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Thursday, September 22, 2016

Out Of Whack Priorities

Some pet owners have their priorities all mixed up.  It's something that really bothers those of us in this profession because it often means that the pet loses out.
 
Recent case in point....
 
We had a dog brought in because the owner was worried about vomiting for a few days.  We didn't have any available appointments but wanted to make sure the pet was okay so the client agreed to drop it off.  When she did she asked how long it would take because she had a grooming appointment for him.
 
Really?  You brought your dog in for vomiting and you're more worried about his haircut?  He might have pancreatitis, a toxin, an intestinal foreign body, or something else bad and you are more interested in him getting his bath and trim on time?

This happens more frequently than those outside of the profession might realize.  And it often revolves around grooming.  Often we'll see a pet for a rabies vaccine only because the previous one had expired and the grooming facility required it.  Otherwise the client would have never brought their pet in!  I have also seen many cases where we do the rabies vaccine and the owner declines all other vaccines, heartworm testing and prevention, and any other preventative care.  Why do they refuse these necessary preventative services?  Because they can't afford it.  Why can't they afford it?  Because they need the money to get their dog groomed.

So basically they're saying that they can't afford a $40 test and $35 prevention against a common and life-threatening disease, but they can afford $60 or more to get their dog a bath, haircut, and cute little bows. 

Really?

This frustrates the heck out of us in this field.  We are worried about preventing serious diseases or diagnosing and treating health issues, and this is our primary focus.  For some clients they could care less about the health risks to their dog and put the priority on them looking pretty and smelling nice.  Frankly, I'd rather see a stinky, dirty dog who is current on vaccines and heartworm prevention than one with the perfect haircut who barely has his rabies vaccine up to date.

I'm really glad that clients like this are the minority of our caseload, and most people do a great job of putting the focus for their pets on the important things.  Most of my clientele are great people who listen to our recommendations (for the most part).  But I don't think I'll ever be comfortable with the ones who put their priorities for their pets in the wrong order.

Monday, September 19, 2016

Some Amusing Irony

Several years ago I changed the comments on this blog so that all of them had to be approved by me.  This was done because I was having a big problem with people making comments, often unrelated to the original post, that contained a link to some other website or service.  For example, on a post about skin problems in dogs I might get a comment with a link to hair loss treatment for men.  I'm always open to opinions contrary to my own (as long as they are polite), as anyone can see by reading my comments sections.  However, I don't want to clutter the comments with spam messages and I absolutely don't want to support those spammers in any way, shape, or form.  So I screen each and every comment, deleting ones that are obviously spam.
 
Today I had a comment on a blog I made two years ago.  My post was titled "Vaccines Are A Money-Making Scam!" and talked about some of the financial issues around vaccinating pets.  The comment I received was the following: 

 Get daily ideas and methods for generating THOUSANDS OF DOLLARS per day FROM HOME for FREE.
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The last line included a link, which I have removed from this quote.  This is the kind of comments that I get every week on various posts and is the main reason why I screen and authorize every comment.  But what I find particularly interesting and ironic is that whoever wrote it only saw the key words of "money-making" in the title and didn't realize that the title was completely sarcastic.  They obviously never read the post or even considered the topics or theme of the my blog.  The irony comes in that I was talking about scams, and the link is almost assuredly a scam!
 
Typically I just delete the comment, but I couldn't resist sharing this one.  These spammers and marketers are pretty darn stupid since I have a clear statement that this kind of comment will be deleted immediately and yet they still make them.

Friday, September 16, 2016

Is Charging For Prescriptions Legal Or Ethical?

Connie recently emailed me a great question....
 
As a veterinarian do you feel justified in charging a fee for writing a prescription?
 
I was a long-time client of a veterinarian who had one of my cats on a common medication that is very inexpensive at the pharmacy. I had been purchasing the medication from the vet who was charging substantially more for the medication. The condition my cat had was chronic, and I had spent quite a lot of money over time. The cat would continue to need this medication for the rest of his life, and I finally decided that it was nonsensical for me to be paying so much extra by purchasing this medication from the vet, so I asked for a written prescription which I planned to take to my pharmacy and save myself a little money. My vet did provide me with a written prescription, but charged a fee to do so. This actually hurt my feelings. It was as though he was saying, "I don't care about your many years of loyalty to my practice and the many animals I have treated for you, all I care about is your money. If you're not going to pay my high prices for medication, I will punish you by getting my share of the profit this way instead." I never went back to that vet.
 
