Taking A Stand And Facing Consequences.

How many veterinarians work at a hospital that give them the latitude to express their own voice?

A place where they can stand up and say "NO!," when they don't feel right about what they are being asked to do?

I often wonder this?

The biggest reason that I decided I needed to own my own clinic after I graduated veterinary school was that I knew I would have some hard cases that required a decision to be made between the business and the patient. I did not enter veterinary medicine to get rich. Not that some can't but there are compromises every wealthy person makes. Some spend less time with their family in an effort to make a living, or sacrifice personal time to develop stronger business practices, and some sacrifice the reason they went into veterinary school. History and revenue sheets all indicate that to be successful in the veterinary business world you must treat the business like a business. You charge for what you do, you do what the customer asks, and you don't get emotionally or personally involved. Almost all successful big veterinary practices have established protocols, business plans, and spread sheets to maximize their revenues. It is exceptionally difficult to run a person to person to patient business based on a spread sheet. The intimacy gets lost in the numbers. There is lost revenue in time spent with clients talking, and there are muddy treacherous waters in having your own opinion and your own barriers. Then, should you still decide to side with the pet and stand in opposition to the owner there is the whole big messy ball of wax about what the hell to do with a pet that the owners no longer want? This is the place where associates get crucified. This is the place that your heart gets broken, your soul gets sacrificed, and the burn out and fatigue gnaw on you until you either break or become indifferent.

I have had to learn that my ability to care for other peoples pets is a tenuous complicated road of where my beliefs stand and, often, the great divide, of others. I have to remind myself every single day that I am the vet who worked a lifetime to be a healer and not anything else.

It is never an easy answer; the reasons that people make the decisions that they do about their pets, especially when it relates to end of life decisions.

Veterinarians are asked every day to be the person who will;

• end a life due to financial constraints
• end a life due to necessity
• end a life due to lack of perceived value
• end a life due to many reasons that are beyond my ability to justify..like moving, death, unmanageable medical needs, lifestyle changes, and such.

Last night was a repeat of a situation I find myself in every so often. Hard as I try to avoid it, it still happens.

I have told the staff repeatedly that we do not take appointment requests for new clients seeking to euthanize their pet. All requests should be booked as an 'examination'. IF the veterinarian examines the patient AND agrees that the condition warrants euthanasia the pet will be humanely euthanized. IF NOT, the client has been notified that the request must be consensual and cannot be expected. There are those who disagree with this position. I remind those veterinarians that there is a divide between the law and the beliefs of our desired clientele. Not one single small animal vet desires to work for clients who regards their pet as simply 'property'. If we did our average client transaction would never pay our mortgages. Don't ask for one, "patients = property and therefore protect against liability", and hope for the other, "client spends thousands to treat life threatening disease." We market our goods and services, encourage diagnostics, allow walk-ins, emergencies, provide surgical treatments always in excess of "replacement value" and then euthanize at whim. It is a contradictory incongruous hypocritical business model. 

And so I arrived at the exam room paperwork in hand for tonight's euthanasia. The clients had never been to see us before, I did not know this case, and I had no history to accompany the file. And there stood before me a happy, bright, inquisitive, young dog. If he was sick someone had forgotten to tell him. He had an obvious limp but he was happy to be here and anxiously awaiting a "Hello" from me. The night froze and I knew the story was about to get sticky. 

I am not sure how many vets would have stopped their incredibly busy night to talk to this couple? but I spent the next 30 minutes talking and trying to understand to their story, their concerns, and what my role in helping this pet was? In the end I stood between a husband who was unwilling to spend any more money on a case that he believed was not treatable, a wife who loved her dog desperately, and a dog who was happy, maybe not perfect, maybe not going to live another half decade, but today, at this moment happy and functional.

In this appointment debacle the husband and wife were at odds about what to do. The husband wanted to let the pet go. The wife stood quietly sobbing. The dog was running around the room wagging, jumping, playing, and soo happy to be round new people. And there I was thinking that I should have gone to floral design school. How do I pick a side on this one? It was a perfect example of the worst cases to be a part of. Where the hell do I go? What do I do? Who loses here? 

I had to walk away and get out of the room for 15 minutes to think about what I was about to do.

I found my associate and asked her. Her words of encouragement and advice put the wind back in my sails. "Screw them! Say NO! and get rid of them!" Now, I didn't go back and use this language, but damn it felt good to hear it! I needed her support and I knew then that my guts decision to refuse was the right one. 

This is the point where judgments are made. This was the point where I knew I was about to enter a landmine of emotions and risk my neck for a dog I didn't know. This is where the sick feeling in my soul reminds me that I better have a backup plan because the Board of Veterinary Medicine was going to get another letter with my name on it. This is where I had to decide if I could really stand behind my words, my thoughts, my beliefs, and my desire to elevate veterinary medicine to the place my clients believe it exists.

