Happy Memorial Day

Today in the US we remember those who have fallen and died in service to our country.  There is a saying, "freedom isn't free", and it's so true.  Without the service of the men and women in the military, past and present, we would not have the freedoms we have.  No, our country isn't perfect, especially nowadays.  But we have incredible freedoms to speak and argue because people have been willing to sacrifice themselves to protect those of us back home.  From the Revolutionary War, through the War of 1812, American Civil War, both World Wars, Korea, Vietnam, the various conflicts in the Middle East, and numerous smaller fights around the world, our military has defended the freedoms of ours and many other people in different countries.  Sure, we've made mistakes and haven't been perfect, but the brave, self-sacrificing military personnel far outweigh the bad apples.

I had two uncles who served in the Pacific theater in World War II.  When I was in high school I interviewed them for a US History class project, as well as a friend of theirs who was in a German prisoner of war camp.  Hearing their personal stories made a big impact on me that I can still feel 30 years later.  My Uncle Dan told me about having to dive into a ditch when Japanese fighters strafed his base.  My Uncle James told me about seeing a Japanese plane fly into a ship near his own.  Their friend told me about life as a prisoner to the Germans.  All of that made me see the daily life of soldiers, sailors, marines, and airmen/women.  It made me so proud that my family had served with distinction, and gave me an appreciation for what the military has to go through to keep the rest of us safe and free.

In my adult life I have had friends, relations, and clients who have served in more modern conflicts, from Vietnam to Afghanistan, and I owe so much of my ability to live and work in a free country to them.  I am truly appreciative of those who take time out of their lives and make the choice (remember, the US has an all-volunteer military....there is no required service) to defend our way of life.  Those who have died as a part of this service are especially deserving of our honor.

Happy Memorial Day.  Never forget the real reason why we celebrate. 

Veterinarian Or Therapist? The Conversation That Wouldn't End

The other day I saw a cat owned by a regular client.  I had only ever talked to him and he was always very pleasant.  He had come in because his cat was having soft stools and was eliminating outside of the litter box.  Typically if a cat only defecates outside of the box it is due to a behavioral issue.  I spent time really trying to find out if there was any stress, changes in the environment, or anything else that could have induced behavioral problems in the cat.  The owner said that there was nothing, and it seemed like that this was the case.  I ended up suspecting inflammatory bowel disease and starting appropriate treatment for that.

Today I returned a call from his wife, whom I had never spoken to before.  She had questions about the new diet and several other things, at least according to the note that had been left for me.  When I started the call I didn't anticipate what I was getting into.  I just wanted to help the client and make sure the pet was getting the right treatment.

I spent 35 minutes on the phone with the lady.  The conversation should have lasted 5 minutes.  During that conversation I learned that she was mostly bed-ridden due to health problems, that she and her husband argued, that her husband worked and traveled a lot, what kind of shelter they had gotten the cat from, and numerous other details that I didn't really need or want to know.  And it wasn't just the sheer volume of information.  This poor woman didn't seem to breathe and talked so fast and long that I couldn't find any normal breaks in the conversation to jump in and ask questions.  There was one point where I didn't say anything at all for 10 minutes straight (yes, I timed it) as she continued to simply talk.  

In a way I felt bad for her.  She was obviously a shut-in and didn't have a good relationship with her husband.  She was frustrated by many aspects of life.  I didn't want to be rude and I was trying to be very understanding and empathetic.  I was also learning some important information about the cat that her husband hadn't shared.  In fact, her explanation of the situation fit perfectly with what I had originally suspected....behavioral issues.  As I listened to her I tried to piece together the relevant details while sorting through the plethora of useless and private information.  My heart went out to her at the same time that I was looking for an opportunity to move on to my next patient.

In all my years I can't remember a more frustrating situation.  I had a woman who honestly wanted to help her cat and didn't feel that her husband was giving the full picture.  I had a cat that needed help, and I had to get the right information in order to be able to do so.  I also had a woman who was apparently lonely and unhappy in her relationship, and I was a friendly, patient voice.  I really did feel bad for her and her situation.  But I couldn't afford to stay on the phone for over half an hour, as I had other patients to see and clients to call.

That 35 minute conversation resulted in the following details:  her husband didn't clean the litter boxes and they were often full of waste, and there was significant stress between the people in the home.  That was what I needed to know!  Unfortunately it took me far too long to get there, and there was no easy way to break in during the conversation.

Vet school doesn't prepare us for things like this situation.  We aren't trained in how to be a therapist to our clients or how to handle seemingly endless conversations.  Such skills are hopefully picked up over time and with experience.  It is often surprising how many things a vet has to handle other than being a clinician and surgeon.  Sometimes I wish I had taken psychology courses in order to be able to better understand and handle some of my clients.

I really do hope that things work out with her husband.  I also hope her health improves and she will have other people who can help her.  But I hope that it will be a while before I have to talk to her.  If I do, I'll have to allocate plenty of time.

