Practice Makes Perfect

Being a doctor isn't easy, and I don't think anyone would disagree with this comment. One of the hardest things to learn is how to take the information from the classroom and textbooks and apply it in a clinical setting.  This is why experienced doctors tend to make better clinical judgements than new graduates (everything else being equal).  It may not seem like it, but there can be a bit of disconnect between what is reported in the texts and what you may actually see.

It's common for doctors to talk about whether or not a patient "reads the textbook". This means that some cases present exactly like is described in the textbook.  For example, a hypothyroid patient would have a thinning coat, weight gain, and persistent skin infections.  However, some cases don't have classic characteristics, such as a diabetic patient without an increase in drinking or urinating.  It's easy for a doctor to read symptoms and lab results in a book or class notes and figure out what the disease is and how to treat it.  However, if the patient doesn't have all of the symptoms, or has some conflicting lab results, it can be difficult to make conclusions.  That's where experience and learned clinical judgement comes into play.

There is an art to medicine.  It takes experience to learn how to interpret lab results, determine what treatment is best, and how to implement that.  Lab results do not stand apart from the patient.  Two patients can have the same lab values but look and act differently. Conversely, you can have two patients with the same basic symptoms but radically different lab results.  You can have the same disease that presents in several different ways.  A newly graduated doctor has an incredible amount of "book knowledge", and knows a lot.  But they haven't learned how to apply that knowledge.  There is absolutely no way to teach this.  It only comes from seeing enough cases to learn the wide variety of presenting symptoms and clinical outcomes.

Believe me, this isn't disparaging newly graduated doctors.  Every single doctor was a "new grad" at one point, myself included.  I have had to learn many lessons of the years, and am a better doctor for it.  At the same time, I enjoy mentoring newer doctors as I always learn something from them. 

One reason for this entry is to caution laypeople about reading journal articles and text books and then interpreting their cases.  Yes, many times you can learn a lot and I don't discourage.  I also encourage people to be well-informed, ask their doctor lots of questions, and keep copies of lab results and medical notes.  But you have to be cautious in interpreting this information in light of your particular case. There is a reason why becoming a doctor takes years of intense education and why an experienced doctor's judgement is so critical.  Now, this doesn't mean that a given doctor will always be right...we're only human after all, and it's impossible to make perfect decisions every time.  But in general, an experienced doctor will know more than a new graduate and both will be able to handle cases better than a layperson.

For the educated layperson, this means that you should ask even more questions.  Like I mentioned last time, there is nothing wrong with respectfully questioning the "whys" of your doctor's decisions.  But a little knowledge can be a dangerous thing, and you should realize that no matter how much you read, this information can never compare to a doctor with the same information and years of experience.

Never Be Afraid To Ask

In her comments to my last post, Stefani made these statements....

I get records every time I leave, and I go over them. I review bloodwork. I ask lots of questions about anesthetic protocols and monitoring. I go a place that uses licensed techs. I make specific requests. 

I wanted to bring these up for those who don't read the comments because they are great words of advice.  While I think that the average professional deserves some degree of initial trust (or you would never follow any recommendations the first time to went anywhere), I also think that full trust needs to be built.  Part of that depends on the professional you see acting in an appropriate, open, and ethical manner.  But a large part of that  depends on you as the client to do your part. 

A common bit of advice you will hear about medical treatments is to ask your doctor questions.  While I have mostly heard this in relation to human physicians, I also believe this holds true for veterinary doctors.  We as doctors understand what we're talking about, and try to explain it to people.  Unfortunately, some clients are afraid to admit that they don't know what in the heck the doctor is talking about.  And unfortunately some doctors (or other professionals) aren't good at communicating (though this doesn't make them incompetent).

Whenever I see a pet and I'm getting ready to leave a room, the last thing I always ask is "do you have any questions" or "is there anything else I can help you with."  I deliberately and actively make a point to ask something like this whether it's a well pet or a sick one.  I want to make sure that my clients always understand what I'm talking about.

I also strongly believe that any professional should be able to explain rationally, logically, and with evidence why they are doing or recommending something.  I certainly do so in my own practice.  That's why I don't mind when a client questions me or asks for more clarification.  I also have no problem with clients wanting copies of their medical notes or lab results.  If your doctor/vet/professional can't explain their rationalle or isn't willing to give you copies of the records, you most certainly should wonder why and possibly consider switching. You may or may not agree with your doctors reasons or conclusions, but medicine isn't always 100% certain.  Disagreement is okay, as long as the disagreement is for legitimate reasons.

