How "Obamacare" Will Affect Pet Owners

Here in the US the government is in the early stages of starting to implement the Affordable Care Act, more commonly known as "Obamacare" since it was heavily pushed by President Obama.  I'll try to stay mostly politically neutral, but it's no secret that I am socially and politically conservative, so you can probably guess my opinion on this particular piece of legislation.  The idea is that it is supposed to provide more and cheaper access to health care for people who don't normally have health insurance.  This is going to significantly increase costs in the US and will affect all citizens.  In order to help offset some of the costs of health care there are going to be new taxes and charges.  Okay, I understand this even if I disagree with the policy.  What surprised me was recent news of how this will affect the veterinary industry, and how this is a very unintended consequence of the law.

One of the new taxes is a 2.3% excise tax on all medical equipment.  Anything manufactured for the human medical industry is subject to this tax, effectively raising the costs of this equipment by 2.3%.  That cost will be passed on to the consumer, but is supposed to somehow be offset by lower costs elsewhere.  Okay, maybe some will understand that.  But there is a problem.

The tax is applicable to anything made for use in human medicine but not veterinary medicine.  Anything labeled exclusively for veterinary use is excluded and not taxed.  However, there is a lot of equipment we use in this profession that is also used in on humans.  That means that when we order this equipment for use in our veterinary practices we will pay 2.3% more.  And that increased cost will be passed on to the pet owner in the form of increased fees.

This isn't a good thing.  Some reports that I've read say that the costs will be minimal, but the end result is that veterinary care will increase, even if a little bit.  Unlike what is happening with human medical care in the US, the government isn't paying for our pet care.  In fact, the government is taxing pet care, even if unintentionally.  Because of the attempts to fix our broken health care system in people, we are putting more of a pinch on the purses of pet owners, and this may mean that people won't be able to provide their pets the care they need.

There are many unintended consequences here.  I wish the politicians had thought this through better.

Do Vets Love Science?

Bonnie sends this in....

My daughter is a sophomore in high school and has wanted to be a vet for some years.  She is getting a taste of honors biology and chemistry and says she doesn't love science (except she does like biology).  She thinks she needs to be a science buff to be a vet. I'm sure many vets loved the science.  But I wonder, do some vets go on to be successful in the field and say they toughed their way through science classes to enjoy/excel at the rest?

Science is obviously important to a veterinarian.  We have to have a strong grounding in various scientific disciplines, especially biology.  But that doesn't mean that we have to love all sciences.  

I'm not sure if the standards have changed, but when I was in my undergraduate pre-vet program I had to have extensive biology courses, a lot of chemistry, and two semesters of physics.  In fact, I had to take so much chemistry that I took one elective chemistry course and qualified for a minor in that field.  Basic physics is necessary because there are certain principles that apply to medicine, especially the equipment, that makes it easier to understand with the proper background.  These are the core sciences that an aspiring veterinarian needs.

While I love science in general, beyond the above disciplines I don't have much interest.  Geology is uninteresting, and I know meteorology mainly through my wife's paranoia about bad weather.  I actually don't even like ecology, even though it's related to biology.  So being a "science buff" isn't necessary.

I graduated with a BS in Biology and a minor in Chemistry.  But that's not even necessary for veterinary school.  Many of my classmates had a degree in Animal Science, which is more focused on the practical aspects of animal management, especially livestock.  In a way, that may be a more appropriate major as I had no experience at all with livestock until vet school, yet my classmates with an Animal Science background had already been exposed to this information and found it easier to remember.

Your daughter needs to keep focused on biology and chemistry, but it's also important to have good communication and writing skills, so don't neglect the English classes.  Math is also important, though don't ask me why calculus is required....I received an A in both semesters in college, but can't tell you exactly what calculus is and certainly don't use it in practice.

Best of luck to her!

When A Clinic Comes To A Screeching Halt

It was a busy but otherwise pretty normal day.  We had lots of appointments, routine surgeries, and patients dropped off for minor illnesses and well visits.  Thought it was a little hectic, we were getting through okay and I anticipated being able to get a short lunch break for the first time in over a week.  

I should have known better.  

It started with a hollered "Kain is seizuring in the car!"  Kain is a 120 pound Presa Canario who started having seizures a few months ago.  He is a sweet boy but rather large and strong.  At seven years old we were worried about the seizures, but they were mild and infrequent and all lab tests were normal.  We had elected to not start him on antiseizure medication yet because it only happened a few times.  Until today.

