Trifexis Safety Concerns: Poor Reporting And Media Hype

Anyone want to take bets on how long it takes for someone to make a disparaging or hateful comment on today's blog post?  Or how quickly someone accuses me of being stupid, uninformed, or a shill for Elanco?  I'm expecting it because I know that there are some people who are pretty heated about this topic.  Well, so am I, so prepare for my rant.

Last November WSB TV in Atlanta, Georgia "broke" a story about possible dog deaths related to the owners having given them Trifexis, a common and popular oral preventative for fleas, heartworms, and several intestinal parasites.  Living in the metro area near Atlanta and carrying Trifexis, I was of course interested in the story and even a little concerned.  Then I watched it and had to shake my head in amazement at the hack job that was done.  I have always liked WSB and watch them in the morning when I'm getting ready for work.  But the reporter, Jim Strickland, did such a horrible job of presenting the facts that I can no longer fully trust their news department and when I see his reports I wonder what he's leaving out.

Here's a link to the original story, including a video of the broadcast segment.  I encourage you to watch it, as I'll be discussing specifics about it.

It seems pretty damning, right?  But let's analyze how the story was presented.  You get a mention that a University of Georgia pathologist concluded that the hearts of these puppies were inflamed, consistent with a bacterial infection and that there were no signs consistent with a drug toxicity.  Okay, seems like the toxicity has been ruled out.  Nope!  Just a little after that we see a huge "31 DEATHS" fill the screen, even though these were not confirmed to be related to Trifexis.  Which part do you think people will remember?  Does anyone really think that the reporter was trying to present a fair and balanced representation of the facts?

A couple of weeks later a follow-up story was broadcast.  This one proudly proclaimed "Owners blame 700 dog deaths on Trifexis"!  And during the lead-in to the story Strickland says "Since the pill was launched on the market on average every 36 hours a pet owner reports that Trifexis killed a dog."  Shortly after that you see a big yellow "700 DEATHS" fill the screen.  The story goes on and a couple of times the reporter mentions that these are reports made by owners and not confirmed deaths.  He admits that there is no proof of the connection.  Hmmmm....How different would people have taken the story if they mentioned 700 deaths reported but then flashed a big yellow "NO PROOF" on the screen?  Manipulation, folks.  And many people bought into it.

There was also a whooooole lot that was left out and that is pertinent to interpreting the case.

• Trifexis is made of spinosad and milbemycin oxime, neither of which are new compounds.
• Milbemycin is the same antiparasitic used in Interceptor and Sentinel.  It has been on the market since the 1990s and has been used consistently since then with no significant adverse effects reported, especially deaths.
• Spinosad is the same compound used in Comfortis.  It has been on the market and used extensively since 2006.  The only significant side-effect reported is vomiting.
• Trifexis has been on the market since 2011 and tens of millions of doses have been sold in 15,000 veterinary clinics across the US.  The only thing "new" about Trifexis is that it is the first time that two already existing chemicals were combined into one product.
• There is extensive testing before any pharmaceutical makes it to market.  While this certainly does not eliminate all possible reactions or problems, it rules out many of the common ones.
• The reporter never looked into whether or not any of these dogs had any underlying health conditions or were on other medications.  Some investigation!  He never even seemed to consider the possibility of other causes of death or illness.  I'm sure he never bothered to look at the medical records of these dogs to see whether or not the people's thoughts were supported by science and diagnostics.  Investigative reporter my lily white toches!!!  It's obvious that Strickland was more interested in emotions than facts.

Stop and think about this for a moment.  If either spinosad or milbemycin was a dangerous chemical, why are there no reported deaths with the products prior to this news report?  And why are we not getting reports about deaths with Interceptor, Sentinel, or Comfortis?  I think that knowing the history behind the chemicals puts good perspective on how not dangerous they really are.

Speaking of perspective, let's delve into how the Food and Drug Administration handles reporting.  If a client contacts them and says "Product X killed my dog!", they have to put down that Product X is a potential cause of the death.  The "700 deaths" reported are simply the owner claiming that it happened and is prior to any investigation of the facts and other details of the cases.  I'm not knocking the clients as they likely legitimately feel that Product X was the cause.  But when someone like one of the clients in the Trifexis story are convinced that the product killed her dog, then an independent pathologist reports heart disease unrelated to toxicity, which one is a fact and which is an opinion?  And even if the conclusion is that the dog's death was unrelated to Product X, the FDA report will still list it as a "possible" death.  The big yellow "700 DEATHS" is owner-reported and isn't necessarily connected to the truth at all.  And there is no way to remove cases that are confirmed to be unrelated.  So even cases confirmed to be unrelated stay in these preliminary reports.  People don't seem to understand that a report of death doesn't mean that it's confirmed.

