locuming question

Re: locuming question

Edward Jones — Thu, 20 May 2010 14:03:20 GMT

[quote user="Vikki Moran"]

the last point actually is what makes me angry, because i think that does appear to be the OOH vet questioning my technique with the client, which i think is inappropriate. I think she should have contacted me personally if that were the case.

[/quote]

As an aside:

From the RCVS Guide to Professional Conduct, part 1F, paragraph 2a: "Veterinary surgeons must not: a. speak or write disparagingly about another veterinary surgeon". http://www.rcvs.org.uk/Templates/PreviousNext.asp?NodeID=89723&int2ndParentNodeID=89717&int1stParentNodeID=89642

If you're sure the OOH vet did speak disparagingly about you I see no reason not to make a complaint against them with the RCVS.

Re: locuming question

Peter Ding — Thu, 20 May 2010 11:56:36 GMT

Hear hear!

If unhappy with a locum one just refrains from re-employing them.

Re: locuming question

Bob Russell — Thu, 20 May 2010 11:15:18 GMT

The VN in question has two hats on.

As a VN he/she is not ultimately responsible for the actual treatment/surgery side of things but as a practice owner he/she is responsible for the actions of her employees.

As the owner of a practice I always take responsibility for ALL that happens within these walls - that is what practice ownership is. Ultimately as a practice owner the buck stops here!!!!

Re: locuming question

Peter Ding — Thu, 20 May 2010 08:51:33 GMT

[quote user="Louise Buckley"]The practice principal is a VN. Therefore, it would be inappropriate for him/her to 'take any responsibility for the way work was carried out at that point'. [/quote]

I beg to differ Louise. On several counts.

Firstly for her employer to withhold payment there must be evidence she was at fault. A level of fault equivalent to professional negligence or at the very least her work was not of "merchantable quality". There is no evidence of this. The suture material broke in every single suture, but knots were all intact. Considering the logical possibilities for suture material to fail in such a small dog the only one i can think of where the employee might have been at fault is poor selection of size of material although I expect even 6 "O" Vicryl would have been inherently strong enough. A cruciate suture pattern is perfectly acceptable. This was an experienced locum etc. Whereas there are numerous possibilities that do not involve the employee, many being the responsibility of the employer. Make of suture material, source, correct storage, being in date, type of suture material available and of course, a faulty batch and premature hydrolysis.

I find it incredulous that an employer fails to see other possibilities for this occurrence given the facts.She disowns all possible responsibility. Was the "locum" not following practice policy in her employment. If there wasn't a practice policy on suture techniques for abdominal closure then why not?

Secondly a VN is certainly able to close wounds and is familiar with suture patterns. In some practices she might even have stitched the dog up herseIf, although that grey area is best left untouched. But it ain't rocket science. If one of my nurses suggests putting another suture in a muscle layer I certainly reflect on whether it needs one and we work together to get the best outcome. Ditto checking dentals. If she saw something she was not happy with in the locums technique to the point of incompetence why on earth did she not say something at the time. If she didn't see anything wrong, and i am pretty sure she did not, how can she suggest negligence? She's pretending not to have been a member of the surgical team at the time? Would she have refused to pay the employee had her own monitoring of the anaesthetic been negligent and the dog had died? It's ridiculous to suggest she bares absolutely no responsibility for any errors within her own practice because the vet always takes full responsibility. That may be the strict legal position but its fallacious.

Thirdly, the locum has insurance for professional negligence and the employer should more correctly sue her. The facts do not support any suggestion of negligence.

Lastly to offer to split the loss would set a dangerous precedent IMHO . This locum works for her regularly part-time. She really should be covered by normal employee legislation.

Things occasionally go wrong, that's life, there isn't always someone to blame, and under such circumstances the practice should sort an amicable resolution with the client. An employee just doesn't need to be involved.