Many doctors don't explain something further not out of a lack of caring, but because silence from a client is often interpreted as comprehension.  Always be willing to respectfully question your doctors, and never be afraid to ask questions.  Taking this attitude will only help you.

A Few Bad Apples

Over my lifetime (all 40 years of it so far) I have seen many people do reprehensable things.  Professional businessmen and CEOs who embezel and drive companies into the ground.  Ministers who steal or hire prostitutes.  Teachers who seduce and sexually abuse their students or other children.  Police officers who abuse their charges, physically beating them.  Respected officials who abuse their power.  Celebrities who are supposed to be role-models falling to drug and alcohol addiction.  And don't even get me started on the problems with politicians.

There's the old adage that a bad apple will spoil the whole bunch.  And I guess that it's human nature to see a prominent figure as a representative of their "type".  But is that really fair?  In recent news we're seeing a barrage of apparent infidelities performed by Tiger Woods.  Does this mean that all professional golfers are likely to be adulterers?  Remember Debra LaFave, the Tampa teacher who slept with her 14 year-old student?  Does this mean that all of my son's teachers secretly want to have sex with him?  Back in the '80s the televangelist Jimmy Swaggart infamously was outed over a relationship with a prostitute.  Should we assume that all preachers are secretly hiding scandalous behavior?

My recent discussion on the potential ramifications of increased legal awards in veterinary malpractice suits has brought this home to me because of similar views of my profession.  Most of the commenters on that entry appear to have a very strong view against veterinarians.  Reviewing some of these people's web sites makes it appear that veteriarians as a whole should not be trusted (and please forgive me if I'm mischaracterizing anyone's comments).  One web site seems to proudly boast that they have received "hundreds" of similar reports of horrible veterinary malpractice from around the world.  Reading these sites you would almost never want to take your pet to a vet again.  And I'm sure these people probably feel that way themselves, as the circumstances they describe seem particularly and legitimately heinous.

But let's put a bit of perspective on this.  Okay, so there are "hundreds" of reports.  Can we assume 500?  Just for the sake of numbers.  And that's from just one web site, so we can assume that only a small number of people contacted that webmaster.  It's also a safe bet that only a small percentage of malpractice concerns are ever reported.  So we need to increase that number many times.  Do you think that a 10-fold increase (5,000) is to small?  Let's go with a 100-fold increase, and say that there are 50,000 malpractice cases that happen. In the US alone there are approximately 200,000,000 veterinary visits annually by all pet owners.  So our 50k malpractice cases represents 0.025% of veterinary visits.  Well, maybe only 1 in 1000 malpractice cases are reported, so there are actually a half-million horrible and malicious veterinary visits annually.  Pretty big number, right?  But that's still only a fraction of one percent of all visits in the US alone, let alone the world.  Suddenly "hundreds" of reports from around the world is a prety miniscule number.

Please understand that I'm not trying to belittle the people who have had truly horrifying experiences with their pets, or who have to deal with someone who should have their medical license stripped from them.  I honestly feel regretful that someone with the same title as I have caused them and their loved ones so much unnecessary pain.  But let's not throw the baby out with the bathwater.  I fully agree that anyone (regardless of profession) who behaves abusively and unethically needs to be fully prosecuted and probably deserves anything they get in the process.  However, it's wrong and unjust to assume that all members of a given profession are automatically guilty of the same behaviors. 

I can honestly say that the huge majority of veterinarians that I've known and worked with are honest, ethical, compassionate, and thorough people.  Yes, there are bad apples in my profession, as there are in EVERY profession out there.  Unfortunately, some people fall victim to laziness, greed, anger, and any other sin.  That most certainly does NOT excuse their behavior, and they need to be faced with the consequences of such actions.  However, I would ask people to exercise some common sense and discretion and not let these people spoil their view of the whole bunch.

