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Tuesday, June 30, 2009

Quantity vs. Quality

Today I saw the most pets I have ever seen in one day...47! Considering that an average doctor should see 20-25 pets per day that's a pretty crazy number. Probably 40 of those I saw between 2:00 and 7:00, which averages 7-8 pets per hour. Again, that's a crazy amount to see. My practice has a policy that we will see any pet that needs to be seen. We simply don't turn people away. For the most part I agree with this, as it keeps pets from having any delay in diagnosis and treatment when they need it. However, at some point I think that pet care potentially suffers.

It's a question of quality versus quantity. And it really makes me wonder which people want. When I'm seeing almost 8 pets per hour, that averages to spending less than 10 minutes per pet. For a routine puppy booster vaccine this may be enough. But for a sick pet it definitely isn't. Personally I would rather give fewer patients better care. It would also improve client service, as I had several clients wait over 2 hours to be seen. Now, they were warned of the wait and they were happy to sit around, but I still don't like doing that to them.

So it's a bit of a conundrum. Do I turn some people away? The ones I turn away might need only minor care, or might turn out to be a serious case that needs immediate evaluation. Turning people away might mean better care for the pets I do see, but might mean denying care for other pets. Honestly, I've never worked at a location this busy before, so I've never been faced with this dilemma. It's great for business in the short run, but I also need to put aside the business at times and concentrate on being a doctor and providing the best care possible.

So now you can see the challenges of being a doctor and a hospital manager. I am continually weighing the business versus the medicine, trying to find a balance between them. And that brings me to my first ever poll! Look on the top right and let me know what you would prefer.

Friday, June 26, 2009

What Is Quality?

For the past week I have been in meetings to help improve the quality of service, medicine, and performance of my clinic. Having managed veterinary hospitals for the last 9 years, there wasn't anything earth-shattering that I learned. Definitely a few confirmations of what I believed, as well as some new hints and tweaks to my methods, and for that I am pleased. But another thought began to occur to me. How do we define quality veterinary medicine?

In reality, quality is pretty subjective. What might be good quality to one person may not be the same to another. "Quality" is a word that we think we all can understand, but really we need to define it. Is someone a high-quality doctor because they use all of the latest and best equipment? Does a vet give you quality service because they charge less than others in the area? Would someone who is a highly skilled clinician but has poor bedside manner be considered a quality veterinarian? What exactly does quality mean to each person? That's a hard thing to determine, and I have seen my clients vary in these opinions. One may see my need to run numerous diagnostic tests as a sign that I am thorough and consider every possibility to get to the bottom of what is wrong with their pet. The next person may see the same situation as an attempt to drain their wallet.

Since in the end I have to first and foremost answer to myself, I have to be comfortable with how I practice medicine. So here's what I see as "quality". A high-quality veterinarian is someone who puts the concerns and the needs of the pet as the highest priority, even over the needs of the client. This is someone who recommends the best medical care possible, even if the client can't afford it. However, that once the recommendation is made, that quality vet must then listen to and consider the client's desires and abilities (both financially and emotionally). He or she must be compassionate to the humans and animals, but also reserve a bit of detached clinical judgment, looking at a case as objectively as possible. A high-quality doctor is extremely knowledgeable about current medical diagnostics and therapy, and is not hesitant to go through the diagnostic process. Yet they are also very aware of their personal limitations and weaknesses, and will not attempt a surgery or case that would be better served by being referred to a specialist or someone else more skilled in that area. The high-quality vet charges for their services at an appropriate rate, realizing their own personal worth, and not trying to discount and be the cheapest. At the same time, they do not look at finances as the end goal, only a means to accomplish their medical efforts. In short, a high-quality vet is compassionate, knowledgeable, and skilled in modern medicine, considers the health and needs of the pet as their highest priority, and isn't afraid to stand by their diagnostic plans and charges in the face of some resistant clients.

Does that sound like your vet, or someone you would want to take your pet to? If not, why not? As I study ways to improve managing my own clinic, I have to worry about these issues and how clients will perceive them. Once I was told that clients have a choice. Their medical services can be fast, high quality, or cheap. The client can have two of those three choices, but not all three. Which would you choose?

Sunday, June 21, 2009

Do People Still Fall For It?