Gingival Hyperplasia In Boxers

Boxers are great dogs, but unfortunately are prone to numerous diseases, including heart disease and cancer.  One of the more common disorders is overgrowth of their gums, a condition called gingival hyperplasia.

"Hyperplasia" simply indicates higher than normal growth or development.  When it affects the gums it will result in thick, lumpy, overgrown tissue.  In mild cases this just looks odd and by itself isn't harmful.  But in more severe cases it can cover the teeth and provide deeper pockets where food and bacteria accumulate, significantly increasing the risk of infections.  Very mild cases often don't need treatment but the aggressive ones always do.

Because this is a breed-related genetic disorder there isn't anything that can currently be done to prevent the problem.  The cells in the gums simply over-grown and over-produce tissue, ignoring the normal signals to stop growth and development.  Without somehow changing the genetic structure of those cells it isn't possible to stop it from happening.  The only option is treating it as the problem develops.

Treatment is rather simple and straight-forward.  We remove all of the excessive gum tissue.  This can be done with a laser, with a cauterizing tool, or simply with a scalpel blade.  There is more bleeding with a  blade than with the other methods, but it is never enough to be dangerous and will stop rather quickly.  The goal is to cut away the overgrown tissue until you have a relatively normal level of gums around the teeth.  In some cases this can result in quite a lot of tissue being removed, but results in a healthier, more normal mouth.

Here is a picture of a recent patient of mine, showing more severe gingival hyperplasia during a dental cleaning and before we removed the extra tissue.

Here is the same dog after we removed the excessive gums but before we cleaned the teeth and the mouth.  You can see that there is some blood but the teeth are visible at a normal level.  Notice how much calculus and tartar is on the teeth that were covered by the hyperplastic gums.

My patient recovered normally and went home without any bleeding from the mouth.  We did send her home with antibiotics due to some infection, but she made a full recovery and was eating normally within a few days.

The unfortunate part of this condition is that it is always recurrent.  We aren't removing the cells that trigger the hyperplasia, so it always comes back.  Most of these patients require some degree of annual removal of excessive gingiva for the rest of their lives.  That seems a bit brutal, but it is better than the discomfort and infection that they can suffer without the procedure.  If they are examined twice per year and have a dental cleaning annually, the amount of tissue that needs to be removed is less than if it goes for a few years without treatment (as it was in the case above).

I want to mention that there are oral tumors that can be quite aggressive and malignant, so simply seeing lumps on the gums isn't always benign hyperplasia.  If there is any doubt at all the tissue in question should be sent off for a biopsy.  If you see any kinds of lumps or growths on your dog's gums, take them to a vet right away to have it evaluated.

Not Smart Enough? Vet Student Challenges

Recently I received the following email from a worried veterinary student, Brittany. 

 

I'm in my 3rd year of veterinary school and have been struggling a bit more than usual lately. Vet school has never been easy (I'm convinced those who say it is are lying to the world haha), but I've always done moderately well. I focus more on attempting to learn the material and making excellent reference materials than on making top scores on each exam (unfortunately the two techniques are often more mutually exclusive than I would have expected). I also try to be kind to myself with my expectations, which is a goal I still struggle with. Like most in this profession, I am highly self-critical and a perfectionist.

Lately, I've started to feel a bit of a panic at the thought that I'm simply not smart enough to be a good or even decent veterinarian. Information is jumbled in my brain, and I cannot easily recall the entirety of things I think I should know by now (such as pathophysiology, common signalment, common clinical signs, diagnostic findings, & treatment options for a standard disease process). Instead, I will have lumps & bumps of information-- but the holistic knowledge is still missing despite it having been presented to me in various classes during the past 3 years. I just don't feel like I'm "getting it", but I also feel that I'm at the point where I should be having more "aha! Of course it's __X___" moments instead of "that kinda sounds familiar" moments.

I apologize if this doesn't really make sense. My brain is a bit frazzled, and I only hope that all of this is simply a result of being burned out & needing my upcoming vacation quite badly. I guess I'd just like some input from someone who has been in my shoes before and walked farther down my intended path. I know you can't really comment on my intelligence (or lack thereof), but any insight on how you felt as an almost graduate (and recent graduate) would be immensely helpful.
 

I can promise you that you are not alone.  If you polled your veterinary class I would put money on most of your classmates feeling similarly.  I don't know of any vet who hasn't had feelings like this.  I know that I sure did!  When you're in school you are constantly it with a wide variety of diseases, physiology, anatomy, drugs, toxins, surgical equipment, and dozens of other things.  It's unreasonable to expect every person to retain and understand every bit of that knowledge. 

Veterinary school is not intended to get you to the point of knowing everything by the time you graduate.  That's impossible!  No matter how smart you are or how hard you work you simply won't remember every little fact or detail. Even if you are a straight-A student!  You are getting hit with new information every day, some of it so similar that it is easy to get jumbled.  You also are trying to figure out different anatomy and physiology for the dozens of species that we learn about in school, each of them needing different care, surgery, and medications.  A drug safe for one species may be toxic to another.  Colic in horses is extremely different from that in dogs.  It's actually more of a wonder that vet students come out remembering as much as they do!  Human medical students have it really, really easy by comparison.

