Fleeting Fame?

I'll admit that I like having my ego stroked.  Who doesn't?  I don't think I'm egotistical, and I hope that most of the time I come across as at least relatively humble, but that doesn't mean I don't like getting recognition.  That may be one of the reasons I enjoy being on TV and radio.  I love to educate people and this is my primary goal for any appearances, but I certainly don't mind the idea of seeing myself "famous".  I've even joked that my goal is to be the next Marty Becker (Google him if you haven't heard of him and you'll understand).

But fame can be fleeting.

Regular readers may remember my most recent TV appearance back in June.  Just after that broadcast my blog traffic went from around 1200 hits per day to a peak of over 7000.  My monthly hits more than doubled, from 41,530 in May to 114,910 in June.  Alas, such fame was not to last.  By the beginning of July the hits dropped, and even though I had a surge in mid-July, my daily traffic went back to average for the month, and though I had over 58,000 hits in July, that was mainly due to a few days of increase.

Well, I may see it come back a little.  A couple of days ago some clips from the footage I taped showed up in a similar story in Milwaukee.  The framing of the story was a bit different, but my appearances were the same.  I actually liked this story a bit better, even though I strongly disagree with the vet who cropped her dog's ears.

I know that when I see or hear something interesting I'll look it up online to find out more details.  It's not surprising that someone would see me on TV and wonder "who is this guy?"  Since I maintain an active blog it's not hard to find me, hence the bumps in my daily traffic.

Would I like to be famous?  Sure.  Most people would.  But it's not the foremost thing on my mind and isn't the reason why I maintain this blog.  So if my readership grows I'm okay with it.  If things peter out, I can handle that also since it's not my main focus in life.  

But if any TV networks need a vet to be a regular correspondent, please feel free to get in touch!

The First Time

Every vet has to start somewhere.  Heck, every doctor, hair stylist, lawyer, or other professional always begins their career with limited experience.  At some point they are going to be faced with a situation, procedure, or case that they have never encountered before and have to handle.  That is always nerve-wracking for the professional, but can also induce fear if the client learns that this is their first time.

One of my associates is a new graduate and recently encountered this situation when a client freaked out a little after learning that the doctor had never done a certain procedure before.  I certainly understand the caution and apprehension from the client, as nobody wants their pet to be the first time a doctor performs a surgery, does a test, etc.  I'll be honest in saying that even I would prefer a doctor who was experienced with a given procedure rather than one doing it for the first time. However, somebody's pet must be the first one for the vet, otherwise they would never gain the experience.

In veterinary school we do get practice at many procedures and surgeries.  Some schools have programs where a student performs many spays and neuters before graduating.  With more complicated procedures it often depends on what cases come into the clinics while you are on that particular rotation.  For example, when I was on my two-week orthopedic surgery rotation I ended up helping on two total hip replacements but no ACL repairs, even though the latter surgery is much more common.  But even with this experience there is no way we can get hands-on practice on every procedure we might perform in practice.

I remember the first time I ever performed a "cherry eye" surgery (prolapsed tear gland).  I had seen them done a couple of times and when I looked in the text book it seemed like a fairly simple procedure.  Because I had basic surgical and tissue handling skills I felt confident in my ability to be successful, and went ahead with the surgery.  The case turned out great and I've done it many times since then.  This wasn't my "first" in practice, either.  There are many surgeries and other services I've done for the first time after looking it up and studying prior to being with the patient.  All of them turned out well, in part because I try to be honest about the limits of my skills.

I know this may sound scary to many clients, and we veterinarians don't typically say "this is my first time doing X" because we're aware of that fear.  But every vet has a pet that is their first spay, their first hernia repair, their first tumor removal, and so on.  Because of the nature of how cases come in we may not have the opportunity to watch or assist in a procedure before we're called on to perform it.  If we're in a good practice we'll have a mentor doctor that can watch us do it or be available to jump in and help if needed.  For example, my new associate recently was faced with a case where the dog needed a tooth extracted.  She had never done this before so I did it for her with her watching.  The next time she'll do it with me watching, and after that she'll do it without observation.  This is often as much "training" as we get in many procedures.

