Don't Take Yourself Too Seriously

I'm a bit of a jokester at work.  I enjoy sarcasm and literalism and will crack jokes whenever I can.  One of my favorite tricks is to scare the easily frightened among my staff, especially my office manager who startles rather easily.  Sometimes I'll use odd accents just for the fun of it or will dance in a silly manner.  I enjoy making people laugh and keeping the mood light.

This humor extends to my clients when I can.  I've worn bunny ears at Easter and a dog-head visor hat during the summer.  If I can make a client smile I consider myself successful.

I also enjoy self-deprecating humor and am not afraid to make fun of myself.  Among staff I don't care that they always call me "Dr. Bern", and will sometimes pick up nicknames like "Bernie" or "Bernster".  I readily acknowledge when someone gets me with a joke or witty comment and admire their ability.

I work in a profession that can be depressing and heart-wrenching.  Every day I see sick and injured pets.  Death happens every week.  I routinely see owners neglect their pets and refuse necessary treatment.  This can be a very emotionally draining job if you stop and think about the hardships and challenges. Burnout is high in veterinary medicine due to long days and nights of dealing with illness and getting few breaks.

That's why I value humor.

When the day wears on you it helps to inject some humor into the situation.  This is actually common in other professions that face similar emotional roller-coasters and life-or-death events.  I have a good friend who is a paramedic and he says they also have a sort of gallows humor.  It's a coping mechanism that allows us to deal with things that sometimes make us want to spiral into depression.

I have found that it's a good idea not to take myself too seriously.  It keeps me honest and humble.  It also allows me to lead my team by being willing to be the butt of a joke, thus allowing them to laugh.

It's also just fun.

Why It's Important To Remember Medications

One of the biggest problems in the veterinary field is owner compliance with our instructions.  I believe that for the most part it's simply misunderstanding or common forgetfulness  rather than any malicious will on the part of the pet owner.  Unfortunately the consequences of such inactions can affect the pet.

There are good reasons why we prescribe medications at a certain regimen and duration.  People may not truly understand, but there is a plan to saying that a medicine has to be given twice daily, three times daily, or whatever.  By not following these recommendations the treatment may not work effectively and the problem may not be resolved.

Some medicines simply don't last long in the body and are quickly metabolized.  In the case of eye medications the tears and blinking can wash away drops more quickly than when they are applied to the skin.  Even within a category such as oral antibiotics some will stay in the blood stream longer than others.  Personally I always try to prescribe medications that have to be given as infrequently as possible, realizing that the more times daily a drug has to be given the more likely it will be that a client forgets a dose.

Another factor related to antibiotics is that a certainly level must be maintained in the blood for a certain period of time in order to properly kill the bacteria.  The organisms aren't destroyed with a single dose or two.  I certainly wish that was the case!  When doses are skipped there is a period of time where bacteria can reproduce and grow again in number.  The bacteria that survive this kind of intermittent dosing are also more likely to develop resistance to antibiotics, making further treatment more difficult.  

My most recent poll shows that the majority of people forget medications at least sometimes.  I am at fault for this myself, having forgotten my own medications or to give it to my children, so I certainly can't cast the first stone.  But I know the real reasons why I need to follow doctors' orders, and I get mad at myself when I don't do so.

Remember that we don't necessarily like making pet owners have to give numerous medications throughout the day.  But we as doctors are limited by the realities of the biomechanics of drugs and the body's physiology.  When we say that something needs to be done twice daily for two weeks, that's because it needs to be done that way.  Stopping too early or failing to give it at the right intervals can result in a prolonged illness or a lack of resolution.  

It's so frustrating as a doctor to try to send home an antibiotic with a client and have them say "Oh, I still have some left from the last time.  I'll just give that for a few days."  Why did you not finish it the first time?  I wasn't giving you those instructions just because I like to hear myself talk.

To clients:  Please follow the directions from your doctor.  Don't decide to stop or alter dosages without consulting with them.  There are legitimate reasons why we gave those instructions that have nothing to do with money.