In the time that I've been in and around veterinary medicine I've seen similar hype that turned out to be simply hot air.  When I first started practicing in the late 1990s Rimadyl (carprofen) had recently come onto the market as a pain medication for dogs.  It was great and helped a lot of pets, especially with chronic arthritis.  But then all of the message boards (remember, we're pre-Facebook and pre-Twitter here) started blowing up over "Rimadyl killed my dog!"  There were "thousands" of dogs who had died from it, or at least that's what the internet was claiming.  The manufacturer and FDA investigated and found that there was no connection.  In fact, some of the details were pretty ridiculous once you looked into them.  I remember one dog died from lymphoma, yet it had been originally reported with Rimadyl being a possible cause of death.  Some of the deaths happened months after being given Rimadyl.  This is why the "700 deaths" above really doesn't mean anything without more details.  What happened to Rimadyl?  Well, almost 20 years later it is now the single most common pain medication used for dogs in veterinary medicine.  It is trusted and used by tens of thousands of vets in millions of dogs world-wide and we haven't seen wide-spread problems since that initial set of reports (and those were not really "wide-spread problems").

Back in the early 2000s a heartworm preventative called ProHeart6 came onto the US market.  It's an injection that lasts for six months, keeping people from having to remember a pill every month and possibly missing doses.  After a couple of years of use there was an internet blow-up about dogs dying from ProHeart6 injections.  This spread like wildfire as people talked about it via email and forums.  It reached the FDA as people wanted it pulled from the market because of its extreme danger.  Around 2006 the manufacturer volutarily pulled it from the market to conduct further research on safety.  The worked with a well-know epidemiology specialist and compared reaction rates of all heartworm preventatives in the US market.  The study (peer-reviewed and published) showed that reaction rates were statistically the same across all types of heartworm prevention.  There was no difference in illnesses or death regardless of whether the pet took Heartgard, Interceptor, or ProHeart6.  In 2008 it was brought back on the US market with significant restrictions, which were then mostly lifted in 2010.  Over the last six years it has been very closely tracked and monitored, and there haven't been the wide-spread deaths that people seemed to claim.  You know what else?  During all of this investigation it was available outside of the US at a much higher dose that gave a full 12 months of protection, all without the reports of deaths that were seen in the US.

Okay, so the Trifexis report was last November, why bring it up now?  Because apparently WSB and Jim Strickland believe that there is still a story there, and on July 30th broadcast an update.  What was the new, breaking information that caused them to visit it?  There wasn't any.  Seriously.  There really wasn't anything new.  There apparently have been more reports to the FDA of adverse reactions, but once again these are concerns that clients had, and not illnesses or deaths directly related to Trifexis.  So far, every case has shown other causes related to the illnesses or deaths. Thankfully, he was more obvious about stating that these cases were not proven to be related to Trifexis.  But if they weren't proven, where is the story?  What is it other than speculation and emotions?

Here's something else frustrating about these news reports....there is more information on the TV station's website that isn't mentioned in the broadcasts.  So to get more details you have to be willing to go to their site and click on links other than the video.  For example, here is part of a statement from the FDA that you can find on the WSB site:

FDA is aware of adverse event reports in connection with Trifexis and continues to closely monitor them. It is very important to realize that reports of adverse events do not necessarily mean that the product caused the event. Other factors, such as existing disease, exposure to chemicals or contaminants, foods, or other medications may have triggered or contributed to the cause of the event.

I also bet you don't remember Strickland saying anything like the following in his reports: 

For any given ADE report, there is no certainty that the reported drug caused the adverse event. The adverse event may have been related to an underlying disease, using other drugs at the same time, or other non-drug related causes.  And, this listing does not include information about underlying diseases, other drugs used at the same time, other non-drug related causes, or the final outcome of the reaction.

Yet that statement is on the WSB website from last November, specifically attributed to him.  Knowing other underlying conditions and treatments is extremely important in fully evaluating adverse events like the ones currently in question.  I think it's worthwhile to point out a few of those cases so that the average person can see just how much is left out of these stories and how biased the media is in presenting the case.

