Archive for the ‘Medicine Decision Making’ Category

When to Say Yes to a Diagnostic Test

Friday, April 8th, 2011
As veterinarians we have access to so many incredible diagnostic tests. They help us uncover medical issues in our patients that, in the past, we could only guess about. How can you know whether or not to say, “Yes” to your vet when she or he recommends a diagnostic test, whether advanced or more basic? Here are my suggestions:  

© Susannah Kay

 

Begin by talking with your veterinarian about all the potential risks and benefits and pros and cons associated with the recommended testing. What will be involved for your dog or cat (sedation, general anesthesia, time spent in the hospital) and what will be involved for you (time, expense)? Most importantly, before making a decision about whether or not to proceed with recommended testing, be sure to ask yourself the following two questions:   

1. Will the results of the testing have the potential to change what I do next?
2. Will the results of the testing have the potential to provide me with some necessary peace of mind?   

If your answer to one or both questions is, “Yes” then it is certainly reasonable to consider proceeding with the diagnostic testing. However, if your answer to both questions is, “No” the testing is impossible to justify. Not only will it be a waste of your money, why on earth subject your dog or cat to a needless test? Remember, satisfying your veterinarian’s curiosity is definitely not a reason to proceed with any recommended testing!   

Here are a couple of real life examples excerpted from my practice life that illustrate how the answers to these two questions help in the decision-making process. Shasta is a sweet as can be twelve-year-old Golden Retriever mix, brought to see me because of vomiting and anorexia (food refusal). When I noninvasively looked inside her belly with ultrasound I found multiple masses within the liver, stomach, and spleen. As I told Shasta’s mom I was 99% certain I’d identified cancer involving multiple organs. Surgical removal would not be an option (disease too widespread) and the only option for potentially helping Shasta would be chemotherapy, that is, if the cancer were of the type that is responsive to chemotherapy. We discussed performing an ultrasound guided biopsy to “name the enemy” and know whether or not chemotherapy might be of some benefit. Shasta’s mom was clear that, depending on the tumor type, she would wish to give chemotherapy a try. She opted for the biopsy procedure (the biopsy results are pending at the time of this writing). In this case Shasta’s medical advocate opted for diagnostic testing because the results had the potential to change what would happen next.   

Here’s a second example- this time it’s Pixel, an eight-year-old mid-sized mutt who presented for coughing. X-rays of his chest revealed multiple lung masses, and I told Pixel’s family that I could be 90% certain that they were malignant growths. I left the 10% door open to the slim possibility of an unusual infectious disease. We discussed further diagnostics including a computed tomography (CT) scan of the chest cavity and aspirate or biopsy of a mass in order to “name the enemy”. With that information we could know whether or not we might be able to provide effective treatment for Pixel. His family members felt certain that if Pixel had cancer they would not wish to treat it. Additionally, 90% certainty that their boy had cancer was good enough for them. Pixel’s people had all the peace of mind they needed and the results of the testing would be highly unlikely to change what they would do in terms of treating their little boy. Pixel went home on a cough suppressant and pain medication and is doing reasonably well for the time being.   

Have you ever found yourself in a decision-making dilemma concerning diagnostic tests for your pets? If so, would answers to the two questions above have helped you make your choice?  

Best wishes for good health,         

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
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. 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 is available at Amazon.com, local bookstores, and your favorite online book seller.

Reasonable Expectations VIII: Written Cost Estimates

Saturday, January 8th, 2011

This is the eighth part of an ongoing series describing how people are developing new expectations when it comes to veterinary care for their pets. Parts one through seven can be found at www.speakingforspot.com/blog.

You’ve just taken your best buddy to see your veterinarian because he’s been vomiting for three days and is now beginning to refuse his food. Your vet performs a thorough physical examination with all normal findings, so she recommends blood tests along with X-rays of your dog’s belly.  If these tests don’t provide a diagnosis, she tells you that the next recommended step would be abdominal ultrasound.  Of course you want to proceed with this testing because your dog is a beloved family member and you want him to get better, but do you know how much the recommended diagnostics will cost?  Will you be charged $300, $800,  $1,300? Unless your dog is a “repeat offender” how in the world could you possibly know? Three hundred dollars might be completely within your budget; whereas $1,300 might mean coming up short on your mortgage payment.