To vets (soon-to-be or otherwise):  Communicate clearly to clients, passing on why the treatment needs to be done a certain way and what can happen if those instructions are not followed.

Thirty-Five Bites

**WARNING--GRAPHIC IMAGES**

Sometimes I want to throttle pet owners and take their pets away.

This past Saturday a client walks in, says their dog was in a fight and asked if we could see her.  We were busy but something like that needs to be seen right away, so we said we would.  The dog had to be carried in on a gurney from the car because she wasn't able to walk.  This was a 70-ish pound female pit bull and we could quickly see that she was in bad shape.  She was covered in blood and we knew this wasn't a simple bite wound.  Apparently she had been attacked by another dog in the family and was brought in quickly.

One of my associates was the primary doctor on the case but we worked on her together due to the severity of the case.  As we examined her we could tell that there were numerous small to medium puncture wounds on her body, legs, and ears, all which were oozing blood.  None of them were serious by themselves, but added together they were a sign of a severe attack.  If it was just a few we knew we could sedate her, use local anesthetic, and quickly clean and suture the wounds.  But due to the sheer number of wounds it was obvious that it would take a long time to fix her, requiring general anesthesia.  We gave her some potent pain medications and a sedative while we were trying to work with the client on what needed to be done.  Here is what she looked like at that point.

Believe it or not, the pictures don't really do the injuries justice.  And through all of this she never stopped wagging her tail!  She was the absolutely sweetest dog, and despite being covered by bruises and bites whenever we would talk to her or touch her she would immediately wag her tail.  All of us fell in love with her.

We were amazed at how many small punctures there were, but at the same time we knew this was a fixable situation.  With proper care she would likely be just fine.  It would take some work, but we knew we could do it.

That's when things became complicated.

The total for anesthesia, disinfecting the wounds, suturing the large ones, antibiotics, and analgesics came to over $700.  The actual owner was in California, the opposite side of the continent and country, and a friend of his was watching the dogs.  When my associate called him to discuss the case and get authorization to treat, he told us he didn't have the money and to just clean her up and send her home.

SAY WHAT????

Even though the wounds were not immediately life-threatening there were so many openings into the muscle that systemic infection was a real and serious concern.  If we didn't treat her properly she could possibly die from infection.  This was also a case where it really had to be all-or-nothing.  We needed to do the expensive care in order to save her life.

We didn't know what we were going to do.  In good conscience we couldn't just let her go home like that.  We do have funds for situations like this, but in order to make sure they are available for pets who really need it we require the client to apply for Care Credit first, with people who are declined then having to meet financial needs requirements before being given the funds.  With these rules we keep people who have the money or credit from taking funds that other people need more.  This guy wouldn't even bother to try applying for Care Credit.  A nearby local shelter offered to take her if the owner would sign her over, but then when they saw the bill they said they didn't have the funds for that much care.  We were all extremely frustrated at the situation and couldn't believe how callous the owner was being.  The friend also didn't seem to be offering any solutions.  The whole time this dog was suffering.

I was on the verge of calling Animal Control and talking to them about whether they would intervene as an animal neglect case.  I've never come closer to doing so and trying to get law enforcement involved, but this was a moral issue as well as a medical one.  I also think I would have had a mutiny on my hands from my staff if I simply let them walk out.

Thankfully we managed a work-around.  When we send someone to collections for an unpaid bill it is first handled in-house through our own financial staff (we are a large practice with several satellite clinics, so we do things a bit differently than many vets).  Our own financial department gives the owner three months to pay their debt.  If it isn't paid off during that time they get sent to an outside collections agency and affects their credit.  This option was discussed with the client, who agreed to pay $100 and get sent to "collections" for the rest, planning to pay it off during the three months.

This meant we could get to work on her!  She was anesthetized, the wounds cleaned, and the long process of suturing begun.  It took somewhere around 30-45 minutes to get finished and my associate counted a total of 35 puncture wounds!  Here's a look at some of them.

Later that evening she walked out of the clinic wagging her tail.  Yes, that's right.  Despite all of the injuries and deep bruises, despite hobbling out on four injured legs, her tail was wagging furiously.  Through all of the pain nothing could stop her spirit.  To me, that was the most amazing part of the whole ordeal.