Kain had been seizuring off and on for nearly and hour by the time the owner managed to get him in.  He couldn't walk in on his own and wouldn't stay on the wheeled gurney, so the owner somehow was able to carry Kain into the treatment area.  The dog was scared, breathing heavy, and disoriented.  Everything in our well-planned day came to a grinding, screeching halt.  Three assistants tried to restrain this dog that outweighed at least one of them and was stronger than all of them while a fourth tried to place an intravenous catheter.  Between his struggles and poor positioning this wasn't an easy task.  My associate was trying to get our surgery cart over to him so we could get oxygen up to his face.  That's when we discovered that the tube from the machine wasn't designed to reach all of the way to the ground, something that had never been an issue before.  Putting him on an exam table wasn't an easy prospect given his weight and the fact that he kept trying to struggle and move around.  It was better for him to be on the floor, and easier for us to work on him there.

Out of the six people in the back of the clinic I was the only one not directly involved in the case.  And that's because I thought it was best for me to stay back and not add to the crowd around the dog.  I tried to help from afar, getting drugs and materials, but knew I'd only get in the way if I tried to get in the middle of things. While that many people on one pet may seem excessive, it really did take that many to keep him restrained and allow work to be done.

Unfortunately, that meant that there was nobody available to do the dental cleaning and spay that had yet to go under anesthesia.  And since we only have one anesthesia cart which was being used to give Kain oxygen, it wouldn't have mattered much if someone was free to help me.  So for nearly two hours the team worked on this one dog until we manged to get him controlled, oxygenated, and heavily drugged.  As we reached this point we were finally able to start allowing people to take lunch breaks and could start to concentrate on the remaining procedures.

Of course, by this time we were well into the normal afternoon appointment times.  I had anticipated this happening and had the receptionist start calling to reschedule appointments.  In the end we had to move six different appointments, having gotten about 90 minutes behind, even with us doctors basically skipping lunch.

We're not sure what is going to happen to Kain.  The owner can't afford to take him to a specialist and we don't know if we can control seizures like this easily.  Tomorrow we'll find out how he did overnight and see if he still has some time left before they make a final decision.

This also illustrates how even in a general practice we never know what is going to come through the door and how that will affect us.  Experienced vets and staff know exactly what I'm talking about.  Vet students?  This is your future.  And to pet owners out there who don't work in the field, please understand that if we ask you to reschedule because we had a sudden emergency, we don't do so lightly and we really do have times when we have to drop everything to save a life.

Reconstructing A Face

**WARNING--GRAPHIC IMAGES**

I enjoy surgery, especially soft tissue.  So when a dog came in with a large mass on his jaw my associate had me take a look to see if I could remove it.  The dog was a sweet, older lab mix, and the mass had started as what appeared to be an insect bite or small puncture.  It grew quickly and didn't respond to antibiotics, so the decision was made to remove it.  By this time the mass had gotten large and was tightly attached to the jaw.  After the exam I decided that I could probably take it off, but it was going to be tricky because there wasn't much loose skin.  This meant that I would have a challenge trying to close the wound I would make.  

Here is the "before" picture.

As you can see, this was a really nasty mass that had eroded through the skin.  It was deep enough that I was worried about having to scrape the bone once I got in there.  For days before the surgery I kept running through my mind how I would put everything back together.  It was a daunting task, but I like a challenge and like this type of surgery.  I wasn't completely sure how it would go until I started cutting.

Here's some intraoperative pictures.  I got a new phone that I'm using to take pictures, and it made this look redder than it actually was.  However, this absolutely was a bloody surgery.

The mass went quite deep, but didn't quite reach the bone.  And you can see that there is a significant gap that I had to pull together.

That's where a bit of creativity comes in.  The skin doesn't stretch enough in this area to get the edges together.  So I cut the corner of the mouth and loosened the tissue so I could advance the skin forward.  To allow for a relatively normal ability to open the mouth I sutured the top of the incision backwards, preserving the anatomy pretty well.  Here is the post-operative appearance.

Not bad!

The dog recovered well and was doing well a the time of the suture removal ten days later.  Unfortunately the case doesn't have a happy ending.  The biopsy report came back as squamous cell carcinoma, an aggressive cancer.  It has a low risk of spreading in dogs, but still isn't a good thing.  A couple of weeks later he came back because he was having difficulty walking in his hind end and seemed possibly painful.  He was placed on pain medications and antiinfalmmatories, but this didn't improve his condition.  Less than a week after the medications he was unable to move his hind end or stand.  When I examined him he seemed to have neurological deficits related to his spine.  I suspected that either there was spread of the cancer to his spine, or a blood clot had lodged in his spinal cord.  Regardless of the cause it wasn't good, and the owner decided to euthanize him.