I imagine that it's legal for a veterinarian to charge a fee for writing a prescription, but I find it unethical when the obvious reason for the fee is to recover lost revenue. I would really appreciate your thoughts about this type of situation.
 
Issuing a prescription isn't quite as simple as pulling out the pad and a pen.  Sometimes the size of medications in the human and veterinary fields can vary, so the doctor will have to look up what may be available somewhere else.  Sometimes we have to tweak the dose if we're changing medication.  We also need to take time to record the prescription in the patient's medical notes so that we can track it appropriately and any other doctors that see the records after that can know exactly what medications the pet is taking.  In some locations we have to do extra recording for controlled substances.  All of this takes time, and in any business time is money.  If we're taking even 5-10 minutes to do all of the above it can take away from other patients or services.  When we fill prescriptions in the clinic the costs of the time to do all of this is included in the prices, as well as the costs of labels, prescription bottles, and the medication itself.
 
In the US if a client asks for a written prescription the doctor legally must given them that prescription.  It is absolutely illegal for a doctor to refuse to authorize a prescription at another facility or pharmacy if they have fulfilled a legal client-patient-doctor relationship and would allow the prescription to be completed in their own clinic.  So if a vet (or any doctor) refuses to authorize a prescription just because you won't buy it from them they are breaking the law.  You are always legally entitled to a written prescription.
 
It is perfectly legal for a veterinarian to charge to write a prescription, and my first paragraph is generally the justification that is used for making these charges.  The question then changes from "can they charge" to "should they charge?"
 
I don't think it's unethical for a vet to charge for a written prescription.  However, I think that it's more trouble that it's worth, and pushes away more clients than an average practice would want (as in Connie's case).  Several years ago my practice owners decided to charge for prescriptions.  That lasted for a year or two but frequently caused problems with owners complaining and was a big hassle to explain why we were doing it.  They finally decided to take away that charge and we write prescriptions for free.  Personally I was very pleased with this decision, even though I understand the justification for the charge and won't condemn a vet who does so.
 
In my opinion you are losing more in goodwill and client loyalty by charging for written prescriptions than you lose in revenue or time.  I believe that if you happily and readily authorize prescriptions for patients those clients will be more likely to trust you in your decisions and agree to treatment plans in the future.  I would rather keep great clients than turn them away over a $5 prescription fee.
 
The veterinary profession has been facing big challenges in the last couple of decades as more people want prescriptions from online pharmacies.  Historically our clinics have been the only ones able to provide many veterinary-only medications which aren't stocked in human pharmacies.  Online options and even some regular pharmacies can be cheaper than the vet because of lower overhead and bulk ordering, all of which makes it hard for a veterinarian to compete.  But that's a problem with certain models of veterinary business and not with the medications themselves.  For too long veterinarians as a profession have relied far too heavily on income from vaccines and medications.  With vaccine durations lengthening and medications being available from other sources, many vets have seen reductions in revenue.  This topic has been heavily discussed in the profession for as long as I've been practicing, and I doubt we'll stop talking about it any time soon.
 
I believe that the answer to these challenges is to more closely model certain aspects of human medicine.  Human physicians don't stock medications for dispensing and concentrate pretty much on doing exams, making diagnoses, and authorizing treatment.  The real value in a doctor is in their knowledge and experience, not what they sell.  This is true of veterinarians and something that many of my colleagues need to realize.  We need to get away from retail and medication sales and focus on what we know and can do as doctors.

Doing so will result in somewhat increased costs of office visits and procedures as the lost revenue from pharmacy sales has to be made up in order for a vet to stay in business.  But having this kind of business model more appropriately represents where our true value lies, and clients will be able to find medications elsewhere, often for lower prices than a vet clinic can charge.

First and foremost we are doctors and surgeons, and need to position ourselves as such.

Connie, I hope that answers your question!

Sunday, September 11, 2016

Will Teeth Grow Back?

I know that many times veterinarians (and other professionals) shake their heads and make fun of clients or customers.  On one hand we probably shouldn't be laughing at the people that provide our livelihood.  But on the other hand sometimes people say things that are so crazy that you can't help but wonder what they were thinking.

Today I saw a dog for a routine dental cleaning.  His teeth were pretty bad and several were loose due to periodontal disease.  During the cleaning some incisors came out and we had to pull a bad molar.  These were pretty minor procedures but because of infection I sent him home with antibiotics.  All in all, a common outcome for a day.

When the owner picked up at the end of the day my technician was going over the discharge instructions.  The client then asked "will those teeth grow back?"

