This reminds me of ABC 20/20 where they talked about having botched plastic surgeries to save money. Years ago my dog needed cruicate surgery and my vet at the time told me he was quite capable of performing the operation with no problems. I wanted an Orthopedic Specialist and I knew of one that would go to all the vets when needed and use their operating room/clinic and then leave the recovery for the vet to oversee. I felt very awkward because not only was I not going to use my own vet but now the specialist was operating using his operating room. The surgery was successful and my dog walked perfectly, played and even ran until she died at 14. I had insurance at the time and thinking back I wonder if things would have been different if I didn't.

Though I don't practice in Dr. Khuly's neighborhood, this is such a common scenario that I've encountered this even though I don't work on dogs. One of my clients asked me what I thought she should do because her small animal veterinarian presented her with almost the exact same options when her dog injured her cruciate.

I told the client that while I wasn't familiar with the skills of her small animal veterinarian or the "traveling surgeon", I'd prefer a true orthopedic surgeon if it were my dog. Cruciates can be tricky, and it's a fiddly surgery... I know, I learned how to do it, too, in veterinary school, on cadavers, which does not mean I'd ever try it on a living animal without further instruction.

The client chose a consultation with an orthopedic surgeon at her own facility. Interestingly, after examining the dog, the surgeon said surgery wasn't indicated at this time (!). Several months of restricted exercise later, the dog is actually doing fairly well.

A, B, and C and report the "surgeon" who performed the original surgery to the veterinarian licensing board. Have his license to practice medicine yanked.

The pet owner should be able to make an informed decision as to whether or not to take the negligent vet to court.

c only

I have been told that my 5 1/2 month old Rottie needs a double hip replacement and it will cost 12,000.00 just for the surgery. my vet told me there are only 2 specialists in Ottawa that can do this surgery so I started calling around and was pretty much told the same thing from different vets. I think people should do their homework to make sure. phone calls do not cost money and most vets will talk to you. I believe that some vets are money hungery just like people and will tell you anything to get your business. Everyone has a right to report negligent only if they can proof that the vet riped them off.

It's hard, but your best interests and that of the client will be best served by keeping your cool and giving a level-headed, professional response. Going off risks alienating your client and then who will be looking out for the dog?

I would recommend the client get a second opinion (she'd do it for her car, why not her dog?) and strongly suggest she try the person you originally recommended because you're very familiar with his work, you and your other clients have been happy with past experiences, and even though the surgeon might be more expensive, he/she charges a rate comparable with what other experts charge.

If you say anything negative, I'd make it very oblique (You're not the first person who's had similar experiences with this vet ...). If I was the client who went with the bargain surgery and you went off in front of me like you want to, I'd want to know why in the world you didn't tell me this before I put my dog through all of this if you feel so strongly. Humans being how they are, I'd probably find a new general practitioner to go to to cover up my embarrassment and anger.

the good of the dog, I would choose B. This person will probably come to the realization that they have been penny wise/pound foolish soon enough, and no one likes the fact that they've been had pointed out to them. They know they ignored your sensible and educated advice to save a buck and they know YOU know. I would just try to take the high road, as hard as that is.

Couldn't A and C also possibly lead you into some ugly libel/slander thing with the poorly qualified vet, if your comments ever got back to them?

I expect total honesty from my medical professionals. I want their best "guess" assessment. Also, if I need a referral, they should provide me with the best person available.

Having been through cancer, my medical professionals (including techs and nurses) have all communicated to me when they thought something was wrong.

They often do not or cannot come right out with the blunt version, but they do tell me when something or someone is off the mark.

If I don't get the subtle version, I want them to come out and "save me from myself."

I only want honorable people around me.

As a specialist I see this every day. It never ceases to be a struggle to handle it diplomatically.

What people want is VALUE, but what they ask about is COST. It's really hard to make people understand that you get more value from the board certified specialist, even though the up front cost is higher. Quicker recovery, better outcomes - how much money is that worth?

