Posted on September 8, 2013
The Most Important Thing a Client Ever Taught Me
When I met Martha in 1985 I was an internal medicine resident at the University of California, Davis Veterinary Teaching Hospital. Right from the get-go, Martha impressed me as a kind, soft-spoken, intelligent woman, devoted to her one-year-old Cocker Spaniel named Murphy. Upon entering the exam room I learned that I would be providing a fourth opinion. Three vets prior to me had run most every test in the book, but could find nothing amiss. According to Martha, they believed the patient was normal and the client was a hypochondriac.
Martha readily admitted that she could not identify any clear-cut symptoms. Yet, she was certain beyond a shadow of a doubt that something was troubling her beloved Murphy. His appetite and activity level at home were completely normal. There had been no vomiting, diarrhea, coughing, or sneezing. It was while Murphy was on his daily walks that he appeared abnormal to Martha- a bit less exuberant than normal.
I examined Murphy from teeth to toenails hoping for the clue that would help guide the diagnostic process. I found nothing. I reviewed all of the laboratory test results and X-rays previously generated. Still nothing. Was I truly face-to-face with a hypochondriac? Listening to Martha and observing her body language, my gut told me otherwise. I believed her conviction that something truly was wrong with her darling dog- something a trio of veterinarians had yet to figure out. More than anything, I admired Martha’s calm perseverance. She had been turned away three times, yet here she was before me in her ongoing efforts to be an effective medical advocate for her beloved dog.
Although Murphy had no heart murmur, based on the change in his energy level while out on walks, I opted to proceed with an echocardiogram- an ultrasound examination of the heart. Lo and behold, this study revealed the abnormality responsible for Martha’s concern. Murphy had a birth defect within the heart known as a patent ductus arteriosus (PDA). The ductus is a normal structure through which blood flows in the developing fetus. The ductus normally closes shortly after birth. In some puppies, this ductus remains open causing abnormal blood flow that can ultimately result in heart failure. This abnormal flow typically moves from the left side of the heart to the right side and is associated with a loud heart murmur. The left-to-right PDA can be quite readily corrected. In rare instances, as was the case with Murphy, the abnormal blood flow moves from the right side of the heart to the left. This “reverse direction” does not cause an audible heart murmur- the reason why three vets before me had been stumped. Unfortunately, there is no feasible way to correct a right-to-left PDA and symptoms invariably progress.
When I delivered the diagnosis to Martha I recall that she burst into tears, a combination of sadness and relief that her concerns had finally been validated. Martha expressed profound gratitude. The search for a diagnosis was over and she now knew what to expect. Martha and Murphy enjoyed another 18 months of good quality time together. When his symptoms intensified, Murphy was euthanized after which Martha sent a note once again thanking me for having believed in her.
I’ve always remained profoundly indebted to Martha as she taught this young veterinarian a most valuable lesson. I learned the importance of trusting my clients’ instincts, gut feelings, and intuitions about their pets, even when others are demonstrating doubt. Martha helped me understand that no one knows my patients better than my clients- the people familiar with the nuances of their pets’ daily routines and behaviors. If they sense something is wrong, those hunches are deserving of my attention and some investigation. In more than 30 years of practice I can count on less than one hand the number of clients I’ve encountered who falsely reported symptoms for reasons other than the best interest of their pet.
It’s been so long that I honestly don’t recall if I purposefully thanked Martha for the lesson she taught me. I do know that, in my mind, I have thanked her hundreds of times over the course of years as I’ve evaluated animals with ill-defined or subtle symptoms that other veterinarians have doubted. Martha’s perseverance was inspirational to me and I am profoundly grateful that our paths happened to cross.
Have you ever had a hunch that your pet had a medical issue based on a subtle symptom?
Best wishes,
Nancy Kay, DVM
Diplomate, American College of Veterinary Internal Medicine
Author of Speaking for Spot: Be the Advocate Your Dog Needs to Live a Happy, Healthy, Longer Life
Author of Your Dog’s Best Health: A Dozen Reasonable Things to Expect From Your Vet
Recipient, Leo K. Bustad Companion Animal Veterinarian of the Year Award
Recipient, American Animal Hospital Association Animal Welfare and Humane Ethics Award
Recipient, Dog Writers Association of America Award for Best Blog
Recipient, Eukanuba Canine Health Award
Recipient, AKC Club Publication Excellence Award
Become a Fan of Speaking for Spot on Facebook
Please visit http://www.speakingforspot.com to read excerpts from Speaking for Spot and Your Dog’s Best Health. There you will also find “Advocacy Aids”- helpful health forms you can download and use for your own dog, and a collection of published articles on advocating for your pet’s health. Speaking for Spot and Your Dog’s Best Health are available at www.speakingforspot.com, Amazon.com, local bookstores, and your favorite online book seller.
