Why seeking a veterinary specialists could just mean the difference between life or death for your pet

I’ve recently returned from the annual forum for the American College of Veterinary Internal Medicine (ACVIM), held in Nashville Tennessee.

For those not familiar, the ACVIM (www.ACVIM.org) is the non-profit organization dedicated to the education, training, and certification of veterinary specialists in the fields of small and large animal internal medicine, as well as cardiology, neurology, and oncology.

This was the third conference I’ve attended this year. Each time, I’ve returned feeling renewed and invigorated about being an oncologist. I’ve felt more confident in my career path and my knowledge base. I’ve felt assured I’m doing the best job I can do, and that I was adequately adhering to my responsibility to keep current in my field. Sadly, within just a few short days of arriving home from each occasion, I’ve found my enthusiasm become re-routed as I tackle events that completely question my faith in the public’s perception of veterinary specialty medicine.

I’d barely arrived home when my husband excitedly told me the wine store near where we lived was having it’s grand opening that afternoon. Though I am an avid lover of animals, I also really enjoy wine, so I was equally enthusiastic about the event.

Within a few minutes of our arrival at the store, we met two gentlemen who struck up a conversation with us about a baseball game we all were watching on the large flat screen TV. My husband and I have an unwritten rule that we will not voluntarily bring up our profession in social situations unless asked directly, as inevitably the tides of conversation will change and then simply become monopolized by animal talk. So we happily discussed the game, the wine store, and things to do around the area with our newfound friends.

As is so often the case, it somehow came up in conversation that we were both vets and immediately the topics shifted from discussing pitching stats and the merits of beer flavored with Old Bay, to questions about our new friend’s pets, breed specific illnesses, and then once they found out I was an oncologist, stories of their dogs who were previously diagnosed with various tumors and their outcomes.

I listened intently as one owner recounted the events surrounding the death of his older Golden retriever. He accurately recounted how his dog became acutely weak and inappetant one morning, with no premonitory signs of illness. His owner knew enough to know the behavior wasn’t normal, but figured his dog had contracted a stomach bug or ate something he shouldn’t have. He diligently brought him to his primary care veterinarian for evaluation that same day. That’s when the story took a disheartening turn for me.

Turns out his dog’s signs were not due to a simple virus, but rather a bleeding tumor along his spleen. Given the age, breed, and presentation of his pet, the most likely diagnosis was an aggressive tumor called hemangiosarcoma. However, other possibilities existed. The only way to know would be to perform an immediately life-saving surgery and remove the spleen and submit the tissue for biopsy.

The owner recalled the story with the following chain of events: 1) the primary care veterinarian diagnosed his dog with a bleeding tumor that had a > 90% chance of being a type of cancer, 2) that he would live only 3 months with an immediate life saving surgery, 3) the life saving surgery needed to be done at a specialty veterinary hospital and would cost no less than $10,000, and 4) the dog had a less than 50% chance of surviving the surgery. He ultimately elected for humane euthanasia.

As he told the events of his pet’s death to me, I could feel myself struggling between a strong sense of sadness over the sudden loss of his beloved companion and a growing sense of frustration and anger towards the misconceptions he had about what may have been the outcome for his dog.

Yes, there is a strong likelihood of a diagnosis of splenic hemangiosarcoma, but I will stand by my conviction that so many dogs are euthanized prior to surgery, that we actually do not know the true prevalence of benign vs. malignant splenic tumors.

Yes, if the diagnosis is splenic hemangiosarcoma, the prognosis is considered very guarded with surgery alone, but chemotherapy following surgery can be effective in prolonging survival.

Yes, the surgery is expensive, but likely would range between about 1/3rd to ½ the amount quoted by the primary veterinarian.

And yes, though the dog was quite ill at the time of diagnosis, the survival rate for splenectomy surgery is far higher than 50%.

At the time, I silently agreed with the owner as he told the story, as nothing I would say or do could change the events of what transpired with his dog. But I made a mental note that although I am only one small voice for my profession, I have the potential to be a proverbially powerful one. Therefore I put forth two main suggestions for our profession at this time:

I sincerely urge owners to seek referral to a specialist when offered, but also consider asking for a referral when they want to learn more about their pet’s health.

Likewise, I urge primary care veterinarians to discuss cases with your local specialists to be sure, as frontline consultants; you are providing the most accurate information to owners.

