Equine practice has a reputation for being the most litigious discipline of veterinary medicine, and within that the pre-purchase examination remains at the forefront of practitioners' minds. It remains true that around two thirds of all equine claims made to the Veterinary Defence Society (VDS) arise from pre-purchase examinations; and while relatively few complaints made to the Royal College of Veteirnary Surgeons relate to equine work, pre-purchase examination issues account for around a third of those made (Stephenson, 2015; T Brazil, personal communication, 2021). Furthermore, additional pressures outside of formal complaint procedures have developed by way of social media, which enables today's blame and compensation cultures. Perceived or actual case mismanagement is readily aired online and rapidly disseminated as ‘urban legend’, often before the clinician is even aware of the specific issue, let alone has a chance to respond.
The pre-purchase examination process has not changed over the past few decades, while people's expectations of both guarantees of outcome and speed of reporting have altered significantly. Couple this with an explosion of technologies available and the result is an increasing number of pitfalls to navigate.
A survey of UK doctors revealed that 55% feel they will be blamed unfairly for errors and 49% declared they practise defensively (Wise, 2018). Although no similar evidence is currently available in the veterinary sector, there is a longstanding awareness of vets practising defensive medicine (Anon, 1984). Sadly, this supports the equine owner's perception of the veterinary surgeon's attitude to the pre-purchase examination: that we are there to ‘find fault’ with the horse and perhaps even, find a reason to justify ‘failing’ the horse, rather than conclude that it is suitable for the purchaser's intended use. As in all aspects of practice, clinical diligence and clear, well-documented communication are essential and serve as a proactive means of mitigating the risks of complaints arising.
Clinicians need to have confidence in assessing the level of risk attributable to their findings and communicate them to their client, so that the client can decide whether to accept the level of risk and proceed with the purchase or not.
Effective communication underpins a successful pre-purchase examination and often lies at the heart of the matter in a complaint (Moyer and Werner, 1999; Brazil, 2021). The pre-purchase examination is associated with several tiers of communication involving multiple people, and managing each of these tiers is essential to ensure a successful experience for both clinician and client.
First point of contact
Practices must have a clear booking policy and reception staff should be suitably experienced to manage PPE enquiries in a timely fashion, as this is an increasingly complex role (Werner, 2015a; 2015b). Failing to gather all the essential information during the initial enquiry can result in errors. Establishing accurate vendor, purchaser and horse details is essential and can be easier said than done. Similarly, yard addresses are often given in place of the vendor's home address; an important distinction for the pre-purchase examination certificate. It is valuable to have a pre-purchase examination proforma on which to record all the necessary details of purchaser, vendor and the horse to pass on for the vet to review. It can also act as a checklist to ensure that the facilities required to carry out the pre-purchase examination will be available on the day. Likewise, clients requesting a limited pre-purchase examination should have the limitations explained and informed consent sought in writing by way of a letter of request (VDS, 2020).
A clear strategy should be in place for managing scenarios such as undertaking a pre-purchase examination where the vendor is or has been a client of the practice, or booking a pre-purchase examination for a vet who has a personal relationship with the vendor and/or agent. If the veterinary surgeon or their practice has any knowledge or clinical history of the horse then, with the vendor's permission, this must be disclosed to the purchaser before the pre-purchase examination. If the vendor declines to give permission for disclosure then the veterinary surgeon can not carry out the pre-purchase examination. While it is advisable to decline carrying out a pre-purchase examination in these circumstances there are certainly situations in which such pre-purchase examinations are performed (Stephenson, 2015; British Equine Veterinary Assocation, 2018; RCVS, 2020). Vets must be mindful of both actual or perceived conflict of interest. If in doubt as to whether a factor is a potential conflict of interest then it is better to disclose it and reassure the purchaser that you are acting independently on behalf of them.
