Raised in the Roman Catholic faith, I was introduced with the concept of Purgatory, a place in the afterlife where a sinner must linger while undergoing a cleansing or purification before being allowed full ascension to Heaven. It is neither the torment of Hell nor the bliss of Heaven, but a state somewhere in between neither here nor there. I use the term in veterinary medical diagnostic terms to describe the diagnostic work-up scenario where I have performed a series of diagnostic tests and have not been able to pin point a specific diagnosis. On the other hand, I have also not come up with any bad news per se, unless one considers spending money and running tests with no concrete diagnosis bad news.
The path of diagnostic purgatory begins with patients that cannot speak for themselves and we have to rely on sometimes very subtle clues from the patient’s physical exam and/or behavior (as well as an often imperfect history from the owners) to compile our list of possible diagnoses for what ails the patient. We often get very nebulous histories like “not eating,” ”acting strange,” ”not self.” This is not necessarily the fault of the owner, but may legitimately be the only things that they observe. These signs can be the result of any number possible diseases or ailments.
I was inspired to write this post because I am currently managing what I though a clear cut case of pancreatitis in a King Charles Cavalier Spaniel this week, that is just not coming around to conventional therapy for pancreatitis. The patient was showing all of the hallmark signs of pancreatitis: abdominal pain, vomiting, not eating, etc. The only abnormality in his bloodwork was a strong positive canine PLI, a very accurate blood test for pancreatitis. Yet, 4 days into treatment, he is not coming around with text book pancreatitis in hospital therapy. Subsequently, I have begun x-ray imaging for intra-abdominal lesions that may not reveal themselves in bloodwork but may reveal that the pancreatitis is a secondary consequence of some other disease. X-rays were unremarkable, as were x-rays with a follow up GI series (when we take several abdominal x-rays over severe hours after swallowing a liquid that shows up brightly on x-rays to check for bowel transit time and obstructions of the gut).
This brings me to our last reason for diagnostic purgatory in veterinarian medicine: cost. While in human medicine there most certainly is not an open check to run unlimited diagnostics, with health insurance usually covering at least a portion of the patient’s diagnostics costs, there is a lot more diagnostic leeway. For example, in the aforementioned patient, I would love to run an intra-abdominal CT scan and in the event that was unremarkable, follow up with a PET scan. Both are cost prohibitive for the family of the patient, as they would be for many pet owners. With only 3% of American pet owners carrying health insurance for their pets, the vast majority of the time pet owners are paying directly out of pocket for, or financing the cost of their pet’s health care.
When scenarios like this play out with barely more answers than we had and the patient barely better than he was on presentation, it is frustrating for both owners and doctors alike. As animal health providers that have great empathy for our patients and their owners, take pride in striving to alleviate their suffering, and feel responsible for the emotional and monetary resources a family expends on our animal patient’s care, diagnostic purgatory is a place we despise every bit as much as the loving owner does.
Dr. Roger Welton is the President of Maybeck Animal Hospital in West Melbourne, FL, Chief Editor of the Veterinary Advice and Information Website, Web-DVM, and founder/CEO of Dr. Roger’s Holistic Veterinary Care