Good vet, Bad vet; who's to decide

 

        As I have confessed to many before, I’m no epitome of Veterinary surgical practice. Very few in their right mind would nominate me as one. However, ‘pragmatic’ would be a more apt adjective for my description. Apart from the chosen profession and a smidge of knowledge regarding anatomy, incising and suturing live tissues, humanity is the common room I (and all vets) share with each one of you. It’s ironic that Veterinary practice is in-fact deeply rooted in human values, which tend to have major flaws and by its very nature is startlingly imperfect. 

        But this is the last thing anyone who entrusts their pet with us wants to know. They surely don’t want to hear the lengthy list of things we know for sure we could have done better if we went that extra mile, or if we were more willing to improve or if we didn’t get ourselves distracted.

        And they surely as hell don’t want to hear about our mistakes. Instead, our clients want to believe that (a) their veterinarian graduated at the top of their class which is statistically unlikely, (b) expect that the 30-year-old veterinarian has a minimum of 25 years of experience! (c) a vet who does it out of passion and not for money (or no money!!) and most important of all, (c) a veterinarian who never, ever makes mistakes.

        If one stops to give this a thought, (which majority clients won’t), it wouldn’t be hard to understand that the possibility of getting a veterinarian with at least one of the above credentials is scarce, if not non-existent. Unfortunately graduating at the top and say 25 years of experience doesn’t make one immune to the tendency of committing mistakes, let alone blunders.

        The Mars Climate Orbiter, built at a cost of $125 million, was a 338-kilogram robotic space probe launched by NASA on December 11, 1998 to study the Martian climate, Martian atmosphere, and surface changes. The navigation team at the Jet Propulsion Laboratory (JPL) used the metric system of millimeters and meters in its calculations, while Lockheed Martin Astronautics in Denver, Colorado, which designed and built the spacecraft, provided crucial acceleration data in the English system of inches, feet, and pounds. JPL engineers did not take into consideration that the units had been converted. In a sense, the spacecraft was lost in translation, thanks to the blunders of the human mind. Now did the minds that were involved underperform? or was it our assumption that the ‘human mind cannot err’ that let us down? Yes, the medical profession belongs to a different class in the sense that we are dealing with ‘life’ and not materialistic or monetary subjects, but it’s the same human error-prone minds that run the profession.

        This is why so many of our clients think twice before having a consultation from someone or why they don’t think twice to get a second opinion. Its human after all. But here’s the thing, with this mentality we’re turning a blind eye to the harsh reality of all allied medical professions: ‘We are imperfect’. The foundation of the entire profession is uncertainty. Missing a diagnosis or erring in treatment isn’t synonymous to being a bad vet.   

        Not every veterinarian can offer years of experience, not every surgeon will have performed the procedure they’ll perform on your loved one and ironically, regardless of their skill or years of experience, they may well make a mistake anyway. Having worked under quite a few senior veterinary surgeons myself, I’ve observed mistakes made more often than I expected them to, leading to the epiphany- Almost everything we do carries risks and there are thousands of ways things can go wrong.

        Making mistakes is instinctive. It’s the negative reactions which it gathers with age which often makes it a social stigma. All of us stumbled more than a hundred times if not more while we learned to walk or say, cycle, yet we never considered it a ‘mistake’ or more importantly never stopped trying because we fell each time we tried. I guess the education system and the ‘fixed mindset’ that played its part in negatively reinforcing us because we made ‘mistakes’, thanks to which committing mistakes are seen as a disgrace. And this mentality cripples our progress. Dr Carol Dweck’s comparative studies on the two mindsets make it clear that the growth mindset trumps the other hands down.   

        The fundamental affirmation that some diseases have only ‘treatment’ and not ‘cure’ can’t be emphasized more to unknowledgeable clients. Unfortunately, veterinarians aren’t wizards and there’s no magical potion that we formulate or a spell that we cast that rid all illnesses. Its pitiful that some clients think otherwise.

        Clients often want a medication to nullify their faulty management or practices and the onus is on the vet to provide them the same. Its equivalent to substituting a healthy diet with multivitamins and Granola bars because its more ‘convenient’. Thanks to latest fad on ‘Healthy Lifestyle’ some people do get the concept. Every time a client says, “Let me first make small changes in his diet, take him on longer walks and hold back on treats before shifting him on to an obesity diet” or “Let’s wait for a couple of days before we put him on antibiotics if that’s feasible”, an angel gets its wings. Not only do such pet parents let us practice evidence-based medicine, but they also indirectly contribute to combating worldwide issues like antibiotic resistance and bestow their pet with a healthier lifestyle on the longer run.