The horse must be located in a facility appropriate to enable a complete and thorough pre-purchase examination. The author prefers requirements to be conveyed directly to the person presenting the horse; be it vendor, agent or purchaser. This way limitations can be identified and discussed ahead of time, preventing omissions of parts of the pre-purchase examination deemed essential by both vet and purchaser. For example, there may not be a suitable area of hard ground on which to lunge the horse. In such cases, prior knowledge of this allows the vet and purchaser to discuss the merits of lungeing on a firm surface and provides the opportunity to arrange the pre-purchase examination at an alternative location. The use of a proforma and thorough communication before the pre-purchase examination prevents firefighting issues that inevitably end in compromising the pre-purchase examination and discontent for all parties.
Establishing a rapport
The art of the pre-purchase examination lies in establishing a rapport with the purchaser, who is often unknown, and in current times not present at the examination itself. For existing clients well-known to the clinician, this may be by way of a brief telephone conversation to confirm that your understanding of their requirements is in line with theirs. This is more challenging for remote clients, yet building this relationship before the pre-purchase examination is vital for a successful outcome (Miller, 2015; Morley, 2017). Direct communication allows the client's expectations to be managed from the outset (Brazil, 2021). It is valuable to discuss the pre-purchase examination process itself, and the value and limitations of any additional diagnostic techniques, should they be relevant. Realistic timescales should be provided and adhered to for communicating the veterinary opinion and written report(s) after the pre-purchase examination. Furthermore, the method of communication following examination should be discussed. It is often best to send a brief message after completing the pre-purchase examination providing a summary and realistic time for further communication to take place, rather than inviting misunderstanding and confusion.
Any concerns that the purchaser may have should be documented at first contact, although this is often asked as a closed question and the information given is not as helpful when the horse is being sold unseen, an increasingly common situation in the wake of COVID-19. It is useful to ask the purchaser not only if they have concerns regarding this horse specifically, but also if there are other conditions of particular concern to them. For example, a sarcoid located on the sheath would not preclude the horse from being suitable for endurance activities; however, it is not uncommon for the presence of sarcoids to be a dealbreaker regardless of their location. Pursuing a full PPE without notifying the purchaser once the lesion is identified would likely lead to dissatisfaction, particularly if a reduced fee would apply should the pre-purchase examination be aborted at the preliminary stages.
The author's aim is to approach a pre-purchase examination through the eyes of the purchaser, so that the final opinion is aligned with theirs. To achieve this it is fundamental to fully understand their requirements: from the rider's current experience to their end goals, the discipline and level in which the horse will be working; as well as the purchaser's view of the horse's most important attributes. This lays the groundwork for communication during and after the pre-purchase examination, particularly if there are concerns to raise. It is impossible to advise the client on the risks of purchasing the horse if their expectations of the horse and their attitude to risk is unknown (Mitchell and Dyson, 2011). This conversation also enables the clinician to find a communication style suited to the individual purchaser. The ability to recognise and adjust communication styles rapidly is a valuable skill, essential to ensure important information is delivered effectively in the future.
Establishing boundaries
Finally, this is a useful time to establish consent on disclosure of information found during the pre-purchase examination to the vendor or agents. It must be remembered that the clinical information found during the pre-purchase examination belongs to your client (the purchaser), and not the vendor/agent. It is helpful to ascertain the degree to which the purchaser wishes the clinical findings of the pre-purchase examination to be communicated to the vendor/agent. In the author's experience, purchasers often consent to some communication between the vet and vendor, but without clearly defined boundaries this can easily result in conflict. It is preferable for the purchaser to be present at the vetting, so that immediate communication is possible, but this is increasingly uncommon. The ability to be able to mention clinical findings, but not an opinion about them, with the vendor/agent can be very useful during the pre-purchase examination; and if carefully undertaken helps avoid misunderstandings or veterinary opinion being used inappropriately as a bargaining chip during the purchase negotiation. For example, stating the need to discuss a skin lesion with the purchaser signposts the finding warrants consideration, but cannot be misconstrued. Casual comments during an examination may be perceived as reporting and should be avoided (Moyer and Werner, 1999; Karpinski, 2004). The final interpretation of clinical findings can only be fully established following discussion with the purchaser; passing of opinion to the vendor/agent before this is poor practice and will likely end in conflict with either or both parties (Moyer and Werner, 1999). It is useful therefore, to create ‘exit strategies’ to use when concluding a pre-purchase examination (Box 1), particularly if the exam is aborted because of clinical concerns, as the vendor/agent will try to solicit information. While the vendor is not entitled to any feedback, leaving without comment is uncomfortable and does little for professional relations, so it is useful to establish what communication is acceptable in advance (Stephenson, 2015).
