A few surgeons and I were trying to answer a provocative and delicate question: Can you refuse to perform surgery? Why would you? When should you? Here are nine reasons why you should seriously pause before agreeing to perform surgery on a patient. 1) Knowledge This might be the easiest reason to humbly decline a procedure. If you don’t know how to perform a surgery, why would you do it? Sure, there is always a first time for everything. We all performed our first spay, our first cystotomy, and our first amputation. But there is a big difference between being rushed in a high-pressure, poorly-timed experiment on a live, client-owned patient, and learning from someone else, or a book, or a course, than practicing on a model or a cadaver until you master an approach and a technique. 2) Technical Unfortunately, I regularly see colleagues trying to “be nice” by performing a perfectly good procedure on the wrong patient. Most surgeries are not a matter of opinion or dogma or level of expertise, or letters after someone’s name, or even ego. Most are a matter of indications. Let’s go over three common, every-day situations. If you perform a lateral suture in a 100-lb dog with a tibial plateau angle of 40 degrees, don’t be surprised when the irate client calls you to help cover the cost of a TPLO. If you pin a long bone (humerus, radius, femur, tibia) and you don’t address rotational forces, don’t be shocked if you end up with a non-union, and a bone plate (or an amputation) is now required to solve the problem. If you perform a Zepp procedure in a cocker spaniel and therefore don’t clean up his pus-filled bulla in which three different bacteria are festering, don’t be offended when the local surgeon recommends a revision with a TECA and a lateral bulla osteotomy. Compromising to be “nice” or help out a cash-strapped client often leads to confusion, frustration, and anger… not to mention a complaint to the state veterinary board. 3) Equipment Should you take risks if you don’t have the proper equipment? For example, is it acceptable to explore a hemoabdomen when you don’t have a suction machine? Sure, some colleagues do it regularly, but is it reasonable? Is it the best possible care? Incidentally, if you end up in that situation regularly, maybe it’s a good reason to purchase a suction unit, even if it’s secondhand. There are many others uses for it beyond a hemoabdomen. Similarly, please also think twice if you don’t have overnight care after treating a GDV or performing a thoracotomy. Tracy Nicole Frey, DVM, DACVS, a board-certified surgeon near San Diego, explains,”: “I will decline a surgery if overnight post-op care is required, yet unavailable. It wouldn’t be fair to my patient.” 4) Client There are some extremely delicate situations when you should seriously consider refusing to perform a surgery because of the pet owner. They might be incapable of taking care of the post-op care, or may threaten to sue you. Or she’s your mom. A client with Munchausen syndrome is another reason to refuse to perform surgery. One real-life example includes a client who has had several cosmetic surgeries and demanded I perform rhinoplasty (a.k.a. a nose job) to treat stenotic nares that did not exist in her perfectly healthy dog. 5) “Digestive” Trust your gut. If an upcoming surgery causes you to lose sleep and get an ulcer, that’s a clear indication you are in over your head and you shouldn’t do it. If you have a bout of stress colitis and need to visit the bathroom three times before you walk in the OR, that’s a reason to question what you’re about to do. If sweat is dripping from your forehead inside your patient’s incision (true story), maybe you should reconsider your life choices. Kathy Collins, DVM, CCRP, a board-certified surgeon near Rochester, N.Y., explains, “I’m at a point in my career where if I’m likely to lose sleep after a surgery, I won’t do it. Just because I can, doesn’t mean I should. Quality of life is not only important to me, it is essential. It can impact the care I provide to future patients and my relationship with colleagues.” 6) Time Starting an unplanned resection and anastomosis between appointments or when you should be driving to the airport is unfair to your stress level and to your patient. Surgery should be performed when you can 100 percent focus on the task at hand, not on calculating how fast you can drive without risking a ticket. For instance, if your receptionist interrupts you every five minutes because you are late for a 3 p.m. appointment and the client is subsequently going to be late picking up her son from school to take him to the dentist and then soccer practice, this is going to cause you an amount of stress that will likely not lead to your best surgery. If your enterectomy site leaks three days later, how will you feel? 7) Staffing It’s 5 p.m., and Ms. Dough, a breeder and longtime client, demands you perform an emergency C-section on her award-winning bulldog that is expecting 12 puppies. Problem is, you close at 6 p.m. and the only person who can stay late is your faithful nurse, Mary. Is it really fair to ask Mary to run anesthesia and resuscitate 12 puppies? How will you—and Ms. Dough—feel if you lose half of the pups? Putting your patient at risk is likely not why you chose this profession. 8) Financial This is where so many of our big-hearted colleagues compromise their ethics and standard of care. Is it really reasonable to offer to fix four broken legs (and a pneumothorax) in a patient whose owner only has $50 sitting in her bank account? 9) Ethical For ethical or personal reasons, you may decide you simply cannot accept an emergency surgery after a certain time. Or on certain days. Or that you will not perform a declaw. Or remove vocal cords. Or dock tails. Or crop ears. It should not matter how much a client is willing to pay you. It’s reasonable to refuse to remove a mass that is seriously affecting a pet’s quality of life and expectancy, and is not likely to improve either despite surgery. One real-life example includes a 15-year-old cat with a gigantic squamous cell carcinoma on the rostral mandible, kidney failure, and a body condition score of minus three. Declining is not only reasonable, it is critically important to your mental well-being, your happiness, and your reputation. “That is so difficult to do” says Jennifer Vandervoort Hoch, DVM, DACVS-SA, a board-certified surgeon near Greensboro, N.C. “We are so driven and willing to help, yet we have to learn to say no to protect ourselves and our sanity.” In many of the above examples, your liability could easily be at risk. Even though you clearly had the best intentions in mind and obviously wanted to help a patient or a client in need, there comes a point where your position becomes indefensible. No amount of pleading will appease an expert witness or the local veterinary board. As we should with our time, health, and freedom, we should all have boundaries when it comes to surgery. Think carefully about the nine criteria above. Consider discussing them with a colleague in your practice or outside of it. Decide for yourself. What is acceptable? What is not? Never let anybody lead you to compromise your ethics, your values, or your soul. Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified, is a board-certified veterinary surgeon and serial entrepreneur whose traveling surgery practice takes him all over Eastern Pennsylvania and Western New Jersey. He also is cofounder of Veterinary Financial Summit, an online community and conference dedicated to personal and practice finance (www.VetFinancialSummit.com).
