The shared decision making consultation model

RE: The shared decision making consultation model

Lucy Fleming — Tue, 26 Nov 2019 16:02:29 GMT

[quote user="Bob Russell"]Yes, an anal sac problem can be an emergency. I suspect an abscess in that area is likely to be very, very painful. Pain alone can be an emergency![/quote]

One of the things that I find frustrating about those insurance claim forms with a yes/no box to tick that says "If the animal was seen out of hours, was the condition life threatening". To my mind (and I do think it's reasonable for them not to foot the bill for the clients convenience) there's a large number of cases seen out of hours that fall into the gulf between "life threatening" and "Ok to wait until Monday". (

And that's even without including the vague over the phone descriptions that could be anything from a perfectly healthy dog to a GDV and you won't know without laying hands on it.)

RE: The shared decision making consultation model

Bob Russell — Tue, 26 Nov 2019 13:49:34 GMT

My first boss had a phrase that I like to this day.

Client phones up out of hours, apologetic and not sure if it is an emergency. Response along the lines that if it was worrying them enough to phone out of hours it is a bit of an emergency.

Phone triage to weed out the silly and a warning at that point about the fees involved to weed out those wanting convenience. Should sort out at least 95% of client calls.

Yes, an anal sac problem can be an emergency. I suspect an abscess in that area is likely to be very, very painful. Pain alone can be an emergency!

Bad toothache anyone?

RE: The shared decision making consultation model

Anthony Dennison — Tue, 26 Nov 2019 13:24:22 GMT

[quote user="Anthony Todd"]Surely that would now include surgery, biopsy and chemo, in my cat with a massive mobile irregular mass in the abdo [as an example, and not with modern developments in chemo which I will have [now] mentioned][/quote]

It might do, however there are more options than just surgery biopsy and chemo in this case. We all know it, and we all discuss these options with owners. You've gone full on rant Tony and just not listening to what anyone says anymore.

[quote user="Anthony Todd"]My analysis some years ago showed that the high of "bloods" was 18.45 and the low was 10,30.... but how many scored additional vital or significant information?[/quote]

This doesn't even make sense. If you mean hit rates - you may get a definitive diagnosis but even if you don''t you have a much better idea of what's going on and prognosis.

[quote user="Anthony Todd"]but on a cat "not eating" would be near 5% so the history and further info./observation from the owner is needed AND FREE rather than a blood![/quote]

It wouldn't be free to the owner.

RE: The shared decision making consultation model

Anthony Todd — Mon, 25 Nov 2019 17:36:43 GMT

[quote user="Anthony Dennison"]People often put in their post 'finances limited' so people don't suggest referral or advanced, expensive procedures.[/quote]

Surely that would now include surgery, biopsy and chemo, in my cat with a massive mobile irregular mass in the abdo [as an example, and not with modern developments in chemo which I will have [now] mentioned]

I would still favour a published "hit rate" on any test, not the negatives but the positives, or confirmations, as someone has criticised me for, the differences might surprise !

My analysis some years ago showed that the high of "bloods" was 18.45 and the low was 10,30.... but how many scored additional vital or significant information?

I'd bet on the 10.30% but it wouldn't be 0%

Eg, I say the hit rate on a # femur, or radius and ulna, would be near/at 100% but on a cat "not eating" would be near 5% so the history and further info./observation from the owner is needed AND FREE rather than a blood!

RE: The shared decision making consultation model

vs0u — Mon, 25 Nov 2019 17:07:35 GMT

[quote user="Gillian Mostyn"]I know cystitis was just an example, but I really don't think many owners would prefer to present their pet at midnight for a completely non-urgent issue? But I'm happy to be corrected by someone with more recent OOH centre experience?[/quote]

You'd be surprised how many emergency anal glands there are!

RE: The shared decision making consultation model

Anthony Dennison — Mon, 25 Nov 2019 16:19:21 GMT

[quote user="Anthony Todd"]I would be very surprised if OOH fees and an "insured??" inquiry were not mentioned in an OOH request??[/quote]

We do our own OOH and also provide OOH for 3 other local practices. Insurance is never questioned on initial contact, only if an animal needs to be admitted for a procedure. And it's asked at the end of everything, not before.

