Client drama

I have a feeling that 11.5 months from now I will have had about a hundred blog posts that could have had this title. Sigh.

Today's dramatic client was actually a pretty sad situation. Mrs. A is an elderly, disabled client with extremely limited income. She has a 14 year old dog named Timber that she loves very much.

Timber has very severe arthritis in his hips and stifles (knees). He's been on carprofen, a non-steroidal anti-inflammatory drug [NSAID] kind of like a doggie version of Advil, for many years. He also has ulcerative bullous keratopathy, an eye condition that causes him some pain unless he is medicated daily, and has caused him to go basically blind.

Mrs. A started bringing Timber to the VTH this past January to see Ophthalmology for his eye problems. Given Mrs. A's severe financial constraints, Ophtho basically wrote off everything in the $150 visit except about $20 worth of fees.

Since then, Timber had several more rechecks with Ophtho (again, all but $10-20 of the bill written off) and a couple appointments with Community Practice (and again, tons of write offs).

Timber's most recent visit at Community Practice was to check bloodwork to see if his organs were doing okay with his chronic NSAIDs, since carprofen can sometimes cause liver problems in particular. Timber's liver values looked pretty okay for a 14 year old dog, so he was sent on his way with 3 more months of carprofen, instructions to come back in 3 months to repeat bloodwork, and a bill that had Mrs. A paying only the cost of the medication and not the $39 exam fee or the $45 of bloodwork.

Fast forward to this afternoon. Being a kindly, congenial student who likes to work as a team with my classmates, I jumped up from my chair to answer the Community Practice phone when it rang. I found myself conversing with Mrs. A, who started crying almost immediately, and told me all about her life, her financial problems, her health issues, Timber's health issues, and how she had made an appointment in 10 days to recheck bloodwork but would have to know in advance exactly how much she would be expected to pay.

Ugh. This is my favorite kind of random phone call-slash-complicated situation to wander into.

I went on my way to do some investigating. I first discussed the case with the head doctor in Community Practice, who said we really couldn't write off any more services for Mrs. A, but that it would really be an ethical concern to continue prescribing carprofen for Timber without checking his bloodwork to see if the drugs we were giving him were hurting his body ("first do no harm," and all that).

My next stop was Ophthalmology to consult with the specialist that Timber saw in January to learn at least a little something about ulcerative bullous keratopathy and whether it would be necessary for Timber to keep having his eyes medicated twice daily, at a cost of $30 per tube of ointment. The answer was "Um... I guess not? As long as he doesn't seem painful?" Ooookay, then.

Stop #3 was back to Community Practice to pull up the Walmart $4 drug list on my laptop to see if we could get either Timber's eye meds or his NSAIDs at a lower cost than through the VTH pharmacy. Unfortunately, his eye meds weren't on the list and carprofen is not a drug that's used in humans. It might have been possible to switch Timber from carprofen to meloxicam (another NSAID), but the dose of meloxicam he would need was about 1/7 of the smallest size tablet carried in human pharmacies, so he'd have to have it compounded into a special liquid formulation which would end up being more expensive than the carprofen anyway.

My last stop was to our fantastic client support institute, staffed by wonderful people who are highly skilled in talking to all manner of angry, sad, bereaved, frustrated, or confused client, in addition to giving us students advice on how to handle difficult situations. I mostly knew what I needed to tell Mrs. A, but it was just nice to let somebody know about the situation I was dealing with and get their opinion.

Finally I called Mrs. A back (by this time, all my classmates had left for the weekend and most of the hospital was shutting down). We talked for about 20 minutes (well, mostly she talked) and she told me about her beloved cat that she had for 20 years that died a couple years ago and she has never gotten over it, how she has had problems with severe depression and has a lot of health problems and takes many medications, how she has stopped taking her own meds at times so that she can afford care for Timber, how she cannot take him to the low-cost vet clinic in the large metro area an hour away because she doesn't have money for gas, etc. etc. etc.

She was very sincere and I got the feeling that this is a client in a truly difficult situation, not somebody who's just out to manipulate us into giving them free services. The complicating factor is that the medical records from Timber's most recent visits seem to indicate that he is not in very good shape despite the medications he's on, and that the students and doctors that have seen him in the past have been concerned about his quality of life.

Long story short, we eventually got to the point where Mrs. A said she has spent the last 3 months saving up the $94 that will cover Timber's $45 blood test, his $18 carprofen prescription, and his $31 eye ointment. So she can bring him in for a check up as long as we can waive the office visit fee. I guess it's my job next week to figure out how to convince somebody to do that before she comes in.

I did get into a bit of a discussion with Mrs. A about quality of life issues, although she would get very teary whenever we mentioned Timber's age or his serious health issues. I offered to have one of our client support people call her next week to chat about some of these things, which, fortunately, she readily agreed to.

All in all, it was a pretty emotionally draining afternoon. Mrs. A's situation raised two of my own fears -- at some point not being able to afford the care I'd like to provide for my pets, and getting to the point where it's time to let them go and not being able to recognize it. It's so unfortunate in veterinary medicine that we have to deal with this kind of financial situation all the time (fortunately not often to quite this degree of severity). Life would be a lot easier if care could be cheaper and pets were insured.

In other news, 4 of the 9 members of our Community Practice student team are leaving us after today. Next week we'll gain 2 new students who will join me on my "Team B" to make a 3 person team, versus 4-person "Team A." I'm sure it'll be fine, except for maybe Tuesday, when Team A will be down at the local shelter gettin' their surgery on, and my 2 new Team A-mates (who have no experience with how Community Practice does things) and I will be left at the VTH to handle a full schedule of 9am-6pm appointments, plus a double-booked afternoon from 1-3pm with surgery intake appointments every half hour in addition to the regularly scheduled 1, 1:15, 1:30, 1:45, etc. visits! Should be an interesting (and long) day. Hooray for the 3 day weekend!