The 2nd half I didn’t write is, how would I approach my vet and say, “My dog keeps making mittens on my nose in the morning? I think there’s something wrong with her and she’s trying to tell me so…………”
Thank you for listening to your patients’ intuition(s).
Thank you for this support of us, the clients, Dr Kay! As a “mom” of a very stoic Mustang, I can say I truly know the importance of nuances of my gelding. Because of evolution, his breed has learned that show weakness or illness can attract a predator. I pay close attention to anything out of the ordinary with him because there could be something much bigger and sicker underneath. He hides things well, and doesn’t want me to worry. I paid attention today when he started out stiff on a trail ride — proven right by the end: he was three-legged lame, which tells me he was really hurting.
My father, a human family doctor, told me when I had children that he always listened well to the parents of his patients, as they knew their child better than he ever could. I believe the same should be true with dog /cat/pet owners and veterinarians. I bet Martha remembers you fondly and gratefully. And I am sure she stood by her gut feelings with subsequent “pets”. Your posts are excellent as are your books. Thank you.
My neighbor has a lovable dog who seemed not to feel his usual, waggy-tailed self. One eye seemed a little droopy. Most folks would have waited, but they took their dog to the veterinarian, who sent them immediately to an opthalmologist. Xrays showed a tumor behind the eye, which turned out to be malignant. After surgery and chemo their pet is doing well. A good call all around thanks to an observant owner, a responsive veterinarian and a competent specialist. We are all keeping our fingers crossed for Benjamin.
A vet I once had when I lived in the Oregon said, “I always pay attention to what the owner says because I see the pet for 20 minutes—they they see it for 24 hours, 7 days a week.”
Once again, I have tears in my eyes! Great article Dr. Kay! Before the butterfly lesion appeared on her nose, Katie would gently take her paw(in the morning before we were out of bed) and “make mittens”(as cats do) on my nose! She was trying to tell me there was something wrong…………..
I had a similar experience with my sweet palomino, Bud. He did not feel wweel nad his symptoms were vauge. THe vet first thought that he might be colicing. I am very lucky to know and animal communicator, who was able to help me pin point his malady. His bladder was about ready to burst due to the fact that he had some slurry material in the bottom of his bladder, blocking the opening to the uretha. He is a pasture horse, so I do not reguarlarily see him urinate. My vet was very attentive to my suggestions about his issue and he was able to get him catherized and drained….whew!!! His bladder had to be “rinsed out” several times to remove a bunch of the gunk. Finding a vet that you feel confiedent in takes some searching….but when you find that jewel, who listens to your observatoins, follow him/her wherever he/she goes!!!
Thank you, Dr. Nancy Kay, for your wonderful articles!!!!
I had an experience similar to Martha’s with 2 different dogs. The first one I believed occured because I live in an Appalachia region and I think the vet just expected I would not pay for expensive test. After many months, I did visit another vet who ran blood work and pills for the rest of his life was an easy treatment.
The 2nd vet told me he could not find anything wrong, but referred me to another vet. After 3 veterinarians, problem solved.
But do you know how much I respected the first vet that believed me and made a referral for me. For the vet’s reading this, don’t be afraid to make referrals if you do not know. It will not make you look incompetent, but make you more respected!
Hoiw tragic that so many of us have sad tales of a vet NOT listening. Mine is about a 12 year old Weim bitch who “was not right” starting in March 2012 and ending when she was euthanized due to metastatic Cancer in July 2012. Usual vet found nothing after $3000 worth of tests. Second opinion vet said “follow your regular vet’s advice-I can’t think of a thing to add”. Third vet (a rent a vet at my regular vets) at my insistemce did a chest x ray(dog was coughing and skin ocver lungs retracting) which showed diffuse shadows in both lungs. She withdrew a sample of lung fluid, sent it to Pathology and of course it was Cancer. The abdominal ultrasound also showed tumors thruout this suffering dog’s belly. After a bowl of her favorite chicken soup, our sweet dog, AKC Champion, Certified Therapy dog and cherished soulmate was euthanized while she lay in my lap. Guilt is my daily companion.
