The cost of veterinary medicine is steep—we all understand this truism from personal experience…vets included. But the cost of veterinary care can be diagrammed on a price/quality axis so that owners can access a spectrum of these choices based on their needs, their goals and their ability to pay.
But don't be confused...this post isn’t about the many ways to get better quality care for your dollar. (You can find information on this in my archives here and here.) Rather, this post is more about what happens when a relationship of trust breaks down…and how that can cost the recipient of veterinary care…and his owners...when that price/quality axis isn't so clear.
Here's the deal:
Figgie is a Maltese whose latest neighborhood escapade landed him in a neighbor’s backyard bougainvillea bush with injuries of unknown origin. Normally a sprightly, sassy guy, Figgie’s traumatized alter ego manifested as a white ball of snarling fur.
What the whopping dose of pain reliever could not relax, the titch of tranquilizer finally soothed. Figgie finally gave in to the chemical restraint with a big sigh and a lolling tongue.
His owners: “Please help him. We want to do everything possible to save him.”
Findings…fractured canine tooth…lower back pain…diagnosis…automotive trauma…lumbosacral subluxation…sacro-caudal fracture (with significant displacement)…treatment…get thee to the surgeon for tail amputation and possible lumbosacral stabilization.
The surgeon saw Figgie immediately. He suggested that radical tail amputation followed by strict cage rest would likely do the trick, but cautioned that extreme care would be required in handling the close amputation due to the possibility of permanent nerve damage to the area (potentially rendering Figgie powerless over his bowels).
Figgie’s owners agreed…then changed their minds overnight and carted him over to the nearest low-cost clinic (a not-for profit designed to help those with minimal funds afford reasonable-quality care).
Mind you, the ginormous, late model luxury SUV might have looked out of place in the low-cost’s parking lot, but I guess they decided they had to save their pennies wherever they could given that one monthly payment on that automotive beast was very nearly as high as the surgeon’s estimate.
So that’s how “we want to do everything possible” was amended by, “but only if it costs as little as possible.”
We have a saying in Spanish that goes, “lo que cuesta barato sale caro.” Translation: What comes cheaply...will cost you.
That’s what I had in mind when I heard the story second hand from another client (friend of Figgie’s family). And that was even before I learned how it would end:
After his surgery, Figgie had to be rushed after hours to the very same surgeon’s hospital for follow-up care…after his surgery very nearly exsanguinated him. (Those pesky tail vessels are hard to reach properly, encased in spinal bone as they are.)
For my part, I confess that I felt slighted by the owners’ decision. After all, I’d gone above and beyond for him, even going so far as to visit him that night at the specialists’ place to check on his progress and the surgeon’s assessment and plans.
After all my work, his owners could have at least called me for advice before venturing off into the wilds of an unknown hospital in search of the lowest price-point possible. They could at least have asked me what I would have charged, right?
But this isn’t so much about my feelings or the need for clients to solve financial problems through low-cost alternatives. Rather, this is more about what happens to our patients when that bond of trust is breached…for financial reasons.
In some ways I feel responsible. What could I have done to head off this problem? In hindsight, I realize that by not offering the client a clear alternative solution in a general practice setting, I failed to secure their trust that I could manage Figgie’s case if the surgeon proved “too costly.”
By taking the owners at their literal word (“everything possible”) I assumed they would want nothing less than the most appropriate care possible. Instead, they arguably opted for the least. Surely I could have offered something in between. But I didn’t, so consumed by my assumptions on what my long-time clients wanted for their pet.
Figgie has doubtless suffered more pain (I don’t want to think about the pain protocols that may or may not have been employed) and what’s worse, he may well lose motor control of his bowels in a week or two (which is the main reason I urged he see a boarded surgeon). This latter possibility is a scary prospect. And owners don’t often comprehend the critical nature of this euthanasia-prompting possibility.
Sure, we can all say with certainty that his owners made the wrong decision—especially if we assume his owners had the financial wherewithal to treat Figgie with the best care available (and I still do). More so if you consider that these owners would be horrified to consider the services of the cheapest lawyers, bankers or accountants. (And they don't buy their clothes at Wal-Mart, I can assure you.)
Nonetheless, in Figgie’s little tale of woe there’s a big lesson for veterinarians...one we ignore at our own peril: When we provide informed consent to our clients, we should diagram that price/quality axis (figuratively speaking, of course) so that they clearly understand where their choices lie on that continuum-of-care curve. No, we can't contriol our clients' choices. But if we fail them in this, we must accept some responsibility for the final outcome.
Add Comment73 Comments
I agree completely!!! When my pets are in pain or injured, I'm in freak out mode. The Vet needs to tell me all the options because I don't know enough to know what, if any, there are. Discussing things like this has gotten easier over the years but it's never comfortable. We all want "the best" but few can actually afford it.
Feel for the dog on this one but not the client. You've got a client who's probably in debt up to their ears and living beyond their means (ie the average American) and discussing cost would mean admitting that and they probably can't admit it to themselves; let alone you. Back when, I did straight 7 bankruptcies for $850 and it was shocking how many people with $250,000 houses and brand new cars couldn't come up with that much cash. It's gotten so bad out there that I suspect the average American can't deal with a $2,000 emergency of any kind, at least not without a credit card and that's a lousy position to be in.
PJBoosinger January 19th, 2009 10:48:18 AM
Dr. K re: "Sure, we can all say with certainty that his owners made the wrong decision" and the "price/quality axis."
Frankly, I would not be in such a rush to place blame at the feet of the owners. Clearly, by your statements, you feel that the budget clinic's emphasis on low cost rather than good quality care had something to do with the near "exsanguination" of Figgie. I.e, he nearly bled to death post surgery.
Clearly, you feel that the choice of a care provider was the cause of the outcome here. That means that the blame lies at the feet of the budget care provider, NOT the owner.
There is not a sliding-scale standard of care. It seems that the budget vet may not have provided standard of care to this dog. Regardless of price, that's their fault.
Owners do not realize, until it is too late, that there are actually vets that screw stuff up. Therefore, when faced with decisions involving wide variations in cost, (since no vet is going to tell them: "Yeh, we're cheap, but we're also sloppy and/or cut corners and commit malpractice left and right") owners sincerely do not understand that the lower cost clinic may also expose their pet to unnacceptable risks.
Clearly, that is what you are basically saying -- that the clinic choice is what has caused this perilous outcome.
If that is true, the responsibility lies at the foot of your low-cost colleagues, and I would entreat to you explain to the owners exactly what corners that clinic cut(s). Perhaps they will choose to do something with that information that will cause the clinic to . . . rethink things.
