The rhetoric and economics of veterinary health care

Our dog's fractured radius and ulna, March 28, 2009

Our dog's fractured radius and ulna, March 28, 2009

Our crisis

Last weekend our 11-month-old puppy broke his leg while running down our stairs too fast.

Yes he is okay now, recovering from his surgery.

The extremely different experiences we had at 2 veterinary hospitals prompted me to think more than I ever have before about the communication we engage in at veterinary hospitals.

It’s complex:  in a crisis, one needs to communicate about the medical options, the expense of veterinary health care, the emotional trauma of the owners,  and the intrinsic value of their animal companions.

This is a perfect occasion for applying rhetorical concepts to real life.

  • Hospital telephone communication

Our dog at 7 months, shortly after being neutered.

Our dog at 7 months, shortly after being neutered.

We first phoned a local veterinary emergency clinic.  We were told exactly what to do, not to try to splint the bone, but to wrap him in a blanket and bring him to the hospital.

Yet we were at a loss regarding some crucial things about transporting our dog in a way that would reduce our anxiety and his pain.   We are not a dog ambulance service, we are distraught owners.

  • What behavior could we expect in our dog as “normal” in this situation?
  • Was it normal for him to drool and pant and shiver and pee on us like he did?
  • How was I supposed to hold his leg?  let it fall limply from the breakage and let the limb wiggle around as we drive, or what?
  • Was it just pain or was there likely internal bleeding?

Was time an issue in getting to the hospital as soon as possible?

  • Hospital reception

Upon arrival in the hospital, the reception staff were very kind and sympathetic.   However, they were surprisingly calm and seemed to treat it as a minor ailment.

Yes it may well be a lower-level emergency from the point of view of the hospital, but we are not experts.  It would have been wise to tell us that he appeared to be in no immediate danger and that they have seen a lot of broken legs, rather than just to behave that way and rely on the implied authority of their role and the posh, professional building they were in to assure us that they were not being incompetent or unkind.

At this point we needed the hospital to demonstrate its rhetorical ethos: its moral standards, expertise, and good will.

It was also very strange, in my opinion, to bring a weigh scale and put it high up on the counter and ask us to weigh him right then and there during check in.  Couldn’t they get that information later, after giving him a pain shot and having him lay or sit in the back for hours as he waited for treatment?  The poor little dog had only three functioning legs to stand on and needed some support since he was shivering and in shock.  The weigh scale looked like it did not offer much traction– a slippery, white, hard plastic.  We are also rather short people, and so it was a little hard to put him up there and feel confident that I could steady him in case of another fall!

This is a matter of kairos, the rhetorical term for appropriate communication at the appropriate time.

If it really was appropriate to weigh him now using that method, then we needed to know it was safe given his condition, and that the person on the other side of the counter would ensure he would not slide off.

  • The 1st vet hospital experience, part one

I can’t remember who we talked to after the receptionist.  There were at least two people in lab coats, the second one the actual vet doctor, and she referred to a specialist surgeon being there that morning, whom we never actually met.  We were asked to tell our story several times to different people about how he broke his leg.

I think someone told us the cost of the xray and initial examination and got our verbal permission to go ahead, but nothing was on paper that I recall.

We were really at a loss of what to do with our anxious thoughts.  I grabbed a newspaper from high up on the wall where the doctor’s supplies were, and my husband played with his metal ring puzzle.  I did find an interesting picture book on dog health issues in the reception area, but it had no information about broken legs.

At this point in the process, I would strongly recommend an information brochure from a reputable organization like the AMVA or ACVS be given to people, focusing on the process from the break to the recovery, and the medical, financial and emotional issues to consider when a dog breaks his leg.

  • What do they need to check for in the xray and why?
  • What is the cost breakdown?
  • What are the implications of not doing one or the other type of intervention?
  • In the mean time, what is our role?

Without this information, we were wasting our time on stressful thoughts.

  • Waiting for the diagnosis and suggested treatment

It was not long into the process that we were separated from our dog and did not see him again for hours, probably four or five hours.  Simply being told he was “resting nicely” was reassuring but sad — we wondered, if the doctors are very busy, did he need to be resting while separate from us?

