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Friday, December 2, 2016

A Client Apologized

A few weeks ago I had a client do something that has never happened to me in almost 20 years of practice.  She apologized for her behavior.
Vets are often faced with rude, thick-headed, or just difficult clients.  Most of us realize that this is part of working with people and most of those clients aren't intentionally causing problems.  We don't enjoy those kinds of people as it makes communication and treatment much more difficult.  But we learn how to handle it and how to continue caring for that client's pets.  Sometimes a client becomes very belligerent, unreasonable, or a general pain in the tush.  If the person is beyond the norm in their behaviors many vets will politely but firmly let that client know that they should seek veterinary care elsewhere.  While we can be used to tricky interpersonal situations, we're not psychologists and don't get paid enough to put up with anything that the worst client can throw at us.
Let's call my client Ms. A.  She is a long-term client of mine and I've cared for her pets for several years, being the preferred doctor when she comes in.  In October I saw her dog for some skin issues, and not serious ones.  I vaguely remember her being worried and asking some very pointed questions, even repeating them and saying "are you sure?"  But overall I didn't think much of it.  She can be a slightly difficult person, but well within reasonable limits and I've learned to have patience with her because she really does care about her animals. 
She came in for a follow-up visit and I was happy to see that her dog was much better and the problem had completely resolved.  As we were finishing up she asked my tech if she could speak to me alone.  That sent up some red flags!  I have never had a client do that, and I immediately started worrying and trying to figure out why she needed just me in the room.  I considered that there were problems with my staff, that she was angry at me, and a whole list of bad situations.  I was completely unprepared for what happened next.
"Dr. Bern, I need to apologize to you for my behavior last visit.  I was a real jerk."
I swear I think my jaw dropped open.  That was definitely not what I was expecting to hear!  And I started going through my memories to try and figure out what in the world she was talking about.  As I thought back to the previous visit I honestly couldn't remember her being a problem, and definitely not something that needed an apology.
I told her that and she thought I was just being nice.  I had to really firmly let her know that I couldn't remember anything bad that she had said or did, and emphasize that if I couldn't remember it then the incident must not have been a real problem.  She appreciated that but continued to explain and say how sorry she was for her attitude, as I've always done such a great job of caring for her pets and listening to her.
We talked for a bit, I assured her that there were no problems at my end, and we hugged it out.  I walked out of the room and explained it to my tech, who had also been wondering why she was asked to leave.
Over my career I've had numerous clients who really did owe me an apology.  I've been yelled at, cursed at, called names, blamed for every problem under the sun, and generally been treated by dirt.  Thankfully these bad clients are few and far between, otherwise I probably wouldn't be able to keep working in this field.  Most of my clients are wonderful and appreciative of our care.  But many of those difficult clients really did act impolitely and unreasonably, completely out of the realm of normal reactions.  Yet with all of those people I have never had a single one apologize.
Now I've had a client apologize for an attitude that I can't even remember! 
I told her how much I appreciated her and her apology, even if I couldn't recall any of the specifics and it didn't stand out in my mind.  Too many people don't take personal responsibility for their actions, and always try to blame someone else.  Ms. A absolutely sucked it up and put herself in a vulnerable position because she felt it was the right thing to do.  That amazed me and restored some of my faith in humanity.  And I'll be happy to put up with her in the future if she continues to have this attitude about herself.  A great client and one of the most positive experiences I've ever had.

Tuesday, November 29, 2016

Are "Prescription" Diets Really By Prescription?