Anyone reading this blog has at least a basic knowledge of the internet, email, and everything that entails. Which means you are also likely aware of the various email scams out there. Most of them come from someone overseas that needs help moving money, and promises you several million dollars (pounds, etc.) if you will help them. I receive those emails virtually daily on all of my email accounts (I have three). The one I use for my blogs isn't used for any other communications, yet I still get 10-15 per week.

Knowledge that these are scams is very common, and has been reported on the internet, TV, radio, and print media. There shouldn't be anyone using computers that doesn't know that these are bogus and are used to bilk people out of considerable money. Yet they are still ubiquitous on the internet. This must mean that there are still people out there who fall victim to these emails, or it wouldn't be worthwhile for the perpetrators to send them out. And that boggles my mind. I know that people want to get rich quick and want free money. But come on! How desperate, ignorant, or out-of-touch do you have to be to believe that these emails aren't scams?

It's sad to me that people are evil and greedy enough to submit these emails. They should be persecuted to the fullest extent of the law regardless of their country of origin. But it's even sadder that people still fall for it. Use common sense and just delete these emails!

Saturday, June 20, 2009

Are You Ready For The Hair?

We're in shedding season, if you haven't figured that out by now. That makes me think about the type of fur pets have, and what people have to deal with. Personally, I would never have a long-haired pet because of the high maintenance. I have seen too many people come in with heavily matted dogs and cats, or have to get them groomed every month or two to keep the coat manageable. It's a lot of work! It's also important since a matted coat can trap dirt, cause skin irritation, and can be painful as the hair pulls the skin.

Thick coats can be as bad as long ones. Dogs like Siberian huskies and German shepherds have dense undercoats that will come out in clumps during the warm months. These coats require regular brushing to keep them from being a problem. Honestly, these dogs don't need to be shaved down, just brushed daily.

Unfortunately, many pet owners don't think about this when they get a pet. That little lhasa apso puppy is so cute, but the people don't know what it takes to manage the coat. It's a lot of time and cost, and not doing so can affect the pet in a negative way. It's an unavoidable consequence of these kinds of pets. Definitely think about maintinence when you pick a certain breed!

So keep up with those coats. Brush and see the groomer. Your pet will be better for it, and you'll want to be closer to your pet.

Wednesday, June 17, 2009

"That Flea Medicine Isn't Working!"

This time of the year it's a daily occurrence to talk to my clients about flea control. Here in the southeast US we have a lot of fleas, especially during the warm weather, so flea prevention is a necessity. Without using it, you're just asking for flea problems. However, many clients apply one dose, a week later see fleas, and complain that it isn't working. Last year I wrote an entry about flea control, which I wanted to remind everyone about (right here). But here's a quick review...

*A single dose of flea prevention will NOT get rid of your flea problem.

*Fleas have to jump on the pet in order to be affected by the topical preventions.

*You have to treat the house and yard in order to completely control the problem.

*Every pet in the house must be treated.

*You can't bathe your pet too often or you will cause the product to work less effectively.

*Once you start seeing fleas it will take you several months to get the problem under control.

*Flea medications work best as prevention, before you see fleas.

So basically you need to use the topical products from your vet very consistently every single month, treat the environment, and avoid overbathing. All of the current veterinary products (Frontline, Advantage, K9 Advantix, Vectra, etc.) are indeed effective, but must be used regularly and appropriately in order to work. Don't give up after a single dose!

Monday, June 15, 2009

Can You Hear Me Now?

A stetheocope is a very important piece of diagnostic equipment that every physician and veterinarian uses. High quality ones can cost $200-300, so this is not simply a rubber tube, ear plugs, and a head. With a good stethoscope you can hear very subtle changes in the heart and lungs, aiding in the diagnosis of cardiac and pulmonary disorders. Very small differences and alterations can be difficult to hear with a lot of ambient noise, so we try to listen in quiet areas. To aid in hearing these faint sounds, the ear buds fit very snugly in the ear canals, keeping sounds from overwhelming what you are trying to hear.

Why am I describing this? Because I want you to understand that when we put the stethoscope in our ears, we are deliberately trying to filter out and elminate all sounds except those coming through the bell on the head. In fact, if we are using a high-quality stethoscope, it's difficult for us to hear anything except what's coming through the instrument. And why is this important to know? Because I constantly have clients try to carry on a conversation while I'm using it.