So why aren't we trained more?  It's simply a matter of time and cases.  If we didn't graduate until we had done 90% of the things we'll do in practice it would likely double the education process.  We do as much learning on the job and under the tutelage of an experienced vet as we do in school.  This is true of all professions, as there is only so much you can learn in school before you have to go out and actually do things.

Why is this safe?  Isn't there more risk to a patient if the doctor has never done the surgery before?  To some degree, yes.  The first several times a procedure is performed it takes longer and there is less skill.  You have to do something multiple times before you get really good at it.  When I was a new graduate a spay took me at least 45-60 minutes and I often had bleeding due to sutures that had slipped (which I always identified and fixed before closing the patient).  Now I can do the same thing in 15-20 minutes and have "bleeders" once or twice a year.  But if I hadn't started doing those "first" spays, I wouldn't be as good of a surgeon as I am now.

Another reason this is safe is because of the extensive training we do receive.  Much of what we learn is general principles rather than specifics.  In surgery we spend as much time learning different suture materials and patterns and how to handle different tissues as we do with a single surgery.  Once we understand the general ideas and tissue handling we can extrapolate that knowledge to other areas.  If I know how to remove a skin tumor on the chest, I can also do it on the ear.  And if I learned how to do surgery on intestines I can use similar methods on the eyelid.  Certainly there are procedures that should be learned first-hand by a mentor (such as orthopedics), but that is not true of ever case.  Much of our veterinary education is based on learning the broader principles that we can apply in many circumstances rather than a single instance.

To new vets.....You know more than you realize and don't have to have witnessed every single thing before doing it yourself.  Yes, it's scary, and be aware of your limitations, but don't be afraid to do something just because someone isn't there to hold your hand.  That being said, you'll gain skills and experience quicker with a mentor, so find a practice that is willing to take you under the wing of an experienced vet.

To pet owners....Don't get too worried if your vet hasn't done a given procedure before, especially if they seem very confident about it.  By all means ask lots of questions and get a feel for why that vet is comfortable making your pet their "first".  But keep in mind that every single procedure we've ever done had a "first", and the huge majority of those turned out great.

Instant Expert....Just Add Textbook

Any clients who read this post are in for a shock.  Your vet doesn't know everything.  *GASP*  No matter how much you love your vet or think they walk on water, they don't know all there is about every disease out there.  "But every time I come in he/she always seems to knowledgeable!"  Ah, but there's a reason for that.

Textbooks.

When I go to conferences the busiest vendors are always the textbook publishers.  These books are not directed at veterinary students, but instead are bought by experienced practitioners.  Every good vet has a decent library of books in their office, many of which are coming apart at the binding because of being opened so many times.  One of the things I emphasize to new graduates is that there is no shame in looking things up.  Every vet does so daily.

Often right before we go into a room.

A few days ago I had a dog come in for a discussion about Addison's disease.  This is a disorder where the body doesn't produce enough steroids and can be life-threatening.  Thankfully it's a very treatable disease with and excellent prognosis.  But I don't see a case every week, so the small details were a bit fuzzy.  In fact, it's been a few years since I've had a confirmed case come to me.  My memory remembered the basic lab values (decreased sodium and increased potassium, often with kidney values out of whack), the very vague symptoms (lethargy and weakness), the confirmatory test (ACTH stimulation) and general treatment (steroid supplementation).  However, the specifics of the disease escaped me, especially specific values and dosages.  So before I went into the room I pulled out one of my textbooks and read the section on Addison's disease to refresh my memory.  By the time I went into the room I could talk to the clients like I diagnosed this disease every day.

This is in no way deceitful or dishonest.  There is so much to know in medicine that nobody could possibly keep all of the information in their memory.  One of my associate doctors has a seemingly encyclopedic knowledge of even obscure veterinary diseases and treatments.  Sometimes I shake my head at the facts that she easily spouts.  Yet even she looks things up daily.

Yes, talking about this is a bit like pulling back the wizard's curtain in Oz.  But I want clients to know that doctors aren't all-knowing, despite our best intentions.  And I want veterinary students to know that having to look things up doesn't mean that you aren't a good doctor.  Sometimes all of us need a little help.