As a follow-up to the last two posts I've made on "prescription" foods, I wanted to add this topic.  It's actually something that is currently being debated by the profession for various reasons and there is misinformation out there.  In fact, astute readers may have noticed that I've frequently put the word prescription in quotation marks over the last week of posts.  My discussion is going to focus on the US, even though I have an international readership, because I know US laws and not ones in other countries.
To begin, "by prescription" really does have a definition.  Each state has their own laws so there are essentially around 50 different variations on the theme, but there are a lot of similarities.  The basic idea is that there are certain medications that have been established by the Food and Drug Administration (FDA) as requiring a prescription from a licensed doctor.  Without that prescription you cannot purchase the medication or product.  States typically require a prescription to be written by a licensed doctor that has a valid client-patient-doctor relationship with that person or pet.  The specifics may vary, but essentially the doctor must have personally seen the patient within at least the last 6-12 months and be familiar with their medical conditions and history.  Over time some prescription-only medications can be approved for over-the-counter use, such as many antihistamines and stomach acid reducers.  Whether or not a drug is by prescription is determined by the FDA, and what is required to issue a prescription is determined by the state.
What about "prescription" foods as produced by Hill's, Royal Canin, Eukanuba, and Purina?  Here's a shocker for you....they technically do not fall under prescription laws. 
Yes, that's right.  These "prescription diets" do not legally require a prescription.  They fall into a gray area of foods and supplements that the FDA does not regulate.  It's similar to taking Echinacea for colds or St. Johns wort for depression.  The manufacturers do not specifically claim that these products treat any specific condition, and they often even say so on the label.  By not making a claim of treatment they can bypass the FDA regulations and do not have to prove their efficacy.  Any claims come by word-of-mouth between people or through books and internet sites, but not directly from the product label.
So-called prescription foods in veterinary medicine occupy the same category as vitamins and supplements for humans.  They do not go through any FDA trials or tests, and therefore do not fall under that agency's jurisdiction.  Since it's the FDA that determines whether something is dispensed by prescription, these foods technically don't need one because the FDA hasn't ruled on it.  And because they don't legally require a prescription, a valid client-patient-doctor isn't necessary.
So why do vets require a visit?  Why do vets talk about these foods as "by prescription".
Some of these diets are fine no matter the health status of the pet that eats it.  Others, however, could cause problems.  For example, diets for kidney failure have significantly low protein levels.  This is necessary to help progression of kidney disease, but it's low enough that we wouldn't want a health pet eating it.  We don't want a client picking up a food for urinary issues because their dog is peeing a lot, when in reality that dog has diabetes and should be on a much different diet.  Clients also aren't sure exactly which food they need or even have purchased in the past, so we don't want them to be able to just pick up any food and make their own judgment.
Using the wrong therapeutic diets can indeed lead to health consequences because of how highly specialized they are.  By requiring authorization from a vet both the doctor and the food manufacturer take steps to ensure that the correct food is being given to the right patient and we're not doing any harm to pets.  If someone wants to buy a therapeutic diet from my clinic we don't require that we have seen them, but we do require a written or oral confirmation from their vet as to which food is being used.
Recently the FDA has been paying more attention to these foods, since they actually are recommended and used for the treatment of diseases.  Anything with that definition must be regulated by the government, and foods currently aren't.  This is leading to discussions as to whether or not the FDA may actually start doing tests and requiring that foods follow the same laws and rules as antibiotics, antidepressants, and other medications.  If so, expect the cost of food to go up because compliance on these issues is very expensive for the manufacturer.
This increased government scrutiny has already resulted in some changes by the food companies.  For example, Royal Canin makes a diet for food allergies that breaks down the proteins into single amino acids, putting their size below the threshold that would trigger an allergy.  It used to be named Hypoallergenic, but that name implies a specific claim about the function of the food in relation to a disease.  Because that treatment claim would classify it as a medication and the Royal Canin wanted to avoid trouble with the FDA, they changed the name to Ultamino.  Same product and no change in the ingredients, but an important change to comply with prescription laws and regulations.  Several other foods have had name changes for similar reasons.
When your vet talks about a "prescription" food, realize that they are using the word loosely and probably incorrectly.  Heck, I've been doing it for 30 years, so I still fall into that habit even though I know better.  If you walk into a store or vet clinic and they don't know you, understand that they may not sell you the food, but not because of the law.  In fact, if they say that it is illegal for them to sell it to you they are absolutely wrong since it doesn't fall under prescription drug laws.  But there are darn good reasons for them not to sell it to you if they don't know the specifics of your pet's case.
Hopefully this makes sense, as it's a somewhat complex issue.

Saturday, November 26, 2016

Are There Differences Between "Prescription" And Over-The-Counter Foods? (Part 2)

My post earlier in the week was specific for one situation but opens a wider discussion.  Are there really differences between OTC foods and "prescription" foods?