Stop and take a look at your internal medicine text book.  Flip to the back and look at the page number.  If it's like most of the books it's over 1000 pages.  Do you really think that it's reasonable to expect a person to remember every detail on all of those pages?  And while internal medicine covers a lot, you still have parasitology, toxicology, surgery, pharmacology, anesthesiology, and numerous other "-ologies".  Through the four years of school we are taught information from tens of thousands of pages of texts!  And no, that's not an exaggeration!  I can promise you that even the editors of those books don't know every detail on every page. 

Also remember that you learn a disease and then move on to the next one.  How long do you spend talking about atopic dermatitis?  Probably a lecture or two, and then you're on to dermatologic problems you'll encounter much less frequently in private practice.  But this time of year I see potentially atopic dogs almost every day.  In vet school you simply don't have time to really see cases again and again.  It's one thing and then move on.  When I was on my surgical rotations I didn't see a single ACL tear, yet I've had three dogs come in with them in the last month.  The speed and case load in school is absolutely not representative of what you see in practice.

So what is school for if it's not to memorize these thousands upon thousands of facts?

It's to teach you how to think.  How to work through a diagnostic process.  Where to find the information that you need.

If you haven't been to a veterinary conference yet, you will find that the busiest vendors are usually the ones selling textbooks.  You sometimes have to squirm through other attendees to get close enough to look at the books.  Who are they selling to?  Experienced veterinarians.  Often people with decades of experience.  NOT students.  Why are they so busy?  Because there isn't a single vet (or human doctor) in existence that never has to look something up!  Sometimes we just want a reminder to make sure we're on the right track.  Other times we're completely stumped and really need to delve into the case.  In any veterinary practice you will find dozens of text books on the shelves, all ready for the skilled vets to grab.

Look at some of the trade journals and magazines that reach private practitioners (not the ones focusing on research).  You find case studies, diagnostic algorithms, articles on things as simple as how to interpret a urinalysis and what to do with chronic ear infections, and dozens of other tools.  Again, these publications are useful for experienced practitioners, not students.  They are needed because we forget things or need reminders.

We can't remember everything.  With enough time you certainly will be able to rattle facts off the top of your head and you will look things up less frequently.  During school you learn how to go through the process and how to think through a case, even if you don't know every detail.  This is especially important when you get the weird cases that doesn't follow the textbook examples.

I graduated from vet school with a solid B average, right at the 50th percentile in my class.  I had several Cs and several As, but I landed smack in the middle of my class.  I struggled through many classes, especially ones with lots of detail such as pharmacology.  Right now I could tell you the mechanism of action and dosage of dozens of drugs.  Back in school?  Nope, not very easily.  I've also forgotten the information on dozens of other drugs!  If I need them I know I can pull our my veterinary formulary and quickly look them up.  Why do I know them so much better now than back then?  Because I had to look up the doses so many times (dozens!  hundreds!) that it finally stuck in my thick skull.  But having to look up the information didn't stop me from being able to practice. 

Seeing cases day in and day out really help solidify the information in your brain.  I hardly look at information on otitis externa (ear infections) any more because I've seen so many hundreds (maybe thousands?) of cases that I've finally remembered what causes it and what I need to do.  That gets me through 90% of the patients.  What do I do with the other 10%?  Look it up or call a specialist.  The longer you practice the more your studies make sense.  You also start to better understand the kinds of things you see commonly.

Here's something that may seem heretical.....you don't have to have all of the facts memorized for rapid recall!  Take Cushing's disease (hyperadrenocorticism) for example.  In vet school I struggled to remember the two pathways and how it was caused.  Now I can draw a diagram from memory.  Other than doing well on a test and proving to my professors that I learned the information it really didn't matter that I had it memorized.  After seeing several cases after graduation it all finally started making sense.  And you know what?  I still have to look up the dosages of the drugs we would use to treat it, even though I know which drugs are an option.

Brittany, you said it yourself...people in veterinary medicine tend to be perfectionists and self-critical.  Your struggle is something that every vet has faced to one degree or another.  If you can pass classes with a C average or better and then pass your final board exams, you have all of the tools necessary to be a successful and skilled veterinarian.  Being a doctor is a continual process of learning.  I'm a far better clinician and surgeon that I was in 1997 when I graduated from vet school.  I'm not as good as I will be in 2027, with another 11 years under my belt. 

Last year I wrote a similar post, one that many people may find helpful as it directly relates to this situation.  Click here.

Brittany, I wish you the best of luck!

Most Costly Medical Conditions

When I found the information for my last post I also came across some other interesting data.  From DVM 360 comes this list of the most costly medical conditions for pets. 

 

While those may seem expensive, comparable human conditions are typically 10-20 times the cost, and are mostly covered by insurance.  Even though many people would consider these very high prices, for the difficulty of the procedure and the quality of care that pets receive these are bargain basement prices.

Top Medical Conditions

Recently Nationwide insurance released data on the most common medical conditions based on 1.3 million pet insurance claims in over 550,000 pets.  It's an interesting list.