It may seem like a no brainer to us that there is NO WAY that a clinic-on-the-cheap could offer the same level of care that a higher cost clinic can. But there are reasons why we know this -- either we are industry insiders like you, or really savvy and/or previously burned pet owners here. Most owners just simply think that the only difference between two vets is -- cost. The cheaper vets will generally argue that their options are just as good, albeit cheaper. No one goes to these places and is told "although we are less expensive, there is a significantly higher chance your pet will be permanently damaged/die, etc.". In other words, these people are misled our lied to by vets and perhaps, choose to believe those lies, because of the enticements (cost).
I had a long conversation the other night with a woman who took her beloved young dog to be neutered at one of those low cost, nonprofit associated clinics. He died before they ever even made a cut -- in other words, sometime after "induction" and before surgery. This was for a simple neuter. Necropsy showed NO heart problems. Turns out, they used 100 mg/ml strength xylazine, although of course they claim they titrated to the correct dose. When she said they charged $68 for a neuter, I had to bite my tongue. The person I am today would know that serious corners are being cut for a $68 neuter. I also rememered your post about budget spays, vividly, when speaking with her. But unless you had been through something like I have, it would never occur to you to ask such questions. They just think they are lucky and are getting the SAME THING cheaper. I adamently believe that the owner is NOT to blame when a health care practitioner cuts corners to keep costs down and therefore compromises quality of care.
Stefani January 19th, 2009 10:50:09 AM
PS -- thank you for feeling at least partly responsible for not underscoring the price/quality axis thing. It is good that you reflect on these things. In fairness, though, I doubt they would have believed you even if you had told them this. Because, once they showed up at Dr. Cheapvet, Dr. Cheapvet would have said something like: "Oh phooey, they are just trying to charge you gobs of money, all that's not necessary. What we can do for your dog is [X] which is just as good but will only cost you [Y]." Not knowing who to believe, there is a good chance they would have made the same choice.
Stefani January 19th, 2009 10:55:54 AM
Stefani - I totally disagree. The only blame I'd put on the budget vet is if he represented himself as being able to offer the same quality of care as the specialist - which we don't know. (and you seem to be assuming). And even if he did misrepresent himself, some blame has to go back to the owners for a.) actually believing them or b.) knowing the care level would be lower but not giving a rip due to the price. When my automobile needs engine work done, I sure as hell am not going to take it to the Jiffy Lube or the unliscenced roadside mechanic. This is what is known as common sense "caveat emptor", be it getting your car worked on or finding a vetrinary surgeon to do critical repair on your pet. Whatever happened to taking some personal responsibility for ones own actions?
chip January 19th, 2009 11:16:39 AM
I think the problem/fault is in the owners not asking you, after they went to the specialty clinic and thought it was too much $, and found another clinic that cost less, what the difference was. No one who buys an expensive SUV over a simple Kia Roi can claim that they think the two options in transportation are equal, yet they bought the expensive one "just because." They knew very well their car cost more for a reason, and as Dr. K. points out "they don't buy their clothes at Wal-Mart" so they do understand a difference in price points and "would be horrified to consider the services of the cheapest lawyers, bankers or accountants" to which I'd firmly say they certainly wouldn't pick the cheapest doctors/surgeons for themselves just because of price.
If it was any other member of their family or themselves, the deciding criteria would not have been made only on price. They would have asked someone what the difference in price entailed - unless you think that they truly had no brains or no concern about the issue, and I'm sure that Dr. K. explained this was a serious issue, or she wouldn't have directed them to a specialty clinic in the first place. So, yes, Dr. Cheapvet's a vet who didn't try hard enough to provide a better standard of care, but it's also the 'fault' of the public who both sometimes cannot afford better and often don't think better is warranted because "it's just a dog/cat/hamster." Societal attitudes have moved a tiny bit in the West, but not enough to change this age-old idea of 'worth' versus 'cost.'
KateH January 19th, 2009 11:54:37 AM
Chip, caveat emptor assumes the "customer" has a realistic way to make those judgments--bearing in mind that "most expensive" does not automatically equal "best."when you have your car's engine worked on, you have some good general idea of the cost of the parts and labor, and the skill level required. Most people have no idea what veterinary surgery actually costs, and therefore no way to tell whether Dr. Khuly is over-charging or Dr. Cheapest is charging so little that assuming use of anesthesia is overly-optimistic.
An acquaintance of mine has a young female cat that's relatively new to her household. She's arresponsible owner, and it's important to her that all her pets be spayed or neutered. When the new kitty reached six months, she considered it to be the right time--but they'd been hit with some unexpected big bills, and things were tight. Delay the spay, or go to the low-cost clinic? She thought carefully about how even the most careful owner can have a moment of inattention and wind up with a kitty who slipped out and got pregnant, or who slipped out and something worse happened, because they're indoor kitties who don't know the rules of the road. And spaying is a really routine surgery, not all that complicated, that most vets do all the time, right? (Yeah, I know, but the point is, most people don't.) She opted for the low-cost clinic.
Uneventful spay, uneventful recovery from the surgery afterwards--and then a few weeks later, kitty starts acting like she's in heat. Can't be in heat; she's spayed. Right? Very odd. Call their regular vet, make an appointment. But in a hectic day, someone's attention slips--and kitty slips out.
Kitty is now pregnant.
Exam by their regular vet concludes that the spay clinic removed most of the uterus--but not all, and not the ovaries. Kitty has an abdominal pregnancy. Needs a spay/abort. Owners contact the spay clinic, report the news, and get an apology and an offer to do the second surgery for free. Regular vet will charge $600.00. They opted to have their regular vet do the surgery, even though they really, really don't need an unexpected $600.00 bill right now.
This didn't happen because low-cost spay clinics can't do pre-op blood testing. It didn't happen because low-cost clinics don't have the staff to spare for anesthetic monitoring or for aftercare that would be provided at a full-cost vet hospital. It didn't even happen because some low-cost clinics re-use instruments that aren't sterile anymore because they've been used on the previous two patients.
It happened because the screw-up that did the spay surgery wasn't paying attention when he/she had the patient open. That's not excusable, and it's not the fault of the owners, who were trying to do what was best for their cat.
The second, riskier surgery, performed by their regular vet, went smoothly and without complication--at least in part because the regular vet was paying attention to the patient, and not something else.
Lis January 19th, 2009 12:17:17 PM
Lis, you say "when you have your car's engine worked on, you have some good general idea of the cost of the parts and labor, and the skill level required" which I can't understand how anyone would know this, or how much skill/cost it takes to do a lot of things, from car repair to driving a school bus. No one is born knowing these things, yet, if you have the ability to make most choices, such as what kind of food, car, medical care, you learn that there is at least one and usually many reasons, why all choices don't cost the same. Whether it sounds harsh to say "buyer beware" the point is illustrated well by your friends paying $600 for an end result (a spayed cat), that would have cost less if the 'more expensive' vet had been chosen in the first place. Paying twice is a good recipe for paying more.