The short answer is "Yes, absolutely!"
When I prescribe a specific food for a patient it is common for clients to say "Wow, that's expensive.  Isn't there anything over the counter that can do the same thing?"  And I certainly understand their concern.  Being worried about money and affording food is legitimate, as few of us are wealthy.  We do have to watch the cost of feeding our pets, and some of these therapeutic diets are two to three times as much as a "regular" bag of dog food.  So I don't take offense when a client brings up to me their financial concerns.
It's hard to make a blanket statement about how all prescription diets are different, and it would take more than a simple blog post to go into the "why" behind each and every one on the market.  But I can take a few examples as illustrations.
Foods for kidney disease are specially designed to lower the protein and improve the protein:phosphorous ratio.  There are no OTC diets with the right ratio and a low enough protein.
Dogs with recurrent pancreatitis need to be on an extremely low fat diet to help lower the risk of future episodes.  OTC diets aren't low enough in fat.  In fact, the labels only give maximum and minimum percentages for things like fat, so you can't even tell the exact amount in a food without contacting the manufacturer.
Dogs and cats who have had bladder or kidney stones need to be on a urinary diet that will properly regulate the pH of the urine, lower certain minerals, and promote drinking to ensure dilute urine production.  There are no OTC foods that will do all of these things.
Animals with severe food allergies need to be on extremely restricted diets which avoid certain ingredients.  Currently most OTC foods don't have significant enough restriction and could cause trace ingredients.  Severely allergic animals may need to be on a food that not only limits ingredients but also breaks down the proteins into smaller chains (hydrolyzed) or single amino acids in order to prevent a reaction.  There are no OTC foods that process the proteins in those ways.
Like diabetic humans, dogs and cats with diabetes need dietary regulation, especially with a high protein to carbohydrate ratio.  OTC diets don't achieve the same ratio and are worse at regulating blood glucose levels.
As you can see from just a few examples there really are significant differences between these prescription diets and what people typically feed their pets.  When comparing virtually every therapeutic food there simply are no cheaper foods that achieve the same results.  So that cat with kidney failure, the schnauzer with pancreatitis, or the bulldog with food allergies really do need to be eating a food that a client can't get other than through a vet.  There are decades of research to show the importance of these foods compared to "normal" pet foods. 
The ancient Greek, Hippocrates, is famously quoted as saying "Let food be thy medicine and medicine be thy food."  He was referring to using the right kinds of foods as a central part of treating diseases, and no modern doctor would disagree.  The same principle applies with pet foods.  I have successfully treated many disorders by placing the pet on very specific diets and did not have to give medicine to some of them.  Think about that for a moment...what do you think would be better?  To give the dog pills twice daily every day for its life, or to feed it a specialized food for the rest of its life?  Which is healthier?  Which will have fewer side effects?  Which will be easier for you and the dog?
Yes, prescription diets are much more expensive than other foods.  But pet owners have to stop thinking about them as merely food.  They are an essential part of medical treatment and are usually not recommended lightly.  Sometimes it comes down to spending $90 per month for a bag of food, or $40 for food plus $60 for medications.  Suddenly that expensive food doesn't seem so unreasonable, right?
If your vet recommends an expensive prescription food, it is usually for a very good reason and I recommend following their advice.  It is fine to ask if there are other options, but the likelihood is that there are no other comparable OTC foods and you could be delaying or preventing adequate treatment by using a cheaper diet.

Thursday, November 24, 2016

Happy Thanksgiving

Today here in the US we celebrate Thanksgiving Day, which is supposed to be a time to reflect and give thanks for what we have.  In reality it ends up being an opportunity to spend time with family and eat lots of food!  And as it does every few years today coincides with my daughter's birthday (she is 14 today).

I hope that everyone does pause to count their blessings and give thanks for what they have.  I hope all of my readers have an enjoyable day and truly can give thanks for many things.

P.S.:  Indulge in food for yourself, but please don't share Thanksgiving goodies with your pet or you may end up at the vet soon.

Monday, November 21, 2016

Are There Differences Between "Prescription" And Over-The-Counter Foods? (Part 1)