I refused to euthanize that dog. I offered every single option imaginable. If I am going to duck out of what my client wants I better be able to offer assistance to that pet and the only way that pet is going to get assistance is with some options. It is the luxury of my position, my lack of debt, and my compromise to sleeping at night with a clear conscious. When the husband told me that he preferred the dog dead versus in someone else's home I knew this was an examination and euthanasia to absolve myself of. How could dead be better than elsewhere? 

As the appointment ended I made one last desperate move. I secretly handed the wife my cell phone number. 

For those of us who live a life as a female I know that husbands often dictate the financial decisions. I know that there are millenia of women told to keep quiet while the husband decides where resources can be spent. I hear it every day. The women love and adore a pet that the husband does not. I know this sounds terribly sexist, generally broad sweeping and that there are some men who love their pets as much as any woman does. But in 10 years of practice here is what I have seen: In general men make financial decisions over emotional decisions (perhaps the reason of my clinics financial back seat?). Whereas women live by a more maternal guidance. We are programmed to nurture and men are more pragmatic. An expense is calculated and assigned a priority. Your pet doesn't drive you to work, pay the rent, or keep food on the table. BUT a pet is the center of many a woman's heart. I would give up a car, a trip, an expensive meal for the companionship and unconditional love of my pet. I cannot take every pet, and I cannot work pro bono consistently, but every time I have offered to help I knew it was the right decision for me. I would regret making a different choice. 

I often torture myself over the afterward.. What will happen? Where will that pet end up? To try to alleviate this I offer those clients lots of options. I keep talking even after I refuse to help them with their request. 

• "You can take your pet elsewhere if you are still electing to euthanize." I understand there will likely be a backlash from other vets about this. 
• "You can find or look for financial assistance through private companies. Like a credit card, bank, etc."
• "I can ask for help from my network of rescues, friends, etc."
• "We find some way to compromise to get your pet care." I think and behave outside of the box. I find a way to build a bridge between caring for their pet and avoiding shouldering the entire responsibility of a pet. In some cases the clinic will take responsibility for the care of a pet and then assist in finding that pet a new home. These cases remind my staff that there is a heart here. Our primary mission is to help pets AND people. We do not sacrifice one for the other.

Clearly, I understand that people have different feelings about their pets. Clearly, there are very few veterinarians in the world who do not understand that pets have moved into peoples homes and hearts and that this is very unlikely to change. But, there is still a great divide on who a veterinarian is at the seat of their soul and the tasks that they are asked to participate in.

I know that there are many veterinarians out there who are told to do as the client asks. If the client pays the veterinarian participates. If the client cannot pay the patient is left to...?? 

There is no doubt that compassion fatigue exists, that there is an over represented number of suicides in our profession, but there is a reason for these. A deep cumulative reason. A small incessant chipping away of the soul of the people we wanted to be, thought we were, and make excuses as to why we have become who we are. 

Our clients know who we are. They know where we stand, where our obligation lies and they support us. The days of clients asking and expecting services that are inconsistent with our mission are few. The clients that remain are our foundation, our support, and our cheering squad.

If, at this point in time veterinarians do not embrace that segment of society who loves and treats their pets as children we will lose our ability to be the provide both exemplary care and care with purpose. 

Update;

Two days later the wife called me. We scheduled a treatment plan for her dog. I will help her with costs, use some of our donation fund for him, and hope that we can find him a palliative care. Shoot, I am hoping for a miracle, and who knows? Sometimes there is salvation in trying.

A week later Charlie had surgery.. The end to his story can be found here.

Related blogs;

Compassion Fatigue

How Many Sides Does Your Equation Have?

When Trying Is All That Matters.

The Cat And The Line In The Sand.

If you have a pet question you can find me on Pawbly.com. Pawbly is free for everyone and created to help people find answers to their pet concerns. We are a platform full of dedicated caring people. 

You can also find me Twitter @FreePetAdvice. Or at the clinic, Jarrettsville Vet, where I get to hug, kiss, and enjoy the 99% of the wonderful things that being a veterinarian brings. 

How Many Sides Does Your Equation Have?

I'm going to stick my neck out and make a prediction. The pet owning public, who I refer to as "clients" are going to influence our profession so much so that IF YOU ARE NOT PERCEIVED AS A KIND, COMPASSIONATE, AND PROFICIENT veterinarian that you will never succeed in veterinary medicine. In some cases I believe that veterinary medicine is following very closely in the foot steps of human medicine. In almost all cases every veterinary disease has a human equivalent treatment option. The boundaries between your treatment options are really only limited by your ability to pay for it or believe in it. The list is long, varied and includes prosthetics, organ transplants, brain surgery, and even surpasses the human side by now offering cloning. The options are limitless and almost beyond the imagination of science fiction.

With this in mind I was saddened and shocked to hear from a veterinarian serving on my state medical board who forcefully and authoritatively reminded me that the one of the four treatment options available to owners was euthanasia. Euthanasia is an option as long as pets are considered property and owned I understand that. I don't necessarily participate in this particular kind of pet ownership, but it is the reality of the society we live in. But I would argue that we do not treat a disease or illness, or behavioral problem, or blatant irresponsibility on the owners part by killing a pet. We may perhaps resolve a problem with the option of euthanasia, but "treat"? If your physician came to you and offered to cure you of your ailment by killing you would you consider it an option? Seems absurd to me. But we have already agreed that my perspective is skewed.

