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Friday, February 26, 2016

Toxoplasma Doesn't Cause Mental Disorders?

Toxoplasma gondii is a parasite transmitted through rodents and sometimes found shed in cat feces.  Historically it has been a concern among pet owners because human infection is possible.  While in most cases humans only have flu-like symptoms, it can cause problems with the fetus when pregnant women become infected.

In recent years this parasite has become a new concern because evidence came out that the parasite causes behavioral changes in rodents and could do so in humans.  To quote the Wikipedia entry on the disease:  

A number of studies have suggested that subtle behavioral or personality changes may occur in infected humans, and infection with the parasite has recently been associated with a number of neurological disorders, particularly schizophrenia. A 2015 study also found cognitive deficits in adults to be associated with joint infection by both T. gondii and Helicobacter pylori 

However, a recent study by Karen Sugden et al. at Duke University** has given some evidence that psychological and behavioral changes previously described may not exist after all.  

Our results suggest that a positive test for Tgondiiantibodies does not result in increased susceptibility to neuropsychiatric disorders, poor impulse control or impaired neurocognitive ability…  this is, to our knowledge, the most comprehensive assessment of the possible link between T.gondii infection and a variety of impairments in a single cohort.

This is, to our knowledge, the most comprehensive assessment of the possible link between Tgondii infection and a variety of impairments in a single cohort. Previous positive associations have been reported across different studies, often in selected or clinical samples; for example, one study will examine the link to violence, another the link to schizophrenia, and yet another the link to self-injury, and so forth.

Is this definitive?  I'm not sure about that.  Several other studies have shown some degree of correlation so I'm not completely ready to rely solely on this more recent paper.  However, the results are interesting and certainly call into question some of those previous research.  

The main point to take away is that toxoplasmosis is very uncommon from pet cats, and few cat owners are at risk from any kind of disease due to this parasite.  There is reason to be cautious, but people shouldn't get rid of their cats or be overly concerned.

** Sugden K, Moffitt TE, Pinto L, Poulton R, Williams BS, & Caspi A (2016). Is Toxoplasma Gondii Infection Related to Brain and Behavior Impairments in Humans? Evidence from a Population-Representative Birth Cohort. PloS one, 11 (2) PMID

Tuesday, February 23, 2016

When Your Doctor Can't See You

This past weekend my wife was pretty sick.  She ran a fever, felt horrible, and had multiple lymph nodes enlarged.  It wasn't going away so Monday morning she called our doctor to see if she could get in to be seen.  The office said that he was fully booked but would see if he could work her in and would call back.  As we were waiting for the call we talked about how long it might take to hear back, eventually deciding that it may not be for several hours if at all.  She was tired of feeling so sick so she decided to go to a local urgent care facility.  We knew it would take a while for her to be seen as the clinic is first-come, first-served, and it would cost more than going to our regular doctor.  But we didn't want to take the chance of waiting all day and not being able to start treatment.   The doctor at the urgent care diagnosed her with strep throat, prescribed antibiotics, and she is feeling much better today.

Why do I bring this up?  To illustrate a point about many veterinary clients.

Multiple times per week (and sometimes multiple times per day) my clinic gets calls from clients with a sick pet that they want seen right away.  Sometimes we can't accommodate them because their doctor isn't working, our schedule is full, an emergency comes in, or other situation.  More often than you might imagine the client gets upset and demands to be seen anyway.  It's not uncommon for some of them to be quite rude and insistent in their request.  

The worst situations are near the end of the day, especially within an hour of closing.  At that late hour if a client calls in with a potentially serious case we may end up recommending that they go straight to the local emergency clinic.  There is often little we can do that close to our closing time and rather than delaying care or having them go to two locations, so we recommend the best care....going somewhere that can see them faster and where they can take the time to fully work up a case.  But it's not uncommon to have clients get upset because we won't take them in anyway, even if we have no available openings.

