Veterinary diagnostic error: Advice, please?
January 2, 2015 4:53 PM   Subscribe

Veterinary professionals (only!): we’d like your opinion on a check-up that produced an errant finding. We'd like to know if the error and the circumstances suggest bad practice.

A few days ago, we had a housecall-only vet in to do a check-up on our cats. She hadn’t seen them before. Our 15-year-old Tonkinese neutered male indoor cat had been vomiting with a bit more frequency than usual, and meowing up a storm. The vet took his history, and noted that he had lost 2 lbs in 3 years (she had his records from his previous vet). Upon palpating his abdomen, she became visibly alarmed and said that she felt a hard, irregular mass in the upper abdomen. She said that she had rarely encountered a mass of that size, and that we needed to be prepared for a diagnosis of cancer. She kept saying “I’m worried”, and after drawing blood samples, she left, apologizing for giving us upsetting news.

She referred our cat to an internist for an ultrasound, and called yesterday to tell us that the bloodwork (a basic panel) came back normal.

After 3 days spent pre-grieving our cat’s imminent demise, we took him in for the ultrasound today. The internist (at a major emergency and referral practice in Toronto) palpated his abdomen and said “frankly, I don’t feel anything”. 20 minutes later, the ultrasound came back clean as well.

On reflection, I suspect that what the vet actually felt was… wait for it… kibble. The cats have their afternoon snack around 4 pm, and the vet came at 5:30.

While we’re delighted about the absence of a mass, we’re upset at the fact that an apparent error - along with some abysmal people skills - led us to spend 3 miserable days (of our scarce holiday time) and several hundred dollars for the follow-up consultation and tests.

Our questions: Does this error seem to fall outside of good professional practice? If so, should we respectfully ask for a partial refund on the initial consultation fee? And, should we relate our experience to others in the neighbourhood?

We want to be fair and reasonable - mistakes do happen, we’re not out to exact revenge, and we certainly aren’t going to involve the legal system. But if this seems like bad practice, we’d like to follow it up appropriately. We would of course give the vet in question ample opportunity to explain herself prior to taking any action.
posted by stonerose to Pets & Animals (19 answers total) 1 user marked this as a favorite
Mod note: Asker, I'm fine leaving this up so you can potentially get some use out of it as an ask-the-Metafilter-community thing, but to be clear there's no site expectation that questions on Ask Metafilter can be restricted to answers from only a narrow professional demographic, and asking that the only advice you get is from medical professionals isn't a reasonable use of the site.
posted by cortex (staff) at 5:15 PM on January 2, 2015 [11 favorites]

I don't see any way that another vet could say whether it was reasonable to misdiagnose a mass without palpating the abdomen herself, at the exact time the first vet did.

In your shoes, I'd probably just be glad kitty is okay, I guess.
posted by Pax at 5:26 PM on January 2, 2015 [12 favorites]

Did you happen to mention at the time that the cat had just eaten a meal?
posted by BlueHorse at 7:35 PM on January 2, 2015

Response by poster: @ BlueHorse: no, it didn't seem material except in retrospect, and we weren't asked.
posted by stonerose at 8:33 PM on January 2, 2015

Best answer: I'm not a veterinary professional, but I play one on Metafilter. Sounds like a real mistake but not much more than that. You would be in the right to leave a negative review or Nextdoor or Yelp, but the poor catside manner is more important to others than the misdiagnosis. Negotiating a refund entirely depends on your ability and how much the vet cares about curtailing negative opinions.
posted by michaelh at 8:59 PM on January 2, 2015 [1 favorite]

Stonerose and I share the cat. We're not worried about money. We can survive a $700 consultation, but this could ruin less stable pet owners.

Our concern is competence and professional ethics. I work with human internists who deal with ambiguity and difficult diagnoses routinely. They're exceedingly careful about diagnoses and are transparent when they recommend a second opinion. To me, the appropriate response would be: "I feel a mass and think you should get a second opinion, ASAP," not "prepare yourselves for the worst, it's probably cancer." Medical tests are not just expensive, they can be painful and even harmful.

We are thrilled that our cat is probably fine. We're just not sure how something could go so terribly wrong. We're very open to criticism. We posted this as a discussion, not a yes/no /should we trash this vet.
posted by gesamtkunstwerk at 9:23 PM on January 2, 2015 [3 favorites]

I'm a human medical professional, not a veterinary one, but I am usually very hesitant about the idea of throwing someone under the bus without knowing all the facts. I usually find that stories presented from the point of view of the patient often differ considerably from the story you'd get from the point of view of the provider. Whereas when a patient tells me "Dr. X totally screwed up and here is why" it often sounds like a clear cut error, if I then call Dr. X, they often have a very reasonable sounding explanation for why they did what they did, and it ends up just revealing that poor communication and a lack of understanding of the medical details led to the impression there had been an error.