KateH January 19th, 2009 01:06:46 PM
Chris, I have to disagree with you. You can not play "caveat emptor" when it comes to a standard of care & "licensed" professionals". And where on earth is human Dr. Cheap or human cheapo Esq.? Nobody holds themselves out to be this "inferior quality" person or work.
Furthermore, you can be going to Dr. Expensive & Dr. Quality and get neither one and not know the difference!
People don't know the difference between Mr. Cut-corners plumber or electrician either!
Barbara A. Albright/New Hampshire
Pocket's Story from NH January 19th, 2009 01:17:45 PM
KateH: In my state of NH, MANY people are obtaining the "cheaper" spay/neuter under a state sponsored program and I would venture to say with "good outcomes". Are these people supposed be concerned over lack of proficiency or quality? If so, it behooves the "professional" paticipants to so inform these clients.
And on the flip side: One can not quote "Dr. Incahoots" for the poor outcome of Figgie's treatment, since it is accepted widely that a referral is NOT BLIND, and the initial professional chooses and suggests the "referred to" party, right?
Barb Albright/life-long NH resident
Pocket's Story from NH January 19th, 2009 01:46:32 PM
Barbara, your statement "it behooves the "professional" paticipants to so inform these clients" needs to admit that no vet will come out and say, and the customer will most often resist a professional who says anything along the lines of "I charge X, but Dr. Cheap charges less than X because they aren't doing all the things I would do." It just is not a good way of doing business to denigrate another service provider without the customer asking "What's the difference?" first. To demand that any service provider, whether a car mechanic, a veterinarian, or a tax preparer, tell you up front why the competition might not do as good a job is not fair. The customer needs to accept that they are part of the decision-making process, and that they need to participate by getting some information.
KateH January 19th, 2009 02:04:23 PM
Oh, please.
Is anyone seriously challenging the proposition that going to a budget clinic for medical or veterinary (or any other type of professional) services presents a substantial likelihood that you will receive a lower standard of care than from a full-priced professional?
Yes, of course there are low cost professionals who do highly professional work, but should you assume that? Not if you are making an emergency decision in the middle of the night! Maybe if you have done research, but I wouldn't risk my dog's life or mobility on it in a crisis decision.
And Dr. Patti, given the attitude displayed by these boneheads, it is just as well that you did NOT offer to do the surgery yourself, because who knows what they will do next. I feel terrible for their dog, but at least now they are the ones responsible for the result -- they can't try to pin it on you.
Susan January 19th, 2009 02:23:31 PM
Always easy to blame the uninformed victim. Quite honestly, I would not know who is the high or low priced quality or on-the-cheap professional.
How are people supposed to know who is/who isn't? Money & education does not= quality.
Just as assumptions are made based on "appearance" , it is wrong to do so. I learned that YEARS ago.
Trust, value, morality, ethics do not "wear" a face.
And just what is wrong with a Wal-Mart wardrobe or 8 year old used car?? ;)
Did Dr. Incahoots send me to Dr. brilliantly educated-Cheap for $3700?
Barbara A./NH
Pocket's Story from NH January 19th, 2009 03:33:58 PM
You keep missing the point. It's not that there's anything inherently wrong with something costing X versus something costing Y - it's asking WHY the difference that's the responsible thing to do. Saying "I didn't know that person wasn't as good, or wouldn't provide all the same services" is fine, but to have been given two different prices and not asked why there's a difference, means one has made an uninformed choice. To turn around and say that it's all the fault of the service provider is not taking care of your financial, let alone other, responsibilities.
KateH January 19th, 2009 03:45:28 PM
KateH: I am not sure we are arguing about the same thing.
One would have to have a referance guide for everything! A state issued "license" is supposed to represent a minimum standard of: education, proficiency, quality of work/services. "Money & cost" are not regulated, therefore can not be interpreted as a representation of "anything".
Barbara Albright/NH
Pocket's Story from NH January 19th, 2009 04:12:24 PM
I come back to this: People on this blog are sophisticated about vet care. You understand this purported "cost-quality" continuum. But NO, clients don't. And they shouldn't be blamed for this, and here is why:
With such a HUGE range of prices in vet care, the average pet owner, I believe, assumes that markup is a huge factor. In other words, they assume that expensive care is expensive because these clinics are billing themselves as "boutique" and running higher profit margins. How can they continue to think that?
Well, here are some contributing factors:
Paying a lot for veterinary care DOES NOT ensure quality. I can think of several expensive places around here that come with major repeated horror stories. I wouldn't get within 100 feet of two of our regions most expensive places. So consumers learn that paying lots doesn't ensure quality.
Then, they show up at Dr. Cheapvet. Dr. Cheapvet's got the same degrees and licenses hanging on his wall as say, Dr. K. And Dr. Cheapvet will give them his argument:
"Oh, those other vets, they just want to charge you lots of money. I can do just as well for you, for much less." Yes, many of them really say this. Like "The Old Country Vet" who is a nightmare person. And many of these Cheapvets have a fabulous bedside manner.
How is a consumer supposed to know? Unless, of course, vets like Dr. Khuly join forces with consumers to report the vets with the botched jobs doing things on the cheap, so that they end up with a public disciplinary record . . . and then we train consumers to check the disciplinary records. Unless we train consumers to ask questions like: do you use licensed technicians? What is your anesthetic protocol? How many times have you done this surgery? What are your reasons for doing this yourself rather than referring to a specialist?
BTW, where I live, although the best hospitals are among the more expensive, there are PLENTY of expensive places around here that flat out suck. They don't use licensed vet techs, and they are arrogant, and their poor clients think that because they are shelling out a lot they are therefore getting the best.
OTOH, one of the vets I trust the most volunteers for our local SPCA and barely makes any money.
One of the reasons consumers don't make the cost=quality connection is that it doesn't hold true . . . cost alone is no gurantee of quality.
Obviously it never occurred to Dr. K that her client would turn around and take the dog elsewhere after all of that. But even if she suspected this, what's the liklihood that she would have said: "Now, I'm telling you, if you go to Dr. Cheapvet, he may offer to do something for less, but it will be dangerous for your dog," because that would have implicated Dr. Cheapvet, and vets rarely are willing to make such statements about other vets (As Kate points out.). But, that is yet another reason why consumers don't know how to make good decisions. Yes, it would help if vets helped educate people, but keep in mind, that vets are often telling the same client different things, and when you've got Dr. K in one ear and Dr. Cheapvet (or the "Old Country Vet") in the other, you've really gotta hope you have an inner voice and some intuition to smell out the truth. Or, unfortunately, the benefit of very bad experiences that have given you the rude awakening that changes you forever.
