misdiagnosis at neighbouring practice - advice please

Re: misdiagnosis at neighbouring practice - advice please

Hannah Wynne Richards — Sat, 26 Feb 2011 11:40:30 GMT

Argueing in Court with a barrister who has another veterinary surgeon giving an opposing viewpoint is stressful enough when the one on trial is a member of public who is being prosecuted by the RSPCA-when it's one 1st opinion veterinary surgeon's opinion against anothers- and the other veterinary surgeon is the 1 on trial-well it's not a position I would want to get into-not unless I was 1 million % certain that I was absolutely right

We haven't enough information to judge-other than it's nasty, and likely to become even nastier

Wynne

Re: misdiagnosis at neighbouring practice - advice please

Bob Russell — Sat, 26 Feb 2011 10:57:24 GMT

I suspect in this case you were probably right in your interpretation of the radiographs but this is with the benefit of hindsight!

It is very easy to criticise others and it may well be something may have been missed on X-rays. I freely admit (and my referral centre would probably quietly agree) I am not that wonderful reading radiographs but I accept this and often ask for a second opinion which fortunately for me and my patients they are happy to give!

I know you don't think some of the posts have been that helpful but you only have to get embroiled in a major legal fight once to realise that it is not something you want to do again!

Unless you are comfortable to present yourself as an expert witness (few of us genuinely qualify as true experts) I would suggest you follow VDS advice. This does not mean you cannot help but you can assist your clients without getting caught in the middle.

VDS advice seems up to their usual very high standard so follow it! They are good at putting everything into perspective and always seem so wise!

If you are unlucky enough to give evidence in court I guarantee that the Judge/Magistrate will consider you an expert witness even if you are a mere mortal such as me and you can get into very hot water. I have been there but fortunately did not leave with egg on my face!

Every client is entitled to challenge our diagnoses and treatments and get compensation if appropriate. The majority of posts here are trying to make sure you don't get into a situation you will regret! Keep good notes and direct the clients to the RCVS. I guarantee their solicitor will be able to find expert witnesses willing to have their day in court!

Thank goodness for VDS!!

Re: misdiagnosis at neighbouring practice - advice please

vs0u — Sat, 26 Feb 2011 10:51:51 GMT

[quote user="An On MRCVS"]The VDS were very helpful. In contrast to the majority opinion on here, the VDS were keen to make sure the profession is not a closed shop and that owners can and should get a second opinion on cases that go wrong.[/quote][quote user="An On MRCVS"]The VDS were very helpful. In contrast to the majority opinion on here, the VDS were keen to make sure the profession is not a closed shop and that owners can and should get a second opinion on cases that go wrong.[/quote]

But a second opinion would be looking at the live animal and making a plan for the future, (often based largely on what has/hasn't worked for the initial vet and tests that they did, but without needing that information). You would not need to directly criticise the previous vet even if they had done something wrong. Is it a second opinion if the animal is dead - what can you really say without the animal there, without criticising someone else? Also your opinion will be based on the report of an emotional client and someone else's clinical notes, rather than examining the cat. It's a very tricky situation...

Also it looks like there are enough varying opinions on here amongst experienced vets that there wouldn't necessarily have been a clear cut answer anyway.

Re: misdiagnosis at neighbouring practice - advice please

Gillian Mostyn — Sat, 26 Feb 2011 10:28:18 GMT

[quote user="i am ed"]I don't think a general practitioner should act as an expert witness to cast criticism on a fellow general practitioner.[/quote]

Especially not one with the same catchment area - definate conflict of interests!

Re: misdiagnosis at neighbouring practice - advice please

Hannah Wynne Richards — Sat, 26 Feb 2011 10:16:41 GMT

Could also have 1 loop of SI which has strangulated, and produced fluid

Wynne

Re: misdiagnosis at neighbouring practice - advice please

Hannah Wynne Richards — Sat, 26 Feb 2011 10:15:12 GMT

I would be very cautious about getting involved. Whether the original veterinarian's diagnosis was correct or not, nothing will bring the cat back, and if you write that there wasn't a diaphragmatic hernia, and it goes to court, and an RCVS Specialist in DI appears and says that it's impossible on the rads to be 100 % certain that 1 liver lobe wasn't in the chest, the owners fury is likely to turn on you

Wynne

Re: misdiagnosis at neighbouring practice - advice please

Edward Jones — Fri, 25 Feb 2011 22:53:32 GMT

Well I think the advice here has been good - "don't say anything until you speak to the VDS". No one here speaks as a lawyer and the general attitude is understandably cautious, not least because if you're careless you could easily fall foul of the guide.

