In veterinary medicine, we have greater incentives to make our clients happy than most physicians have to satisfy their patients. Pet owners choose their vets, often on the basis of location or personal recommendation, and they can choose to find another if they aren’t happy with the care they and their pets receive. Our clients don’t experience the benefits and discomforts of our treatments directly, and they often don’t have the background or information needed to judge our competence. The veterinarian-client relationship is more about effective communication and personal rapport than it is about pet owners objectively evaluating veterinarians knowledge and skill.
On the whole, I think this is a good thing. I believe veterinarians are often better at communicating with our clients and, somewhat ironically, at the “human” side of healthcare; talking to people about their goals and fears and giving them the information they need to make important decisions. We have to be! It is still unfortunately true that veterinarians often don’t have extensive training in the communication skills that are so critical to our being able to do our jobs effectively, but as a profession I think we have the desire and the incentive to serve our clients as well as our patients as well as possible.
There is, however, a down side to the importance of subjective impressions and communication skills in establishing and maintaining relationships with pet owners. Most owners judge our manner, and how well what we say fits with their own beliefs and values, but most cannot objectively judge our competence or the accuracy of what we tell them. Therefore, clients can easily misjudge the quality of the medical care their pets are receiving.
I once worked with a doctor whose clinical practices would have been considered grossly outdated and unacceptable by the standards of almost any other veterinarian. Yet his personal charm and comforting manner immediately engendered trust and loyalty from clients. It didn’t seem to matter how his patients fared, his clients adored him even when their pets received inadequate or ineffective care and did not improve.
In contrast, I have also worked with a vet who was intelligent, compassionate, and skilled and to whose care I would have trusted my own pets without hesitation. Yet clients consistently disliked her and distrusted her recommendations due entirely to her reserved manner. It is a reality that vets are judged on how they communicate more than on the truth of what they say or the objective quality of their medicine. We must accept this and make vigorous and good faith efforts to communicate more effectively with clients so that we have the opportunity to care for our patients.
I feel, however, that it is worth warning pet owners that the reliance on somewhat superficial personal attributes in judging whether or not you have found a good vet can be misleading. A recent and stark example of this is a glowing testimonial recently posted on the web site of the American Holistic Veterinary Medical Foundation (AHVMF).
This pet owner feels she has received the best possible care for her pet, and because her pet has done well, she believes the judgment and recommendations of her vet to be correct. An evaluation of some of these recommendations informed by science, however, shows that many of these recommendations are complete nonsense, and it is very likely this patient is thriving despite rather than because of the veterinary care discussed in this testimonial.
The case was a new puppy with, according to the anecdote, skin and ear infections and intestinal parasites. The first warning sign is the blame given to vaccination for the skin and ear problems.
Our doctor suspected that the rash was most likely an allergic reaction to the vaccinations he had received from the breeder so…we began working to bolster Ceelo’s immune system.
While acute hypersensitivity reactions do occur in response to vaccination, the limited information here does not suggest that was what this pet was experiencing. Vaccine reactions are quite rare and quite distinctive, and the mistrust of vaccines induced by incorrectly blaming them for unrelated medical problems does real harm.(some facts about veterinary vaccines) And if this were a case of a vaccine reaction, it would represent an inappropriate and excessive immune system response, so the notion of “boosting” the immune system is not only nonsense, it is exactly the opposite of what ought to be done.
Things go from bad to worse as the testimonial describes the use of “various supplements,” which in most cases in veterinary medicine are almost never supported by good evidence and have significant problems with quality control and potential risks. The fact that this use of supplements was guided by “muscle testing,” a term often used to describe the quack practice of applied kinesiology, is a further red flag. Inevitably, unproven but passionate claims about the value of raw diets appear as well:
I switched him off of kibble and on to raw venison mixed with simple fruits and vegetables. This had a huge impact on his skin.
However, the ultimate leap from dubious practices to quackery comes with the mention of Traditional Chinese Veterinary Medicine (TCVM).
…his skin was still red and inflamed, especially at night. Our doctor mentioned that in Chinese medicine, that was the Liver’s way of releasing toxins from the system so we then worked on purifying his liver and eliminating anything that might be an allergen…our integrative vet who took one look at Ceelo’s tongue and knew immediately that something was not right with his Spleen. He then did muscle testing to confirm his initial diagnosis. He prescribed a Chinese herb along with whole food and glandular supplements.