My understanding is that in the human field, there is a much more hard-nosed, accusatory attitude, with doctors accusing other doctors of negligence in a heartbeat. I'm not sure if that's true, but maybe we need a little more of that in vet med. I sure know that I rarely say anything negative, because I need the local vets to like me so they'll send cases my way. It's a huge moral dilemma. I've heard veterinary attorneys say that we NEED more lawsuits in vet med; not sure if I agree with that but it's an interesting viewpoint.

And the icing on the cake is that we have all dealt with the opposite situations before. We've all paid a lot for a service, only to realize after the fact that we could have gotten exactly the same thing for a lower price. That makes us all try to be more 'savvy' consumers, and the end-result is we often shoot ourselves in the foot.

Veterinary specialists need to do a better job of marketing who and what they are so that consumers understand the differences.

SBM

If I found out that my vet had strong opinions (good or bad) about another vet I was allowing to treat my dog, and my vet didn't share those strong opinions with me, I would become distrustful of the vet I loved in very first place and would wonder why she wouldn't have let me in on this when it could have risked my baby's life. I personally think it is a moral obligation to explain to this customer why he shouldn't take his dog back to the vet who "messed up" his dog even worse.

>>It's really hard to make people understand that you get more value from the board certified specialist>>

My favorite surgeon, who has the best colic surgery outcomes (survival, repeat surgery, laminitis, incisional infection, post-op ileus etc.) not only with my clients' horses but with my colleagues' clients horses, is not boarded. Neither is my second favorite surgeon. Two of the worst surgeons I know are boarded, as are two very recently boarded surgeons who may, eventually, become my favorites, but currently have only average outcomes and the very occasional train wreck. My third and fourth favorite surgeons are boarded. One is a sweetheart. One can be an @$$ to clients, though I rather like her. Referral is complicated.

Board certification, just like practice affiliation and years in practice, is one of many factors that can help a client determine the competence of a specialist. An idiot with a DVM who becomes board certified is still an idiot, in my experience, sad to say.

A client's best protection from a poor experience with a specialist is a good relationship with a primary care veterinarian. In this case, Dr. Khuly provided her best advice, which her client disregarded. I've been there. It's a tough place, because the client has already demonstrated that he values the advice of his friend/Dr. Google/random acquaintance more than that of his primary care veterinarian.

>>Quicker recovery, better outcomes - how much money is that worth?>>

That's what I tell clients when I recommend referral.


>>My understanding is that in the human field, there is a much more hard-nosed, accusatory attitude, with doctors accusing other doctors of negligence in a heartbeat. I'm not sure if that's true>>

According to my physician friends, it's not. Physicians are more tight-lipped than veterinarians re: their colleagues' competence.

>>I sure know that I rarely say anything negative, because I need the local vets to like me so they'll send cases my way.>>

Piece of advice: if you want the local veterinarians to "like" you, never do anything to an animal the local veterinarian could do herself. We hate that. My favorite surgeons wouldn't dream of injecting a joint, for example, without first advising the client I'm just as capable of performing that particular procedure. It's a partnership, not a competition: the specialists perform services I don't offer, and I try to refer cases before they've gone sour and the client has run through her funds.

Also, at least among equine veterinarians, we talk amongst ourselves. If a specialist has good outcomes, word gets around.

The Dr. Quack described by Dr. Khuly may not actually be breaching the standard of care, though he certainly sounds like a crappy surgeon. Unfortunately, there's no law against being below average - and just as you said, clients ask about cost, not value. Dr. Khuly's client's friend probably recommended Dr. Quack because he had a good experience. Even crappy surgeons have successes. After all, a stopped clock displays the correct time twice a day.

>>I personally think it is a moral obligation to explain to this customer why he shouldn't take his dog back to the vet who "messed up" his dog even worse.>>

Think about this again, because I disagree with you very strongly.

Dr. Khuly already made her best recommendation to this client, to see a boarded specialist, NOT Dr. Quack. The client chose to disregard Dr. Khuly's advice and follow the recommendation of an acquaintance who is not a veterinarian. Now, Dr. Khuly has to swallow her ego and tactfully, professionally, advise the client - again - to consult the boarded specialist. Keep in mind the client ignored her advice once. How will trashing Dr. Quack help this situation, given that the client's dog is still lame? We can't save all clients from their own poor decisions.

