24/09/2023
Question:
My corporate owned veterinary practice has now said that they will provide care for my overseas dog if he/she tests positive for Brucella canis but have said that any urgent surgical procedure would need to be approved by the Chief Veterinary Officer at [corporate name]. Should I accept this as a client?
Answer:
Obviously I cannot tell you what to do, and this will part depend on:
• Availability of alternative veterinary care within your geographical region, and distance willing/able to travel to another veterinary practice
• Your wider trust in the veterinary team at that practice and in respect of the veterinary service they offer
• You willingness to accept the above caveat in respect of surgical care for your Brucella canis positive dog (and potentially other in contact dogs – clarify this with them!)
My position on this matter:
• I absolutely would NOT accept this restriction on the veterinary care offered to my dogs in my household if any of them were to test positive unless I was desperate (i.e. had no viable alternative)
• It is good that they have told you this as part of early stage discussions around the care that they could offer your dog as a dog with a Brucella canis positive status. This is part of giving you information likely to be important to you when giving your implicit informed consent to stay with them as a veterinary practice and provide potentially suboptimal care after being told this.
• However, the devil here is in the detail and you may need additional information before ‘implicitly consenting’ by staying with the practice.
• I would be concerned that this may operate as a ‘get out clause’ for local level staff who want to avoid offering surgical veterinary care to your dog by shielding them from direct blame for this and I see no good clinical need for the CVO to be contacted. A decent risk assessment and personal protection equipment provision and use should be sufficient to allow local level clinical assessment.
Things to consider:
• Why ‘urgent’ care? Why not all surgical care? Does this imply that non-urgent surgery just would not be carried out? This is potentially a massive red flag and needs exploring further with your veterinary professional.
For example non-urgent surgery might be:
- Neutering
- Stitch ups which could be managed by second intention medical management but where surgical closure would be preferable
- Orthopaedic procedures to repair broken bones (where they could be splinted instead) or torn cruciate ligaments (where they might be conservatively managed or braced)
- Dental procedures undertaken before periodontal disease has become advanced enough to be causing significant local (in or around the mouth only e.g. root tooth abscess) or systemic (e.g. bacteria floating round in the blood stream causing potential issues elsewhere in the body) disease.
Would you be comfortable if these kinds of procedures were denied to your dog as non-urgent routine procedures? As a former registered vet nurse with 25 years experience I would NOT be so I would be wanting to explore this further to understand better the parameters for inclusion as a service.
Clues for inferior limited care may include:
• Refusal of any kind of dental or surgical care
• Documents that outline that they will provide medical care and/or non-invasive care and/or remote care and don’t mention surgical/dental! Do NOT assume medical care means everything you think it does. If in doubt, ask an independent veterinary trained and familiar professional to look at the information given.
Also, these are just examples of potentially‘ non-urgent’ procedures. But, as always, it can be a grey area, and I would want to know what urgent procedures would not be considered either. For example, my dog broke, it’s two lower canines and these are all infected and exuding pus. As you can imagine these were painful too! This could have quite profound behavioural and health implications of both the local and systemic level and so they need removing for the welfare of the dog. Would this procedure be considered?
• Why does the Chief Veterinary Officer (CVO) need to be contacted? Why is the vet not able to make the clinical decision based on the clinical need for your dog to receive this veterinary care in line with modern day standards and expectations? The litmus test here to ask is: If my dog did not have Brucella canis, what would you be currently offering in order to maximise animal welfare outcomes for my dog? If it differs from what is currently being offered, what can the CVO offer that you cannot as my primary care vet? You have already now told me what would be best practice to be offered after all. Your vet will probably tell you the CVO is needed to assess the risk to the veterinary staff. Read the next point.
• Why is the CVO needed to assess the risk to veterinary staff? I would be concerned that this is an inefficient way of assessing risk. A robust approach is a proactive risk assessment that removes the need to contact one individual before every decision is taken and would be the norm. If other veterinary organisations can achieve this, why cannot all corporates? You may be told this is because it is it is a schedule 3 pathogen (see link below) – but so is Covid-19 (SARS-cov-2) and clients and staff are not screened before entering the building or the CVO contacted before they are allowed entry to the veterinary clinic! Also in this schedule is anthrax (which we would want very stringent controls over!) illustrating that there is no a one size fits all approach to pathogens in this category and a bit of evidence-based common sense is needed here.
