Letter To UPenn Veterinary Teaching Hospital Seeking Access To Care

 Access to Care

There are those of us who live our lives with the hope that our pets will find us worthy. We spend the majority of our time giving gestures of thanks for all that they give us. We feel humbled by how little their loyalty costs, and yet we still want to offer them more knowing it will never repay all that they give us. The relationship between ourselves and our pets, with whom we share the most painful, joyous and raucous moments of our lives, is unsurpassed. Our pets are our truest, most trusted, most faithful companions. They give us so much without asking or expecting anything in return. Most of us would chose them over any other person, even those we call a relative. This, this single sentiment, has forged many a veterinarian to face arduous years of disciplined study and turmoil. Those quiet, unseen moments with them for that one soft purr, a gentle wag, a velvet ear and wet nose, for these we would, and do, give everything. 

Jenn and Johnny Cash

Johnny Cash was the beloved dog of our hospital manager Jenn. He was growing older and like most large shepherds, was struggling with issues associated with his breed and age. He needed help getting up, staying up, and his self- assigned guard duties pressure suffered as these progressed. Jenn was determined to do everything for him. During the course of almost a week he went from not feeling well to unable to stand, eat or interact. Over that time he was given an immense amount care from the staff of our clinic. When one of our own is not doing well the hive swarms around them to lend a hand.

This is a story of love and the dedication/devotion that all pet parents feel when their pets life is tenuously suspended on the precipice of life meeting end of life. Veterinarians, those of us in the sweaty, grueling, chaotic trenches of day-to-day medicine life forget this. We lose sight how much we are needed. How much power we yield, and how devastating the loss of our companions can be when we fail to live and deliver the purpose our knowledge and skills provide. There is the potential loss of a life with every patient we see. We veterinarians know that. We are so used to it that for some it is an acceptable, albeit an inevitable sequela that it permits a degree of indifference some call a "healthy boundary." It allows us to practice without prejudice and without emptying our own internal well so thoroughly that we can go on to help others. What we forget is what the loss of these patients does to their family. The void of losing their unsurpassed love, and the living through the phases of grief that loss requires. But, the real pain of too many of these situations is the cold, indifferent manner that we treat those coming to us for help. This is the place that vetmed has gotten itself to. We did not come here to be this. We must never forget why we are here, and what kind of legacy we are building as we walk each footstep of our professional life.

Within the week Johnny Cash's decline he was given 5 examinations, 2 ultrasounds, 4 full lab works, 2 internal medicine teleconferences, 3 x-rays, and two radiology reviews. Every person at our very busy practice was working to help him. 

When his disease eluded us, and he continued to slip away, we knew we needed more help. We did for him what we would do for every case we cannot figure out fully, we referred him to those who could. In our part of the country the most competent place we can send a patient is the University of Pennsylvania Veterinary Teaching Hospital. 

The veterinary teaching hospital is the foundation of all that a veterinarian holds as the building blocks of who we are and all that we hope to be. There is no other place that holds greater power nor greater minds. These institutions employ the most notable, credible and wizard-like masters. For the greatest medical minds of our world, these 30-odd colleges represent the best of our abilities and the fringes of our most modern advancements. They built us, each one of us, and for that we are forever indebted. They also hold unparalleled optimism for the cases we cannot heal. With great power comes great responsibility. This is where we sent Johnny Cash as our last hope to help him, and Jenn. 

This is the communication sent back and forth over Johnny Cash's care. The first is Jenn's letter about her concerns and experience when she brought her very sick, very fragile, very much loved Johnny Cash to UPenn. What concerned her the most, as we look back on this, was how hard she had to advocate for her dog. How hard she had to insist on being heard, and how, if she hadn't been an "insider" and hadn't had me on the phone, 3 times during her stay at the hospital, she would have paid $6,000 to $12,000 to be given his diagnosis. Within the course of 4 phone calls (1 to transfer him in, and 3 while she was there) I, me the referring vet, had to repeatedly remind them to use the skills we were all taught. Listen to the history, listen to what the patient tells you during the exam and start with a presumptive diagnosis and a minimum database for that presumptive diagnosis. JC needed 1 abdominocentesis after an ultrasound and we had our answer. He came back to his vet and we helped him from there. All of this could have, should have, been done within a short time. We were very clear on our needs, hopes, and expectations. We just weren't heard.

