Saturday, August 14, 2010

The Other Side Of The Coin: The Cost Of Defensive Medicine

Guest article by Jennifer Coates, DVM

You may have heard the phrase “defensive medicine” used during the recent health care debate in the United States.  Defensive medicine describes the situation where a doctor makes a decision regarding a patient’s care not simply based on what is best for that patient but also taking into consideration a perceived need to cover his or her white-coated backside in case things don’t go well.

Defensive medicine is not limited to the human health care system. Veterinarians often fall into this mindset as well. Consider the following scenario:

A previously healthy, well-taken-care-of, adult dog is brought into the clinic with a relatively mild case of diarrhea. The vet performs a physical exam and nothing remarkable is uncovered. The dog is not dehydrated, his abdomen feels normal, he doesn’t have a fever and he appears to be bright and feeling like himself. The veterinarian will probably want to examine a sample of feces under the microscope to look for parasites or abnormal bacteria. If everything looks good under the microscope, the vet is left with a decision to make.

Option A: The conservative approach

Many dogs with these symptoms have a simple case of gastroenteritis, often because they ate something that they shouldn’t have. Treating them with a bland diet and a medication to help clear up the diarrhea is a perfectly reasonable approach, even though a definitive diagnosis has not been reached.

Option B: The CYA approach

Granted, gastroenteritis is a strong possibility, but a long list of other diseases, some of which can be very serious, cannot be ruled out without more diagnostic testing.  Blood work, a urinalysis, abdominal x-rays and other laboratory tests should be run to gather as much information as possible from the outset.

Frankly, both options have their pros and cons and neither is ultimately right or wrong.  The secret to navigating these types of situations is COMMUNICATION.

In a perfect world, veterinarians in these types of situations should describe all the options available to owners, including their risks, benefits and costs, and the owners can then make educated decisions as to what the right choices are for them under their own unique circumstances.  This is exactly what many veterinarians do, but alas we do not live in a perfect world.  Some vets get into the habit of routinely offering only “Option B.”  Should something go wrong, which is a possibility no matter which option you go with, it is always easier to defend oneself by saying “I did everything I could think of” than “in my judgment, more testing was not necessary.”

So, if you are in a situation where you think that your vet is only giving you “Option B,” speak up.  Most doctors are perfectly willing to approach a problem in a different way as long as it doesn’t compromise your dog’s comfort and chances of recovering.  The trade-off is that you, your dog’s guardian, have to take responsibility for the decisions that you make.  If you choose “Option A” and your dog’s condition doesn’t improve, it is time to go back to the vet and move on to “Option B.”


Jennifer Coates, DVM graduated with honors from the Virginia-Maryland Regional College of Veterinary Medicine in 1999.  In the years since, she has practiced veterinary medicine in Virginia, Wyoming, and Colorado.  She is the author of several books about veterinary medicine and animal care, including the Dictionary of Veterinary Terms: Vet-speak Deciphered for the Non-veterinarian. Jennifer also writes short stories that focus on the strength and importance of the human-animal bond and freelance articles relating to a variety of animal care and veterinary topics.  Dr. Coates lives in Fort Collins, Colorado with her husband, daughter, and pets.


  1. I liked this article very much. It describes a quandry that all of us in the veterinary profession find ourselves in every day. I always try to do what Dr. Coates suggests and give my pet parents all the options available to them. Once we've had that discussion, the client is able to decide which is best for them.

    Where the waters become muddled for me is when a client asks me "What would you do if he were your dog?" In these situations, I try to use my best clinical judgement (based on my experiences) as to whether Option A is likely to work or whether Option B is a safer option. But I always wonder whether I'm giving the best advice, especially when we choose Option A and the pet gets worse :-(

    I would also add that sometimes Option C may be referral to another facility and another doctor that is better able to offer the services and procedures that the pet needs.

    Thanks, Dr. Coates, for a very thoughtful and well-written article. And Jana, thanks as always for presenting some great information.

  2. Hi Lorie. It is a quandary, no doubt.

    HAHA, I pulled the "What would you do if it was your dog" on our vet too couple times, but it was when the situation was very serious and the decision was really hard.

    To me, the rule of thumb is to take a look at how serious the situation looks and how long it's been going on.

    Given the above scenario, a dog having a mild diarrhea lasting for one day and there are no other warning signs, I'd start a fast and see if it clears up (even after all our experience). Sometimes it truly is just a dietary indiscretion or like and giving the body a chance to sort itself out is the best thing to do.

    If I see no improvement after 24 hours, then it is time for me to see a vet and start investigating.

    I believe that considering a patient's history and a big picture is also an important part of the process.

    There would be a time when I'd want to do something at the first onset of signs, such as in our case in the past when daughter's Chihuahua (who's been spending the days with us) had severe diarrhea and was diagnosed with an infection. I went to a vet at the first sign of decline in stool quality, because the odds of it being an infection were substantially higher than they would be normally.

    Of course when a situation, regardless of how mild, keeps repeating frequently, then I suspect a chronic issue and would also look at an onset of mild diarrhea differently.

    I think that seeing the big picture is always important. What are the odds that the dog got into something? What would it be? (garbage, something potentially more dangerous)

    Even myself, even after all our horror situations, I am being cautious not to over-react and specifically not to over-medicate.

    It is a fine line and the judgment call should depend on each individual case and situation.

  3. Hi, Jana.

    I agree with you. It is a fine line and definitely considering the individual animal and its history and physical condition together with the severity of its current signs always needs to be part of the mix.

    It's an interesting discussion. I suspect that other factors probably come into play more often than not also, such as previous experiences with similar circumstances. Experience is sometimes a hard teacher but once the lesson is learned, it's hard to forget. If we (vets and pet owners alike) have a seen a particular set of symptoms lead to severe illness or even death in the past, we're a lot more likely to act aggressively when we see a similar set of symptoms occur, even if they appear mild at first.

    For instance, I have one greyhound owner whose last dog was diagnosed with and passed away from a hemangiosarcoma. So, when their greyhound developed a small spot on the skin that looked similar to them, they panicked and wanted it checked right away. And I don't blame them. Fortunately, in this case, it turned out to be a benign lesion, which we knew it was likely to be from the start. Still, biopsying the lesion gave us all piece of mind that we weren't labeling something benign when it wasn't. And there's always that small chance that if we hadn't biopsied it, it could have been problematic. But another pet owner might have decided to wait and see what happened rather than pursuing diagnosis immediately. After all, the lesion we were concerned about was only about the size of the head of a pin.

    It's a tough call to make sometimes, hard to know whether you're over-reacting or being proactive. Thanks for the thought-provoking conversation :-)

  4. Hi Lorie.

    Yes, experience plays a major role in influencing our decisions and the way we view things.

    I have to agree than when in real doubt, I'd rather go with the over-kill.