second opinion

Re: second opinion

Clive Ansell — Thu, 25 Mar 2010 08:08:16 GMT

I don't see the problem, other than a pain in the backside client. Tell them to s** off, and if they are abusive over the telephone, hang up. You did nothing wrong.

You offered further work up and referral which was declined. If the dog deteriorated as a result, that is entirely the fault/responsibility of the client, not you.

If the blood and ecg results were written in the clinical notes that were faxed over, all useful information would/should have been included.

The referral centre would almost certain perform their own work up; ecg, rads, ultrasound etc as they deemed fit. If any information was missing, they could ring and ask for it.

The neighbouring practice should not have taken on a routine second opinion consult until they had all of the clinical history including results, particularly with such a complex case. If the dog presented as an emergency that is different, but that would not be a second opinion consult.

As the dog was referred by the second opinion vet, then this was an arrangement between 2nd vet, client, and referral centre, so the responsibility lies with that vet to communicate with and supply all necessary information to the referral centre.

As with a recent VDS case involving a vomiting dog with a FB, it highlights the importance of making good contemporaneous notes, when the chips are down the so and so's will lie!. If I ever feel a client is going to be difficult I ask a VN to attend the consult as a witness and to make brief clinical notes too, belt and braces really.

Re: second opinion

Utlendigur — Wed, 24 Mar 2010 21:47:56 GMT

I saw a dog last week with mild cough for few weeks, one week of exercise intolerance and a syncopal episode. Pale membs, possible mild ascites and hepato+splenomegally, severe bradycardia. In house biochem mild increase liver enzymes, PCV 55%, abdomenocentesis -ve, ECG appeared to show 3rd degree AV block + ventricular escapes (had discussed xray + ultrasound but the owners - some of our most difficult clients- pulled a face, and anyway after the ECG I felt the dog really needed referral for further work up and probable pacemaker). Owners declined referral due to cost (£4000+ workup) but didn't put it as politely, then went off to a neighbouring practice on Saturday for a 2nd opinion at a time when our surgery was shut so the 2nd opinion practice couldn't get the notes - so they saw the clients anyway, and arranged referral for Tues am. They then phoned for the notes Monday morning. At this point I admit we cocked up - when I got over mid morning from the branch one of our nurses said she'd sent "everything" - I didn't realise she'd sent the notes but not the print out of blood results (written up in notes though) or the ECG (also written up in notes + which probably wouldn't have faxed well anyway). I spoke to the 2nd opinion vet later that day and he didn't mention the missing bits so I was unaware until....This morning I had the client screaming at me down the phone claiming I was trying to hide something and had caused him to have to fork out hundreds of £s referral fees by not sending all the records (which I hadn't realised had even happened til then), and had also not given him the option of referral!. My feeling on this

1. if the second opinion vet had deferred the consult until Monday (dog had a serious problem but was coping fairly well) he could have done a proper 2nd opinion with the notes and work up to look at, knowing the situation, plus the confusion over the ECG/bloods could have been avoided

2. All we knew Mon am was the client was being referred, not where - so how we could have posted a usable copy of the ecg to the referral centre for Tues am is unclear, and sending it to the 2nd opinion vet would have achieved nothing since he'd already seen the dog and referred it on.

3. The second opinion vet seemed not to have discussed that the referral centre would repeat everything anyway (plus more besides) + would be expensive just for the work up - the client seemed to think they would just look at our ECG printout...

4. We need some staff training and protocols

Re: second opinion

Evelyn Barbour-Hill — Sat, 13 Mar 2010 15:24:36 GMT

[quote user="Vikki Halliday"]I do think that although as a profession we endevour to follow the most professional course of action, it has to be accepted that in some cases, we are unable to do so due to the valid wishes of clients, who after all provide us with an income.[/quote]

Kate did the right thing and she did follow the most professional course of action.

Re: second opinion

Vikki Halliday LLB — Sat, 13 Mar 2010 10:46:35 GMT

[quote user="Kate Dawes"]

I completely agree that it is professional courtesy to contact a previous vet, and have no wish to 'stab a neighbouring practice in the back', but I didn't feel happy turning away a very upset owner because they refused to let me contact them.

[/quote]

I agree totally with you Kate, and whilst there are guideline in the GtPC, they are in many cases set in an indeslistic world where all vets are nice to each other and clients understanding of these guides.

I do think that although as a profession we endevour to follow the most professional course of action, it has to be accepted that in some cases, we are unable to do so due to the valid wishes of clients, who after all provide us with an income.