The principles of TCVM, including tongue diagnosis, are pre-scientific myths and metaphors that have never been reliably linked to health and disease through scientific research. While some of the herbal remedies used likely have beneficial compounds, the lack of a rational system for employing them and the lack of appropriate testing to determine their real risks and benefits make the system as a whole as likely to do nothing or even hurt patients as to benefit them. The addition of the nonsense of detoxification, applied kinesiology, and glandulars make this a classic description of pseudoscience which should serve as a warning to anyone thinking of bringing their pet to this veterinarian.
Unfortunately, the interpretation given by the client, and the message of the testimonial, is exactly the opposite. Despite the advocacy of multiple kinds of unproven and outright quack therapies, this vet has a happy, loyal client. Why?
Well, I don’t know anything about this doctor personally, but I suspect like most vets he or she is a genuinely smart, caring person. He/she probably demonstrates true concern for patients and clients alike and likely offers advice and recommendations in a confident, comforting manner. All of these characteristics are necessary to an effective veterinarian/client relationship. Unfortunately, none of them have anything to do with whether or not the medicine being employed is effective or nonsense.
I also have clients who like me and trust me to care for their pets. Yet my approach to medicine is very, very different form that described here. The fact that we both have clients who are happy with the care we provide for their pets doesn’t say much about which style of medicine is superior because clients don’t judge us on the basis of the objective truth of our knowledge or effectiveness of our interventions, since these are not accessible to them.
“But,” this client might object, “the pet got better so that must be evidence the medical care was effective, right?” The core concept of the entire scientific method, and certainly of this blog, is that such anecdotes cannot be trusted and often do not mean what we think they mean. I have written about this often, but the bottom line is that it is deeply misleading to say that when an individual patient does well or badly that this validates or invalidates the treatment given. If this were true, science would be unnecessary, and yet the evidence of history is quite clear that science works far better than anecdotal methods or evaluating medical treatments. Here are a few reminders of why:
Medical Miracles: Should We Believe?
Testimonials Lie
Alternative medicine and placebo effects in pets
Placebo effects in epileptic dogs
Apart from the effect of a nice manner, and the ultimate positive outcome for the patient, the other reason why I suspect this client views her story as confirmation that she has a great vet is that she and the doctor share some key aspects of their world views. If this client were a scientist or a skeptic with a strong commitment to objective evidence and science-based medicine, I doubt she would have stuck with unproven recommendations based on pseudoscience for very long. We are naturally inclined to seek confirmation of our beliefs and to reject challenges to them, and this influences who we seek information from and how we interpret that information. Clients may like or dislike their vets personally, and they may believe the care their vets provide to be excellent or terrible based on the outcome, but they also tend to view more sympathetically advice consistent with their existing beliefs.
Bottom Line
It is natural to trust people we like, and this plays a large role in how pet owners judge their veterinarians. It is also natural to believe that something has been done right when things go well and that something has been done wrong when things go badly, though this is often not a reliable way to judge the quality of the care one’s pets receive. And finally, we are all predisposed to seek confirmation of our beliefs and to avoid challenges to them, which leads us to prefer vets who seem to think the way we do about health and disease, science and nature, and all the values-laden subjects that touch on veterinary medicine.
All of these inclinations are unavoidable, and for better or worse they influence the veterinarian-client relationship. Vets should recognize this and make their best effort to understand and respect their clients’ values and perspectives. We need not agree on everything with our clients, but we cannot help them or their pets if we cannot communicate effectively. I have plenty of clients with whom I disagree about the merits of specific therapies but with whom I get along great and who trust that I have their pets’ best interests at heart and the knowledge and skills to give them the best care.
On the other hand, clients should be aware of their own tendencies to judge their vets on the basis of factors that may not really have much to do with the quality of the medical care they provide. Without a thorough education in science and medicine, clients are stuck trusting their vets to some extent. Just as I cannot expect to effectively judge the competence or skill of my airplane pilot or tax accountant without having expertise in those domains, so pet owners have to recognize that while they have the right to control the care of their pets, they often don’t have the knowledge or skills to do so alone. If they did, they wouldn’t need a vet at all! And this means they must take a certain leap of faith when choosing a vet.
The key, then, is how one evaluates whether this faith is justified. The ability to empathise and communicate is essential, but it is not sufficient to mark a veterinarian as a skilled doctor. Ideally, an open and explicit adherence to established and accepted scientific standards of care would be the best way to know if your vet is doing the best they can for your pet. By this standard, an anecdote like the one on the AHVMF web site is a warning, not an endorsement!
Of course, if you doubt the value or reliability of science and science-based medicine, and if you already have a preference for the alternative philosophical perspective underling alternative medicine, well adherence to scientific principles and methods won’t seem a very reliable guide to quality to you. But at the least pet owners should be aware of the limitations of these natural human tendencies to trust those we like personally and who seem to agree with us. And we should recognize that individual anecdotes, good or bad, aren’t really a reliable way of evaluating the competence of those experts we hire to guide us in areas where our own expertise is insufficient, whether in medicine or other fields. Testimonials are far more persuasive than they are trustworthy.