She came back and told me this and I just stared with my mouth open.  In 34 years in this profession that's the first time I've ever heard anyone ask that.  And frankly, the question kind of took me by surprise.  Other than sharks, I really can't think of any animals where lost teeth grow back.  Certainly not a dog!  When would an average person expect teeth to regrow?  

I hate to laugh at a client who was doing the right thing for their pet, but at the same time it was a really crazy and unexpected question.

Thursday, September 8, 2016

It's Pumpkin Season!

Here in the US we really celebrate Autumn, Halloween, and everything related to it.  Over the last few years one of the biggest and fastest growing trends has been pumpkin spice flavoring.  It's becoming almost comical how many products come out with a pumpkin variety this time of year. 
And I love it!
Yes, I'm one of those weirdoes who will consume just about anything pumpkin flavored.  These companies are marketing to me when the make these seasonal varieties.  Look at some of my recent purchases.
I know that this has been ingrained into the public consciousness (at least here in the US) enough that memes are all over social media.

 

 




Some of my friends have ranted because Fall doesn't officially start until September 22nd, so the fact some of these products came out while it was still technically Summer bothers them.  I can sympathize, as I get frustrated at how early Christmas is advertised by retailers.  But at the same time I am so excited to have all of my pumpkin products!

This time of year reminds me of the scene in Forrest Gump where Bubba is talking about all of the ways to make shrimp....



But in my case, it's pumpkin!  Pumpkin spice latte, pumpkin pie, pumpkin spice cereal, pumpkin donuts, pumpkin snickerdoodles, pumpkin pie Pop Tarts......

Someone actually made a meme about that!


I have only a few months to enjoy this pumkiny goodness, and I'm going to take full advantage of it.




Monday, September 5, 2016

E. Faecium, Sodium Tripolyphosphate, And Corn in Dog Food.

I received this email from a reader, Sharon....
 
I have a question regarding the ingredient E. Faecium in dry dog food… namely, is it a healthy ingredient?  I understand that it is actually not a probiotic but almost an antibiotic.  I understand that it is colonized in us and in our pets.  However, I have read so many posts about it being dangerous and that it can cause a super bug by over colonizing when it is in dog food or additives like probiotic supplements.  I am finding this ingredient listed on everything from Mercola Probiotics to almost every “Natural food”… from Canidae, Taste of the Wild, Blue Buffalo, Holistic Select, Orijen/Acana, Artemis, Evangers, Dr. Tim’s, Life’s Abundance, etc.  I am so concerned about it, that I will not even consider a food with it in there.  Interesting, it leaves almost only the very well researched  and long lived foods.. like Purina, Iams, Royal Canin and Science Diet.  There is a discussion thread on the dogfoodadvisor.com website regarding the dangers of e. faecium in dog food.  If you google that, there is an entry a little way down (3rd entry or so) where a lady goes through her issues with e. faecium and has all kinds of research articles about how bad it is.  The link will not copy or paste in here.. or I would have added it for you.  She even has CDC articles.
 
Also, I really want to feed my dog Royal Canin mini breed.  It checks so many boxes for my dog and it is one that he will actually eat.   He is a 10 pound, 2 year old  morkie.  However, I am having trouble with a few things about it.  First, the ingredients for all the small breed formulas are heavy in brewers rice and corn.  I think those make my dog itch like crazy.. he must have a sensitivity to them.  Also, my theory is that he gets super barky and neurotic on food with a lot of corn and brewers rice.  Eukanuba is one we cannot use because he gets so crazy on it.  Is that common?  Then, the Royal Canin foods have Sodium Tripolyphosphate to keep their teeth clean.  Of course dirty teeth directly cause all kinds of health issues in a dog, so I would love to have a food with teeth cleaning benefits.  But, I have read online that this ingredient is toxic.  I know RC puts all kinds of research into its products, but I am concerned about this ingredient.  I have also read that it is a neurotoxin.. an am wondering if it is the STPP and not the corn that is making my pooch a bit nutty on the food.  Any thoughts?  I would love to get my dog to stop itching on this food and feel comfortable with the STPP in it.. then we would finally have a winner!  Currently, we are feeding Science Diet Small and Toy Breed Chicken.. but he truly will only eat enough to make it.  He does not like it.  But, it does like him.. it digests, he has no tear stains, great poops.. so we keep with that.  He is a bit lethargic though.. I think from not eating regularly.  With the RC Mini, I think he would dive in and eat regularly and feel a spunkier.. but, like I said, he actually gets more than spunky.. he gets just crazy barky and even growls at his friends when playing..which is totally out of character for him.  I was wondering, too, if RC has changed its formulas since it got bought out recently.
 