Thank you Dr Nancy Kay for validating that a client can know when something is “off” with their pets! One of my dogs, had waxing and waning energy levels for months, was dismissed as “acting out” – when he went into full Addisonian crisis, his vet dismissed it based upon the earlier “findings” that he was “acting out” and would not see him for another week. A different vet squeezed us into a full schedule and even helped carry my dog from the car to the exam room and immediately sent us to an IM specialist where my dog was hospitalized and put on IV fluids. I also had a senior dog with an apparently picky appetite and frequent inappetance and a funny smell to her breath – she would approach food hungrily and then back away from it – she was dismissed as typical small dog with a finicky appetite, given appetite enhancers, etc. Months later, I went to another vet and he listened and ran bloodwork and diagnosed her with chronic renal failure. She was backing away from food because the smell made her nauseous. My cat was given a chiropractic adjustment that caused her to be in more pain and a subsequent adjustment to “fix” the bad adjustment paralyzed her and six different vets gave a probable diagnosis of a brain tumor causing the paralysis and all recommended hospice and euthanasia. – I “knew” the cause was due to the improper adjustment and eventually found another animal chiropractor – who restored 60% mobility after the first adjustment. I learned to trust my gut when it came to my pets because I am their only voice and if a vet won’t listen to my concerns or dismisses them, then it’s time to find another vet who will listen.
My vet calls it AQR – Ain’t Quite Right. I will not use a vet who doesn’t trust that I know my pets better than anyone on earth. By the same token, I respect that he knows more about veterinary medicine than I do. I’ve now had to also use this with my own doctors. When I meet a new doctor, I tell him that the deal is that he must respect that I know my body very well, and I will respect his superior knowledge of medicine.
When a vet or human doctor agrees to this, the patient is always better served. Vets are far readier to do this than human doctors, but it’s worth the search to find one who will.
Dr. Kay, GREAT article. Thank you!
I am going through this now with my beloved horse, Tiger. He presented with lameness early June. At first it seemed one of his chronic muscular issues, but was persistent. Something was NQR. Over time, I had a vet, chiro, farrier all express different opinions, mostly around bruises or thin soles. None of these rang true with my gut, but I didn’t know what DID ring true!
Finally I had a different farrier give a 2nd opinion. She suggested in no uncertain terms to get the vet back out there and do xrays. Lo and behold, his RF coffin bone had rotated a great deal. Everyone was surprised. The relief of finally nailing a dx along with the remorse for time lost-what an odd feeling.
Thanks Nancy for posting this. Many vets would be defensive in this situation-like my farrier was-as though I was threatening his knowledge base. Instead, you proceeded and found the cause. Many many thank. Best, Susan
I was fortunate to learn this from a veterinarian I initially worked for as a vet assistant before I went to school. He said that the clients always end up being right.
Even with my own pets I know that my dog is limping before any of the other vets can tell, because I know what is normal for *my* dog better than anyone.
Usually if I’m working with clients and we don’t have a clear idea of what is happening, I always tell them I believe them, but sometimes we don’t have enough hints yet to go on. We make the best decision we can about what direction to head, knowing we might have to change course later.
Great article.
It’s called ADR.
Ain’t Doin Right.
It is a thing.
With Mel it was a disk getting ready to blow.
With Moe, Lyme disease.
Pip, carcinoma.
My vet believed me, but couldn’t find the diagnosis, nor see the signs.
Specialists thought we were both nuts.
Yes, I too had a similar circumstance. My Dane had many orthopedic issues to deal with on a daily basis. Diagnosed with wobbler’s syndrome before he turned 1 years old, he also experienced acl ruptures at 18 months of age and then again at the age of 2 1/2 yrs old. He had acl surgery 31, followed by spinal surgeries 1 and 2 about 6-8 weeks later. Then he had his next acl surgery about 10 months later and an additional repair 2 weeks later. That 2nd acl surgery never seemed to heal quite right. He needed 2more spinal surgeries that summer. A year later, I was begging our ortho surgeon to remove the implant hardware in that knee as well as culture it for infection. He felt it was overkill but finally agreed to do the surgery. It was then that he discovered abnormal synovial fluid and sent a culture out to a lab. An unusual cancer was detected in the knee. Had I not pushed, I don’t think I would have had another 18 wonderful months with my boy. We eliminated the cancer through amputation and holistic meds but we couldn’t stop the progression of wobbler’s due to hopping on 3 legs. We always have to listen to our intuition as dog parents if our intuition is generally on target.
