Case study: Clinical management and client communication

background a nine year old dog was taken to a veterinary clinic over an eight week period for the assessment and treatment of a left eye condition the dog was seen by three different veterinarians at various points the dog initially had a check up with veterinarian a the client had several concerns, including issues with the dog’s left eye the veterinarian suspected the dog had uveitis after examining the eye clinical records noted mild bluish discolouration of the cornea, watery discharge, conjunctivitis, a slight reduction in the pupillary light reflex in the left eye, and some degree of entropion veterinarian a prescribed maxitrol ointment and arranged a follow up appointment with another veterinarian at a clinic that provided ophthalmology services the dog was seen about 10 days later by veterinarian c, who had a special interest in ophthalmology at that time, the eye had returned to normal one month later, the dog was taken to veterinarian a with irritation, inflammation, and a blue tinge affecting the left eye the veterinarian noted a line of keratitis across the centre of the cornea, scleral vessel inflammation, conjunctivitis, and a mild bluish discolouration of the cornea upon examination pupillary light reflexes were recorded as normal no ulceration or foreign body was identified and maxitrol ointment was prescribed again seven days after the most recent consultation, the dog was presented to veterinarian b, who was a locum at the clinic while veterinarian c was away the client reported there was no improvement in the left eye and that the condition was not responding to maxitrol veterinarian b reviewed the clinical history and performed an examination the findings recorded included scleral vessel prominence, a cloudy bluish cornea, a slightly reduced pupillary light reflex, no fluorescein uptake, no foreign body, and no increased intraocular pressure on digital exam, although the eye was noted to be tender to touch veterinarian b prescribed maxitrol eye ointment (twice daily) and a course of prednisone for seven days a follow up consultation was recommended in five days with veterinarian c, to further assess the eye and perform a tonometry assessment during this examination, the veterinarian recorded enlarged episcleral vessels, generalised corneal oedema, inflamed conjunctiva, a reduced pupillary light response, and a tonometer reading of 55 mmhg there are conflicting accounts regarding the discussion that followed the veterinarian said that they explained the tonometer reading was “high”, diagnosed glaucoma, and discussed the nature of the condition, its effects, and available treatment options the treatment options included medical management, surgical removal of the eye if medical treatment was unsuccessful, and referral to a specialist the client elected a specialist referral the veterinarian said that obtaining a timely specialist appointment may be difficult due to availability, and a plan was made to arrange a referral the following morning the complaint the dog’s owner made a complaint to the vet council, which was referred to a complaints assessment committee (cac) the cac is a preliminary screening body that decides what should happen next with a complaint the cac can conduct a formal investigation and decide what steps, if any, need to be taken to ensure the veterinarian is fit to practise and public interest is protected the client complained that veterinarian a misdiagnosed the dog’s condition, demonstrated uncertainty regarding the medication prescribed, and failed to advise of the potential seriousness of the eye condition, including the risk of uveitis progressing to glaucoma they complained that veterinarian b failed to recognise indicators consistent with glaucoma, took a conservative approach by not arranging an urgent tonometer test, and did not convey an appropriate level of urgency or concern regarding the eye condition they also complained that veterinarian c failed to inform the client of the tonometer reading of 55mmhg, did not demonstrate compassion, and did not adequately communicate the extent of the dog’s vision loss, instead referring the dog to a specialist without sufficient explanation what professional standards are expected? veterinarians must deliver evidence based veterinary services of a high standard, appropriate to meet the needs of their clients and the welfare health care needs of the animals under their care, as part of the veterinary services part of the code the code also outlines that veterinarians must act in a manner that promotes the public’s trust and confidence in the profession veterinarians must practice in a way that promotes effective communication, trust and meets confidentiality requirements they must obtain the client’s informed consent before proceeding with a proposed course of action this includes making sure clients have enough relevant information to make an informed choice about treatment options competency standard 3 requires veterinarians to analyse information and enable accurate diagnosis and develop appropriate treatment strategies indicators for this standard include providing an adequate analysis of information provided; accurate diagnosis; fully informing the client of the treatment options, likely outcomes, risks and costs and obtaining their informed consent to proceed with the treatment; and recognising personal limitations in dealing with unfamiliar and complicated cases and seeking further advice or referring such cases to others competency standard 4 expects the veterinarians to know when and how to refer this includes recognising the limitations of their knowledge and experience and referring for advice or treatment in situations where required competency standard 7 requires veterinarians to communicate effectively this includes clearly and accurately explaining to clients the findings, treatment and likely outcomes it also includes demonstrating sensitivity and empathy how it was managed when reviewing a complaint, the cac measures the veterinarian’s conduct against the standard that is expected of a veterinarian practising in similar circumstances it also refers to published professional standards the cac commented that glaucoma is a rare condition in dogs it acknowledged that most veterinary clinics in new zealand do not have a way of measuring intraocular pressure, and tonopen ownership is rare due to the cost therapy is not curative and although exceptions do exist, most affected eyes eventually go blind in response to the client’s medication concerns, veterinarian a said that they considered the most appropriate treatment options for the dog’s symptoms before prescribing veterinarian a said the dog’s eye had previously responded well to maxitrol and appeared to have improved by the time of the consultation with veterinarian c because of that, they did not think further diagnostic testing was necessary and recommended a follow up consultation to monitor the dog’s response to treatment the cac was satisfied that the quality of care provided by veterinarian a met the expected standard of the profession the cac acknowledged that veterinarian a had implemented changes to their practice, including routinely offering a three day recheck for eye cases to ensure they responded to treatment veterinarian a said that they would ensure inflammatory eye conditions are not just purely conjunctival or scleral involvement, and would offer further diagnostics where necessary veterinarian b said that their clinical management of the dog’s case was influenced by a history of allergies and the recent positive response to maxitrol they considered that the likely cause of the eye condition was allergic or infectious in nature, noting that seasonal allergies were common in late summer when this event happened veterinarian b said that because of the clinical history of allergies, the recent response to treatment, and the clinical signs, they did not consider that there was urgency at the time of the consultation the cac considered it reasonable to arrange a follow up with veterinarian c for further assessment, including a tonometry assessment, and felt that the treatment and care provided by veterinarian b was appropriate veterinarian c said that it was not their intention to withhold the specific tonometry reading and that they considered it more meaningful to convey whether a result was “high”, “low”, or “normal”, rather than providing the numerical value alone they also said that, as a pupillary light response was still present, they hoped that the dog may have retained some vision in the affected eye and that prompt referral to a specialist could preserve the eye veterinarian c said that due to the timing of the consultation at the end of the day, the need to provide eye drops to reduce pain and pressure, and promptly arrange referral, there was not an extensive discussion regarding glaucoma the cac considered that while the veterinarian’s communication could have been better, it met the minimum expected standard the cac acknowledged veterinarian c’s reflections that, in future, they would adopt a different approach when communicating significant or distressing diagnoses, ensure that all discussions were clearly documented, and provide clients with written information, such as a take home information sheet the cac was also encouraged by the clinic’s proactive steps to improve access to diagnostic equipment, including the purchase of an additional tonometer so that both clinic sites are equipped decision the cac decided that the three veterinarians had each met the standard reasonably expected of a veterinarian practicing in similar circumstances no further action was required