Panel Discusses Standard
of Care at MVMA Fall Conference
The MVMA addressed the standard of
care in veterinary medicine with a day-long CE track at its 2012
Fall Conference November 8, 2012. The track concluded with an
interactive discussion between conference attendees and a panel
of six leaders in Maryland's veterinary community. Panelists
included Chris Runde, DVM; Krista Evans, DVM, DACVS, CCRT; David
Handel, DVM; Sarah Babcock, DVM, JD; Tanya Lynn Tag, DVM,
DACVECC and Thomas Bauk, DVM. Following are excerpts from the
conversations. Questions from the audience are in bold, followed
by the panelists’ answers.
If you prefer to review the list of
questions and read only those answers that interest you,
Younger veterinarians are taught
to refer a lot of surgeries with which they are not comfortable.
As a practice owner who employs younger veterinarians, I have
always encouraged them to do these surgeries to build their
confidence. How should we approach that with a client? If we
tell them we'd like to do the surgery and we have some
experience but also inform them there are more experienced,
board-certified surgeons available, is that enough?
Dr. Evans: If you are
comfortable doing the procedure and you tell your client about
other options and where to find them, you've covered your bases.
Your client can make an informed choice. The owner wants a
quality procedure but may want to pay less. It is not
unreasonable to say, "one of the advantages of having it done
here is it may be less expensive."
Dr. Runde: I cannot think of
a specific case where a complaint arose when a veterinarian was
presented with an animal that needed a procedure, surgical or
diagnostic, and an option was given to see a specialist or have
the procedure done in house. Be completely open with the client
about your level of skill and experience. Dr. Babcock's DR TAP$
philosophy is a pretty good tool to have in your toolbox.
Dr. Handel: I would document
everything. This is where your records are your friend. Take an
ACL tear, for example. In your practice, you may have a comfort
level doing extracapsular repair whereas you may refer a TPLO.
So you would record that you discussed the pros and cons of
extracapsular vs. TPLO and offered the owner a referral. The
owner chose the extracapsular repair at your facility. If you've
had an honest discussion with your client, if your client is
comfortable with you and your records reflect this, I can't see
why you would have a problem.
If you haven't done the procedure
before but are willing to try, the same discussion applies. It
boils down to your relationship with your clients. Do they trust
you? Do you trust yourself? Are you confident you can perform
the procedure so you will more likely have a desirable outcome?
If you don't, it behooves you to decline the procedure.
Dr. Babcock: Problems start
when veterinarians take on more than they can handle or put
themselves out there as specialists when they really are not.
That is something I would caution against.
Dr. Handel: Maryland code
says if you present yourself as a specialist, you will be held
to that standard. That's why, if you are a general practitioner,
you want to tell your clients you are a good general
practitioner but not a specialist, and your documents should
What about low cost spay and
neuter procedures? What do we need to tell our clients?
Dr. Handel: I believe the
public's perception is the low cost procedures are not
different. The consumer goes to a lower cost spay or neuter
clinic thinking they're getting the same thing --that somehow
the clinic, through donations or tax credits, is able to do this
at a lower cost. They think they are getting the same service.
It's up to general practitioners to say their service is not the
same where the State Board views it as it should be the same.
Dr. Runde: If the level of
care and service is made entirely transparent to the pet owner
at the time they drop the animal off, you minimize the chance
they're going to think this $30 cat neuter is the same as the
$180 cat neuter they would get at a full service veterinary
hospital down the street. You make it clear to them it's not the
same service and, if they go down the street, they get a more
sophisticated, theoretically safer procedure. If you've done
that, stated it clearly in writing, if the case blows up and
ends up before our board, you've put yourself in a better
position to have that case dismissed.
If the customer knows that the
reason the procedure costs $30 is we're doing everything "on the
cheap" here and trying to perform a service to the community,
then that might work in your favor.