Orphaned Rabbit Adventures

Today we ended up with an orphaned wild rabbit.  My father-in-law was mowing the high grass in an elderly neighbor's yard.  In doing so he apparently disturbed a rabbit's nest, making the doe (yes, that's what a female rabbit is called) run off, killing one baby, and narrowly missing the other.  My wife was nearby shortly after and looked at the remaining bunny.  He was so tiny and young that she couldn't bring herself to leave him there knowing that he probably wouldn't survive.

So what does the wife of a vet do in a situation like this?  She calls her husband.

On the phone call I couldn't tell how injured he might be, so I told her to bring him in for me to look at.  I estimated him at around 2-3 weeks old based on his size and physical characteristics.  Though he seemed shaken up, I couldn't find any obvious injuries.  My daughter was there also and started virtually glowing when I said that he looked okay.  Not knowing what else to do and not having the heart to turn him out to possibly die, I agreed to trying to save him and nurse him until he could be on his own.

Luckily we had a spare 20 gallon tank that had previously been used for a rat.  While far too small for a full-grown rabbit, it will be enough for the 1-2 weeks I expect to keep him.  Given his estimated age, that's how long it should be until he can eat on his own and doesn't need to be nursed.

To be honest, I've never raised a wild animal before.  Almost thirty years in the field of veterinary medicine and I've avoided taking on an orphaned animal.  I guess this is what happens when you have a soft-hearted wife and an equally tender daughter who wants to be a vet.  So I'm not sure how this will go.  I would say his chances are only around 50% at this point as orphaned rabbits don't usually do well in captivity at this age.  We are giving him a milk replacer and I hope to have him eating hay and pellets within the next week or so.  My inexperience in doing something like this is certainly a factor, and it does make me nervous.  I have theoretical knowledge of how to care for orphaned wildlife but have never been faced with the reality.  We'll give him the best care we can, but a lot of this is up to God.

As this is a progressing story, I'll update in a few days when we see how he is doing.  Oh, and the kids named him Thumper.

More Bad News For Veterinary Jobs. What Now?

The American Veterinary Medical Association (AVMA) just released its 2013 Veterinary Workforce study.  There are several conclusions that the study made, none of which should be a surprise to anyone who has been following the profession in recent years.

• The supply of veterinarians in the US exceeds the demand by about 12.5%
• An excess of 11-14% annually is expected through 2025.
• There is little evidence of widespread workforce shortages in the profession
• Annual growth in new graduates from 2004-2013 averaged 2.6%
• Projected mean annual growth in new veterinarians (including foreign graduates) from 2012-2015 is 4.5%

So essentially the supply of veterinarians in the US exceeds demand, and we're putting an increasing number of vets into the workforce.  Simple math would indicate that this would decrease salaries (since practice owners can hire desperate vets for less) and decrease the number of jobs available.  Combine a less-than-rosy job prospect with skyrocketing costs of a veterinary education, and it's not a good time to be a new vet.  According to this study that will continue for the next 10-15 years. 

Ouch!

But none of this is really "news".  While we might have some quantifiable numbers now, the trends have been there for years and anyone watching the data or reading my blog for the past year won't be shocked.  And hopefully this is is being discussed in veterinary colleges.  So what is to be done?  It's all well and good to know this information, but then what can we do about it?

This is where I get very frustrated by the leaders in our profession.  The study continually talks about needing more research.   "Identify", "Implement", "Research", and "Collect" are frequent words thrown around.  Here are some quotes.

The AVMA should identify and implement strategies to increase the demand for veterinarians and veterinary services and provide an annual update on the estimated current and projected supply of and demand for veterinarians and veterinary services.

A program should be implemented to collect and analyze data that provide reliable information on the number of veterinarians entering the US workforce each year including specific data related to geographic region and practice sector.

A system should be developed to assess the number of veterinarians changing employment sectors or becoming temporarily or permanently inactive in veterinary medicine and their reasons for doing so.