We moved back into the main waiting room because the small examining room had uncomfortable hard chairs.  We were offered coffee, we moved our car out of the 2hr street parking, we shifted chairs, we went to the washroom.  I heard a dog whining and thought it was our pup, and I craned my neck to see into the back room to no avail.

A lot of this has to do with the rhetoric of the vet hospital’s architecture.  Walls, windows, soft or hard chairs, and counters divide the experts from the consumers, and the patients from the pets.  Walls communicate very powerfully in a way that discipline people into submission based on secrecy.  We depend on others to act responsibly behind the wall but cannot truly know what goes on there.

At this point the rhetorical principle of presence comes to mind.

Although Perelman’s concept refers to the way ideas are made more salient and relevant, when a person’s or pet’s presence can be made possible in a time of crisis, it is better than mere verbal representations and abstractions.

In this situation, the hospital can choose between the rhetorical presence of the dog and the real presence of the dog with its owners.

What could be done?

It would have been better, if it were at all possible, for us to be able to sit with our dog once he was given some pain medication, at least between the times that doctors could examine him or apply treatments.  It really made us more anxious to be separated from him for 4-5 hours wondering if he was in pain.

  • Being told the bad news

Everything so far seemed to be treated by staff as if it were not that big of a deal.  Broken leg, they’ve seen it before.  All this was false reassurance.

When we got the news that the break was serious and required expensive surgery, it fell like a bombshell on us.  We were expecting something like 1,000 dollars, but not 3,800 dollars (Canadian).

This sounded to us like a death sentence. We were in tears.  We wanted to be with our poor puppy and hold him to comfort him as much as to comfort ourselves in such a tragic situation.

The setting for this rhetoric was not very appropriate.

At that point we were in the public waiting room and could not really let go emotionally.  We tried not to get each other too upset by saying the wrong thing.  The silence was tense and awkward.  We both reached for kleenex, I paced, and I can’t even remember what we were waiting for at that time.

We also needed written genres of communication besides the oral communication with the doctor.  No written estimates were provided to us.  No price breakdown.  No other options were offered voluntarily. We lacked any sort of knowledge that, in her absence, would distract us from our emotions and put our minds to work on the facts at hand.

In this situation I realized that I needed to take initiative and ask questions. I am not sure that every consumer would have the confidence to do this in a situation that is very new and stressful, but I suppose my rhetorical habits as a researcher and teacher kicked in.

I asked about external splinting.  She explained that it would not be successful given the size of the bones and the complete break of  both the radius and ulna.

I asked about other options, and she did mention that we could try another vet in town and she named some other places that I could not remember.  That gave me a ray of hope.

I asked them to discharge our puppy with a bandage and some medicine and give us some time to think about it.  If we had to let the dog die, I at least wanted to make that decision in the comfort of our home, and after doing more research online.  And maybe we could find someone to do the surgery for a price within reason.

Again, it would have been good to have something in writing.  The vet cannot be with us to talk for very long (I think we had max. 10 minutes with her),  and in our state, we needed something to ponder and discuss, and something that would not fly out of our memories so quickly because we were so distracted and stressed.

  • Discharge

I am glad I thought to ask for a copy of the Xrays.  Come to think of it, I have no idea why we were not shown the xrays visually at the hospital if they were accessible to the vet.   Why wouldn’t they provide a copy of the Xrays to anyone without having been asked first?  We had to wait longer after we asked. If we are paying so much for them, we should automatically have a copy.

We were given our poor puppy with his leg wrapped in a blue soft bandage.  We were given some pain meds that would last us 5 days.

I can’t remember now the ride home.  I can’t remember how we made supper or how we helped our dog into his litterbox to go pee (he is litterbox trained).  All I remember is the blue bandage on his leg.

I could not do anything the rest of that day but research our dog’s situation.

We had some more tense conversations and tears, and a restless night.

  • Research

A lot of health communication is based on the assumption of the “lay audience” who does not have special knowledge of the vocabulary and history of a medical issue.  However, in our day and age, the huge inequality of knowledge between audience and the medical rhetor/speaker can be reduced pretty quickly by online self-education.

Of course, I would never have the same knowledge without the same education and experience as a Vet, but on a particular medical issue and its treatment, I could become more knowledgeable than I was before.