[quote user="Anthony Todd"]I'd be vet B every time.[/quote]

You come across as being Vet A a lot of the time which is why everyone gets infuriated.

[quote user="Anthony Todd"]I apologise then, because I got the impression that, sometimes, with some vets, tests were done straight off without any provisional diagnoses, differentials or discussion.[/quote]

I don't get that at all. Reading posts I see a summary of what's been done. Don't think a record of dialogue between owner and vet is required.

People often put in their post 'finances limited' so people don't suggest referral or advanced, expensive procedures.

RE: The shared decision making consultation model

Anthony Todd — Mon, 25 Nov 2019 16:01:15 GMT

[quote user="Anthony Dennison"]For example -[/quote]

I'd be vet B every time.

I apologise then, because I got the impression that, sometimes, with some vets, tests were done straight off without any provisional diagnoses, differentials or discussion.

Glad to be reassured.

RE: The shared decision making consultation model

Joyce Whitehead — Mon, 25 Nov 2019 15:44:08 GMT

We do our own out of hours, so are not an OOH centre. However, although I will always tell owners that out of hours consultations are significantly more expensive, and give them a rough quote, I never ask about insurance. I have had owners who have said “oh he/she is insured“ when I say out of hours cost more, as they assume they can therefore claim back and want to be seen more quickly.

RE: The shared decision making consultation model

Anthony Todd — Mon, 25 Nov 2019 15:33:23 GMT

[quote user="Gillian Mostyn"]The OOH centre won't know insurance status on initial enquiry.[/quote]

I would be very surprised if OOH fees and an "insured??" inquiry were not mentioned in an OOH request??

RE: The shared decision making consultation model

Anthony Dennison — Mon, 25 Nov 2019 15:27:27 GMT

[quote user="Anthony Todd"]

So, Gillian,please listen to me, even just with a consult fee, history and a thorough exam one should be able to get a long way down the diagnostic path, in fact a pretty short list of possibles, and, from this an estimate of costs including all necessary tests and/or procedures??

Then "I need to do a blood etc. which will cost £xxxxxx is this OK?"

[/quote]

This is what we do as vets. Yes there may be the odd outlier that just does bloods as a fishing trip but the vast majority of qualified professionals will narrow down the differentials then used bloods to 100% confirm and start treatment.

[quote user="Anthony Todd"]This is why I said "money" should come further along the "consultation pathway [better?] than at the beginning.[/quote]

Again most often money does come up at the end when suggesting diagnostics. However we have to be open and honest about our fees. If a client comes in OOH, they need to know how much a consult will be as they may want to go elsewhere.

[quote user="Anthony Todd"]I remember various posts on here [not recently I admit] apolgising for a lack of any diagnosis because there wasn't enoough money, or no insurance, even to suggest a diagnosis or pathway.......[/quote]

These posts were 'cases of the week' to try and stimulate discussion. And often these posts won't have all the information in them otherwise they would be full essays that aren't easy to read - people will bullet point the salient information so they can get the answers they need. Just because you treated things blindly Tony and it got better doesn't mean your diagnosis guess was correct, it just means the symptomatic treatment was succesful (ie preds - give preds and it will improve most things clinically. Doesn't cure it...).

For example - dog comes in, pot bellied, bad skin, PU/PD and poor quality coat. Vet A and B perform a full clinical exam and get a history.

Vet A - 'It's Cushings. Here's some vetoryl, come back in a month.'

Vet B - 'I strongly suspect Cushings, but could be hypothyroidism or liver disease/neoplasia. To confirm I recommend bloods to check liver enzymes, total T4 (included in our senior profile). Costs £XX. Is that a bit much Mrs Smith? Ok well lets get a urine sample first to check a couple of things then if indicated we can progress to bloods. Ok with that?'

Work up is done - with costs explained at every step, and dog is diagnosed with a liver tumour. Owner decides on palliative care and support, dog is euthanased after 6 weeks.

With Vet A, dog becomes Addisonian, has a crisis, given a poor prognosis and is euthanased there and then. Or dies at home, or goes to another vet practice for a 2nd opinion. Vet A thinks 'I've cured that dog, aren't I amazing' but in fact made the dog worse, just never saw it back to find out what went wrong.

