Friday, November 26, 2010

How to know a good veterinarian from a bad one

So, I am going to talk about what separates the good from the bad. Some pertains specifically to ER medicine, some to both GPs and ER. I'll elaborate as I go.

A good veterinarian does a full physical exam - whether at an annual exam for vaccines or at a sick patient exam. This is a head-to-toe exam that should include listening to the heart and lungs, feeling all the lymph nodes, palpating the abdomen, examining the head and mouth, a rectal exam, a full set of vitals, and a weight.

There are 12 important things that can be learned from a rectal (such as the presence of malignant rectal cancer or prostatomegaly in older pets). So if your vet isn't checking there, request that they put on a glove and find the lube.

A good (especially ER) veterinarian takes a thorough history and listens carefully while doing it. This includes any medications your pet is currently on or that you might have administered at home, any previous medical history whether related to the current problem or not, and a myriad of other questions.

A good veterinarian recommends diagnostic testing for a problem with no obvious cause. If the owner cannot afford diagnostics, a good veterinarian will carefully select the safest treatment that will be the most efficacious.

A good veterinarian vaccinates on a 3 year schedule. It is well-known and accepted in veterinary medicine that yearly vaccines are not necessary or healthy, and that they may contribute to the development of immune disease in cats and dogs.

(I won't say that bad veterinarians vaccinate yearly. It is taking the veterinary community a long time to come around on this subject, and many otherwise excellent veterinarians are still doing once a year vaccines. Become informed before having your pet vaccinated yearly! Know what vaccines are required by law (rabies), recommended for your animal's particular lifestyle (such as FeLV/FIV for outdoor cats), and know what is not recommended.)

A good veterinarian is a member of VIN or another continuing education/learning site, is interested in getting help with cases from colleagues, and refers when a case is not going well and could use the services of a specialist (owner finances allowing, of course). Many good vets aren't members of VIN, but I believe one hallmark of an interested, informed veterinarian is a VIN membership (or the equivalent for large animal and other non-small animal veterinarians).

A good (GP) veterinarian offers overnight care to any ill, post-operative, or injured animal - especially if they are painful, require IV fluids, or any monitoring. Many owners cannot afford this, but the offer should always be made.

A good veterinarian keeps excellent, legible records. Whether hand-written or typed, they should follow a general SOAP format : subjective (physical exam, history, overall patient assessment), objective (hard data such as labwork, xrays, etc), assessment (differential diagnosis, other recommended testing), and plan (medications prescribed and administered, fluids given, etc). Every day an animal is in the hospital, a new SOAP should be done. If another veterinarian can't clearly follow the notes and understand them (or READ THEM, in some cases), your pet could suffer the consequences.

A good veterinarian will inform owners if a mistake that affects their pet's health or safety has been made.

What do I think is not necessarily an indicator of a good veterinarian?

Bedside matter doesn't mean doodly-squat, to be perfectly frank. I know some well-loved veterinarians that are complete and total quacks. I also know some harsh, abrasive doctors that are excellent clinicians.

** Addendum: I meant to say that bedside matter does not necessarily correlate with capability as a doctor. I know some very cold fish doctors that are brilliant. If your vet doesn't mesh with you...but does a good job, I would personally choose to stick with that - but that's just me.

Your veterinarian should be concise, explain any medical problems clearly, have a list of possible differentials if the cause for illness is unclear, and a clear plan of attack for treatment and further testing. We don't always have the answers, but a veterinarian should be up front about that. Owners should know that we don't always know either - but we will try our darndest to figure it out. If not - you should be given a referral.

A good veterinarian selects excellent pain control for any procedure that is painful. Butorphanol ("torb") is no longer considered acceptable premedication for a painful procedure. Studies have shown that its analgesic properties last only about 30 minutes to an hour. A pure mu opioid (like hydromorphone, morphine, oxymorphone, or fentanyl) should be coupled with a sedative/tranquilizer like acepromazine, Valium, Domitor, or midazolam for pre-medication/pain control.

A good veterinarian has someone monitoring anesthesia during surgery. This includes monitoring blood pressure, oxygenation, end-tidal carbon dioxide, and heart rate. More importantly - the PATIENT should be monitored - gum color should be checked, pulses periodically assessed, and auscultation of the lungs and heart should be done.

