Why Your Pet Sometimes Needs a 3rd Opinion

By Joanne Lynn Intile, DVM, MS, DACVIM on Nov. 13, 2013

I’ll admit to a guilty pleasure – I’m a Grey’s Anatomy fan.

No, I'm not referring to the human anatomy book memorized by medical students throughout the world; I mean the T.V. program about a hospital in Seattle best known for harboring victims of innumerous natural disasters, and an infamous neurosurgeon referred to as “Dr. McDreamy.”

Despite the sensationally unrealistic plotlines, and my firsthand knowledge that the majority of medical professionals are neither as attractive nor able to work intimately under the remarkably stressful situations the doctors of Grey’s Anatomy encounter without plotting murder, I really do enjoy the show.

Last week’s episode centered on something known as the “two-challenge rule.” The idea is taken from a training model in aviation practice where one crewmember will automatically assume the duties of another crewmember who fails to respond to two consecutive challenges, in the name of passenger safety.

Dr. Weber (chief of surgery) describes when, as a lowly resident, he scrubbed into an operation and questioned his attending surgeon’s decision to break down adhesions to an anatomical structure previously evaluated as scar tissue. Dr. Weber felt the scar tissue was actually a vital anatomical structure, and voiced concern. Initially he was dismissed. However, the chief resident intervened, recognizing that Dr. Weber’s assessment was correct. This raised two challenges against the attending, who was forced to step aside. The surgery was modified, and the patient (of course) was saved.

The take home message of the scene (and the concept of the two challenge rule) is the need for a “back up” plan for questioning decisions made by a single individual, especially under times of increased stress. Whether flying a plane, designing a building, or removing a tumor, it’s a systematic checklist put into place to ensure mistakes are avoided and safety is ensured.

A two-challenge system was developed because the voice of a single individual may be insufficient to elicit change, regardless of whether the concern raised is valid or not.

Research within human medicine indicates several key perceived barriers to the physical action of doctors challenging those in authoritative positions (e.g., residents to their attending), including:

Assumed hierarchy
Fear of embarrassment of self or others
Concern over being misjudged
Fear of being wrong
Fear of retribution
Jeopardizing ongoing relationships
Natural avoidance of conflict
Concern for reputation

I’m fascinated by these reasons, as the characteristics listed above center on insecure personality traits I would not typically associate with health care professionals.

I’ve not yet heard of the two-challenge rule being enforced in veterinary medicine, yet the more I consider it, the more I realize it has its place.

The hierarchy of our training is very similar to our human physician counterparts. We start as first year students and methodically work our way up to senior status over a four-year period.

We elect to pursue internships, followed by residency programs, with each year bringing additional knowledge, responsibility, and status. The entire process is designed to represent continual advancement and we are constantly aware of being only scant steps beyond the level we’ve recently surpassed, and still immediately below the next rung we are destined to climb.

Why then does experience allow us to dismiss the thoughts of others who are not quite at our expertise level? I’m not sure of the answer, but I do recognize that though we’ve all spent a great deal of time, energy, money, and training to become the doctors we are today, some of us tend to forget our less “lofty” selves somewhere along the journey.

What I find more fascinating is how despite attaining board certification status, with no further hoops to jump through, and supposedly beyond intimidation of hierarchy, I still encounter examples where my voice is stunted because of another opinion. Now I find that my peers are the largest barriers to communication.

As an example, I’m often asked to consult with owners referred to me from other veterinarians who recommend chemotherapy for a form of cancer I am certain would better be treated with surgery and/or radiation therapy. For the average pet owner, hearing conflicting information about recommendations is nothing short of overwhelming.

What would you do if a surgeon tells you they wouldn’t do surgery for a tumor, they would recommend chemotherapy, but an oncologist tells you they wouldn’t do chemotherapy, they would do surgery?

Owners leave confused or frustrated, or often follow the route of the “least invasive” path, which (ironically) often involves medical management (e.g., the chemotherapy I prescribe) even when I am certain it’s not the ideal option for that pet.

One could argue that my perception could be related to a lack of assertiveness or, alternatively, an inability to persuade owners to “do the right thing.” After last week’s television lesson, I’m wondering if the two-challenge rule would reduce disparity in such situations, or would it simply confound an already complicated situation?

In the scenario above, the patient’s life is not immediately threatened. However, I would argue that their best interest might be. I’m forced to ask, “How can I be better about voicing my concerns without coming across as questioning or inconsistent to an owner?” In considering my relationships with my peers (other veterinarians and veterinary specialists), how do I decide when to relinquish the controls to the other pilot? Would a third person help or hinder the process?

I’m certain that “speaking up” ultimately enhances patient care and improves teamwork, but in reality, it may not flow quite as easily as it does on T.V.

I’m curious to know what others think about the two-challenge rule and what it means for them as pet owners or colleagues. If it works for “Dr. McDreamy,” shouldn’t it work for a “Non-Dreamy” veterinarian as well?