Re: locuming question

Louise Buckley — Wed, 19 May 2010 22:51:39 GMT

[quote user="Peter Ding"]It seems odd to me that the practice principal was present at the original surgery but seems unwilling to take any responsibility for the way work was carried out at that point. [/quote]

I can see your point Peter but I think on one interpretation there is a problem. The practice principal is a VN. Therefore, it would be inappropriate for him/her to 'take any responsibility for the way work was carried out at that point'. The decision regarding which suture pattern to use, etc is a veterinary decision and not one for a VN to dictate to a vet. The nurse is contracting a vet to provide that service on the basis that the vet has the knowledge/experience in these circumstances to proceed appropriately.

Technically the VN is right. If Vicky is self-employed then if the workmanship is considered faulty/flawed the VN is within her rights to withhold payment. Mistakes happen but in any other 'trade' if the tradesman makes a mistake they are expected to correct that mistake in their own time and at their own expense. I think this is actually one of the criteria that Inland Revenue uses when deciding if someone's employment status should be self-emploed or not. So the individual above (I forget their name - sorry!) who was quite a pedant regarding technique, suture failure, etc is actually pursuing a valuable line of enquiry worth revisiting. Perhaps self-employed locums should have insurance to cover them in cases such as this?!

As an interesting, warped aside but I do like these- she/he may have done you a MASSIVE favour by forcing you to pay. Given Inland Revenue's current obssesion with the employment status of vet locums she/he has actually just given you proof on a plate that you should be classified SE and not PAYE - paying the £400 could save you £ssss!!!

BTW - putting the above aside I am also watching this debate with interest. As someone who sometimes works as a VN on a self-employed basis and who is not above potentially making mistakes too(!) this is something that has always interested me as I have always been aware of the easy with which practices could find a reason to with hold payment. I personally think the practice should foot the bill - apart from anything else this is to keep themselves considered in high esteem by the locum market for fear of never being able to find a locum otherwise. I also have problems with the OOH clinic vet for their effective speculation as to Vikki's competence which is blatantly unprofessional. I do a lot of work for various OOH clinics and all of them make it very clear that their client is as much (if not more!) the member practice as the owner of the pet and the pet itself.

Apart from raging on your behalf Vicky, I think Niall makes the most reasonable case for how to proceed. I think a 50% goodwill gesture looks a good plan to me - and then avoid this practice in the future. There are plenty of others out there to choose from - and I have NEVER heard of any practice ever doing this to a locum - PAYE or Self-employed.

Goodluck.

Re: locuming question

Niall Taylor — Sun, 16 May 2010 17:57:08 GMT

[quote user="Vikki Moran"]I will be having a meeting with the practice principal next week[/quote]

How did it go?

Niall

Re: locuming question

Bob Russell — Tue, 11 May 2010 18:02:43 GMT

This whole issue seems to have been spectacularly mishandled on every level! The practice owner has ultimate responsibility (as has the ultimate benefit when things go well).

The OOH service was totally unsupportive and should reassess how it tackles this type of situation. If it was a genuine post-operative complication such is life - they happen remarkably rarely - the owners should be supported and sympathized with but these things happen.

Unless there is clear evidence of incompetence it should be assumed that the failure may be due to the suture material and appropriate action taken. If faulty (or out of date) suture material may be out there it needs to be investigated to prevent the same thing happening again.

I make a point of trying to support colleagues as a priority - there but for the grace of god etc. I would like to think that my colleagues would similarly give me the courtesy of similar treatment.

Re: locuming question

Peter Ding — Tue, 11 May 2010 15:39:45 GMT

Has this peculiar situation only arisen because Vicki is in essence a part time employee but for tax reasons is being treated as a self emlpoyed locum?

It seems odd to me that the practice principal was present at the original surgery but seems unwilling to take any responsibility for the way work was carried out at that point. To me there would have been significantly more responsiblity had the locum been a sole charge locum tenens.

Has our profession created problems for itself by sanctioning this sort of "artificial business arrangement" for someone who should really be a part time employee?

However..........

To me this seems a clear case of material failure, and that is the avenue that appears to have been least explored. A cross stitch is a perfectly acceptable suture pattern for a linnea alba. End of....correctly applied it's fine. In both it's forms.

If the knots stayed intact and muscle was intact but the suture material broke, I would suggest technique was not a problem. Especially with a locum of 8 years experience!