Dogs
1. Allergic dermatitis
Average cost: $210

2. Otitis externa (ear infection)
Average cost: $153 per dog

3. Benign skin neoplasia (cancer)
Average cost: $348 per dog

4. Pyoderma and/or hot spot
Average cost: $122 per dog

5. Osteoarthritis
Average cost: $299 per dog

6. Periodontitis/dental disease
Average cost: $312 per dog

7. Gastropathy (stomach problems)
Average cost: $279 per dog

8. Enteropathy (intestinal problems)
Average cost: $139 per dog

9. Cystitis or urinary tract infection
Average cost: $284 per dog

10. Soft tissue trauma
Average cost: $229 per dog

 

Cats

1. Feline cystitis, or FLUTD (lower urinary tract disease)
Average cost: $441 per cat

2. Periodontitis/Dental disease
Average cost: $326 per cat

3. Chronic renal disease
Average cost: $628 per cat

4. Gastropathy
Average cost: $313 per cat

5. Hyperthyroidism
Average cost: $396 per cat

6. Enteropathy
Average cost: $189 per cat

7. Diabetes mellitus
Average cost: $862 per cat

8. Upper respiratory infection
Average cost: $185 per cat

9. Allergic dermatitis
Average cost: $158 per cat

10. Inflammatory bowel disease

`Average cost: $311 per cat

 

Overall I would agree with these lists, though I don't see hyperthyroidism or diabetes in cats as commonly as reported here.  I would also put dental disease higher on the list for dogs.  But these lists are also a bit skewed considering that the vast majority of American pets are not on any form of insurance, so this may not be a completely representative population despite the absolutely huge sample size.

 

I notice that there are several preventable diseases on this list.  Dental disease can be completely prevented and controlled with the proper care.  Most stomach and intestinal disorders come from eating things that the pet shouldn't, which can be at least somewhat controlled by the owners.  Most cases of diabetes in cats happen with obesity, which is preventable if the owners are careful about what and how they feed.  Chronic skin and ear problems in dogs are definitely difficult to manage and can get expensive, but it is possible to do so.  We could certainly change these lists quite a bit with proper preventative health care in pets.

 

Find Me At Sam's Club

This month Sam's Club released their newest issue of their bimonthly magazine, Healthy Living Made Simple.  It is available in clubs around the US as well as on their website (http://healthylivingmadesimple.com/).  And I'm in it!  I'm very proud and excited to have been invited to write for them, especially considering that it will reach over 8 million Sam's Club members.  The article is rather short, but still hopefully helpful.  In it I discuss tips on introducing a new pet to the home with existing pets.  You can find it in the Lifestyle section, or click on this link.

I'm really excited about having had the opportunity to write this article.  If you search back through my blog you will find similar things in which I've been involved, such as TV interviews (some of which were in multiple markets around the country), a pet care video on a now defunct web site, and some articles in veterinary trade magazines.  But this article in the Sam's Club magazine will reach far more people than anything I've done in the past.  That's pretty cool!

While I'd love it if this turned into an opportunity to partner with that magazine more, I'll be satisfied with this one article.  Not may people get chances like this so I'll count my blessings.

Superman, Cat Lover

After the last few posts I think it's time to lighten things up a bit.  Last month I posted some pages from a Superman comic book that I thought was really powerful and breaks any stereotype that comic books are just for kids.  I also recently came across some pages from a different comic where Clark Kent (Superman) reminisces about a pet cat he had as a kid.  I wanted to share that here as it directly relates to anyone who has owned a pet, and I thought it was a very uncommon but sweet perspective on the character.  I hope you really enjoy it as well.  I especially love the last panels.  You can find the original post here.

Don't Feed The Trolls, Part 2

Here is the continuation of my conversation with m_michaels17.  For the first part read my last blog post.

MM: Restaurants, and entertainment are not valid comparisons because they are not life sustaining. To answer your questions.... yes, if you broke down and needed gas most attendants would help you get the gas you need to get back on the road. It's actually happened to me more than once when I was a teen. Yes,grocery and general stores have historically run tabs that people pay later. Yes, if you're so poor you can't afford clothes, there are clothing drives and food banks that will help you. Yes, if you're behind on your water bill they will not shut you off as long as you attempt to pay some of the balance. Trust me on that one, my father is a plumber. He deals with the water and sewer authority on a daily basis. I'll give you another example that comes to mind.... my father has had his own lucrative plumbing business for 30+ years. He's given many local customers payment options over the years. For instance there was one particular 70 year old lady with roots in her sewer that completely clogged her line and backed the sewage up into her shower, floor drain, and was filling up her basement. Her husband had recently passed away and she could barely afford to pay for the sewer cleaning. My dad cleaned her line and discovered all of the under ground lines were collapsed. She needed a complete restoration which involved digging up her whole yard down to the street. The job cost approximately 30 grand. If she didn't get it fixed the county would condemn her house. He did the job up front and let this lady make him payments with out interest because that's what decent Christian people do for others in need. It's a shame so much of this country is so consumed with money and nobody cares for each other anymore. She paid him every last penny. A deal made out of desperation and a handshake. I understand you have to charge to run a business but sometimes life happens and we aren't prepared for it. It happens to all of us. Making exceptions for people in need once in a while will not kill a business because you're making really good money every day. So if you did a surgery at cost it wouldn't be close to what we actually charge and you know it. Nobody is even asking for you to do that. All people ask is to let them pay you weekly in extreme cases. That wouldn't break the bank or put you out on the street.

