 low-cost spay/neuters can have. The difference is that you have more eyes actively monitoring and more preparation (IV fluids, pre-anesthetic bloodwork, etc) but for the majority of the general public their pet will not need this level of care and most people won’t pay for what they probably won’t need.

“I realize that you are saying these things don't go on at your practice, but it sounds from general commentary here like they do go on at lots of practices, and that the steps the vets take to make themselves "cost competitive" have risks associated with them that may not be known by the client.”

I volunteered at a low-cost spay/neuter clinic. I am not a licensed vet tech. The clinic relied on donations from fundraising, and most procedures were between $25 and $75. The clinic carried a very small selection of antibiotics and pain relievers (the cheaper ones), there were few intubation tubes which were used mainly for spays, and neuters were performed by lining up the unconscious cats on the exam table and going down the row and neutering. The vet changed gloves between patients but not hat or gown, and did not change gloves between cat neuters. New scalpel blades were used on each patient but the scalpel holder was used for more than one patient. Animals recovered in unheated cages (covered with a towel but not actively warmed) with periodic monitoring by the “techs”, who were busy prepping patients for surgery. Complications were very rare. These animals would not otherwise have been altered if their owners had to pay for an increased expense level of care. As it was, people complained about the prices, and many owners refused even the cheap $8 vaccines. If we had to explain each and every risk and potential complication to every customer, and what their pet won’t be getting, I believe that many people would just get overwhelmed and unjustly terrified of surgery and their pet would just go untreated and unaltered.

I now work one day a week at a “standard” vet clinic and they do most of the things mentioned in the document. They will gas down some animals if it’s deemed to be needed, and they will box down really nasty cats. Gowns, gloves, etc are all changed between patients. IV fluids are offered for older or at-risk animals and every animal gets an IV put in before surgery, and every animal is intubated. The result is that our charges are significantly higher than competing practices, and we do fewer surgeries. Is it better to not do an alter rather than do a low-cost, bare-bones one? That’s the kicker.

There’s a balance between cost and standard of care. It exists. It may not be fair but there is the practical side that a clinic is a business and you cannot pay the rent with altruism. Until we have standardized mandatory pet insurance for every animal born, you’re going to have a trade-off between cheap and fancy. It may not be right or entirely ethical but since pets are essentially considered property, it’s going to take a LOT of change in the very fundamentals of how people view their pets before people start to see the value in paying a bit more for a bit more services.

"We will charge you $100 for this spay, but no IV line, no intubation, and monitoring will be done by an assistant" -- would most of us even really know what that means? Would it raise a red flag? Probably not, UNLESS the vet ALSO told you at the same time, the increased risks associated with this.”

-
Like I said in my previous post, this would take too long to explain, and the average client would not understand anyhow, as detailed medical knowledge is required. (Honestly, I mean as a vet student you do 5 years of physiology, anatomy, pharmacology, etc before it all comes together!!).
The average client simply will not grasp the consequences, and by and large all the “average” client sees is cost If it cost you more, then the vet is ‘ripping you off’ as a vet down the road is doing it cheaper. Sad world.

I think also you have to look at consequences. If anything goes wrong in a spey, the most likely causes are anaesthesia (or reaction to it from an underlying illness eg cardiac disease), ligatures that slip and cause internal bleeding, or complications from incorrect severance of ureters. Most of these complications are overcome by careful surgery from an experienced surgeon. (bearing in mind that EVERYONE will encounter complications at some stage of their career as surgery always carries risk even when done in the most sterile surroundings by the most highly qualified people & monitored properly).
Infection is rarely (if ever?) a complication– so is a gown really necessary? Probably not IMO so long as the surgery is done within a reasonable time frame under aseptic conditions (scrub, sterilised instruments). Lack of fluids rarely (if ever?) causes immediate death, but can lead to long term kidney damage and chronic renal failure down the track from hypovolaemia during surgery. It’s really a preventative measure. IMO intubation is non-negotiable although I have heard of clinics that do not intubate. I have seen vets operate with no gloves. There were no particular consequences. I have seen animals with no anaesthetic monitoring at all, and I have seen animals with only intermittent monitoring. Most young, healthy animals are going to be fine, despite some shoddy practices, so where do you draw the line?