Whether a bitch that has had numerous prior exposures to various suture materials is more likely to rapidly hydrolyse suture materials is certainly question that arises. I doubt it personally, but its worthy of discussion.

I am somewhat surprised suture material was not retained by the OOH practice, if they were aware it had broken as to me it seems obvious that 3 sutures of vicryl would not normally break within hours of surgery unless grossly out of date or faulty. I am very surprised faulty suture material was not specifically mentioned as a possibility by the OOH service vet. Far better than needlessly criticising a colleague.Had it been a single suture broken adjacent to a knot i could believe handling might be a possibility but not three. I see no possibility of a wake of wound breakdowns following falsely maligned Vicki!

Re: locuming question

Gillian Mostyn — Tue, 11 May 2010 14:21:44 GMT

[quote user="robloxley"]

[quote user="Anthony Todd"]BTW, a continuous muscle layer suture relies on one knot and one thread for the whole length of the incision; always worried me.[/quote]

I was always taught that if you couldn't trust your knots at each end to hold, then why should you trust any of your knots in the middle with an interrupted pattern?

[/quote]

hear hear

I was also taught there is almost no difference in breakdown rates between interrupted and continuous sutures, assuming both done correctly. It's all about technique...

Re: locuming question

Rob Loxley — Tue, 11 May 2010 13:51:52 GMT

[quote user="Anthony Todd"]BTW, a continuous muscle layer suture relies on one knot and one thread for the whole length of the incision; always worried me.[/quote]

I was always taught that if you couldn't trust your knots at each end to hold, then why should you trust any of your knots in the middle with an interrupted pattern?

As for the thread in between, there is lots of human data on laparotomy closure pattern dehiscence/herniation (e.g. most recent a quick search threw up http://journals.lww.com/annalsofsurgery/Abstract/2010/05000/Elective_Midline_Laparotomy_Closure__The_INLINE.11.aspx), and some animal data exists (e.g. http://www3.interscience.wiley.com/journal/119071725/abstract?CRETRY=1&SRETRY=0).

Re: locuming question

Bob Russell — Tue, 11 May 2010 13:06:27 GMT

A number of years ago we used Bondek on a reel - to our alarm we had two major breakdowns within a few days. One was a Great Dane!!

We had to go back in and repair. The suture material could be pulled apart with no effort whatsoever. Not what we had expected nor had we ever had a failure with vicryl.

The manufacturers were hopeless and even took back a full sealed reel we refused to use. We did not even get a credit for it!!!

We now use PDS for muscle - tough as old boots and we do not use any of this type of suture on a reel.

Normally a good manufacturer will bend over backwards to help. They do not want a faulty batch to go through undetected.

If the material was individually packed was it in date?

If on a reel how long had it been open?

As many other have stated this is something to discuss in private with VDS and the practice owner and should be reported as an adverse reaction on a yellow form.

Sorry if this has all been said in previous posts but I have just read the first few pages of posts!!!

Re: locuming question

Anthony Todd — Tue, 11 May 2010 00:14:39 GMT

The suture material broke within 8 hours of surgery, the knots were intact, and it was all sutures in the muscle layer?

And, apparently, it was a vicryl equivalent. It doesn't really matter, any material can be faulty, however unlikely.

For heaven's sake at least talk to the suture manufacturer.

BTW, a continuous muscle layer suture relies on one knot and one thread for the whole length of the incision; always worried me.

There is a feeling out there that some generic suture materials have quality control problems. Have you asked the principal [or, better, the other vets in the practice, how many problems she's had and how long they've been using the material.

We did have a problem when we tried one generic brand. One,and only one, vet kept breaking the needles at the swaged joint, so technique can be a factor.

Re: locuming question

Clive Ansell — Mon, 10 May 2010 16:00:18 GMT

one of the important lessons from this is a reminder to make good, comprehensive, contemporaneous clinical notes including reference to any discussion with client.

When I work in ooh clinics and see post op complications, I am always mindful that clients may complain to their user practice and a claim or even litigation could result. Therefore I never pass comment or criticise a colleagues work with the client. I keep clinical notes to the facts; "wound seems infected" , "suture broken" , "no buster collar", etc. Where possible I will refer the case back to the user practice for treatment.