Re: second opinion

Kate Dawes — Fri, 12 Mar 2010 11:20:42 GMT

I think it's easy to say what we should do in theory, but slightly harder when you have an extremely upset client in front of you. I don't think this was necessarily an emergency - this condition had been going on a long time, but I do think the cat was suffering.

I did feel very uneasy about it at the time, as without a clinical history I couldn't assess whether there were other options for treatment or further investigation. I did make this very clear to the client though.

Re: second opinion

Hannah Wynne Richards — Fri, 12 Mar 2010 11:11:05 GMT

Exactly Clive Cross-reference with post about OOH If we all treated neighbouring practices as professional colleagues, instead of trying to stab them in the back, there would be far less difficulty in arranging rotas

Wynne

Re: second opinion

Clive Ansell — Fri, 12 Mar 2010 10:57:52 GMT

Unless there was a need for emergency care or euthanasia on welfare grounds, I would ask/insist on contact with the previous vet and access to clinical records as a matter of professional courtesy if nothing else.

Re: second opinion

Hannah Wynne Richards — Fri, 12 Mar 2010 10:49:52 GMT

I agree with the people who say that the animal's welfare must come 1st, if it is suffering. If not, and they just want to change practices, without informing their current veterinary surgeons, then the attitude of this cynical old practice owner is that they have probably exhausted their credit, and I don't want bad debts, so will refuse to have anything to do with them, until I've had thier records

Wynne

Re: second opinion

Kate Dawes — Fri, 12 Mar 2010 07:58:59 GMT

Good to have some reassurance, thanks.

I think the main reason that they didn't want us to contact their previous vet was they felt that he would probably be reluctant to put the cat to sleep as he had been treating it for so long, and would want to try some other course of treatment, which they didn't want.

I did suggest that we contact the other practice afterwards just to let them know the cat had been euthanased, but again they refused to give us details.

Re: second opinion

Evelyn Barbour-Hill — Fri, 12 Mar 2010 00:59:46 GMT

[quote user="Michael Woodhouse"]Even using one practice for neutering and vaccinating (cheap?) and another because they think they are clinically better.[/quote]

If I found out a client was doing that I'd charge 'em extra.

Re: second opinion

Michael Woodhouse — Fri, 12 Mar 2010 00:22:23 GMT

Kate - I too would have put the cat to sleep. The animal's welfare takes precedent.

I can think of a couple of occasions where clients move to us and sometimes seem unable to remember their old vets details. There was a cat brought in with skin problems that only mentioned after the 2nd/3rd visit that they had been under treatment at another practice (we then contacted them).

We can only act on the information we are given at the time.

People are becoming very fickle consumers and chopping and changing vets - this is something that is going to happen more and more. Even using one practice for neutering and vaccinating (cheap?) and another because they think they are clinically better.

Re: second opinion

Charlotte Marshall — Thu, 11 Mar 2010 23:01:49 GMT

I think I probably would have done the same thing. If the cat was obviously suffering and euthanasia was a valid treatment option I would feel did I want to let them go out with the cat and perhaps wait until it deteriorated even further if they were not willing to pursue any other treament? I think it is a case when you have to try and decide what is in the best interests of the cat from a welfare point of view.

I wonder why they did not feel able to ask their original vet for euthanasia.

Re: second opinion

Kate Dawes — Thu, 11 Mar 2010 18:08:40 GMT

This has reminded me of a case that I saw a few years ago. It was an elderly cat with a terrible chronic skin condition (weeping sores all over from what I remember). The cat had been under treatment with another vet for years with apparently no, or only very limited success. The owners phoned up very upset requesting euthanasia as they had had enough and felt the cat had too. When the receptionist advised them that we should contact their vet they refused. I did see them - they were absolutely adamant that they wanted euthanasia and no further treatment or investigation. I advised them that I couldn't give a second opinion without finding out what treatment/investigation had been done in the past. Again they flatly refused to let us contact the previous vet, and didn't want to discuss any other options for treatment. After a very long discussion I did agree to euthanase the cat as it was clearly suffering. May be I was wrong to do this I don't know, as I saw it if I didn't they would have been even more upset and I'm sure would have gone to another vet who would have agreed. Just interested to know what other people would have done.

Re: second opinion

Clive Ansell — Thu, 11 Mar 2010 16:59:05 GMT

Many 2nd opinions I have seen tend to be skin cases, in fact last week I saw a pruritic SBT for a 4th opinion. In short the owners have no money and want a magic wand instant fix and don't want to pay for any investigation. I examined the dog and advised investigative work rather than just the usual preds/ab's/malaseb/advocate - they informed me the previous 3 vets had said the same thing!