Box 1.Exit strategies for concluding pre-purchase examinations
- The no comment exit. Courteously ending the pre-purchase examination by stating ‘that concludes my examination for today’ or similar and thanking the vendor or agent for their time.
- The gentle equiry exit. Often useful when vendors ask if anything of concern has been found. The vendor is reassured that the potential purchaser will be encouraged to contact them as soon as they have reached their final decision following discussion of the pre-purchase examination. A reminder is also given that in any given pre-purchase examination it is exceptionally uncommon to find no areas worthy of discussion and that only the purchaser understands their own individual level of risk acceptance.
- The mid-point exit. In many cases the vendor or agent also recognises a problem and halting the pre-purchase examination is mutually accepted. The examination is paused to make contact with the potential purchaser from the yard at that point to dicsuss concerns in private. The author prefers to gain consent to discuss the concern with the vendor or agent, as well as direction to continue or end the pre-purchase examination. In circumstances where the purchaser is not contactable, or advises you not to discuss the findings, but it is clear the horse is unsuitable, the author reverts to the no comment exit strategy. In these circumstances it is not uncommon for the vendor or agent to push for further information. A continued, firm reminder that examination findings are confidential to purchaser and only interpreted following joint disucssion with a final ‘thank you once again, I'll not take up any more of your time’ style statement is generally effective. worthy of discussion and that only the purchaser understands their own individual level of risk acceptance.
Pre-purchase examinations in the 21st century
Perhaps of more interest is the role technology plays in the pre-purchase examination. Social media represents the leading platform for equine sales and, in recent times, more horses are being bought based on video and photography than ever before.
Photographs
It is commonplace to be bombarded with dozens of videos of variable quality from clients showing prospective purchases and requesting veterinary interpretation and opinion, before a PPE has been requested. Inevitably, there are concerns that should an issue arise following a pre-purchase examination and successful purchase, a video is presented by the disgruntled client as evidence of a pre-existing problem. It can be prudent to discuss whether any video has been taken or seen by the prospective purchaser in communications before the pre-purchase examination taking place. This is an extra task for clinicians to complete in already overloaded days, but forewarned is forearmed. Certainly, in the author's experience, reviewing footage that is of suitable quality can be helpful in screening for orthopaedic issues in particular, saving time vetting an unsound horse and bonding the client further by saving unnecessary financial expenditure. Equally, reviewing photographs of lesions giving cause for concern is worthwhile and may influence interpretation of certain aspects of the pre-purchase examination, and/or help recommend further diagnostic evaluation (Figures 1 and 2). In an age of increasing telemedicine, consideration will need to be given as to whether the time spent reviewing videos and photographs should be part of the normal fee for a pre-purchase examination or whether there should be an increased fee levied.
Radiography
Additional diagnostic techniques have played a role in pre-purchase examination for many decades and radiography is known to directly affect both sale outcome and purchase price (Bladon and Main, 2003; van Hoogmoed et al, 2003). Buying horses solely based on radiographic examination is increasingly popular, particularly in certain disciplines, such as showjumping. Consequently, requests from purchasers to screen radiographs they have obtained from the vendor are common. This area is of particular concern, as without concurrent clinical examination, it is hard to qualify the relevance of radiographic findings and their prognostic value (Werner, 2017). Amateur purchasers in particular have been reported to misunderstand radiography as a reliable prognosis for future competition success (Hellige, 2021). Radiography may be useful in screening for certain conditions, such as osteochondrosis dissecans; however, other radiographic findings, like navicular changes, are not prognostic for future lameness (Ramey, 1994; van Hoogmoed et al, 2003; Vos, 2008).