Of course there are plenty of vets willing to act as expert witnesses, but I don't think a general practitioner should act as an expert witness to cast criticism on a fellow general practitioner. The case should be referred.

Re: misdiagnosis at neighbouring practice - advice please

An On MRCVS — Fri, 25 Feb 2011 22:03:24 GMT

[quote user="Bob Russell"]

Cats often die as a result of pleural effusions (and the causes of them) and can live for years with undetected diaphragmatic hernias. Life is never straight forward but in this case the risks associated with dealing with a pleural effusion and a suspected hernia can both be high.

[/quote]

Yes I agree and unfortunately I have had dyspnoeic cats die on me too. I do tend to be very cautious with them and I felt concerned that the cat was opened up after the x-ray without any further investigations and it really did look to me that all the abdominal contents were in the abdomen so I wouldn't have had any concerns about sticking a needle in. I am well aware that the outcome may have been the same for me using my approach.

[quote user="Bob Russell"]

Try not to get overly involved. Have VDS recommended a particular course of action?

[/quote]

The VDS were very helpful. In contrast to the majority opinion on here, the VDS were keen to make sure the profession is not a closed shop and that owners can and should get a second opinion on cases that go wrong. I was advised that as I do not feel comfortable making comments on another vets work, especially in writing, to a client, I should write a factual report and direct the clients to the RCVS to make a complaint and find independent experts. Apparantly there are plenty of vets out there who a more than happy to act as expert witnesses and give threir opinions on other vets cases - probably a good idea to keep very detailed clinical notes as that is all they will have to go on!

Re: misdiagnosis at neighbouring practice - advice please

Edward Jones — Fri, 25 Feb 2011 22:00:31 GMT

There's not a barge pole long enough to touch this one. The matter is between the client, their solicitor and the RCVS (or anyone but you).

If I was concerned on welfare grounds then my only communication would be with the RCVS and VDS. Definitely not the client!

Re: misdiagnosis at neighbouring practice - advice please

Bob Russell — Fri, 25 Feb 2011 17:22:09 GMT

Try not to get overly involved. Have VDS recommended a particular course of action?

Re: misdiagnosis at neighbouring practice - advice please

Gerry Henry — Fri, 25 Feb 2011 14:44:39 GMT

[quote user="Michael Woodhouse"]

[quote user="An On MRCVS"]However, misdiagnosing a pleural effusion as a diaphragmatic hernia then opening the cat up without attempting a chest tap resulting in the death of the cat is not something that should be happening in any first opinion practice is it? [/quote]

All of us make the wrong call at times. You don't know what additional info the first vet had, that unless there were complete transcripts of all conversations may not be in the notes.

[/quote]

If the Xay didn't clinch the diagnosis, and sometimes it doesn't, then, with respect, I certainly wouldn't be tapping anything; ultrasound to look for bowel perhaps but I'd be wary of a needle; anyway, if you aspirate nothing it tells you nothing; can't prove a negative and all that.

Re the original post; don't let clients bully you, ever.

Re: misdiagnosis at neighbouring practice - advice please

Simon Neuhoff — Fri, 25 Feb 2011 13:57:11 GMT

My 2 pnece - I agree with Peter, Bob Wynne Jane etc. It is very easy to diagnose things in hindsight, you don't know what info the client gave the first vet which may have lead to the presumed diagnosis, nor do you know what constraints were imposed on the original vet (no doc, don't do any tests that you don't need to, just fix 'im.) It is very easy to confuse a pleural effusion with a diaphragmatic hernia and they often go hand in hand.

Whilst I agree that a thoracocentesis should be part of the workup -as Jane indicated you are most ikely to get a modifed transudate - giving you dd's such as trauma, cardiac, lymphoma, metabolic causes amongst others AND pleural effusions.

