A Veterinarian's Duty of Care

What is expected of us and how much can we honor?

A local veterinary surgeon is a close friend. He’s a brilliant person and a gifted surgeon. He is, without exaggeration, not only the best surgeon but one of the best people I’ve ever known. When the weather’s good, we play tennis at a local park before going to work.

One morning a few weeks ago, he walked out to the court looking worried and upset. I asked what was wrong, and he said that his dog was really sick. The surgeon and his wife, who is also a veterinarian, had just gotten back from a trip and their dog, Bob, had lost a lot of weight and looked awful. Naturally, I suggested that he bring Bob into the hospital for a workup that day. As a mobile surgeon, he doesn’t have his own hospital. And, honestly, what’s the point of being a veterinarian, marrying a veterinarian, and befriending veterinarians, if you can’t get your own dog healthy?

We finished our game, batting diagnostic plans and tennis balls back and forth, and he brought Bob in. We went to work. Among the less cheery differentials we discussed was leptospirosis, a particularly nasty disease that can be fatal not only to dogs but to people —and of extreme concern to a man whose one-year-old daughter loves to pet the doggy.

Duty of Care

I heard a podcast recently where the veterinarians spoke about the question of “duty of care,” the extent to which a healthcare professional is obligated to provide care for a patient. In human medicine, the United States has the Emergency Medical Treatment and Active Labor Act (EMTALA), which mandates that hospital emergency departments that accept payments from Medicare provide an appropriate medical screening examination to anyone seeking treatment for a medical condition, regardless of citizenship, legal status, or ability to pay.

That this act is only compulsory for emergency departments accepting payments from Medicare will be important in exploring this issue.

The veterinarian podcasters cited several examples where there have been efforts to legislate or demand the same status for pets. They cited a proposed bill in Arkansas, a Facebook group based in the Mid-Ohio Valley, and correspondence from the Alabama State Board of Veterinary Examiners. I was able to find the proposed bill with some Googling. I requested the other primary sources from the podcasters and they directed me to the Facebook group but were unwilling to share a copy of the correspondence they discussed.

Bob’s Story

I am a small animal clinician, and, being a one-doctor general practice, I don’t have unlimited resources. I have an ultrasound and an X-ray, but I don’t have blood analyzers in-house. (The contracts to acquire such machines are often quite onerous.) I pride myself on being a good diagnostician. I work hard to be excellent at a skill I believe to be among the most fundamental of my duties as a veterinarian.

Bob was severely dehydrated, down 20% of his body weight, and looking sick. An ultrasound of the “big five” organs was unremarkable. With the dehydration and inappetence, the radiographs were useful in eliminating some things but did not provide a definitive diagnosis. An ELISA test for tickborne and heartworm disease was negative. The ELISA test for leptospirosis, however, was positive.

It had been a while since Bob’s leptospirosis vaccination, and we had to check the likelihood of a false positive following a vaccine. It was possible that the test was reacting to the vaccination rather than the disease, but given his history, the severity of his clinical signs, and the delay in confirmatory lab testing we decided to treat Bob anyway. We felt the risk-reward calculation erred towards the lesser side effects of beginning antibiotic therapy than waiting for confirmatory results. We sent out bloodwork and a urinalysis to my laboratory services provider. We drew extra tubes to send in case we needed further testing. We had also started Bob on fluids and took other supportive measures.

Bob’s owner is a brilliant guy, ferociously intelligent and constantly working to further his knowledge. I don’t lack for horsepower, and we both endeavor just about every day to study and learn more. We are experienced clinicians, we work well together, each of us have a wide array of colleagues to consult, and we had the resources of a hospital at our disposal in addition to the motivation of treating a pet whom both doctors regard as family.

It was still touch-and-go. Bob showed little to no improvement with supportive care. Physical examination had yielded only vague, nonspecific clinical signs. A diagnostic test indicated a fatal, zoonotic disease but the findings were unconvincing. We did not have an answer and Bob was getting worse.

Legislation

On February 16th of this year, Representative DeAnn Vaught of the Arkansas House of Representatives filed HB1453. The bill was cosponsored by Representatives Jon S. Eubanks and Jeff Wardlaw. Interestingly, the Arkansas State Legislature website includes a section on the biography page for its members to list not only their Church Affiliation but also their Occupation. Reps. Vaught, Eubanks, and Wardlaw all list their occupation as “Farmer.”