We had a huge problem in one of the ooh clinics, seeing a large number of infected wounds, seromas, post op haemorrages, suture breakdowns and some eviscerations all from the same low cost clinic. Most of the midline breakdowns post spey that were presented were related to the use of continuous suture catgut 3 or 3.5 metric that broke adjacent to the knot. Lots of angry clients, the low cost spey was around £50, but the GA/re suture between £300 and £400 usually

Re: locuming question

Gillian Mostyn — Mon, 10 May 2010 10:19:22 GMT

[quote user="Anthony Todd"]

How suture material's breaking can be regarded as a normal complication post-surgery is beyond me, assuming the break occurred soon after the op.

All suggests a fault in the material, once the unanswered questions are answered, and the manufacturer should be advised to comment and/or should accept responsibility and liability.

[/quote]

I don't think it is that simple. Even if the suture material broke, this can still be due to handling errors (eg grasping the material with forceps or needle holders will damage it's integrity.) I am NOT saying the locum should pay the bill - I think that the practice should cover the cost - but maybe some analysis of technique should take place? Don't we all analyze our own technique whenever we have post op problems (as we all do!)

If I was the locum in this case, I'd be knocking on the door of the OOH provider, requesting a chat. If they have a comment to make on the technique being inappropriate, which they choose to immediately discuss with the client, then they are deliberately causing problems. Noone would make a statement like that to a client without knowing the repurcussions for the vet involved, including possible negligence claims. The problems with fees have all stemmed from their decision to discuss the case in this way. Thus I'd get a first-hand account of what was said. I wouldn't be at all surprised though if their account is different to the one that has come from the client and practice owner.......amazing how stories change to suit those who tell them......

Re: locuming question

Malcolm Ness — Mon, 10 May 2010 09:00:57 GMT

There is a lot of silliness being written here.

First, let's state the obvious: something went wrong and that was not the desired outcome.

There are two aspects, the technical and the ethico-legal-personal aspect.

While it is true that if you do surgery right, it goes right, we all make mistakes and human error is why most "complications" occur. So, as far as the technical side goes, if the suture material was intact after the breakdown, it is likely that either the sutures were inadvertently placed in the wrong place or that there was a problem with the integrity of the tissue (in which case a pedant would argue that that should have been recognised and appropriate modifications to technique made). If the suture material was snapped. that implies too light a suture (unlikely) or a material problem with the suture (out of date, poorly stored, manufacturing problem (though the latter is very unlikely if a recognised brand was used). Infection is not going to be a primary problem this early on but the patient chewing the wound might have been. Importantly, had the OOH vet kept proper recrds, none of this would be up for debate, it would all have been established and documented fact. There is a lot of literature published about wound closure etc and although a forum like this tends to encourage the relating of anecdote and personal experience, it is always better to go back to the source.

However, none of this is really the issue - if the technical questions were answerable, they would have been answered by now. With regard to the ethico-legal-personal aspect there is a simple decision to be made - walk away or stand and fight. There is only one person who can make that decision - I know what I would do but I am notoriously argumentative!!

As a locum, you should have access to VDS through the host practice's cover even if you don't have personal indemnity insurance - if you haven't done so already, 'phone VDS and talk it through with them.

Re: locuming question

Niall Taylor — Mon, 10 May 2010 07:44:35 GMT

[quote user="Vikki Moran"]

She is also convinced that id she refuses to pay, and the OOH clinic chase the client, that it will give her a bad reputation. and she is very paranoid that this will be bad for her business, that she would rather alienate a vet than a client.

[/quote]

Well, in that case, your opening gambit should be a cool, calm and collected summation of how much you are/have been worth to her as a locum, and good locums aren't always easy to find. I don't know your relationship with this practice but I would imagine, like most of us you will have been supportive with difficult clients, perhaps you have clients in the practice who prefer coming to you and supportive when talking to staff and other veterinary surgeons/practices. Your honesty and bedside manner, your discretion and respect for confidentiality (your reluctance to 'name and shame' on this thread for example is a prime example); all these are things that she should be worried about losing if she loses your services over this affair. And if she's concerned about the reputation of the practice then they are things which should be worth more to her than £400.00.