There is debate about E faecium as a probiotic.  Most of the articles that I could find say that it's pretty safe and has been used for 20-30 years without extensive problems.  Yes, there are reports of issues, but the benefits seem to outweigh the risks and there are more positive reports than negative ones.  However, I don't think probiotics are necessary in dogs that are overall healthy and digesting well.  If they have a normal digestive tract then there shouldn't be any need for probiotics.  I do prescribe them sometimes, but only in specific GI cases, and typically only short-term.  I can't find good evidence justifying adding it to a regular daily maintenance pet food, and am curious as to why some companies decide to do so.  I notice from the list in Sharon's email that it seems to be mostly the "niche" and "natural" brands, none of which have strong evidence to support their practices and advertising.
 
Sodium Tripolyphosphate (STPP) is included in some products to help prevent dental tartar accumulation and aid with dental disease risks.  It is considered very safe in the dosages found in dog treats and dental products.  If you look at the studies, the only problems seen were in rats when given 10 times the recommended dosage.  I checked several veterinary specialists, and nobody is worried about the small amounts found in pet products.  In fact, I'd challenge those who think it's toxic to back up their opinions in real-world dosing, not the extremely high doses in laboratory animals.  Now, there is some disagreement on whether or not it is an effective product, and I found even board-certified dental specialists who have different opinions on whether or not it should be used.  But their disagreements were only on efficacy and not at all on safety.  I wouldn't stop feeding a food that included it, but I also wouldn't use it as the sole form of preventative dental care.
 
As far as behavioral effects of the other ingredients, I've never heard or seen that.  True reactions to corn, brewer's yeast, and similar products are extremely rare, far less common than is typically believed.  You could have an individual patient who has a sensitivity, but the reaction is just in that single animal/human and doesn't reflect on the ingredient overall.  I've done a lot of advanced training in animal behavior (though I'm not a specialist) and I've never come across any reports of behavioral problems created by food ingredients.  If you have a particular individual with such a sensitivity, then you would want to avoid the particular ingredients for that pet.  Other pets would likely tolerate the ingredients without any problems.
 
I  hope this helps.  Personally I really, really like Royal Canin and it's what I feed to my own pets.  I don't know of any board-certified nutritional specialists who don't like Royal Canin or think that it's a bad or dangerous food for any reason.
 
 
 
 
 

Friday, September 2, 2016

Fixing A Hooded Vulva (Vulvoplasty/Episoplasty)

Here's one I bet most people never thought of.  "Cosmetic" surgery on a dog's genitals.  But it's really not for the sake of appearance.

Some female dogs have what we'll call a "hooded" or recessed vulva.  A normal dog's genitals should be easily visible and not hidden.  But sometimes there are folds of skin that cover the vulva.  This causes several problems.  First, the urine can stay in contact with the skin and get into the folds on either side of the vaginal opening, causing irritation and leading to infections.  Second, the close contact of the skin with the outer vulvar lips can make it easier for bacteria to get into the vagina, ascending to cause bladder infections.

My latest case of this was plagued by chronic infections and discharge to the skin around her vulva.  Antibiotics and medicated wipes would help for a little while but the problem would always come back.  The deep folds trapped urine and other moisture, leading to the ongoing disorder.  Besides the irritation to the pet there was a persistent foul odor that the owners didn't like.  And I can't say that I blame them!  When repeated medical therapy didn't resolve the issue we decided to do surgery.

Here are some pictures with her anesthetized and on the surgery table.  You can see in the first one that her vulva is not visible at all, deeply hidden in the recesses of the skin fold.  This is not normal! 


In this photo I'm pulling the folds apart so that you can see the vulvar lips.  This is what should be readily visible in a female dog.  You can see the big difference between the pictures and the kind of problem she had.

The surgery is often called a vulvoplasty, but is more properly called an episoplasty.  It involves cutting away the excessive folds of skin and returning the area to a more normal structure.  When the skin folds are removed we suture the incision together.  You can see the post-operative appearance in the picture below, which returns her to a very normal conformation.

I took the sutures out 10 days later and the incisions had healed very well.  There was no infection or odor, and the skin in the area was returning to a normal appearance.  This dog will no longer be plagued by chronic infections around her genitals.



Not every vet will perform this procedure as it's a more advanced soft tissue surgery.  I enjoy these kinds of surgery so I learned how to do it and have done several of them.  But if your vet is not comfortable doing it they may refer you to a specialist.  If you think that a hooded vulva may be the cause of odor or infection around your dog's genitals, have your vet evaluate her.