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Sunday, June 30, 2013

Politically Incorrect Rant On Breeder Advice

Warning: This blog post will offend breeders. Read at your own risk.

In every professional field there are groups that butt heads. Architects and engineers, artists and art gallery managers; the relationship between breeders and veterinarians is no exception.  I recently had a client make a very interesting comment that her dog was having diarrhea in the warmer weather to cool itself off.  When I asked why the owner thought this, the owner replied, "oh the breeder told me." When I tried to discuss the chronic diarrhea and low body condition score, the owner got very defensive and insisted her dog was eating fine and had no issues.

To many owners, the breeders' knowledge is gold. To many veterinarians, the breeder is NOT a medically trained professional who pursued 8+ years advanced education. We, as veterinarians, must spend a lot of our time re-educating owners and explaining the truth behind what they already believe. Needless to say, this can make our already challenging jobs, even more demanding.

Responsible breeders who believe in the welfare of their animals and are not out for just a pretty penny, can really have an impact on wellness care for the life of that animal. Unfortunately, not all breeders take the time to work with veterinarians to educate themselves, thereby the owners. Many rely on Dr. Google.  For example, many breeders do not follow recommended deworming protocols and do not inform the owner that deworming needs to occur multiple times. For many owners, their understanding is "my pet was dewormed, so how could they have intestinal parasites?" There is also a lot of circulation of information against spaying and neutering, including waiting until the animal is older. For dogs, spaying before their first heat significantly reduces the risks of ovarian and mammary cancer. With each heat cycle, however, that benefit declines. While there is debate, even among veterinary professionals, among the best time to spay/neuter, the full story is not always communicated to owners. Often, breeders recommend not fixing an animal or waiting too long.

Then there is the issue of vaccines. Unfortunately in Arizona, parvovirus and distemper virus are current infectious diseases. These diseases are essentially eradicated in certain geographic areas, where the majority of dogs receive the proper vaccination protocols. In Arizona, however, so many dogs do not receive the full puppy series or not vaccinated by a veterinarian and these diseases are all too common. While not all the blame relies on the breeder, it is the informed owners fault if they were told to have the next vaccine in x weeks with your veterinarian- not a feed store vaccine. I have seen expensive bulldogs and pure bred cats, that have never been to a veterinarian for an exam, much less a vaccination, because the owner can just call the breeder for advice.

Like any conflict, the welfare of the subject would be better served if both sides tried to make things right. Many veterinarians work with breeders closely and help educate them, to which some breeders are responsive.

Regrettably, in my experience, many breeders use Dr. Google to inform an owner not to seek a veterinary consult regarding chronic diarrhea and poor weight gain; it probably just is a cooling mechanism.

Wednesday, June 26, 2013

Veterinary Internships Part 1- To sacrifice or not to sacrifice

Many current veterinary students have to face the looming question of whether or not to pursue an internship after graduation. Wait a second I have my DVM degree, can't I just start practicing? Indeed you can, but internships have become more popular for clinics and students. For the graduating new veterinarian an internship has pros and cons that need to be weighed before making this major decision. In this post, I will break the answer down from simplest to most complicated situation. In a follow-up post, I will discuss what an internship is like, based upon my actual experience.

Scenario 1: If as a student you know for certain that you want to specialize and embark on the journey to become a veterinary surgeon or oncologist, etc. this is your only option.  There is no need to read any further.

Scenario 2: If you think you may want to specialize, but you are not 100% sure, you should probably complete an internship. Once you practice full-time, regressing to an intern salary will prove more difficult, as will being a student vs. practitioner. Some internships, many in fact, allow you to be your own practitioner with guidance as needed. However, there is always some hazing/unfairness in being an intern and not an associate. Completing an internship may also provide the information you need to make your next career move. Many internships rotate through the specialities and have elective time. These opportunities would give you a chance to decide if you want to specialize. These opportunities may also provide good references and potential mentorship opportunities for your future specialization. It may even open a door to a specialization internship- the new wave in the long road to a veterinary specialty.

Scenario 3: I want to go to into emergency medicine. The simple answer used to be: complete a small animal internship. This is the path that I chose. I chose this path because I exclusively wanted to work in emergency and most of the larger small animal emergency hospitals n major metropolitan areas only hire internship-trained veterinarians, and occasionally will hire seasoned general practitioners. I was not taking any chances. I also have toyed with the idea of doing a critical care residency (see scenario 2).  My experience was difficult, but worthwhile. When it came time to apply for a job in a new state, I was a very competitive candidiate because of my internship experience.

The flip side to this story is that at least 3 of my classmates found positions with good mentoring in emergency clinics as their first or second job. They also have now received more surgical experience then I have. The risk you take is the question of good mentorship, I am not a risk taker, but if you are and are willing to weigh your options, completing an internship is not a requirement for a position in small animal emergency.  It does provide a competitive advantage in a tight job market. You must also consider I made a 1/3rd of my current salary during my internship year, so there is an opportunity cost.

Scenario 4: I want more mentorship and experience prior to becoming an associate. This is where the question becomes harder and will be different for every person. For many graduating students, jumping into practice is scary and they do not feel they are ready.  You are more ready than you think, however the first 3-6 months is tough with or without an internship.