Therefore, given your level of concern, I would suggest that before you post your review, you contact the vet in question and ask for an explanation of her side of the story. As we say in medicine, hindsight is 20/20 - now you know that all the tests were negative, so you want to know how it could be that there would be a mass that felt like cancer one day and nothing shortly thereafter. She's the one in the best position to tell you that. Maybe it was something like a stomach full of lunch, but wouldn't a vet routinely examine cats after they've eaten a bunch of kibble? It doesn't necessarily add up to me. And at least in the human world, we don't typically do referrals or suggest second opinions on something unless we've tried to figure out what's going on and it's either beyond our scope of practice or we can't figure it out. A general vet initiating a workup for cancer prior to making a referral sounds appropriate.

That being said, I do think it's unfortunate if someone communicates "this is most likely cancer" when they probably should have been communicating "this is something that seems abnormal to me and could be cancer or something else, we'll need the test results to know." I don't know exactly what she said or how she said it. "I'm worried" seems appropriate if she did think it could be cancer, but the magnitude of that error is low compared to the issue of the physical exam finding, which is something none of us can know the truth about.
posted by treehorn+bunny at 9:56 PM on January 2, 2015 [10 favorites]

Best answer: Hi,
I'm a vet. I remember the first time I felt a full stomach in a cat and thinking it might be a tumor. I also remember a few years later a younger vet at my practice asking me to feel an abdomen on a cat with a full stomach because he thought is was a tumor. It's actually pretty uncommon to feel a full stomach on a cat- they have a really fast GI transit time (like 1 1/2 to 2 hours mouth to colon) which means the stomach empties in 15 to 30 min. So by the time most people wrangle the cat into a box and bring it to the vet the stomach is pretty empty. I trying to think of the last time I palpated a full stomach and its been months to years. So I'd cut your vet some slack. It doesn't sound like she diagnosed your cat with cancer but said she felt an unusual mass in the abdomen and was concerned it may be cancer and recommended appropriate tests to determine what it was. One of the downsides of house call practice, is that something that might take a few minutes or hours at a regular practice,like snapping an xray, takes days to arrange. I also know whenever I mention that an animal may have cancer, 99.99% of people hear " your cat has cancer"- its human nature. After 20 years I still have trouble telling really hard stool from a tumor. Your hands can tell you a lot but they're not xrays or an ultrasound. Tell your vet what happened. If she's like most vets I know shell feel like s*** and will lose sleep for a week. But next time she feels a full stomach she'll realize it may not be a tumor.
posted by morchella at 9:57 PM on January 2, 2015 [30 favorites]

Response by poster: Thank you so much, morchella. This is very insightful, and will help (all of us) in our conversations with the vet.
posted by stonerose at 10:35 PM on January 2, 2015

Morchella--this is what we need to put it to sleep. The specialist she referred us to said he would contact the examining vet. Based on your knowledge of vets (and mine of internists) this should be enough. We can enjoy our senior cat's bill of relative health.

Thank you. This helped a lot. And to you Treehorn+bunny.
posted by gesamtkunstwerk at 10:42 PM on January 2, 2015

Is the cat still vomiting more than usual and meowing up a storm? Knowing now there is no mass and likely not a cancer, what did the vet say was an alternative possibility? I guess I would call the vet to follow up with that question and have a general discussion with the vet about the first visit.
posted by 724A at 10:46 PM on January 2, 2015 [2 favorites]

There are two embedded questions here: (1) Is this a reasonable error, and (2) should you ask for a refund?

To the first, I think it sounds as if your vet said some things to prepare you for potential bad news, but may not have done so in the most considerate fashion. I also think that without a transcript of the actual conversation, you will never be able to reconstruct what happened. So I would lean towards this being a miscommunication over a reasonable mistake. With that in mind, the second question is academic: you should absolutely not ask for a refund for a professional who traveled to your home, examined your pets, and expressed concern over a mass she felt in the abdomen of one of them.

If I were you, I would not use this service again ($700!?) and would not ask for a refund.