Re: misdiagnosis at neighbouring practice - advice please

Peter Ding — Fri, 25 Feb 2011 12:35:09 GMT

Fully agree with the last two posts. Unless you were present at the time how can you really criticize? Owners often forget much of the misleading information/history they give you.

Abusing a retrospectogram is unfortunately all too easy and common in both owners and vets.

Re: misdiagnosis at neighbouring practice - advice please

Hannah Wynne Richards — Fri, 25 Feb 2011 10:36:27 GMT

Again I haven't been able to view the full original post, but I find that when clients change from another practice, the 2 of the 3 following phrases often defuse the situation, and, being true are above criticism

1) I didn't examine the dog/cat AT THE TIME so can't say what I would have done

2) Mr/Ms X has done such and such tests, so that saves me repeating them (also a reason to be strictly ethical and refuse to see anyone without proper liason )

3) It will be necessary to carry out such and such tests to establish a diagnosis, and Mr/Ms X could have saved you money by trying the simple treatment 1st

Don't lie to the owner, but don't be too eager to condemn the other veterinary surgeons either-not unless you want them to criticise you when one you got wrong goes to them-as will happen

Wynne

Re: misdiagnosis at neighbouring practice - advice please

Bob Russell — Fri, 25 Feb 2011 10:04:33 GMT

I cannot view the full original post but I generally tell owners that getting it wrong rarely equates to negligence. We are not fixing washing machines. Remember there but for the grace of god etc......

Even the very best clinicians can (and do) get an incorrect diagnosis on occasions, it is not an exact science. Try not to make comments that the client can interpret as supporting a claim against another practice. You cannot 'un-say' things. It is not a cover up but many owners do not understand the large grey areas that are present in medicine.

VDS will give you good advice, make sure you follow it to the letter. Write your notes fully but do not write a report unless you feel you qualify as an expert witness! Contact the other vet only if cleared by VDS. Too much contact may be interpreted as collusion by the more cynical out there.

These are always sensitive matters and one of the more uncomfortable parts of running a practice.

Re: misdiagnosis at neighbouring practice - advice please

vs0u — Fri, 25 Feb 2011 01:11:06 GMT

I agree with what's been said above. We all make mistakes at times. Certainly don't write anything down. You writing a report won't make the first practice refund the client or change their ways, but it will get you a very bad reputation, and clients that act that way will only turn round and do the same to you. I would refuse to comment on another vets work and tell the clients if they are unhappy to contact the RCVS .

It might be worth considering ringing the vet in question if you think they have made a mistake. It would clarify things and I know I would rather be aware if a client was complaining about me. I don't see why this wouldn't be allowed as presumably you have already rung them for a history, so just ring back and request a few more details.

Re: misdiagnosis at neighbouring practice - advice please

Evelyn Barbour-Hill — Thu, 24 Feb 2011 23:20:52 GMT

[quote user="Michael Woodhouse"]Let [s]he who be without sin cast the first stone.[/quote]

One need not say more.

To be frank, An On, your best option might be to mind your own business. It will save you a great deal of heartache.

The second client, the one who wants you to write up all your findings so that she can take action against the other practice, is requesting your services to aid her in her action. This is not a piece of work you are obliged to take on. Unless you want to take it on (and I don't think you do, or you would not have posted) you should inform her politely that you do not wish to take it on. She is, I suppose, entitled to a copy of the pet's clinical notes, so if she insists you should provide that, without comment.

Re: misdiagnosis at neighbouring practice - advice please

jd2008 — Thu, 24 Feb 2011 23:11:58 GMT

[quote user="Michael Woodhouse"]

All of us make the wrong call at times. You don't know what additional info the first vet had, that unless there were complete transcripts of all conversations may not be in the notes.

I really wouldn't get involved if at all possible, if they are wanting to get back at the other vet may be wise to watch your own back!

[/quote]

I have to agree. My advice would be similar to others. You only have a very small amount of info to go on. Sharing your opinions of this other vet with anyone with only this information and no discussion with the vet in question could be construed as acting unprofessionally. Speak to the VDS before doing anything else.