The text of HB1453 is available here. And while the bill was withdrawn the following Tuesday by Rep. Vaught, on February 21st, 2023, the language strikes me as troubling. Though seemingly noble in its intent “to require emergency veterinary treatment of animals by veterinary practices and veterinarians; and to create the Animal Emergency Treatment Act,” the text, to this doctor, is worrisome.

HB1453 would require that a veterinarian provide an examination and stabilizing treatment for any animal brought to them and further stipulates that the veterinarian must not delay the medical screening examination or treatment to inquire about the payment ability or insurance status of the animal’s representative. I must be ready to provide care at all times and I must not inquire about being paid for doing so. This isn’t a bill aimed at hospitals opting to accept Medicare payments, this is a blanket mandate for individual veterinarians and hospitals to provide examination and care for any animal whenever they are asked to do so.

There is a crucial difference between this legislation and EMTALA. While a hospital may opt-in to submit to government mandates, it does so in exchange for compensation. This legislation would have simply mandated it for veterinarians working in the state, with no elective element, and no compensation. Such a mandate would rob them of their agency and freedom, as well as remove their freedom to exercise their obligations of medical judgment. There’s no provision to tell a client, “I’m sorry, but I don’t have the means, materials, or expertise to examine and stabilize this patient.” That’s awfully troubling. Such a law would force the veterinarian to disregard some of the vital moral and ethical considerations of applying their professional expertise.

Pretty neat idea for a trio of farmers to require that medical services be provided regardless of the client’s ability - or intention - to compensate the doctor for their services. Further, to do so without specifying a setting, such as an emergency hospital, would seem to mean that a veterinarian would need to be prepared for any emergency in any species at all times. Anyone could approach me at my kid’s soccer game or at the gym and insist on a physical examination for their pet. If you woke me at home in the dead of night to request an examination and stabilizing of your macaw, I assure you that you’d find my assistance well short of useful no matter how dire the patient’s need.

While my tone is informal, my purpose is neither recreational nor merely rhetorical, I submit respectfully to the State Representatives of Arkansas that I have never been nor have I ever known a doctor in a position to provide such a spectrum of services, at all times, and without the need to be duly compensated. Requiring such a law would surely result in many veterinarians being unable to comply with the law and, I’d worry, veterinarians choosing to practice somewhere with a less onerous legislative demand. It would also all but certainly be ruled unconstitutional when challenged. I hope that is why the sponsor and her cosponsors chose to withdraw the bill.

Back to Bob

My friend had sent the radiographs (which we’d retaken twice) to a radiologist friend of his. And then another. And both were suspicious but not convinced of the potential of a foreign body. A gastric or intestinal foreign body is not a far-fetched diagnosis is a not-quite-two-year-old dog living with a just-about-one-year-old who frequently drops things out of her high chair. But the surgeon, who’d seen hundreds of foreign body cases in internship and residency, was unconvinced. “He just doesn’t look like a chronic foreign body dog,” he said.

This was a Saturday, so my hospital was only open for a half day. Bob’s doctors stayed after the staff left. It got late, then it got dark. Fortunately, those doctors had spouses to care for their animals and children at home. Bob had only mildly improved with continued supportive care and antibiotics.

Again we were faced with a critical decision in a critical patient. The diagnostic test that had guided our decision to treat earlier in the day was questionable. The lack of response made us doubt the diagnosis and more suspicious of a foreign body. We had a radiologist’s opinion supporting it. The option to go to surgery was on the table.

We decided to wait until the bloodwork came back the following morning to take the next steps. The surgeon, in particular, was not keen to do an abdominal exploratory that night, feeling that we’d be able to do a better job the next day instead of pulling an all-nighter. I live close, so I offered to check on Bob throughout the night in person and on our cameras.

We agreed to meet at the hospital the next morning at 6:00 am. I got there early, mostly to ensure that my friend wouldn’t find his dog dead.