Vet B is with the owner throughout the process, and at the euthanasia. Gets a nice bottle of wine and card for all their care.

Scenario 2:

Dog is PU/PD, losing weight. Owner brings in a urine sample, which has lots of glucose in.

Vet A: 'Your dog is diabetic. Here's some insulin, come back in a week'

Vet B: 'There is glucose in the urine but also it is isosthenuric, with protein present. I recommend bloods to check renal function and blood glucose. I suspect Diabetes but it could be something with the kidneys'.

Dog turns out to have a weird renal tubular disease that is managed with medication and diet. Dog treated by Vet A goes hypoglycaemic and passes away after seizuring.

Vet A - 'never saw that dog back. Must have cured it.'

RE: The shared decision making consultation model

Gillian Mostyn — Mon, 25 Nov 2019 15:00:34 GMT

[quote user="David Mills"]The classic is out of hours providers and how urgently something "needs" seeing according to how much money is available or what is "covered by insurance". [/quote]

But to be fair, the OOH centre isnt making the decision about whether it needs seeing, the client is, so the issue is not related to insurace cover. The OOH centre won't know insurance status on initial enquiry.

[quote user="David Mills"]Makes me wonder how some people can tick the box on the insurance form stating a female cat with cystitis was a £300 "emergency". [/quote]

As the client pays the first £100 or so, it is probably cheaper for them to attend in normal hours. Therefore, you have to assume the cat's behaviour is what alerted the owner to it being urgent/an emergency, not just their convenience. Could you sit and watch your cat constantly straining to pass urine all night, crying and distressed, often passing frank blood? Unfortunately I can speak with some experience and confirm that cystitis can require urgent analgesia! As an owner can't just give some Calpol or ibuorofen and wait till morning, I think it is a kindness to be prepared to see the cat. Not one to be punished by refusing to confirm it needed seeing!

I know cystitis was just an example, but I really don't think many owners would prefer to present their pet at midnight for a completely non-urgent issue? But I'm happy to be corrected by someone with more recent OOH centre experience?

RE: The shared decision making consultation model

Anthony Todd — Mon, 25 Nov 2019 14:27:35 GMT

I get slagged off for wanting to mention , and therefore justify, finances, but only after reasoning the need, and then the slagger says:

Hmmm not sure actually. The classic is out of hours providers and how urgently something "needs" seeing according to how much money is available or what is "covered by insurance". Makes me wonder how some people can tick the box on the insurance form stating a female cat with cystitis was a £300 "emergency".

Quote Review Entire Thread

RE: The shared decision making consultation model

James Dunne — Mon, 25 Nov 2019 07:49:34 GMT

'Hmmm not sure actually. The classic is out of hours providers and how urgently something "needs" seeing according to how much money is available or what is "covered by insurance". Makes me wonder how some people can tick the box on the insurance form stating a female cat with cystitis was a £300 "emergency". '

Hi David

While my observations may be somewhat away from the point of the thread, the above clinical condition is both common and maybe an example for debate. With regard to money, it is possible that such a case would be put off being seen as an 'emergency' since it is not life-threatening and, as you pointed out, some (?many?) customers would choose to leave it until the next day rather than shell out £300 for an OOH consultation. But, as I think (?David Coffey?) pointed out many years ago in VT, cystitis is quite painful, so why leave it waiting when it is relatively simple to give pain relief? I would hazard a guess that most of us doing OOH in our own practices would just see the patient and adjust the fee to keep the owner happy and patient comfortable rather than leaving it if financial considerations came into play. I also understand the difficulty OOH vets working for others have in needing to finance the centre and having to charge the same initial visit fee for cat flu cases as for ones with haemoabdomen. Neither would any of us like to be 'woke' to see cystitis cases at 2am….I'd say though in this kind of case, money has a considerable impact on whether treatment is undertaken swiftly, depending on the time of day!. There are plenty of other examples no doubt (cat bite abscess, broken toe etc etc) and it should boil down more to whether we see an emergency as how threatened the patient's life or function is versus how much pain the patient is in, whether life-threatening or not. The money side of things should only really be the client's problem and not influence our initial advice, whether we lean more on average towards diagnosis first, treatment later or empirical treatment first, diagnose further if required. Whether they take our advice may depend on finance, but then we offer whatever plan B or C is etc. And I think there is room for shared decision-making in this instance because it is our responsibility, surely, to explain the value of whatever money - or not - the client is being recommended to part with.