Whether you are independently wealthy, barely making ends meet, or somewhere in between, know that it is perfectly reasonable to request a written cost estimate from your veterinarian before services are provided.  Why must you be responsible for asking- shouldn’t your vet automatically offer forth a written cost estimate?  Much to my chagrin, I must tell you that only the minority of vets voluntarily provide written estimates. This was documented by veterinarian/researcher, Dr. Jason Coe and his colleagues. Their research appeared in 2009 within the Journal of the American Veterinary Medical Association.  The article titled, “Prevalence and Nature of Cost Discussions During Clinical Appointments in Companion Animal Practice” documented the following:

• Actual cost is addressed in only 29% of veterinary appointments.
• When cost is discussed, 33% of the time it is the client and not the veterinarian who initiates the discussion.
• Talk related to cost information constitutes a mere 4.3% of the total dialogue time.
• Written cost estimates are discussed during 14% of appointments.
• Written cost estimates are actually prepared and delivered to the client in only 8% of appointments.

Dr. Coe’s research certainly supports the notion that veterinarians are squeamish when it comes to discussing fees for their service.  I must admit it is certainly one of the least favorite parts of my job.  Nonetheless, I consistently provide written cost estimates, particularly if I’ve recommended something other than a single treatment or test, in order to avoid communication snafus and clients who are disgruntled when it comes time to pay their bill. 

Why is a written estimate preferable to a verbal estimate? Written estimates require time and focus. Guaranteed such estimates are far more likely to be accurate than those prepared by the vet using mental math while “on the fly”.  Additionally written estimates avoid uncomfortable conversations such as, “You told me it would be $100, not $300……..” and, “But you never told me you were going to do that……”.   So, please don’t encourage your vet to simply give you a “ballpark estimate” or an estimate “off the top of his or her head.”   I avoid providing such guesstimates at all costs (no pun intended).  Try as I might, I invariably lowball such estimates because of my innate desire to make the cost for my client as reasonable as possible.  And when this happens I end up cutting corners (not a good thing for the patient) and/or having to make uncomfortable phone calls advising clients of added expenses (and I definitely get called into the principal’s office).

It is completely reasonable to receive a written cost estimate before services are provided, but keep in mind, you may need to be the one who initiates this process!  With written estimates everybody wins- communication is so much clearer and there are no surprises when it comes time to collect fees.  Additionally, a written cost estimate provides an itemization for you of everything that is planned for your pooch. Have you received estimates from your veterinarian?  If so have they been delivered verbally or in writing?

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
Recipient, American Animal Hospital Association 2009 Animal Welfare and Humane Ethics Award
Recipient, 2009 Dog Writers Association of America Award for Best Blog
Recipient, 2009 Eukanuba Canine Health Award
Become a Fan of Speaking for Spot on Facebook 

Please visit http://www.speakingforspot.com to read excerpts from Speaking for Spot. 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 is available at Amazon.com, local bookstores, and your favorite online book seller.

Veterinary Care Links and Resources for You and Your Four-Legged Family Members

Saturday, August 15th, 2009

Some new educational links and resources have just been added to my website! I invite you to visit www.speakingforspot.com and take advantage of all that is there. In addition to the “Advocacy Aids” (free downloadable health care forms for your dog or cat), you will now find resources and links about all of the following:

1. Behavior & Training
2. Canine Disease Registries
3. Deciding Whether Veterinary Health Insurance is Right for You
4. Disaster Preparedness
5. Disease-Specific Information
6. Paying for Veterinary Care
7. Pet Loss and Grief
8. Symptom-Specific Information
9. Veterinary References
10. Veterinary Specialty Organizations
11. What to Do When the Diagnosis is Cancer

All of this new material can be found on our “For Dog Lovers” pages. It has been designed to supplement the tools and information found in Speaking for Spot, and will be updated on a regular basis to keep you informed about advances in veterinary medicine. I hope you will find it useful and welcome your feedback. Please let me know what you think and advise me of any additions or changes that would make you happy.

Please feel free to link to our website and share the information with your animal-loving friends and relatives.

Now, here’s wishing you and your four-legged family members much good health!