Campaigns

The podcasters referred to a group in the Mid-Ohio Valley seeking to drive change in their community via a social media and letter-writing campaign. The Facebook group cites the death of a pet who died because “of the 30 or so veterinarians in my community, none of them work weekends, so I didn't receive the immediate emergency care that I desperately needed” as their raison d’etre.

The group seems to seek to have their local veterinarians, individually or collectively, provide local emergency services to the area.

Not wanting to form (much less write about) an uninformed opinion, I checked. The Belpre Animal Clinic helpfully provides a lengthy list of urgent care and emergency care facilities. Almost all of them are within a two-hour drive of Belpre, Ohio —the hometown of the Facebook group’s founder. One, in Charleston, West Virginia, is little more than an hour away. A two-hour drive for veterinary care is not something I assume is available to anyone, and the cost of care would likely have been significant. I’ve been fortunate in that I’ve never had to make the decision between my pet’s care and a one- to two-hour drive.

The tone of the Facebook group’s posts appears to put the onus of responsibility for having care available at all times on the local veterinarians rather than the pet owners. And some of their posts seem to have engaged local legislators to pursue their goals.

And I’m inclined to be sympathetic to their plight. However, my empathy turned hesitant when I found the post screenshotted below.

The post ends “preferably peacefully.” The implication seems that if the lack of convenient 24-hour veterinary care doesn’t end, the author will pursue non-peaceful actions.

I suspect that the veterinarians of the Mid-Ohio Valley are working plenty of hours. And they’re completely entitled by right to do so, or not to do so. The founder’s place of work does not have weekend hours listed on its Google page.

Then there’s the issue of the thinly veiled threats. The group’s founder shared the text of the correspondence he alleges to have sent to all the veterinarians and hospitals in the area, and his language is insistent in calling for a meeting but not offensive or threatening. But I wouldn’t attend an in-person meeting with a group that used phrases like “at all costs” and “preferably peacefully” in other communications.

While I might have taken a different approach as a younger man, I’d avoid a meeting like that these days. I think attending a meeting like that would be inviting conflict for sake of conflict rather than resolution. Even now, with a bit of age and wisdom, the most measured response I can offer is this: if you’d like to ensure my non-compliance, threaten violence as retribution for my non-compliance. President James Garfield wrote, “Of course I deprecate war, but if it is brought to my door the bringer will find me at home.” We have a similar but less refined saying in Philadelphia. With all the self-righteousness of a middle-aged, American white man who imagines no consequences for his threats, the author proclaims his intentions to force the resolution “at all costs.” Even, it’s implied, the costs of violent action.

Though not the cost, the astute will note, of a 75-minute drive.¹

Back to Bob

The results of the bloodwork came back the following morning. The findings, in particular the high potassium known as hyperkalemia, were suggestive of, among other things, Addison’s Disease. But Bob was the “wrong” age, gender, and breed to be an Addisonian. It’s less common in young, male, boxer mixes like him. We called the lab and the lab’s customer rep to beg for an expedited cortisol level, but it was impossible on a Sunday. We called every emergency hospital within an hour of us, including a university, to see if they could do in-hospital cortisol levels, but no luck. We called more than ten tertiary care facilities without success. They all sent out a resting cortisol level, and none would be back faster than the one already at the lab.

We deliberated for a bit before deciding on our next steps. The traveling surgeon called in a favor from a traveling radiologist to come out to do a more thorough abdominal ultrasound, one beyond my scan of the spleen, liver, kidneys, and bladder. The radiologist, to her credit, went above and beyond being merely collegial and drove nearly an hour to my hospital on a Sunday to scan Bob’s abdomen. We were worried he wouldn’t survive the trip to her.

The radiologist’s ultrasound proved the key to the diagnosis: one of Bob’s adrenals was two millimeters and the other couldn’t be found, the one abnormally small and the other so small as to be invisible.² We had as good a diagnosis as we would get on a Sunday. We turned back to the studies and textbooks to find the appropriate steroid dose for Bob.

I’m fairly facile with mental calculation of medical arithmetic. “Rainman” jokes abound, but it’s just the result of practice. When I did the math for Bob’s steroid dose, it seemed outrageously high. I wrote it down, checked it with a calculator and I got the same value. I asked my buddy to check my math.