• The case that started these reports was related to three Viszla puppies who died after receiving Trifexis.  All three puppies had necropsies preformed by an independent pathologist and reviewed by another pathologist.  In all three puppies there were no signs related to the Trifexis and all three had changes in the heart consistent with a bacterial infection.  Elanco has provided a copy of this report to vets, which I've read, and it is very clear that the pathologists who were not paid by Elanco concluded that the deaths were unrelated to Trifexis.  How much of that made it into the news reports?
• A Scottish terrier was reported to have had a reaction after a single dose of Trifexis in 2013, having vomiting, lethargy, and ataxia lasting a few minutes, but the recovered.  Okay, that sounds like a problem, right?  And this may be the same dog in the most recent broadcast story, though Elanco's case report doesn't list the client's name.  That same dog had been reported to have vomiting and lethargy after Comfortis in 2012 (remember, same flea ingredient).  The dog also had been diagnosed with cerebellar atrophy in 2004-2005, though that wasn't initially disclosed by the client.  In 2010 there was an elevation in one of the liver values.  Prior to taking Trifexis the dog had other health problems, including hypothyroidism, and was on various homeopathic nutritional supplements.  A liver biopsy after the Trifexis dose showed long-term cirrhosis of the liver.  You see on the news report "my dog took Trifexis, did poorly, and died."  You don't get the full story of the multiple factors and problems involved.  You aren't told that the dog had previous history of liver and neurological problems.  With all of these underlying issues there were multiple potential causes of the dog's illness.  It may also have reacted poorly to the Trifexis due to pre-existing liver problems.  Did these already existing problems make it on the news report?  Only a brief mention, which isn't as impactful as the owner getting emotional.
• Watch the bulldog case on the same video.  The dog suffered seizures "after her third Trifexis dose".  And her other dogs continued to take it without any problems.  But the woman breaks down crying over this tragic death.  When you read the full report of the case you see that the dog had Trifexis for over six months, with a seizure starting in October 2013.  The vet she saw at that time concluded that the seizures happened unrelated to the Trifexis.  Seizures continued off and on for a month, but seemed to resolve from November until January 2014.  They became worse and by March the dog was euthanized due to seizures being uncontrolled.  The timing and likelihood of underlying problems weren't reported on the news.

The news reports the upset, crying owners, which pulls at the hearstrings.  I completely understand that these owners honestly believe that Trifexis was responsible for their dogs' death and illness.  Their grief is real and in their minds they know the answer.  I'm not belittling their feelings and genuinely wish this hadn't happened to them.  But when you get past emotions and look at ALL of the details objectively, a different picture comes to mind of other health problems.

Could Trifexis be a problem?  Possibly.  I'm open to that possibility, especially if further objective investigation leans in that direction.  But so far I've seen nothing that convinces me that this is a general problem of the medication's safety.  I still consider it safe for the majority of dogs and continue to recommend it to my clients.  If information comes out that confirms deaths and other serious adverse reactions, I'm willing to change my opinion.

Could an individual dog have a sensitivity to the ingredients in Trifexis and have serious health concerns?  Absolutely.  In fact, that may be what has happened in some cases.  However, unexpected or rare reactions are unpredictable and don't indicate a pervasive problem with the product.  We can never tell when a pet is going to have an unexpected reaction.  But the same thing happens in people.  I think most people consider aspirin to be safe, and never think to look at the warnings on the label.  Well, I did, and here are some of the possible side effects listed: 

Body as a Whole: Fever, hypothermia, thirst.

Cardiovascular: Dysrhythmias, hypotension, tachycardia.

Central Nervous System: Agitation, cerebral edema, coma, confusion, dizziness, headache, subdural or intracranial hemorrhage, lethargy, seizures.

Fluid and Electrolyte: Dehydration, hyperkalemia, metabolic acidosis, respiratory alkalosis.

Gastrointestinal: Dyspepsia, GI bleeding, ulceration and perforation, nausea, vomiting, transient elevations of hepatic enzymes, hepatitis, Reye's Syndrome, pancreatitis.

Hematologic: Prolongation of the prothrombin time, disseminated intravascular coagulation, coagulopathy, thrombocytopenia.

Hypersensitivity: Acute anaphylaxis, angioedema, asthma, bronchospasm, laryngeal edema, urticaria.

Musculoskeletal: Rhabdomyolysis.

