Thursday, December 18, 2008

um.......quoi?

so remember how i had the patient that i "mis-diagnosed"? i sent the cytology out to the state lab, and they agreed with my diagnosis of lymphoma.

now - the answer to this question might seem easy. call the owner and tell her that her dog - in all likelihood - has cancer, right?

wrong.

i'm an emergency doctor. i don't have an established relationship with this owner. further, she doesn't like me, and she was upset that i incorrectly diagnosed her dog. she was seen by her veterinarian for follow-up care after my diagnosis. that vet - with whom she does have an established relationship - diagnosed something different and is treating accordingly.

so there's the difficulty of navigating the emergency doctor/referring vet relationship to consider. and here's the other part of the dilemma: lymphoma can be a tricky diagnosis on cytology. usually it's very straightforward. unfortunately, there are occasions where lymphoid hyperplasia (hyperactive lymph node) occurs and can mimic lymphoma. i've know cytologists to say that the two can be mistaken for one another. it's possible the cytologist is wrong. possible but likely? biopsy is the gold standard diagnosis - which is what the referring vet offered to the owners. they declined.

the dog is doing well on antibiotics appropriate to the disease the referring vet diagnosed (doxycycline for suspected tick-borne disease) and prednisone (which will TREAT AND SHRINK lymphoma, if present).

i've done my part. the owner is not going to like me, regardless of what happens. the results have been sent to the regular vet and now she can decide what to do from here on out, right? i should be out of the picture. the ball is in the rDVM's court as to how to proceed. and yet, it niggles at me. the owner of said dog was rude to me on the phone, had no faith in my abilities (this was even apparent the night i saw the dog as a patient), and it irks me - ESPECIALLY when i see that the cytologist agrees with my assessment of the cytology.

it is no matter. if it is lymphoma, and the dog is only treated with steroids - it has about 1-3 months of life left - at the very most. so i'll have the real answer, one way or another eventually.

i need to learn to swallow that desire to be right about everything, to have people know i'm right and know i'm a good doctor, learn what i can from the situation (which was still a valuable lesson, despite the fact that i turned out to be right), and MOVE ON.

ok.

moving on now.

any minute the moving on will begin.

seriously.

i'm just worried that in all this tiptoeing around the referring vets and irate owners, the animal's well-being will suffer. and that is strictly against the creed of "first, do no harm." i'm doing harm if my patient's illness is not managed accordingly.

dammit.

5 comments:

DrSteggy said...

You should always remember that though you clearly have the pet's best interest at heart you do not have control over what happens to that animal. You can be very blunt and persuasive and tell people over and over and over what you believe is going on and what their next step has to be, and they can still take all that information you give them and decide to NOT take your advice.

It isn't fun when that happens, and sometimes, even though you have been very clear to the owner, they may still choose to blame the outcome of their inaction on you, but you do have to learn how to do the best you can do and when your advice is not acted upon to move on. You are going to burn out otherwise, especially in emergency medicine where you always meet people in bad situations and they are likely to take out their fear and frustration on you anyway.

You did the right thing for that dog, and he DOES need a biopsy--he is a BOXER for crying out loud! It is the owner's choice to ignore this, not yours.

elizabeth said...

could you forward the cytology results on to the rDVM so that he could decide if he wanted to pursue it and discuss it with the owners? Tricky situation!

Homeless Parrot said...

"the results have been sent to the regular vet and now she can decide what to do from here on out, right? i should be out of the picture. the ball is in the rDVM's court as to how to proceed."

i'm quoting myself. heehee. haven't heard back from the referring vet yet.

labmom said...

Please let us know how this turns out ( if you know ).

Life in vet school said...

Sounds like if you sent the results to the referring vet, then you've pretty much done everything you can. If they decide to ignore it, they're negligent (and insane, so I HOPE they don't ignore it!). I guess you could wait a week and call the other vet just to make sure they got the lab report. It's possible they'll think you're calling to make sure they realize you were right and they were wrong, but if for some reason they didn't get/see/pay attention to the cytology report, you could be prolonging the dogs life. Which to me would be worth potentially looking like a jerk over. Especially if I knew I wasn't really being one. :)