Due to cost concerns, veterinarians are asked often by clients to cut medical corners for medical work ups or procedures in order to save them cost. This is a constant ethical dilemma that we confront as veterinarians at least daily. Thus, we find ourselves constantly challenged in reconciling our medical standards and what are best practices for the patient and how best to mitigate the cost for our clients. It really is the single most frustrating aspect of the veterinary profession. I am in the midst of a recent case that has me convinced after 15 plus years of practice that for once and fall all I will be drawing that ethical line in the sand once and refusing to toe that line of cost reduction over quality of medicine.
A 12 year old intact male Pomeranian presented to me about 2 months ago with a history of swelling and foul smell coming from the anal area as conveyed by the owner. Upon examination, I quickly discovered that the “swelling” was actually a series of coalescing and unsightly tumors around the dog’s anus that were infected. Since the patient was not neutered, I surmised that theses tumors were likely perianal adenomas, benign tumors that commonly grow around the anal region as the result of abnormal proliferation of glandular tissue in the area as the result of testosterone in senior aged, intact males dogs.
The treatment for perianal adenomas is to neuter the dog and the tumors usually shrink up and resolve within weeks once the source of the testosterone (the testicles) is removed. Complicating matters in addition to this dog being 12 years of age, was that he also presented with a pronounced heart murmur. This brings into question the patient’s potential stability for even a brief anesthetic procedure given the heart issue alone, not to mention whatever other metabolic compromises a 12 year old dog could plausibly have. I naturally recommended pre-anesthetic bloodwork, chest x-rays, and a pre-anesthetic EKG (electrical pulse wave reading of the heart). If all of that checked out well enough or at least gave us sufficient information necessary to proceed with the safest possible anesthesia for the patient, then I recommended a plug biopsy of the masses to confirm the diagnosis (neuter would not resolve any other kind of mass than perianal adenoma), and ultimately neuter the patient once confirmed.
Unfortunately, given the total estimate of costs for the diagnostic and treatment plan, the owners had major constraints in running the diagnostics and getting the procedures done. They asked if I would please skip the blood work, the x-rays, and the EKG; that they were fine with taking their chances with the unknowns and their potential implications for anesthesia stability. They went so far as to imply that if I insisted on the pre-anesthetic diagnostics, that they would not likely be able to have the procedures done. Subsequently, I agreed to proceed provided they signed a waiver understanding that they proceeded at potential grave risk.
Even with this concession, it still took them nearly another 3 weeks to schedule the procedures over financial concerns. I ultimately confirmed the diagnosis via biopsy and performed the neuter. All went well and the masses were even beginning to shrink up and the area looked healthier by the time of suture removal. By all indications, the little Pom was going to make a full recovery and the owner’s gamble paid off.
Shortly after the New Year, roughly 3 weeks since the neuter procedure, the Pomeranian presented once again, his rear end issue nearly resolved, but acting listless and sleeping a lot. On presentation, the dog was visibly depressed but not much else was remarkable aside form the heart murmur which was nothing new. With so many unknowns and nothing tangible to treat, I told the owners that I had nothing to proceed with without blood work and x-rays to shed more specific light on the case. Somehow, this time around, they were able to come up with the necessary funds to run the diagnostics.
The chest x-rays revealed an enlarged heart which is not uncommon in dogs that have loud heart murmur, but other than age related changes, beyond that there was nothing else. The abdomen, however, had an area of increase density that seemed to be pushing the intestines downward suggesting a possible mass. The blood work revealed a severely elevated white blood cell count of 40,000 (normal should not exceed 16,000). Severe infections can cause spikes like this, but a spike of this magnitude would be unusual for an infection alone. Between the possible mass in the abdomen and a severe white blood cell count elevation, my suspicion of cancer is high.
With no other recourse, I suggested to the owners that we start the dog on an antibiotic and hope his findings were all the result of an infection, the white blood cell count would hopefully go down, and the infection resolve. That is where we stand right now.
So, why am I so frustrated over this case? Without have had the benefit of running pre-anesthetic blood work prior to the biopsy and neuter procedures, I have no baseline to evaluate if these circumstances existed prior to the procedure, or, if the patient’s current condition was the result of a surgical complication. Had I run the diagnostics and I suspected cancer as I do now, I likely would have advised against the procedures and not put the patient through them, while preventing the owners from spending money they clearly do not have on what may be an ultimate lost cause. Unfortunately, we will never know the answers to these questions.
While the acquiescence to cut corners for the sake of saving a family cost may start with honorable intent, the potential subsequent costs to the patient and the family all too commonly end up exceeding those of the original diagnostic and treatment plan. This takes a physical toll on the patient and an emotional toll on all parties involved, not the least of which, the veterinarian. At this point in my career, I find myself no longer willing to take on that burden.
Dr. Roger Welton is a practicing veterinarian and well regarded media personality throughout a number of subjects and platforms. In addition to being passionate about integrative veterinary medicine for which he is a nationally renowned expert, Dr. Welton was also an accomplished college lacrosse player and remains to this day very involved in the sport. He is president of Maybeck Animal Hospital , runs the successful veterinary/animal health blogs Web-DVM and Dr. Roger’s Holistic Veterinary Care, and fulfills his passion for lacrosse through his lacrosse and sport blog, The Creator’s Game.