Case study on communication and clinical management
Published in the December 2012 issue of Vetboard Victoria's newsletter
The following case study provides an opportunity for general reflection. The case study is based on a complaint about an individual set of circumstances at a particular time. As veterinary knowledge and professional and community standards and expectations change over time, readers should not assume that the Vet Board would make the same decision when presented with a similar complaint.
Summary
A domestic short-haired tabby was adopted from a veterinary clinic. Prior to the adoption and over the weeks following, the cat suffered from an ongoing lameness. The cat was examined and treated with a non-steroidal anti-inflammatory drug but despite this treatment, the cat’s condition deteriorated and the owner sought a second opinion at another clinic. The cat was subsequently diagnosed with septic arthritis, treated with antibiotics and has since made a full recovery.
The owner alleged that Dr A was negligent in the care of the cat and that Dr A and the staff at the clinic failed to adequately communicate. The matter was referred to an informal hearing into the professional conduct of Dr A. The panel considered the allegation that Dr A had failed to exercise the reasonable skill and care expected of a registered veterinary practitioner in the clinical management of the cat.
Dr A was found not to have engaged in unprofessional conduct.
Reasons for Board's finding
The informal hearing panel made its finding based upon the following reasons.
The panel reviewed all of the information provided, including clinical records supplied by Dr A, statutory declarations from two veterinary nurses, radiographs from the veterinary clinic and the clinical records that the subsequent treating veterinary practitioner supplied. The panel considered each of the owner’s allegations in turn.
Negligent / inadequate care
The panel considered that the veterinary care that Dr A had provided was satisfactory and that which could be reasonably expected of a veterinary practitioner. Dr A had examined the cat for lameness. Clinical examination had revealed mild discomfort on hyperextension of the left elbow but no swelling or heat was identified. Dr A made a presumptive diagnosis of soft tissue trauma. The cat was treated with an injection of meloxicam, which is a non-steroidal anti-inflammatory drug (NSAID). Dr A re-examined the cat the following day and the lameness was found to have resolved. The panel considered that based on the results of this initial clinical examination, a differential diagnosis of soft tissue injury and treatment with a NSAID was reasonable.
The cat re-presented a week later for continuing lameness and was examined by another practitioner in the clinic. This practitioner noted the cat’s intermittent lameness, prescribed oral meloxicam and rest and advised the owner to re-visit if the problem persisted.
Dr A examined the cat again 10 days later for continuing intermittent lameness. Dr A advised further diagnostics were required and the cat was x-rayed at the clinic. The radiograph revealed an abnormality in the region of the left olecranon. Dr A discussed the finding with their colleagues but the clinic was unable to diagnose the cat’s underlying problem.
Both the clinical record and Dr A’s response to the Board documented infection or inflammation as a possible cause for the cat’s lameness. There was no further evidence, such as swelling or radiating heat to the area or increased body temperature, to support such a diagnosis. The Panel accepted Dr A’s clinical judgement that at this stage the cat was not exhibiting symptoms indicative of septic arthritis.
Diagnostic investigation is generally a case of excluding the disease processes that most commonly cause the presenting symptoms. The cat’s clinical management was undertaken appropriately, based on this principle. Clinical examination, drug trials and radiographs were all undertaken in an attempt to ascertain the cause of the cat’s condition. Many possible causes of the cat’s symptoms were able to be excluded based on the results of diagnostic testing.
Dr A presented the owner with options for the cat’s ongoing care. As the cat was an adoption cat, the clinic had been providing services at no cost. However, the costs arrangement could not continue given the competing pressures of running a business with that of an adoption program. Dr A gave the owner the option of returning the cat to the clinic for a full refund of the purchase price. The owner was aware that it was possible that if the cat was returned to the clinic it might be euthanased. The owner was offered the alternative option of attempting to control the cat’s symptoms with medication until the case could be reviewed by a senior practitioner at the clinic (who was on leave at the time). The panel considered that, based upon the cat’s symptoms and results of diagnostic testing, the clinical management of the cat’s case was undertaken with due care and the diagnostic plan was reasonable. At this stage, the cat’s lameness was still intermittent and it was not deemed to be distressed or suffering overt pain. The panel's view was that immediate referral was not necessary and maintaining the cat with ongoing medication until review by a senior practitioner was a reasonable option.
Dr A did not examine the cat again. In the following weeks, the owner had several conversations with veterinary nurses and staff at the clinic about the cat’s condition and prognosis. This included an appointment with a veterinary nurse, during which an injection of an anti-inflammatory drug was administered. During this consultation the cat was found to be in significant pain. Dr A was in surgery at this time and was therefore unable to examine the cat. The nurse spoke to Dr A about the cat's state, and Dr A recommended that either the cat be left at the clinic or the owner wait with the cat. The owner declined both options because they needed to get to work and feared that the cat may be distressed if left at the clinic. The panel considered that if Dr A had been given the opportunity to examine the cat later that day, it was likely that the cat’s condition had progressed to a stage where a definitive diagnosis could have been established, given the cat’s worsening signs. Two days later, the senior practitioner noted marked joint effusion when they reviewed the cat's condition.
Inadequate communication
The panel considered that, while not serious enough to constitute unprofessional conduct, there were deficiencies in communication in this case and that much communication had taken place with and through the veterinary nurses. Although it is not uncommon for veterinary practitioners to communicate through their nurses (while they are in surgery, etc), the panel considered that the nurses were allowed too much authority in this case. While the panel acknowledged the collaboration between practitioners and nurses, ultimately the veterinary practitioner is responsible for the medical management of patients. There needs to be a degree of control and confidence in communication imparted on a practitioner’s behalf. The panel considered that in this case, Dr A did not have the requisite degree of input to effectively manage the communication between clinic staff and the cat’s owner.
The panel noted that communications between staff members and the owner were not routinely documented. It recommended to Dr A that all communication with clients be adequately and contemporaneously documented.
Relevant guidelines