A good veterinarian takes the time to educate owners on the "whys" of preventative care, diagnostic testing, and treatment plans. This may extend to giving owners hand-outs with information that they can take home to read. (I do this frequently, as diagnosing disease in the ER can be very stressful for owners, and they do not always fully absorb information.)

I could go on in this vein for hours on end, but this is a good starting point. Let me know what you guys think...what have you found has been most important to you in a veterinarian - and what has turned you off most about a veterinarian?


Fi from Four Paws and Whiskers said...

Nice summary. Unbelievable that there are still vets around who use money to undermine some of those important bullet points...
Won't refer to after hours care so they don't lose a patient to another clinic
Leave animals in pain
Sell unnecessary goods to people
Prolong treatment and perform procedures on an animal when it should be euthanised and when owners are struggling to pay anyway
Inadequately monitor anesthetics
Perform surgery beyond their capability
I could go on, but I also know there are many really good, thorough, pleasant and conscientious ones who work hard to ensure that your list is covered. I just advise people to ask around about any vet, and if they feel uncomfortable, move on to another!
Now, what about the clients that stop your wonderful list from happening- reality for many people is money shortage,.
Vet as they fill out consent form for surgery: "would you like pain relief to take home for your dog this evening after her Spey?"
Owner " I'll have to.see if I have any money left after the groceries!"

Holly said...

I won't say that bedside manner means nothing...I think there needs to be a compromise. Sometimes, when patients are hysterical, or borderline hysterical bedside manner can mean the difference between engaging them or not.

Being a good technician is also important, bedside manner won't carry the day in surgery or emergencies.

For me, I also need a vet who will include me. If I am brushed off, I won't go back. If there are multiple options, I need to know what they are and how to sift that information. The Vet needs to be able to help me sift that.

Kindness to my pets also matters. I will never go to a vet or clinic that I believe is going to be physically aggressive to my pet.

Kindness to my VET also matters. Most of my dogs are very good, but I have one rescue here that is muzzled before we go in, stays muzzled the entire time and leaves that way. Because I have taken away one means of protecting himself, the Vet needs to be kind to him, and thus by extension me.

Holly said...

I went to a vet for a second opinion for a skin issue with one dog. He would not come near her, or touch her.

How could he see .anything. without an exam?

Won't be using him again for much.

Outrider said...

Most of the equine veterinarians I know, myself included, do not belong to VIN. We do belong to ECN and/or the AAEP listserv. Much better source of information (I cancelled my VIN subscription after the trial period for this reason).

Elizabeth said...

Great post!
For me it is important to have a vet that works with me, explains what is going and and doesn't just tell me what to do but gives me choices.
About 2 years I found a red raised lump on my lab that literally tripled in size in 3 days over the long holiday weekend. My regular vet was on holiday so I took an appointment with another vet in the practice.
He immediately told me that the lump was cancer and would need to come off.. Now somehow the intelligent part of my brain just turned off.. He then want to check his ears because of a previous history of ear infections. My guy is terrified of having his ears looked at and my own vet is an expert at getting a good look with a few soft words and cuddle.
What ensued was a nightmare for my dog and me. He ended up having two people try and hold him and still could not get a look so then he gave me a lecture on how I needed to train my dog so a vet could look in his ears etc..and I should stop trying to coddle him and not tell him he was a good boy when he would not let his ears be looked at. Then he said he would need to flush his ears out during the surgery..
That was all he did, never even laid a stethoscope on him.. Just gave me an appointment for surgery.

When I came to my senses a couple of hrs later I knew he was never touching my animals again ever!
I figured he must be a genious to be able to tell me for sure my dog had cancer without a biopsy and needed his ears flushed without being able to look in them.

I immediately went over my boy with a fine tooth comb and found another similiar lump.
A couple of days later I took my boy to see my own vet she did a complete exam including blood work. We decided the lumps should come off. She was even able to look in his ears after a little cuddle. Nothing wrong there at all.

The lump the first vet said was cancer turned out to be a histiocytoma, and the second lump turned out to be a stage one mast cell tumor. They looked alike to the naked eye so it just goes to show you how you cannot tell by just looking.

Every lump gets a biopsy..

I know what I don't want in a vet.. which makes it easier to see what I do want.

Kim said...

What I want is a veterinarian who hires educated, certified/licensed veterinary technicians to care for my pet. Someone who knows what it means when the CO2 is high or the pulse ox is low & what to do about it during surgery. If my GP does keep my pet overnight, I want a veterinary technician or a doctor to be in the hospital also.