• Will the CVO always be available 24/7? Some corporates have businesses that operate night services as well as day services (e.g. CVS owns MiNightVet which provides out of hours emergency care every night and all weekend in many areas). Will the CVO be available to be woken up at any point of the day or night in order to give an immediate answer? We are talking about urgent (read: emergency) procedures here so by virtue of their nature quick decisions are needed. If your dog had a gastric dilatation for example, every additional minute delaying surgery could have major implications for the likelihood of your dog surviving surgery. Some procedures are less urgent but any delays in order to discuss with a vet ‘remote to the case’ are still likely to be suboptimal and clinically not necessary. Remember: these discussions are not being taken with your dog’s animal welfare at the forefront of their endeavour – if that was the case, the vet would already have cracked on with surgery. They are contacting the CVO because they believe that surgery is in your dog’s interest and are basically seeking permission to proceed (or potentially as a get out clause if they don’t personally want to carry out the surgery).
• If the CVO has delegated this decision making to a team of senior remote clinicians, is there a rota that ensures that no matter what time of the day or night it is, there will be a senior member of the clinical leadership team at the corporate prepared to be contacted (and guaranteed to respond with a suitable timeframe e.g. 5 minutes) to make this decision? Remember that the company has made the professional decision that a regular vet is not sufficiently competent to make this assessment (otherwise there will be no need to escalate it), and therefore it needs to be undertaken by a very senior member of the clinical board/leadership so it is beholden on the CVO to ensure that this top level provision is always available.
• Is the CVO prepared to take responsibility for committing to always being available and to ensuring that, where a proxy is used (e.g. a wider trained clinical leadership team) that there reasonable endeavour (use of rotas, clear evidence of overtime payment to members on an out of hours rota, etc) such that, should anyone be not available to contact, there is clear evidence of culpable failing on their part? I.e. could you have reasonable grounds for reporting the CVO to the RCVS for failing to meet reasonable standards of clinical service that has led to poorer welfare, outcomes or death of your BC+ dog?
These are just some of the considerations, and I’m sure others can think of additional ones. If you can pop those in the thread to provide owners with additional guidance and food for thought.
• As always, you ideally want answers confirmed in writing as part of your decision making needed to consent to accept the provision of veterinary services being offered to your Brucella canis positive dog. You may also want to make a note in the reply to the practice that you’re not in agreement that it would be appropriate to delay offering surgical care in the event of an urgent procedure inorder to contact the CVO and it’s not clear that this offers animal welfare benefits to your dog. By putting this in the reply, you’re making clear that there is no implicit informed consent to accept that restriction should come to pass. This will not be a fool proof approach though, as you could find this parameter redefined, should your dog subsequently tested positive and then you would be in a difficult position trying to find another practice to take you on.
Warning!
• If you are currently the owner of a Brucella canis positive dog you will not have a good range of veterinary choices so be careful not to be too inflammatory.
• Establishing the above is much more easy to do while you have an untested dog or if you have another dog with a negative status but may go on to adopt further dogs that could potentially test positive.
• Ask the questions calmly and non-aggressively but it is not unreasonable to seek further clarification here. You would not hesitate to do so before many very expensive purchases (e.g. when you buy a house you pay for a survey!), and these questions are about ensuring the best veterinary practice to meet the needs of your dog – an important member of your household!
• Remember that your financial spend is important to a practice, particularly if you are a multiple pet household, or a ‘bonded client’(e.g. you buy your pet food from the practice, you subscribe to one of the ‘preventative healthcare plans’ that many vet practices offer), or you otherwise spend a lot of money at the vets! When I left my vet practice the financial lost to that practice over the next 15 years was approximately 75k gross income at today’s prices 🧐
As always, what you’re seeking is a vet practice that will align ethos and service wise with the standards of care that you want for your dog, whether your dog has a positive or negative or uncertain status!
I hope this reply helps. I’ve put it public because it’s obviously a very detailed response that you needed to have, and I think it will be useful to others too.
Me: In my vet nurse scrubs prior to stepping off the register to concentrate on raising awareness and empowering owners to advocate for their dogs.