Recently I received a great question from a reader:
One of our cats was recently put on a novel-protein diet for IBD, in addition to prednisolone.  He's been responding well to the steroids, and we just put him on the new diet today.
The diet prescribed was Royal Canin PV, which is Venison and Pea, and goes for the lovely sum of $67/8lb bag.
I see that Natural Balance also has a Limited Ingredient Diet Venison and Pea dry formula, and the ingredient list is awful similar.  Is there any significant difference between the two, other than the Natural Balance being $40 cheaper?
Many food companies have realized that the "prescription" veterinary diets are a huge revenue opportunity.  Therefore some of them are trying to develop OTC foods that are supposedly comparable to the veterinary ones as a way to capture a share of that market.  While I understand this from a business perspective and don't fault them for wanting to increase their corporate revenues, it does cause confusion among pet owners and difficulty for vets.  But the OTC foods are not always comparable to the veterinary ones. 
Royal Canin, Hills, Purina, and Eukanuba all make veterinary-specific diets for use in treating various medical conditions.  Inflammatory bowel disease (IBD) is a common one that needs a change in food, as it is often related to a sensitivity to ingredients (typically proteins, but secondarily carbohydrates).  Because these ingredients are not brand-specific we look at changing to "novel" foods, which means foods containing ingredients to which the pet has not previously been exposed.  In the above case the protein comes from venison and the carbohydrates from peas.  For a truly novel food you want to avoid other major ingredients, especially the protein.  In order for a diet to qualify as "limited ingredient" you want single sources of proteins and also ideally carbohydrates.
I compared the ingredients of both the Royal Canin PV and the Natural Balance LID Venison and Pea.  Both of them pass the "limited ingredient" test, as both rely only on venison for protein and pea as the major carbohydrate.  But there are some slight differences in minor ingredients, though none that I can see will make a huge difference in the nutrition of the diet.  One thing that Royal Canin has is some added fish oil.  The omega fatty acids in fish oils are a natural anti-inflammatory so they can be a great additive to cases like this.
On the surface it looks like these two foods are nearly identical.  However, there is another consideration that is not obvious, and there is no way tell from the packaging.....quality control.

With veterinary-specific diets the manufacturers spend a lot of time and money to ensure that other trace ingredients don't get into the mixture.  OTC diets may not have those same quality controls.  Ingredients must be listed by pre-cooked weight, but when you get to trace ingredients you may not have them listed because they are below a certain threshold.  What this means is that if there are minute amount of ingredients not listed on the label, that is allowable.  The more expensive diets are very careful to keep these trace ingredients out of the diet, while OTC diets typically don't care about them and may include them.
Why is this an important distinction?  Think about someone with a severe peanut allergy.  These people can't eat anything that has even touched nuts, whether or not it is an ingredient.  A food prepared on a counter that had previously had nuts on it could trigger an allergy.  Some people are so sensitive that even the nut dust being in the air is enough to cause a reaction.  While not common, some pets are similarly sensitive to even trace ingredients that wouldn't be on the label.

When these questions come up with my own clients I typically recommend feeding only the veterinary diet until the pet is stable for several months.  Once we have achieved effective control we may discuss trying a comparable OTC diet and watching for a reaction.  If there is no reaction we can use the less expensive diet.  If there is a return of symptoms we have to go back to the veterinary one. 
Remember that when using these very specialized foods you are not just providing nutrition.  These are being used as medical therapy.  You need to look at these foods in the same way that you would consider pills, capsules, and other medications.
Before making any food switches be sure to consult with your veterinarian first.  If you make the switch and the dog or cat isn't any better, the vet may assume that the prescription diet is failing when it's really the OTC one.  Since the diet recommendation is a vital part of the treatment, you need to keep your vet in the loop on any decisions.
This is a great topic and brings up some other issues that I'll discuss in some upcoming blogs.

Friday, November 18, 2016

Joyful Parts Of Being A Vet.....An Update On The "No-Eye" Dog

My last post was rather sad and depressing, so let's talk about some happy things!

Back in 2013 I wrote about a Siberian husky named Diesel.  Due to worsening glaucoma I surgically removed both of his eyes, and it turned out well.  You can read about that experience here.  He has continued to be a regular patient and has been doing exceptionally well since then.

A couple of weeks ago I saw him for a routine wellness exam and checkup, and was talking to one of our new staff members about his case.  It really made me think about some of the positive things about being a vet, and I thought that would be great to include in a blog.

One of the things I love most about being a vet is the bond that will often develop between me as a doctor and the clients and patients.  There is something magical about being able to continue to see patients year after year and continue to get to know them.  Diesel is a great example of this!  His surgery in 2013 is very memorable because it was the first time I removed both eyes at the same time.  I've used him as an example many, many times since then when discussing similar issues with other clients.  I love when he comes in because he is still such a friendly, happy dog, and being completely blind hasn't affected his quality of life at all.  In fact, the quality is much better than when he was dealing with glaucoma.  It is a true joy for me to see him a few times a year since that surgery, and to see how well he has been doing.  In fact, the clients recently moved to a new home and were worried about how he would adjust to the new environment.  We were concerned that he might become anxious because he didn't know the layout of the home and furniture.  But it didn't affect him in the least!  He didn't seem to care about the new place and hasn't had any problems making adjustments.  Over the last three years he's learned how to move around a place he doesn't know without hurting himself.