Dr. Handel: Where it would
help you the most is you'd be less likely to have a complaint in
the first place. Your goal should be to never have a complaint.
By documenting the details, your hope is the client understands
and has made an educated choice. There may be a percentage of
clients that decide to pay more down the street. But for those
who opt for the lower cost procedure, they have accepted this
and would be less likely to complain.
Are you suggesting that, in
addition to telling clients what we will do, we tell them what
we're not doing that the more expensive procedure would include?
Dr. Handel: If you are
offering a lower cost surgery, I don't know that you have to go
into every detail, but you should tell them it is a lower cost
procedure and there are things anesthetically and technically
that a higher cost procedure might use that you will not be
using. You can tell them you are not subsidized and you're doing
this because you feel it is for the public good.
Dr. Tag: Emergency clinicians
run into this problem a lot. Certainly, we all try to offer what
we feel is ideal for patient care. For example, if a cat was hit
by a car and comes in with hind area lameness, certainly we have
to address shock and then we have to address the fractured area
and the pain and stabilization. But when we start talking to the
owner about everything we recommend, chest radiographs are
typically part of that because of the velocity of the impact.
Most owners, sadly, can't do
everything we think is ideal. We document just to make sure it's
clear that, whatever we've agreed to, we do offer full
stabilization and care. We do that to make sure we've protected
ourselves from problems that might arise later.
Dr. Babcock: From an ethical
standpoint, just because all of these specialized services are
available, it doesn't mean everyone has to go that extra mile.
Some people want to be given a choice and allowed to make an
informed decision. We also need to step back and try not to make
clients feel guilty if they can't afford everything that is
available. Be as forthcoming as you can so the individual can
make a choice without feeling guilty or without having a grasp
of what the risks truly are.
Dr. Handel: I don't ever
speak of what a colleague would or would not do. I discuss the
pros of what I have described as the best quality medicine I can
If you present what you're going
to do and your cost, are you also obligated to tell them about
the other facility down the street that will do it for half the
Dr. Handel: There are those
who debate this, but I don't believe you are obligated to do
that. It is up to the client to shop services. It's up to you to
do the best job you can and offer your clients reasonable
What is the difference between
telling someone they can go to a specialist and telling them
there might be someone down the street who can perform the
procedure better? Why is one okay and not the other?
Dr. Babcock: You have no duty
to inform that something can be done cheaper. You have a duty to
inform your clients of all of their diagnostic and treatment
options, but you don't have to talk about cost options. You have
to provide the cost of your services, but you have no obligation
to shop around.
Are we obligated to tell a
customer that someone could reasonably be expected to do it
Dr. Babcock: Better is a
judgment call. You can say they have newer technology, they have
a board certified practitioner, they have digital radiographs,
they have rehab services on site. Those are differentiating
services. You have a legal duty to inform that there is a
different level of care available, but not a different cost of
Let's talk about dentals and
whether digital radiography is going to become a part of
dentals. Let's say a dental today costs $200 and let's say
digital dental radiography becomes the standard of care. If you
buy it, you're going to have to charge for it. Let's say you
charge $50. You're doing it and let's say you see 15 teeth that
should come out and you have to charge $150 to take the teeth
out. The cost of your dental has now gone from $200 to $400. Is
the cost going to start precluding people from doing the
procedures because digital radiography has changed the standard
of care? Are we beginning to price ourselves out of the market
because of what the standard of care becomes?
Dr. Bauk: As a practitioner,
I have the same concern. We're all seeing the impact of this.
There is a decrease in the number of visits to veterinarians
and, when asked, consumers identified price as the primary
How is the standard of care defined?
I picked up a brochure from one of the exhibitors today. It
says, "Carbon dioxide lasers have become the standard of care in
veterinary surgery." We cannot have claims like this. They're
made in national publications as well. I have three or four
examples just from the past couple weeks.