The equation for a successful resolution to every client's pet concern is not always balanced. Sometimes the easy part is the diagnosis and the very difficult part is the treatment plan. When a client brings a pet in for what I know will be a long, expensive, or labor intensive treatment I know that I have to very carefully and honestly design a feasible and realistic plan and discuss what that pet will require for a successful outcome. The skill in being a veterinarian is part scholastic learning and part psychological mediation. Knowing your client, their unique individual thoughts and beliefs is a start in being able to openly and honestly discussing how to proceed down the path from identifying the problem to resolving it. Articles have been written about the subject of "knowing when to treat or euthanize."

Of particular interest was a an article written by Dr. Lore Haug on helping owners decide between treating or euthanizing behavioral problems. His article can be found here.

The take home points directed toward the veterinarian are valid and helpful but I found the articles all centered around an equation that had only two sides, the family and the pet. As if we veterinarians are just the tool to provide options?. The veterinarian is expected and recommended to remain an impartial unemotional tool, either the hand of healing or the executioner. I find this short sighted and short changing our clients. I also find it to be the singular most important problem in our field. This ridiculous expectation to detach yourself from your job, your patients, your clients, your reason for entering veterinary medicine, and your purpose.

Many of those on the  advisory board that reviewed his article explained that they believed that their responsibility was to assist the owners in making a "guilt free decision." Ugh, guilt, that awful emotional feeling that we are all supposed to shelter each other from. In actuality many of the experts advised against feeling anything. There were comments that included "Use your head not your heart," Dr. Philip VanVranken, "Make the decision guilt-free," Mili Bass DVM, "Help clients feel confident" Corey Entriken, DVM. Goodness, we are talking about putting pets to sleep! You can't undo that one.

Our clients come to us for advice. Advice includes all aspects of disease/behavioral/illness resolution. Even judges, who are supposed to be impartial vehicles of the justice system know that their personal opinions, life experiences, and interpretation of the law is skewed by their own bias.

When I was being reprimanded by the state board representative it was essentially because I refused to euthanize a four month old puppy with a pelvic fracture. I had discussed euthanasia with the owner and told her that this was one of her options (because I am REQUIRED TO DO THIS), but I prefaced it by stating that I would not do it. It was not the first time that I have refused to euthanize a pet, and for as long as the State of Maryland allows me to practice medicine, it won't be my last. At the end of my professional career I will never regret the refusals, but I do regret giving up on a few pets that maybe I could have made a difference for.

Now, I know that there are arguments and cases where almost every one would agree that a pet needed to be euthanized for the sake of the public's protection. It is my position that there are areas in veterinary medicine where I am not the expert. And when asked to act or treat as an expert that I need to defer to those who are. For example, if a client asked me to diagnose a heart condition I would in many cases need an echocardiograph to do so. Because I am not trained, nor do I have to needed equipment to do this, I would have to refer this case to a cardiologist. The same would go for the above mentioned organ transplants and brain surgery.

I am extremely uncomfortable euthanizing for behavior conditions. Here's why. In almost all cases I believe that the failure of that pet to behave properly is the failing of a human being. Whether it be lack of socialization as a puppy, not neutering, not understanding the needs of the breed, not being able to handle the needs of the pet, or not seeking help before the tragedy struck (in spite of the plethora of red flags), etc. Ultimately we failed them. I also have been practicing long enough to know that life is not about looking for the easy answers to the hard questions. The day I start taking the easy road is the day I turn my back on why I decided to become a veterinarian, and what I believe this profession needs more of, which is ultimately caring for pets.

Here's where I know my perspective is skewed. Most of my colleagues have decided to practice medicine to make their clients happy. For some of us it requires us to turn our back on the emotional fulfilling side of our job. And we wonder why we are burning out?

We burn out because we slowly, methodically, consciously or subconsciously decide that NOT feeling anything makes this job easier. We are all malleable and the longer you practice medicine the more indifferent you are likely to become. Shielding ourselves and our clients from guilt is as deceitful and counterproductive as avoiding responsibility in the part we play in all of the lives our actions impact.

I know that this topic is fraught with complexities and I am not trying to diminish this. I just think that this sheltering each other from feeling something is destructive and feckless. Go out there and love someone, OR some pet, and if your heart is wounded or broken get back in the saddle and try again,, the best things in life are those we feel.

To find more information about all things pet related, share information about pets, or just to share your pets photos, stories, or experiences, you can find me and a whole bunch of other pet lovers at Pawbly.com or on Twitter @FreePetAdvice, or at the clinic Jarrettsville Vet.

And please, always be kind.

My pup Jekyll,
who came to me at 8 weeks old by his breeder requesting I put him down
 because he was given too much of the wrong de-wormer and prolapsed his rectum,,,
oh, he was brought to me 10 days after this happened.