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Wednesday, October 21, 2015

Questions About Becoming A Specialist

I haven't answered many questions about becoming a veterinarian lately because I've done so much of that over the years in this blog, and it should be a simple matter of putting in a keyword search to find answers.  But Tara asked some questions that I've never handled, so I think they're worth going over.
So I've always had a huge interest in veterinary medicine, and I had a couple of questions to ask you.
1. How does the work/family life balance work if I'm planning on specializing. (I'm thinking dermatology, radiology, or dentistry)
2. Should I go into either of those 3 specialties, how well is the pay? (Obviously I'm not going to be filthy rich, but I want to make sure I can live comfortably)
3. How does the whole board certification/ residency thing work?
Before delving into answers, I want to give a disclaimer.  I am a general practitioner and have never gone through the process of board specialization.  I considered it when I was in school but decided against it by my senior year.  I know the process in general, but you would have to talk to a specialist in a given field to get more specific details.

So let's go through the questions.

Work/life balance as a specialist is about the same as it is with any veterinary profession.  You will likely put in a lot of hours and hard work at your job, and mentally it can be hard to leave it at home.  However, with those particular specialties it is likely a bit better.  There are no such things as dermatology emergencies.  Almost all dermatologists and radiologists I know have very specific, regular weekday hours, and are closer to the 9-6 schedule that non-vets may have.  You put in your work hours, then go home and don't have to rush to the clinic in the middle of the night for an emergency.  The hours per week can still be long, and I imagine that most vets in these specialties are working a typical 40-45 hour week or more.  But you have more structure in your day and are more likely to have set appointments that rarely vary.

Pay for any specialty is certainly higher than a general practitioner, but it takes longer to get there and that can make it come out even at the end.  When I was in vet school I did an externship at a surgical referral practice, as I thought that I might want to go into that speciality.  I talked to the owner and lead surgeon about the money, and he said that he did make a good bit more than an average small animal practitioner.  However, it had taken him and extra 6 years after vet school to get that specialty training, while his private practice colleagues were working a job.  He accumulated more debt during that training, so even though he made more money by the time he was finished, he had more loans to repay and it took him longer to make a steady income.  He said that lifetime earnings for him as a specialist were about the same as a regular small animal vet. 

To achieve a board certification you first have to be a veterinarian, so that means completing vet school.  Most specialists do a 1-2 year internship in small (or large) animal medicine, then apply for a residency in their field of interest.  Those residencies are competitive, so there is no guarantee that you'll get one when you apply.  The residency program is about 3-4 years long, and is a very intense training in that specific field.  During the residency and internship you are making about half or less of what your general practitioner classmates are making, while often putting in 50-60  hour weeks.  Many residency programs also require a research project that will need to get published in a recognized scientific journal.

So let's say that you have made it through vet school, internship, and residency with flying colors.  Congratulations!  You're now a highly skilled veterinarian after about eight years of medical training, but you are not a specialist.  You are qualified to take the board exam.  These exams are usually only held once or maybe twice per year, and are required in order to call yourself a specialist.  The sad part is that even after all of this schooling I've been told that for the pass rate for most specialty exams is only about 40% .  So after those eight years of school it make take another couple of years of taking tests before you can truly call yourself a board-certified specialist.

As you can see, it is a long, hard road to become a specialist.  And doing so won't automatically make you wealthier than an average vet.  But if you have a particular passion about an aspect of medicine it can really appeal to someone.  You won't know if this is the case until you are nearly through with vet school.  During my education I considered going into cardiology and surgery before deciding that I was done with school and happy with the idea of being a general practitioner.

Great questions, Tara!

Sunday, October 18, 2015

Diabetes, Hypothyroid, Age, And Dental Cleanings

This email came from Jim....
 
I thought your article was very informative. However, my 12 year old dog does have diabetes which is now under control. Previously, it wasn’t due to her thyroid. For the past 8 months she has been on Levothyroxine .2mg and she gets 9 units of Vetsulin twice a day after each meal. She is perky, energetic and runs down my apartment hall at full gallop to go outside. My vet thinks it’s too risky to have her go under anesthetic because of her condition, but I am leaning towards getting her teeth cleaned because I think the risk of dental disease might be far worse in the long run. I know your not my vet, but I would really appreciate your thoughts on my situation.
 
This is definitely a situation where I would rely more on your vet's opinion than my own. In principle there is no reason why a dog with stable diabetes and controlled hypothyroidism shouldn't be able to undergo anesthesia for a dental cleaning. I've had patients with these diseases and we've continued to clean their teeth year after year. Age alone isn't a reason to avoid a dental, and I routinely do dogs older than yours. Even dogs with low-grade heart murmurs can safely undergo anesthesia for routine procedures. 
 
