Holding a mirror to the veterinary industry to show the realities you work with every day.
A photographic documentary that relates what working in a busy veterinary practice looks like – the highs, lows, challenges, day-to-day, unusual and extraordinary.
“If only vetting just consisted of treating sick animals. But it didn’t. There were so many other things.”James Herriot, If Only They Could Talk
Part 7: Gold Standard & The Real World
Financial constraints on owners can create significant obstacles to animal care, requiring vets to seek more affordable clinical options that won’t jeopardise an animal’s health.
The easiest way to see this is by considering the “gold standard”.
Dr Fiona Starr describes the gold standard as “the recommended treatment or test based on research and agreed upon by experts in that field.”
It is the best science at the time and, from that perspective, the best option for an animal. It also has an emotional benefit: using the best option can equate to doing all that can be done, alleviating possible guilt by owners and vets by using anything less.
It’s not hard to imagine the tension that can arise if the gold standard can’t be afforded, and it’s easy to find examples where it does.
15:29pm. Dr Fiona Starr palpates Otis, who has been feeling flat and hasn’t eaten. 2 March 2018
Consider the case of Gorgeous George, whom Deric Kenyon brought in suffering from vomiting, diarrhoea and weight loss. After taking a history and doing a physical exam, the attending vet [anonymised for safety concerns] outlined the options. The “gold standard” meant a suite of diagnostics, including, “faecal tests, blood tests, potential imaging and some sort of endoscopic gut biopsy or exploratory laparotomy.”
But Kenyon’s financial circumstances were a factor. The vet said, “We’re talking several thousand dollars; Mr Kenyon is a pensioner and he can’t afford that.”, and also suggested a conservative option that involved waiting to see if the symptoms would dissipate and gave Kenyon a chance of avoiding financial stress. In this case, Gorgeous George made a full recovery.
Kenyon made a choice from the options presented by the vet and it worked out. But what if it didn’t? Gorgeous George’s condition might have declined, or he might have died. In those cases, even if a client decided on an option presented by a vet, it might mean being taken by the owner to the veterinary board, even if unjustified.
Going the other way, advocating for more diagnostics and treatments than an owner can afford, also has challenges, including the possibility that a client feels like their vet wants them to pay for diagnostics or treatments their pet doesn’t need. It’s a concern for Gorgeous George’s vet, who says, “I don’t want to be seen as someone who’s trying to over-service.”
Of balancing finances with clinical options, Dr Gwen Shirlow says, “It’s a fine balance and quite a hard line to walk sometimes. It has to be professionally appropriate, and medically or surgically appropriate but, unfortunately, you do have to take finances into account because not everyone can afford that gold level.”
15:53pm. After analysing blood from Otis, Dr Fiona Starr suggests to his owner, Jocelyn Bruemmer (middle), a conservative approach using antibiotics to rule out infection as the blood tests aren’t conclusive of anything more nefarious. Otis subsequently recovered without the need for more invasive and expensive testing. 2 March 2018
Shirlow also comments on what she sees as an increasing focus on the gold standard in education.
“It’s becoming drilled into new graduates that you have to provide the gold standard, that you have to do as the book says, or why bother. But that’s not the case. That’s not the real world, and there are often things you can do. You go for the gold standard but, if the owner can’t afford it, that doesn’t mean you have to go for euthanasia. There are compromises that can be found that mean the animal gets the treatment that is effective within the financial constraints.”
Dr Deborah Williams highlights the personal risk to vets who aren’t able to reconcile the gold standard with the “real world”.
“At university, you learn how to follow a case all the way through. In the real world, though, a client can say, ‘Yes, I want a CT scan, I want the brain tumour removed, but I only have three hundred dollars.’ This is not going to go well for high-achieving perfectionist vets. It can create emotional problems for those vets who then don’t think they are doing their job properly.”
Starr manages that risk by thinking in terms of options.
“With vet science, there is no single way to do things. I believe in providing options and describing their risks, limitations and costs so that the owner can make an informed decision.”