Stefani January 19th, 2009 04:18:09 PM
We use a clinic (that I've mentioned here many times before) that is, well, dirt cheap.
They're open 24/7/365, and offer all the bells and whistles like in house ultrasounds, laser surgery, a fairly substantial in house lab, etc. The reason they're so cheap is that they have seven or eight exam rooms and 20 or so vets on staff at any given time. They're always busy, but never so busy that you can't walk in, so they don't lose that small-town feeling even though they're a large practice.
HOWEVER, they are not staffed with the highest quality vets in the neighbourhood. There are a few on staff that I would present with just about any issue (I have one DVM who even does amputations for me when necessary) but the majority of the staff is just decent and I don't mind because I can ask and receive the tests and treatments that I feel are best.
There are many vets in my city who are double and even triple the price of my own clinic, and yet provide worse care than this so-called "economy" clinic. There are also a handful who are fabulously more qualified and talented, and when I have a REALLY difficult case I won't hesitate to use one of the more expensive, more thorough, better educated veterinarian.
The point is, I know the care I'm getting wherever I'm going - generally because I've been there before. If I haven't, I've received a glowing recommendation from a knowledgeable friend/rescuer/vet that I trust. If by some chance I'm walking into a clinic blind, I'm not going in with a surgery case - and if I was, I have to say I would agree with Chip - Buyer Beware.
How do you choose any service provider? Do you call around for the cheapest price? If so, if things don't go perfectly don't you kind of accept a certain level of error in exchange for said price? Or do you ask for recommendations such as the one Dr. K provided? (and I don't mean "oh yeah, I had my dog neutered there and it went fine" - I mean an actual, useful recommendation such as a major invasive surgery or long time relationship)
When choosing a garage, I may just drive to the one nearest to my home for convenience, but if things don't go well, I chastise myself for not checking them out thoroughly prior to trusting them with my car - not the mechanic for cutting corners and screwing me on the bill. I should have done my homework.
If they were operating on price alone, (unless they are complete idiots - we're talking IQ=shoe size) they should expect some cost-cutting procedures/practices. Dr. K - as much as I love the fact that you feel bad about this (sorry, but it's unusual for me to see vets personalize choices that they make themselves, let alone choices made outside of their ability to control - which this one certainly was) you shouldn't feel anything but sad/irked that such blatantly selfish people are not only failing to provide the standard of care to their pet that they are capable of, but also that these people are using services meant for those less fortunate, reducing the resource pool for those who really need it.
I guess what I'm saying is, you don't drive your Beamer to the soup kitchen and then complain about the consistency of the chowder.
Kim January 19th, 2009 04:31:11 PM
Kim, but it's not chowder. It's a living feeling being. And it's not a mechanic or a soup kitchen. It's a health professional, a vet. No health professional should provide lousy care at any price.
Stefani January 19th, 2009 04:54:53 PM
We live in a world where there is indeed a sliding-scale standard of care. professions merely set MINIMUM standards. KateH "If it was any other member of their family or themselves, the deciding criteria would not have been made only on price". Many people have to make this choice every single day. Susan: "Yes, of course there are low cost professionals who do highly professional work, but should you assume that?" I wouldn't assume that; nor would I assume a high price means quality.
Although it makes professionals cringe, Vets and others (medical pros just added) are on Angie's list. I can't wait until they put the lawyers on there! The average person doesn't know how to evaluate a professional; that they should at least check their license and status (and most professional organizations make it difficult to even do that). There's no "Consumer Report" for professionals and there should be. I'm sorry but I can't possibly learn the minimum standards for each profession I interact with: lawyers (OK, I know that one), accountants (yeah, that one too), mechanics, Vets, doctors, medical technicians, the utility companies (should I be able to double check my plumber and electrician too?), and on and on. Think for just a minute how many pros you deal with on a regular basis! The world has become very complex and becoming more so very rapidly. It is long past time for us to move from caveat emptor to caveat venditor. That places the responsibility on the person who SHOULD know.
Now, Doc, do you think Dr. Cheap violate the minimum standard of care and, if so, did you tell your client that?
PJBoosinger January 19th, 2009 06:06:27 PM
Thankfully Stefani has the ability to clarify, what I attempted to convey.
Just "how" is one expected to "weed" through hiring anybody to do a job, unless you have thoroughly educated (yourself) & understand what the job should consist of to be successfully done?
How are you supposed to "gather" intelligent references without a huge pool of people to poll OR a government-trusted entity to consult with (by publishing public complaints)?
A degree, certification, or license is "supposed" to represent a standard.
Barb A./NH
Pocket's Story from NH January 19th, 2009 06:26:30 PM
With this discussion, you've all just made a great point: Making healthcare choices is difficult and confusing. Money decisions can be especially difficult for the ill-informed (my point to begin with). Nonetheless, I firmly believe that there is a probabilistic way of dealing with these cost/quality issues.
Sure, there's no guaranteed outcome with any approach, but if you assume that every provider offers a minimum level of care, you can expect that the lowest-cost provider will probably offer the fewest safeguards within these standards...the highest cost will probably offer the most.
Of course that's not alway true. The low-cost provider may have just hired a shockingly competent, upstart vet who wants to cut his teeth in a high-volumne environment. And the boarded surgeon may be having a bad day, what with fourteen cases to manage. It happens on both ends of the spectrum.
Caution: We also know that price does not automatically dictate quality. Nevertheless, we all intuitively understand that there is a corellation. Most of us--low-income though we may be--can also compare estimates and objectively see what's being offered for our money in place x vs. place y. When you receive one estimate with thirty line items and another with four, there's almost no mistaking the probabilties involved in the kind of care you'll likely be getting with whatever choice you make.
In this sense, I DO fault my clients to a large degree. Anyone should have known better. A trained monkey could pick out the better level of care. They should also have realized that there's a spectrum of quality in between. But it's also my purview to make sure I explain all options up front, which I didn't, which is why I accept some responsibility for Figgie's suffering.