It's great that you love your primary care veterinarian. If she recommends a particular specialist, I suggest you take her advice. If you have a poor experience with the specialist she recommends, please tell her about it, because she would want to know. If you choose to see a specialist your primary care veterinarian didn't recommend, you're on your own, IMO.

We suggest B, while thinking C, and venting over cocktails with close friends later.

From the consumer's standpoint, we'll go with the Board Certified specialist in the first place thank you.

Another great post with excellent timing! Just yesterday, we posted about How to Choose a Veterinarian for Amputation Surgery in Jerry's blog, including a video interview with the head technician at the Veterinary Emergency Specialty Center, in Santa Fe, NM.

I agree with treefinder. This is all about honesty. If I ask you if my pants make my butt look big, don't lie or sugarcoat it - tell me honestly.

If I've made an unwise choice in the vet I took my pet to, and the pet is now to pay the consequences, then be up front with me.

Tell me what you would tell a family member or close friend - give me the dignity to make wise choices. If I choose not to follow your council, then shame on me. But at least you can wash your hands of it and know that you did the right thing. It's a moral obligation. How would you feel if you received a botched plastic surgery and then found out that your aquaintences knew the surgeon was a butcher? Wouldn't you appreciate their honesty up front, or at least have them tell you where to go to get your botched surgery fixed?

In essence, the client is asking you for a second opinion of her dog's current condition. As such, I think you should tell her that "There is no reasonable explanation for this new lameness." In other words, you disagree with the vet's opinion who did the surgery. The client can think make up her own mind whether she wants to continue to work with that vet.

I think there is a moral obligation to warn clients against vets you know are incompetent. This can be done carefully, but to hear that a client is relying on a vet you know to be bad and say nothing is unfair to the client and especially to the pet.

Chevygirl, what about TPO (triple pelvic osteotomy)? At five and half months, that should be a viable option (it must be done before arthritic changes start). I know a Rottie who had that surgery done on both hips at a similar age (one at a time, a few weeks apart) and is doing extremely well a couple of years later. It's not inexpensive, but it's a lot less than total hip replacement.

I realize that I repeated the "moral obligation" line that Equine DMV objected to. Let me explain.

You said, "Dr. Khuly already made her best recommendation to this client, to see a boarded specialist, NOT Dr. Quack. The client chose to disregard Dr. Khuly's advice and follow the recommendation of an acquaintance who is not a veterinarian."

As I understand it, Dr. Khuly recommended the board-certified surgeon, but was never asked about Dr. Quack. The client ignored the advice about the surgeon, but no advice was given about the quack. The client is now asking about Dr. Quack, and I believe deserves to know at the very least that Dr. Khuly does not agree with his assessment of the current situation.

tgrllyct:

>>Tell me what you would tell a family member or close friend.>>

My family members and close friends tend to respect my opinion and follow my recommendations. Clients, unfortunately, sometimes do not.

>>If I choose not to follow your council, then shame on me. But at least you can wash your hands of it and know that you did the right thing.>>

The "right thing" does not include mud-slinging. Consider: if I trash Dr. Quack and the client then confronts him, Dr. Quack may offer the client a revisionist tale of why I'm a moron and he's doing his best to help her with this "difficult, atypical case". Who should the client believe then, me or Dr. Quack? We're both veterinarians, right?

dogaware:

>>I think there is a moral obligation to warn clients against vets you know are incompetent.>>

Yes, you repeated this, and I see we're actually in agreement.

I'd tell the client I disagree with Dr. Quack's assessment and recommend a second opinion by the specialist I recommended originally.

It's impossible to "warn" clients about "incompetent" veterinarians. Every veterinarian has successes and failures. Clients, unlike most referring veterinarians, don't know who has the best success rate. Clients do know how their neighbor's dog fared. That's why it's unfortunate Dr. Khuly's client decided to take his friend's advice, not hers.

Equine DVM:

I didn't mean to sound as if mudslinging was the right thing to do. I think it's absolutely possible to get a point across to a client in a very diplomatic way, without trashing the other vet in question. With that being said, a client also has to be open to actually hearing what you have to say; as you mentioned, family and close friends will generally follow your professional advice, but clients don't necessarily do so.