As we are held to this type of
standard, costs are going to have to go up and customers are not
going to be able to afford it. As articles like this are
written, expectations increase that this is what should be done.
We're going to have to discuss this.
The profession is going to have to decide whether there is a
place for different levels of care.
Dr. Babcock: As long as you
inform your client and discuss the options, the customer can
always decline them. Yes, the standard of care is elevating, but
that doesn't mean you have to provide everything. You can just
make your customers aware that those options exist. Then
document the path forward chosen in a shared decision-making
process. You look at all the options and decide what is best for
that animal based on all of the circumstances. That maintains
the appropriate level of standard of care.
Dr. Evans: The standard of
care has elevated because of people specializing. But if it is
documented that a client was given all the options and they
decided not to pursue those options, I don't know how a
veterinarian can be held to a standard of care that the client
We get cases via referral or the emergency clinic and we make
recommendations about how the problems should be fixed. If the
client can't afford that and asks for other options, I'll
present them. For a severe tibial fracture, for example, other
options would be to do nothing. I don't recommend euthanasia for
a healthy young dog. There are rescue legs. There are casts. I
will not be the one to perform the cast because I will be held
to a higher standard of practice. But the customer can go back
to their regular veterinarian who can put on a cast, monitor the
patient with radiographs and see how it's healing. Other options
are there and still have their place.
Dr. Bauk: I read an article about extracting a deciduous tooth.
It called for a multi-drug anesthetic protocol, pre- and
post-extraction x-rays, a mucosal flap bone burring ovular
socket, suturing and pain management. If I'm doing a snap spay
on a cat for $40, how do I tell the customer it's $500 to get
its tooth out? I don't want to feel like I'm providing
sub-standard care, so I object when these articles are published
and people throw this out as a standard of care. It's
You see one article in the journal talking about how our incomes
are going down and the debt loads of students coming out. Then
the next one is putting stuff like this out there. It doesn't
make any sense. There has to be some balance.
Dr. Handel: On our consent form, we ask for the client's phone
number. Frequently, they're not there. So we ask if they would
consent to, for dental your example, extractions being done. We
try to keep it at a reasonable number, say one or two. If the
client consents to nothing else being done, we don't do anything
without talking to them, even if we deem it medically necessary.
The other thing is if the client tells you they can spend an
extra $200 or $500, that puts pressure on you to compromise. Now
you have to decide what absolutely needs to be done today.
What kind of service am I doing if I see them once and never
again because the price was too high? It seems better to do
things incrementally so I see the customer more frequently.
Dr. Evans: If you're doing regular dentals, that certainly would
Dr. Tag: This is great here because we're on the same page. But
that idealistic young associate needs to realize that, even
though they might have learned one thing in school, they're
going to have to compromise when necessary. I'm not sure they
would all do it.
Let's say we've gotten verbal consent from the customer and
something goes wrong. We explained the options, documented
everything but the customer comes back and denies being told.
How do the courts and the licensing board handle that situation?
Dr. Babcock: If you receive oral consent, document it in
writing. When it comes down to "he said, she said," your history
-- your practice with other clients -- protects you. If you have
a pattern of obtaining consent and educating and involving
clients in the discussion, I don't believe you'd be in a
situation of liability. If you've properly educated that client,
they wouldn't turn around on you and say they didn't consent to
Dr. Handel: I'd agree from a State Board perspective. The burden
of proof would be more on the owner than you. If you do not
adequately document this in your records then the burden of
proof is on you. But since your records are complete and you've
documented the conversation reasonably well, it would be up to
the client to prove the conversation never happened.
Dr. Babcock: If you're in doubt, you can always pass the phone
to someone else. Obviously, in a euthanasia, you would always do
that but, if you're in surgery, put the client on speaker phone
so everyone in the room can hear.