Dr. Khuly---I LOVE this type of post!! We learn something & appreciate WHAT we learn! And thank you for your candidness, as Stefani was so astute to notice. That's the "most" of what we are afraid of : the pretty 'front office' and 'dirty back room' !(in more ways than one--)

I never questioned s/n for years, had the "cheapest" & the "pricey"--the latter being the only bad one.Finally, after being present for a C-section---I stupidly thought that a spay was done the same way, except shorter time. Noooo, it isn't & learned about the anesthesia, recovery, etc. and why intubated for teeth. Ok then, I don't think fluids were involved for my young pets.

My old, old gal? Well, she was so edemic when I picked her up, I hardly recognized her & she didn't drink water for 2 days. My girl last week or so? Well, it states a charge of a liter of fluid, but that can't be---she would have swelled to a beach ball. (this isn't a complaint being registered)

I do notice that a shot of penicillin & followup ab isn't routine, and kind of wish it was--especially if a catheter is needed.

This verifies that an "educated consumer" is your BEST consumer. You techs should hang in there, your speeches will pay off with patience!!

Lis, I'm with you!! And you are very lucky to have the recommendation that you got--it is my belief that the ultimate quality & good sense lies with the "human". A good PC vet is going to be the "first" to tell you when referral is needed and WHO to go to!!

I'd just like to add that of course each line of the treatment plan is gone over with the owner with an explanation of why we are offering it.

I work in specialty/er so we don't do spays and neuters but I have a similar experience with our "simple" surgeries, such as a laceration repair. Keep in mind I'm talking about larger lacerations that need several staples or sutures, not a minor cut that can get by with a clip and clean.

We offer pre-op blood work, full for an older pet or a pet with other issues, partial for a younger pet. We offer IV, gas anesthesia, fluids. If there is concern of a penetrating wound we offer radiographs. We offer at least one injection of IV antibiotics in addition to the oral meds going home with the owner. You get the picture...we offer everything that would be ideal for the pet in its specific situation.

Many clients balk at the cost so line by line we will try to get it down to what the owner is OK with. And the general response? "Gee doc, if you knew you could do it that cheap from the start, why did you even offer me all that extra stuff. Thief!"

Some things at my practice are non-negotiable, however. All pets do get their own laceration pac and new suture and pain meds are a must. We will always have at least a pulse ox on a pet and a tech is always watching what is going on (a tech is the best piece of monitoring equipment there is). Sterile gloves, of course, but honestly for a straightforward laceration we might not gown, cap, or mask. Longer procedures? Definitely.

Lis,

Re:
"But the rest of your comment seems to presume that all those _other_ pet owners are aware, and are only uninformed about the _risk_ of that corner-cutting.

I gave you the wrong impression -- perhaps I could have worded it more clearly. I don't presume that -- Which is why at the end of my post I commented:

"shouldn't customers be MADE AWARE of the "continuum" and the cost-risk relationship, so that when they choose spay-on-the-cheap, they know exactly what they aren't getting, and how it increases surgical risk to their pets? "

I don't assume that anyone knows what corners are being cut, even when they are paying a low amount for a spay. AND, IF they were told by the vet:

"We will charge you $100 for this spay, but no IV line, no intubation, and monitoring will be done by an assistant" -- would most of us even really know what that means? Would it raise a red flag? Probably not, UNLESS the vet ALSO told you at the same time, the increased risks associated with this.

I really appreciate your passion on this issue and in no way meant to imply that you, or any other pet owner, cares less or is cheap. What I am saying is that there is a whole bunch of communication NOT taking place. If a pet owner is not told the difference between a $100 spay and a $400 spay, they won't know. AND to top it off -- in many cases there probably isn't a difference between a $100 spay and a $400 spay, either because as in Dr. Khuly's case, they don't cut corners on this procedure at lower prices, OR because (as in Khuly's employment offer example) even when they are charging top dollar, they may be doing the bare minumim. How would you know?