Metabolism: Hypoglycemia (in children), hyperglycemia.

Reproductive: Prolonged pregnancy and labor, stillbirths, lower birth weight infants, antepartum and postpartum bleeding.

Respiratory: Hyperpnea, pulmonary edema, tachypnea.

Special Senses: Hearing loss, tinnitus. Patients with high frequency hearing loss may have difficulty perceiving tinnitus. In these patients, tinnitus cannot be used as a clinical indicator of salicylism.

Urogenital: Interstitial nephritis, papillary necrosis, proteinuria, renal insufficiency and failure.

Holy, freakin' heck!  If you take an aspirin it might kill you!!!!

EVERY medication carries potential side effects, some of them potentially serious.  There are no medicines on the market, even natural supplements, that have a completely 0 risk of adverse effects.  It simply doesn't happen!  Seriously, the next time you buy any over-the-counter medication, take a look at the product labeling and worry about the problems you might have.  Could Trifexis have caused some side-effects?  Yes.  But there is no evidence that it is a "dangerous" medication.

If anyone doesn't believe in media manipulation of facts, they need to seriously analyze these stories by Jim Strickland and WSB.  This is pure and simple one-sided fear-mongering and manipulation of emotions.  This is not real reporting, as a true investigation would easily bring up the facts that I've written here.  But that would not make good ratings, and that's all this story is about.  It's designed to make people watch because they fear for their pets.  It's not presenting all of the facts.

Now I know that there are plenty of web sites and reports from people who are convinced that Product X is deadly and should be removed from the market.  I've visited many of them in relation to Trifexis, Rimadyl, and ProHeart6.  I know that there is a good likelihood of someone making a comment, screaming at me for my ignorance, willingness to ignore "facts", and being a "Big Pharma sheep".  In fact, I'm expecting it.  But let's get beyond emotions and look at facts.  Let's look at the full details on cases, not just the emotional people that make it on the news, or the 10 second snippet from pet owner.  And let's put everything in the same font and style, rather than filling the screen with "935 DEATHS". 

With both Rimadyl and ProHeart6 there was a hue and cry about dogs getting sick and dying left and right.  When it was fully investigated it was learned that there was no basis to wide-spread problems and subsequent use over years and years proved the fears to be unfounded.  I fully expect the same thing to happen with Trifexis.

The question I then frequently get is "What do you use with your own dogs?"  I use ProHeart6 for heartworms and Comfortis for fleas.  If ProHeart6 wasn't available, I would use Trifexis.  Yes, even after all of these recent reports.   

Whelping/Queening At Home

Recently I was asked whether or not it was safe to allow pet dogs and cats to give birth at home (called whelping with dogs and queening with cats).  After all, humans in Western countries typically give birth in hospitals due to the risks to the baby and mother.  Is it the same with animals?

 

Definitely not.  It has been years since anyone brought a pet to me during the birthing process, and then only because there were problems with the mother being able to give birth.  Animals run much more on instinct than do humans and the process typically goes much smoother.  Often a dog or cat will give birth when the owner isn't around, so the person happens to go to their bed and find puppies or kittens wriggling around after everything is finished.  In the huge majority of cases the birth will happen safely and without the need for human intervention.

However, problems do occur and may require veterinary intervention.  Babies can be too big to pass through the birth canal or become stuck partway through.  If this happens get your pet to a vet immediately and do not try to pull the baby out yourself.  These cases may require a c-section and you could do more harm than good by simply pulling.  A good rule of thumb is that if the mother is having obvious labor (active abdominal contractions) for 45-60 minutes without a baby coming out, or that long between babies, contact a vet right away.  Some of these cases may simply require an injection of oxytocin or similar care, but there is always the risk of a stuck baby.

Some dogs and cats want to give birth right next to you, so don't be surprised if they pick a spot on your bed or under your kitchen table.  Others want the birth to happen in a quiet, secluded area, including the back of a closet or an unused room.  Let the pet pick their own location as that will be less stressful for them.  Provide a queening/whelping box (just do an internet search for those terms and you'll find links on how to make one) and keep an eye on things, but for the most part you simply let nature take its course.

Does Trap-Neuter-Release Help Feral Cat Populations?