Dr. Runde: If you have the conversation and document it in your
records, the State Board is going to accept that as long as it
looks legitimate and as long as there's a pattern of routinely
documenting this sort of thing. If you don't document the
conversation, that State Board would not ignore your claim of
having the conversation, but it wouldn't be happy about the lack
Dr. Babcock: It would be your client's burden to prove you had
breached your standard. It's a different burden between the
malpractice standard and veterinary licensing board.
Does the court or the State Board ask for additional records to
see what veterinarians have done in the past?
Dr. Runde: Yes, we might send an investigator by the office to
randomly select records from similar cases to review. Depending
on the practice, that could be easy or it could be difficult. I
suspect, with today's computer systems, that could be done
relatively quickly. They would produce those records and we
would have a look at them. That's not something we would do a
Dr. Babcock: Either side could request records to submit as
evidence in court. I would not recommend just sending, on your
own, a bunch of records to support your case because they might
find other problems in there.
A lot of practices don't routinely do anesthesia logs for basic
procedures such as spay/neuters. It's noted as part of the
record of the procedure, but do we need a log for anesthesia?
Dr. Handel: Assuming you have a technician in the room with you
while you're performing the procedure, it's wise to have them
document what they're checking. It's easy to put together. I
believe AAHA has a sample. I would encourage you to have the
technician write down basic stuff every few minutes -- heart
rate, SpO2, mucous membrane color, periodically check
temperature. Hopefully you won't need it. But it's that much
more that will protect you and show your standard of care.
Something adverse happened in this case, but you did everything
you could to monitor the situation.
Dr. Babcock: It's in the patient's best interest too to have a
log of the anesthesia you used and how they responded. That will
serve as a baseline should a negative outcome occur.
I'm a mixed practitioner and often the only one in my clinic. If
I'm doing a C-section on a cat, there is no one else to document
anything. That's the difference between an emergency clinic
charging $1,800 and me doing it for an old farm client for $400
on Sunday morning. How am I liable for those anesthesia logs
that are not being done?
Also, let's say the procedure is done, the kittens are alive,
the cat seems fine and I get a call and I'm gone for three
hours. What if something happens then? Am I liable for all of
Dr. Babcock: On the civil side, standard of care is determined
by an expert witness. So you would find a similarly-situated
expert witness who would say it's typical to leave the clinic
when I get emergency farm calls. If an expert testifies to that,
you would not have breached your standard of care.
Dr. Runde: If you explain the circumstance to your client prior
to performing the procedure and they understand the nature of
your practice, I don't see where you would be getting into any
trouble. The client then makes the choice between your clinic
and the emergency clinic. They know the circumstances. As a
board, it would be hard to find fault with that.
Dr. Babcock: Even if there are specific procedures that elevate
standard of care options, it doesn't necessarily elevate the
acceptable standard of care. We still have a standard of care as
determined by our peers. If a significant percentage of your
peers are doing things the same way, you're fine.
Dr. Handel: During my time on the State Board, I've seen three
primary reasons for cases being in front of us. Misunderstanding
is by far the biggest reason. We should strive to communicate
without clients as best we can. That will help a lot.
Money is also a big factor. That's where estimates and treatment
plans are important. If people expect to pay $100 and you give
them a bill for $500, they're mad.
The minority of cases that I've seen are relative to
malpractice. Communication is first, money is second and
malpractice is a distant third. So if you focus on the first
two, you'll avoid a lot of issues.
At what point is it the veterinarian's responsibility not to
enter into a new client relationship if you're already providing
care for another animal? If you're in the middle of that
C-section and you get the emergency call, where do you draw the
line? When the cat initially recovers from anesthesia? An hour
later? When can he take on that case?
Dr. Babcock: He already took on that case because he had an
existing duty. It that geographical region, there wasn't an
option to call three other people and see if they were available
immediately. It's very fact-driven. If you're the only one
available and you have to balance the critical cases and
communicate with the clients.
How much influence on the standard of your care does a similar
procedure in human medicine have?