Dr. Nancy Kay
Specialist, American College of Veterinary Internal Medicine

Join our email list – http://speakingforspot.com/joinemaillist.html

Look for us on Twitter – http://twitter.com/speakingforspot

Become a Fan of Speaking for Spot on Facebook

A “First” in Veterinary Medicine

Monday, August 10th, 2009

Diagnosing and treating canine and feline cancer is part of the daily routine for most veterinary specialists.  In fact, I’ve guesstimated that 75 percent of the patients I care for have cancer. Depending on which source you read (and believe) as many as 50 percent of our companion animals will develop cancer at some point during their lives.  Depressing stuff, I know, but perhaps this is why I’m particularly excited about a new drug called Palladia, recently introduced by Pfizer Animal Health. 

Palladia (toceranib phosphate) is the very first drug ever developed specifically for the treatment of cancer in dogs.  We are using it to treat a common type of canine cancer called mast cell disease.  Mast cells normally function in the body as part of the immune system.  In fact, they are the cells primarily responsible for producing allergic reactions.  Just as with other types of tumors, mast cell cancer develops when these cells proliferate in an unregulated fashion. Palladia is being used to treat dogs with mast cell tumors within the skin (where they most commonly arise) that cannot be cured surgically.  The drug works directly at the level of the cancer cell and interferes with blood flow to the tumor. 

Palladia is an exciting, new treatment option for dogs with mast cell tumors.  I’m pleased that, for the first time, an effective cancer-fighting medication has been developed specifically for the veterinary profession. Please let me know if your dog happens to have mast cell cancer.  I will be happy to provide you with more details about treatment options.

Now, here’s wishing you and your four-legged best friend good health! 

Dr. Nancy Kay
Specialist, American College of Veterinary Internal Medicine 

Please visit http://www.speakingforspot.com to read excerpts from Speaking for Spot. 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 is available at Amazon.com, local bookstores, or your favorite online book seller. 

Join our email list – http://speakingforspot.com/joinemaillist.html

Look for us on Twitter – http://twitter.com/speakingforspot

Become a Fan of Speaking for Spot on Facebook

Listen to Dr. Kay’s interview – A Veterinarian Advises “How to Speak for Spot” on NPR’s Fresh Air with Terry Gross –

Way to Go, Alabama

Friday, July 3rd, 2009

Alabama is the last state in the union with a law requiring annual rabies vaccinations for dogs and cats.  I was delighted to learn that this is about to change – plans are in the works for the state to amend its requirements from once a year to once every three years.  Why am I so pleased about this?  If you’ve read Speaking for Spot you know that I am a proponent of vaccinations, but I am adamantly opposed to overvaccinating (giving unnecessary vaccinations and giving necessary vaccinations more frequently than necessary).  Giving a rabies vaccination once a year is definitely too much of a good thing. 

Vaccines are not without potential adverse side effects.  As with any other medical procedure, all of the risks and benefits of a particular vaccine should be weighed before a pet is inoculated.  A once a year rabies vaccination offers all the risks with no benefits (protective immunity lasts a minimum of three years).  Kudos to the Alabama state legislature for waking up from their “vaccine slumber.”  I’m delighted they’ve chosen to do what is in the best interest of our pets.

Wishing you and your four-legged family members good health, 

Dr. Nancy Kay
Specialist, American College of Veterinary Internal Medicine 

Please visit http://www.speakingforspot.com to read excerpts from Speaking for Spot. 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 is available at Amazon.com, local bookstores, or your favorite online book seller. 

Look for us on Twitter – http://twitter.com/speakingforspot

Become a Fan of Speaking for Spot on Facebook

Listen to Dr. Kay’s interview – A Veterinarian Advises “How to Speak for Spot” on NPR’s Fresh Air with Terry Gross –

A Delightful Coincidence

Saturday, May 30th, 2009

Seung will be entering his last year of veterinary school at Colorado State University.  On top of his busy academic load, he manages to work part time as a technician at Fort Collins Veterinary Emergency Clinic. As a way of figuring out which area of specialization to pursue following graduation he decided to experience an externship in a large emergency/specialty hospital.  His wife Stephanie heard my NPR interview on Fresh Air with Terry Gross and suggested that Seung consider my hospital.  Being the good husband that he is, he did exactly that- an externship was arranged.  Imagine his surprise (and mine) when Seung learned that one of his coworkers at the Emergency Clinic is none other than my 22-year-old son, Jacob!  Seung has stayed in our home and worked at my hospital this week.  He’s an exceptional student who is going to go far in the veterinary profession, and we’ve enjoyed his company enormously.  What a delightful coincidence! 