He didn’t look up from the study he was reading and snorted, “I don’t need to check your math.” When I told him what I’d calculated, he looked up at me, paused, and said, “Let me see?” The math was right, but the amount we’d be giving our patient raised the eyebrows. If we were wrong, this was dangerous. Especially to a patient in Bob’s condition.

We were as comfortable as we could be in the diagnostics, the diagnosis, and the treatment, and faced with a patient who was so clearly flagging we gave the daunting dose of steroids.

Bob looked markedly improved and started eating and drinking not even 20 minutes later. Inside of an hour he was standing and wagging his tail. His clinical signs almost completely abated. But for the memory of the numerous ways we could have killed my friend’s dog, witnessing a patient’s rapid and dramatic recovery would’ve done a lot for what a professor at my alma mater drily referred to as “the ol’ Messiah Complex.”

Our patient survived the ordeal and is doing well today. His condition is under control and Bob is back to (Bob’s approximation of) normal.³

Regulations

While I couldn’t find the correspondence discussed in the podcast and the authors were unwilling to share it, I looked up the Alabama Veterinary Practice Act.

At 88 pages, it’s much longer than any practice act for any state in which I’ve been licensed. It includes a number of interesting elements. For example, a veterinarian must be licensed in Alabama to provide care to a patient or client in the state, which makes me wonder how veterinarians in Mississippi, Tennessee, Georgia, and Florida work with clients who might live across the state line.

Further, “six members of the board shall be graduates of an accredited school of veterinary medicine; legal residents of Alabama; currently and validly licensed to practice veterinary medicine in Alabama; actively employed and licensed in the practice of veterinary medicine in the State of Alabama for the five years immediately prior to appointment; and continuing at least 35 hours per week in the practice of veterinary medicine while serving on the board.” Those seem to me to be unusually strict guidelines for a veterinary practice act, though I appreciate the care in ensuring that their board is populated with active practitioners from their own state. There are a number of regulations that protect not only the public but also the veterinarians.

The nature of the correspondence was said to refer to elements of the Practice Act that set minimum standards for veterinary facilities and I came across this line:

(k) Emergency service must be provided and readily available. After hours and emergency information provided by answering machines should be clear and concise as to whom will be responding or what facility will be accepting the referral.

This would cause me some hesitations as a practice owner. I have no control or influence over the accepting status of the local emergency hospitals. Though there are numerous options, it seems that just about all of them have been “on divert” at some point or another. Large, well-run, tertiary care facilities are not without occasional staffing struggles. Even practices with dozens of doctors can become overwhelmed. To make an individual practice owner responsible for another facility’s emergency availability seems too much to demand.

Where I practice in the Greater Philadelphia Metro Area has a population more than 20% greater than the state of Alabama, is home to dozens of tertiary care facilities, many more dozens of specialists, hundreds of veterinarians, and a veterinary school, and we still can’t keep up with the demand for care. It isn’t for lack of effort, as many hospitals have been opened in the past few years, including my own.

If we were held to the same standards as the veterinarians of Alabama, I wonder how many of us would be comfortable practicing medicine when the state’s minimum requirements are unattainable and beyond our control.

These regulations were passed in 2000, and the state of the profession more than twenty years ago is no longer the reality we face. The Alabama Veterinary Practice Act is clearly a thorough and thoughtful work. It’s just dated. The regulations have not kept pace with the times, but then neither has our profession.

“Painters, poets, and philosophers have seen many things in the myth of Sisyphus. They have seen an image of the absurdity of human life, the futility of effort, the remorseless cruelty of fate, the unconquerable power of gravity. But they have seen too something of mankind’s courage, resilience, fortitude, endurance, and self-belief. They see something heroic in our refusal to submit.” -Stephen Fry in Mythos

The Problem

These folks who pursue legislation, campaigns, or enforcement of regulations all speak to veterinarians’ duty of care. But they are all subject to the effects of much greater forces: namely a nationwide shortage of veterinary professionals.

The shortage should be diminished, though not solved, in the coming years as more veterinary schools have opened and class sizes have increased. The AVMA’s economic data indicates that help is on the horizon, but the problem will persist. AVMA Immediate Past-President Dr. Lori Teller has written and spoken on the topic at length. Mars Pet Health, which has at least a modest interest in staffing their thousands of veterinary hospitals, has also published reports on the shortage.