Dr. Babcock: Your standard of care in a civil suit would be
determined by an expert witness that is similar to you. There
would never be a situation where a human surgeon would come in
to testify on standard of care for a veterinarian. Certainly
human medicine impacts veterinary medicine, but it does not
impact standard of care.
Dr. Handel: Nothing like that has come before the State Board,
nor do I think it would have any weight.
Dr. Runde: Much of our conversation today has focused on
expense, technology and specialization. A lot of standard of
care has nothing to do with cost. It's tied up in communication,
doing a really good physical exam and keeping good records. If
you do those three things, these other things don't become
Don't focus too much on whether you have lasers or digital
radiography, or whether you know everything there is to know
about dentistry in small animal medicine. If you're a good
communicator, keep good records and do a good physical exam and
follow Dr. Babcock's rules of DR TAP$, you'll go a long way
towards keeping yourself out of trouble and being a high quality
Going back to DR TAP$, how much needs to be in the records as
far as rule outs? If I want to do a chemistry profile on an
animal preoperative, do I have to go over every detail of what
I'm looking for -- sodium, potassium, creatinine, etc.? Do I
have to go over my interpretation of every result or can I just
say normal? Do I have to go over every complication that is out
there for the surgery or am I okay with the common ones of
hemorrhaging, infection, general anesthesia?
Dr. Babcock: Put in
the information that would make you comfortable as if you had
never seen this patient before and were reading the records. You
don't have to put everything in there, but if you wanted a CBC-chem to rule out something specific, note it. And when
you're interpreting the results, do the same thing. You need to
put enough in there so that if you didn't have results attached
to your record another veterinarian could look at it and
determine what you wanted to do.
A good exercise, especially if you have a practice with multiple
veterinarians, is to play that game. Have lunch bring, some
records, and trade. See if another veterinarian can pick up that
record and understand the case.
Regarding the interpretation of tests, note any findings you
didn't expect. Note any recommended follow-up tests. Again,
provide enough information that another veterinarian would be
able to pick up where you stop.
So if a referral comes with an x-ray and there's no
interpretation of that x-ray, should I record my interpretation
of that x-ray even though it was not my x-ray?
Dr. Babcock: If you agree to interpret that radiograph, then
your record should include that interpretation. If you order
your own radiographs, your record should include an
interpretation of those you order. Whatever you rely on in
formulating your diagnosis and treatment recommendations should
be noted in your records.
Could you review what DR TAP$ means?
Dr. Babcock: DR TAP$ is an acronym for things to be included in
your records - Diagnosis, Risks and Benefits, Treatment,
Alternatives, Prognosis, and I use a dollar sign ($) because you
should always include a cost estimate.
Dr. Handel: As a practitioner I put my top three or four
differentials when I see an issue. It's helpful because it gets
your thought process going. If it's not on your differential
list, you're not going to diagnose it. You don't need every
detail, just enough to show your thought process. "Assessed the bloodwork. Elevated BUN and creatinine. Ruled out dehydration
vs. kidney failure. Recommend owner drop off a urine sample."
That would be a very thorough record and that's not a lot of
Dr. Runde: If someone else looks at your record, they should be
able to see what you've done, what your plan is, what your
thought processes are and what your chief rule-outs might be.
Regarding blood work, there are minor abnormalities that are not
particularly compelling. However, I once had a customer who was
furious with me because I told her the blood work was normal
and, when she saw the results, she pointed out several minor
abnormalities. I had to backpedal and explain to her that none
of those abnormalities, taken individually or together, were
compelling. So ever since that day, I go over each item and, if
it is abnormal, tell the customer but also tell them it is not
Does the blood work ever speak for itself? If it comes back from
the lab, the report says it's abnormal. Do you have to note in
your records that it's abnormal?
Dr. Runde: It has to be written in the record if it's compelling
and it means something in terms of your treatment plan with the
Dr. Babcock: Also important to put in the record is a note that
you discussed the results with your client, even if that
discussion is simply that there's nothing to be concerned about.