I can understand the frustration of not being able to see your own doctor.  And I know that going to an urgent care or emergency facility costs more than going to your regular physician/vet.  But the reality of life is that doctors get busy, fill their schedules, and don't always have time to see every single patient.  There are only so many hours in a day and each patient takes some of that time.  At some point a doctor simply runs out of hours.  Trying to squeeze in more patients means that each patient gets less time, which can decrease the quality of medicine that is performed.  Getting mad over not being able to get in right away doesn't change these realities.

Not being able to see a patient doesn't mean that the doctor doesn't care.  It doesn't mean that they're cold, unfeeling, or don't want the patient to get needed care.  In fact, they may very well want to but know that they wouldn't be able to give their patient the time that was really needed.

When my wife couldn't get in at our regular doctor we had a choice.  We could have gotten upset, ranted at the receptionist and demanded to be seen.  Or we could have realized that our doctor was filled up and there were other options available to us that would allow her to be seen and treated.  We decided on the latter option and were quite satisfied.  We also don't hate our physician.  

Some veterinary clients could use a lesson like this.

Saturday, February 20, 2016

Closing Eyes To Hear Better

Here's an odd one...I close my eyes if I need to hear something better.
I've done this for most of my career so it's something that I picked up early on.  Sometimes I'm trying to hear a subtle noise in the heart or lungs and there are people talking, machines whirring, or pets barking near me.  Sometimes I'll take the pet into a quiet room if I'm really having problems.  But I start by closing my eyes and focusing on the sounds.
Maybe someone can explain scientifically why this works.  I firmly believe that it does!  Perhaps it's psychosomatic, but closing my eyes seems to eliminate many of the distractions and helps me better isolate minor changes in sounds.  It really seems like it shouldn't matter since your eyes obviously don't have anything to do with your hearing.  Maybe by eliminating one sense the brain can concentrate on the other senses.  At least, that makes sense to me!  I've often heard that deaf people have more acute hearing and touch as they are more dependent on their non-visual senses.  However, I don't know if this is actually true or just an old wives' tale.
I've noticed a few other people doing this as well.  A couple of my staff do and I recently worked with another doctor who does the same thing.  So it's not just me!  If other people do the same thing there must be some truth to the practice.
If anyone in the medical profession does this or has seen people do this, let me know!  I'd love to hear from other oddballs out there.

Monday, February 15, 2016

The $1000 Bouncy Ball

My kids sometimes get the small rubber "bouncy" balls like what you can get in vending machines.  I always warn them to keep them out of reach of our dogs, as I am worried that if one of the dogs swallowed one we would be doing surgery. 

One of my clients learned that lesson the hard way.
They brought their husky in because he was vomiting and acting lethargic.  After some discussion I was suspicious that he may have swallowed something that had become obstructed in his intestines.  We took x-rays and here are the results:

I think even the average layperson can see the obvious round object in the abdomen!  It looked like a ball of some sort and when I showed the images to the owner the son said it looked like a bouncy ball.
We did surgery and I quickly found the object in the intestine.  The surgery was very routine (for this kind of procedure) and there was no damage to the intestine so I thought he would make a good recovery.
Here's a picture of what we found in his small intestine, after it was cleaned up.

I went home that night and showed the picture to my kids, reinforcing the lesson I had previously given about being careful not to let our pets have access to these kinds of things.
I called the owner a few days later and the dog was doing great, back to eating with no vomiting.  That initial post-operative period is one of the most critical, so I have no reason to think he'll have further problems.  The owners did take home the ball, which I jokingly called their "$1000 bouncy ball" due to the cost of the surgery.  I think they'll be a bit more careful in the future!