From what I’ve read of the issue, I find myself aligned with Dr. Teller. I’m no fan of veterinary telemedicine as it’s being peddled these days, and I don’t know that the “mid-level practitioner” offers a realistic solution. I’m also inclined to believe Dr. James Lloyd’s opinion on the topic, in particular his point that “these results strongly suggest that failure to address the current shortage of veterinarians successfully might well lead to an even greater shortage as we go forward.”

If we demand too much of this generation of veterinarians, we might solve no problem at all. We might make it worse.⁴

And I believe that legislation, regulation, and social media campaigns to force doctors to work at any cost will certainly have that outcome.

If my home state of Pennsylvania passed a law matching the one proposed in Arkansas, if my community banded together to demand that I provide 24-hour care or else, or if my State Board made the staffing of local emergency hospitals my responsibility, I’d relinquish my license. I wouldn’t work under the threats of punitive legal action or violence. I’d just quit.

I love what I do, but I value my freedom and agency even more.

Impact

I bring up these cases because I feel it represents the gap between the popular ideas of what is possible in veterinary medicine and the reality we experience as veterinary professionals.

For Bob, two doctors, with considerable knowledge, experience, resources, motivation, and support, were able to stabilize and diagnose a single patient only with nearly two days of work and no small amount of good luck. Sure, we did everything right, but that might not have mattered. Bob’s endogenous steroid levels were just barely high enough for him to live the 30 hours or so it took us to diagnose him. And no emergency hospital could’ve run the confirmatory tests any faster. Maybe there might have been one with a radiologist capable of locating and measuring a two-millimeter adrenal gland on a 40-pound dog on a Saturday night or Sunday afternoon, but maybe not. We had to beg a favor from a friend. And nobody had the laboratory testing available in-house.

If we’d given that dose of steroids to a dog with leptospirosis, we’d have killed the patient. If we’d given that dose of steroids to a dog with a chronic foreign body, we’d have killed the patient. If we’d done surgery on a dog with uncontrolled Addison’s Disease, we’d have killed the patient. If we’d waited, deliberated, or struggled too long, we’d have killed the patient. If we’d chosen the wrong bag of fluids, we’d have killed the patient. We’d walked along a razor’s edge, and we didn’t need to look down to be all too aware of what awaited us, and our patient, at the bottom.

The number of mistakes, missteps, and errors we could have made at every step of the diagnostic process is too long to list in its entirety. Literally dozens of those potential actions could have resulted in our patient’s death. Not just any patient, but the dog of my best friend. We needed not only two doctors working on the patient but also the support of my hospital’s technicians, as well as the help of our families to look after our other pets and kids as we worked.

With a hospital, two doctors, five consulting specialists, twenty years of experience, and thirty hours we just barely succeeded. While there’s a feeling of happy triumph with the outcome, there’s also a heaping helping of humility. And the work we did was neither sustainable nor scalable in any fashion to meet the greater need.

While it sounds nice and is likely popular to demand that level of care and readiness from medical professionals, we simply aren’t equipped, prepared, or capable of providing the level of care demanded in these bills, campaigns, and correspondence. We do our best, and frankly, I believe we perform services that can, at times, far exceed the level of care available in human medicine and its associated cost.⁵

The sort of demands from social media campaigns and withdrawn legislative measures are, thankfully, unconstitutional. The 13th Amendment and any number of state and federal labor laws protect against the sort of extreme mandates that might play well on social media or with politicians. But the solutions suggested by these groups don’t demonstrate an understanding of the problem of the shortage, or just how hard it is to keep a patient alive. The practice of medicine is not a trivial matter.

I don’t believe that these groups are out to harm or punish veterinarians, I believe they’re just trying to solve a nationwide problem with local remedies. Old standards won’t resolve modern problems. I’m broadly sympathetic to their concerns, and I hope we can all work to resolve the problem on national and local levels. I can’t tell you how many clients have my cell phone number and are encouraged to use it, but I have no influence on how many veterinarians practice, how many veterinary schools operate, and how many graduates there are each year.

