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Listen to the patient first, the owner second, and the tests a distant third.

One easy case where the pet, the owner, and the veterinarian all agree there's a problem.
The pet, the owner, and the veterinarian all agree there’s a problem here.
Veterinary medicine is unique in that our patients don’t pay the bills. Instead, a very specific set of steps must be carried out in a specific order to keep a veterinary practice operational.

First, a dedicated human, or family of humans, voluntarily takes a pet into their home. Second, one of those humans recognizes the symptoms of illness (or even better, seeks to prolong wellness). Third, someone makes the conscious decision to seek the professional opinion of a veterinarian, instead of (or after) Googling the pet’s symptoms. Fourth, that same someone finds your practice somehow, and actually picks up a phone and schedules an appointment. Fifth, they actually show up for that appointment, and are willing to pay for your advice. Sixth, they listen to what you’re saying, hear what you’re saying, and agree internally to follow your advice. Seventh, they follow through with your recommendations, which may or may not include physically contacting or manipulating their beloved furry family member in ways they are probably not used to (giving pills, trimming nails, bathing, whatever the prescribed treatment is).

That’s an awful lot of steps that can go wrong! It’s important that the veterinary team proactively encourages compliance, which occurs when the client agrees internally to follow the veterinarian’s advice, and commits to following through with treatment. It turns out, clients are best at following a veterinarian’s advice, when the client agrees with the veterinarian’s diagnosis, and understands how that diagnosis contributed to the symptoms they recognized in the first place.

Here’s where things can get complicated. If a veterinarian diagnoses something is wrong with a pet that doesn’t jibe with what the owner sees is wrong, or feels is wrong, or has observed is wrong, that causes cognitive dissonance – defined as “mental stress or discomfort experienced by an individual who holds two or more contradictory beliefs”, also known as that eerie feeling we all get in our gut when what someone tells us is occurring, doesn’t match what we’re observing.

In other words, if an owner comes to a veterinarian because a pet is limping, and the veterinarian spends the entire appointment discussing flea prevention instead of the pet’s limp, the veterinarian risks failing to connect with the client, which will lead to failure in treatment, and loss of the client.

Similarly, if an owner comes to the veterinarian because a pet is limping, and the veterinarian recommends blood tests but doesn’t explain exactly how an abnormal blood test might be useful in monitoring the patient’s response to anti-inflammatory medications used to treat the limp, the owner might feel the veterinarian doesn’t understand the problem, or doesn’t know how to do his or her job, which again, will lead to loss of the client.

Here’s another example, but this one’s a little complicated. Stay with me. Imagine an owner comes to the veterinarian because a pet is limping, and the veterinarian recommends blood tests that reveal a slightly abnormal liver value. By the time the lab tests come back two days later, the pet is walking normally again, so the owner expects the veterinarian to call with normal results. The veterinarian instead, reveals the slightly abnormal liver value over the phone, and recommends x-rays and an ultrasound of the liver. The owner reluctantly consents to x-rays and ultrasound, neither of which reveal anything abnormal looking. The veterinarian recommends a biopsy of the liver “just to be safe”, which similarly does not reveal anything abnormal. This whole time the veterinarian is chasing down the abnormal liver blood test, the dog is walking normal, eating and drinking normal, and no longer has any symptoms of illness. Now, if you are this owner, your brain has one of two choices. You must now either convince yourself a) the tests were useful, even though they ended up normal, because they proved the abnormal blood test did not indicate a serious problem, whew!, or b) the veterinarian is a money-grubbing crook, who used your concern over your pet’s well-being to dupe you into running “unnecessary” tests and rip a colossal amount of hard-earned cash out of your pocket for no damn good reason.

Putting yourself in the client’s shoes, which of those conclusions would most normal people with no knowledge of veterinary medicine, normally come to? Hmmm…

The moral of this story is pretty simple, from an “art of practice” point of view. First of all, if an owner presents a pet with a particular symptom, it’s good for the veterinarian to address that symptom, and keep addressing that symptom until the symptom goes away. That’s listening to the pet first.

Second, if the pet looks normal on physical exam but is “acting funny” according to the owner, it’s good for the veterinarian to address what the owner perceives as a problem, until the pet starts acting normal. That’s listening to the owner second. To an owner, perception is reality, and a veterinarian who doesn’t address the owner’s perception, is failing as a veterinarian.

Third — a far-off, way-off, distant-on-the-horizon third — if the pet looks normal, and is acting normal, and the pet is happy, and the owner is happy, but the veterinarian runs a test that suggests maybe, possibly, there’s a chance that something isn’t right, or something “not right” might maybe, possibly develop in the future, or spots an abnormal lump that isn’t bothering the pet or the owner, or notices bad breath and tartar that isn’t bothering the pet or the owner, or in some way discovers something during his or her due diligence that causes the veterinarian concern, but that hasn’t bothered the pet or the owner prior to this point in time, this here is the fork in the road where extreme caution is warranted. This is the place where relationships are either built or torn down, where trust is either created or destroyed. Convincing an owner that something is wrong when all her visual, olfactory, auditory, cutaneous, and all her other senses suggest that her pet is completely normal and fine, is where medicine becomes less science, more art.

It takes years of practice to develop the kind of trust where a veterinarian can look someone in the eye and tell them something is wrong when everything looks right, and have that person believe you. And it takes one appointment, one bad phone call, one false move, even one false word, to tear that entire relationship apart, leading to bad feelings, bad reviews, bad treatment outcomes, and ultimately, rifts in the pet-parent-veterinarian relationship we’re all trying to build.

So. Listen to the pet first. The pet is always right.

Listen to the owner second. The owner is sometimes right.

Listen to the lab tests a distant third, and only if the owner is ready to trust your professional judgment over their instincts, and will continue to believe in you even if everything comes out “normal”, which is a very rare relationship indeed.

Abnormal lab tests in a normal pet with a normal owner, are often wrong, or said another way, normal pets often have abnormal results even when they’re clinically normal, and so those abnormal results can safely be ignored, or at the most, noted and monitored later on. It takes a lot of experience to know the difference.

Very few animals (including ourselves!) look and feel totally normal, all the time.

Symptoms come and go. Learning which abnormal results are worth chasing down takes a lifetime of clinical practice, and knowing which is which makes all the difference between your highly rated, successful and critically acclaimed veterinary practice, and the guy down the road who chases down every abnormal result without listening to what the pet and the owner want first.

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