I think it comes down to a "6th sense" from the veterinarian's point of view as to how to proceed with each individual client. If the client is sitting there with her arms crossed and her body language indicates she's not open to hearing your advice (even though she asked!), then proceed accordingly. But if a client is genuinely wanting to know then I think you can sense that and steer her in the right direction. But never trashing - that's just inappropriate on all levels (unless it's family and closest friends, over drinks, of course!) :)

Really, a combination of 2 and 3. But all they knew was that someone they knew had a good experience with this guy. Instead of remonstrations, maybe a quiet explanation that you are not confident that this was a new injury and that you had some suspicion that it might be a surgical complication; however, an opinion from a disinterested specialist would carry the most weight, especially if they were going to seek any recompense.

The conversation might lead them to ask you whether you had any knowledge about the vet they used, and rather than having volunteered the information, you can answer you had treated some cases which, in your opinion, were the result of his errors. Tread carefully.

The flagging system on this site is very odd. It would not let me post my comment until I cut a sentence which simply said I was sympathetic these days to cost concerns. I have no idea what it found inappropriate.

I choose B.

Not everyone is fortunate to have the money that is required to pay for expensive surgery so they have to look for the best price. Also not everyone trust that their Vet is not trying to soak them.
For those that may say you shouldn't own a pet in the first place if you can't afford it. If that was the case there would be a lot more animals waiting in shelters or being euthanized

Sent you an email on this. Looking into it, OK?

I say option B. Anything else could be construed as petty, bitter or unprofessional. Dealing with crappy counterparts suck, but you still need to come out on top :)

A doctor has to tread lightly in situations such as this. My suggestion would be a "soft B".

If the client would pay $1000 for a surgery, I would suspect that, even if money is tight, if $2100 had been the only option, they would have scraped it together.

A good client always wants the facts of the condition. You might give a percentage of chance that the extended problem was re-injury. "It could be re-injury. However, in my opinion, there's probably only a 15% chance that is the case."

Bad-mouthing another doctor could be repeated to that doctor. What kind of problems would that cause you? You gain very little and risk alienating the client as well as Dr. Quack.

Speaking as a client whose doctor (who walks on water in my eyes) doesn't hesitate to confer with or refer clients to board certified specialists, if there is anything he feels strongly about, the magic words are "If it were my cat, I would _____".

I do not envy that you were put in this position.

Instead of trashing Dr. Quack, I would suggest politely advising the client to seek a second opinion from the specialist you recommended before. I think there are ways to quietly convey that you’re not a fan without overtly maligning his skills (or lack thereof). It's more professional, and you'll avoid alienating the client (and possibly causing her to run back to Dr. Quack, if he was cordial, and she perceives that you're judging or attacking her).

The last time I boarded the boys, a member of the kennel staff spent the better part of an hour trashing one of the specialists we work with (unbeknownst to her). She had no personal experience with said specialist (who we’ve been using for years and love). Everything she had to say came from a snarky gossip session she'd had with her regular vet, who discussed at length how his staff sit around and make fun of her. It was totally unprofessional. As a client, if he’d had that sort of a talk with me, I would have left questioning his professionalism just as much as that of the vet he was knocking.

Honestly, based on what was said, I’m betting the truth is that the husband and wife team at that clinic just don’t care for the specialist on a personal level. (I think I know why, and suspect it has very little to do with her ability to do her job.) So, yeah. Not that I think that you would ever approach things in such an inappropriate manner... I just think it’s better to refrain from openly knocking Dr. Quack. If it’s a situation of genuine incompetence (and not just the fact that he’s not the greatest vet in the area) and he is regularly performing procedures he lacks the skill to pull off to the detriment of his patients, I think that is an issue better taken up with the board than the client. If he's just not the greatest vet in the area, you can do your part by continuing to avoid recommending him. If a client directly asks you about Dr. Quack, I think it's appropriate to mention (in a tactful way) that you haven't been impressed with the outcome of some of the procedures he's performed on your patients, or to suggest that your clients seem to have had better luck with Dr. Competent. But I wouldn't volunteer the fact that you don't like him.