Cats Vs. Carriers

Today one of our clients couldn't bring her cat in for a routine dental cleaning.  Why not?  Because as soon as she brought the carrier out the cat disappeared and couldn't be found.  This is a common problem and it shouldn't be surprising to people if you think about it.  The only time cats get into carriers is to go somewhere unpleasant for them, such as a vet, groomer, or boarding facility.  They associate the carrier with the stress of travel and then the results once they get to the destination.  So of course as soon as they see the carrier come out they remember previous episodes and want to immediately avoid it.

It doesn't have to be this way!

There are actually several simple things that clients can do to get their cats over this fear.  And it's something I recommend every cat owner look at doing as soon as possible.  Taking the following steps can help reduce your stress as well as your cat's.

1.  Make the carrier a piece of normal furniture.  What I mean by this is keep the carrier in a conspicuous place all of the time.  Instead of putting it away and then bringing it out when it's time to take Kitty to the vet, make it a regular part of the environment.  Put it near the litter boxes, food bowls, cat tower, or just in a corner of the room.  Wherever you put it is fine as long as the cat can see it and interact with it.  Before long it won't become an object to be feared.  It will be as normal and routine to them as the couch or a chair.

2.  Make the carrier a positive item.  Change the associate from something of stress to one of pleasantness.  The best way to do this is to put the food bowl in the back of the carrier every time the cat is fed.  Leave the door open so the cat will go in and out whenever they want to.  Cats want to eat and if they associate the carrier with their regular, everyday meal, it stops being something to fear and starts becoming something they willingly go into.  Yes, there may be some initial anxiety and they may be reluctant, but once they get used to it they won't think twice about it.  This works especially well if you spent a few weeks having the carrier out and open as I mentioned above.  Once they are used to eating in the carrier it can also be simple to put some food into it, wait for them to go inside, then quietly close the door.

3.  Just before traveling use Feliway.  I'm a big proponent of pheromone therapy for anxiety issues in dogs and cats.  If you're not aware of it, Feliway is a synthetic duplication of the pheromones found in cat facial glands and when they inhale it the product helps to relax them and give them a feeling of well-being.  It can lower their anxiety and keep them from being as stressed during travel.  This is a trick that feline specialists have used for years and works well in most cases.  If you combine Feliway with the above counter-conditioning techniques, the trip may be quite relaxed and pleasant for you and your cat.

Of course all of this will take a little work, planning, and forethought, which many owners won't bother to do.  But with just a little extra effort not only can the cat be less stressed, but so can the owner.  And your vet will appreciate you not missing appointments because your cat became scared.

You Can't Make Everyone Happy

When you deal with clients it's impossible to make every single person happy.  No matter what you do, somebody isn't going to like X, Y, or Z and will complain.  This is as true in the veterinary profession as in any other business.

My practice has several locations and we utilize and outside survey service to measure our client service.  Like many businesses our receipts have a website where you can rate your experience and enter to win a prize.  The location I manage repeatedly has the highest service score in the area, so people like us and what we do.  On a less "scientific" basis I also know we have many loyal customers and our business is growing.

Even so we get upset clients.  Last week I had someone get very upset because her cat may have had a vaccine reaction.  It had diarrhea and vomiting after being in for kitten immunizations, which are potential signs of a reaction.  The diarrhea had started while in the exam room, something noted by one of my associates who cautioned the owner about reactions and offered to treat.  The next day the client called because the kitten still vomited some.  We told them to bring her in, but they went and had lunch instead and by the time they came in our doctor was at lunch.  Rather than understanding they got upset because they hadn't been told not to come in at a certain time, and wanted one of the techs just to give a shot.  They also didn't want to bother leaving the kitten with us for observation.  All of this was clearly documented in the pet's medical notes, so when she came back for boosters we expected to have her dropped off for premedication and observation (our practice's required protocol for suspected or known vaccine reactors).  The client got upset at this and refused to drop off, so I went up front and talked to her.  She was livid about the whole situation, even though I explained that we had documentation of all of the discussions with her (which she denied having had).  Knowing that this wasn't going well I said "I can see that we aren't going to be able to give you the care you want.  I'll be happy to provide you a copy of your medical records or send them to another vet."  She debated a bit but despite all of the complaints decided to leave the kitten with us after all...until she saw the costs.  Yes, we do antihistamine injections and place an intravenous catheter in cases like this, which the client must pay for.  Once the charges were rung up she took her records and stormed out....to one of our satellite clinics with the same policies and costs!