MM: And I'm not saying you can't rely on a veterinarian. There are many of us out there that are compassionate and would do anything for our patients and their owners. There are many of us that became a vet to help animals at all costs. I donate hundreds of hours a year to charity. So please don't tell me I'm saying vets aren't reliable. I have about 10 clients that make payments currently and pay me on time every month. Once in a while someone misses a payment but they always end up coming through. Contrary to your beliefs the lights are still on and shining brightly.

DB: Now we're having a good discussion! I appreciate that.

I will trust in what you say of your own experiences. I've never seen a grocery store run a tab, known a gas station attendant to let someone go without paying (and I've had friends who managed or worked at convenience stores), and have known people who have had utilities shut off when they fell too far behind even if they were making small payments. So let's chalk up these differences in our viewpoints to our personal experiences.

     "And I'm not saying you can't rely on a veterinarian....So please don't tell me I'm saying vets aren't reliable". Actually, you did say that veterinarians can't be relied on. Here are your own words: "There are two professions that only except cash... drug dealer and veterinarian." "Most animal hospitals take donations for this exact purpose but yet rarely use the money to actually help cover the cost of a surgery." These are direct quotes from you where you have stated that most veterinarians are dishonest, unreliable, and basically scum. You not just implied, but directly stated that you believe the majority of the profession is bad. If that was not your belief, why did you say those things?

     "There are many of us that became a vet to help animals at all costs. I donate hundreds of hours a year to charity." Are you actually a veterinarian? You have not stated or even implied it until this time, which is odd to me. If so, then our conversation will need to take a different turn, and I would encourage you to get on the Veterinary Information Network to see how many people agree or disagree with you. As a vet you should have enough experience to know not to run off at the mouth and make snap decisions about a colleague when you don't know the entire situation. This is something that has been taught and emphasized in vet school for at least the last 20 years. If you are not a vet, then you have seemed to misrepresent yourself here and need to correct that immediately, as this is a very serious situation.

     I don't take payment plans, and I never will. That's not a debate and we both recognize that. However, I accept Mastercard, Visa, Discover, American Express, and Care Credit. People can pay with those and then make payments to those companies. I'm glad that your clinic has clients who pay on time. I have tried doing that more than once, and have ended up having to send many people to collections companies because they failed to pay and never communicated with us. It happened enough that I stopped doing it. I can never tell at the beginning which person will be responsible and which won't, and it was becoming a big problem. You will find that the majority of veterinarians feel this same way. It's not because we don't care or are heartless when someone is down on their luck. It's because we have a business to run and that business isn't being a credit agency. For me it's not about making more and more money so that I can buy fancy cars and big TVs (I don't have either). It's about paying my staff well, being able to afford good equipment so I can provide a better quality of medical care to my patients, paying the debts of my clinic, and overall simply staying in business and keeping the doors open. If you don't believe me that most veterinarians have had bad experiences with trying to do payment plans, simply start talking to other vets in your city or ask questions on veterinary boards where you can get interaction by my colleagues. But I have trusted your statements about things like grocery stores running tabs, based on your experience. Please trust my own experience that most vets have found payment plans to be difficult to manage and unreliable for being repaid.

     Now that doesn't mean that I never help people out, which you seem to have assumed. I have frequently waived office visit fees in order to help clients afford their bills. I have charged some people less because they seemed truly in need. We do have an emergency fund created from donations by other clients, and have used it many times to help with expensive procedures. But we can't help everyone. It becomes hard to decide who we are able to help and who we can't. Who is truly in need and who is being irresponsible with their pet? We reserve our help for a small number of people because we can't extend that help to everyone. And ultimately it is NOT our responsibility to care for the pets owned by other people. THEY are the ones who took on that responsibility, and ultimately it is their burden.

     "Restaurants, and entertainment are not valid comparisons because they are not life sustaining." I only brought them up because of your own assertions. "They work in every other business and practice. There are two professions that only except cash" These are your words, and you made a rather large blanket statement. I was pointing out the problem with your logic and words, as well as using specific professions that you mentioned would help me out if the tables were turned. If you make a statement that "every other business and practice" uses payment plans and then I can bring up multiple kinds of businesses and practices where that is not the case, I have shown that your logic is flawed and you have made a mistake, and shown more than two businesses or practices that do not accept payments.

