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A New Grads Challenge: the Balance Between CYA Medicine and Practicality

pete the vet

Pete the Vet General

In an increasingly litigious age, it’s no wonder that many vets are fearful of complaints. At best, these lead to internal investigations; at worst, they can bring on disciplinary hearings or civil court cases. For the inexperienced, the fear of something going wrong is at its greatest.

The simplest way of reducing this risk is to do everything possible for every patient, using so-called CYA approach (Cover Your Ass – a term imported from the United States).

Arguably, this is the “safest” form of veterinary medicine, minimising the risk of anything being missed. But the downside is that the skill of using professional judgment to prioritise the most important interventions risks being lost. Furthermore, CYA medicine is more expensive for owners, contributing to hyper-inflationary veterinary fees, with a knock-on effect of increased insurance costs in the long term.

It’s unfortunate that in some quarters, CYA medicine is encouraged because it’s “good for business”. If there’s a mark-up on every item that’s billed to a client, the more tests that are done, the better for practice profitability. When I see terms like “minimum database”, with routine bloods being done on every case, regardless of the clinical signs presented, I find myself groaning. Is this really necessary? Will it really make a difference to the diagnosis and treatment of the case?

I’ve been qualified for 33 years now, and I know that some will put my attitude down to being an old fogey, out of touch with 21st century medicine. And I do accept that there is a tiny minority of cases where an unexpected abnormal routine blood result will pop up. But I believe that the art of veterinary medicine should include an ability to judge which tests should be done, at what time, based on the clinical circumstances of the animal in front of you.

I believe that in the long term, a measured approach to investigations will be the most effective strategy for our profession: it will help to keep veterinary fees (and insurance premiums) at an affordable level, providing a more sustainable long-term model for most pet owners.

I’d like a new parameter to be logged when clinical audits are carried out: the “hit rate” of abnormal results of tests. What percentage of blood tests identify an abnormality? How often are radiographs “abnormal” versus “normal”? I believe we should be able to rank ourselves in this way, developing a way of grading ourselves in CYA-ability. It must be possible to benchmark these parameters: if the hit rate is less than 5%, do we need to ask ourselves questions about our approach?

If a vet misjudges the level of care that’s necessary, complaints from clients are common, and they can happen at both ends of the spectrum.

One owner may be upset because the vet “did not do enough tests”, leading to a delayed or a missed diagnosis. For such an owner, the CYA approach is the only remedy.
Another owner may be annoyed because the vet did “far too many tests, most of which were normal”. For this type of owner, a more practical approach is desirable.

Perhaps the best answer is for vets to offer clear options: I find that it can help to discuss a bronze, silver or gold standard of care. A recent case of diabetes mellitus in a dog provides a good example.

The bronze approach would be just to give the dog an average amount of insulin, and to teach the owner to carry out urine dipstick tests for glucose. If there was just a trace of glucose in the urine, then they could be reasonably sure that the insulin levels were approximately right. This is far from an ideal way of treating a diabetic dog, but it would allow a dog to survive on a tight budget. It’s certainly a better option than economic euthanasia because that occasionally is requested because an owner feels they cannot afford the cost of treating diabetes.
The silver approach would be my usual recommendation for diabetes: regular visits to the vet for glucose nadir blood tests for the first few weeks until stabilised, then three-monthly blood tests for fructosamine to ensure long term control is optimised.

The gold standard would involve admitting the dog to the vet clinic for regular blood glucose curves for the first few weeks, as well as doing extra tests like urine culture to rule out intercurrent urinary tract infections, and regular blood samples to monitor haematology.  This is the most expensive approach, but there’s no doubt it’s also the best.

When I gave these options to the dog’s owner, she chose the middle way, with a silver level of care. If there’s a subsequent complication, I am less likely to be criticised: the owner made the choice themselves. If they decide that the care was too expensive, I can point out that, they could have chosen the cheaper bronze level. And if there’s a rare complication that could have been prevented by a CYA approach, I can remind them that they could have paid for the gold standard.

Perhaps in the future it will be possible to use big data to fine tune our understanding of the risk of using different levels of care. But for today’s new graduates, perhaps the bronze, silver and gold approach may help to keep that all-important customer happy, as well as offering the optimal care for each individual patient.

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