"Let's play the sharing game"

One of my most "interesting" clients on Orthopedics last week was a middle-aged woman who brought in her 9-week-old Australian shepherd puppy, Howie, for an exam.

Howie's presenting complaint was "Check legs, littermate had problems." Always ready for a cute puppy with possible deformities, I signed up for Howie's appointment right away.

After the requisite small talk with Howie's mom, we were ready to get down to business -- or so I thought.

"So, tell me about Howie and his littermate," I began.

"Well," said Howie's mom, "there's something wrong with Howie's littermate, but... I don't want to tell you what it is. I want to see if you can figure it out."

"Um, okay?" I offered.

"Because, you know," she continued, "I'm sure that you won't look at the rest of him as thoroughly and do a good orthopedic exam if I just tell you what was wrong with his littermate and what I think is wrong with Howie. And I'm sure you like to have a challenge, so I'd rather just see what you come up with."

(Let me just set the record straight here: A thorough orthopedic exam is performed on every patient that visits the ortho department, even if the abnormality is glaringly obvious. This means that we look at the neck, spine, digits, wrists, elbows, shoulders, hocks, stifles, hips, and tail of each and every patient, whether or not we expect to find anything wrong. Additionally, there are subtle variations in certain joints such that the only way you know whether a finding on orthopedic exam is significant is by placing it in the context of the dog's history and other problems. That is, a slight amount of laxity in a forelimb joint may be significant if the dog has been limping on that forelimb, but insignificant if the limp is in the hind end. Thus, having all the information that owners can offer us actually helps us do a better orthopedic exam with more reliable results.)

Having never encountered a client unwilling to provide information like this, I didn't know what to say, so we discussed Howie's general puppyness (has he had vaccines, when, how many? What are you feeding him?) and I completed my physical exam.

Physical exam showed an apparently normal, healthy, happy (though somewhat bratty) Aussie puppy.

I excused myself to take Howie to the surgery pit to meet with the new first-year surgical resident for Howie's orthopedic exam.

Gait observation (which by the way is rather difficult in a 9-week-old puppy who isn't really leash-trained and nips at your pants the entire time trying to "herd" you) was unremarkable.

Standing exam revealed normal puppy joints, bones, muscles, ligaments, and tendons, as far as we could tell. Nothing significant was found on recumbent exam, either.

By this point, after I had relayed the minimal amount of history that Howie's mom had shared with me, the surgical resident was fairly irritated.

One of the most important factors to a successful veterinarian-client-patient relationship (or physician-patient relationship) is mutual trust. That means that the veterinarian trusts the client to provide truthful information about the pet, lying neither directly or by omission. In return, the client trusts the veterinarian to answer questions honestly and act in the best interest of the client and patient.

Within the first 2 minutes of meeting me, Howie's mom had shown definitively that she did not trust me, the resident who would be Howie's doctor, the orthopedics service, or by extension the VTH. That did not set a great stage for a healthy vet-client-patient relationship, so I could see why the resident was frustrated and even insulted.

On our way up to discuss our findings with Howie's mom, the resident informed me that he was uninterested in telling Howie's mom what he had found on orthopedic exam until she shared with him the very relevant information about what she felt was abnormal with Howie and what his littermate's diagnosis was.

The resident introduced himself to Howie's mom, then said, "Let's play the sharing game. You have information I need and I have information you want. Tell me what was wrong with Howie's littermate."

At this point, Howie's mom fortunately got the drift that the resident wasn't interested in playing games, and readily offered everything she knew about the littermate, and everything she'd noticed in Howie.

In the end, Howie is probably perfectly normal. In any case, it's very difficult to know the accuracy of findings on an ortho exam in a young puppy. Puppies have a normal amount of looseness or "laxity" in their joints, so that you can find things in a normal healthy 9-week-old puppy that, if present in a 5-month-old dog, would be suggestive of orthopedic disease. Conversely, the absence of abnormalities at this age in Howie's case doesn't mean he won't develop orthopedic disease as he matures.

Though Howie appeared normal at 9 weeks and may stay orthopedically normal as he matures (though he'll probably always be a neurotic Aussie), we offered to see Howie back at 6 and 12 months of age to reevaluate him and see if any abnormalities had developed.

And if Howie's mom knows what's good for her and Howie, she'll learn to trust his doctors so they can trust her.