When the Patient is Absent from the Visit
From time to time I will be scheduled a new appointment, and in our database, in the “comment” section below the client and patient information portion, there will be a note stating “Owner not bringing pet to appointment.”
I’m always surprised when I see this, as it seems counter to the goal of what I do for a living.
How can I provide owners with accurate information about their pet’s cancer without having examined them? How can I provide treatment options when, by law, I need to have an active client-patient relationship and can’t even prescribe an antibiotic to an animal I’ve never actually seen? How can I answer honestly if they ask me if their pet is in pain? How do I determine if an animal is a good candidate for surgery, radiation therapy, or chemotherapy?
Most of the time, owners who elect to not bring their pet to an appointment do so because they feel traveling to and from the hospital is too stressful for their animal. Having two cats of my own who do not travel well (one is guaranteed to yowl incessantly, scrape his nose along the front of the carrier until it bleeds, and urinate no matter how short the trip, while the other drools uncontrollably until she is a soaking wet mess) I understand this completely.
Yet, this past week when I saw another appointment on my schedule indicating the owners would be present but the pet would not, I jokingly said, “I would never think of going to my dentist without bringing my teeth!” So why do owners feel satisfied just listening to me talk?
The majority of time spent during a consult is dialogue between owners and myself. I begin by asking questions about their pet’s past medical history, what signs they noticed prompting a visit to their vet, how the cancer was diagnosed (if coming to see me with a diagnosis already), and going over what tests were already performed. I also spend a lot of time describing the pathology behind their pet’s diagnosis and the different treatment options, including expected side effects, prognosis, and what we look for to decide if a treatment is successful or not.
The verbal portion definitely takes up a great deal of time, but I also gather so much information from my physical examination of the patient. Sometimes I discover secondary or tertiary health problems completely unrelated to the animal’s cancer (e.g., heart murmurs, cataracts, orthopedic disease, etc.). These conditions may influence recommendations for treatment or even prompt me to recommend additional testing before moving forward with more definitive care.
As an example, this past week I was referred a dog whose primary veterinarian was worried it had leukemia. “Leukemia” is a catch-all phrase used to describe a cancer of white blood cells that usually starts in the bone marrow. The patient had a moderately high white blood cell count on several repeated blood tests.
When I examined the dog, I noted that her lymph nodes were all enlarged as well. This was not covered on her previous exams. Though dogs with leukemia can have enlarged lymph nodes, this is far more common with a different type of cancer called lymphoma. Leukemia and lymphoma can look very similar on blood tests, but can potentially have different therapeutic options and have very different prognoses.
If I had never examined this dog, I never would have felt her lymph nodes and I never would have had a suspicion that she may have a different disease process going on than what she was referred for. My diagnostic recommendations changed based on my exam findings. We ultimately diagnosed her with cancer, but a far less aggressive variant than the disease she was originally referred for.
What would have happened if her owners had not brought her along to the appointment? I likely would have just discussed the form of cancer she was referred for — telling her owners about the grave prognosis of only a few weeks with or without treatment. Would they have considered euthanizing her before she started showing significant signs of illness? Thinking about this outcome certainly prompts concern for the absence of the animal during a consultation.
I truly am flattered that people feel the time spent hearing my opinion and knowledge about veterinary cancer is so valuable. When owners come to see me, they are looking for accurate information they can use to make decisions about their pets’ care. Their primary veterinarian is often the frontline educator, and it’s fantastic when I hear owners say, “My vet told me some of the basic information, but said I should really meet with you to learn all of my options.”
We always encourage owners to bring their pets to appointments when they are apprehensive about doing so. For most cases, we are able to successfully convey the importance of the exam, that if the pet is present we can perform recommended diagnostic tests that same day, and if appropriate, get started on treatment protocols right away.
I’m sure there are some specialists out there who would decline to see appointments without the animal being present for an exam out of concern that the appointment may not be productive on their end, or because they are concerned about offering advice for a pet they’ve never seen.
For me, it’s just another part of deciding what kind of an oncologist I want to be. As is true for so many aspects of my career (and life in general), as long as we (the pet owner and myself) are all on the same page about the limitations of me not examining their pet, I would never refuse the occasional appointment without the pet present.
I want to be the kind of oncologist who always remembers the most important aspect of any appointment is the patient. For now, I am content knowing this means sometimes I never actually meet them in person.
Dr. Joanne Intile