Anyway, it sounds like she has already decided to reimburse the client - so whether or not she extracts the money from you will have no impact on the practice's reputation with clients although it certainly will have a big impact within the veterinary profession.

I still think that if these points in a letter or face to face meeting don't persuade her then, unless you have the time, money and stomach for a protracted legal wrangle you should at least be prepared to make a compromise in the knowledge that you have done nothing wrong but just want to draw a line under the affair.

I agree with the comments about the OOH practice, by your account they have behaved badly, they should have shown more discretion. Their opinions are merely opinions, they are not veterinary forensic experts. The only actual fact they have is that the suture material appeared to have broken (though I don't know how they are supposed to rule out the possibility they may have broken it during their surgery, and if they really thought that they should have kept it as evidence). Their opinion on your suture technique is, as Evelyn puts it, "sphericals" (of the complete and utter variety) - people use alsorts of sutures all the time and they are fine. If one suture pattern was inherently unsafe we wouldn't be being taught it.

I absolutely do not believe her report that several other vets have said it must be your fault - they have no more idea than anyone else - I think she has perhaps misunderstood.

[quote user="Vikki Moran"]i am never locuming again you know! I don't think it's worth the hassle!![/quote]

Don't let the behaviour of one practice principal influence what you do in the future. Learn from this situation, make sure you put steps in place so it doesn't happen again but this person isn't worth consideration in the great scheme of things.

Niall

Re: locuming question

Evelyn Barbour-Hill — Mon, 10 May 2010 02:05:31 GMT

[quote user="Vikki Moran"]however the practice principal has since spoken to some other vets she knows who have all told her that it must have been something I did (or so she says, and she has quoted two people who are surgery certificate holders, who apparently say that this sort of thing only occurs through vet error!!!).[/quote]

Sphericals.

No veterinary surgeon with the slightest regard for professional behaviour would make such comments without properly examining the full facts.

So, now, did the suture material break or is it all your fault for not using the suture pattern that the OOH lady (obviously a suture expert) favours?

[quote user="Vikki Moran"] if the PP wants to get involved that I think is her business, not mine surely?[/quote]

Exactly.

Stick to your guns.

[quote user="Vikki Moran"]i am never locuming again you know! I don't think it's worth the hassle!![/quote]

Oh come now. We're not all that horrid

Re: locuming question

Evelyn Barbour-Hill — Mon, 10 May 2010 01:56:21 GMT

[quote user="Vikki Moran"]

I have seen the clinical notes from the OOH provider, and they do clearly state the suture material was ruptured, and that the herniation resulted from that. they also clearly state that the vet at the time advised the client that they would not be requiring immediate payment, as they suspected the original practice would cover the cost. The notes also state that the vet and the client had a discussion regarding suture patterns and how it might have been done differently by the other vet.

[/quote]

Blooming right.

Re: locuming question

Vikki Moran — Mon, 10 May 2010 00:04:37 GMT

[quote user="alison howell"]

Without knowing for certain whether the client is telling the truth, it does sound like the situation was created by the out of hours vet who should have kept their mouth shut, billed the client and contacted the practice direct the next day if they really thought there was a clinical mistake. Your practice principal is put in an annoying position as her practice has been criticised and she has a bill for treatment she did not authorise. She should take it up with the out of hours provider and refuse to pay and then it's up to them to chase the client.

It's not up to the out of hours vet to decide who's fault it is and tell the client they will pay without being allowed to defend themselves.