Research should be performed to better understand how demand for veterinary services is related to the overall US economy, consumers’ disposable income, and the price of veterinary services.

Really?  That's it?  Those are the things the "great leaders" of our profession are stating in order to handle a legitimate crisis?  All they are saying is "we need to do more studies".  

Um, hello....haven't be been doing studies for years?  Haven't we seen this trend coming for many years?  Personally I've been reading reports like this going back four to five years.  When are we going to stop studying and start acting?

This is where I get upset with the leaders in the AVMA and the veterinary colleges.  The solutions are out there but nobody seems to want to make those tough decisions.  First would be stopping any planned new veterinary schools.  If supply already exceeds demand, why are we graduating more vets?  We don't need new vet schools and it's only going to worsen the problem.  Second is to stop increasing class sizes.  I know that the existing colleges need the tuition for survival during budget cuts, but once again we are already a saturated market and don't need even more vets.  These two solutions could be implemented immediately and give a quick fix pending further decisions. 

Then we need to strongly educate people considering a veterinary profession on the realities of the financial prospects.  How realistic is it to pay back $200,000 or more of student loans on a $60,000 salary?  We need to give the hard facts to the point of virtually discouraging students out of the field.  This is a very touchy-feely profession where people go into it for the love of the animals rather than the money.  But loving animals and wanting to take care of them doesn't pay the rent, car loan, or grocery bills.  I think that anyone accepted to veterinary school should be required to take a one-time class on personal finances before they start classes.  This information would go over their expected starting salaries, how much student loans they can expect, and how difficult that is to pay off.  Some students would drop out then, and that's a good thing for them as well as other students.  Does this sound harsh?  Good.  There needs to be a strong dose of reality thrown at students very early on, because dreams and good wishes don't pay the bills.

We also need to toughen the requirements to get student loans.  In many ways it's far too easy for veterinary students to get the loans to accumulate hundreds of thousands of dollars in debt in only four years.  Part of the reason for the housing crisis in the US over the last several years is because mortgages were too easy to qualify for and people ended up in loans they couldn't repay.  That same problem is happening with veterinary students, where new graduates are ending up with debt burden that they have difficulty repaying.  If it was more difficult to get loans we would screen out some of the people trying to enter vet school, which does help.

Now don't get me wrong.  I'm not trying to be elitist or think that being a vet is only possible for the wealthy.  In fact, I'm trying to consider the difficulties that new vets face and save them that burden and challenge.  Anyone who has graduated in the last few years can attest to how hard it is to simply make ends meet.  But there are realities to loans and salaries that our leaders have noted but don't seem to be able to do anything about. 

Rather than more studies, the AVMA and others need to start acting and be willing to make tough decisions.  The solutions exist, but nobody seems to have the guts to actually do them.  Until then everyone who is considering or is in veterinary school needs to look long and hard about their fiances and chances of employment.  If the veterinary leaders won't take action it's up to the individuals to have responsibility for their own futures.

The Over-Hype About Pit Bulls

There was a great tragedy last week in Atlanta.  A two year-old boy was mauled and killed by the family's eight year-old pit bull.  This made local and even national news and was a horrible event.  One of my part-time staff also works as a paradmedic and was the first medical responder to the call.  We were talking about it today and I can't imagine having to look at a child in that state and then tell his mother that he died.

As you can expect, the discussion among people hearing the story quickly became oriented around the dog's breed.  "How can you let such a dangerous dog around a child?"  "Those dogs should be outlawed!"  "They're a menace to society!"  As a veterinarian I often have clients asking me about pit bulls and whether or not their reputation as a dangerous breed is true.  After having worked almost 16 years as a vet and almost 30 years in the profession, I absolutely say "no".

Do you know what breed has the highest reported bite rate?  Labrador retrievers.  Yet they're considered good family dogs and generally friendly.  I talked about this back in 2009, where a study looked at bite rates and concluded that veterinarians get bit most by Chihuahuas and have the worst bites from lhasa apsos.  I completely agree with the study's conclusions.