Thursday, February 11, 2016

Clarifying Cat Nutrition

I recently received an email from George with some questions about cat foods and cat nutrition.  At the same time I just this week read an article on the issue of carbohydrates in cats, so all of this ties together quite well.  If this is your first time reading one of my blog posts on nutrition I would highly encourage you to go to the search box on the top left of the blog and put in "nutrition".  I've written quite a lot on this subject over the years and you'll find a lot of answers about corn, byproducts, grain-free, etc. in these older posts.  I'll try to avoid repeating myself too much in today's post.
I'll break George's email into sections and respond to each part individually.  I am also going to be quoting the article I read, which is by Cailin Heinze, MS, VMD, DACVN (Diplomate of the American College of Veterinary Nutrition), an assistant professor of nutrition at Tufts University.  Her opinion weighs stronger than mine because of her specialty in nutrition, so if you don't believe me, maybe you will believe her.
Hello Chris i read your article regarding cat food. You say that these nutritionist tell you that Hills, Purina, Iams, and royal canin are what they feed there cats. That is amazing to me. My research tells me that firstly dry foods have no real moisture content. So cat are already semi dehydrated due to there lack of thirst drive.
Yes, board-certified veterinary nutritional specialists routinely recommend these foods and feed them to their own pets.  It is also true that dry foods have a lower moisture content than canned or soft foods.  However, that doesn't mean that there is no moisture.  A dry food may have 10-20% moisture by volume while a canned food may have 80%.  Yes, a considerable difference, but not a harmful one.  It is true that in the case of urinary disease we want as much fluid passing through the kidneys and bladder as possible, so we recommend canned foods for these pets.  But dry food is fine for most other cats.  Also, cats are NOT semi-dehydrated.  Trust me on this as a vet, a dehydrated cat is a sick cat, and a healthy cat should never be dehydrated at all (even "semi-dehydrated"...which is a term that we don't use in medicine and has no real definition).  Cats also very much have a "thirst drive".  When they are thirsty they will drink.  You may not notice it as much as with dogs because cats are more likely to eat and drink privately.  Their original ancestors were desert cats, so our modern house cat is virtually a desert animal.  Their kidneys are very efficient so a cat has to drink less than a dog of the same size.
From Dr. Heinze's article:  "I never criticize owners for feeding dry diets...Some health conditions will dictate that a cat ideally be fed a canned diet later in life, so it's best to have flexibility."
More from George:
Then take into consideration that the first ingredients of these foods are 1. poultry by product, corn meal, corn gluten meal , brewers rice, soy fiber, animal fat. The first ingredient should be turkey, chicken, venison, duck or what ever the protein source is. Am i wrong here?
No offense, George, but unfortunately you are wrong.  The first listed ingredient does not mean that it carries the most protein or other nutrients.  Ingredients are listed by pre-cooked weight, not by nutritional quality or density.  So an ingredient is first just because it weighs more, not because it's "better".  It is very possible for a manufacturer to manipulate the ingredients so that "real meat is first", even if it doesn't give the most protein.  I wrote extensively about it this past December so I'll link you to that post.  Click on that link for a much longer explanation as to why the first ingredient is somewhat irrelevant.
Please educate me on this because i am spending alot of money on these brand name foods. My disagreement with what you say is this. Cats and dogs do not need gluten, soy, corns, wheats, etc in there foods. And it has been debated that these grains are harmfull.
Unfortunately there is a ton of misinformation in these sentences.  There is absolutely, positively NOTHING wrong with gluten, soy, corn, wheat, etc. in dog and cat food!
Dr. Heinze:  "Misconceptions about cats and carbs stem from the popular belief that, since cats are obligate carnivores and don't really eat carbohydrates in the wild, they shouldn't eat them, period.  A healthy cat doesn't require carbs, but can digest them." 
There are a lot of great reasons why these ingredients are found in pet foods.  Dogs and cats absolutely have an ability to digest and utilize carbohydrates from many different sources.  Here's a link to a post I wrote in January of last year
The people debating about whether or not grains are harmful are not the nutritional specialists.  I have never read or heard a veterinary nutritionist say anything against grains.  The recommendations for grain-free diets have to do with fad and misinformation, and have nothing to do with scientific facts. 
Dr. Heinze:  "Another misperception among owners is that grain-free diets are inherently healthier than diets with grains.  Grain-free does not equal carbohydrate-free.  Ingredients substituted for grain, such as peas, tapioca, lentils or potatoes, are no more part of a 'wild' cat diet than grains.  However, it is likely that the type of carbohydrate matters.  Tapioca starch is a very simple carbohydrate, not too different from glucose.  Whole grains and complex carbohydrates are likely better choices, because they are less likely to trigger dramatic changes in blood glucose."
Wow, grains may actually be beneficial to cats!  Maybe we should listen to a board-certified nutritionist. 
Dr. Heinze continues:  "Diets both with and without grains can be very healthful.  Corn, for instance, is highly nutrition and not a so-called dietary 'filler'.  If clients have concerns about feeding their cats diets that contain grain along with meat protein, I remind them that grains provide a high-quality source of protein....On a related note, gluten is a big bad word these days.  If people are forgoing gluten themselves, it's very hard to convince them in most cases there's no real benefit to feeding their pet a gluten-free diet.  I emphasize that feeding too many calories and allowing cats to become obese is the real cause of health problems in cats, not feeding gluten."
I don't know about you, but reading Dr. Heinze's words seems to be pretty convincing against the fad of grain-free, gluten-free diets.  Which brings us to the last part of George's email.
This is why every cat food company has jumped onto the Grain Free Foods.
Do you want to know why pet food companies have started making grain-free foods?  Because customers want them!  It's supply and demand, nothing more.  Some people without any scientific basis started talking about grain-free foods, and it somehow became wide-spread among pet owners.  Pet food companies are out to make money and sell foods.  If clients want a particular flavor, ingredients, shape, and so on, they'll absolutely make that food as a way to sell product.  As more and more people are "convinced" that their pets should eat grain-free diets the food manufacturers are merely making products to meet that demand.  Customers are willing to pay a premium price for these newer diets, even though there is absolutely no evidence that they are nutritionally better than other foods.  The plethora of grain-free diets is not about science or nutrition, it's about meeting customer demand.  Unfortunately those customers are misinformed.  And have you noticed that while there are many grain-free diets on the market, the companies haven't stopped making diets containing grains?
If you really want to know why nutritional specialists recommend brands like Iams, Purina, Science Diet, and Royal Canin, you can call these companies and ask them yourself.  A few months ago during a nutrition series I listed questions that nutritionists use to assess a company's ability to produce high quality foods.  None of that information is found anywhere on the labels!  These questions are agreed on by most veterinary nutritionists and are what they consider when making food brand recommendations.
George, I hope this has been enlightening and informative.  Hopefully you can see a different perspective from what you have learned so far, and know a bit more why specialists recommend these foods.  If you still disagree, then you can reach out to Dr. Heinze and other members of the nutrition specialty, as all of my information comes from them.