[/quote]

that was exactly how i felt initially.

however the practice principal has since spoken to some other vets she knows who have all told her that it must have been something I did (or so she says, and she has quoted two people who are surgery certificate holders, who apparently say that this sort of thing only occurs through vet error!!!).

i am currently bouncing between offering to pay half (which I don't really want to do, but which is probably the fastest resolution), or refusing point blank and telling her to deal with it herself as it's a problem arising from her lack of comunication with the OOH provider, and failure to have a clear policy.

as far as I am aware the outstanding bill in reality is between the OOH provider and the client. if the PP wants to get involved that I think is her business, not mine surely?

i mean, if the client had chosen to go somewhere completely unrelated (which in the area would certainly have been possible) I would imagine that they would have had to pay unrelated vets, and then might have come back trying to claim reimbursement right? the unrelated vet would not have said - don't pay we will chase your original vet? would they?

i am never locuming again you know! I don't think it's worth the hassle!!

Re: locuming question

Vikki Moran — Mon, 10 May 2010 00:04:37 GMT

[quote user="alison howell"]

It's not up to the out of hours vet to decide who's fault it is and tell the client they will pay without being allowed to defend themselves.

[/quote]

that was exactly how i felt initially.

as far as I am aware the outstanding bill in reality is between the OOH provider and the client. if the PP wants to get involved that I think is her business, not mine surely?

i am never locuming again you know! I don't think it's worth the hassle!!

Re: locuming question

Vikki Moran — Sun, 09 May 2010 23:58:15 GMT

for the record then:

the breakdown occured on the same day as the surgery, approximately 8 hours post op.

i do not believe there was any sign of infection at the time of breakdown. at the time of surgery the bitch was given antibiotics (as well as pain relief) and had been sent home with some too. she was also spayed at the same time as the caesarian. however i did not see the case at the breakdown so I have no idea. though i did see her the following day and she seemed fit and well then. I have lso seen her to remove her sutures and she is now absolutely fine as are her 3 puppies.

As to how she was managed after she left my care, I have no idea.

to the best of my knowledge, although this was not the bitches first litter, it was her first csection (though she was a new client to the practice, and we did not have history from previous vets, so I cannot be certain, but i do not recall thinking she had been a previous csection based on what I could see grossly).

Re: locuming question

Anthony Todd — Sun, 09 May 2010 23:44:32 GMT

I try just once more.

We have established that the knots were intact but the sutures broke.

Opinion is that the suture technique was acceptable as the sutures broke, and appropriate professional opinion is that cruciate sutures have advantages.

We do not know how long after surgery the breakdown occurred.

We do not know if there was any sign of infection.

We do not know how the bitch was controlled after surgery. Did it jump out of the car etc.?

How suture material's breaking can be regarded as a normal complication post-surgery is beyond me, assuming the break occurred soon after the op.

All suggests a fault in the material, once the unanswered questions are answered, and the manufacturer should be advised to comment and/or should accept responsibility and liability.

Re: locuming question

vs0u — Sun, 09 May 2010 22:49:51 GMT

Hi Vikki,

It doesn't sound like you did anything wrong and you definitely shouldn't pay them anything. If you have been spaying bitches for 8 years with no problems then it's highly unlikely there is anything wrong with your technique. Especially as your sutures normally hold in much bigger dogs than a 4kg one!

Sounds like the OOH vet doesn't know what she is talking about anyway...cruciate sutures spread the tension on the tissues compared to simple interrupted don't they? I always do continuous as I was taught there is less material there in the way of knots so a reaction is less likely. Anyway I know plenty of vets who do all 3 suture types.

I think the most likely cause is dog's tissues were weakened as a result of too many pregnancies and as a result the sutures tore through. Nothing anyone could have done about that.

Having worked in an out of hours clinic our policy was always to avoid any mention of fault with post op complications and to state that these things are a risk of surgery (which they are, and the owners should have been made aware of before the op was performed). We would normally try to contact the practice before doing anything expensive as some would rather do the re-suture for free/cost as a goodwill gesture, but if this was not possible or the practice wanted us to do the surgery, the client would be billed as normal. There is no way the practice would ever get billed direct unless they specifically asked to be. None of them ever did whilst I was there - they always expected the client to pay.

It's not up to the out of hours vet to decide who's fault it is and tell the client they will pay without being allowed to defend themselves.

Re: locuming question

Clive Ansell — Sun, 09 May 2010 09:56:25 GMT

[quote user="Anthony Todd"]

I am disappointed that most replies in a veterinary forum seem to be more concerned with the money and less concerned with the veterinary aspects of the case.