Dr. Patty Khuly January 19th, 2009 07:19:39 PM
IMHO, this all could have been avoided if the owners had been upfront about what they were willing or able to spend, but for whatever reason they weren't, and their pet suffered for it. I don't buy that consumers would need inside knowledge to understand that a lower cost clinic is unlikely to provide the safeguards and precautions that a specialist's would. I also don't think that all complications resulting at a lower cost clinic are due to substandard care. Most importantly, I think veterinarians are obligated to always present what is best for the pet in any given situation - and Dr. K did that by referring immediately to a specialist. It is then the owner's responsibility to make decisions regarding their pet's care as best they can. In this case, the owners made a seemingly autonomous, rash decision to transfer their pet's care elsewhere in order to save money...it's unfortunate that they didn't consider the consequences. I don't believe anybody was necessarily wronged here (besides the pet)- there's not always someone to blame.
anna January 19th, 2009 07:38:19 PM
The only fault I put on the people, is that they should have checked out the vet. Price does not always equal quality but a deal that's too good to be true often isn't. That being said, its not easy to get good information on vets. I've checked out my own vets on Angie's List and Yelp and not surprisingly - most people love them, some hate them. Most of the haters are due to the high prices, but some cite problems they've had. Well, in any large practice, expensive or not you are going to have some mistakes and complications. And if its your pet that's affected than the failure rate is 100%. But the same goes for a low cost neuter clinic. In our town these are often staffed by volunteer vets - often from the pricier practices. Now I don't know who staffs the clinic mentioned earlier. But the death could be due to some undetermined abnormality with the cat (I'm assuming a necropsy wasn't performed) or some other cause unrelated to price. How can a consumer know? Its very hard to sort out the unpreventable bad outcomes from the poor quality care unless you can actually talk to the person or read the complete story on their web site. A comment like "my sick dog died while in their care" tells you nothing about the situation except that you have a dead pet and an upset owner. I think that Dr K is being too hard on herself, but it wouldn't hurt to tell clients that once they talk to the specialist that can call you to discuss if they have any questions about the procedure or cost. Maybe this would help clients get past the embarassment of not being able to afford/or wanting to to pay for the care.
2CatMom January 19th, 2009 07:43:00 PM
The above comments reaffirm how "difficult" it is to determine anything. The beautiful waiting room, friendly front office vet, and "dirty room in the back". Didn't we read that, a few blogs ago?
Reading on Yelp & other consumer-post sites? Who honestly does that? Who believes that most of the good comments come from real clients? Who wonders if some of the bad ones are from sabotagers to the competition?
Oh yes, some are unmistakably real.
If price equaled quality, I got the best medical care to be had in October 2006, for my dearly loved Scottie "Pocket", along with a REFERRAL clinic employing the best certified & degreed ACVIM & licensed "professionals"---pretty darn frightening.
Pocket's Story from NH
Barbara A. Albright/#189/200
Pocket's Story from NH January 19th, 2009 09:50:41 PM
Stefani,
I take some offense at your first post about subsidized clinics. I have worked for and with subsidized spay/neuter clinics for years. At ours, we were always very up front about what we could and could not do. We accepted only the healthiest patients, refusing to take on animals with higher risks of complications. We also used better monitoring equipment than many of the private practice hospitals in our area and kept better records. We didn't "cut corners" to offer our services at a lower cost - we took donations to make ends meet. The charity practices I have worked with have always been very up front about their intended clients (generally low income clients who cannot afford to go anywhere else) and about the services they can offer.
There are vets at very expensive hospitals who practice terribly and vets at subsidized or charity hospitals that practice great medicine. The reverse is also true. Expense is NOT shorthand for quality.
Tara M January 19th, 2009 09:55:09 PM
Alright, after reading some of the other comments here, I cans ee that mine may have been premature. Still, it's not cool to paint everyone performing subsidized services with the same brush (or everyone performing expensive services.) Some of us really are out there doing what we can to help people who have no other options.
Tara M January 19th, 2009 10:06:36 PM
Tara, when I said that its a no brainer that a low cost clinic can't offer the same level of care, I should have said without subsidy. There are things you just flat out can't provide for $100 in a spay. If you are providing full frills spays that cost your hospital $300 for $100 because you are being subsidized, then obviously the cost-quality thing wouldn't apply to you. Which actually helps prove my point about it being so difficult for owners to discern quality based on cost alone.
If you reread all my posts you see that I pretty much agree with you. In fact I think most owners assume exactly what you are saying -- that nonprofit related clinics who offer the reduced priced spay/neuter clinics are offering the same level of care at a lower price due to subsidy. But that is not always the case and there is a clinic here locally that I believe is definitely cutting corners to lower costs -- ordering for example 100 mg/ml xylazine which is concentrated for use in larger animals because its the same cost as the 20 mg/ml version which is for small animals. I guess they just figure they are getting 5 times the drugs for the same price -- but doesn't this make dosing a lot more dangerous? Other S/N clinics around here I know don't intubate or monitor electronically.
Anyway, I actually agree with ALL of your statements -- there are lots of expensive places practicing terribly and some lower cost places (like that SPCA vet here I talked about who provides seriously discounted care to shelter and foster cats and she's pretty much the best vet in Maryland as far as I can see, although she provides only basic care).
Stefani January 19th, 2009 10:12:58 PM
Tara: Absolutely! You play a critical role in offering good care to those who might otherwise cut out veterinary care altogether. Over the years I've known many great vets that started out in not-for-profit, low-cost settings. I've volunteered for some of these. I even know a couple of highly competent vets that work in these places. As I'm sure you've realized, the goal here is not to bash the practice that caused the complication (my outcome may have been no better, for all I know). It's to examine why people choose what they do and wonder whether there might have been a better way...for this pet, at least.
Dr. Patty Khuly January 19th, 2009 10:17:23 PM
I think another side of this is when the owners feel pressured to take the higher cost "do everything possible" route from the vet. My old dog had a pretty severe eye injury about 3 years ago. Went to the regular vet who sent me to the specialist. I was cool with that. Specialist said we can save the eye but it will cost about $2000 - taking the eye out won't be much cheaper - and we have to do the surgery tomorrow because he is in so much pain.
Well, about $3000 later (with meds, follow up, etc.) - yes the dog has the eye, can't see much out of it, and I found out that having my vet remove the eye would have been a lot less expensive, with a lot less follow up care and aggravation on the dog. He had to wear a cone for 2 months to protect the eye - was on 7 different eye meds 3 times a day, on pills that made him sick. Not fun.
Had I not felt pressured to "do the surgery tomorrow" I might have called and talked to my own vet that I trusted, and been a bit less poor today. With a dog that would have done just fine.
Teri January 20th, 2009 07:30:36 AM
Teri: Exactly. You got all your options but you got them from the specialist. Even the simplest surgery at the specialist will cost you two to four times as much due to their detailed protocols for every procedure, regardless of complexity.