Here is a photo of Diesel from his most recent visit.  

Besides just being able to continue to follow up on him I also have the bond with his owners.  They are great people who love their dogs, and always try to do the best for them.  Since he did so well they have never regretted the decision to have the surgery done, and we always enjoy talking to each other when they come in.  I love clients like that!

I also recently saw another long-term client for a semi-annual checkup on her puppy.  As we were talking she happened to mention that her oldest child was now eight years old and I had seen her when she was pregnant with him.  I didn't realize it had been that long!  During those eight years I helped her with one epileptic dog, another who developed cancer, and the unfortunate euthanasia of both of them (at different times).  When she got a new puppy I was happy to see her family able to move on and welcome a new love in their home.  There is something so rewarding about knowing that family for so long, and having go through so many things with their pets.

The human-animal bond is something incredibly special.  As a life-long pet owner I couldn't imagine my life without my pets.  As a vet I love seeing that bond in my clients, and love getting to know them over many years.  When things like what I described in my last post happen, it's cases like Diesel that remind us of why we went into this profession.  It's great clients like his owners and many others I have that make the job worthwhile, and give us those emotional boosts that allow us to make it through the hard cases.

Veterinary medicine is hard and often emotional.  We deal with real tragedies and life-or-death situations.  But thankfully it's not always like that, and we can look at all of the patients we've helped and the clients we've gotten to know.  Those bright spots are what get us through the darkness, and why so many people want to become a vet.

Tuesday, November 15, 2016

Death, Death, And More Death

I think that some people look at veterinarians and imagine us playing with cute puppies and kittens every day.  They think about all of the "warm, fuzzy" feelings of making animals better and saving lives.  Some of those people would likely be surprised with what actually happens sometimes.

Last week was pretty tough for me.  In the middle of the week I had several dogs scheduled who were old or sick.  To make a long story short I ended up having to euthanize three dogs in a row.  Yes, that's right, three back-to-back.  At one point I had some of my staff placing an IV catheter in one dog while I euthanized the one before it, then went straight into the next room to euthanize that one.  

Each of these situations were very justifiable as the dogs were suffering.  The decision to euthanize was the right one in each case, though it was emotionally hard for the owner.  And each one went to sleep very peacefully and quickly, making it easy for me and the owner.  I hated doing so many so close together, but there really wasn't a good reason to wait on any of them.

The next day my first appointment of the morning was another euthanasia.  Then a few hours later I had yet another one.  Once again these were all pets that were suffering and needed to be gently eased into a painless death.  But I hated being the one to do so many in such a short period of time.

Losing a pet is always hardest on the pet owner.  They are making an emotionally difficult decision, no matter how justified it may be.  No matter how close a vet may be to the client and patient, their sadness is nothing compared to the sorrow of the owner who is going to be mourning their pet.  But that doesn't mean that it's easy for the vet.

Most of the five pets I euthanized over those two days I didn't know well, and some of them I hadn't seen before.  But it's emotionally draining to end an animal's life.  It can also be draining to handle the human grief that is inevitable in these situations.  Whenever you try to comfort someone who is grieving it takes some of your own emotions and energy.  Both of these factors make every euthanasia somewhat difficult for the vet, and can affect our feelings for a while.

Now do that three times in the span of an hour without even a few minutes break between them.

Then do it again the next day.

I was exhausted after the third euthanasia on the first day.  I really did feel physically tired from the emotions and sadness that happened in such a short period of time.  By the time I came in the next morning I had regained my normal energy, but that quickly left me when I saw my first appointment.  Because of the events of the previous afternoon I was drained more quickly than I would have been otherwise.  When it happened once again the same day I was bordering on becoming truly depressed.

Thankfully this many terminal patients is rare, and it's been many years since I had to perform more than two euthanasias in one day.  And my days since these two have been pretty routine, which is good because I wouldn't have had to try to handle similar set of days.

Being a veterinarian isn't all cute animals and fuzzy snuggles.  It has many ups and downs and a vet will often see tragedy.  It takes great emotional strength to succeed in this profession.