Even when a surgery goes well the case may not end happy.  Those are the ups and downs of being a veterinarian.

Choosing A Vet School

Kerrie sent me this....

I have been accepted to 2 vet schools, Minnesota and UPenn.  Both are out of state so the tuition is the same.  I've been trying to collect people's opinions on how to decide which school to go to.  I've heard some students/recent grads say that all schools provide roughly equal education because they can be so picky with the students they accept, I've heard some say the caseload of the hospital is the most important thing, and I've had others tell me how important the early hands-on experience is.  As someone who has been practicing for quite some time, what things about the school you attended were most beneficial to you once you became a vet?  Are there certain things you wished you learned or were exposed to while in school before you started practicing?

Here are a few examples of things I am comparing, I'm just wondering how much of a difference each makes in the grand scheme of things:

MN has professional development classes in the curriculum and begins clinical skills practicals the first year, whereas UPenn doesn't include professional development as part of the curriculum and hands-on things don't start until the 3rd yr, but there are opportunites to do both early on through clubs and workshops.

MN also claimed to have a higher annual caseload at the teaching hospital (45,000 vs Penn's 30,000).

MN class size for this upcoming year is 100, UPenn's is 125.

UPenn recently built a new hospital, MN is in the process of renovations so the facilities were comparatively dated.

Many students who hope to become vets are happy to get accepted in just one school.  But some are lucky enough to get multiple acceptance letters and then have their choice of schools.  How do you make that choice?

If you talk to the academics, each school will list all of the reasons why you should go there rather than somewhere else.  They'll bring up things like Kerrie mentioned:  case load, new facilities, etc.  There will be points and counter-points about the particulars of a given school's instructors and what they can offer.  Then you have to weed through all of that and make a decision.

As someone about to enter my 16th year in practice, I look at it very differently.  I've also seen many new graduates from virtually every vet school, including some outside of the US.  I take a very practical approach  to the situation, and look at it in the light of whether or not it will make a difference after you've been out a few years.  And in my opinion, it doesn't.

Seriously.  When I'm interviewing a potential hire, which vet school they attended is really only a point of conversation, not something that I really weigh in my decision.  If you're going into general practice, the choice of vet school doesn't matter much.  Sure, you might get some different experiences at one school versus another, but after you've been out a couple of years your practical experience outweighs and evens out what you learned at the university.  

What would I have liked to have more of?  Dentistry and finance.  When I was going through school the former was barely discussed and the latter not at all.  Knowing how to do basic extractions and dental care is something you deal with on a daily basis.  Personal and business fiance is essential to daily life.  Both of these are far more important than learning how to do a total hip replacement or using the most advanced method of radiation therapy.

Due to AVMA accreditation, all schools must meet certain standards, and I honestly don't think graduates from any one school have a particular edge over another.  I graduated from North Carolina State University, which consistently ranks in the top five veterinary colleges in the US.  I don't think I got a better education than anyone else, and don't think I was better prepared than a lower ranked college.

So which do you chose?  In my opinion, chose the cheapest.  Always go in-state if you have that option, as it will be cheaper.  When looking at out-of-state schools pick the least expensive.  The debt load on newly graduated vets is crushing and only getting worse.  The best thing you can do in your career is help yourself out financially.  

When you combine a basic education with practical experience, the knowledge and skills of being a vet will take care of themselves.  And you'll continue to learn as you go along.  I've learned as much in continuing education seminars as I did in school, and in some cases far more.  Pick a school you like, and most importantly, pick a school that will put you in the best financial position.

Too Long Dog Nails

Stefanie asked me the following question, and it's one I get from time to time in my clinic.

I have a question on how to keep a dog's nails trimmed naturally.  I walk and/or hike with my dog at least 6 times a week.  The hikes/walks typically last from an hour to two hours.  However, her nails are pretty long.  For a few months - I tried taking her to the vet for a nail trim every 3 weeks to try and get the quicks filed down.  It wasn't working.  My vet suggested maybe putting her under an anesthetic to file her nails down better with a Dremel or even going so far as to putting her under and cutting the quicks back (a choice even my vet felt would be quite painful and something to be used only as a last resort).  