Not only do we not necessarily know that our pets aren't getting intubated, IVs, and being monitored by licensed techs or vets, BUT we aren't nurses . . . We aren't vets . . . We aren't doctors. So even if we did have an inkling of those things, we wouldn't KNOW what it means clinically.

In other words, I AGREE with you.

And as Dr. Khuly's bone chilling post about her lucrative job offer at a hospital where unlicensed vets were doing the spays makes clear, EVEN WHEN you are paying top dollar for vet care, you aren't NECESSARILY getting any of these precautions anyway. Some practices charge top dollar and invest it in something other than patient care.

Is it me or has this conversation taken a personal tone? Let's not rush to tackle the messenger, OK?

"It's just an animal" is not in the vocabulary of most veterinarians and you should not assume that the bare-bones, cutting-corners approach to sterilizing animals to help lend a hand to the overpopulation problem applies to how we treat your pets. Nor does neutering my neighborhood stray cats on a kitchen table (as I've occasionally done) presume that I'm treating them with disrespect.

That said, it's true that some of us DO cut corners on some things--relative to the *ideal*, that is. But don't misconstrue that to assume I'm saying that your veterinarian is scamming you. We all make choices in our healthcare providers based on *trust* and I my goal is not to prove that trust is undeserved.

Most decisions have risk benefit ratio. The risk of not intubating, not using sterile gloves, no IV lines is much higher than foregoing a gown (Unless you are puting your elbows, shoulders or chest into the surgical field). Going from a neuter to a spay with the same pack is worse that going from a spay to another spay, if either were acceptable under any circumstance. With feral cats you are by necessity foregoing a preop exam and lab work, client expectations are usually lower for these animals than with an owned pet. Clients are going to have to learn that you usually get what you pay for. These guidelines when applied to shelter pets or feral pets are not realistic in a private practice setting. For a routine spay on a young healthy appearing pet, how much does the rate of complications go up with the omission of a gown? Intubation? IV fluids? Preop Lab work? Preop exam? Pain meds? Electronic monitoring? I have a colleague spaying pet cats for $35 in the neighboring town, how does he do it?

"Lis: The trouble is that basic surgical standards are hard to assess--hence the importance of this set of guidelines. Nonetheless, it remains to be seen whether these guidelines will be accepted by the profession as a minimum standard of care for spays and neuters (that's how I interpret them but that's not necessarily how things will play out in real life)."

If it's hard for the profession to assess, how can it be the fault of the clients if they don't know what to ask for and what it costs?

"Do I believe that the profession is *mostly* adhering to these guidelines? Yes. But it's going to vary by region. Ultimately, our clients' expectations for better care will drive the profession to adopt better standards but it's going to be a sticky process, and some areas will always lag behind."

Do you think yours may be one of the areas that's lagging behind? Because I have to say, I don't know anyone who takes the "it's just an animal" approach to the medical care they want for their cat or dog.

"As to *expecting* that you're getting *the best* care at your local hospital: forget it. If you want *the best* spay you should be willing to pay a board-certified surgeon at a specialty hospital for ALL the bells and whistles available--including *the best* set of hands money can buy. Will you pay $1250 in Miami? $2500 in New York City?"

Probably not intentionally, but that's a cute bit of rhetorical trickery, there. I didn't say "the best;" I said "high standards"--but if I point that out, am I placing myself in the category of people who won't pay for good care for their pets because they're too cheap?

For some things, you go to your doctor's office or your community hospital. For other things, you go to Mass. General. No, I'm not using Angel Memorial or Tufts Veterinary for my pets' regular vet care, and I am not under the impression that my vets are _same_ as those distinguished institutions--but I do believe that they provide a high standard of care, and are knowledgable, caring, and secure enough to refer me if needed.