Clients communicate with us using cell phones, so we're not
making contemporaneous notes, but I may be giving medical advice
without the ability to write it in the record at that moment.
How do we document those kinds of things?
Dr. Runde: If you make a good faith effort to document those
conversations when you are able, the board would look favorably
on that. It's part of the deal now that some conversations are
difficult to record. In some cases, it would take a really
supreme effort to do so.
Dr. Handel: Also, now that we communicate more with e-mail, I
encourage practitioners to print their e-mails and make them
part of the record.
We still keep paper records along with our computer. The amount
of paper we have in each record now is hideous. We have our
anesthetic log, our surgical consent forms, our surgical
discharge forms, our medical records, two or three other pieces
of paper and the inch-and-a-half stack they had sent from their
15-year-old-dog's previous vet. Do we have to keep that?
Dr. Handel: You have to keep your records. As for the rest, if
they're of value to you, you might want to keep them. I don't
think it's imperative, though.
Can I summarize an e-mail or text exchange rather than printing
it? That's what I do with phone conversations.
Dr. Handel: As long as the exchange shows up in your records,
Some animals we know are not going to be around in six months.
When we offer all of the options and the owner decides he wants
pain management and palliative care for the dog, we'll document
that now. For the rest of that dog's life, we'll provide what
the animal needs to be comfortable. How do we document that each
Dr. Handel: You document it once during that initial visit as
you suggested. You don't need to document it on each subsequent
We had a pregnant client whose dog has lymphoma and she came to
pick up Cytoxan. I was not comfortable with her handling the
medication. What's our liability with that?
Dr. Babcock: That might warrant having her talk to her
physician. Even if you aren't at fault, you wouldn't want to be
blamed later for anything that might have gone wrong.
Dr. Handel: A safe answer would be to see if there's someone
else in the home who could handle the medication during her
pregnancy. I would certainly document that you warned her about
your concerns. If you want to provide an additional service,
tell her to bring in the dog and your staff will administer the
medication for free. It may be a hassle, but it's an option you
can offer to make a good-faith effort.
Dr. Runde: Many computer systems will generate safety data
sheets for the medications you dispense. Depending on what
you're using, you may already have something you can print for
your customers. That's not the same as having a conversation,
but it's a supplement.
Why is handwriting important in our records?
Dr. Babcock: You need to be able to hand off those records to
someone else who might take on the case. That person needs to
know exactly what has been done, the status of the animal and
the treatment going forward. If they can't read your writing,
they can't provide treatment to the animal. Computer records
help, but your writing must be legible as well.
Dr. Runde: The regulations specifically say the writing needs to
We provide 24-hour care. On our consent form, it says no one is
there 24 hours a day. The animals are checked between 10 and 11
p.m. and someone is there by 7 a.m. Is that good enough?
Dr. Handel: I'm a general practitioner in the same situation. It
behooves you if you are going to sedate a patient, you should
make sure it is adequately stable before you leave. If it's your
opinion that the animal should go to the emergency clinic,
recommend it. If the patient declines, note it in your records.
Dr. Babcock: I would never classify someone's services as
expensive or inexpensive, I would tell customers what they're
getting for what they pay. Here you leave your animal that is
not awake and no one is here. Give them a price. Tell them the
risks. Then tell them the alternatives.
Dr. Runde: In Calvert County, we have an emergency clinic with
an overnight monitoring service that is $150 if you're a
shareholder. If you have a animal that needs to be monitored
overnight -- just basic monitoring -- it's a standard package.
That seems to work for us.
When animals are in the clinic being boarded, is that clinic
responsible for any care the animal needs for something that
happens in that facility?
Dr. Babcock: You would be responsible for returning the animal
to the owner in the same condition as when it was dropped off.
You should have a contract in place that authorizes you to
perform whatever emergency services are needed.