Yep, it happens every day. I will talk to a client, then pause to listen to their pet's chest. While I'm listening, I can see their lips move or hear a little bit of their voice. And what little I hear I try to ignore so I can listen for any abnormalities in the heart or lungs. I think that most of the time they don't realize that I can't hear them. I try to be polite, but sometimes it's hard to say "I'm sorry, I couldn't hear a word you were saying." Even after 12 years of practice, I still find this a hard thing to say.

So the next time you go to your doctor or vet, pause while they're using their stethoscope. They really can't hear you, even if they want to. Wait until they're done and then continue the conversation.

Saturday, June 13, 2009

Good News....It's Normal!

Making a diagnosis and implementing a treatment plan is not something that happens instantly, but is a process. When we as doctors see a set of symptoms in a patient, we have a list of possible diseases or disorders in our mind. We then need to try and figure out which of those possibilities is the likely correct one. With many patients we can't determine which problem is the right one merely on symptoms alone. For example, let's say that a patient comes in for excessive drinking and urinating. Possible causes include diabetes, kidney disease, a urinary tract infection, or Cushings disease. Each of these are radically different disorders with equally different treatments. We can't simply try a treatment and hope it works. If we put a patient on antibiotics for an infection, we could be delaying needed treatment for diabetes.

So we run tests. Let's say that in this fictional patient the blood glucose and kidney values are normal, there are no abnormalities suggestive of Cushings disease, and there are bacteria and white blood cells in the urine. The conclusion here is that the patient has a urinary infection, and we place her on antibiotics. At this point some people would think that those other tests had been unnecessary, and might even ask for their money back. Yes, this happens, and it frustrates us vets. We have no way of knowing what the results would be before running them. Sorry, we usually forget to bring our crystal balls to work. The way I try to explain it is that these normal results are GOOD news. We have just ruled out the possibilty of several serious diseases, and this is something we should be happy about. The tests weren't pointless because we didn't know what the results would be ahead of time.

Coming to a diagnostic conclusion is rarely as simple as just examining a patient. Almost every symptom has at least a few possibilities, and we need to do tests to try and figure out which one it is. When we have those results we can determine which of our possible illnesses are more or less likely, and then proceed to the next round of tests or begin treatment. So when your own pet comes up with normal test results be happy about it, and realize that your vet is merely trying to help you by properly diagnosing the problem.

Thursday, June 11, 2009

"Do I Have To Pay Again?"

How many of you have gone to your doctor for a problem, had a tentative diagnosis made, and a treatment plan prescribed? Then if the treatment doesn't work, you go back again. Would you demand free treatment then? Would you demand a refund on your money for the medicine that didn't fix you?

What about a mechanical problem on your car? You take it to the garage and they replace a part they suspect is the problem. Well, the problem doesn't go away. Would you demand that they fix it for free since you already paid once?

In situations like this I bet that most people realize that not all problems can be fixed quickly, and that it's often a process that can take some time or trial and error. Why does it seem like people don't consider vets in this equation?

It's not uncommon for me to have clients that are unhappy about having to pay for a follow-up exam. We also have people that don't want to pay for a second round of medications when the first ones didn't work. It seems that they think that because we didn't diagnose and correct the disorder on the first go-round, that we should somehow be responsible for any further follow-up. I hate to tell them (and any readers who feel this way), but medicine is not always precise. I sometimes tell people that medicine is as much art as science. Some problems are easy to diagnose and fix. Others simply aren't, and take repeated visits and attempts to find just the right solution. These follow-ups cost the doctor time and money, and so that cost gets passed on. Our knowledge and time is worth money. If we didn't get paid for it, we couldn't do what we do. Failing to correct a problem on the first visit is not a sign of incompetance. It's indicative of the disease process itself, not the attending doctor. Sometimes an important part of the diagnostic process is response (or lack of response) to therapy.

So give your vets (and physicians, and mechanics) a bit of break. We really do want to help and do it as quickly as possible. When we have to see you back it doesn't mean that we didn't do our job, but that we're actually doing it!

Wednesday, June 10, 2009

Feeding Pregnant Dogs

I think you all know by now how much we vets talk about how important it is to feed pets the proper pet food, and not to feed people food. Believe me, we're not in the pocket of the pet food companies, and are just trying to help you take care of your pets. Here's another reason why.

Mattie was a little dachshund, about 2 years old. I saw her last week for sudden weakness, incoordination, and overall just acting strange. She had given birth to a litter of 5 about three weeks previously. As I did my exam I noticed a dazed look to her eyes and muscle trembling, even though she was alert and could walk around. My immediate thought was a low calcium level, and lab tests confirmed this. I spoke to the owner, and he said that his wife kept insisting on feeding the dogs hamburger and hot dogs, and that Mattie didn't eat much dog food. That's where the problem was, and he agreed with me.