The large majority of pit bulls I see are very friendly and outgoing.  Some of them are a little shy but aren't a danger.  Every once in a while I'll see one that is truly agressive and we have to watch carefully.  However, I can say that about every breed.  I've known some labs, golden retrievers, Siberian huskies, and just about every other breed that we have to muzzle or even sedate to handle.  As a vet I am more concerned about the bite tendencies of Chihuahuas and shih-tzus than I am about pit bulls.  I'll trust the average pit over the average dachshund any day of the week.

That doesn't mean that pit bulls can't be dangerous.  In my opinion and based on my personal experience they as a breed are not likely to bite.  But when they do bite it will be serious because of their jaw strength.  If a small dog bites me I might have to have stitches if it's a really bad injury.  If a pit bull decides to bite me I'm going to end up hospitalized.  To me the danger of pits (if any) is in the severity of the bite, not the likelihood.

ANY dog can have the potential to bite under the "right" circumstances.  I've had very sweet patients that will snap at me if they're really painful.  If you provoke a dog enough you run the risk of it biting just out of fear or retaliation.  That's why when I hear of a bite I always want to know the circumstances.  If a dog is not properly socialized and is treated roughly it will have a higher tendency to bite.  In this case last week, I have a hard time seeing how a normal, well-treated dog will suddenly turn aggressive at eight years old.  With my background in behavior I have to wonder if the dog was not properly trained or handled and had this tendency prior to this event.  There is also the possibility of a medical condition such as pain, a brain tumor, and so on.  A normal, healthy, well-adjusted dog doesn't suddenly go psychotic at eight for no reason.  But you won't hear about those potential causes on the news.  All you'll hear is "Pit bull attacks and kills toddler!"   I think this is sad, as it makes people afraid of the breed when they don't need to be.

The question will probably come up "So what breeds will bite?"  In my personal, non-scientific experience I get nervous around the following breeds:  Rottweilers, German shepherds, basenjis, shar-peis, chow-chows, Chihuahuas, dachshunds, akitas, Cane Corsos, and Presa Canarios.  Before people with these breeds get up in arms, I've known very sweet examples of all of these.  I'm just listing the breeds with which I've had repeated issues, as well as breeds that can do some serious damage.  Again, any dog can bite depending on the circumstance, and the breed that has the most reported bites is also universally recognized as a good family breed.

If you talk to vets and those in our profession you'll find very few who agree that pit bulls are an overly aggressive breed.  Unfortunately the breed attracts people who want a "tough" dog and deliberately train it to be this way, or neglect it's social development.  Because of these irresponsible owners there have been more serious bites from the breed than we would otherwise see.

Increasing Pet Care Costs & Expectations

I received a great question from Jennifer....

Do you think that the cost of owning a pet has increased over the years (more than just the general increase in the cost of living) as more advanced, sophisticated, and expensive treatments become available?  My cat has chronic kidney disease, and I am dreading that one day my vet might suggest a transplant, and I will have to make a conscious decision to NOT spend $10,000 to keep my cat alive.  I know that's a extreme example .... I know that a pet owner who can't pay $50 for shots or for basic treatment shouldn't own a pet if they can't afford it - but what if they can't pay $1000, or $5000, for a treatment that didn't even exist 10 or 20 years ago?  10 or 20 years ago, when no treatment existed, it would be acceptable to have your pet put to sleep.  Now that a condition can be treated, but at great expense, is the bar being raised so that the expectation of what a responsible owner should pay includes more and more expensive treatments?

I certainly think there is validity to the idea that the costs of owning a pet have increased.  It may not be as much as many people think, but it does seem to be going up.  The question is "why"?  And I don't think it's just because newer and better treatments are more expensive.

Go back 100 years and veterinary medicine was focused on livestock, not dogs and cats.  These animals were seen as companions, but not as much as family members, at least not to most people.  Vets would often see a client's dog or cat while they were at the farm looking at the horses and cows.  Fast forward to 2013 and the focus has shifted.  Now most vets end up in companion animal medicine to the point that there is a growing crisis finding veterinary care for livestock.  At the same time dogs and cats have come into the houses and become not just companions but family members.  I believe that this switch in the mindset of the owner is more responsible for increased care costs than simply better medicine.  The clients are the ones expecting better care and the veterinarians are working to provide that level of diagnostics and treatment.