My current vets were recommended to me by my previous vets, when I moved. My previous vets were recommended to me by a bunch of attorneys who took their own pets there, several of whom did animal welfare litigation. They were unequivocal about that being the best place in the area to take your pets. The current vets were also recommended by other satisfied clients, and I did rude things like use my librarian skills to check disciplinary records.

I believe I'm justified in thinking that my pets are getting a high standard of care, from people who are responsible enough to tell me when something is beyond their skills or experience.

And I'm really having difficulty with the idea that caps, gowns, and sterile instruments are not basic for surgery, but some sort of gold-plated, diamond-studded "extra" level of service that I should know I'm not getting, or that the vet is providing only as a charity, when I pay only $300-$400 for a spay.

Sian: If you're shocked now you'll be really shocked when you start looking for work in some places. I recommend that all new graduates work a few days before making a decision to work somewhere. When I first moved to Miami eleven years ago I was impressed by the $80-$100K job I was offered (I only had two years of experience). After one afternoon in the hospital, however, I was persuaded I could NEVER work there. Among other things it was obvious that unlicensed vets were performing all the spays and neuters and miscellaneous procedures. The licensed vets were hired for their pretty faces and personability--not for their skills or their knowledge. This is definitely a rare situation but I'm convinced there are a few hospitals in every area who don't just cut corners--they lop off most of the box. (And by the way this is not considered an illegal practice--as long as vets are in the hospital and when asked they fess up to the fact that they're not performing the procedure it's totally OK.) Don't be swayed by big money--it's often too good to be true.

I'm shocked by this-and I'm a vet student (but it's early years)! The vet practice I did my work experience at before getting into vet school covered all the basics mentioned here for the rescue dogs they were neutering (including clean gowns and instruments). I, too, would have assumed that the price I paid for my rabbits to get neutered was enough to cover basic operating procedures-and I would've paid a lot more for that to be the case, despite being a poor student. I am aware that I care more for my pets than a lot of people though, and I understand the reasons for vets doing this. But next time I'm going to check, and I will offer to pay more for services I regard as essential for my pet. But I would prefer in an ideal world just to be able to trust the vets.

Lis: The trouble is that basic surgical standards are hard to assess--hence the importance of this set of guidelines. Nonetheless, it remains to be seen whether these guidelines will be accepted by the profession as a minimum standard of care for spays and neuters (that's how I interpret them but that's not necessarily how things will play out in real life).

Do I believe that the profession is *mostly* adhering to these guidelines? Yes. But it's going to vary by region. Ultimately, our clients' expectations for better care will drive the profession to adopt better standards but it's going to be a sticky process, and some areas will always lag behind.

As to *expecting* that you're getting *the best* care at your local hospital: forget it. If you want *the best* spay you should be willing to pay a board-certified surgeon at a specialty hospital for ALL the bells and whistles available--including *the best* set of hands money can buy. Will you pay $1250 in Miami? $2500 in New York City?

Lis

From a Vet hospital employee standpoint, I don't ASSUME anyone is only willing to pay a certain price. All I KNOW is that MOST of the people walking through our doors ASSUME that our higher prices mean that we are gouging them.

They refuse to believe that the guy-down-the-street vet is doing anything differently that we are. And maybe he isn't, but it would be pretty hard for him to make a living if he is charging 1/2 as much for the exact same procedure. He must be cutting corners somewhere- by paying his staff less, by using old equipment, by hiring untrained staff, who knows? He certainly isn't shy about advertising his lower prices but I'm he doesn't advertise how he saves people so much money!

Some clients, perhaps pet owners like yourself, appreciate the time I take to explain why we charge the way we do and the safetly measures we include in our higher prices. Many people just stare at me like I am a used car salesman and I'm lying through my teeth. It is the second kind of client that we feel aggrieved by. It doesn't make you feel very good when you leave a conversation with a client doubting your right to get paid for your services.