TNR programs (Trap-Neuter-Release) are common in many Western countries as a way to control feral cat populations.  The idea is that when there is a community of wild, unowned domesticated cats we can help reduce and eliminate this population by capturing them, testing for certain diseases, vaccinating, spaying and neutering them, then returning them to the wild.  Advocates of this policy believe that simply capturing and euthanizing these cats provides a vaccuum in the population which allows new cats to enter and continue the process.  They also believe that this is the most human method of handling feral cats.  But does this really work?

 

Unfortunately a growing number of studies is casting considerable doubt on the efficacy of such programs.  The stated goals of reducing the number of feral cats is rarely reduced unless there is considerable effort made.  In fact, studies have shown that in these cases populations tend to remain stable rather than decreasing.  The more that researchers have looked at the issue, the less support there is for the idea that TNR programs reduce feral populations.

 

Yet you'll find that most humane societies, animal control departments, and rescue groups support this idea, and even promote the position that it really does work.  If you simply look at the logic of procedure it really should work since you're removing breeding cats from a population yet keeping them there to compete for resources.  Unfortunately the reality of the situation doesn't tend to support this, and many of the studies quoted by such groups really don't provide data as the grops think they do.

 

Does that mean that TNR shouldn't be done?  Honestly, I'm on the fence about it.  You'd be hard-pressed to find anywhere in the world where an average TNR program has eliminated a population of feral cats.  By this evidence it really is a waste of money.  At the same time, we must be affecting populations by spaying and neutering, and hopefully reducing cats with FIV or feline leukemia by testing for and euthanizing those who are positive.  Maybe it's my heart rather than my mind that wants to believe in continuing them.  I still wonder if there are better ways to spend limited resources.

 

For more information here are a few links.  Read through them, compare the data, and make your conclusions.

 

Skeptic North

TNR Reality Check

State VMA Position Statements

AVMA

 

Dogs And Sunscreen

Most people don't think about it but animals actually can get sunburned.  It's not as common as in humans because their fur is typically so dense that direct sunlight doesn't make it to the skin.  They can still become overheated but true sunburn is uncommon.

 

That doesn't mean that it can't happen.  Breeds that are hairless are absolutely at risk for getting burned.  The same is true with a dog that has a thin coat where skin is exposed through the hair, or one that has a localized patch of hair loss due to another disorder.  Geography can also increase the risk, due to an area having a lot of direct sunlight or at higher elevations where the atmosphere is thinner and allows more ultraviolet rays. 
 

Excessive sunlight can carry the same risks as it does with humans.  You can have physical burns that can be painful or become infected.  You can increase the risks of certain kinds of cancer, especially squamous cell carninoma on the face and head of primarily white animals (dogs, cats, and horses).  Obviously these are things that we want to avoid.  The reason that pigs wallow in mud is to coat their skin and help block sunlight. 

 

Thankfully there are ways to help.  First, don't shave your dogs too short for the Summer.  The longer hair coat actually helps prevent sunlight from directly hitting the skin, so if the coat is too short you can increase the risks of burns.  As with humans, provide plenty of shaded areas for your dogs and try to avoid them staying in the direct sun for prolonged periods.  There are sunscreens specifically designed and approved for dogs, but in a pinch you can use plain zinc oxide sunblocks.  However, be careful not to let the dog lick at this kind of sunscreen as zinc can be toxic in high enough doses.  The key is to not ignore the potential for problems and burns.

 

Summer sun and heat can carry as much risk for our pets as it does for us.  Don't forget about them!

Dental Floss Doesn't Remove Skin Tags, But Thanks For Trying

After over 17 years in practice it gets difficult to surprise me or for me to see things I haven't seen before.  But today it happened.  It caused more of a sigh and face-palm than a true surprise, but it was still a variation that was new to me.

 

One of my other doctors saw a dog that has been a regular at our clinic for years.  He is an older beagle and generally in pretty good health.  He has had a rather large and long, but otherwise benign, skin tag for a long time.  We have talked to them about removing it while he was under anesthesia for a routine dental cleaning, but they had always declined.  It seems as if they had an inkling to try it themselves.

 

Today they brought him in to remove the dental floss they had placed around it. Yes, you read that correctly.  Dental floss.  About a month ago they had tied it tightly around the base of the skin tag, hoping that it would cut off blood supply and cause the tag to fall off without surgery.  The floss dug into the skin and tag, but didn't actually result in enough blood occlusion to cause the tissue to die and slough off.  But it did dig in enoug that they couldn't remove it themselves.  So our doctor had to use some suture scissors to get underneath it, cut it loose, and then clean the infected tissue around it.  All while the skin tag flapped around like it always had.