Dr. Nancy Kay

Specialist, American College of Veterinary Internal Medicine 

Please visit www.speakingforspot.com to read excerpts from Speaking for Spot. 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 is available at Amazon.com, local bookstores, or your favorite online book seller. 

Look for us on Twitter – http://www.twitter.com/speakingforspot

Become a Fan of Speaking for Spot on Facebook - http://www.facebook.com/home.php#/pages/Nancy-Kay/105415179814?ref=share

Listen to Dr. Kay’s interview – A Veterinarian Advises “How to Speak for Spot” on NPR’s Fresh Air with Terry Gross – http://www.npr.org/templates/story/story.php?storyId=102105836

Speaking for Spot on NPR's Fresh Air with Terry Gross

Friday, March 20th, 2009

The segment I taped for NPR’s Fresh Air with Terry Gross aired on March 19, 2009 and is now available on the NPR website – http://www.npr.org/templates/story/story.php?storyId=102105836

Please visit www.speakingforspot.com to read excerpts from Speaking for Spot. 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 is available at Amazon.com, local bookstores, or your favorite online book seller.  

 

Wishing you and your dog good health,

 

Dr. Nancy Kay

Specialist, American College of Veterinary Internal Medicine

Look for us on Twitterhttp://twitter.com/speakingforspot

Getting More Bark for Your Buck

Thursday, February 12th, 2009

Today the human-animal bond is stronger than ever. Seemingly, the more tumultuous the world around us, the tighter we cling to our beloved pets. They soothe us with their predictability and unconditional love, and they consistently give in excess of what they receive. Imagine then, the heartache one feels when it’s necessary to cut back on a pet’s health care because of financial hardship.

Last week I worked with Joan and her ten-year-old Labrador, Rudy who still acts like a puppy. They are devoted to one another, and Joan has always done everything possible to care for her best buddy’s health. Rudy had been vomiting and not finishing his meals (keep in mind, most Labs would quit breathing before they quit eating). When I mentioned blood tests and X-rays, Joan began sobbing and expressed profound guilt and worry because she was unable to afford these diagnostics. Like so many others in this diseased economy Joan recently lost her job, depleted her financial reserves, and was in the midst of foreclosure. I gave Joan a big hug, told her how much I appreciated her candor, and reassured her that a diet change and medication to soothe Rudy’s stomach might be the solution. She will call me with an update next week.

If you are feeling a financial pinch (who isn’t these days), here are some things you can do to economize while still caring for your pet’s health.

-When talking with your vet, lay your financial cards on the table. Yes, this is difficult (talking “fleas” is one thing- having a candid conversation about your bank account is whole ‘nother ball game), but know that such discussion can open doors to options that make better financial sense. Rarely is there only one way to diagnose or treat a disease. You are entitled to an explanation of the risks and benefits of every single option, regardless of your financial status.

-Request a written cost estimate before services are provided. In no way does this reflect how much you love your pet; you are simply being fiscally responsible.

-Learn about all of your payment options.

-Consider investing in pet health insurance, especially if you are inclined to take the “do-everything-possible” approach.

-Don’t neglect the preventive care that could save you money in the long run. Administering heartworm preventive is less expensive for you (and safer for your dog) than treating heartworm infection.

What should one do if forced to contemplate euthanasia for a pet solely because of financial constraints? Before succumbing to such a drastic decision, I strongly encourage thoroughly investigating every other conceivable option. Consider coming up with a creative payment plan such as bartering services or goods, borrowing money from friends or relatives (borrowing from a bank might be a silly suggestion these days), contacting a dog rescue association, applying for a donation from a pet health assistance organization, or finding a new, financially capable guardian for your pet. Such exploration of options might just save a life and will do wonders for everyone’s peace of mind.

Please visit www.speakingforspot.com to read excerpts from Speaking for Spot. 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 is available at Amazon.com, local bookstores, or your favorite online book seller.

Wishing you and your dog good health,

Dr. Nancy Kay
Specialist, American College of Veterinary Internal Medicine

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