The Homeless Parrot said...

Outrider: the caveat should be SMALL animal vets for the VIN comment. I can definitely see that VIN is heavily skewed (on the msg boards etc) toward SA. I would likely not be a VIN member either, if I did LA. I should change it to association with a CE program of some sort.

The Homeless Parrot said...

Holly: you're right - bedside manner does matter. What I meant was that if you have to pick between great doctor/bad personality and bad doctor/great personality - you want to err on the great doctor side. Bedside manner and kindness to pets is imperative and makes owners trust you much more than a cold fish personality and aloofness, I agree.

The Homeless Parrot said...

Kim: absolutely on all of those. If a pet needs to be hospitalized, and there is no one to stay with it, it should be referred.

I will say that some of the best techs I have ever worked with were OTJ trained. And some of the worst I have worked with were certified. I do think that moving toward requiring certification for vet techs is important, and I support that movement. But don't let training fool you! (same with vets and MDs)

The Homeless Parrot said...

Elizabeth: I think I went to school with that guy :)

Good for you for being an advocate for your pet, thinking clearly, and getting a 2nd opinion. 2nd opinions never hurt!

Carrie said...

I worked for a vet during summer break who would hit aggressive (nervous, possibly) pets. She tried to justify hitting the dog to me, and let's just say her answer wasn't that plausible. Her clinic doesn't monitor anesthesia either and they'll use it on dogs who need to be groomed. The dogs don't even need to be aggressive to get that treatment.

And she's one of three vets in my city; the others are worse.

Great post, by the way!

Anonymous said...

Just reading this now after being out of town. Great post! I have a question about vaccines. Rabies is the only one required by law (city) here. However there is not a kennel in town that will board a dog that is not "up-to-date" on shots, and to them this means yearly (except rabies, which they accept bi-yearly). The vet clinics here all recommend yearly vaccines (with bi-yearly rabies). I start getting reminder cards a month before the year is up.

So if the vets here all recommend yearly shots, and the kennels require yearly shots, what are my options other than not ever boarding my dog? I don't kennel often, but we do usually take a week long trip every spring break.

How do you find a kennel and a vet that won't require unnecessary vaccines?

Angie in MN

Elizabeth said...

Most of the vets in my area don't tell their clients that the overnight and weekend care is not monitored.. The animals are there all by themselves once the clinics close.
Not my pets.. I refused a spay on my girl when I found out they insisted she stay overnight yet no one was going to be there.. I would rather have my dog home with me than alone in a clinic.
So now the clinic I go to has monitored overnight care by a vet.
I pay more but I feel the standard of care my pets get is worth it.

Mary said...

I had such a horrible experience at my last vet visit I wanted to blog about it, but was worried about potentially pushing someone to not get care for their bird that I didn't.

Unfortunately, my great vet moved across the country so am trying (so far unsuccessfully) to replace him.

At this last visit, they had put the information under the wrong animal, their scale was wrong, and I got lectured about having an obese pet (I don't -- their scale was wrong plus he flies a lot so has great muscle tone -- something not normally seen in companion parrots.)

She wouldn't let me stay in the room during the examination, didn't listen to my concerns, etc. Horrible and $500!

Though one time I took my caique in (different vet who does mostly avian practice) and talked about him with the vet. He went in the back, and the tech asked him "That's a beautiful bird -- what is he?" and the vet replied -- "I don't know -- some kind of conure."

So it's also important to me that my vet know what species my bird is!

I wish avian practice was near what's available for dogs and cats. And as long as I'm wishing, that my good vet hadn't moved.

The Homeless Parrot said...

Angie: I really don't have a suggestion for that. Kennels require the vaccines as CYA medicine, I'm sure. It's hard to get away from that, unfortunately. I wish I had a better answer.

Elizabeth: I always find it odd that vets recommend that pets stay overnight post-operatively. They usually unsupervised during that time, so that if there is a complication - who would know?? I'd rather send a patient home with an owner so that SOMEONE is watching it!

Mary: that's an awful story! I can't believe anyone would think your pets were fat. I can tell from the pics on your blog that they are fit, trim fliers.

As to the caique thing...I would think an avian vet would know the species. I wouldn't necessarily expect them to know that there are white-bellies and black-heads. There are a great deal of different parrot species, so I can see someone not being familiar with all of them. I love parrots, and I still occasionally see a species I have never heard of - esp in the Cockatoo family.