What strikes me as the most unacceptable part of her experience is that she wasn't treated as the instrumental part of the patient care experience she should have been. This is a teaching hospital. The safest place for anyone to be. The place where mistakes are used as the crucial crucible of molding future veterinarians. It is the place where asking  questions, challenging all aspects of medicine, and putting the patient above all else should happen. It should be encouraged. Nothing is more important than preserving the bond between a pet and their family. Nothing is above being kind when faced between choosing being right over being compassionate. This is another crucible of a veterinary teaching hospital.

Jenn's letter to UPenn after her visit;

Good Morning,

I am sorry for the delay, as its been only a week since I lost my beloved dog and articulating our experience in a coherent manner does not come easy.  

I do want to preface this email by saying that I have utilized both Ryan Hospital (2019) and New Bolton (2021) in the past and was incredibly pleased with my experience and the care that my animals received. We were treated with respect and compassion. This experience was so outside of the norm I know from Penn.  As stated in Dr Magnifico's email, she had called ahead as the referring veterinarian to the Emergency Department hoping for a second set of eyes on the case. We were asked how far away we were to which we stated about 2 hours. Records were forwarded outlining all we had done in our clinic and Johnny Cash was loaded into my car on a stretcher. I kissed his head and promised that we were trying to help him. 

I arrived at UPenn on 1/23/2024 around 3: 15 pm. The stretcher was loaded onto a gurney to take him back. I gave my information at the desk and signed all consents. Our stretcher was brought out along with the blankets that he had soiled. 

Around 4:20ish I met with a 4th year student to give Johnny Cash's history. 

Around 6:30ish I finally met with the attending to go over her assessment, more than 3 hours after we arrived. I was told that we needed to start "at square one" with diagnostics. It was recommended that fluid be pulled off his abdomen for assessment. I was told his pulses were low. There was concern for cancer and that he would need to go to the ICU. I was told a urinary catheter would be placed. I questioned this as he was not outputting urine despite being on fluids and was told this was to keep him clean. My estimate to start was $4,000 - $6,000. I was a bit in shock as we had called ahead to see if we could send him for a second set of eyes, along with record of everything we had done in our clinic over the prior four days. I wasn't sure why we would need to start at square one. When I questioned this I was told nothing was open at this time to do any diagnostics, ultrasound, etc.

I questioned why we were told to come up, two hours away, if there was no ability to provide the services that were requested. The attending told me that she would look through the referral log to see if there was anything recorded there, which she stated there was not. I was given the option to return in the morning when we could have the necessary testing which would eliminate the cost for overnight care and likely be around$2,000 but result in a total of 8 hours of driving with a dog who was in critical condition. After a lot of back and forth we agreed to at least pull off the abdominal fluid before we left. Some time around 7:30 pm his abdomen was tapped. Around 7:43 pm we were given the news that the fluid was septic. My estimate changed from $8,000 to $10,000 to start as he would need an emergency ultrasound and surgery. I made the decision to take him home to euthanize at our clinic in the morning.

As a pet owner, and someone in the veterinary industry, I have several concerns;