RE: The shared decision making consultation model

David Mills — Sun, 24 Nov 2019 23:06:20 GMT

This used to be an interesting thread.

The peculiar ramblings of a retired vet have destroyed it.

With a heavy heart, christ, ban him. If you just look at when his posts started and people's responses? This was an expansive, thought provoking thread. Run into the ground, yet again, by rambling shite. 'm never going to reply to this nonsense. He evidently can't behave.

RE: The shared decision making consultation model

Nicola Cole — Sun, 24 Nov 2019 21:54:24 GMT

[quote user="Anthony Todd"]

[quote user="Gillian Mostyn"]That really doesn't happen.[/quote]

Not trying to flog the thread but these quotes from the forum seem to query that:

-referral not an option financially (very limited finances

Finances didn’t stretch to GA X-ray either! So looking at things we could test for cheaply in house that would change treatmentI did an in-house Baermann’s-positive for Angiostrongylus larvae.No money for further investigation or referral.

[/quote]

Right well as that quote is from one of my posts I think I’ll answer that one!

It was a ‘case of the week’ showing neuro signs.

I said finances limited because I wanted to demonstrate that, in this specific case, the answer could be gained from a simple in house test. A lot of neuro cases end in either trialling treatment based on what is the most likely diagnosis OR in referral especially if a young dog with significant neuro signs.

The reason I decided to use that in house test was because I had taken a careful history, examined the patient carefully and had come up with a differential diagnosis list based on that information alone (specifically the history in this dog to indicate lungworm as a possible cause). I then decided what tests I could do in house that would significantly change treatment/plan.

I was asked about whether could do an GA and X-ray and I said finances didn’t stretch to that. I personally don’t think that a lot of people would have thought of lungworm straight away. So in terms of in house tests that could be done to help rule in/out things on my differential list it was fairly limited.

Lungworm was confirmed in the faeces. However, I cannot 100% say that that was the cause of the neuro signs and that the patient wouldn’t have just recovered anyway.

He was treated for presumed lungworm and recovered.

Most dogs with significant neuro signs don’t just have lungworm. Unfortunately, a lot of neuro cases need referral for a definitive diagnosis.

Do we always need a definitive diagnosis? No, of course we don’t. But this was a young dog with significant neuro signs. My point about finances in the post was to head off talk of referral as an option.

Pray tell, what would you have done differently in this situation?

RE: The shared decision making consultation model

Gillian Mostyn — Sun, 24 Nov 2019 16:47:27 GMT

OK, Anthony.

RE: The shared decision making consultation model

Anthony Todd — Sun, 24 Nov 2019 12:52:28 GMT

[quote user="Gillian Mostyn"]That really doesn't happen.[/quote]

Not trying to flog the thread but these quotes from the forum seem to query that:

-referral not an option financially (very limited finances

we are confined by costs and owner compliance with this case, but have started medical management and will reassess in a month

some clients demand an absolute diagnosis, particularly some of the insured ones who seem to have a mindset that they want their pound of flesh out of the insurance policy.

In this case the demanding overbearing clients demanded a precise and complete diagnosis, almost accusing me of fobbing them off by not referring immediately.

PS: EBVM continues, and my case of the "swinging abdo. mass" would have a different discussion and prognosis prediction today!

[even if the owner might, even today, not have the funding.....]

RE: The shared decision making consultation model

Gillian Mostyn — Sat, 23 Nov 2019 08:45:25 GMT

[quote user="Anthony Todd"]NOT "I don't [begin] to know what is wrong with your pet because I need to do various expensive tests and you have said you cannot afford them and are not insured.[/quote]

That really doesn't happen.

RE: The shared decision making consultation model

Anthony Todd — Fri, 22 Nov 2019 23:10:24 GMT

[quote user="Gillian Mostyn"]

That very much depends on what the diagnosis is, surely?