When a person or an animal is pregnant, the baby (or babies) don't take in their own food. Every bit of the nutrition they get comes from the mother, including minerals. The babies are drawing a lot of calcium from the mom as they begin to develop and grow bones. Mom also draws a lot of calcium from herself by making milk, which the babies further reduce by nursing. If the mother isn't getting any extra calcium in her diet, she will use her own body's stores of it, potentially putting her in a dangerous situation. That's what happened with Mattie. By eating mostly "junk", she was not getting enough calcium in her diet. The pregnancy and nursing of a relative large litter further depleted her.

Calcium is important for a number of reasons in the body. Everyone thinks about it in relation to bones, but it is also essential for proper muscle contraction. Hypocalcemia can lead to poor muscle contraction and coordination, including the heart. This problem can develop rapdily, but thankfully is easilly corrected. I gave Mattie intravenous calcium supplements and she responded quickly, going home at the end of the day. I made sure to have the owner talk with his family and let them know how dangerous this was. Female dogs and cats should be on a high quality puppy/kitten food from the time they become pregnant until the babies are weaned (at around five weeks old). The extra nutrients in the juvenile food will help to support the adult mother during the pregnancy and nursing, similar to prenatal vitamins taken by human mothers.

Mattie is now doing great, and I think the family learned an important lesson. Their bill was a little over $300 last week, and this was a preventable issue if they had only fed the right kind of food. A bag of dog food doesn't seem expensive by comparison, does it?

Sunday, June 7, 2009

Escaping The Modern World

Sometimes I think it's easy to forget that doctors are just people. We have interests and hobbies outside of medicine. Our lives aren't filled with diseases, injuries, diagnostics, and surgeries 24/7. We aren't constantly thinking about medicine. And sometimes our other interests are far removed from our jobs. In my case one of these departures is Renaissance Faires.

I have always had an interest in Medieval and Renaissance time periods. The ideas of knights, damsels, intrigue, and swashbuckling have always drawn me to them. When I was in college and was required to take Physical Education courses, I deliberately chose classes in this vein: archery, fencing, and canoeing. When I was in graduate school I attended my first Renaissance Festival and was hooked. That was back in the early '90s and I haven't given up since then. I took my wife to one when we were dating, and she began to embrace them as well. Over the years we have collected clothing and equipment for several outfits and have gotten our kids interested in the hobby.

For those of you who have never been to a Ren Faire, let me describe them a bit. They usually begin in the Spring and the "season" lasts into the Fall. Depending on the size of the Faire, some will last anywhere from a week or two to several months. They are held on the weekends in parks and other natural areas where permanent buildings are often erected. Once inside the Faire you can visit artisans and vendors for clothing, weapons, tapestries, candles, jewlery, and many other crafts. Official workers at the Faires walk around dressed in period clothes, and will enact various scenes to tell a larger story that goes on throughout the day. There will be a king and queen presiding over the affairs. And there is usually an arena where live jousts and swordfighting happen. The larger Faires will have stages where other performers will give shows ranging from music to comedy, daring acts of tightrope walking or juggling, and singing to belly dancing. Many attendees (such as my family) also dress in costume to the point where it can be difficult to tell who works there and who simply showed up.

The Faires are not always interested in complete historical accuracy, and are more about the idealized versions. They exist more for fun and escapism than anything. But it's so nice to be able to spend a sunny day wandering for miles in a world pulled from the 15th, 16th, or 17th century. For a day you can imagine yourself a stalwart night, a dashing musketeer, a rougish pirate, or a delicate princess. You can address people as "my lord" and not feel silly. You can say "huzzah" when you cheer and feel completely at ease. And above all you can pretend that the worries of the 21st cenury don't exist for a few hours.

For those of you who have never been, I would highly recommend it as a fun family outing. Who knows, you might actually run into me and my family one day.

Friday, June 5, 2009

X-Ray Week: Knee Problem

This dog came to me because of fluid draining from his knee. Over a few years he had undergone two surgeries for a torn anterior cruciate ligament (ACL). I could feel the suture material in the knee, and was concerned that the fluid had been caused by the surgery. Over time the suture had caused inflammation and irritation in the joint, which had begun draining through the skin. To see there was any problem with deterioration of the bone, I took some x-rays.