Incidentally, if you obtained fluid on thoracocentesis would that exclude diaphragmatic tear/hernia completely? I've come across several diaphragmatic tears which produced a pleural effusion. Especially the more chronic ones.

Re: misdiagnosis at neighbouring practice - advice please

Gillian Mostyn — Thu, 24 Feb 2011 22:51:16 GMT

"hands remaining firmly in pockets"

Re: misdiagnosis at neighbouring practice - advice please

Michael Woodhouse — Thu, 24 Feb 2011 22:45:45 GMT

Let [s]he who be without sin cast the first stone.

Re: misdiagnosis at neighbouring practice - advice please

An On MRCVS — Thu, 24 Feb 2011 22:43:56 GMT

[quote user="Gillian Mostyn"]

I don't think commenting about this scenario, beyond agreeing that you should contact RCVS and VDS, is wise.

It would be different if you had asked for advice about the situation without giving any details at all of the cases but I think that the clinical details you have posted are too detailed for an internet forum. It is very possible that someone related to this case could identify it. It is also possible that a member of the public, or press, could read it. That would be unfortunate. It is very unprofessional, and against our GtoPC, to criticise another veterinary surgeon in this way and could land you in as much trouble as them.

I would strongly recommend you removing all clinical details from your OP and also your posts that directly criticise another vet.

[/quote]

I have removed all the clinical details and will discuss with VDS tomorrow. I had looked at previous discussion threads prior to posting and found a similar level of detail on them - especially the thread about incompetent vets! I wanted to post anon so as not to give any clues as to which practice these cases have come from but you are correct, the level of detail might be picked up by someone involved in the case and as they may end up in court it is definitely better to keep the details away from public view!

Re: misdiagnosis at neighbouring practice - advice please

An On MRCVS — Thu, 24 Feb 2011 22:30:01 GMT

[quote user="Michael Woodhouse"]

I really wouldn't get involved if at all possible, if they are wanting to get back at the other vet may be wise to watch your own back!

[/quote]

I'm not sure they want to get back at the other vet, one client definitely wants her money back so I expect that will end up in court. I feel sorry for the client who lost her cat and as much as I'd rather not be involved, I do feel the cat should have received better treatment. It really does annoy me when the RCVS can strike off a vet for not going on a house visit but when owners and pets are being let down by vets nothing happens!

Re: misdiagnosis at neighbouring practice - advice please

Gillian Mostyn — Thu, 24 Feb 2011 22:29:13 GMT

I don't think commenting about this scenario, beyond agreeing that you should contact RCVS and VDS, is wise.

I would strongly recommend you removing all clinical details from your OP and also your posts that directly criticise another vet.

Re: misdiagnosis at neighbouring practice - advice please

Michael Woodhouse — Thu, 24 Feb 2011 22:19:04 GMT

All of us make the wrong call at times. You don't know what additional info the first vet had, that unless there were complete transcripts of all conversations may not be in the notes.

I really wouldn't get involved if at all possible, if they are wanting to get back at the other vet may be wise to watch your own back!

Re: misdiagnosis at neighbouring practice - advice please

An On MRCVS — Thu, 24 Feb 2011 21:45:24 GMT

[quote user="Martin Jones"]

You're being asked for your professional opinion in situations which may end up in court or in front of the DC - but more likely the former as the central issues are likely to come under the remit of civil litigation. In such situations, your findings and report are unlikely to be admissable as evidence as (a) there's a clear conflict of interest in that you now benefit from a financial relationship with the claimants, to the detriment of their former vets; (b) your opinion is actually unlikely to carry any weight in a court of law over the opinion of the former vets, unless you are a registered specialist, or at the very least recognised locally as a referral facility.

In both situations, any solicitor will require a third, uninvolved opinion. I'd therefore suggest that you avoid at all costs even getting into a discussion with the owners or former practice about any misdiagnoses or mistreatments, and instead suggest that the owners engage the services of a third party.

Don't lose sight of the fact that you might not be correct in your suppositions, and that your clarity of thought in each case owes as much to hindsight and outcome than to your own skills.

[/quote]

Thank you, very useful.