The cons of doing an internship in this situation are:

  • opportunity cost, less earning potential your first year
    • There is little evidence to support you will make more money as an associate after completing an internship, but depending on your field and the job market you may have a competitive advantage.
  • spending time doing emergency medicine if you don't like it- this can be brutal
  • longer hours
  • more learning/research based, especially if you are at a university
  • less surgical experience
  • One more year at the bottom of the veterinary food chain- ego's can take a beating
The pros of doing an internship in this situation are: 
  • Depending on your field and the job market you may have a competitive advantage upon completion. Some practice owners prefer non-internship trained students, so they can be modled. Others prefer internship trained and find the associates more seasoned, stronger medically, and more efficient.
  • Keeps the door open for a specialty.
  • Guaranteed mentorship, although this will differ in style by program.
  • The first few months may be tougher, but you will edge up the learning curve faster than your peers. This is important to some people but in no way a requirement.
  • More time to explore specialized interests in veterinary medicine.
This debate rages on, as more students have been selecting internships post-graduation. The AVMA’s 2011 survey found that, of about 1,540 graduates who had accepted employment offers, 700 had accepted internships, according to JAVMA. The 2009 survey indicated that, of 1,525 graduates who had accepted a position, 600 had accepted internships. 

Source: American Association of Veterinary Clinicians

Based on AVMA data, the average internship salary is $25,000 annually versus $65,000 mean starting salary for all veterinary employment types. 

In conclusion, there is no black and white answer for scenario 4. My best advice is to know yourself and do your research. Consider the financial and career implications in order to make the best decision.

Friday, June 21, 2013

Quick Post: Top 10 Small Animal Conditions

While I am working on my internship guide blog series, I wanted to post a list of the Top 10 conditions for dogs and cats to quickly get in my weekly post. The list is compiled from Veterinary Pet Insurance Co. (VPI) based on their policy claims for 2012. It is important for pet owners and veterinarians to familiarize themselves with the most common medical conditions, most of which can occur in any pet.

Top 10 Canine Conditions:
1. Skin Allergies (my mixed breed dog has skin allergies, so breed selection won't get you out of this one). average cost $96/visit
2. Ear Infection...good old otitis externa- also allergy related
3. Skin Infection
4. Non-cancerous Skin Growth- so dermatology is almost 50% of medical conditions in dogs...yup?!
5. Vomiting
6. Arthritis- average cost $260/visit
7. Diarrhea
8. Urinary Tract Infection
9. Dental Disease
10. Bruise or Contusion

Top 10 Feline Conditions:
1. Bladder Infection- I assume this is more likely urinary signs related to Feline Cystitis. Average claim cost $251/visit. This typically involves checking kidney values, x-rays to screen for bladder stones, a urinalysis and medications.
2. Dental Disease
3. Hyperthyroid- typically occurs in middle aged to older cats
4. Chronic Kidney Disease- typically occurs in middle aged to older cats
5. Vomiting
6. Diabetes Mellitus- typically occurs in middle aged to older overweight cats
7. Diarrhea
8. Skin Allergies- okay so not the top 4 but still very common in our kitties
9. Lymphoma (cancer)- can occur at any age and affect the GI tract, nervous system, lymph nodes
10. Upper Respiratory Tract Infection- usually due to herpesvirus, calicivirus or secondary bacterial infection.

Many of these issues are chronic and can be frustrating to treat if they recur. This would be a good list to share with new dog/cat owners and to remind frustrated clients currently treating these diseases. Luckily, because they are common new treatments are constantly being researched.

Thursday, June 6, 2013

Humane Euthanasia: The Gray Zone

One of my recent emergency shifts was what we in business reluctantly call"one of those shifts." This is a shift in which almost every patient that walks through the door is here for euthanasia, or PTS (put-to-sleep) for those in the jargon know. Nights like these, no matter how the end result may benefit the owner and/or the pet, take an emotional toll on the staff and myself. The term for this is empathy fatigue.

What tends to bother me the most is when it is a problem that goes undiagnosed, but the owner feels the patient is older and usually states, "while it's not the money, I just don't want to put him through testing when we don't know how much longer he has." While that makes sense to me emotionally, as a doctor, I want to find out more. I have a need to form a diagnosis in an attempt to treat and provide a prognosis.   I also feel that maybe we owe it to the pet to try some therapies, if the condition is treatable and the animal is not currently suffering, prior to ending a life. By offering diagnostics, I hope to give the client as much important information as possible to make an informed decision. The conflict arises because the amount of information needed is a personal choice and differs for everyone; and, ultimately the owner determines the right time for an animal to pass on.

If a client has a 13 year old dog and the dog started having some respiratory issues that clinically appear mild and a low grade heart murmur is detected, is that cause in itself for euthanasia without taking x-rays?  What about if, in addition to those signs, the owner may have to undergo a long distance move?

If we suspect strongly that a portosystemic shunt is the cause of persistent hypoglycemia that is difficult to manage, is it time to give up on that puppy prior to definitive diagnosis with an ultrasound?

Some clients worry about what they will find out and prefer to remember their pet in their best condition and accept the inevitable. So where do we draw the line between treating too aggressively and not treating enough? When is the right time to let our best friend go, and when is humane euthanasia an opt out card versus a means to end suffering? These are very real and permanent choices and questions we must face as part of being a responsible and caring pet owner.  There is, of course, no right or wrong answer. However, I know after nights of numerous euthanasias I start to wonder what my role should be in the decision process.

As a veterinarian, clients will ask you all the time, (especially with respect to humane euthanasia) what would you do if this was your pet? The truth is they usually already have a decision made and sometimes your job is to support them.  After all, it is their pet, their loved one, their choice...or should it always be?