Just for reference, my vet is (to my great chagrin) among the most expensive in NYC, but I go to him because he is well and truly brilliant and knows every specialist in veterinary medicine in the northeast. He saved my previous cat's life with his quick thinking and connections. That said, the most I have ever spent for a diagnostic visit with him is $400--and that was with lots of lab work. $700 is highway robbery, even if they do come to your house.
posted by yellowcandy at 11:32 PM on January 2, 2015

FWIW, I wouldn't say that her becoming "visibly alarmed" and saying she's worried is necessarily a bad bedside manner or poor people skills. It sounds like she really cares about pets. I know she scared the hell out of you and turned out to be wrong, and it has to be frustrating as hell to pay for something like that. But she felt a big mass in your cat's belly and was apparently truly worried about it.

I suspect you won't be able to get the money back, and it sucks. But even if she was wrong, you can't say she was callous. She was trying to do the best thing for your cat.
posted by Ursula Hitler at 1:28 AM on January 3, 2015 [2 favorites]

I find it somewhat bizarre that you had a vet come to your home, where there would not be the full complement of diagnostic tools available, and you fault the vet for being candid about what she felt when she examined the cat. She did not tell you your cat had cancer. She referred the cat to a specialist. Her concerns ultimately not being borne out is no failure of professional competence. She referred your cat to a specialist precisely to determine whether her suspicions were correct.

Just be glad your cat is ok.
posted by jayder at 6:04 AM on January 3, 2015 [10 favorites]

We didn't fault the vet--we asked if such a mistake were common, or easy to make. Medical discussions are part of my professional life, so I'm pretty attuned to distinctions. The questions I asked were: "could this be anything else," "how concerned should we be?"

Home visit vets are pretty common in big cities, where people don't have cars. We opted for a home visit because one of our cats contracted a herpes virus that is aggravated by stress.
posted by gesamtkunstwerk at 9:32 AM on January 3, 2015

3 days spent pre-grieving our cat’s imminent demise

I think the vet did fine, and that perhaps there is a little buyer's remorse in receiving an all-clear after anticipating a poor prognosis.

if such a mistake were common, or easy to make

I agree that it is much more common in a house-call practice where definitive diagnostics are not available. And in the absence of those diagnostics, some alarm on the part of your vet is justified upon palpating a mass in your kitty cat's abdomen. As mentioned above, feeling a full stomach in a cat in the clinical setting is not common. I have no doubt that she feels terrible about your situation.

$700 is highway robbery

I suspect that this sum represents the home visit with examination, blood work, and examination with ultrasound scan by perhaps a board-certified specialist. And if it does, that it is about 70% what those services cost at my hospital.
posted by Seppaku at 10:17 AM on January 3, 2015 [3 favorites]

If it helps you feel a little better, even when a vet doesn't find a palpable mass or anything on xray or bloodwork, if a cat is still sick then ultrasound is just the next step. At least your vet was proactive. Mine wanted to send us home with some anti-nausea meds for a week to see if it would go away on its own before even scheduling an ultrasound, because it is expensive. I declined. $700 is about what I paid for an ultrasound with needle biopsies, done by a board certified radiologist. The base price is $300. I was lucky to only have about $1100 worth of expenses (not including a trip to the emergency vet for unstoppable vomiting) to get my cat to a diagnosis of large-cell lymphoma. If I had been "optimistic," I'd probably have lost both of my cats last year to problems the vets at my local clinic could have been more honest about, instead of just one.

Ultrasound is cheap compared to chemo. But because we caught it pretty early, before he'd lost weight or had any other symptoms, Pumpkin was able to tolerate chemo relatively easily and is already in remission! He only has one treatment left to go before we downgrade to monitoring.

You have a good vet. Really.
posted by monopas at 12:43 PM on January 3, 2015 [3 favorites]

My soon-to-be-vet kid said if she had never known your cat, came to your home and learned the cat had been throwing up and crying and she palpated and felt a mass, she would have done bloodwork and referred for an ultrasound. She would have told you she felt something, it could be cancerous, and it needed further assessment.

She says clearly the vet was mistaken, but she did all the right things during an in-home visit with a pet she never met. Such is the nature of having patients who cannot talk.

Now, this is MY vet/kid, but she would tell a client that it might be cancer so you could have a sense of what to expect and not be blindsided by the ultrasound results and asking, "Why didn't the vet mention cancer was possible??!!"
posted by kinetic at 12:58 PM on January 3, 2015 [2 favorites]

I really valued the discussion and your responses. I just had a very constructive conversation with the vet who referred us to the specialist. As Morchella predicted, she felt horrible, but quite justly defended herself as exercising caution, and she seemed genuinely happy that: 1) our cat is mostly likely okay and 2) we're not dismissing her concerns about inflammatory bowel disease/ lymphoma.
posted by gesamtkunstwerk at 6:12 PM on January 4, 2015 [1 favorite]

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