“So, it’s hepatitis, right?” Sigh. I never said that. In fact, I had been careful—very careful—to avoid anything definitive. Hepatitis was on the list, but not the diagnosis. Not yet anyway. I really hoped they would get it by now. I had already been talking to these clients for hours, and it felt like I had explained the uncertainty 17 times. Yet somehow, we were stuck in the same place, with the clients locked into the more hopeful explanation for their pet’s illness. “Hmmm …,” I said. “Let’s back up.” GETTYIMAGES/WOLF IMAGES Minerva was supposed to be simple. An eight-year-old, female spayed pitbull mix, she presented for an outpatient ultrasound on a Wednesday afternoon. Like many ER veterinarians, I coordinate same-day scans for pets too sick to wait. She came in for the next steps after several weeks of intermittent lethargy and gastrointestinal signs. Everything else was done. Minerva’s primary care veterinarian worked her up beautifully: bloodwork, radiographs, even a fecal parasite screen and cortisol. It all suggested a hepatopathy, but she was getting worse, and her owners were anxious to get an answer as soon as possible. Really, all I had to do was facilitate the scan. We have a close partnership with the radiology service and can often get imaging done the same day. The trick is timing. The rad people work normal business hours, but in the ER, that fluorescent sun never sets. I work a swing shift, so I know when an outpatient ultrasound case comes in after 3 p.m., I need to hustle to get probes on bellies. I went into the exam room and introduced myself. The clients, a young man, his mother, and his pregnant wife, were pleasant and eager to learn more about Minerva’s condition. They didn’t argue or complain and knew how much things would cost. They had already left a deposit. Things were clicking along nicely, and these people seemed like dream clients, but just like a well-scrubbed ventral abdomen that, once incised, reveals a peritoneal horror show, I had no idea of what I was getting into. The task list Hydra The ultrasound was finished within an hour. It did, in fact, reveal a hepatopathy: hypoechoic parenchyma, enlarged lymph nodes, gallbladder wall thickening, and moderate ascites. The radiologist thought it was likely to be either lymphoma or hepatitis, and recommended aspiration cytology. Of course, all of this was just another list of tasks in my brain. I had been steadily checking them off ever since Minerva and her family arrived: explain risks and benefits of procedure, get financial approval, coordinate timing, etc. However, now, instead of a satisfying row of check marks, I had to add more open boxes: do all that crap over again as it pertains to poking the liver with a needle. We didn’t have a diagnosis yet, but the clients came in believing they would receive one after the ultrasound. Ambiguity is ever-present in clinical medicine, but it’s not something many clients know how to handle. Research in veterinary communication shows pet owners can struggle in situations where there is no clear-cut answer. In studies examining decision-making about seriously ill companion animals, owners reported distress when confronted with uncertainty.1 So, even though I made it absolutely clear I did not know the exact cause of Minerva’s ultrasound abnormalities, my clients appeared to have decided (subconsciously, at least) inflammation sounded a lot more tolerable than cancer. I swear I heard them murmuring like they had rapidly growing intracranial hydatid cysts. Hepatitis, right? Hepatitis, right? They were lovely clients, who quickly approved tissue sampling. The best way to reduce that pesky uncertainty would be to get a microscope jockey involved. Then things get messier At this point, the medicine was becoming more complicated, but I made sure never to compromise the quality of my relationship with my clients. From their perspective, they were supposed to get an explanation for their dog’s illness this afternoon. I kept a clear sense of their expectations and priorities and let them know when I couldn’t meet them. I checked for understanding, expressed partnership and empathy, and used simple language. Balancing interpersonal relationships can feel distracting from clinical tasks, but it is essential to healthy practice, both for your clients and yourself (not to mention outcomes for patients improve).2 I was nervous to discuss the aspirates, but the clients quickly approved the cost. Then I realized something, right when the radiologist, a smarter veterinarian, asked, “Don’t you think we should check coags before aspirating?” The radiology team is definitely staying late now, but it is easy enough to check coagulation. So, we go ahead, and–damn it! The PT was dramatically elevated; the PTT, much less so. Now, instead of reducing uncertainty with these clients, I have to introduce more of it. I picked up the phone and explained that things are, unfortunately, more complicated (remembering to give them a “warning shot,” a technique to prepare clients for unexpectedly difficult conversations).2 “We can’t safely aspirate the liver right now,” I explained. I waffled a bit on why (venipuncture