Another client had called to get her dog in for a routine rabies vaccine.  We had seen this dog a few times over the last year, so it was a normal set-up.  Apparently one of our receptionists made a mistake and accidentally misquoted one of the prices. The owner called up to confirm the appointment, spoke to my office manager, and was told about the mistake.  The person was furious, and began to yell about the situation.  My manager tried to get a word in edgewise and warn the client not to be loud or use that tone.  At one point she even offered to waive the office visit charge as a gesture towards rectifying the mistake.  Instead of taking this the client proceeded to register an official complaint with the practice owners, even saying that the manager was "screaming" at her.  Keep in mind that in over three years of working with this manager I have never heard her raise her voice to anyone in any circumstance and she is very good at client service.

Client's like this aren't just recent.  Many years ago I was doing routine vaccines on a dog and talking to the client.  The dog was well behaved and didn't flinch or react when I gave the shot.  I walked the client to the reception desk and then he suddenly accused me of not giving the vaccine.  I was surprised because he was standing across the table from me when I did it.  I tried to explain that I had used a small needle and it didn't always cause pain, so his dog simply didn't act bothered.  He didn't buy that and continued to press the issue.  I offered to re-vaccinate his dog with him watching at no extra cost, though I warned that this might increase the risk of a reaction.  He didn't want to do that either.  He paid the bill and left, still not seeming to believe that I could give a quick shot without him noticing.

So why am I posting about this?  Believe it or not I'm not trying to rant against stupid clients (at least, not this time).  I'm pointing out to anyone who has been or will be in these situations (vet students and new graduates, I'm looking at you!) that no matter how hard you try or what you do there will always be people that you can't please.  There will always be people that seem to have a chip on their shoulder and are ready to take offense.

Don't let them get to you.

One of the things I've learned in my 16 years in practice is to quickly get over these clients.  I know that the majority of people love us and what we do, so a cranky person here and there doesn't bother me anymore.  In fact, I get a little amused by them.  I wasn't always like this, as earlier in my career I took it personally or as a reflection on me.  Then I realized that the problem was actually with the clients themselves.  Sure, there is always room to improve client service, and I'm always on the lookout for these opportunities.  But some people just refuse to be satisfied.

One of my favorite websites is NotAlwaysRight.com.  I go there every day to see stories of other client/customer nightmares.  It helps give me perspective on my own job to see other people dealing with similar situations in different professions.

So once again advice to those new to the profession.  No matter how nice or good you are, you're going to get displeased clients.  Rather than getting depressed by their actions, recall all of the clients who really appreciate and like you.  The latter will outnumber the former.

If Dr. Seuss Was A Vet

A veterinary friend of mine sent this to me on Facebook and I fell in love with it.  Though I think only those who work in the veterinary field can truly appreciate it, I hope everyone else can see the humor also.  I'm not sure who started this so I can't give credit.


If Dr. Seuss Was A Vet
I won't dispense it, Sam I am,
I won't dispense without exam.

I won't dispense it to your dog,
Although you'll bash me in a blog.

I won't dispense it to your friend,
Who yells at me without an end,

I won't dispense it for the ear,
For the eyes, or for the rear,

I won't dispense it though you yell,
How mean I am the world you'll tell!

I won't dispense it to your cat,
to your bird, or to your rat.

I won't give in--I'm standing tall.
Although you'll whine and cry and call.

I won't dispense it, Sam I am!
You can't have meds without exams!

Dealing With Bored Dogs

Here's a great behavioral question sent from Nicole....

