Case study: Diagnostic pathways

11 june 2025 background a 14 year old bichon frise was taken to a veterinary clinic after its owner became concerned about a reoccurring cough the veterinarian performed a physical examination and recommended a cardiac work up, which included radiographs and an echocardiogram these diagnostics were scheduled for six days later (at the first available time) three days after the appointment, the owner called the veterinarian because they were worried that the dog’s condition had deteriorated the veterinarian noted the dog had a grade three systolic murmur it was agreed that the dog would still come in for the previously scheduled cardiac work up, and codeine and frusemide were prescribed the dog came back to the clinic three days later as scheduled but the owner declined the recommended echocardiogram and a referral for specialist level care they agreed to proceed with thoracic radiographs only the veterinarian noted the dog had cardiac enlargement and abnormalities they prescribed vetmedin and flusapex, and advised the owner to limit the dog’s dose of frusemide the veterinarian said their preference was to perform an echocardiogram before starting vetmedin, which the client declined they agreed to monitor the dog at home and come back in one month three weeks later, the client requested a referral to a specialist veterinary clinic the attending specialist veterinarian there performed an echocardiogram and said there was little cardiac disease present and that the dog had mild thickening of the mitral valve the veterinarian recommended stopping the prescribed frusemide and pimobendane the complaint the dog’s owner complained to the vet council, following a complaint to their usual veterinarian, saying the veterinarian misdiagnosed their dog with cardiac disease (an enlarged heart and onset heart failure), incorrectly prescribed heart medication, and failed to suggest further diagnostics the complaint was referred to the complaints assessment committee (cac), which is a preliminary screening body that decides what should happen following 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 when reviewing a complaint, the cac measures the veterinarian’s conduct against the standard that is expected of a veterinarian practising in similar circumstances and the expected professional standards what professional standards are expected? the vet council’s competency standards and performance indicators for veterinarians expect veterinarians to obtain and record relevant information that is sufficient for analysis, diagnosis, and retrieval indicators of this standard include carrying out or arranging the tests and procedures needed to make a diagnosis competency standard 3 requires veterinarians to analyse information for an accurate diagnosis and develop appropriate treatment strategies indicators for this standard include providing analysis and diagnosis, and obtaining the client’s informed consent before starting treatment a veterinarian would be expected to discuss the potential diagnostic pathway and their recommendations for investigation, including how these recommendations might aid or inform a presumptive or definitive diagnosis ideally, there would be a discussion between the veterinarian and client about the spectrum of care, which considers the client’s perspective and resources the cac would expect that any potential side effects, limitations, or adverse outcomes from the proposed diagnostics or treatment plan are included in the conversation how it was managed the cac noted that the veterinarian recommended doing a full cardiac work up (radiographs and an echocardiogram) on three separate occasions the veterinarian also emailed the client their recommendations in writing in the view of the cac, the veterinarian discussed the full spectrum of diagnostic options, which included a strong recommendation for a complete cardiac work up referrals for specialist care were offered twice and documented in the clinical records the cac reviewed the proposed diagnostic pathway, where the veterinarian noted a grade 3 systolic murmur, mild inspiratory dyspnoea, and a strong cough reflex on tracheal pinch radiographs are an appropriate modality for detecting cardiac abnormalities and cardiac enlargement, but an echocardiogram is needed to identify and make an accurate assessment about the presence of any cardiac disease the veterinarian recommended a rational and logical diagnostic pathway diagnostic imaging, including both radiographs and an echocardiogram (which are complementary investigative tools), alongside a complete physical examination, are appropriate investigative steps for detecting and evaluating cardiac disease the cac noted that radiography was also indicated because there were suspicions about underlying lung pathology radiographs are a suitable diagnostic tool for assessing the potential of pulmonary oedema or other underlying respiratory issues, and refining the list of differential diagnoses the proposed diagnostic pathway and recommendations were reasonable in the circumstances, and appropriate for a point in the case management where both cardiac disease and lung pathology were considered in the view of the cac, it’s unlikely that a veterinarian would be able to reach an accurate, definitive diagnosis without the results of a recent echocardiogram the veterinarian communicated that their preference would be to perform an echocardiogram before prescribing vetmedin (which was given as a preventative measure in case of any disease progression) how well this decision was communicated and understood by the client was debated however, the cac did not believe that the decision to prescribe medication as a preventative measure reflected negatively on the veterinarian’s fitness to practise decision the cac decided that in this case, the veterinarian met expected standards and no further action was taken the cac commended the veterinarian for their approach to the case and said they had demonstrated a good standard of veterinary medicine it was clear that the veterinarian had advocated strongly for a complete cardiac work up, and had explained to the client that these diagnostics were necessary to make a definitive diagnosis learnings for the profession the cac suggested that the veterinarian review the process or standard operating procedure (sop) they have in place for addressing internal client complaints having a set process for internal complaints or an sop can help improve client satisfaction, identify opportunities for learning, and can be a valuable source of feedback this information can be used to improve service delivery and the management of future cases the cac also suggested that veterinarians ensure they have an internal complaint process for handling client concerns for guidance, review the vet council’s practice guidance for handling complaints