Addison's is pretty difficult to diagnose without at least a blood test.

[/quote]

Obviously, but I would have said "confirm"!

Then "I need to do a blood etc. which will cost £xxxxxx is this OK?"

NOT "I don't [begin] to know what is wrong with your pet because I need to do various expensive tests and you have said you cannot afford them and are not insured.

This is why I said "money" should come further along the "consultation pathway [better?] than at the beginning.

I remember various posts on here [not recently I admit] apolgising for a lack of any diagnosis because there wasn't enoough money, or no insurance, even to suggest a diagnosis or pathway.......

RE: The shared decision making consultation model

Gillian Mostyn — Fri, 22 Nov 2019 22:20:44 GMT

[quote user="Anthony Todd"]But even with a consult fee, history and a thorough exam one should be able to get a long way down the diagnostic path??[/quote]

That very much depends on what the diagnosis is, surely?

Addison's is pretty difficult to diagnose without at least a blood test.

Anthony, please listen to me. I'm sure you was a great vet who pleased your clients and fixed most of your patients. But maybe some of those patients were misdiagnosed. Some of those really sick pets that you was convinced were suffering with renal failure, tumours or other dreadful diseases could have been misdiagnosed? There is a limit to what we can do without 'tests'.

A few weeks ago I posted about an elderly dog with peritonitis. When it first presented to me, after 2 weeks of illness and looking dreadful, I discussed with the client that the prognosis was poor as the massive hard painful swelling I could feel behind the last rib on the right was probably a tumour. I offered imaging but also PTS. If we had PTS I'd have been convinced to this day that it was a tumour. As it happens, the owner was happy to pay for an ultrasound to make sure there was nothing to be done. Turned out a kebab skewer had punctured the SI and wedged itself in the abdominal wall, creating a massive amount of inflammation. That dog is now fit and well.

None of us know if all our presumptive diagnoses are correct. There's nothing wrong with giving your educated opinion. But there are few confirmed diagnoses to be made without any lab work or imaging at all.

RE: The shared decision making consultation model

Anthony Todd — Fri, 22 Nov 2019 19:07:13 GMT

[quote user="Gillian Mostyn"]

Insurance has a massive impact on client choices. Apart from the inevitable rare cases, it has no impact on vet choices.

Exactly, 'cos the money is there.......

But then you say:

Money comes before diagnosis only in that sometimes no money = no diagnosis.

[/quote]

But even with a consult fee, history and a thorough exam one should be able to get a long way down the diagnostic path??

RE: The shared decision making consultation model

David Mills — Fri, 22 Nov 2019 13:45:30 GMT

[quote user="Gillian Mostyn"]Apart from the inevitable rare cases, it has no impact on vet choices. [/quote]

RE: The shared decision making consultation model

David Mills — Fri, 22 Nov 2019 13:43:21 GMT

[quote user="Sarah Keir"]

From Arlo's link:

"Woke is a political term of African American origin that refers to a perceived awareness of issues concerning social justice and racial justice.

It is derived from the African American Vernacular English expression "stay woke", whose grammatical aspect refers to a continuing awareness of these issues."

Cultural misappropriation?

[/quote]

Ironically a very woke thing to say! Check out Oxford dictionaries or similar.

RE: The shared decision making consultation model

Gillian Mostyn — Fri, 22 Nov 2019 13:34:23 GMT

[quote user="Anthony Todd"]I may be wrong,but my impression is that these days "money" often seems to come before diagnosis eg "not insured, so no testing" etc. which is even stated on here sometimes.[/quote]

You're wrong Anthony.

Insurance has a massive impact on client choices. Apart from the inevitable rare cases, it has no impact on vet choices.

Money comes before diagnosis only in that sometimes no money = no diagnosis.

RE: The shared decision making consultation model

Sarah Keir — Fri, 22 Nov 2019 12:18:07 GMT

From Arlo's link:

"Woke is a political term of African American origin that refers to a perceived awareness of issues concerning social justice and racial justice.

It is derived from the African American Vernacular English expression "stay woke", whose grammatical aspect refers to a continuing awareness of these issues."

Cultural misappropriation?