Stefani

What you may have just realized, is that you are a minority client. MANY of our clients care only about cost without regard for the safety of the pet. To them it is just a cat, a family pet that can be replaced if it doesn't survive surgery. Just the other day we had a cat in for neuter that had a heart murmur on its pre-neuter exam. We strongly recommended a heart ultrasound but the owners declined and were perfectly happy to sign a form that said they understood their cat had a good chance of not surviving the procedure.

Some clients, a few, will relent to my clinics higher prices when they are educated about bloodwork, iv fluids, pain control, and monitoring (all are included in my clinics s/n prices). Many don't care about standard of care- they refuse to believe that there is 'more than one way to neuter a cat' so to speak.

When my clinic does free feral cat spays and neuters, we too cut corners. We still monitor vitals, and give pain control, but we change gloves without re-gowning, and we don't do pre-op bloods or iv fluids. Our instruments are cold sterilized between spays, which is not ideal for an abdominal procedure. Our free spay days are also run with volunteer staff to minimize cost to the clinic.

To give each spay a brand new autoclaved pack would be WAY too expensive. We would sometimes do 15 spays in a day. That would mean having at least 10 instrument packs. Each pack probably contains at least $300 worth of instruments (and that is if you buy bottom-of-the-line). That would mean at minimum a $3000 investment to perform low-cost (or free) surgery. Not to mention all the time to wash, re-pack and re-autoclave all those instruments.

Stefani, you asked, "Are they AWARE of the risks when corners are cut?"

I can't find anywhere that you asked, "Are they aware that corners are being cut?"

You say, "Wow, I just assumed it was standard protocol to put a surgical patient on IV fluids at any decent practiced. I just assumed that all patients were monitored for anesthetic plane and vitals at any standard practice. As cynical as I've become I'm still naiive enough to be surprised."

But the rest of your comment seems to presume that all those _other_ pet owners are aware, and are only uninformed about the _risk_ of that corner-cutting.

I have always assumed that corners are cut in shelter spays, with the emphasis after all being on volume. I have also always assumed that a vet in private practice, has procedures for doing surgery, and follows them. I try to choose good vets, on the basis of quality and not price, BECAUSE I want high standards for the care of my pets.

Dr. Khuly, I don't know what things cost you, except the few numbers you've quoted here. I don't know what things cost my vets, and can't assume that the numbers you've given are necessarily informative, given we're in not just another state but another part of the country. I assume that my vets, not being able to live on air, price their services with some regard to what things cost them, including theirown and their staff's need to be paid.

If they are charging less for a spay than it should "really" cost, I cannot appreciate that as you apparently think that I should, UNLESS I KNOW! And since I am not in their computer system studing their accounts, no, this is not magically apparent to me. If you want to feel aggrieved by the fact that I'm not a mindreader, go ahead, but it's not going to change the fact that I'm not a mindreader.

And if corners are being cut to bring the cost down, in order to charge what they ASSUME is all I'm willing to pay, and I'm not being told about it--how am I supposed know? Given that I'm not in there while they're operating? Magic again?

I'm a fairly educated person, and I've learned to be moderately assertive about asking questions. A background as a medical librarian has made me both more aware of some of the questions I should ask, and maybe more ready to understand some of the answers.

But it has never before occurred to me to ask if a good veterinary practice, with a generally high standard of care for its patients, was following basic surgical care standards when spaying my pets.

And apparently that proves that I'm stupid, selfish, and cheap.

Second attempt at trying to prove I'm not a machine.

Wow, I just assumed it was standard protocol to put a surgical patient on IV fluids at any decent practiced. I just assumed that all patients were monitored for anesthetic plane and vitals at any standard practice. As cynical as I've become I'm still naiive enough to be surprised.

I know I am preaching to the choir, but when you say you can't afford to charge your clients the "real" cost of the spay, I have to wonder: Can pet owners afford NOT to pay for these kinds of measures?

Are they AWARE of the risks when corners are cut?

Do they understand the problem created when there is not an IV line in a patient and they get into trouble?

Not intubating?

Not monitoring or monitoring with staff that aren't adequately trained?

