There is a fifteen-year-old German shepherd named Duke who has spent most of the last few years on chronic NSAIDs. His owners know exactly what that means. We talked about it more than once, and it is written all over his file: the drug carries risk over time, and they accepted that risk with clear eyes. Over the years we tried other NSAIDs, tried adjuncts, tried the things you try. This was the one that kept him comfortable and kept him himself. They were not interested in heroics at this point in his life. They wanted their beloved family member to be comfortable, and that is in the file too.
At fifteen, Duke is winning the age game by a wide margin. And then one day I learned the owners were unhappy, because our new graduate associate had declined to refill the NSAID.
The Question She Never Asked
At his most recent appointment, she had requested bloodwork, as most chronic medication protocols call for. The owners declined, for two reasons. Cost was one. The second mattered more: even if the results showed the drug was affecting his organs, they would still give him the medication, because it was keeping him comfortable, so a test that would not change the plan was not one they needed to pay for. Her reasoning for refusing the refill was not malicious, and it was not inept. It was the opposite.
My new associate struggled with that, and I understood why, because the same thing was drilled into me. Dogs on chronic NSAIDs get routine bloodwork. Full stop. You do not refill without it. But there was a question she never asked, at any point in that appointment: what did the owners actually want for Duke that day? They had answered it without being asked, when they said they just wanted him comfortable. She heard a client declining a test. She did not hear a family telling her their goal.
Here is what twenty years has taught me. That rule about bloodwork is real, and it is also not the whole of medicine.
The Spectrum Between Gold Standard and Standard of Care
There is a difference between the gold standard and the standard of care, and the confusion between the two is what put my new associate in a corner. Standard of care is a legal term. It means the care practiced by the average reasonably prudent, competent veterinarian in the community. Notice what it does not say. It does not require the most expensive, most invasive option on the shelf, and it does not ask a general practitioner to practice like a specialist. The gold standard is one point on a much longer line, and everything else along that line is spectrum of care.
And here is the part that should settle the anxiety for good. In late 2025, authors from the American Association of Veterinary State Boards, the people who actually discipline licenses, published guidance on exactly this. Practicing along a spectrum of care does not endanger your license. What the boards ask is simpler than the fear suggests: give the client the real range of medically sound choices, then record that they understood and agreed. The refill was not a deviation from the standard of care. Declining it, when the owners had made an informed choice we had documented for years, was arguably the deviation. We had the conversation. We had the consent in writing. That is not a shortcut around good medicine. That is good medicine, done correctly.
What Fear Does to a Treatment Plan
So why did she balk? Because fear is the real engine here, and it does not go away, it just wears a different face on each of us. When I ask new graduates what they are afraid of, I hear a familiar list: hurting an animal, getting sued, a board complaint, the private fear of not doing the right thing. When I first graduated, mine was plain: I worked for a corporate group whose founder held a firm rule that you never took anything off a treatment plan, and I was afraid of being disciplined or fired for doing it. I had clients in front of me who could not afford what was on the page, and the message was that I was not supposed to work within their means. The particulars shift from person to person. The engine is the same, and it steers us toward the plan instead of toward the patient.
Ask the Goal First
Here is the fix, and it is almost embarrassingly simple. Before you write a single line of a treatment plan, ask the client what their goal is today. What are your goals today for Duke? If the answer is I don’t want heroics, I just don’t want him to hurt, then you already know what kind of plan will actually get followed. Everything after that question is in service of the answer. Everything before it is guesswork.
We tend to do it backward. We build the plan first and ask about the client’s life second, if we ask at all. And then we hand it over like a four-course prix fixe with the wine pairings already chosen, so when the client cannot take the whole thing, the answer is no, instead of a conversation about which courses matter most. Medicine like this should be more à la carte. That is not lowering the taste of the meal. It is an honest reckoning of what this table wants and can manage tonight.
It Is Not Always About Money
Start with the goal and the barriers show themselves, and they are not always about money. Ask a family with six kids and two jobs to give four medications on three dosing schedules, and you have built a plan that fails by Thursday. Ask a client with a bad tremor to draw up insulin twice a day, and you may be setting both of them up to lose. Sometimes the barrier is the wallet. Sometimes it is a full week and too many people to keep alive. Sometimes it is a pair of hands that shake. You do not know until you ask. I wrote a while back about what we owe clients before we run the test. This is the other half of it. Meeting a client where they are is not a consolation prize for the ones who cannot afford the ideal. It is the actual job.
Back to Duke
So why would we not refill Duke’s medication? The conversation had happened. The owners understood how this drug is metabolized and what that means at fifteen. Their goal was comfort, not another decade. The medication was doing exactly the job they asked it to do. I see too much of our medicine ruled by defaults that are right for a three-year-old dog and nearly meaningless for this one. The honest question is never did we follow the protocol. It is are we practicing the best medicine for the patient in front of us.
The refill was the right call, and I would have signed it. But this was never really about a refill. It was about the question that comes before all of it, the one my new associate walked past twice, first by not asking and then by not hearing the answer when the owners offered it anyway. What are your goals today for Duke? Everything we owe this family, and this dog, starts there.
This piece is a companion to What We Owe Clients Before We Run the Test. Together they make one argument: the conversation comes before the medicine.
— Dr. V
The Gray Oak Journal
Dr. V is a veterinarian with over twenty years of clinical and operational leadership experience. She has owned and operated several veterinary hospitals, weathered many shifts in the industry, and served on advisory councils. She writes The Gray Oak Journal at grayoakjournal.com.