Enucleation (eye removal) is a great example. I charge about $500-$750 for this, nut to bolts, while the surgeon charges about $1500. If I didn't TELL you I could do it for less, you might assume I wasn't comfortable with the procedure or that it was one always lef to a specialist (after all, removing an eye sounds a lot harder than it really is).
Again, it all boils down to trust....but it always helps to have a high degree of comfort in picking up the phone and asking your GP what she thinks. In the future I will be more careful in letting my clients know that for any questions or concerns, medical, financial or otherwise, they can always call me even after they've been to the specialist.
Dr. Patty Khuly January 20th, 2009 07:41:46 AM
You're so right about the trust issue being at the heart of this question. My vet sometimes recommends things I don't think are worth the money - for example, a weight loss drug for my dog who has already lost 14lb without the drug - why spend the money when I've already found a feeding regimen that's working? At the same time he does give me pros and cons of most treatment options and I feel comfortable that he won't recommend more expensive options than I need. He answers questions about levels of care & costs frankly and honestly without getting offended - not every vet does so. I think if you are in a position where your clients trust you, the more information you can give them about options, even if you assume they want the best one, the better armed they will be to make decisions. You never know who else is talking in their other ear - friends, relatives who think it's silly or even shameful to spend thousands of dollars on a dog, or have their own anecdotes about how this or that vet is overpriced and ripping people off. My favorite are the people who spend a lot on diagnostic tests and are upset rather than relieved when the vet finds that nothing serious is wrong!
I also think it's too easy to make assumptions about what other people can afford or should spend. A lot of people are facing financial challenges. I know people who would like to sell their pricy SUV for a more economical car, but are upside-down on their loan, or can't get out of their lease right away. They may have had financial setbacks, recently been laid off or who knows what...I would not cut corners on my pet's life-saving procedure but I have used low-cost, middling-quality vet services in the past because I simply did not know any better.
Anne January 20th, 2009 02:39:08 PM
TaraM----I agree 100%.
Teri: I'm sorry to read about the "eye". Another situation where "pressure" comes into play and you don't have a chance to think it through. I have to say though, if glaucoma was involved, it is pretty darn painful for the pet.
Dr. K: how about a 101 on eye removal, I find it fascinating & I bet others would love to know more.!!!
Barb A./NH
Pocket's Story from NH January 20th, 2009 08:51:07 PM
Dr K, you've hit it on the head. My partner's a vet, and a good-hearted one who does what she can to help clients who don't have a lot of money. But she's sick to death of economic euthanasia over routine care issues. All too often, it's for clients who roll up to the clinic in big expensive SUVs and a whole family tricked out in designer clothes, but complain they can't afford the 60 bucks to leave a sick pet hospitalized overnight. Um, right.
I'm sure some are stuck in bad car loans or whatever. But most seem to be stuck in thinking of pets as disposable commodities that aren't worth as much as a designer jacket or a tank of gas. Because, time after time, they're back a few weeks later with a new pet that probably won't fare much better than the last.
I think vets are often too quick to trot out the old saw "If you can't afford the vet, you can't afford the pet.'" There are a LOT of families who can't afford big-ticket procedures like chemo or hip replacement. and that's totally fair. But the basics - spay/neuter, shots, flea and heartworm, dental and emergency care - I'm not so sympathetic about. That's a fundamental part of the price of pet ownership. It's like factoring in car insurance in figuring out whether you can afford a car. It's just not optional.
And to the commenters who say it's just too hard to know which vet to go to -- bull. When you needed a pediatrician, did you ask around? I bet you did. There are just as many people (more, actually) with pets as with kids. You can ask around about that, too, and I've never met a pet owner who was shy about venturing an opinion (good or bad) about at least one local vet. The experiences of your aquaintances are often a much better indicator than price, anyway.
Psmom January 22nd, 2009 12:15:12 AM
I have a similar issue with my 9-year-old poodle Robbie. He may or may not have Cushing's Disease. But I spoke openly with my vet (who I trust totally) about cost, alternative therapies, etc. Keepign in mind that I will spend every penny I can on my dog's health -- but it's good to hear all of the alternatives and their prices. That does not mean you love your pet any less, it simply means you are gathering all of the information possible, and that includes costs. The couple should have asked Dr. K about alternative measures, other costs, etc. Had they done that, Dr. K could have told them, well, you can do this much for that much, or you can take this route for that much. Again, we cannot lay blame on a doctor when WE do not ask and gather all the information before we go forth and decide on our pet's (or our own) health. Personally, for an operation that sensitive, I would not have gone to budget place for the simple reason that it was a very sensitive operation. For something simpler, sure, I'd go to the budget vet. But not when the injuries were that extensive and needed a high level of care. And a shout-out to Dr. K -- I love your column and three of us at work talk about your articles and your musings. We also wonder where you get the time to do everything you do! -- Jacky, a fellow Cuban-American dog lover in Merritt Island, FL
Jacqueline Rodriguez January 22nd, 2009 05:52:06 PM
please be advised that all of Barbara Albrights statements regarding the euthanasia of Pocket are slanderous and 100 percent untrue. I can prove it.
cathy gajewski January 26th, 2009 12:01:21 PM
Prove it with what? A bunch of retroactively modified, "doctored" records? Isn't it interesting how vet records always say whatever it is vets want them to say? Or perhaps your "proof" is a bunch of sycophantic employees who would say anything for you . . . do anything for you . . .??? LOL. Some proof. So terribly convincing. All statements about all vets are always assumed to be slanderous and untrue, isn't that interesting?
Stefani January 26th, 2009 08:58:13 PM
Cathy Gajewski: If you believe that Ms. Albright's statements are slanderous and untrue, sue her--that is the only way for you to prove that her statements are slanderous and 100 percent untrue!
http://alabamavetboardwatch.110MB.com
Fotini January 27th, 2009 04:45:10 PM
Hey, Dr. Gajewski is a vet, she graduated from Cornell, and she has a rescue dog from Mexico! How can you doubt her? We must all believe every word she says, because we are only lowly, ignorant laypeople, and she is a real vet--just like brilliant & hardworking guy who looked at mange on my cocker spaniel, and insisted it was "just allergies." (Cleared up fairly quickly once we stopped yielding to the authority of the vet and found a different one who was willing to treat, crazy idea, mange.
Sorry, Cathy, but if you want to convince people here, you'll have to try reasoned argument, instead.
Lis January 28th, 2009 02:12:26 PM
Lis:
And then you have all the boarders misdiagnose your companions, cause their avoidable but horrible death, and then refuse to even talk to you!
Let me tell you, I might be a layperson, but I've educated myself (THANK GOD for the net!), and no vet is going to fool me EVER AGAIN!