I'm concerned about the wound breakdown and why it occurred.

Still waiting to hear how long after the op the breakdown occurred, gauge and brand of suture material used, fundamental to the causes of the breakdown.

[/quote]

I agree that an informed opinion cannot be made without all of those facts, but Vikki's question related directly to the financial liability of staff or locums regarding post operative complications. Regardless of fault (If any can be shown), the financial relationship is between client and practice. In my opinion Vikki should be paid in full without question and should fight for it, through the courts if necessary.

[quote user="Anthony Todd"]

Suture patterns. Are cruciate sutures, single interrupted or continuous the best and why?

How far into the muscle should sutures be placed or is the linea alba sufficient?

[/quote]

I prefer to close dogs midlines with a simple continuous PDS suture, but other surgeons use cruciate or simple interrupted, and may use other materials such as vicryl. All are acceptable. I place sutures in the linea alba, not the muscle itself. In this case, where the bitch has allegedly had several previous c-sections, it is well known and accepted that the risk of complication or wound breakdown is increased, therefore any liability rests with the client. (It also supports the argument that we should be speying bitches that have had several c-sections, but thats another story)

[quote user="Anthony Todd"]

BTW, come on, £400 is a bit rich for a post-op complication. They were on call anyway and the materials wouldn't come to £20.

[/quote]

If carried out at an OOH clinic, that is a perfectly reasonable price, around £100 would be for an OOH consult. If the post op complication is not due to error, and is part of accepted or expected risk, then the client should pay in full. In this case, if the client made the choice to breed her dog several times knowing it would need c-sections, she has to accept the increased risk of wound breakdown and any consequences that go along with it.

Some OOH clinics have a pre agreed arrangement with their subscribing user practices whereby they carry out post op complication work pro bono, or at a reduced rate. maybe this practice needs to discuss that option? however, in this case where the bitch may have had several previous ops I would be inclined to charge in full at the time, and discuss later.

Re: locuming question

Clive Ansell — Sun, 09 May 2010 09:04:05 GMT

[quote user="Fiona Dale"]

[quote user="Clive Ansell"]

If this were me, and I was fairly sure I had not done anything wrong, I would hold out for my money. Legally it would be a fairly strong case; as a locum you have an agreement (Always written in my case, but could be verbal) to provide your services to the practice for an agreed fee. If you have provided that service in a satisfactory manner, then payment is due as per agreement. The contracts between client and practice, practice and ooh clinic, and ooh clinic and client (to carry out c-section/repair in this case) are completely unconnected and unrelated. None has any bearing on the others.

[/quote]

Well said Clive, I agree with you entirely. Out of interest, what is in the written agreement you have with practices? Starting to wonder if I should be doing this.

[/quote]

I don't have a written contract that all parties sign and return, but I like to discuss and provide in writing a summary of agreed terms and conditions. Almost always via email, but via letter if requested or if no email. I try and clarify as much as possible; rates and payment terms, accommodation provision, hours, ooh and hospitalised patient arrangements, charges for working extra hours, cancellation terms, private car use and charges, home visits, VDS cover, treatment of animals where clients have no money etc. I like to know practice protocols, vaccine regimes etc. I always make clear I adhere to the RCVS GtoPC and follow cascade regs, don't do conscious rads etc etc.

It may seem pedantic, but I feel it is best to get the i's dotted and the t's crossed to avoid disagreement later on.

It has worked well for me for 9 years, but in light of this thread maybe it is time for a legally drawn up contract?. That said, 75% of my work is with regular practice who I know very well and trust.

It is a learning curve though, I got burnt about 4 years ago. I stayed on for 3 hours one night waiting for a client with a Bulldog needing a C-section, did the op, 7 puppies all fine, bill most of £1000. When I invoiced the practice £100 for my extra time they would not pay as it was not "pre agreed" despite the fact the client had been charged extra for ooh, and had paid the bill. Now, I always discuss and agree in advance. I don't think I had grounds to pursue it, but you live and learn.