I realize that you are saying these things don't go on at your practice, but it sounds from general commentary here like they do go on at lots of practices, and that the steps the vets take to make themselves "cost competitive" have risks associated with them that may not be known by the client.

I guess I am a weirdo. I am the kind of person who finds a kitten with a broken leg and takes out Care Credit to get her surgery at a speciality hospital, and then finds her a good home through a rescue without asking to be repaid. I did that once. Similar with a litter of kittens I rescued and everyone was seen at very "high end" places even though I had to go into debt to do it. I took responsibility for those animals, and even though it took months to pay off the debt (I have chronic vet debt syndrome), I am fine with that.

I realize not everyone has these priorities or sensibilities -- I don't put a price on my animals and many do. But shouldn't customers be MADE AWARE of the "continuum" and the cost-risk relationship, so that when they choose spay-on-the-cheap, they know exactly what they aren't getting, and how it increases surgical risk to their pets?

Because many of those very same clients who shop around for the cheapest price will nonetheless be angry if their pet dies, and something that wasn't done is implicated. That may not be fair, but it is also reality.

Lis, Barbara and Stefani: Not misplaced trust. Not negligence. Not malfeasance. Just a recognition of the reality: There's a continuum in the standard of care that is acceptable for spays and neuters. Example:

A dog spay at the specialist's place includes IV fluids, complete labwork repeated on the day of surgery. Two certified techs to prep. Two to monitor. Two more to recover the patient. Air-warming blankets. Lasers. Linea blocks. Pre-op meds including medetomidine, hydromorphone, etc., intra-op meds, post-op meds, continuous EKG. Total price? $1,250.

My dog spay? It meets the guidelines...but only just. (It costs about $300. And that's a *steal*, considering it costs me probably $200-$250 to do it.)

See what I mean? It's not that we're promising the best and not delivering. It's that we're not capable of bringing you the best at the price you can afford. Is it typically way better than at the shelter. I think so.

The attention to the patient's individual needs are still there. The care with which I monitor their progress and provide the intangibles (gentle handling, pets, hugs and sweet talk, etc.)? I think that's priceless.

btw, I believe I should be charging about $600 for a dog spay. But I can't afford to charge my clients that.

I always take a new pet to my regular vet for spaying. I do this because I know and trust that vet, and I want the best care possible for my pets--especially for what is, after all, major abdomimal surgery. During my leaner years, I was fortunate enough to have as my regular vet, someone who took Friends of Animals spay/neuter certificates, and I used them, rather than going for the even cheaper spay/neuter service at the local shelter, because I still wanted the best care I could get for them. I trusted that Dr. S. wasn't compromising the quality of the care he gave my pet, and I didn't know the vets doing the shelter speuters from Adam. Or Eve, as the case may have been.

You seem to be telling me that I was wrong to have that trust.

Second try at convincing your software I'm not a machine.

My most recent additions, my ten-year-old cat and my two-year-old dog, things weren't so lean, and Dr. S. no longer being a practical choice due to distance, I've used other excellent vets (two different practices because I moved in the interim), and went to them for the spays--as I said, I want the best possible care for my pets. And I paid, without complaint, what they told me it cost. I trusted that they were performing the surgeries with the regard for standards, including basic surgical procedures like caps, gowns, and sterile instruments, that I valued them for.

You seem to be saying that trust was misplaced, too.

Am I miisunderstanding you?

I think the topic is getting a bit confusing, mixing a "normal client/pet spay" with that of shelter/feral spays in "bulk". I don't think we are trying to compare a $35 spay to that of market price (that varies in different regions). Actually in NH, shelter s/n are reimbursed at about 80-90 dollars.

Since I have a recent itemized invoice: a tumor removal was $389 w/o dispensed meds, lab work, x-ray, or histiopathology and does not include the teeth. What 'basics' should I expect for this? As stated, everything went well w/o incidence.

And when I think of the many surgerys of my pets over the course of 30 years, ironically, the one "bad news" neuter was performed at the most "expensive" clinic over the border in Massachusetts. I mentioned previously of the 4 feral cats (young) we took to a completely altruistic vet in the late '80's that spayed or neutered for a flat fee of $15, including vaccines.