Let's go back about 50 years.  Parvo virus didn't exist yet.  Heartworm disease wasn't a highly recognized concern and there were no preventatives.  Effective flea and tick medications didn't really exist.  Pet food manufacturing were dominated by just a few companies and brands.  Vets didn't have access to in-clinic blood analyzers.  Even x-ray equipment wasn't wide-spread.  We as a profession simply didn't have as much to offer our clients and patients, so treatment was often limited and based on good guesswork rather than a battery of tests.

Now look at today.  We have significantly reduced the number of distemper and parvo cases because of vaccinations.  We have several different options for heartworm, flea, and tick prevention.  There are dozens upon dozens of companies making pet foods, often with multiple brands within a single company.   Most vets can now run a full blood chemistry and blood cell analysis in around 30 minutes.  Not only do we have x-ray equipment as a standard of practice, but the profession is rapidly moving to digital radiography.  Even ultrasound is becoming more and more common in a general practice.  We have a far greater ability to quickly and accurately diagnose a problem than we did in the middle of the 20th century, and safer, more effective options for treatment.  Clients also want better quality food for their pets and are willing to pay premium prices.

Better care doesn't come without some increased costs.  It costs a vet money to have the diagnostic equipment and better medications are usually not cheap.  But this isn't something that the vets are forcing on clients.  These are things that clients now expect and look for.

Obviously if you're reading this blog you have an interest in pets.  Let's say we have Dr. A who doesn't stock heartworm or flea prevention, only gives rabies vaccines, doesn't have x-ray equipment, rarely runs blood tests and when he does he sends it out with the results coming back in a day or two.  He's friendly and cheap, but relies more on educated guesses than anything else.  Dr. B has a modern facility with digital x-ray machines, blood analyzers, two different kinds of heartworm prevention in stock, a full spectrum of vaccines, and a pharmacy full of medications.  He's nice but his office visits cost more than Dr. A.  You have a dog that has been lethargic for three days, won't eat, and is vomiting at least once daily.  Which of these two vets would you want to take your vet to?  What level of care do you want for your own pets? 

There are many clients who still can't afford high costs.  Most of my clients wouldn't be able to afford $2000+ in care, and it can even be difficult to get some to spend $200 for simple tests.  But clients expect to at least be offered these things, and in fact if you don't do so it could be considered malpractice.  Does that sound ridiculous?  Those kinds of lawsuits and board investigations happen and the vets often lose because not giving clients these options is below the standard of care.

I don't see this trend changing.  In fact, I see the burden on the client to increase because of the changing perception of society regarding animals.  In most states animals are still considered a special form of property, meaning that owners can't sue for pain and suffering any more than they could for the loss of their couch or car.  There is growing pressure throughout the US to recognize pets differently, as living companions rather than an unliving object.  I've blogged about that in the past and won't revisit the debate at this time.  One of the unintended consequences of changing the laws to allow for pain and suffering of pets is the increased cost to the clients.  To avoid lawsuits and malpractice charges vets are going to want to run more and more tests, even for simple problems.  That means that a veterinary bill will be higher due to more testing.  Conversely, clients are going to have a greater burden to actually do these tests.  If a vet can be sued for the pain and suffering of their patient and client, then the client can equally be held responsible for the pain and suffering of their own pet.  I can absolutely forsee a time when a client faces charges because they wouldn't pay for the dog's broken leg to be surgically repaired or the dog contracted parvo because they didn't do the proper vaccines.  If parents can be criminally charged for medical neglect to their children, they can also be charged for similar situations with their pets.

The bottom line is that it costs several hundred dollars per year to give proper, basic care to your pet (vaccines, heartworm and flea prevention, food, etc.).  If your pet gets sick you can expect at least $200-500 in tests and treatment.  If you cannot afford these costs, I do not think that you should own a pet.  If you have a pet then you should have money set aside for these purposes.