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Issue: 35 - Nov 15, 2011
Quantifying the risk of irrationality among clients: A case study
By: Patty Khuly VMD MBA
Patty Khuly VMD MBA
It’s an occupational hazard in veterinary medicine –– indeed, for any kind of medicine, really. There you are, doing the best you can on a consistent basis, practicing your science and craft to the best of your ability with the best intentions. And still … things can and will fall apart.  It’s not just Murphy’s Law at work here, the triumvirate vagaries of anatomy, physiology and pathology will invariably conspire to blow your house down. It’s inevitable. Which is why morbidity and mortality rounds are so useful in human medicine (and perhaps why they should be more popular in vet med). It’s also why we’re finally going the way of human medicine in attempting to quantify how things tend to go awry.  

But whether we count ‘em or not, there will always be cases that‘ll keep us up at night. And altogether too often, it’s not because the pet is having a hard time. Rather, it’s because the owner is having an issue over the fact that things have not gone 100 percent according to plan. That is, according to their conception of what the plan should be –– rational or not. 
 

I recently was made to suffer one of those clients as part of my daily penitence. The patient was an adorable golden retriever of indeterminate age and remarkable obliviousness to the human stress that surrounded her. Her condition? A low grade mast cell tumor I’d excised six weeks ago. 

The problem? You guessed it: An incision site that refused to keep it together post op. And, of course, the uncooperative wound was attached to –– I know this will shock you –– an unpleasant owner whose disagreeable demeanor was surpassed in its unwelcomeness only by his unwillingness to comply with treatment recommendations.  

But the saddest part of the story? I had tried –– in vain –– to explain, offer, cajole, wheedle and even beg my way out of undertaking this procedure. And yet I’d [very, very  stupidly] finally agreed. 
 
In this case, I’d explained that the mass (a) needed to be removed ASAP, (b) that a board-certified surgeon is always the best choice for removing anything but the smallest mast cell tumors (this was not one of those), (c) that mast cell tumors have a one-in-five chance of dehiscence post-operatively, (d) that this one, over a pressure point and a highly moveable site on the hind limb, was more likely than others to behave badly after surgery, and e) therefore, that judicious home care would be the most crucial aspect of this patient’s treatment regimen. 

None of this, however, seems to have stuck in this owner’s mind. The only thing he can hone in on is that this is taking FOREVER (yes, all caps) to heal. He’s so steeped in his own compulsive ability to make things worse for everyone involved –– including his own blameless dog –– that he can’t get past the obvious up-side: Given the nice clean margins on this mass, I’ve almost certainly cured his dog of cancer.  

Never mind the positives. All I get is stress about how impossible this incision site is and whether it’ll ever heal and whether it really needed to be removed in the first place and how it’s ruined his life so that all I want to say (but won’t) is that he should remember what I told him the very first day: The specialist is the best, the dehiscence rate is 20 percent, and I never wanted to go there in the first place. Therefore, he’s got only his own cheap self to blame if he thinks he got a bum deal on the surgeon.  

Well, you might not be with me on this one. After all, I broke one very serious cardinal rule: Thou shalt not accede to you clients’ demands when you KNOW you shouldn’t. 

Still, I don’t think he deserves to be angry. At the universe or for the cards he’s been dealt? Perhaps. At me? Don’t think so. After all, I did my job more than reasonably well, if I do say so myself. And I warned him more than appropriately, to boot. 

So what’s the take-home message? My biggest sin was not recognizing this client as the kind who would give me grief when things didn’t go perfectly his way. But how was I to know? 
 
We may be getting way better at recognizing how many patients suffer adverse anesthetic events and how mast cell tumor excisions dehisce, but to my way of thinking we haven’t gone nearly far enough in our quest for quantifiable risks. Only when the likelihood of client irrationality can be counted will I be satisfied that veterinary medicine has done all it can to help practitioners navigate the turbid waters of client-based morbidity and mortality.