I don't think I'm buying into the "money" thing of shortcuts or cutting corners to "cheapen" the procedure.

I agree with Circe's comments - clients do not realize the true costs involved. When you can go to the local shelter and adopt a dog for $75, and that price "includes" the spay/neuter, how dare the money-grubbing vet charge $250 for a spay?! Many of our clients, even those with money to burn, balk at our spay prices.

It's kind of the double-edged sword of pushing spay/neuter all these years... people are used to hearing about free and low-cost spay/neuter clinics, so they've become accustomed to thinking that spays/neuters actually ARE low-cost procedures. It's difficult to explain otherwise, so, like Circe suggested, there is a balancing act between reaching for the gold standard, but doing so at a cost that the market is willing to bear, and without compromising patient safety.

Stefani,

there is a common assumption that vets that "care about quality" as you put it will use everything available to ensure a professional standard of operation - fluids, gowns, sterilised kit, dedicated monitor person and monitoring equipment. If every client was prepared to pay the actual cost of these services it would be great, and a perfect world, and I'm sure most vets would love to work like this. However, in reality, vet practice is driven by market forces. Clients shop around for a cheaper price. If you offer a cheaper price you must offer less optional extras to stay in business. Therefore lesser protocols are often used, eg no fluids, no fancy monitoring units, less frequent monitoring, no gown, etc. This does not mean these practices are negligent, just not the gold standard. An analogy would be the type of car people drive. Just because you drive a cheaper one doesn't mean it is too unsafe to justify the benefits of having a car.
In my experience most vet clinics would happily operate at gold standard if the client was happy to pay the $600+ or so to cover a cat spey. To me the issue is about informing the client, however it is often exceedingly both difficult and time consuming to explain the medical benefits of every part of surgery to a client with no medical knowledge. Clients do not realise the true costs of medicine.
With feral animals, I believe it is completely moral and justified to perform proceedures in a basic but effective manner, so long as pain meds are used, as the benefit of preventing future offspring far outweighs the risk to the individual animal.

Dr. Khuly,

As monitoring, anesthesia safety, and pain control are things I would value highly as a pet owner, I am glad to hear that these are non-negotiable musts in your book.

Just wondering though -- what aspects of this document do you think are too expensive for standard practices to implement? If those things are non-negotiable for any vet who cares about quality as you do, AND the other elements (such as choosing to go forward with a spay on a patient with a URI for example, because its a stray and you may never get the chance again; and wearing gowns) have little or no cost impact . . . then why do you think most practices are not in compliance or can't afford to be in compliance?

Hmmmm...how much does it cost to use a fresh gown cap and mask and instruments on each case? Add about $10-$15 and that's about right. For each cat spay you can then add the following: Blades, gloves and suture? $15-$20. Anesthetics and pain meds? $25-$35. Staff time? $15-25. Overhead? Miscellaneous costs? Maybe another $40? It costs us at least $100-plus to bring you a cat spay--and that's at a pretty bare minimum.

And how about all the strays I've neutered on my kitchen table? No gown ever made it past my front door, I assure you. And you can throw out a good bunch of the other guidelines too (most?). It may sound like these guidelines are basic and fundamental but that's not always the case in the real world...

New instruments per case? Disgusting as it sounds I once worked at one of those no-cost speuter clinics in Pennsylvania (right out of school) and the same spay pack was often used on three cats.

Hobson: Thanks for echoing my sentiments.

Guidelines are not mandates. If we lived in a perfect world we would not have to cut corners on any patient at any time. But the reality of paying bills and doing surgeries at a loss necessitate this. You cannot stay in business doing many spays and neuters for less than $100 if you followed all the guidelines word for word. I am starting to get tired of the common perception that Veterinarian's fees are the cause of the pet overpopulation problemand that the problem would go away if we just lowered our fees. I did a free spay day on a weekend a few years ago and only had 8 show up and 5 were regular clients who would have probably done it for my regular fee anyway.

