The human-animal bond does not weaken during recessions, but many caregivers feel more financial and emotional stress when their pets are sick. These days, we might see three or four clients in a row who have serious financial concerns. Some of us recall previous recessions and felt more prepared to deal with this one. But few of us were prepared to endure and share the burdens of a prolonged economic downturn. This recession continues to batter our clientele with job cutbacks, unemployment, falling property values, foreclosures, maxed-out credit cards, health care issues, etc. This unrelenting pressure pushes a big percentage of our clientele deeper into debt and desperation and causes anxiety and heartbreak on both sides of the veterinary exam table when their pets are sick. During my first recession, many of our well-intended clients requested payment plans. Our facility became burdened with accounts receivable that climbed as high as $250,000. Our well-intended clients “slow paid” or “no paid.” Dr. Villalobos Shares Her Thoughts on Each Scenario Example 1: Five thousand dollars is a lot of money. It is tempting to take this case to small claims court because the veterinarian did everything correctly, but be prepared to listen to outlandish complaints and offensive critical rhetoric in court. The hassle and the time spent may not be worth the aggravation or the judge’s decision. Call your liability insurance company and see if they have ideas. Praise the staff for a job well done and rejoice that the dog survived. Note: Insurance companies are teaching physicians to apologize and empathize with their patients when adverse events and complications occur. Empathetic communication can prevent malpractice suits. Many suits are brought to court because the person wanted to hear their doctor say, “I know this complication is causing you a setback and a lot of pain and heartbreak; I am so sorry.” Example 2: Help the distraught owner face the pet’s immediate crisis with pet loss and gift of euthanasia counseling. Guide the pet owner to use the Quality of Life Scale at VetPracticeNews.com. Explain that cancer has destroyed lung tissue, causing labored breathing, which ruins QoL with pointless suffering, then explain the stages of grief. Help the person understand that denial and anger are natural and that bargaining backward to recover the cost of therapy is part of grief. Later, acceptance will bring peace of mind and comfort to the client. Example 3: Consult with the attending veterinarian to get a path review of the first biopsy. Counsel the family to budget and reset priorities to save their house for the greater good of caring for all the animals they love. Inform them that the either/or model of medicine is not always necessary. They can opt for palliative care, save money and still provide well-being for their pets. For the dog with a recurrence, recommend palliative pain control and anti-inflammatory drugs. In the future, advise the family to elect palliative care programs for all their pets that are diagnosed with terminal disease so their veterinary expenses stay within budget. Example 4: This scenario reveals the medical entrepreneur’s dilemma and inherent conflicts of interest. It also points out the need for mutual respect and a code of ethics among specialists. During collection calls, clients had excuses and a greater tendency to bargain or dispute fees. We also found that credit card companies, to please their customers, preferred to debit a business account if the customer complained. They debited the business without investigating the issues. We learned to prioritize staying solvent. We learned to compassionately decline bearing the burden of health care cost for the pets of our clientele and we started to promote pet health insurance. Money may be the symbol of approval or disapproval of case outcome. When money is scarce, like it is these days, it is no surprise to encounter more complaints, bargaining and disputes. Most veterinarians would agree that it is stressful to deal with the anxiety of pressured clients who are compelled to complain, bargain and dispute fees. Veterinarians and pet owners enter into an agreement for treatment of sick pets after consultation. Most commonly, the “either or” option model is used, which suggests treatment or euthanasia. lt probably influences pet owners to select treatment because they don’t want euthanasia and they are not given a third option, that of palliative care. The veterinarian educates clients about their pets’ disease and the goals of therapy with an estimated cost. Veterinarians are expected to communicate compassionately yet frankly with clients so they clearly understand the prognosis for their pet’s particular condition. In the case of severe trauma, aggressive malignancy or other advanced disease where the prognosis is guarded to poor, the pet owner should know that. Ideally, there should be no misunderstandings if and when the chosen treatment protocol fails. If the pet has cancer, the doctor should inform the family about the prognosis and the biological behavior of the cancer and the risk-benefit ratios of treatment and the possible adverse events related to the chosen therapy. It is well known that patients retain only 10 percent of the information their physician conveys. Retention might be less with veterinarians. After a day, a week or a month, clients may create their own (often inaccurate) version of the consultation. Confusion leads to misunderstandings, hurt feelings and frustration, providing justification for complaints. In desperate times like these, veterinarians spend more time making adjustments to lower estimates and modify treatment plans for clients who can’t afford the cost of the proposed ideal treatment. For these reasons, many clinics use handouts that explain certain diseases and consent forms that at least describe the estimated cost of services. Still, much is left unsaid and undocumented in the exam room, which can lead to problems. Here are four examples of recession-related economic issues. Write down your suggestions. Example 1 A client presented a whippet for minor surgery. The dog went into cardiac arrest during surgery and was resuscitated but had residual neurologic deficits requiring monitoring and hospitalization at a 24-hour facility. The dog remained ataxic for several days but gradually regained normal CNS function. It wasn’t until after the dog’s cardiac arrest that the client informed the attending doctor that this dog’s sibling died under anesthesia during dental cleaning the previous year. The client initially accepted financial responsibly but later started offensive complaining and bargaining and then finally refused to pay any portion of the fees for services rendered at either facility totaling $5,000. Would you take this client to small claims court? Example 2 An upset pet owner called for a second opinion and pet hospice consultation regarding a cat with metastatic breast cancer. The client expressed shock, frustration and devastation that the cat suddenly needed oxygen therapy to breathe because of pulmonary metastasis. The client was angry at spending thousands of dollars and time on doctor visits over 14 months yet the cancer spread to the cat’s lungs. The client felt unprepared for this occurrence and wanted to regain the money that was spent. What advice would you give? Example 3 A family called for consultation regarding a recurrent fungating inflammatory mass in the elbow of their senior shepherd-mix dog. The mass recurred rapidly only one week after surgery. The family has five older dogs and two geriatric cats. Most of their pets have chronic conditions that require costly veterinary care and billings from three pet hospitals. Their unwavering devotion to their animals postponed their mortgage payments and they are worried about losing their house. They still feel obligated to have another surgery and biopsy for their dog. What would you recommend? Example 4 A general practitioner took a personal pet to specialty clinic A. After visiting clinic A, the generalist wanted the pet to have an MRI. The procedure was performed at specialty clinic B. When the MRI results were reported to the specialist at clinic A, the specialist seemed offended and asked, “Why did you take him to clinic B?” The specialist at clinic A told the practitioner that clinic A refers MRIs to clinic Z, which is five hours away at a university hospital. Is it right, wrong, selfish, unethical or permissible to send clients or colleagues on a five-hour car ride for an MRI, when the option for a qualified MRI facility is located nearby? What issues come to mind regarding this situation? Alice Villalobos is a past president of the American Association of Human-Animal Bond Veterinarians and president of the Society for Veterinary Medical Ethics.