In the triad of owner, primary care veterinarian, and specialists, don’t we owe to it to the one thing we all share in common? The voiceless companions dependent on our care would never ask for anything more than this.

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9 thoughts on “Why seeking a veterinary specialists could just mean the difference between life or death for your pet

  1. Christa Corbett says:

    I couldn’t agree more! Obviously not every case warrants a specialist, and not every client would choose to see a specialist if this was offered. However, this decision should NOT be made for the client, without presenting them with all of the options. You can’t judge a book by the cover, so it’s not up to the primary care doctor whether a client “looks” like they couldn’t afford specialty care, or they “act” like they wouldn’t want to go. So many pets can be saved with advanced diagnostics, treatments and surgeries, and in most cases these options are not offered at the primary care level. If we do not offer these options to our clients and their pets, we are not giving that pet the best chance for survival, and that goes against our vow as a veterinarian.

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  2. Erin Bonawitz says:

    I would like to offer a slightly different perspective from a GP….

    I believe that part of being a good GP is knowing your limitations. The honest truth is a VAST minority of people are interested in referral, and while I can only speak for myself, I can assure I recommend it when I know more expertise can be offered by a specialist. It is simply politely declined much more often than not.

    This story sounds like many that I’ve also heard, but while I am not suggesting we question this owner’s credibility, I do suggest sometimes owners hear what they want to hear….that “no other choice could be made.” They want to feel like they made the right choice and it is out of their hands. Sometimes they will even try to encourage me to say things that just aren’t true…”so you’re saying nothing can be done?” …when that is certainly not the case. I will also suggest sometimes in the retelling of such stories, dollar amount quoted may inflate and the chance of survival may nosedive. This is not a criticism, I only suggest it is common human behavior to add drama in retelling.

    Lastly I will add that as a specialist, you must realize the cross section of people you see is quite different from a GP….many of our clientele either lacks the resources or desire to move further with any treatments (at our clinic or otherwise) in situations like these. In fact people generally have a strong negative response to even the suggestion of chemotherapy, despite attempts to discuss how different it may be to what they perceive.

    While I have no doubt some vets may not give accurate information, please know that many do, but this advice is simply not heeded.

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  3. Gabby S says:

    I agree with Erin! As a GP, I do offer referral as an option regularly. Unfortunately, most of my clientele cannot afford to see a specialist, let alone perform routine diagnostics. There is only one specialty clinic within an hour of my clinic that offers a few clinicians a couple times a month. Recently, a patient of mine required a unilateral TPLO. The local specialty clinic gave an estimate of $5-7000. If a TPLO costs that much, I can easily see a splenectomy, post-operative care +/- transfusions costing upwards of $10,000. I did do a University based small animal internship prior to my time as a GP and it definitely taught my my own limitations. I also learned to never judge a situation without having been there. So many times, I questioned “why didn’t the rDVM do this or that?” Now being in the opposite boat, I realize that those services are offered, diagnoses and options are explained. I am always happy to refer complicated cases and I always offer referral for every neoplastic diagnosis.

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  4. Pet doc says:

    I wish more of my clients would take me up on referral, but as Erin Bonawitz said above, it’s hard to get them to. I encourage clients by letting them know that all they’re committing to is the consultation to get the most accurate information regarding prognosis, treatment options, and costs and yet still they don’t want to go. I can’t tell you how many clients balk at even performing the minimum database. It’s a constant struggle to try and find ways to minimize expenses. I tell clients that, just like in human medicine, a second opinion is always a good idea and the specialist is going to be the best way to get the most accurate picture.

    I’d like to think that my local specialists realize that everything my clients say might not be the most accurate representation of what I said. Clients distort things all the time. They are trying to comprehend things we spent many years in school learning about in the time of an appointment while sorting through painful emotions about the peril their pet is in.

    This job is full of disappointments with not being able to provide the standard of care due to lack of finances, either real or just because the owner doesn’t want to spend that much. I’m going to go out on a limb and say that GP’s have to deal with this far more than specialists. If they made it as far to your door, they’ve already made it into the very small group that wants to do more for their pet and thus more likely to be compliant with recommendations. When the GP gives an estimate of what it might cost to see you, we’re actually preparing them for you. You probably don’t have to go through as many of those soul crushing conversations where you have a pet sitting there looking at you that you know more can be done for, but the owner just can’t/won’t afford more simply because we’re filtering many of those clients.