• I watched as less critical pets had histories taken quickly. They quickly met with an attending and  were even discharged before I had even met with the attending. If my pet were so critical an ICU was recommended shouldn't he have been assessed before the easy "in and out" cases? (Specifically a Golden Retriever with an eye injury stuck out in my mind, (although there were others). Are cases not assessed for urgency? (Maybe if mine had he would have gotten the services he needed before clinicians left for the day?). Your own website states "Patients are seen on a medical priority basis. Waiting times for clients can vary depending on the caseload at the time of presentation. All patients in life-threatening situations are immediately brought to the treatment area, where the emergency clinician performs a physical examination and provides emergency stabilization." Given our timeline this does not seem to be accurate.
• I was told that my pet could receive "better care" in the ICU than what he was receiving at home overnight. Yes, my dog was hospitalized at home overnight, under the care of someone who works in the veterinary industry and under the direct supervision of a veterinarian. These were the exact words used, and they stung.
• My dying dog was given no pain meds, even when we knew his abdomen was septic and I stated he would be euthanized in the morning at our clinic. A dying dog who was septic was discharged and given no pain meds.
• A week later Johnny Cash's records have yet to be sent to Jarrettsville Vet, I am glad no next steps were hinging on this.
• While I could have likely come up with $4,000 I was told that the $4-$6k estimate was "to start" I work in the veterinary industry because I love animals, unfortunately a love for money does not align with a life in our industry. I do not have unlimited resources. $8-10k to start was completely outside of reachable, and I fear this would be the case for many. I know most of our clients would not be able to manage this
• I have read over your Client Rights on your website, (see here), Johnny Cash and I were failed at every bullet point within those rights.

As humans we have evolved to love our pets as a part of our family. We love them in many cases more than we love many humans. We often grieve their loss more than that of a human as well. Somewhere along the way many in the veterinary industry seem to be capitalizing on this love and in turn emergency care is becoming out of reach for most. If this care is out of reach for someone in our industry I fear what that means for our clients.

I am grateful that I brought my dog back home. He was taken in for an emergency exploratory surgery at our clinic as a last effort to save him, and although that was not possible, I did get my answer (diagnosis) and with that came peace in letting my beloved companion slip away peacefully. I was only given this because I work at Jarrettsville Vet. My heart breaks for the average pet owner who would have had to make the decision to let their pet go amidst an impossible starting estimate, never knowing the diagnosis. 

While we worry about mental health in our industry the reality is there is a pet owner who is more often than not, loves their pet at the other end of the leash or the carrier who deserves to be treated with compassion as well. I hope relaying my experience somehow helps others; I have the unique perspective from both ends of the spectrum - someone in the veterinary industry and a pet owner.

Thank you for your time,

Jennifer

There were two phone conversations that occurred as a result of this letter. One with the UPenn social worker to better describe the care and client experience Jenn received. The second phone call was with the Emergency Hospital coordinator and an ER clinician. It was not helpful to Jenn, nor in any way reassuring to me that what happened to her and Johnny Cash, wouldn't happen again this evening. There was an apology for Jenn's loss, a defensive posture that he was well cared for at their facility, and a lot of excuses and firm language that they are compassionate, AND that they do offer a spectrum of care with affordable options being given when clients have financial constraints, and hurtful commentary from two veterinarians who want to stand by all of the reasons Jenn's concerns were wrong. It was a shocking phone call that further reinforces the state of veterinary medicine in this country.

After we got off the phone with UPenn and after we had put all of our thoughts, grief and taken the time to bring Johnny Cash's case into the learning and call for concern with the state of vetmed, we decided to write an open letter to all of the referral centers around us.

Jarrettsville Vet never puts a pets ability to have a chance at a treatable outcome, and a clients ability to have hope, behind anything other than our mission to Always Be Kind. This is where medicine starts. Where it lives and the only place it can succeed. There needs to be a better place for the conversations to start then the estimate. 

The letter reads;

Dear Referral Facilities,

    We hope that this letter finds you well. We are writing in regards to the patients and clients of Jarrettsville Veterinary Center. It's our hope and goal to honor our promise to stand by them in doing what is best for their beloved pets.

    We understand that emergency situations can arise unexpectedly and we want to ensure that the best care is provided to our clients/patients during these times. We also believe that every life is precious and deserves to be treated with compassion and respect. For this reason, and any other, should a decision ever need to be made to euthanize a mutual pet due to financial constraints please reach out to our facility.  We want to make it clear we do not condone this type of practice at our facility.

    We are dedicated to providing the best care possible regardless of financial constraints. We believe that every pet deserves a chance at a happy and healthy life. We will work with you and our client to find a solution that is in the best interest for all involved. Dr. Magnifico is happy to include her email and personal cell phone number to the DVM's and practice management staff to offer help when needed.