>>If it’s a situation of genuine incompetence (and not just the fact that he’s not the greatest vet in the area) and he is regularly performing procedures he lacks the skill to pull off to the detriment of his patients, I think that is an issue better taken up with the board than the client.>>

Okay, important point: the Board of Registration in many states will NOT listen to the complaints of veterinarians regarding other veterinarians' competence. These complaints need to come from clients, who are the injured parties. If one of my clients reported a colleague to the Board of Registration, I'd certainly supply supporting medical records - and my professional opinion, if warranted.

While I understand and agree with the main point made with this entry, I don't think that cost is a good indication of quality or skill. I will also say that while board certification is a good indicator of skill, it's not fullproof. That being said, if a person wasn't a qualified surgeon, I would take pause before letting them work on my animal.

But the biggest issue is that the professionals need to police their own because board certs and such are things we consumers don't concern ourselves with. It comes down to the vet doing their job, as we are trusting you to do so, and paying you for same.

EQUINEDVM: If what you say is true, that's the most ridiculous thing I have ever heard. I could understand the board not listening to unvalidated complaints, but if there is a documented case of alleged malpractice that another doctor has identified, you are telling me there is NO way for them to report this and have it addressed? REALLY?? Please say it ain't so.

>>I could understand the board not listening to unvalidated complaints, but if there is a documented case of alleged malpractice that another doctor has identified, you are telling me there is NO way for them to report this and have it addressed?>>

Not really, unless the CLIENT complains about it, too. Think about it: medical records are confidential. The veterinarian can't complain unless the client releases the records. Furthermore, if I were to complain about another veterinarian's care, the Board contacted the client in question, and the client said "oh, I don't want to cause a fuss": what is the Board supposed to do now?


>>REALLY?? Please say it ain't so.

Sorry. In many states, YOU must initiate the complaint. YOU are the injured party, not your veterinarian.

For an excellent explanation of the difference between a poor outcome (which may or may not be malpractice, and can happen to ANY veterinarian) vs. a bad physician (also applies to veterinarians), see the book _Complications_, by Atul Gawande, a surgeon.

In one chapter, Gawande discusses in detail a poor outcome experienced by a patient he treated (suboptimally) as well as examples of poor outcomes/suboptimal care by other well-respected surgeons. Poor outcomes, and even suboptimal care, happen sporadically. Unfortunately.

In contrast, in the chapter "When Good Doctors Go Bad" Gawande discusses physicians who should not be allowed to practice for a variety of reasons (mental illness, physical illness, addiction, etc.). This is a small group of practitioners.

Now, consider Dr. Quack: Dr. Khuly suspects he is a true problem veterinarian because she's seen a number of his post-op disaster cases. She does not know, however, WHY he might be a problem: Lack of training/continuing education? Alcoholic? Chronic depression? Visually impaired? Early onset dementia?

Dr. Khuly's dilemma is that she doesn't know Dr. Quack, and thus can't intervene on a personal level. All Dr. Khuly can do is nudge her clients towards qualified specialists, and refer clients who have experienced a poor outcome AND WHO WISH TO COMPLAIN to the Board of Registration. Multiple complaints by clients are taken very seriously indeed, but the injured CLIENT must complain.

C..

If I were your client, I would like to be told the truth, in hopefully no uncertain terms.

Also presuming I trust you and value your opinion, I would like more than a recommendation to go to the specialist and a clear warning that Dr. Quack may not be the greatest doctor however you can do that professionally.

I would hope a combination of b and c.

That being said, you don't always get what you pay for.

I've dealt with hundreds of pet owners who have been downright swindled by their veterinarians.

Just recently:

A dachshund goes in for a neuter and has some baby teeth pulled at the same time. Four teeth were pulled. All canines. All were easily movable by hand - none were anchored. Total cost for the removal ONLY? $400. The neuter? $350, not including pre-surgical screening which was also overpriced.

A pit mix has a limp in her rear leg. A vet diagnoses the condition as a tear and recommends $2500 surgery by a specialist. They are assured that the dog will become lame without immediate treatment. Instead, the dog is taken to hydrotherapy three times a week for two months coupled with crate rest and anti-inflammatories. Today she is med free and injury free. The cost? $25 a treatment. Under $800 in total.