    I’m always grateful for my specialists that are able to provide services and expertise that I can’t. I love it when I get a fax from them updating me on a patient that is doing great with chemo or some other therapy. If we had the GP’s side of the story with that Golden Retriever, would it be the same as the owners? Sure, there are many GP’s that refuse to refer – I’ve met many of them – but I would be inclined to give the person that has been trudging through the trenches of owner non-compliance the benefit of the doubt in most cases.

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  5. Tara says:

    I agree with Erin, I am also a SA GP, and I make recommendations for referral frequently, may be as often as every other day or more depending on the week. I am very passionate about giving my clients all of their options, and discussing possible outcomes of each. I am a strong supporter of my local referral hospitals, in fact I am a client there with my own pet re: surgery and oncology. However, I also agree clients will embelish stories, prices will often be higher in their story, and outcomes will always be worse per the O. We deal with the general public, rich, poor, middle class, different cultures between populations of people, different consideration of what a pet represents in the home. Some of my clients will spend and do anything, some will do absolutely nothing, and some try to find a middle ground. Not that specialists don’t see the same in some way, but only a select few take my advise for specialty consultations. Most do not. And people will try to justify the decisions they make, so that they can sleep at night, whether that is what their GP actually said, or maybe it’s what they read on Dr Google. Having specialists close by is invaluable, they have the tools, the expertise and the experience in their chosen field to be able to take the pet and client to an outcome that I would not be able to. But I find it hasty to take the word of an emotional client months or years after a case has ended, and use that to form an opinion of what goes on inside my exam room. I see 40-50 patients a day, which is like a marathon, and I have to try to give each the care and time they deserve. My entire job is to educate the client and treat the pet. It is hard, often thankless work, and I do it because I love it.

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  6. DoggyDr says:

    Just had a case like this a few days ago…..I made all the recommendations and everything as I would have wanted if the roles were reversed – I even offer surgery here and chemotherapy…but most owners are faced with the cold fact that they can not spend money of any significant amount on their dogs in my area…I believe referral clinics are an asset that some people can not and will not take advantage of. No one should feel inadequate as a practitioner or owner if euthanasia is the option utilized. As others have mentioned, I am sure you are hearing the version of the story the owner is filtering to. Please do not put GP Veterinarians in a generalized class below Specialists…..we are at the forefront of your referrals and we do know what we are doing and to say otherwise is a disservice to our profession……

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  7. Christa Corbett says:

    All of these replies are great, but the people who wrote these responses saying that they offer and the clients decline are not the problem. As the only specialist clinic within a 300 mile or so radius, it’s absolutely amazing how many clinics and doctors in the area that I’ve never heard of, simply because they do not/will not refer. And it’s equally amazing how many clients come in on a self-referral basis because they finally got fed up that they’ve paid $800-1000 for rechecks and new drugs for a corneal ulcer that hasn’t yet healed, and they finally resort to Google to see what else is out there. “I didn’t know there was such a thing as a Doggie Eye Doctor until . . . ” is a phrase that I hear at LEAST 1-2 times a week. That is the problem, these clients were never even offered the option of advanced care.

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  8. jintiledvm says:

    I am not disrespecting referring veterinarians at all. I completely understand how they face a different set of challenges and also remain integral to my ability to do my job. But more and more I find owners seek me out without first hearing it from their primary care doctors. And more and more primary care doctors are doing their own chemotherapy treatments without real knowledge or what the drugs can or can’t do. Metronomic chemotherapy is becoming an “after dinner mint” like option for cases where it has no role. Tyrosine kinase inhibitors are prescribed because they are “easy”. Even injectable protocols are used when they are not warranted. There are reasons specialists exist and owners should be afforded every opportunity to decide what is beast for their pet. Instead I hear too often “my vet said to come and talk to you and get the protocol and they can just do it there fore less money”. With the mentality, my profession and the role is veterinary specialists will never be appreciated. It’s not about egos and it’s not about presuming superiority. It’s about wanting the best options for pets and with full, complete, and honest discourse with owners about what we can do vs primary care. I absolutely love my primary care doctor (who happens to be an internist) but I would not seek her out for my cancer care, even if she told me she could do the same treatments for less cost.

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  9. Catherine says:

    I also echo Erin’s sentiments, people hear what they want to. You must consider the number of people who think there’s “nothing we can do” for the 18 week old, never vaccinated parvo patient whose owner refuses to try supportive therapy

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