    Kindest Regards,

    Krista Magnifico, DVM

    Owner Jarrettsville Veterinary Center

This letter was sent to about a dozen referral and emergency practices within a 2 hour drive from our clinic. As of today we have received these affirmative acceptance replies; 

The UPenn Ryan Veterinary Hospital and Mason-Dixon ER in Shrewsbury, Pa. and the Animal Emergency Hospital in Bel Air Md

This week I tried, again, to refer a patient to UPenn. I was not able to provide the transfer without an authorization that the client would be able to afford the projected estimate even though, as in the case above, the diagnosis, diagnostics, and treatment plan were unknown. They, once again, and as they have previously, were more concerned about sending a client with financial security to allow for the full spectrum of possible care, then helping a patient/client in need find care that mattered to them. 

 

School of Veterinary Medicine

Department of Clinical Sciences & Advanced Medicine – Philadelphia

3900 Delancey Street

Philadelphia, PA 19104

 

 

July 11, 2024

 

Dear Dr. Magnifico,

 

Thank you for reaching out and for your thoughtful message. We appreciate Jarrettsville Veterinary Center's commitment to providing compassionate care to all pets, regardless of financial constraints.

 

At Penn Vet, we share your values and dedication to the well-being of our mutual patients. We understand the importance of ensuring that every pet receives the best possible care, especially during emergency situations. Your offer to collaborate and find solutions to avoid euthanasia due to financial difficulties is truly commendable.

We will certainly reach out to your facility if we encounter any situations where financial constraints might affect the decision-making process for a pet's care. We kindly ask that you discuss estimates with your clients and notify us of any financial concerns when referring a client to us. As we have many clinicians that rotate through our emergency service, this will be a critical step in communications to ensure that the emergency care team helping your clients understand the terms of your support and that nothing is lost in the transfer of information. Having your contact information will be incredibly helpful, and we appreciate your willingness to financially assist clients in such circumstances.

 

Thank you once again for your partnership and for your unwavering commitment to the health and happiness of the pets we collectively serve.

 

       Sincerely,

        PennVet -Ryan Hospital of the University of Pennsylvania

I will be reaching out once again to UPenn to discuss the practice of putting estimates at the gates. The estimates are formulated based on the referring veterinarians findings and suspicions. This estimate is based on many possible scenarios and presumed diagnostics, with presumed treatment plans. All of understand that this is difficult to cement into a narrow dollar figure. What it costs most clients is the fearful restraint that a large dollar figure, a potentially looming poor prognosis and the healthcare plan starting out, and being presented with financial influence at the welcome mat is both unkind, uncaring and costing care we can in all and every case negotiate and compromise. It seems, with all of the recent cases that we have sent, that the gates ability to open rely on the opening estimate. How can a learning institution practice medicine to train its students who will provide care to all kinds of clients with the admission set at worst case?. If they truly want to provide all clients options and follow the standards we were all taught, then these estimates have no place in greeting clients and patients BEFORE they are seen.

I have been a private practice veterinarian and practice owner for 20 years. There has never been one case that we have not helped in a manner that doesn't put the patient first, and the client feeling as if they are the at the center of everything we do, and that every patient has a team based approach.

There are many points of Jenn's letter that I understand as a veterinarian that are harder to explain to a client. The timeline. A clients idea of the passage of time is very different from the veterinarians. While I try to stay on time, Keep every client apprised of the time I am taking and explain/excuse why it is taking so long. It is inevitably impossible to be able to complete a complicated case, with all that we have to do, discern, digest, diagnose and report. Time in the clinic, on the floor, with a difficult case seems like seconds while the client is sitting for hours. We are always. always running behind, over extended, and never is there a moment where we sit down, relax, or eat, drink, or even pee. I will give them the time frame. I empathize.

The idea that any of us read every piece of paper, every diagnostic, each step another vet has taken, well, in reality we don't. We don't have time. And, after all, everyone, every other vet is is a charlatan. Don't waste your time reading over some half-wits work,, they couldn't figure it out, why waste your time looking at what they did.