     On this subject let's think about "life sustaining" and things necessary for existence. Despite what some may think, pets are NOT necessary for life. Plenty of people around the world survive quite well and are very happy without a pet in their life. Sometimes this is due to finances, sometimes due to culture, and sometimes to personal choice. But billions of people live their entire lives without a pet, so it is clear that they are not a necessity. Therefore having a pet is a choice, not a requirement. Having a pet is a luxury, not a necessity. When someone gets a pet, they have chosen (whether or not they think about it in this way) to be responsible for the health and well-being of that pet. Too many people get pets when they cannot afford even basic preventive care, as I'm sure that you've seen. The responsibility for the care of that pet is completely on the owner, not the doctor. My doctor can make recommendations for my health, but it's up to me to follow them and take care of myself. In most of the US a car is a necessity in order to be able to get to and from work. Yet it is not my mechanic's responsibility to make sure my car is running well. When something breaks, it is up to me to be able to afford to fix it, not him. Yes, he may help me or allow payments, but that is not something he is required to do. I bought the car, I make the payment, I chose which car I would get, and I have to take care of it. If I buy a car that is too expensive for me to maintain, that is MY fault, and not that of my mechanic, the car dealership, or the loan company. If a client gets a pet for which they cannot afford to care, that is THEIR fault, not that of their veterinarian.

     That is my main point here. Yes, I do help out clients where I can. But in the end it is NOT my responsibility or requirement to find a way for them to pay. It is THEIR responsibility because they chose or accepted that pet. Sometimes pets are euthanized because the client cannot afford care. While tragic and something that bothers me every time, it's also the reality of life and something that cannot be easily changed. This does not make me heartless, "vile", or "twisted". In modern society we seem to have lost the idea of personal accountability, and see it as the duty of others to help us.

     Now once again you have repeatedly failed to answer most of the questions I have asked. I am starting to believe that this is because you have no reasonable answer for them, that you are deliberately avoiding them, and that you simply don't care. Let's make one more attempt, and I seriously ask you to reply to me on these points.

     Do you believe that attacking and insulting people is a good way to get them to change their views on an issue?

     Did you have a real purpose in your original email to me beyond a quick insult?

   Why did you feel that it was appropriate to make a direct, personal attack instead of trying to engage in calm and rational discourse?

     Is passion an appropriate excuse for insulting a stranger over a single point of disagreement? Would you want people to make comments about you based on limited information as you have made about me?

     What do I really think about my clients? Please base this on quotes from my blog posts so that I can see where you have formed your opinion.

     When did I ever call any client a "dead beat"? You explicitly stated that I did.

 

[Up to this point there has been a reply every day.  Now there have been three days without anything from MM]

 

DB:  Hi!  It's been 3 days and I haven't heard any response from you.  I've been enjoying our discussion and wanted to be fair and give you an appropriate time to response.  I do have some thoughts on what you have said and how you have conducted yourself through our discussion, but before I summarized these things I wanted to let you have another chance to explain yourself and clarify your points and comments.

[Another three days go by without any response]

DB:  Hi, again.  It looks like you have decided to stop this conversation so I will say some last comments and then let it be.

     You have conducted yourself extremely rudely and without an attempt at understanding.  It seems like your initial email to me was nothing more than a personal attack based on limited information, and you were not interested in trying to actually talk to me to either understand my position better or to try and show me the error of my ways.  Instead you let your anger get the best of you which made you appear to be a hateful, closed-minded individual.  You have made numerous incorrect assumptions about me and have denied doing so even when I have quoted your words back to you.  You have accused me of saying things that I never actually said, and never backed up your claims when I asked you for proof of such statements.  You have also backtracked on several of your own statements and seemed to at some points deny what you had said in an earlier email.  To me this indicates someone who is not thinking rationally and is only working off emotion without truly considering their own thoughts and words.

    Another thing that bothers me is your implication that you are a veterinarian.  If this is true then you have violated professional behavior and courtesy, and may even have violated your state veterinary practice act (if you live and work in the US).  I've been licensed and practiced in 6 states and each of them has had clauses in the veterinary law that mandate ethical professional behavior.  Though I am not going to do so, I would be within my rights to contact the veterinary board in your state to register an official complaint at your extremely unprofessional actions towards a colleague.  If you are NOT a veterinarian, then your implication of being so violates other laws, in addition to be quite unethical. 

     By your actions in these regards you have shown yourself to be very hypocritical when you call me "twisted and vile".  Though I don't consider your behavior to be quite as bad as what you accused me of, I do think that you have shown yourself incapable of acting in an ethical, professional, or even simply polite manner.  During this discussion you have come across as angry, narrow-minded, and petty with little to no concern for any view other than your own, and an inability to consider contrary opinions.  If you do not think that these words describe you, I would go back and look at what you have said and do some honest introspection. Maybe even have someone else read this email chain to see how each of us has conducted ourselves.

     I have a very thick skin and am well prepared to take criticism when I put myself out there on the Internet with a public blog.  Other people may not be the same way and your words could truly hurt someone.  In the future I would ask you to give the same respect that you would want for yourself, and give people the benefit of the doubt before you make extremely harsh and hateful accusations.  Rather than wasting your time simply venting your anger, take the time to have a discussion.  I have had those with readers in the past and sometimes came away with my mind changed.  However, those people approached me in a rational way and we had a good discussion on pros and cons of certain viewpoints, all without resorting to insults, attacks, and name-calling.