Monday, February 8, 2016

Being A Leader Vs. Being A Boss

Recently the leaders in my practice have been going through training to improve our leadership skills.  As someone who has long been a leader/manager and have always had someone higher than me in the chain, proper leadership is very important to me.  I have failed in being a good leader many times, though I think I've gotten much better over the years.  I've also had both great and horrible leaders/bosses, as well as those that fall on a spectrum between the extremes.
There is a big difference between a "boss" and a "leader". A boss is someone who directs and pushes people.  A leader is someone who shows people the way and presents themselves as an example.  Both personalities have to manage those under them in the hierarchy, handle bad situations, hire people, fire people, and otherwise make sure the business runs smoothly and appropriately.  But there is a big difference between some one who leads and someone who acts like a boss.

There are some great memes out there on this issue right now, so I'm not going to reinvent the wheel.  Here's the first one.

I like this one because it clearly illustrates the different characteristics of the two kinds of managers.  But I think it can be summed up even more simply.  This is my favorite image on the topic.

The above picture really does capture the idea of what a leader is supposed to do.

These themes resonate in any business and veterinary medicine is no exception.  Paraprofessional staff have managers and associate doctors have the lead doctor or practice owner.  The only time that a person in veterinary medicine doesn't have some kind of manager over them is if they completely own the practice themselves.  So trying to look at bosses versus leaders is very relevant in my profession, and is something on which I often ruminate.  I try to be a good leader, but sometimes creep into boss territory.  I like to think that my forays into "boss" are fewer than they used to be, as I have been able to develop effective teams over the years.