<!-- /* Font Definitions */ @font-face {font-family:"Cambria Math"; panose-1:2 4 5 3 5 4 6 3 2 4; mso-font-charset:0; mso-generic-font-family:roman; mso-font-pitch:variable; mso-font-signature:-1610611985 1107304683 0 0 159 0;} @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4; mso-font-charset:0; mso-generic-font-family:swiss; mso-font-pitch:variable; mso-font-signature:-1610611985 1073750139 0 0 159 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-unhide:no; mso-style-qformat:yes; mso-style-parent:""; margin:0in; margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; mso-bidi-font-size:11.0pt; font-family:"Arial","sans-serif"; mso-fareast-font-family:Calibri; mso-bidi-font-family:"Times New Roman";} .MsoChpDefault {mso-style-type:export-only; mso-default-props:yes; font-size:10.0pt; mso-ansi-font-size:10.0pt; mso-bidi-font-size:10.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Calibri; mso-hansi-font-family:Arial;} @page Section1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.Section1 {page:Section1;} -->
<a href= "http://alabamavetboardwatch.110mb.com/Asp-index.htm">Asproolee’s Story</a>
Fotini January 28th, 2009 06:25:37 PM
Lis:
I am sorry about the garbage above! Trying again. . .
<!-- /* Font Definitions */ @font-face {font-family:"Cambria Math"; panose-1:2 4 5 3 5 4 6 3 2 4; mso-font-charset:0; mso-generic-font-family:roman; mso-font-pitch:variable; mso-font-signature:-1610611985 1107304683 0 0 159 0;} @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4; mso-font-charset:0; mso-generic-font-family:swiss; mso-font-pitch:variable; mso-font-signature:-1610611985 1073750139 0 0 159 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-unhide:no; mso-style-qformat:yes; mso-style-parent:""; margin:0in; margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; mso-bidi-font-size:11.0pt; font-family:"Arial","sans-serif"; mso-fareast-font-family:Calibri; mso-bidi-font-family:"Times New Roman";} .MsoChpDefault {mso-style-type:export-only; mso-default-props:yes; font-size:10.0pt; mso-ansi-font-size:10.0pt; mso-bidi-font-size:10.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Calibri; mso-hansi-font-family:Arial;} @page Section1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.Section1 {page:Section1;} --> <a href="http://alabamavetboardwatch.110mb.com/Asp-index.htm">Asproolee’s Story</a>
Fotini January 28th, 2009 06:44:45 PM
<!-- /* Font Definitions */ @font-face {font-family:"Cambria Math"; panose-1:2 4 5 3 5 4 6 3 2 4; mso-font-charset:0; mso-generic-font-family:roman; mso-font-pitch:variable; mso-font-signature:-1610611985 1107304683 0 0 159 0;} @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4; mso-font-charset:0; mso-generic-font-family:swiss; mso-font-pitch:variable; mso-font-signature:-1610611985 1073750139 0 0 159 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-unhide:no; mso-style-qformat:yes; mso-style-parent:""; margin:0in; margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; mso-bidi-font-size:11.0pt; font-family:"Arial","sans-serif"; mso-fareast-font-family:Calibri; mso-bidi-font-family:"Times New Roman";} a:link, span.MsoHyperlink {mso-style-priority:99; color:blue; text-decoration:underline; text-underline:single;} a:visited, span.MsoHyperlinkFollowed {mso-style-noshow:yes; mso-style-priority:99; color:purple; mso-themecolor:followedhyperlink; text-decoration:underline; text-underline:single;} .MsoChpDefault {mso-style-type:export-only; mso-default-props:yes; font-size:10.0pt; mso-ansi-font-size:10.0pt; mso-bidi-font-size:10.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Calibri; mso-hansi-font-family:Arial;} @page Section1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.Section1 {page:Section1;} -->
Hopefully, third time's a charm!
Asproolee’s Story
Fotini January 28th, 2009 06:49:37 PM
Fotini, what a sad, horrible story!
We all know there are wonderful vets around. I have a lot of confidence in my current vets, just for instance. But while the good vets, and the vet boards, cover for and protect the bad ones, we'll always have very little reason to believe the vet rather than the client, when there's a dispute over a case with a tragic ending.
Lis January 28th, 2009 07:32:52 PM
To shift the blame for a veterinary procedure gone awry from the vet to the victim's owner is preposturous! The safety of a patient should not be compromised under any circumstances, disount or no discount, subsidy or no subsidy. If a discounted service carries a considerably greater risk than a standard procedure, the increased risks should be fully disclosed, and the facts, such as the use of cheaper and more difficult to dose medications, should be discussed. The answer to "if things don't go perfectly don't you kind of accept a certain level of error in exchange for said price?" is NO in the case of a health care professional. The veterinarians' code of ethics requires them to uphold their patients' health above all esle, even considerations of profit. Sounds ridiculous? Where, might you ask, will you find such veterinarians? Well, they exist. The problem is the pet owner who doesn't believe in their responsibility to uphold the standard of care irrespective of price, and who will say that "mistakes happen." The truth is mistakes happen to the extent that they do because vets are able to cut corners, courtesy of the all-tolerant and "understanding" pet owner, who shifts the blame from the vet to the client and lets the vet get away with murder (pun intended). As far as rescue/low cost veterinary care, it is a little known fact that many of these operations (not all of course) are money making outfits, with little care given to the welfare of rescued animals. Subsidy or not, many vets who do lots of "rescue work" at a discount make up what they loose in profits by increasing the volume of procedures they crank out.
Natalie January 28th, 2009 10:13:07 PM
Re:
" . . . we'll always have very little reason to believe the vet rather than the client, when there's a dispute over a case with a tragic ending."
<p>
Well said, Lis. No one could, or would, make this stuff up. Seriously, what mental torture! Not only "why" would anyone make something like that up, but you can't even CONCEIVE of some of this stuff that you hear about happening, and Pocket's case is just beyond imagining -- no one could make that stuff up, nor would anyone dream up such tormenting and awful PTSD-inducing nightmares to inflict on themselves.<p>
And Fotini -- on the topic of lawsuits. The beautiful thing about lawsuits, of course, is PUBLIC RECORD. Clients who are telling the truth should have nothing to fear from a lawsuit (except of course, the time, money and torment of it -- but hopefully the client will be awarded legal fees when the truth comes out). And one thing the vets who bring lawsuits for people speaking out may not be thinking about -- the person you sue is going to get a chance to put all their evidence into PUBLIC RECORD. I think most of us have no fear of such a thing precisely becase we are telling the truth. Ah, boy, if I had money to defend myself (and I'd find it any way I could, there is no way I'd roll over, I'd sell everything I own first) I would LOVE it if Marc Katz of Kindness Animal Hospital in Wheaton Maryland would sue me for speaking out about what happened to my cat at his clinic. Because a WHOLE lot of evidence and additional damning information that I don't currently put on my website because its not "public record" would suddenly be IN public record, and I could subpeona witnesses, etc. Alas, I believe he cannot sue me because his statute of limitations to do so has long since expired. ;) That is another thing to remember -- when people allege defamatory speech, you have only a limited amount of time from the date on which you either learned of the "speech" or SHOULD HAVE reasonably known about it, to file. <p>
For the truth tellers, getting sued can be your chance to slam dunk establish the truth of what you are saying. For the hopelessly narcisstic who believe their position/charm/Godliness will ensure a walk in the park, a rude awakening awaits. Public record, baby. It all comes out.