Since I am a professor, I researched not just what was publicly available, but I found out what was published in the past 20 years about dealing with this specific problem in a dog.

  • I found articles from 1983 to the present and I read them and I used the internet to look up the medical terminology.
  • I found enough to confirm the diagnosis and treatment.
  • I found more information about the percentage of risk or success of various types of treatment.

Then I went online and found out what was publicly available regarding the usual cost of the types of surgery.

It was most helpful to read other people’s narratives and questions on Dr. Carol’s site.  I also found it helpful to compare my dog’s fracture with other images found on Vet Surgery Central and to find more scholarly information about the risks and successes of various treatments in the Canadian Veterinary Journal.

I also found myself considering amputation. 

Narratives are very powerful, especially in cases where the medical literature can do nothing to tell you what to do and what to expect– what life is like for a 3 legged dog.  Based on such success stories found in these sites, if this option was within our price range and the metal plate was not, it would be the way to go.

Tripawds –
Site about dogs with 3 legs, most due to cancer
http://www.tripawds.com/

Another site about amputation in dogs: Cassie’s
http://people.ku.edu/~cadavis/AboutAmputation.shtml

  • The next day: inquiring about amputation

We figured there was little hope of finding another surgeon available on a Sunday to discuss our options.  But I had to try.  We phoned the same hospital back Sunday morning to ask about how much amputation cost in comparison to the metal plate on the bone.

I am very disappointed that the surgeon did not communicate with us directly. We were put on hold while the receptionist talked to him.

And he seemed very inflexible.  We were told that he said amputation would cost just as much as the surgery because it would be just as “simple” to do.  However, from our point of view it is not that “simple” of a decision.

I know that normally amputation does not cost as much as the plate surgery, and at the other hospital removing the leg was much cheaper than the plate surgery.

I figured he must have been morally offended that we would even consider amputation.  Doctors want to avoid harm.  However, given the finances WE would have to bear, I felt this was an unethical response from the surgeon.  It seemed untruthful, in light of the lower market price for amputation in the stories I had found online.  It narrowed our options.  The implications were that we would be financially broken or we would have to say good-bye to our dear puppy.

So I had to look for a 2nd opinion and a lower price.

  • The Happy Ending: A positive communication experience at another vet hospital

    wilburbonefixed2viewssmallwhite

    Our dog's xrays after surgery

I am so glad we brought the dog home from the first hospital.

We had an informative and honest conversation with this surgeon for an hour.

He showed genuine respect for our difficult decision, taking time to go over every line in the printout of the cost breakdown for Wilbur’s treatment.

The price of the surgery was 30% lower at the second vet.

The price of amputation was only $700 less than the plate, at around $2000.

Amputation would result in excessive stress on his other front leg.  In a very long-legged active puppy, what would we do if he broke his remaining front leg?

So,  if we went with the metal plate, what if the plate created structural weakness in the bone and caused it to break again?  He talked about that.

What were the chances of him healing completely with the bone plate?  Pretty good for a young, healthy dog and this kind of break.

The doctor used our paper printout of the broken leg xray and drew on it to show us how the plate would be put on.  He even talked about why the neighboring ulna bone would not need to be fixed, etc.

At this point, the best surgery seemed like the best choice.

He even gave us the option of risking going without the usual $94 of blood work prior to the surgery, which we decided to waive.

We left with the strong feeling that if anyone should take care of our puppy, it was going to be this ethical, caring doctor. We felt we could entrust our dog to his experience, knowledge, and compassion.

If you ever get inquiries from Southern Alberta, please refer them to Calgary North Vet Hospital.  Dr. Gheorghe Rotaru is kind, conscientious and very experienced.  Here is a photo and bio of him from the hospital’s web page.

Here is a video of our dog shortly after surgery http://www.youtube.com/watch?v=cBq6S1_dXGQ

And a little later http://www.youtube.com/watch?v=g6cuL8VtFb0

Go to PART 2 of this story, which discusses the social and economic factors of our decision

More information

Health and science communication: a bibliography
http://www.uiowa.edu/~commstud/resources/health.html

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2 thoughts on “The rhetoric and economics of veterinary health care

  1. Pingback: The rhetoric and economics of veterinary health care (PART 2) « Edu*Rhetor

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