     I truly wish you the best, and hope that you will take to heart the things that I have said.

And that was it.  No more replies, so I am assuming that m_michaels17 decided to block me or simply not write back.  I hope it's because they realized that their comments were uncalled for and that they really didn't have a leg to stand on in their argument.  I wonder if they expected me to reply to the original email and if I would argue back or call them names.  I don't know that they were expecting me to start a strong discussion and actually read and remember their own words.

The psychology of people like this is somewhat interesting, and goes back to my post of a few days ago about civility on the Internet.  I was amused by m_michaels17's inability to answer my questions and their denying of their own words.  I see far too much of this in modern society, though it may not be a recent development and instead is a part of human nature.  But nowadays this kind of knee-jerk over-emotional reaction to something seems to be more of the "norm" than I remember it being a few decades ago.  I hope that this changes soon, as it's not a good way for members of society to behave.

Don't Feed The Trolls, Part 1

Last time I posted about m_michaels17 and their comments towards me.  What I didn't say was that I had a discussion with them via email.  I debated whether or not to even respond, as I typically believe in the internet adage of "don't feed the trolls".

For my readers not familiar with this terminology, let me help you.  UrbanDictionary.com gives the following definition for "troll":  One who posts a deliberately provocative message to a newsgroup or message board with the intention of causing maximum disruption and argument.  This can extend to emails also, and I immediately saw m_michaels17 as a troll.  "Feeding" a troll means trying to give them what they want and argue back, which encourages them to further their own point of view.

In a situation like this the best thing to do is ignore the person and move on ("don't feed the troll").  But I went against my typical procedure and actually responded back.  I became legitimately curious as to why they took such a strong stance.  Here is a transcript of our email conversation.

m_michaels17:  You should not be a vet. Your views are twisted and vile. Payment plans don't work? They work fine at my clinic. They work in every other business and practice. There are two professions that only except cash... drug dealer and veterinarian.

Dr. Bern:  So they work at Walmart?  At Olive Garden?  At your local grocery store?  At a florist?  For admission to your local zoo?  When you're buying tickets for a play?  When you're buying an engagement ring?  A band for a wedding must accept payment plans, right?  Yep, every other business accepts payment plans.

MM:  Wedding bands and most retail yes they do. It's called lay away. Some grocery stores do run tabs yes. As for plays and other entertainment.... I don't believe that really compares to emergency  medical care. Maybe you'll find out the hard way someday when you or a loved one need urgent care and you can't get it.

DB:  Layaway requires full payment before you pick up your product, so it's still not comparable.  But it's obvious that you and I will disagree on this point.

     Just out of curiosity, why did you feel that it was appropriate to make a direct, personal attack instead of trying to engage in calm and rational discourse?  I'm not personally offended, but it seemed like a rather strong stance to say that I am "twisted and vile".  Why is such language appropriate if you wanted to try and convince me that I was wrong?  Is this how you typically handle disagreements?

MM: No its not the way I handle most arguments but I'm extremely passionate about animals and I pray to God the people that work with me and in other animal hospitals around the city do not feel the way you do. Are you that money hungry that you would not help a lower income person with an animal on an emergency visit? Most animal hospitals take donations for this exact purpose but yet rarely use the money to actually help cover the cost of a surgery. You seem like you'd fall under that category. 

DB:  So passion is an appropriate excuse for insulting a stranger over a single point of disagreement?

Why would you assume that I'm the kind of person who would take donations and not use them to help people? That seems like a rather harsh judgement against someone that you do not know. Why would you jump to that conclusion? You don't even know if we take donations, let alone how we may use them. 

     You seem to be making some rather severe assumptions about me without knowing much about me. Should I judge your personality by your original email to me? If so I would say that you are an ignorant, hate-filled person who is more interested in insults than discussion. However, I bet that this sentence doesn't really describe you very well. It's very dangerous to go on a rant against someone when you don't know much about them and don't know all of the facts. Would you want people to make comments about you based on limited information as you have made about me? You are assuming the worst about a person without taking the time or giving polite consideration to find out more.

     I've been in the veterinary field for 32 years and over that time have worked at several clinics in multiple states and have known numerous veterinarians and business owners. You probably won't believe me, but most veterinary clinics have been burned and lost money trying to take payments, and those that do have their own in-house payment plans are the exception rather than the rule. I know that we always want to assume the best about people, but the truth is that enough people default on these plans that it becomes a huge financial risk for the practice. My viewpoint is supported by the vets who have commented on my blog in this regard, as well as the vets I've seen posting on sources like Veterinary Information Network. 

     Please understand that I'm not attacking you back. I'm trying to have a discussion and hopefully help you see how you came across so you won't do the same thing to someone else in the future. I'm also truly interested in direct answers to the questions I've asked you.

MM: I'm assuming nothing about you. You posted comments all over the Internet about what you really think of your customers. 