While this may be the first time I've seen dental floss used, this is an old (and rather bad) way to try and remove masses or even castrate an animal.  Usually rubber bands are used tightly around the offending growth or testicles, constricting the blood supply and eventually causing the tissue to fall off because the cells have died.  For some reason some people think that this is a perfectly acceptable substitution for surgery.

Using floss, string, or rubber bands in this way is one of the worst things you can do.  If the tissue is large enough, such as the scrotum and testicles, there will be pain and discomfort.  Would any man feel fine with having his family jewels tied off and left to rot for a month or two?  If the procedure actually does work, it's doing so because the tissues are dying from lack of blood supply.  It is literally dying and rotting off the body.  Who thinks this is a good thing?  There is a big risk of infection or having more tissue than desired be affected.  In the case of a mass or polyp you leave the base in the skin so it has a chance of regrowing.  In order to completely resolve the problem you have to cut away the attached skin, not just remove the dangling part.

Thankfully this was a relatively minor irritation and the dog is going to be fine.  And he's coming in later this week to have the skin tag properly removed.

Questioning A Veterinary Career Choice

Here's a question from Ingelin.  Though she's in Norway (I love having an international readership!), her frustrations and concerns are universal and really shows some of the challenges for veterinarians world-wide.  I could take out the country references and completely believe that she is here in the US.

 

I am a Norwegian veterinary student, studying in Budapest, starting on my 5th year this fall.

I am currently - and have been for the last year or so, afraid that I have chosen the wrong profession.

 

Ever since I was a little girl (yep, as "all the others" also say..), I have imagined that nothing in the entire world would be better than doing veterinary medicine. My love for animals hasn't changed at all - I would almost say it has become stronger by seeing all the cruel things going on in research, labs and especially in the farm industry. Though, i sit here - closer to the goal than ever, feeling nothing but sad and frustrated.

 

This summer I am doing my practice in, so to say, the only horse clinic in Norway. The past months i have spoken to every vet i could, asking them about their working life and what they have to say about it. As I really really want to do horses, as this is where I feel most confident, I know the horse sport and I have been a horse owner myself for many years, and I feel like this is where I could do best - I have mostly spoken to horse practitioners. In general, most of them tell me: Life is tough. They spend hours and hours working their a**** off, earning nothing compared to what they do. They walk around in horse s*** all day long, one got his arm broken by a horse and a year later his mandibula. Another got her collar bone broken by a horse and actually, just after recovery - her knee got crushed by a horse. One got back problems after just working a year and is now in a lab.

 

Working 70-80 hours a week, one of them were in a period of 7 years in three car accidents due to driving from farm to farm - being so tired and falling asleep behind the wheel. They tell me that driving around day in and day out all alone without a supporting team around you is very hard. The physical work is tough, the organization of equipment that you need is both expensive and lots of work, all the billing/invoice work is time consuming and you would optimally need some knowledge in economics to do it well, it's hard with customers/owners not being willing to pay, or arguing with you that the treatment is too expensive, and especially as a woman you will meet many tough physical challenges and farmers can be very "oh jesus are YOU gonna do that - I could do it better". Ok, I think you got my point.

 

Some veterinarians tell me: do an internship straight after graduating, choose exactly what field you want to specialize in and stick to that. (For example not just equine surgery, but equine orthopedics). Others tell me that doing internships is "lethal": the salary is very little, you get to do very little "hands on" if you are at a big clinic with lots of specialists ect, maybe you wont get work in that field when you finish.. Do a mixed practice and learn a bit of everything so you can fall back on things if you have a hard time to get a job. Oh everyone is giving me different advises.

I feel really lost and I would almost say depressed. I have worked so hard to get where I am now and I want to feel nothing but proud and happy. I spoke to my supervisor at the horse clinic today which is on of the only horse surgeons in Norway. I have thought about doing and externship, and then hopefully get an internship, at the horse clinic in Kentucky, which my surgeon professors at my university has recommended me to do. Today my supervisor told me that the need for horse surgeons in Norway are very very limited, and if I want to work in Norway, DON'T do it. He recommended me small animals - but in Norway, believe it or not, the salary for a small animal practitioner is worse than working on the supermarket. Although there are opportunities to start your own clinic, get a good job if you do specialization first etc - so well, there are always options.