How much do masks and gowns add to the cost of the surgery? How much does sterilizing instruments before the next surgery cost? How can it be reasonable to omit these things?

did i read this right? Sometimes spayings are performed with the same instrutments that were used on another surgery? and no gowns? I thought that was basic procedure . i mean gee isnt that like inviting infection?

Stefani: I know that when we have spays that are low cost, certain provisions have been omitted in the past. Namely: gowns. Also, some patients have undergone surgery despite concurrent illness (so as to take advantage of their having been trapped--who knows if we'll ever see them again). The main problem is that pain meds and monitoring are expensive and I refuse to forego these niceties on my spays, regardless of their status (paying vs non-paying).

Also: On our regular patients we do sometimes use mask induction, which the paper criticizes for the potential stress to the patients and gas exposure to the staff, even though safety to the individual animal is sometimes enhanced using this procedure. Otherwise our regular patients get all this and more (pre-op medication, extra monitoring, careful one-on-one recovery, etc.).

Sorry about the JAVMA link--it's still not working. Here's a direct one:
To view entire doc, scroll down and click on FREE Special Report after following this link:
http://avmajournals.avma.org/toc/javma/233/1

I can't help but add another 5 c. This is a perfect example on how pet medical care all boils down to TRUST. How many people grill or even know the questions this article raises? Slim to none, including myself.

When I brought my dog for 4- hour spinal surgery, we did ask about safety measures for monitoring prolonged anesthesia. When I dropped off my elderly (beyond ave. age of death for the breed) Scottie , 2 weeks ago for teeth workup & tumor removal (biopsy-malignant) , I didn't ask a single question revolving around patient safety & comfort. I placed all my TRUST in the clinic. All went extremely well, with quick non-eventful recovery.

And even if you asked the questions, how are you going to "verify" the answers ? This is where it all comes down to AVMA guideline & VPA adherence, and the utter lack and disregard among the state licensing boards to police the profession and take action on non-compliance, to protect the patient and client. Everyone suffers for this, including the consciencious group of animal medical care providers.

Tara, thanks ! I read the guidelines and am wondering what is usually missing from these routine surgerys? Some equipment used to monitor the patient(s)?
The article allowed for a lot of discretion and variations in protocol. I did note, that not 'forbidden', but highly discouraged was the use of "masking". But what I viewed as the message was: aseptic technique, comfort, stability, and safety of the patient, and identification methods to prevent error.

I am really curious as to what hads been recommended that is often not part of "normal, accepted procedure"?

Here is a link to the article online:

http://www.snapus.org/site/DocServer/javma.233.1.p...

Hope this helps!

Yes. I had some difficulty finding the article online when the link didn't work but I finally did.

I have not read it word for word yet, but skimming it, I can tell you as a consumer that we consumers ALREADY assume that these things are being done.

If they are not, then I think the vets who are not doing this have a moral responsibility to tell their clients exactly what precautions and monitoring etc. they are NOT taking and go over the risks associated with that.

In my review of State Disciplinary Decisions, I see a lot of spay deaths, most of them clearly preventable. Actually, all of them preventable -- boards don't act unless that's pretty evident.

Dr. Khuly, exactly what elements of these guidelines are onerous for regular practices, and exactly why?

What things in this document don't you do at your practice?

P.S. - your link to the article isn't working. I'm sure there's a PDF up somewhere for people to read. I know most of your readers will want to do so!

Yes. Yes we can afford to spay and neuter our shelter pets using a cap and gown and sterile instruments. And if we can't, we need to find a way to do so.

Cloth caps and gowns can be bought and sterilized again and again and again. And good instruments, though very expensive to buy, are well worth the effort of fund raising and the expense of buying them.

The part of the guidelines that covers this is pretty bare bones minimum. I'm a little disturbed that all vets *aren't* already following them. Including in shelters. I worked in a shelter and subsidized clinic for the past couple of years and we found ways to do this. Other shelters need to do so, too, if they aren't already.