Furthermore, it is likely that the same radiographs will be sent to other veterinarians and several opinions obtained. Interrater agreement on mild-to-moderate radiographic findings is poor, despite being good for overall grading, which opens individuals up to conflict (Hellige et al, 2018). This is especially true where clinicians are asked to give informal opinions on incomplete sets of images, or radiographs of variable quality: a request that is best declined. If images are reviewed one must make sure that they are correctly labelled, including the horse's name and the date taken. It is more prudent to generate a written report documenting radiographic findings specifically, rather than prognosticate on athletic performance, since the relevance of findings to future prognosis is questionable, particularly in sports horses (Hellige, 2021). If a horse is to be insured then one must advise the purchaser that it is likely that the insurance company will request the images are sent to their veterinary advisor for review with regard to whether any exclusions will be applied to an insurance policy.
Video
In the author's experience, videoing sections of the pre-purchase examination, particularly the orthopaedic evaluation, is becoming increasingly commonplace by both purchasers and vendors. It is important to establish consent for acquisition of media and, as such, the clinician should be asked for permission. Declining consent is likely to raise suspicion; however, it is perfectly reasonable to do so. It is important to acknowledge that once consent is given, the footage is within the public domain and is subject to ongoing review and opinion. Similarly, purchasers may request that aspects of the pre-purchase examination, such as flexion tests, are videoed when they are unavailable to attend. Consent must be obtained from the vendor and/or agent, and it is worth considering the logistics of acquiring footage without distracting from the examination at hand. It is sensible in such circumstances to take an assistant to acquire high-quality footage on the clinician's behalf. Caveats must be applied to limitations of media. For example, factors affected by individual methods when performing flexion tests include duration, where the limb is held, the force applied and interpretation of the effect on gait, which may not be captured on video. This is also worth considering if asked to review footage provided by the purchaser as a third party.
Phones
Mobile apps allow immediate sharing of photographs of lesions causing concern during the pre-purchase examination, to enable decision making. Uploading relevant images to clinical records and attaching them to the pre-purchase examination certificate provides increasingly accurate recording of clinical findings, and may be useful in controversial findings, for example in cases of occult sarcoids (Figure 3).
One challenge associated with mobile phones providing the constant ability to communicate is the temptation to embark on important discussions regarding the pre-purchase examination as soon as it is completed, while in the car. Of course, while this may appear to reflect excellent client service, calls made while driving are fraught with pitfalls, resulting from poor signal hampering communication. It is impossible to know what information has been received and understood, with an all-to-real possibility of errors occurring, resulting in dismay and grievances once the pre-purchase examination certificate arrives.
Conclusions
Clinical diligence, accurate documenting and timely reporting of clinical findings remain vital in avoiding complaints arising from a pre-purchase examination. It is important to remember that the purchaser is your client on the day, but also to acknowledge disappointment for both vendor and purchaser in an unsuccessful pre-purchase examination, so empathetic, clear communication is essential. It is important to keep an open mind, yet remain focussed on the specific requirements of the client to achieve the best outcome: a satisfied client with an appropriate horse for their intended use. Finally, today's and future technologies must be embraced and the pre-purchase examination process should evolve alongside them. Clinicians can remain mindful of their benefits and limitations.
KEY POINTS
- Communication is key. Open lines of communication with the purchaser ahead of time to build a rapport and understand their requirements and concerns.
- Do not be afraid to decline to perform the pre-purchase examination if there is the potential for conflict.
- The use of a well-formatted proforma helps ensure that all required information is documented and provides a checklist to ensure that all necessary communications and arrangements have been completed before the pre-purchase examination takes place.
- Document all potentially significant clinical findings and relevant known clinical history on the pre-purchase examination certificate.
- Avoid expressing any opinions on findings with the vendor at the time of the pre-purchase examination and without the purchaser's permission.
- If images of significant lesions have been acquired, consider attaching them to the pre-purchase examination certificate.