Stefani January 29th, 2009 01:02:54 AM
شات
amal_ May 21st, 2009 05:12:49 PM
توبيكات
hanoo May 21st, 2009 05:33:01 PM
قلبي
bnt aboha May 21st, 2009 05:43:44 PM
منتدى
malak May 21st, 2009 05:48:53 PM
دردشه
تسواهن May 21st, 2009 06:07:10 PM
Prompted the design of the next how to make money online is to allow all distribution. More chaotic look of your site within a short period of time, people will spend double-check everything. This is good advertising and graphics, and all attempts to spread. To too many making money ideas on the site will only turn off your visitors.
qixinyan May 22nd, 2009 11:42:26 PM
The donkey means one Ugg Sale thing and the driver another ugg bailey button.The benevolent see benevolence and the wise ugg classic cardy see ugg classic tallwisdom.No man is his craft's master the first ugg classic mini day.two dogs fight for a bone coquette, and. A piece of jade unless cut forms no article of vertu.http://www.ladiesugg.com/
ugg boot September 12th, 2009 04:17:07 AM
The timberland mens boots world can be changed by man endeavor, and that this endeavor can lead to something timberland men's 6 inch new and better .No man can sever the bonds that unite him to his society simply by averting his eyes . He must ever be receptive and sensitive to the new timberland men's classic; and have sufficient courage and skill to novel timberland shoes facts and to deal with them cheap timberland boots. http://www.timberboots.co.uk/
timberland shoes September 29th, 2009 10:09:56 AM
Blu ray Ripper
vb4 October 5th, 2009 08:16:59 AM
dew October 26th, 2009 09:55:12 PM
<a href="chopard'>http://www.cartierwatches.us/Chopard/">chopard replica</a>
<a href="chopard'>http://www.cartierwatches.us/Chopard/">chopard replica</a>
Concord watches November 11th, 2009 07:58:43 AM
Rolex Air-King watches
Rolex Air-King watches November 11th, 2009 10:51:48 AM
However mean your life is, tiffany jewelry meet it and live it do not shun it and call it hard discount tiffany jewelry unt tiffany jewelry It is not so bad as you are.It looks poorest when you are richest.
tiffany jewelry November 12th, 2009 11:44:06 PM
Rolex Milgauss watch for sale
Rolex Milgauss watch for sale November 13th, 2009 01:30:32 PM
replica A.Lange & Sohne
replica A.Lange & Sohne November 13th, 2009 01:31:20 PM
replica Rolex
replica Rolex November 13th, 2009 08:09:36 PM
replica Rolex
replica Rolex November 13th, 2009 08:10:00 PM
Glashutte watch for sale
Glashutte watch for sale November 16th, 2009 02:39:51 AM
Graham watch for sale
Jaquet droz watch for sale November 16th, 2009 02:41:34 AM
http://www.cartierwatches.us/Breguet/http://www.cartierwatches.us/Breitling/http://www.cartierwatches.us/Burberry/http://www.cartierwatches.us/Bvlgari/http://www.cartierwatches.us/Cartier/http://www.cartierwatches.us/Chopard/http://www.cartierwatches.us/Concord/http://www.cartierwatches.us/Corum/http://www.cartierwatches.us/DeWitt/http://www.cartierwatches.us/Ebel/http://www.cartierwatches.us/Ferrari/http://www.cartierwatches.us/Franck-Muller/http://www.cartierwatches.us/Glashutte/http://www.cartierwatches.us/Graham/ttp://www.cartierwatches.us/Hermes/http://www.cartierwatches.us/Hublot/
cartierwatches November 17th, 2009 10:47:13 AM
U-boat watch for sale
Graham November 17th, 2009 10:48:46 AM
Tiffany Bracelets replica
Tiffany Rings replica November 17th, 2009 11:07:30 AM
“Marriage bridal gown world pictures pictures of wanted to plan a happy surprise, a number of wedding photography studio is the purpose of holding more money ‘Kengren’, they set a ‘trap’ let you keep track of.” Wedding photos has just finished a small selection mother told the journalists, was originally a good original price 7999 yuan Zhao Shuren said that the wedding package, less than 2,000 yuan only to 5999 yuan.
bridal November 23rd, 2009 11:54:49 PM
Jimmy Choo Handbags
Jimmy Choo Shoes
Jimmy Choo Handbags November 25th, 2009 11:55:26 AM
cheap Christian Louboutin Boot
cheap Christian Louboutin Pump
cheap Christian Louboutin Pump November 25th, 2009 11:55:52 AM
Hublot watch for sale
Christian Louboutin Slingbacks on sale
Hublot watch for sale November 29th, 2009 08:40:20 AM
nfl jerseys cheap
nfl jerseys wholesale
nflboy December 2nd, 2009 09:37:46 PM
iPod to iPod Transfer is best software. Have you been botherring by how to transfer songs/movies from one iPod to the other one? In fact, nowdays, it is rare to find such a tool which can transfer iPod to iPod directly. However, here this wonderful iPod to iPod Transfer can provide you a quite new but easy and effective way to transfer iPod to iPod. After only a few clicks, you can easily backup you files form your iPod to PC and then it is very easy to transfer them to your another iPod.With this iPod to iPod Transfer, you can perfectly and quickly finish the transferring process as fast as you can imagine, with wonderful output quality.
cynthiachen December 22nd, 2009 09:57:50 PM
links of london
links of london January 21st, 2010 05:36:49 AM
Thank you so much for this post, it is very kind of you!
Blu-ray Ripper is an excellent Blu-ray disc ripper and Blu-ray movie ripper, that can help you rip movies from Blu-ray disc and convert to all popular video formats stored on your computer. You can also use it to rip Blu-ray into iTunes for your easy management and watching on iPod, iPhone, etc.
more info:http://www.bluray-hd.net/
sadha January 21st, 2010 09:46:57 PM
Add Commment