No, what really lights me up is that they treated her like she was just another client. Just another replaceable mom, with another dying pet. She is a mom who loves her dog. She is the client we all worked so hard to get into vet school so we could take care of. She is the medium of all of our dreams. She almost walked out because they couldn't/wouldn't see her past their estimate. What an utter failure to even attempt to be anything of value. It doesn't matter what you are capable of if you cannot remember why you are here.

I welcome an open dialogue with UPenn, every ER, and every person who seeks help for the pets they call family. 

Please share your story of your pets care at Pawbly.com storylines section.

Tomato Sandwiches

In the closing days of July I can be found eating one singular thing in mass quantities; a tomato sandwich.

A soft, squishy, spongey white bread cradling thick slices of our own garden grown succulent watermelon-wet purple tomato. If I can sacrifice my inherent impatience I hold I will adorn it with three things; nayonaise, (the veal denying version of the fantastical Miracle Whip of my saccharine-sour youth), bread and butter crisp pickles, (homemade always), and elephant ear-sized leaves of basil, (the only other thing we grow). Summertime is about so many luxuries. The tomato sandwich is mine.

The Summer days begin with tomatoes as my morning coffee's spouse. Breakfasts are followed by a lunch a few hours later by my some-assembly-required sandwich, or else the soggy mess demands a spoon. I close each day with the only meal I yearn to have waiting for me when I get home after 9 pm work-weekdays. 

They never fail to fulfill, and I never tire. Those juicy thin skinned plumm-ey bombs so succulent and drip-ey messy you need to indulge over a skink, a towel, or with a bib.

By the time October rolls around our tomato vines have withered, the fruits shrunken and toughened. My belly is satiated and I resume the internet search for "clinical signs of toxic doses of lycopene."

todays bounty

(P.S. I would have included a photo of my breakfast tomato delicacy,, but I ate it too fast).

Tomato sandwiches are my lustful Summer mealtime desire. They remind me that there cannot be balance when the season is so narrow, and the yearning so insatiable. Who wants to try to be disciplined when you wait a whole other calendar to get back in season? Me, Nope, I will eat as many as I can for as long as I can, year after year. Summer and tomatoes, (Purple Cherokee's to be specific). What could be more perfect? 

Could it be that one good, no, great, (those Cherokees are that), thing marries one with another if you simply choose to recognize it as such? Summer sun and all that its bounty blooms.

prepping for another sandwich

Maybe the marriages are all that we need to look for? The ways in which one magnificent indulgent joy comes from a tiny place that everyone else overlooks.

Maybe if I can alter the perspective, just a teeny bit, I can marry one spectacular triumphant savor into the other parts that aren't so fanciful on the routine basis?

I imagine painting them as works of art. The color is so deep and robust

There is no balance in veterinary medicine. Nor, is there any longer a balance worth seeking. I live my veterinary work life in the maximum height and depth of everything I do. I chose this life, (or, it chose me. I cannot discern the difference any longer). It is the price of being me... so much passion for so many things and just a few trips around the sun to accomplish all that lies ahead. I don't know why people seek balance. That place where nothing swings, or moves, or gets felt for all that it beholds. We are veterinarians. The grittiest of the professions. There is no glamour here. There is no fortune to be won. There are quiet, voiceless badges of courage and lives that will never repay you for the impact that you have delivered. There is perfection in knowing that you can change a fate just because you set your eyes upon them, took a moment to listen, and decided that every little life has unimaginable power to heal another human. Our pets mean everything to us. They are the guiding influence on so much of our daily lives. They hold the calm presence that makes all of the inescapable turmoil of the rest of our lives worthwhile. I am so lucky to not have banal ordinariness about. 

Our clinic Queen, Seraphina

Do any of us want to live with just our toes in the water and not still want to dive in? Don't we all want to feel compelled to jump in, immerse ourselves in the glorious wonderfulness of that one thing that is just soo good you kind of get obsessed with it? That is my kind of balance. The balance of a veterinarian who knows what she loves and still loves it too excess. 

What are your favorite season based delicacy? I would love to hear about them!