was clean, machine was calibrated, coag abnormalities not entirely straightforward), then I stumbled into offering an internal medicine consultation. However, they didn’t want to leave Minerva overnight, so they asked me if I wouldn’t mind reaching out for help. I sigh again, because I am sure this next task will lead to more unchecked boxes on my list. It was getting late, and I had already sent the radiology team home. This obnoxiously complicated case kept getting more complicated, so I figured, why not reach out for help? Fortunately, a local internist is famously generous with consults, so I called him up. He answered but happened to be at a wine bar. Hoping he could solve the Riddle of Minerva’s Liver, I rounded him on the case. As soon as I hit the pesky coag results, he launched into a slightly tipsy lecture on the intrinsic and extrinsic pathways and confidently diagnosed “rodenticide!” before hanging up and returning to his glass of Zin. GETTYIMAGES/GONZALO INFIESTA Relationships are … worth it Late in the evening, the clients decided to visit Minerva. Collecting myself, I entered an exam room, where the three humans formed a protective semi-circle around their sweet canine companion. I told them the informal (and inebriated) internal med consult had not clarified much. They were still pleasant, but the expression on their faces told me they were all thinking the same thing: Is Minerva going to be okay? Medical truths can be both harsh and simple: contraindications on the diagnostic pathway precluded obtaining a prognosis. For the people in that exam room, hoping for a good outcome for their ailing family member and expecting that answer today, the air was heavy. These emotionally charged, uncertain conversations are taxing for veterinarians, too, particularly in busy clinical environments where communication demands are layered on top of medical and logistical complexity.3 We sat for a while and discussed options: referral, hospitalization, empirical treatment, and palliative care. I knew we were not going to get any closer to certainty tonight, but I could still help guide them through the uncertainty with a steady hand. Then, finally, one of them said again: “So, it’s hepatitis, right?” At that point, after spending hours with these clients, after listening carefully, after repeatedly checking understanding, after trying to orient everybody to the changing situation, I finally turned in a little bit of the relational capital we had built together throughout the evening. Instead of another long patient explanation, I simply said: “No. We don’t know whether this is hepatitis or lymphoma right now. We’re not going to get that answer tonight. If we want to get that answer, we are going to have to significantly increase the intensity and cost of what we’re doing, and even then, we may still not get a definitive answer. Or we decide to fly blind a little bit here and start treating supportively and see how she responds.” There was a moment of silence, and I saw their facial expressions change. They seemed to understand, not because I had suddenly found magical wording, but because they trusted me enough to really listen. I had spent hours as their field guide, leading them through the tangled jungles of medical uncertainty, and hadn’t abandoned them. When I finally pushed through that last explanation, one I could have led with, and would have been perfectly acceptable to say to a colleague, they were ready for it. However, I needed to wait until that moment, because their earlier expectation of an answer was too jarring to arrive at all at once. Eventually, we formulated a plan for empirical therapy. Shotgun approach, lots of medications, and instructions for careful at-home monitoring. We sent them home in a state of somber and restrained hopefulness. Minerva did fine overnight, and they called back the next day to ask if it would be okay to take their dog out for a quiet photoshoot. After all the back and forth, the numerous human connections that had coalesced into a team with the goal of helping Minerva, I found this request touching. They struggled with uncertainty but never turned on me. As complicated and difficult as her case had been, they trusted me enough to check in on something as lovely as a brief family outing to document her place in the family. “Certainly,” I said. Greg Bishop, DVM, is a small animal veterinarian and a part-time veterinary technology instructor in Portland, Ore. Dr. Bishop also creates the monthly cartoon series, “The Lighter Side.” The author’s opinions do not necessarily reflect those of Veterinary Practice News. References Christiansen SB, Kristensen AT, Lassen J, Sandøe P. Veterinarians’ role in clients’ decision-making regarding seriously ill companion animal patients. Acta Veterinaria Scandinavica. 2015 Dec;58(1):30. Shaw JR, Coe JB. Developing communication skills for veterinary practice. John Wiley & Sons; 2024 Mar 26. Moore IC, Coe JB, Adams CL, Conlon PD, Sargeant JM. The role of veterinary team effectiveness in job satisfaction and burnout in companion animal veterinary clinics. Journal of the American Veterinary Medical Association. 2014 Sep 1;245(5):513-24.