They declined investigation and left with repeat symptomatic treatment, they even refused a skin scrape (actually costs less than a consult!) to try and rule out Demodectic/sarcoptic mange. Idiots!, the extra 3 consultations would have gone a fair way to paying for some lab work. I guess they will go and get a 5th opinion somewhere.

Re: second opinion

Gillian Mostyn — Thu, 11 Mar 2010 09:14:50 GMT

[quote user="Evelyn Barbour-Hill"]I do think it's silly for owners to tote their animal round one general practice after another until they get an opinion they like.[/quote]

I'd agree. And I have had quite a few where I have told the owners to continue with their own vet as they are pursuing a diagnosis the same way I would, and moving vets would gain nothing. It is usually the case that they expect immediate diagniosis and the vet hasn't explained fully that it will take time in some cases...

I obviously can't discuss this individual case - but I did say the vet hadn't done anything significantly different to what I would have done. However, the animal hadn't then improved and the owners were concerned about the vet's lack of follow-up.

Re: second opinion

Evelyn Barbour-Hill — Thu, 11 Mar 2010 01:40:19 GMT

[quote user="Vikki Halliday"]I don't see how we can then refuse to see the animal [/quote]

We - I - can refuse to see it (unless it's really urgent) if I want to. I wouldn't want to have any client that would seek a second opinion covertly.

But, you know, most of these things arise as much from misunderstanding as anything. Use a bit of diplomacy and a bit of tact and a bit of common sense and deal with it according to circumstances, and don't get on your high horse unless you have to.

Relatively often, I'll get an outline of the problem, and if it's not in my specialist field I'll say "well, there's nothing to be gained by your seeing another general vet: Binky may need to see a specialist, and I'm sure Mr Yourvet will arrange this if you ask him politely".

I do think it's silly for owners to tote their animal round one general practice after another until they get an opinion they like.

Re: second opinion

Utlendigur — Wed, 10 Mar 2010 21:03:49 GMT

[quote user="Vikki Halliday"]If a client wishes to seek a second opinion, then I can't see how this paragraph will apply as although we all should request a history. we don't need the other vet's "permission" [/quote]

But it's not the other vet's permission we're talking about, it's the client giving permission to contact the original vet in order to obtain the history, and there are sections in the GTPC about not hindering a client from seeking a second opinion or changing practices ie you should provide the history when asked.

The paragraph (39) says " Although both veterinary surgeon and client have freedom of choice, as a matter of professional courtesy and in the interests of the welfare of the animals involved a veterinary surgeon should not knowingly take over a colleague's case without informing the colleague in question and obtaining a clinical history."

I certainly wouldn't like the idea of trying to give a second opinion, especially in a longstanding case, with only a clinical exam and the owner's version of the history to go on. What happens if the animal has had treatment which interfere with the clinical signs or lab tests? Owners don't always remember what injections have been given or the significance of results. You could land up in very deep brown stuff quite quickly, aswell as potentially making a misdiagnosis or administering drugs which interact.

I had a couple bring a dog in a few years ago, and what they were telling me just didn't seem to hang together or fit with the clinical exam. Eventually they realised I was getting suspicious and owned up that the dog had been to another vet the previous day (despite initially telling me it hadn't been to a vet in years) and "had a couple of injections" (turned out to be antibiotic and long-acting steroid) - I had been going to put it onto nsaids which would have probably given it lovely GI ulceration. One thing that really annoys me is clients trying to play vets off against each other

Re: second opinion

Clive Ansell — Wed, 10 Mar 2010 20:12:49 GMT

[quote user="Clive Ansell"]

[quote user="Laurence Webb"]

[quote user="Utlendigur"]

When an animal is initially presented a veterinary surgeon must ask whether it is already receiving treatment, and if so, when it was last seen, and then contact the original veterinary surgeon for a case history

[/quote]Is there a difference between a case that has just been examined (but not had any treatment) by another vet and a case that has already received treatment?

[/quote]

I think if the patient has seen another vet, then it is "under their care"

Either way I would want contact with the first vet and access to any clinical history before proceeding. I would also want to know in this case, why the client refuses to name the first vet ??

It is not always possible though. I recently saw a second opinion for a cruciate op that had gone wrong. The op was carried out in Poland and the clinical notes were in Polish. Similarly an unstable diabetic dog that had been treated in Spain and all notes in Spanish.