I am doing my best to use a regular (human) nail file on my dog's nails and there is a little bit of resistance but I am hoping that eventually (with lots of treats) she will learn to tolerate it more.  

Do you have any other suggestions for how I can get her quicks under control so she can get a proper nail trim?  We live in Arizona so the hiking surfaces are pretty hard so I don't understand why her nails aren't being worn down naturally.   

My first question would be whether or not the nails are actually long.  I have many clients who complain about how long their dog's nails are, yet they seem perfectly normal to me.  Dogs are supposed to have prominent nails which serve a function similar to cleats on athletes' shoes.  The nails give traction when running over uneven surfaces.  Cheetahs are the only cats with nails that don't retract, again for the same reason of traction.  So a dog's nails are supposed to extend to the end of the naturally growing quick and make contact with the ground.  It's actually abnormal for a dog's nails to be small nubs and too short to reach the ground.

Routine nail trimming and walking on hard or abrasive surfaces are the best ways to keep the nails at a normal length.  Rough surfaces naturally wear the nails down, and it sounds like you're doing that, Stefanie.  However, this will only keep the nails back to the quick and may recede the quick only a little bit.  At some point normal anatomy takes over and the quick won't go back any further.  In these cases natural genetics determine the length of the quick and you can't easily overcome that.  If regular nail trimming, nail filing, and hard surfaces several times per week are being done, the nails are already as short as they should be according to her genes.  Trying to make them shorter will require some unnatural methods.

Some vets will advocate cutting the nails and quicks back under anesthesia, as you describe.  They may also offer cauterization.  However, I'm not personally convinced that this will actually work.  It's like if you tore off one of your own fingernails, the nail would try to grow back, even if it had an abnormal appearance.  When I was very young I got one of my fingers caught in a heavy door and it almost removed the tip of the finger.  It healed and the nail regrew, but it looks a little different from the rest of my fingers.  Even though it is a bit abnormal, it still grows at the same rate and length as my other nails.  A dog's nails will try do to the same thing.  Also, it is quite painful, just as if you tore your own fingernails into the quick.

Stefanie, this may be the best it's going to get.  I know that's not a satisfying answer, but I think it's important to know that.  

Types & Frequency Of Surgery

J Bob left this as a comment on a recent entry of mine.

I was wondering how often you get emergency surgeries vs. how often you get routine ones (such as spays)? 

Also, is most of your time spent doing surgery or doing other things such as check-ups?

First let me say that I'm a surgeon at heart.  I have consistently found that virtually every vet falls into one of two categories: surgery or medicine.  Some do surgery because they have to and really thrive on dealing with the diagnostic challenges of medical cases.  Others love surgery, often repeating the adage "A chance to cut is a chance to cure."  I definitely fall into the latter category and would be happy spending the majority of my day in the surgery suite.  I considered going into surgical specialty, but I was tired of school by the time I graduated and don't like orthopedic surgery, so opted for general practice.

That being said, I spend far more time on things other than surgery.  It's the nature of a general veterinary practice.  On average a spay will take me around 15-20 minutes of actual surgery time, but there is pre-surgical preparation and post-operative recovery, all of which extends the turnaround time in the single surgery room we have.  Some surgeries will take shorter (I average 60 seconds for a cat neuter and 7 minutes for a dog neuter), while others take longer.  I see around 20-25 pets per day, and in the time it takes to do a few surgeries I could see 3-5 patients in rooms.  Take all of that together and I will do an average of 3-4 anesthetic procedures per day.  This number includes dental cleanings as well as routine surgeries.  In order to accommodate all of the patients who need to come in I have to minimize the surgical procedures.  In a surgical specialty practice the surgeries are far more complicated and lengthy, which means that a specialist may only do 3-5 surgeries, but take the majority of the day doing so.

Routine surgeries (spays and neuters) are by far the most common ones.  I'll do at least one of these procedures every working day, and often more than one.  Non-urgent, non-routine surgeries such as mass removals, bladder stone extractions, and so on happen maybe once or twice per week and it's not uncommon to go a few weeks without doing something like this.  A true "drop everything" emergency surgery happens only a few times per year, probably no more often than once per month at the most.  Between all of that are urgent but minor surgical procedures such as wound repairs.  These usually need to be done the same day, but are short enough that they can be worked into the regular schedule.

To me surgery is the most fun and interesting part of my job.  I wish that I could get to do more of it.