A second opinion is never a bad idea. What is a bad idea is blindly following ANY advice - pro or con. Research, research, research.

Of course I am not suggesting choosing a vet based on low cost - but the two situations mentioned here were both from the same clinic, one that is WELL known for being the most expensive in town. Both owners felt that they were getting the best care - after all, they were paying the most money, right?

I would say what I would want to hear and that is a combination of “a” and “b”. In a polite way you could say that you recommended a specialist and she went to another vet so you did what you could.
Our example is Corky, or Pembroke Welsh Corgi boy. On Monday this coming week he is going to UPENN Vet Hospital in Philadelphia to an eye specialist. Out Vet recommended a Vet Eye Clinic not far from us; however, they never replied to me. I also heard that they were not that good. I do know that UPENN is a great place and have had many recommendations to go there, as well as, having taken all of our 3 Pems there for a PENHIP study last year.
It will be more costly but we did our research. Our vet would have probably sent us there anyway as a result of not hearing from the eye vet.
The moral is: Do you research along with the vet’s recommendation and both should yield the right decision. Money is a factor but the love of our pets supersede this.

I don't agree that a botched up surgery must have to do with cost, though of course it can just as with people.

I do know that you get different quote
a) for different type of surgery for the same issue
b) for the same surgery at different places

For example, we chose extracapsular repair for our dog's ACL injury not because it was cheaper, but because it is less invasive. We combined it with stem cell therapy which added up to the same overall cost as TPLO would have.

Our surgeon is a vet who runs a small clinic and he charges almost a half of what my friend paid for identical surgery in Ottawa. Our surgeon performed large number of these surgeries with great success and his lower price has nothing to do with quality of his work that is superior.

There are however individuals who are unprofessional and unethical and should lose their license. These too offer low cost.

While substantially lower cost should pop some red flags, it does not automatically mean that the service provided will be lesser quality.

I believe that these things are not as much question of cost as the trust you might have in the surgeon and his track record.

I feel that this needs to be said.

As with anything, higher cost won't necessarily buy you a better product and vice versa.

However, individuals such as the one described above should lose their license immediately.

I agree with you Dog Mama. I have now experienced a variety of medical services and "price, quality, education, and experience" did not necessarily correlate to any particular positive or negative outcome.

As far as the State Vet Board comments: although all claim to be in place to protect the public client & patient, neither are true. The complainant does not have "legal standing" and the vet board RARELY imposes a meaningful sanction. If they do suspend a license, it is usually a "stayed suspension" or reinstated in a short period of time.

However a state board can choose to investigate anyone/anytime on their own, based on reasonable suspicion , including a tip from another Vet or employee or "entity"

If more professionals stood up to the Dr. Quacks, Dr. Incahoots, and especially the Dr. Crueltys and Dr. Dangerous' out there-- the profession would be more respected, trusted, and deserving. Sadly, those days have not arrived yet, but I'm hopeful!

>>The complainant does not have "legal standing">>

Yes, that's true. If one wishes to sue a veterinarian in a legal proceeding, complaining to the State Board is not the appropriate venue.

>>the vet board RARELY imposes a meaningful sanction

Depends upon what the offense was and whether it can be proven.

>>If they do suspend a license, it is usually a "stayed suspension" or reinstated in a short period of time.>>

Yes, because most true problem veterinarians are never reported to the State Board. Most complaints to the State Board are about basically competent veterinarians who made one bad decision or caused one bad outcome. This isn't what dissatisfied clients like to hear, but it's true.

>>However a state board can choose to investigate anyone/anytime on their own, based on reasonable suspicion , including a tip from another Vet or employee or "entity">>

Reference, please? This has not been my experience, nor the experience of one of my colleagues who sat on the State Board's disciplinary committee for a number of years.

As I mentioned earlier, most State Boards will do nothing without evidence, and evidence requires release of confidential medical records by the client. In contrast, one dissatisfied client can trigger the investigation of a competent veterinarian.

And no, I've never been summoned by the Board, though it could happen, because it can happen to anyone, at any time.