 

So to my conclusion: I have strongly considered changing to human medicine. In one way it makes me feel as an egoistic and cynical person - I always lived for the animals. They give us so much and I want to give back to them. But I see all the advantages as a human doctor compared to a veterinarian. You have a huge support team and always someone to ask, you never have limitations in treatments (so to say), I would have the chance to specialize in Norway and not having to do many more years abroad, you don't have to deal with everything on the economic aspect but can rather focus on your own profession, and you actually get paid for the hard work you do, which I think is important to a certain point for quality of life. To a human at least they can understand why you are doing what you are. To an animal however, I get a feeling of hopelessness. I know I am helping of course, but it's like: "hey this is gonna hurt like hell but don't worry it's to help you". They get angry, afraid, frustrated and aggressive, and I have never seen so many unhappy and suffering animals and I never thought it would be this tough. (Not that seeing severely ill people is easy..)

Ok i'm gonna put the finish line here. Sorry for all my thoughts and the very long email, but I would really really appreciate an answer! Maybe you have some encouraging thoughts to share.

Thank you very much in advance.

 

I thought it was worth printing all of Ingelin's email, as her thoughts, feelings, and experiences are actually pretty common.  I think that any veterinarian or vet student reading this will be nodding their heads in agreement, having run through the same scenarios in their mind.  I also think this is very important for pet owners to understand, as vets aren't sitting on their duffs just counting their wads of cash.  This is a hard, often thankless profession for which we are significantly underpaid for our level of skill and knowledge.

 

I'm a small animal veterinarian and haven't worked with horses in about 18 years.  I've never practiced on them and have never considered a career in large animal medicine.  But I'm at least basically familiar with that part of the profession and know that Ingelin's experiences are shared here in the US also.  I do think that the typical 70-80 hour work week is gradually going away as we graduate new vets who realize that they can't be everything to everyone, and are trying to have a decent work-life balance.  But it's still long hours.  You often find yourself in creeks in the dead of winter and in shadeless fields in blazing summers.  While most horse vets I've known manage to get away with few major injuries, it is still a much higher risk than with small animals.  There is absolutely the risk of serious injury and broken bones when dealing with animals this large and strong.  It is definitely a physically demanding profession and not one for the faint-hearted.

 

The business aspect depends on where you work.  Many vets, especially younger ones, are learning the benefits of hiring an office manager to handle the financial side of things.  A solo equine practitioner is in for an incredible amount of work if they do everything by themselves.  But if you get into a practice with a physical location and hire a good staff, you can get an office manager to handle payroll, billing, ordering, invoices, and so on.

 

Customers not wanting to pay?  Welcome to veterinary medicine!  Certainly you can get a bias against females among some farmers, as well as sometimes an attitude that they know more than you do because they're older and the farm has been in their family for generations.  You won't find as much of that in small animal medicine.  But if you are seeing client-owned animals you will quickly become frustrated with people who can't or won't pay for needed care.  The species of the patient is irrelevant.  I deal with at least a few clients like this every single day that I work, and have for my whole career.  Because pretty much all of animal health care comes straight from the owner's pocket you see them holding tighter to their purse strings than when it comes to their own medical expenses that are generally covered by insurance. 

 

Animals suffering breaking your heart?  Having a hard time dealing with animals in pain when you can't explain things to them?  Again, welcome to the profession.  It takes a special kind of person to be objective and distant enough to handle sick and injured animals while still maintaining compassion and empathy.  Working in any medical field can be emotionally draining and requires some good mental resilience. 

 

Internships and residencies are indeed brutal.  If you don't really, truly want to specialize I don't think I'd recommend it.  You make less than half of what you would make being in practice and the hours are much longer.  Should you consider going into a specialized field?  Only if you really have a super-strong interest in that area.  When I was in vet school I spent a few weeks working side-by-side with a board-certified surgical specialist.  He told me that he did make more than a general practitioner, but it took him about six years after vet school doing internships and residencies to reach that point.  For those six years he made about 1/3 of what his classmates made.  His lifetime earnings were going to be no different than a general practitioner due to the significant delay in finally practicing his speciality.

 

From what I understand in the US, your prospects of finding a good job in equine medicine may be better than in Norway.  It would certainly depend on where you wanted to live and work, as some areas are more under-served than others.  The areas with fewer vets working with horses and other large animals unfortunately tend to be areas where the salaries would be lower and you'd be working hard due to a lack of qualified vets.  But you may not want to leave your home country, especially for an entire career, so this is something you'd have to think hard about.