“I switched him off of kibble and on to raw venison mixed with simple fruits and vegetables. This had a huge impact on his skin.” I expect it had a huge impact on the deer, as well…..and “glandular extracts”? Whose glands were they?
I always assume that any qualified vet is as good as any other (like for-human doctors) and mostly just find one I can park in front of, though I must admit I have recently changed because the old one seemed lethargic and not very interested in treating my Leishmania dog. Neither is alternative oriented, DG, but a young horse vet who we tried out to give her a leg up in the field started on selling us expensive “supplements” and talking about some “natural” cure she uses on her own horse….goodbye her. Perhaps it’s the case that the young vets coming along are more prone to falling for this stuff, in which case, it’s a poor look out all round.
It’s a poor look out for them, because there is a plethora of young vets coming along and they mostly seem to have to go to work for established vets who may even have chains of practices, meaning long hours and not much pay. On the other hand, real veterinary medicine has come up with some very high tec (and expensive) treatments, which may be beyond the reach of some clients….the whole situation is a potent brew of economics and dubious information and not very positive for vets, clients and, of course, the nonhumans!
Well, I’m not sure it’s as grim as all that. I do think, unfortunately, that some alternative therapies are becoming more acceptable to the younger generation because of more familiarity and effective marketing and despite the absence of good evidence that they work or are safe. That is something that has to be addressed by emphasizing science and evidence in training young doctors.
On the other hand, I don’t think it’s a safe assumption at all that vets are interchangeable. I know brilliant and terrible doctors with the same degrees and state licenses. The problem is that it is nearly impossible for clients to evaluate their vet’s competence, so usually they simply stick with someone they like. This is fine, since rapport and communication are important, but ideally more people would also ask for and expect some adherence to scientific standards of practice.
As for economics, more comprehensive and effective care is going to be more expensive care. If I euthanize a dog with lymphoma or just give it palliative care for a few months, it’s obviously less expensive than chemotherapy. But since I routinely see chemotherapy yielding years of good quality life for these dogs, I think it’s a good thing that more clients are able and willing to afford this level of care. The same is true for surgical procedures, newer medications, and other science-based therapies. The effort that goes into developing and testing them means they are more effective, but it does also mean they are more expensive.
It is always heartbreaking when effective care is available and clients cannot afford this care, and it is natural for people to turn to less effective or less well-studied practices when this happens. There is nothing wrong with this. However, when such alternative approaches are offered as cheaper alternatives without explicitly disclosing the lack of evidence behind them, or even while touting them as better than conventional methods, this is misleading. In any case, cost isn’t any better a measure of scientific legitimacy or competence than charm. Good medicine often does cost more then poor medicine, but nonsense can also be quite lucrative.
From that “miraculous” testimonial:
* Editor’s note: In Chinese medicine theory, Liver and Spleen have functions that go beyond conventional Western functions. So we capitalize those words when we are referring to Chinese medicine, and make Chinese diagnoses that tell us which Chinese herbs to use. Those diagnoses may include some items that Western medicine recognizes. The diagnosis are based on certain Chinese symptom patterns and may sound strange to those only familiar with Western medicine. Chinese patterns tell us how to use Chinese medicine. Western symptom patterns tell us how to use Western medicine.
The fairy dust there is stifling.
I once worked with a vet whom none of the staff much cared for, and she certainly did not have much in the way of a bedside manner with clients. I got along with her great, she was an incredibly skilled vet and didn’t let office politics hinder her. It was her skills that mattered most (to me). Unfortunately, later on she went over to the woo side (and to another clinic whom of course felt that her acupuncture and chiropractic lessons would boost that clinic’s revenue). Sad in a way, she was destined for greatness.
The vet that I depend on is gruff and quite low key. But, the waiting room is always overflowing as he sees thousands of dogs. His value as a diagnostician has never been taken for granted. He is very old school but I wouldn’t trust anyone else.
As a vet student whose cat was recently diagnosed with hyperthyroidism and CKD the experience of how a client feels was invaluable. Some specialist centres I left feeling ripped off – cold, uncaring seeming staff and £££ on my bill for ‘wear and tear of ultrasound machine’ ?! Clinically though I knew they had done a great job. Another centre that treated her hyperthyroidism I can’t recommend enough for the incredible professionalism and outstanding clinical skills of the vets but also client care. I lived for those daily phone calls from the wonderful nurse during my cats hospitalization.