Caffeinated Happiness

I have discovered a very important thing about myself.  I am a much happier person when I am full of caffeine.  I'm not much of a coffee drinker, but I drink sodas almost daily (diet only...trying to keep at my goal weight).  Yes, too much caffeine is bad for you, especially with some diseases.  But I'm otherwise healthy so I don't worry about it.  Caffeine doesn't really hype me up too much.  It does get me energized when I'm dragging, but I normally don't get hyperactive on it. 

Does that mean that I'm addicted?  Probably.  But I'm not as bad as some people I've known.  I don't keep an energy drink around, and rarely even buy them (y'know, Red Bull and similar drinks).  I have at most 2-3 sodas per day, and if I have coffee it's no more than a cup.  I know people that need 2-3 cups of coffee just to get going in the morning!  But I definitely do better and am more pleasant with caffeine in my system.

My wife has learned this also.  When I'm feeling frustrated or depressed, she tries to talk me into pumping up on caffeine.  And I can't say that this is a bad thing.  I never realized it until recently, but I feel happier and joke around more when I have had caffeine.

I guess there are worse things to be addicted to.  At least this particular addiction is legal!

Phosphorous Problems

This question comes from Barbara...

My question is what is the highest abnormal phosphorus level that a canine has ever been successfully treated for without total loss of kidney function and maintained on diet & medications. And is there a citable article in any journals?

First, a little bit of explanation on what abnormally high phosphorous levels mean.  There are several things that can cause the phosphorous levels in the blood to increase. The most common reason is for renal (kidney) disease.  As the kidneys fail in their function, phosphorous is retained in the body rather than being expelled.  Other causes can include low parathyroid hormone levels, increased intestinal absorption, acromegaly (a growth disorder), destructive bone lesions, and normal bone growth (mainly in puppies and kittens).  The main thing to keep in mind is that high phosphorous is NOT a disease.  Phosphorous levels don't increase without another reason, and therefore this value is used as an indication of other disease rather than a marker of a specific disorder.

Now let's talk renal disease specifically.  There are numerous reasons why the kidneys may quit functioning, including toxins, genetic tendencies, cancer, and age.  We use several values to assess renal disease, most commonly creatinine, blood urea nitrogen (BUN), and phosphorous.  It is common to have increases in creatininine and BUN with phosphorous remaining normal.  In my experience, if the phosphorous is also eleveated, it indicates a more severe renal insufficiency.  Once the kidneys are damaged, they do not heal.  This fact makes renal failure difficult to treat in pets, and often leads to euthanasia.

Treatment for renal failure is multi-modal.  Special diets are required to help reduce protein stress to the kidney and minimize certain minerals (such as phosphorous).  Fluid therapy may be used to help increase the flushing through the kidneys, helping to prevent build-up of toxic chemicals in the body.  With increased phosphorous levels, medications may be used to bind the phosphoruous and reduce its absorption in the intestines (usually with common antacids!).  Depeding on the cause, other medications may be used to try and more directly treat the underlying problem.

Now back to the question...Barbara, focusing on the phosporous level is not looking at the whole picture.  In your case it sounds like the elevated phosphorous was due to kidney failure.  You need to look at all of the renal values and the urine values and not focus on a single lab value.  If the kidneys are being treated well and phosphate binders are used, the blood phosphorous levels should be controllable.  If the BUN and creatinine are normalized but phosphorous is still high, then more testing is needed to determine why this value is not falling.

The "highest level ever treated" is simply not something that is recorded or even important to doctors.  Journals don't track this data and truthfully it isn't clinically relevant.  Normal phosphorous value can range from 3.0-8.0 depending on the lab or equipment used.  I have seen phosphorous values in the upper teens to low 20s in my own cases.  But truthfully whether a value is 15, 20, 25, or higher doesn't really matter to me.  All of these are significant elevations, and I'm going to treat them all in the same way:  phosphate binders and try to address the underlying cause.  Diagnostic laboratories do keep track of these values to determine what a "normal" range is, but a "highest ever" would be what is statistically called an "outlier" and is insignificant in the analysis of normal ranges.  Therefore these values aren't reported to the profession at large.  Journal articles also don't focus on these extreme values, but instead discuss clinical relevance, especially in the larger picture of the disorder as a whole.  So I hate to say it, Barbara, but your question isn't something that can be answered. 

I hope this at least explains things a little better.  Feel free to ask any follow-up questions.

Sue For Emotion?