DB: Actually, you've made several assumptions about me. "Your views are twisted and vile." "Are you that money hungry" "You seem like you'd fall under that category." Each of these is a judgment statement about me without actually knowing facts behind who I am and how I conduct myself. Would you like me to make blanket statements about you, your life, and your interactions with people only on this conversation we are having? I'm giving you the benefit of the doubt that you aren't actually like you are coming across, and that there is more to you than how you are treating me. Because to be perfectly honest, you're coming across as narrow-minded, unwilling to have an open discussion, quick to judgement, and hateful. I'd like to think that this doesn't accurately describe you.

You also still haven't answered my questions, so I'll re-post them here for convenience.

     Why did you feel that it was appropriate to make a direct, personal attack instead of trying to engage in calm and rational discourse?

     Is passion an appropriate excuse for insulting a stranger over a single point of disagreement?

     Should I judge your personality by your original email to me?

    Would you want people to make comments about you based on limited information as you have made about me?

     Here are some new ones that I'm adding....

    What do I really think about my clients? Please base this on quotes from my blog posts so that I can see where you have formed your opinion. 

     Do you believe that attacking and insulting people is a good way to get them to change their views on an issue?

     Did you have a real purpose in your original email to me beyond a quick insult?

     How do you define "all over the Internet", and how does a single blog qualify as such?

     Seriously, I really, really do want an answer to all of the above questions and will be disappointed if you don't do so. Let's have an honest discussion on these issues. This can be an opportunity to learn from each other, but only if you are open-minded and willing to do so.

MM: If you don't want judged then don't talk trash about your customers and their pets on the Internet. Are you not judging them? Are you not assuming that the majority of people asking for help are dead beats? Isn't it more likely that these people go to work 40 + hours a week to make ends meet because their parents weren't able to help them with tuition for better careers? Isn't it more likely that these people would do what they ask of you, for you, if roles were reversed? Are they dead beats because they don't make as much money as you? You do realize the people you call dead beats are the same ones that provide you with electric, heat, clean water, gasoline, stock the groceries you need to survive, build the cars you drive, build the house you live in, make the clothes you wear, fix your car, serve you at restaurants, and make sure you don't have to s**t in a hole in your yard. So when their pet is met with a tragedy and they can't afford to pay 5 grand at the drop of a hat..... that makes them dead beats. Seems to me like you are the one judging the many and in turn you have been judged yourself. 

DB:  Two things.....
First, you have still failed to answer any of the questions that I asked. Why?
Second, please quote the parts of my blog where I stated or inferred that my clients are deadbeats. Once again you have made an assumption about me and I challenge you to support your view with actual facts.

DB: Also, you're again making many assumptions about me that are untrue. I have been working a job since I was 14 years old and continued to work through college and graduate school in order to afford my education, as well as taking the maximum amount of student loans (which I am still paying back). Most of my veterinary colleagues received no help from their parents and are dealing with incredibly burdensome loans in order to be in this profession. My father started his career as a mechanic, my mother was a secretary and then a housewife, and my wife has worked retail much of her life. I have friends and relatives in the very professions that you seem to imply that I am calling "deadbeats" (which is an extremely emotional and loaded term that I again challenge you to prove I have stated). You stated "the people you call dead beats", and I would like you to point out where I have done so. Please take the emotions out of this situation (if you are able) and rather than making broad statement and incorrect assumptions, support your views with facts and quotes. If you cannot do that then we cannot have a rational conversation.

DB:  Sorry for the multiple replies, but I have been thinking about our discussion and new things come to mind.

     For a moment let's take your premise ("Isn't it more likely that these people would do what they ask of you, for you, if roles were reversed?") with the exact same people that you have mentioned ("the same ones that provide you with electric, heat, clean water, gasoline, stock the groceries you need to survive, build the cars you drive, build the house you live in, make the clothes you wear, fix your car, serve you at restaurants,").  By your statement, if I have fallen on hard times and am on an empty tank of gasoline, if I go to my local gas station the attendant will be kind to me and let me fill up but pay them in a couple of weeks because they understand what I am going through.  If I go to my local Kroger or Publix I can count on the person stocking my groceries to let me pay for the food I need to live over the next month.  If my clothes are developing holes and I need new ones, I can go somewhere that makes and sells my clothes and they will give them to me that day and be perfectly fine with me coming back at some undetermined point to pay them back.  When I am hungry and go to a restaurant the person who serves me will allow me to pay a few dollars a week until I have paid them back.  If I fall behind on paying for my water bill I can count on the water company to float me a line of credit indefinitely, and I will pay them what I can when I can but they won't actually turn off my water.  And the electric company will do exactly the same thing.  According to you if the roles are reversed and I have limited funds, I can count on any other business to extend me credit or set up a payment plan, no matter what business that is. The only business I can't rely on is a veterinarian.  Is that basically what you are saying?

     Oh, and by the way I am still waiting for a reply to my previous questions so please don't let my most recent comments distract you from doing so.


Since this has been rather long, I'm splitting it into two parts.  Come back next time for MM's response and the last part of the conversation.