There are two things that stand out on these x-rays. First, the suture material had broken, likely leading to significant irritation. Second, the suture isn't placed correctly. One of the loops should be placed behind the knee, not to the side. I don't know if the suture migrated, or if the vet who did the surgery didn't do it correctly, but the suture material wasn't doing anything to help the problem and in fact was causing more problems. I recommended that the dog go to a surgical specialist to remove the suture and repeat the surgery a third time, this time properly. I never heard back, so I'm not sure if the owner ever did it.

Thursday, June 4, 2009

X-Ray Week: Esophageal Disorder #2

This case is from a middle-aged dog that my associate saw. He had been vomiting frequently, so she took some radiographs of his stomach and chest. The ones from the chest were the most interesting. See if you can notice the problem here....

The vets reading this probably can see the issue. We have lots of training and experience in seeing subtle problems. For the laypeople, take a look at the parallel white lines through the chest. Here is the same image with some highlights to emphasize this.

See it now? This is a pretty big abnormality, and indicates an extremely abnormally large esophagus. Megaesophagus is most commonly diagnosed in younger dogs, and is usually the result of a persistent arch around the aorta that encircles the esophagus and crimps part of it. The esophagus is stretched so much over time that the muscle looses tone and it becomes very dialated. Other causes can lead to the same result, including metabolic disorders such as thyroid disease. Unfortunately, this is a permanent disorder where the muscle comprising the esophagus is too loose to be able to contract. This means that food can't go from the mouth to the stomach very easily, and requires life-long special feeding.

More orthopedic x-rays tomorrow.

Wednesday, June 3, 2009

X-Ray Week: Esophageal Disorder #1

Here's a bit of a strange case for those vets reading this blog. And some cool images for everyone else.

This dog came to us about 3 weeks ago for vomiting. Blood tests showed nothing abnormal, so my associate started her on anti-nausea medication and some easily digestible food. The dog was acting good overall, and is a 2 year-old spayed female terrier mix. The problem didn't seem to get any better, so the client brought her back. This time we did x-rays. When we start this kind of diagnostic we do what we call a "plain film", which is a basic x-ray. This is what we found.

See the problem? Yeah, neither did I. So I made the dog swallow barium liquid and took another set of radiographs immediately afterwards. Since barium is a metal, it shows up bright white on an x-ray film and will often highlight things that aren't obvious in any other way. Here's what we saw.

See the problem now? The first image is less obvious, but there is a bulge in the esophagus just before it passes through the diaphragm and into the stomach. This is due to one of several things. There could be a hiatal hernia, where part of the stomach bulges back through the diaphragm and into the chest. But a more likely possibility is that there is a narrowing of the esophagus just before the stomach. So the dog wasn't actually vomiting, it was regurgitating the food. She would swallow too much too fast, and since it couldn't pass into the stomach most of it would come right back up. She is doing well being fed small, frequent meals of soft foods. But she is also being referred to a specialist for upper GI endoscopy to visualize what the problem is and how we can fix it.

This is also a case that illustrates the importance of continued diagnostics. I had to convince the owner to do the barium views, but that's what it took for us to make the diagnosis. I had suspected a problem like this, but we needed to be able to actually see it. So when your vet recommends doing further testing, please listen to him or her!

Tomorrow...a different problem in the same area.

Tuesday, June 2, 2009

X-Ray Week: Broken Paw

Here's an interesting set of images that I thought many of you would find interesting. This dog is a boxer puppy, about 5 months old. He was playing with a neighbor's dogs when one of those dogs bit him hard on the foot. Normally this would cause some wounds, but not necessarily anything serious. Not so in this case. There really weren't any deep wounds, but there was some obvious damage to the foot. When he came in I could tell that the paw was at a slightly odd angle, and the x-rays confirmed it.

All four metacarpal bones are broken, and a couple of them are pretty displaced. In a human these are the bones in the hand between the wrist and fingers. Being a young puppy he has a great chance of this healing. However, the misalignment of the bones is significant enough that he probably needs surgery. Splinting this has a relatively high likelihood of improper healing, though we placed a temporary splint to stabilize it. I saw him for a recheck today and he's bouncing along on his splint like it doesn't bother him, which isn't good as he really needs to have more restricted activity.

I'll be posting some other interesting images as the week goes on.