This essay isn’t meant to be a piece to stoke anger at what some other people did so that the internet might delight in recreational outrage. What these events highlight, to me, is the vast gap in what people understand about our profession and what we experience. It is a failure of understanding, which means that it is a failure of communication. We have done an inadequate job of representing the genuinely high quality of care many of us offer while also expressing our realistic and reasonable limitations. We can do a lot, but none of us can do everything. And there just aren’t enough of us to do it all right now.

I’m sure the politicians of Arkansas, the pet owners of the Mid-Ohio Valley, and the Alabama State Board of Veterinary Examiners don’t seek to punish or enslave the veterinarians of their region, they are desperately trying to solve the shortage of veterinary care in whatever way available to them. Unfortunately for them, their methods are utterly ineffective in solving the problem. And it’s likely that such approaches will make it worse.

Now What

Our responsibilities as veterinarians are not just stewards of animal health, but also communicators and educators for those who entrust us with the care of the animals. It took no small amount of communication to successfully treat and diagnose Bob, and it was a pair of experts and close friends doing so.

It isn’t our fault that expectations often exceed reality, but it is our professional responsibility to bridge this gap with empathy and clarity. At least if we expect a productive, positive outcome. We must strive to foster an environment where our clients feel heard and understood before we can create one to express ourselves. Informed consent is a pleasant idea, but it’s in trust we trust. And we build it through communication.

Equally important is the candid disclosure of our capacity. As much as I’d wish to have the cure for every ailment, we must acknowledge our constraints - be those constraints of resources, expertise, or the limits imposed by the current capability of veterinary medicine, the knowledge and skill of the doctors, as well as those from the client’s own financial and care situation. Honest, compassionate, and courageous conversations about what can realistically be achieved not only set feasible expectations for realistic outcomes but also build trust between us and the people we serve.

Even though we often make the work look easy, it can sometimes be very difficult. It took a pair of competent veterinarians a day and a half to diagnose and treat a patient, and they got advice from half a dozen others in the course of their work. Addressing the shortage and its impact is a much bigger, much broader problem. While I think it will take many more of us much more time to change the way the work of our profession is perceived and regarded, I’m not sure we will ever find widespread agreement on the boundaries of our duty of care.

And we’ll keep working.

Footnotes

1. For what it’s worth to the founder of this Facebook group, his campaign to ensure 24-hour veterinary care near his home has gone on longer than my efforts to open a veterinary hospital. He likely could’ve opened his own hospital in the time spent so far. Staffing it is a challenge, but I’m certain someone so motivated would find a way forward. I emailed the founder of the Facebook group suggesting this approach and offering what help I could in navigating the process. Although as of the time of publication he has not replied, my offer of help remains.

2. A proofreader pointed out that noting the absent adrenal gland could be interpreted as a lack of skill by the radiologist. This note is to disabuse anyone of such a notion. I believe that anyone skilled enough to find an object two millimeters - less than one-tenth of one inch - can be trusted completely in their skill. If she couldn’t find the adrenal gland, it’s because the adrenal gland couldn’t be found.

3. Bob’s owner has also survived the tremendous irony of being a well-respected, highly-credentialed specialist whose own pet has an atypical presentation of a disease for which there is no known cure or treatment within his specialty.

4. I’ll tolerate no “back in our day” arguments from older generations of veterinarians, who faced different challenges medically, socially, and economically. We all face different issues, and honoring the present ones with a discussion doesn’t diminish or demean those faced by past professionals. Such arguments are unproductive, divisive, and incommensurable.

5. I offer this story as an example and comparison: Dr. Eric Topol is a physician and cardiologist who writes extensively, and once about his experience with bladder stones. His diagnosis involved at least two trips to his primary care physician, a trip to the internal medicine specialist, a trip to a radiologist for radiographs, phone calls with all of these physicians and their teams, and follow-ups with nutritionists (from whom he received conflicting information about his care and follow-up status). Had Dr. Topol been a schnauzer with a similar condition, I could have diagnosed and treated him - up to and including surgery - in, at most, 30 hours from the initial visit. And I could’ve done so without three or four specialists and their respective teams. That’s a powerful efficiency from both medical and economic perspectives from both myself and my team. Without specialized training outside of the hospital (and in some cases lacking college degrees or even high school diplomas), my technicians would’ve been able to assist in performing this work end to end with me.