A veterinary practice is a business and has certain things in common with any business.  When the practice manager or owner is a good leader they will have a stable staff and a greater chance of a successful business.

Thursday, February 4, 2016

Stresses Of Being A Business Leader And A Vet

I manage the clinic location where I work, so I have responsibilities beyond being a veterinarian.  I work for a multi-location practice so I don't actually own my clinic (and have no desire to do so), but I am responsible for managing the doctors and medical side of things, as well as some responsibility for the business of the practice.  I have a office manager who does most of the business management, but it also falls to me to make sure we are running a responsible, profitable practice. 

There is a different sort of stress when you manage or otherwise lead a business.  And I think it's a bit harder for a doctor than the practice manager.  We already have a lot of stress from simply being a vet.  Every day we have to make decisions about animals' lives and health.  Our abilities as doctors and surgeons often determine whether a pet lives or dies.  That's a big responsibility and one we never forget!  Believe me, that's a sword hanging over our head throughout the day, and is one of the primary reasons for burnout in the profession.  When it comes to patient care the buck usually stops with the vet and it often weighs heavily on us, especially when we honestly can't figure out what is wrong with the pet or know we can't do much to help them.  Being an associate doctor is hard!

Now add onto that the additional stress of making sure that the business runs well and makes a profit.  No, "profit" is not a curse word in medicine and there is nothing wrong with a reasonable one.  That allows us to invest in newer, better diagnostic and treatment equipment and allows us to entice and hire higher quality doctors and staff.  To be perfectly honest, veterinarians MUST make a profit or they will close their doors.  There are no government-run veterinary facilities for the average pet owner so the only way a veterinary office can stay in business is to turn a profit.  Those who fail to do so end up closing, which doesn't help anyone.  So being profitable is vital to the success and growth of any veterinary practice.

As a business leader I have to help my office manager make sure our schedule is filled, that we're not over-staffed or under-staffed, that we're not ordering more supplies than we need, and that we're charging appropriately.  Thankfully the lion's share of this burden falls on the office/practice manager!  I couldn't function well if I didn't have a good one and she is vital to our success.  But it also falls to me to help motivate the staff, send people home when we're slow, push the front desk to call clients and make sure the come in for appointments, and generally help manage the whole clinic.  Additionally it falls to the clinic managers to handle most of the unhappy clients or any complaints (which are thankfully few in my clinic). 

There are days and weeks that we are slow and no matter how many phone calls we make or take we simply can't fill our schedule.  That doesn't happen often, but Winter is traditionally a slow season in veterinary medicine so it's been happening with a little more regularity in the last month.  I know this as I've seen it every year in my 30+ years in veterinary medicine.  But I still can't just shrug and say "Eh, it's the slow season and it will get better."  I still have to push to make sure that we're doing everything we can to support the business end of the clinic.  And believe me, when I have times that I go an hour without any patients to see I get stressed.  When that happens for multiple doctors on the same day it really makes my stomach churn.  All I see and think about is "are we going to make our financial plan for the week?"

They don't teach us how to do this in vet school!  There are little to no lectures on the business of veterinary medicine, even though the majority of graduates will end up working in a private small animal practice.  Even those schools who do give some instruction in business don't give you training on how to actually lead and manage a business.  So most vets who go into practice have minimal experience or even idea about how to be a leader and manager.  This lack of business training is probably one of the biggest faults in veterinary education, though it is somewhat understandable considering everything else that has to be packed into a four-year program.

Those who want to go into veterinary medicine need to realize that there is more stress than simply being a doctor, and you'll likely be ill prepared when you graduate.  But it is something that can be learned, and I've become pretty good at it.  I still become very stressed about our business at times, but we're successful much more often than not and over the years I've gotten better and handling this side of the job.