A few years ago, I voiced my concern that my tiny toy poodle could be hypothyroid, based only on the fact that she had become very aggressive towards my other dogs. My vet told me that she would not test a dog for this, based on this “symptom” alone. This past January, I convinced her to draw blood for me, so I could send it to Hemopet in southern CA. The results came back, that my dog was in fact hypothyroid.
Love this post Dr. Kay. One of my frustrations with a teaching hospital consult we had early on in our dog’s diabetes was that the IMS treated Chris like he was just any other diabetic dog. Barely glanced at his curves, put no thought into what might be going on with him.
For reasons I still can’t fathom, it didn’t seem to occur to him that he wasn’t our first stop. We had already done all of the standard stuff without success and didn’t need someone to throw a canned answer at us and send us packing. We had come to a teaching hospital and an expert on diabetes because we knew we needed someone to reach beyond standard answers and to not discount anything.
I was very sad to read Murphy’s story… Chris too was born with a PDA but fortunately the reversible kind. He came from a city pound at about five months old and after the worms, ticks, kennel cough, and diarrhea cleared up, it became apparent that there was something else terribly wrong with him. Within a month or so, he couldn’t walk half a block, and one night a few days before his surgery, we honestly thought he had died because he was so weak and breathing so shallowly. The dog who came home from that surgery was pure joy on legs. He reveled in his new found energy, doing laps around the living room through the Christmas wrapping six weeks later.
He suffered some permanent heart damage and never had normal exercise tolerance. And late in life his heart was in pretty bad shape. But he lived every moment after that surgery to the fullest.
From last October until May this year, I went through 6 vets telling me there was nothing wrong with my dog, including specialists, and several thousands of dollars, before I finally got a diagnosis. Yep, they thought I was crazy or a hypochondriac, but my dog and I have a very strong bond, and I know my dog better than anybody, so if my gut says there’s something wrong, I don’t stop until I find out what it is. Sure enough there was something seriously wrong. I’m not happy with the diagnosis, but at least now I know what I’m dealing with.
A few years ago, my dog had several bouts with Ehrlichia. The third time it happened, it was a very subtle symptom. I went straight to the vet. He told me there was no way he had Ehrlichia again and he said “You have Ehrlichia on the brain and think every little thing is Ehrlichia.” I insisted he test for it even though he didn’t want to. I said “So what if I’m crazy. If I’m willing to pay for the test for my own peace of mind, then why not run the test and prove me wrong?” He finally agreed to run it. When the tests came back, he called me and started the conversation with “I want that crystal ball you’re looking at”. It was Ehrlichia. I don’t have a crystal ball. I know my dog. I know Ehrlichia. It wasn’t hard to figure out that there was a big possibility that my dog had Ehrlichia based on just that one symptom.
Thank you for writing this post. Sometimes we owners forget that we should trust our instincts more, even in the face of experts telling us otherwise.
Martha’s experience, while different from mine, reminds me of a situation in which I knew something was wrong with my Sheltie, even though I was hours and hundreds of miles away. I persisted in making sure my family knew something was wrong with her and I turned out to be right. Luckily, her medical issue was corrected with surgery.
Bless you for believing her! There is nothing more frustrating than knowing something isn’t right and nobody listening to the concerns! I still remember how a team of different specialists at our veterinary hospital wrote off Jasmine’s episodes as “just restlessness.” I was so furious. That was the one thing I KNEW IT WAS NOT.
Yes, and I confess that sometimes my hunches were confirmed only by necropsy. My cocker spaniel, Murphy, started coughing when I picked him up, but only when I picked him up, a few months after having a melanoma tumor removed from his lip (clean margins, no other symptoms). Then a little while later he started making a strange crying sound while sleeping, almost like a train whistle. I asked my vet about both of these and they had no idea. Then he suddenly started coughing very badly and I took him to an E.R. where he was diagnosed with pericardial effusion. They said he probably had a melanoma tumor on his heart that was bleeding into the pericardium. This explained his cough and nocturnal cries. If I’d known what was causing these symptoms, I’d have been better prepared for the end and more watchful for trouble. I wouldn’t have let him run in the yard and I would have given him more cuddles. He was almost 16 years old, and had a great retirement with me after being rescued at 14. I now have younger dogs, but I will never, ever ignore a cough in an older dog or fail to get a second opinion if my vet ignores it.