[/quote]

Re: second opinion

Vikki Halliday LLB — Wed, 10 Mar 2010 20:05:19 GMT

[quote user="Clive Ansell"]

[/quote]

Ah yes but this paragraph which I and a few others have quoted actually refers to succession and clearly states so. This would be applicable if a vet attempted to treat the animal in question.

If a client wishes to seek a second opinion, then I can't see how this paragraph will apply as although we all should request a history. we don't need the other vet's "permission" to see a case, that's just ridiculous!

A client has a right to a second opinion, and if that is all they seek, not treatment, then if they refuse to provide you with details of their previous vet, or request that you do not contact them, I don't see how we can then refuse to see the animal unless they try to get you to treat it, and therefore become guilty of succession. The G2PC only gives guidelines of best practice, and I am hard pushed to see where it says anywhere with specific reference to second opinions that "thou shalt not" even give such an opinion without contacting the existing practice.

I admit I would always try to obtain permission, and have not yet had anyone decline, especially, as like Gillian has, I have taken great pains to explain to the client what the issues are.

It does raise a very important issue. We should not "police" clients, or other veterinary surgeons, and if a client wishes to be covert about seeking a second opinion that should be their decision. If all the issues regarding relevance of existing clinical records, and professional guidelines have been raised with the client, but they resolutely refuse permission, I would record same and give them the opinion, but certainly refrain from giving any treatment at all.

By the way well done Gillian sounds like you handled it like a pro!

Re: second opinion

Clive Ansell — Wed, 10 Mar 2010 19:20:52 GMT

[quote user="Laurence Webb"]

[quote user="Utlendigur"]

[/quote]Is there a difference between a case that has just been examined (but not had any treatment) by another vet and a case that has already received treatment?

[/quote]

I think if the patient has seen another vet, then it is "under their care"

Either way I would want contact with the first vet and access to any clinical history before proceeding. I would also want to know in this case, why the client refuses to name the first vet ??

Re: second opinion

Gillian Mostyn — Wed, 10 Mar 2010 19:17:25 GMT

Evelyn - did anyone ever tell you you're a very clever man??

[quote user="Evelyn Barbour-Hill"]You are going to have to talk to the people when they turn up and show that you are actually interested in their problem[/quote]

I explained my situation...

[quote user="Evelyn Barbour-Hill"]Quite often people turn up for a second opinion in all innocence, really not knowing that they should have asked the original veterinary surgeon. [/quote]

They didn't realise that I would need the previous vet's permission.

[quote user="Evelyn Barbour-Hill"]One wonders what the reason for the refusal is!! Sometimes it's "I don't want to upset them".[/quote]

Yup. They've been with them a long time.

[quote user="Evelyn Barbour-Hill"] you can generally give the practice a ring, and according to circumstances it may be by common sense quite all right to go ahead and examine anyway. [/quote]

We did. I went ahead with treatment.

All's well that ends well - many thanks for your advice - worked a treat!

And a lesson learnt - make all staff, especially reception, aware of the 'no previous history, no second opinion' policy.

Re: second opinion

Laurence Webb — Wed, 10 Mar 2010 19:13:58 GMT

[quote user="Utlendigur"]

[/quote]Is there a difference between a case that has just been examined (but not had any treatment) by another vet and a case that has already received treatment?

Re: second opinion

katja wagner — Wed, 10 Mar 2010 19:06:05 GMT

I do understand the quoted guidlines and of course always follow the rules but from a clients point of view i can hardly believe one would not be allowed to see a different vet without having the permission from the original one. it might not be in the best interest of the animal but doese this actually mean that the rcvs can forbid the client to see a new vet?

katja

Re: second opinion

Clive Ansell — Wed, 10 Mar 2010 18:25:55 GMT

I would not accept the case, no question. I would want contact with the existing vet and a copy of any relevant history before accepting the case. If they just turn up, then I'm afraid they would be turned away unless an absolute clinical emergency.

Re: second opinion

Utlendigur — Wed, 10 Mar 2010 17:43:46 GMT

As far as I'm aware if the case is ongoing and the owner refuses to allow you to contact their present vet then you must decline it.

40. When an animal is initially presented a veterinary surgeon must ask whether it is already receiving treatment, and if so, when it was last seen, and then contact the original veterinary surgeon for a case history. It should be made clear to the client that this is necessary in the interests of the patient. If the client refuses to provide this information the case should be declined

Seems pretty definite. I've been in this position several times and have always refused to proceed.