Unfortunately, some pet parents don’t buy it. Their ‘child’ has been up coughing all-night which is driving everyone insane and there’s surely ‘something’ I can do about it. A vet suspecting Kennel Cough has no magic up his sleeve and the cure lies with time, rest and the incredible immune system that they are blessed with. Nothing that a vet prescribes plays a major role except of course acting as sympathy and a placebo to the client. Having said that, if you disclose to your clients the bitter truth, they are most likely to end up with another vet who is ‘better’ because he at least prescribed ‘strong’ medicines. But one rarely ponders over the actual cure; was it the prescription medicines? Or was it the time, rest and the doggo’s immunity that ultimately saw it through? I often find myself wondering if they feel I only prescribe ‘good’ medicines to my ‘favorite clients’ or if they think I’m expecting a pay-off.

Then of course, there are people who are at the other end of the spectrum. Managing an atopic beagle, for instance will need you to have deep pockets. Its one of those diseases which needs a multimodal approach and not something that can be rid with say, a course of antibiotics. And a multimodal approach means multiplying costs of medicines only to manage, let alone cure the disease. Ironically, it’s the ‘doctors’ who are branded ‘expensive’ or ‘money minded’ and not the medicines or the industry. Someone who looks at her dog as her ‘only son’ shouldn’t be skeptical about the idea of having her ‘son’ vaccinated or getting routine wellness checkups regardless of the cost involved (not that it costs a fortune though).

I remember this saying one of my lecturers told in vet school and it keeps ringing in my mind. He said, “In Veterinary Medicine, you have to treat the owner first, and then the patient.” I wish someone told this to me before I took up the profession, cause if there is one animal which I hate to treat, its not the cat that scratches, nor the horse that kicks but this ‘super-smart’ bipedal creature trained by ‘Google’ and which judges us unfairly, that walks into the clinic along with our lovely patients.

The problem arises here; humans are unreliable decision makers. Their judgments are strongly influenced by irrelevant factors, such as their current mood, the time since their last meal, time since they were last complemented, and the weather as portrayed by the Noble laureate, Daniel Kahneman and others in their book ‘Noise’. The chance variability of judgements is called ‘Noise’. In other words, the different sentences given to different criminals who committed the same crime by different judges is an example of noise in the judiciary system. It wouldn’t be right to say a noise-free world is the ‘ideal.’ Diversities in taste and opinion is the reason we read ten different reviews of the same restaurant or say, the same movie. Similarly, every doctor will look at the case from a different context, hence the client ends up with multiple differentials after having multiple consultations.

The confounding fact about certain clients though is that they get multiple consultations with different veterinarians till they are mentally satisfied, and this doesn’t always correspond with the right diagnosis or the treatment. Ironically, convincing the owner is more vital than relieving the pet of pain or doing what is right for the dog. This explains why many clients get multiple consultations; their hankering for personal satisfaction is more than that for the right course of action. ‘Personal satisfaction’ ranks higher than the right treatment.   

This happens more often than one might expect. A terminally ill dog is brought to us after getting a ‘grave’ prognosis from more than one veterinarian. Euthanasia would indeed be the best course of action but that wouldn’t satisfy the client any more than what the other veterinarians were able to, and one is coaxed to prescribe ‘better’ palliative care. Amusingly, its often palliative only to the owner and makes us wince.

The development of trustworthy relationships between clients and veterinarians is important to the continued growth and success of the profession. Lack of patient trust is associated with less doctor–patient interaction, poor clinical relationships that exhibit less continuity, reduced adherence to recommendations and poor clinical outcomes. Trust is developed keeping in mind the values, ethics and standards between two parties but its unfortunate that in our profession like in many others, clients ‘choose’ vets based on factors that are not always corelated to the desired clinical outcome, like word of mouth, proximity, parking availability, google reviews and what not. I am not saying these are completely irrelevant, considering the recent boom in veterinary practices as a business, but these factors shouldn’t be the major influencers while ‘choosing’ a vet. Ultimately, most veterinary practices are businesses, and we sell our services. Although its unmerited to refer our profession as a ‘business’, its something that we are good at, passionate about and depend on for a living.

So, it boils down to individual perspectives and beliefs while branding vets as 'Good' or 'Bad'. Pre-judgement or Judgement however make our opinions highly biased and negatively affect  interpersonal relationships and treatment outcomes.