 

Personally I could never work in human medicine.  Humans gross me out and I can't handle that sort of thing.  I get feces and urine on me every single day and it's not a big deal.  But the idea of getting human feces on me makes my stomach churn.  Yes, the pay is higher, you have much more support staff, and you get to do more things without worrying about money.  But I'm not willing to make that trade because I can't handle seeing human illness and injuries.  It digusts me and makes me uncomfortable.  That may seem strange to some people, but it's actually a common thing among those in veterinary medicine.

 

Ingelin, I had to be a downer but you have actually expressed the same frustrations shared by the majority of the profession.  You have expertly described the daily problems we have and why this is not the best profession in the world.  I actually agree with everything you said, as it's true here in the US as well as other countries.  That is the depressing nature and harsh reality of veterinary medicine.

 

So why do it?

 

There are moments of greatness every day.  You will meet wonderful clients who think the world of you and will follow your every instruction.  Today we had a client bring us fresh, homemade eggrolls, still warm when she brought them in.  I got to work with some incredible cute and sweet puppies.  I was able to tell an owner that her cat didn't have a blocked bladder and had a treatable infeciton.  I helped comfort a client by easing the passage of their terminal cat.  I got to teach an eager veterinary student.  I can walk out of my clinic today proud of the fact that I helped to change and improve lives. 

 

It isn't an easy job and I frequently question my career choice.  But I've also reach the point in my life where I can see the joy in the day and be able to smile when I've helped someone.  Would I do it all over again if I had the chance to go back and make changes?  Probably not, except for the fact that I love my wife, family, and faith, and I wouldn't have those if it wasn't for my choices in and after vet school.  I would definitely pick a completely different career.  But I also don't hate my job (most days) and am very content where life has taken me.  It's a good job and I've been successful at it.

 

This probably doesn't help, and if you go back through the archives of my blog you'll find that I think this is a bad time to try and get into veterinary medicine.  Should you change your career, Ingelin?  It depends on how much passion you feel about veterinary medicine, how desperately you want to work with animals, and how well you can deal with the long hours and low pay.  That's certainly not a simple, easy choice and I don't have an easy answer.

Being A Better Customer

As the lead doctor and a manager in my practice I have to deal with a lot of odd or cranky clients.  Over the years I've had this blog I've talked about many of them.  I also am a fan of the website Not Always Right (www.notalwaysright.com) because of the plethora of stories about strange, unruly, and unreasonable customers.  It's kind of therapeutic for me to read about other people's encounters with the bad customers and clients, as I see similar situations almost daily.  As in any profession we often have to handle clients who are impatient, make unreasonable demands, have a short temper, seem determined to blame us for their negligence, or simply have an inability to understand very simple things.

 

Over the years I've gotten better at handling these situations.  They don't bother me and sometimes I'm downright amused rather than upset by the client.  I've learned a lot of ways to talk to people, help them understand, and overall calm them down.

 

But one of the best things about being a manager and working with the public is that it has made me a better customer and consumer.  When I talk to my team about excellent client service I make people give examples from their own lives of experiences where they were blown away by service and ones where they were so poorly treated that they would never go back again.  I have my own stories, especially of stellar service.  While I use this to teach my staff how to treat our clients, it also helps me understand how to be a consumer myself.

 

I try to smile at cashiers and acknowledge their greeting.  I try not to be upset at someone who merely works at a the desk or answer the phone, realizing that they were not involved in a mistake that was made.  When there is a problem I try to be patient and see how it is handled and rectified rather than jumping straight into yelling.  I try to remember that everyone is human and makes mistakes, so it's more important to see what happens after the mistake rather than being upset just at the mistake.  I try to give businesses time to look into a problem and try to fix it.  When someone gives me exceptional service I always try to remember to thank them, and then find a manager to acknowledge that service.  When I go to a doctor's office I bring a book or something to work on as I know that delays can happen and are often beyond the doctor's control.

 

I'm not perfect and I get as frustrated as the next person.  The difference is that I and my staff have been on the receiving end of bad clients many times, and I don't want to be that kind of client.  I try to remember how those situations made me feel and why I thought the client was unreasonable, and then avoid acting the same way.  I'm in a service industry and have sympathy for others who deal with customers, especially the cranky ones. 

 

I just wish everyone could learn the same lessons.