I have a roughly 9 month old border collie x blue heeler. On paper we probably shouldn't have such a breed- we live in a large capital city (Melbourne, Australia) in the inner city with a small block. However, Ted was a rescue pup, came to us very submissive and malnourished and in the 2 months we have had him he his confidence and personality have flourished, he has a thick healthy coat and he has developed into a delightful, confident companion.

I am concerned about what to do with him in the days we both work (usually only 2-3 days a week when we are both out but he is alone 8-10 hours). We walk him twice a day, every day for about 1/2 an hour each time (no matter how cold it is at 7am). He is attending obedience class once a week plus training him for short bursts each day. We stuff a kong with meat and have a treat ball containing kibble that we leave him with (measured amounts to ensure correct quantity). We have been leaving him with a bone 2 days per week but after seeing him strain and pass a small amount of bright red blood with a very hard bony poop we will not be giving him bones anymore- plus I read the posts on bones on your blog after this episode. He doesn't play with any of his toys unless we are there to throw them and on the days he doesn't have a bone to keep him busy he excavates the yard, remodels the outdoor furniture or spends the day trying to break in to the house (as evidenced by the tooth marks on the back door).

Is there anything you can suggest that I can safely leave him with to chew unsupervised (he is a BIG chewer and I have never seen any chewing behaviour that concerns me- he doesn't tend to swallow chunks)? And is there any other hints or tips or toys you can suggest?

Bored dogs are not unusual, especially in certain breeds.  While it may seem a bit silly to discuss boredom in dogs, Nicole has pointed out that this can be a big problem.  Take an active, young dog, give it nothing to do, and wait for the mess.  Dogs need an outlet for their energy and curiosity, and if those outlets aren't provided they will find some way to make it happen.  Unfortunately that tends to be very destructive behaviors, such as digging holes or chewing up things around the house.

One of the first things everyone should do is to understand their breed.  In Nicole's case she has two very energetic breeds mixed together.  Border collies and heelers are bred with a strong instinct to run around and herd.  This is natural behavior for them and results in dogs that tend to be quite active.  As she said, if given a choice a small inner city region is not the best location for such dogs.  However, given that this is a rescue situation we can skip that part as I'm not going to chastise anyone who has provided good health and home to a pet like this.

Obedience classes are a great start and I recommend that for every dog, not just those with behavioral problems.  But that's not going to be enough.  A 30 minute walk twice daily is also not sufficient if this is the only opportunity for exercise.  He is a young dog and comes from energetic breeds.  The idea here is to tire him out.  Basically give him as much exercise as it takes to get him worn out.  Instead of a walk, take him for a jog (assuming that you can do so yourself).  Try to find a park nearby that allows off-leash dogs and teach him to catch a Frisbee or ball.  If you are in an apartment building or have something like that nearby, take him up and down stairs several times.  Get creative, but you need to give him an outlet for that energy.

Okay, now for the chewing.  Kongs are great, so keep doing that.  For a heavy chewer young not going to find many things better, and they make them in various "strengths".  It doesn't sound like standard chew toys and treats are going to last long enough for him, so keep those to a minimum.  Besides the meat you can seal one end, pour cooled chicken broth in it, and freeze it until solid.  Rotate the types of things you put in there.

There are other ways to provide environmental enrichment when you're not home.  Look into puzzle toys.  These are balls, cubes, and so on that have a small opening or two to allow kibble or treats to fall out when the dog moves it a certain way.  The principle is that the dog has to spend time thinking and figuring out how to move it to get the treats out rather than simply chewing something up in a few minutes.  Another thing you can do is to take a cue from what zoos do to keep their animals engaged and active.  Find some areas where you can hide special treats, such as in a hollow stump, under a plastic flower pot, and so on.  Each day before leaving put some treats around the yard in specific places where he doesn't need to dig or be destructive.  He will have to use time and energy to search them out, thus keeping him occupied and have an outlet for his boredom.  Put them in different locations so he doesn't get used to a pattern.

Some of this may improve as he becomes and adult and gets older, but this kind of energy and boredom can be a problem for several years.  If the problem becomes worse, talk to your vet about antianxiety medications, though this should be a last resort and only after he has reached full maturity.