ETHICS ETHICS
When a second opinion does more harm than good By Ryan Carpenter, DVM, MS, DACVS
HIGHLIGHTS:
Informal second opinions require collegiality between the attending and consulting veterinarians for best outcome.
Complete and accurate information is essential to providing clients with best possible recommendations.
Dr. Ryan Carpenter
Equine practitioners are fortunate to know their clients well—often on a personal level. Because of this daily inter- action, owners and trainers feel comfortable reaching out for advice from a number of sources within their personal and professional circle. For any given case, communication most frequently occurs between the veterinarian and trainer, who then relays this information to the client. Unfortunately, and despite the trainer’s best efforts, important information is often lost during this communication.
No one would argue that the best form of communica- tion is when all three parties directly communicate with each other. However, this is rarely the case, particularly with the instant access of the digital world where radio- graphs, ultrasound and nuclear scintigraphy images are often sent by text or email. Clients have become accustomed to and expect immediate responses, sometimes even going so far as seeking an informal second opinion by sharing diagnostic images with other veterinarians with whom they have an established rapport.
In situations such as these, there exists a need for an additional, vital layer of communication between the consulting and attending veterinarians, not only as a pro- fessional courtesy but also to negate any unforeseen issues of ethical and professional liability. When two veterinari- ans can discuss the case details, the client will get better advice and the horse will benefit. This should be the goal. When this communication does not occur, important details are often overlooked and the horse suffers. Unfortunately, it is not a common practice for both veter- inarians to have this important conversation.
To illustrate, let’s take a 3-year-old Thoroughbred racehorse that developed a right front lameness with moderate fetlock joint effusion following a work. The
lameness was localized to the fetlock joint with diagnostic anesthesia. Radiographically, a rounded fragment was noted on the proximal dorsal aspect of the sagittal ridge. The trainer reports that he has had trouble training this filly for the past several weeks, and she has come out of her works sore so he wants to give her time off. Based on the joint effusion, diagnostic arthroscopy would be useful, allowing removal of the fragment and evaluation of the articular surface for any potential cause of the increased joint effusion. So the trainer calls the owner and says, “There is a chip in the ankle. We need to do surgery and give her 60 days off.” He follows up with a text message picture of the radiograph.
Although this statement is perfectly clear in the trainer’s mind, from a veterinary standpoint there are several inac- curacies that need to be addressed. The client then sends the radiograph off to their veterinarian who says, “That’s an old OCD fragment so it does not need to come out. I would medicate the fetlock joint and continue training.”
By failing to speak to the attending veterinarian directly, the consulting veterinarian fails to take into consideration several important factors that should not and cannot be overlooked. First, the horse is lame, the lameness has persisted after the last couple works and, most recently, was localized to the fetlock joint. Second, the joint effusion is new and has increased over the past couple of weeks. Finally, without knowing the trainer and his style, the consulting veterinarian doesn’t realize that this trainer often trains his horses on NSAIDs. As a result, by the time horses in this stable are coming out of their works sore, they are much further down the road to injury compared to horses conditioned by a trainer with a different training philosophy.
The client instructs the trainer that “their” vet wants them to medicate the joint because he or she doesn’t think the chip is causing the problem and keep training the horse because it is just “a few works away from a race.” The trainer does not want to lose the client so he elects to try this option. The attending veterinarian does not medicate the joint out of fear of potential injury, but the trainer continues to train the horse without the attending veterinarian’s knowledge. Unfortunately the filly sustains a lateral condylar fracture two works later.
This may be an extreme case, but it highlights an important point that exists in all types of equine practice.
continued on page IV
Dr. Carpenter is a racetrack practitioner in Southern California and a member of the AAEP’s Professional Conduct and Ethics Committee.
AAEP News February 2018 III
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