Not all vets go into this profession for the right reasons. Some like medicine but not people or animals. Some want to make money (ha). Is offering alternative therapies (as it caters to a market) worse than offering ‘pain free’ laser declawing of cats as routine when neutering done? MOST vets do go into the profession for the right reasons though I believe.
I am lucky, I have enough clinical knowledge to be able to recognize the charlatans from the competent. However I also like feeling comforted and that my vet cares about my pet and me and will go the extra mile. I have a fantastic general vet for routine work who is competent and compassionate. However, I also have access to some cold but incredibly clinically skilled/equipped hospitals. Not everyone is so lucky.
Certainly, not all vets are good people or motivated entirely by love of animals or a desire to do good. That’s really just another way of saying they are the same as everyone else, no better and no worse. I doubt, though, that many go into it just for the money, at least in the U.S., since it’s about the lowest paid profession one can possibly choose that requires as many years of education and as much educational debt to get into. Still, there are definitely plenty of vets who don’t deal well with people.
I think it might help to view this issue in the context of human medicine. My clients rely on me to call within 24 hours with test results or in response to messages. They can almost always get an appointment within a couple of days and, if not, they are always welcome to come in on urgent care regardless of the reason. Yesterday, I was seeing a full schedule of appointments while managing three critical ICU patients, speaking with the owners of all my inpatients at least three times during my shift. And I routinely see an appointment for a pet with serious illness and am able to get a full diagnostic workup including, when needed, imaging and surgery, within a few hours. None of this is even remotely possible for human patients to expect of their MDs. And vets accomplish all this while getting paid, on average, half of what MDs in the US get paid. So in context, I think most of us do a pretty good job caring for our clients and patients, and most do so primarily because they believe it is worthwhile and satisfying work. I would never deny there are exceptions, and much room for improvement, I just think context needs to be considered.
I agree. I personally believe that clients will get a far, far superior level of service on the whole from their vet for a very cheap price when you consider investment required for education, equipment etc. Having had to take a break from my veterinary degree due to being unable to afford my tuition fees and living expenses (no private loans or government support available) despite being at the top of my class, awarded a scholarship, prizes etc I understand the financial commitment. I have to work and save this money to go back. Not easy to save this in cash. I will never afford to retire and will have to work until literally I drop dead, but for me this is worth it.
I believe there is room in the profession for all sorts of personalities and skills. No reason why the gregarious but not so technical person can’t bring in and retain clients while the talented but grumpy individual avoids client care but works miracles. We all have our strengths and no-one is good at everything. Neither is there anything wrong with making money when done ethically in the best interests of the individual client. Clients won’t get a great service from a vet that can’t afford food and to heat their home.
Our traveling vet practices Chinese medicine, homeopathy and acupuncture (unbeknownst to me until I looked him up). My dad likes him because he’s cheap and let’s us skip ‘unnecessary’ tests because they always come back negative.
great subject and discussion. i’m a scientist (human biology / immunology) by training and better qualified than many clients to evaluate a vet and physician. i appreciate a vet – and physician – who explains her / his analysis, gives options, and discusses the pros and cons of the options.
BTW – an academic scientist is a profession that requires a large number of years to attain, is paid like a pauper, works many hours (or as a friend said: isn’t science great? you can work any 18 hours of the day you want), and is brainwashed to believe that earning lots of money is not noble. ask me how i know…..
How much emphasis should AAHA accreditation bear when choosing a vet?
It’s never a bad thing to have this accreditation since it does require meeting some reasonable standards for some aspects of clinical practice. However, the standards are quite general, and there is plenty of room for a wide range of levels of care within them. Obviously, from the point of this blog, it is disturbing that one could easily meet these standards while still offering homeopathy, TCVM, and all sorts of other therapies which are unlikely to have any real value. So while I think AAHA accreditation is a useful to ensure a minimum standard of quality for the basic features any good hospital should have, they don’t really address the individual veterinarian’s knowledge, skills, or approach at all.
We have a young new vet who has joined a practice where I’ve seen too much woo (the most recent is the marketing for laser “therapy” for myriad conditions). During our first visit with him and our newly adopted cats, I expressed my concern that we stick to science-based medicine. He’s been great to work with. We lost one of our new kittens to “dry” FIP, and our vet helped us to rationally navigate past the poorly researched and very expensive polyprenyl immunostimulant that sounds superficially promising. I found this blog looking for sources for credible information. Thank you.
I agree that it is important to find a veterinarian you trust. It makes sense that keeping this in mind can help you get the services your pet needs and trust you are in good hands. I can see that consulting with several companies can help you make sure you find the one that has experience treating animals like yours.