Equine veterinarians practice in an increasingly difficult environment with a public that has changing expectations of the services provided. Accordingly, equine veterinarians have a higher risk than other disciplines of facing either an administrative licensing complaint or civil litigation due to the value of horses, regardless of whether the complaint has any merit. In this newsletter, we explore the importance of the veterinarian-client-patient relationship (VCPR) and how maintaining a well-balanced VCPR is essential to reducing your likelihood of malpractice incidents.
The veterinarian-client-patient relationship (VCPR) is a cornerstone of veterinary medicine. It is defined in every state’s Veterinary Practice Act,* but the general principles of what constitutes a valid and functional relationship between all three parties are consistent. A valid VCPR is required for a veterinarian to administer any treatment to an animal, and if this relationship is not properly created or maintained, the practitioner in question is in direct violation of their state’s Veterinary Practice Act. Once a VCPR has been formed, an equine veterinarian then has obligations to both the client and horse.
The AVMA’s Principals of Veterinary Medical Ethics states that the VCPR has been established when:
- The veterinarian has sufficient knowledge of the patient to initiate at least a general or preliminary diagnosis of the medical condition of the patient. That means the veterinarian has performed a physical examination of the patient or is personally acquainted with the keeping and care of the patient by virtue of medically appropriate and timely visits to the operation where the patient is kept, or both.
- The veterinarian has assumed responsibility for making medical judgments regarding the health of the patient(s) and the need for medical therapy and has instructed the client on a course of therapy appropriate to the circumstance.
- The client has agreed to follow the veterinarian’s recommendations.
- The veterinarian is available for follow-up evaluation or has arranged for emergency or urgent care coverage; or the veterinarian has designated continuing care and treatmentto a licensed veterinarian who has access to the patient’s medical records and can provide reasonable and appropriate medical care.
- The veterinarian provides oversight of treatment.
- Patient records are maintained.
The VCPR in Action
Below are three scenarios that illustrate the central role of a valid VCPR as well as the risks associated with farm manager-directed treatment and the importance of maintaining up-to-date medical records. Both of the latter issues are closely tied to the VCPR. Understanding recordkeeping responsibilities and setting proper boundaries with your patients’ handlers and managers are crucial to creating and maintaining a well-functioning relationship with both your client and their horses. Recordkeeping serves as the “proof” of your treatment and is considered the final word on whether or not the care was appropriate. And while farm managers are very familiar with their horses’ condition, these relationships must never supersede the veterinarian’s judgment or replace it.
VCPR Closed Claim Scenarios
Horse Perishes from Overdose after Dr. A Prescribes Medication without an Examination
Dr. A received a call from a longtime client’s farm manager who informed Dr. A that a 7-year-old Thoroughbred gelding was exhibiting signs of EPM. The farm manager requested that Dr. A call in
a prescription to the local compounding pharmacy for EPM treatment, a pyrimethamine-toltrazuril combination oral paste. The amount of medication that the farm manager requested was more than would be necessary for one horse, but the farm manager only made mention of the Thoroughbred gelding. Dr. A called in the prescription as requested, and the medication was placed under the name of the Thoroughbred gelding.
Upon picking up the medication, the farm manager administered it not only to the gelding, but to multiple horses belonging to other owners. While some of the horses suffered no adverse effects, two horses reacted badly to the treatment and died. When Dr. A reviewed the prescription, it was clear that the concentrations were incorrect, resulting in drug overdoses. The owners of the deceased horses filed malpractice claims against Dr. A, alleging that the medication was provided to their horses without a valid VCPR. Dr. A had never interacted with the owners, nor had Dr. A interacted with or examined their horses.
This scenario highlights several areas of concern, including lack of an examination prior to filling the prescription, lack of medical justification for the prescription without an examination, and a concentration error that lead to a drug overdose. The lack of examination, coupled with the fact that the high quantity of the medication should have led Dr. A to suspect that other horses would be dosed, was used as evidence that Dr. A had allowed the farm manager’s medical judgment to supersede their own. Allowing a farm manager to diagnose a patient and dispense medication at will is in direct violation of the VCPR; thus, Dr. A’s actions did not meet the state practice act requirements for a licensed veterinarian. Ultimately, the matter was resolved at mediation with the pharmacy making payment to the horse owners for the compounding error.
Farm Manager-Directed Treatment Results in Stallion’s Death
A 10-year-old Thoroughbred breeding stallion was experiencing decreased libido. After consulting with other colleagues, the farm manager decided the stallion should receive a multi-vitamin mineral injection. The farm manager asked Dr. B to administer the injection. Although Dr. B had previously given these types of vitamin injections to Thoroughbred horses without complications, Dr. B and the farm manager did not discuss the contents of the specific cocktail in question or its intended purpose beyond, “It will help him with breeding.” Despite the lack of information, Dr. B administered the vitamin injection intravenously to the stallion, who immediately suffered an anaphylactic reaction and died.
Because Dr. B administered the injection at the request of the farm manager without examining the horse, the VCPR was violated. Veterinary prescription drugs are designed to be used or prescribed only within the context of a veterinarian-client-patient relationship; furthermore, the VCPR requires both examination and diagnosis to occur before any treatment is administered. In fact, Dr. B violated the state practice act on multiple issues, including failure to perform an examination prior to giving the injection; lack of medical justification for the injection based on an exam; use of out-of-date medications; and administration of inappropriate drug dosages. Additionally, Dr. B did not advise the client or farm manager of the adverse risks of iron given intravenously, which was one of the medications included in the cocktail.
In this scenario, best practice would have begun with taking an appropriate history of the patient and performing a physical examination. A differential diagnosis should have been created based upon the history, physical examination, and pertinent diagnostic and laboratory tests, and then a therapeutic plan should have been formulated. This plan should have been discussed with the stallion’s caretakers, including the basis for the plan and the risks and benefits of various treatment options.
Dr. C’s Lack of Continued Care Leads to Excessive Equine Hospital Charges
Dr. C was presented with a 3-year-old Thoroughbred colt with a history of a right front fetlock osteo-arthritis. Dr. C performed an intra-articular injection on the colt without donning sterile gloves, and although Dr. C visited the farm over the next two days to tend to other patients, they did not examine the colt post-injection. Three days following the treatment, the farm manager called Dr. C and relayed that the colt’s fetlock was swollen and painful. Instead of returning to the farm to examine the colt, Dr. C provided recommendations over the phone and did not meet with the manager and examine the colt in person until two days later.
Upon seeing that the colt had not improved, Dr. C administered systemic antibiotics. Over the next 48 hours, the colt’s condition steadily declined, and it was eventually referred to an equine hospital. There, the colt was diagnosed with a joint infection and eventually recovered; however, the treatment incurred substantial veterinary costs. After receiving the large bill, the colt’s owner alleged malpractice, prompting Dr. C to turn the case over to their malpractice insurance carrier.
This scenario exposes several troubling issues, including Dr. C’s non-sterile injection technique and multiple violations of the VCPR. These included failing to provide an examination when informed of the complication; failing to document a working diagnosis and reason for the injection treatment; administering an antibiotic without performing diagnostics; failing to provide proper veterinary follow-up care; and delaying referral recommendations in the face of an emergency, a joint infection.
*All State Veterinary Practice Acts can be found at: www.aavsb.org