It happens from time to time that people will threaten to sue for one problem or another.  Here in the US, as well as in many parts of the Western world, there are people that are ready to jump into the legal system to solve their problems.  Often, this is because of money rather than a true need for justice.  When human medical malpractice settlements and judgements can easily be in the millions of dollars, it's easy to see why some people would be tempted.  But it is quite different in veterinary malpractice claims. 

Pets are considered a special kind of property by the legal system.  Due to this status, a pet owner can only sue for the actual value of the "property" and any medical costs incurred.  For a breeding animal this dollar figure can be in the thousands of dollars due to lost potential revenue.  For a stray it may be less than $100.  Currently people cannot sue for emotional damages due to the loss of the pet, similar to how they cannot sue for emotional damages due to the loss of a car or television.  But this attitude may be changing.

Over the last century the status of pets has changed.  We have allowed them into our homes, families, and beds, and now consider them a part of our extended family.  We have closer bonds to them in ways that were very uncommon 100 years ago.  Our emotional ties have grown as our societies have moved from rural to urban and we have brought our pets in closer contact to our daily lives.  These stronger bonds mean that we often feel the loss even more acutely.  The loss of a pet can generate genuine emotional distress.

And vets are encouraging this.  We celebrate that human-pet bond, calling pets "furry children" and the owners "parents".  In my own practice we delierately call our patients "pets" rather than "animals" to help enhance and recognize this bond.  As medical professionals, we want our clients to care about their pets as much as they do about their children, and get upset when the people don't seem to care as much as we think they should.  Many vets and pet stores sell clothing and other things for pets that make them seem like little people.

As vets we have very low malpractice insurance costs.  I have to pay less than $300 per year to get a $1 million coverage policy.  The same level of insurance for a human physician can be anywhere from $20-40,000 per year.  Someone in a higher risk field such as obstetrics may have to pay $100,000 to get adequate coverage.  Truthfully this has become a crisis in human medicine.  There are more and more doctors getting out of higher-risk fields and specialties due to the outrageous insurance costs.  Doctors are also leaving certain parts of the countries where the courts have historically allowed extremely high settlements.  And a large part of the reason why human health care is so expensive is due to the multi-million dollar settlements and the insurance necessary to cover the doctors.

Now here is the dilemma.  As veterinarians we see what has happened in the human field, and don't want that to happen to us. We pay literally 1/100th of the insurance costs of human doctors, and we don't have to deal with outrageous lawsuits.  Yet we want people to have strong emotional ties with their pets and strongly promote these bonds.  In essence we want to have our cake and eat it to.  We want people to be emotionally attached to their pets but don't want them to be able to sue for damage to this bond. It is also hard for the pet owners, because if we have to start paying higher malpractice insurance costs, these costs will be passed on to the consumer, meaning higher charges on veterinary services.  It also means that we are going to need to be running more diagnostic tests to cover ourselves much like human physicians have to do.

And that brings me to last month's survey.  I asked if pet owners should be able to sue for pain and suffering even if it increased the costs of medical care.  And it seems like people aren't really sure. There was an even split for and against the idea, with 27% each.  And 44% simply didn't know.  As you can see this is a complicated issue.  If people can sue for emotional suffering for themselves or their pets, medical costs will rise. Yet the courts recognize awards for similar suffering in humans, and we are encouraging such bonds and ties with pets.


There are already movements in certain districts in the US to allow pain and suffering awards, though so far only up to a few thousand dollars.  As pets become more integral in our lives, we will likely see this legal trend continue.  And if it does, expect to pay more at your vet.

Fun With Words

Here's a weird thing about me (one of many)....there are certain words I just love to hear and say.  I don't know why, but some words simply sound interesting to me, or I love the specific meaning that they give.  Here are some examples....

Plethora
Ubiquitous
Purulent
Borborygmi
Ornithology

Language can be fun, and I enjoy learning about the origins and underlying meaning of words and phrases.  The English language is such a hodge-podge (there's another good one!) of words from other cultures and languages and is constantly evolving that some people spend their lives studying it.  Unfortunately, people often butcher words, usually unintentionally.  I have learned to live with these mistakes, but it still bothers me sometimes.  For example, there is no such word as "irregardless".  It's simply "regardless".

Anyone else have this quirk?  I'd love to hear other words that people find interesting/alluring/gripping/intriguing/etc.