However, I don't want to specifically recommend that for you because I would want to know your pet's entire health situation including heart, lungs, and recent blood tests for kidneys and liver.   It also depends on what kind of anesthesia and monitoring is used. A pet induced with propofol, maintained with sevoflurane gas, and monitored with ECG, pulse oximeter, and blood pressure is going to be at less risk than a pet maintained on isoflurane gas and minimally monitored. Dental cleanings are very important as periodntal disease can be painful and spread bacteria throughout the body.  Correlations have been made between severe dental infections and increased risk of kidney disease, liver disease, and heart murmurs.  So there are a lot of factors in play here making it impossible for me to give you a straight answer. 
 
Talk to your vet in more detail, ask what kind of anesthesia and monitoring they do, and specifically why your vet feels that the risk isn't worth doing the procedure.  I do have patients with severe health conditions where I have decided that they are at an increased anesthesia risk to the point of making a dental more risky than not doing it.  But those are by far the exception rather than the rule at my practice.
 
 

Thursday, October 15, 2015

When Giving Up A Pet Can Be The Right Thing.

I recently got this email from Margaret.....

I received my first cat when I was 9 years old as a Birthday gift. She was my constant companion and friend and I grew up with her. Finally at the age of 18, I had her euthanized due to age complications. Then, Molly followed.

Molly is my big, black Fluffilicious. What a character!

My mother became sick with cancer in Sept 2012 and passed 9 months later. Cats are not stupid and Molly was no exception; she knew things weren't right and comforted me over the months and after the death.

I moved out in early 2015 to live with my fiance. Ultimately, I decided to leave my now 11 year old cat, Molly, with my father and the decision was not an easy one. If this was Daisy, I'd not have hesitated to bring her with me, but Molly is an entirely different cat, of course.

She is very territorial, a big cat, bold, vocal. All her expressions are shown on her face. The house is the only one she has ever known. My fiance has a cat, a four year old former feral male (he worships my fiance, they've such a sweet relationship. I'm only tolerated in true cat fashion), not declawed or fixed (Molly is declawed and neutered). 

Both cats are Alphas, without a doubt.  

In addition, the intervening months have shown the bond growing between my (elderly) father and her. He is not alone in the house and that is a comfort to me.  

The last visit with my Dad, she greeted me at the door as she always had and "talked" to me. After I'd been at the house for a couple of hours, I went to pet her again and she swatted at me with a stubborn look on her face. She begrudgingly let me toss a plush toy at her that she batted back at me and we played.

I knew she was wondering why and where I'd gone and why I only came back for these quick visits.

My fiance keeps telling me that 'I'm not like the people in the ads who just abandon cats, that I thought the matter through and left her with a loving person that she knew and the home that she knew". I believe this, the statement makes sense. Yet I know there are people who have moved with cats before. 

Did I make the right decision to leave her at my childhood home due to age, personality and the presence of another Alpha?

I want to try and answer this by sharing a personal story of my own.

Back in 2001 my wife and I were without children and only had cats.  Her parent's dog, whom she had also grown up with, died of congestive heart failure.  This started her wanting a dog of our own.  At that same time one of my techs was fostering a young long-haired chihuahua that a friend of hers couldn't keep, and was looking for a home for him.  The timing was right and we ended up taking him home.

Tucker was a great dog, very friendly, loving, and well-behaved.  All things that don't typically describe a chihuahua!  He was there when both of our children were born and was a perfect addition to our family.  He got along well with the cats and was never any trouble.

He moved with us from Illinois to North Carolina and handled it great.  But things weren't always perfect.  Tucker had been chased and even a bit terrorized by a couple of my nephews when they were very young and hadn't learned better.  I believe that this led to him being scared of small children, something he never got over.  He was great with teenagers and adults, but would growl around younger kids.  After we moved we also got our second dog, a Labrador retriever puppy.  She was sweet but she was a typical young Lab, which was more energy than Tucker could really handle.  They never really got along well, which made for some tensions in the house.

In 2005 my family went on a vacation to the beach, leaving our dogs with my parents.  On our way home we got a call that my mother had fallen and broken her hip and was in the hospital.  She had been under treatment for cancer, having undergone surgery and chemotherapy over the previous couple of years.  Things didn't go well, and after a short hospital stay my mother was taken home to be in hospice care.  A few days later she passed away.

My parents had been married for almost 40 years at that time, and my father had always been a "dog person".  Knowing that the house was very lonely for him and Tucker was great company, we let him keep the dog a bit longer than we had originally planned.  As time went on my wife and I had some serious discussions.  Tucker was great, and all of us loved him a lot.  But we had to watch our kids around him, and he didn't handle our lab well.  When he was at my father's house he was calm, affectionate, and very much a lap dog.  I really think that he helped my dad through an incredibly rough time.

It was hard for us, but we made the decision to give him up and let him stay with my dad.  While it made us sad, we also think that in the long run it was better for everyone.  If my father hadn't wanted him we would have gladly taken him back home and worked on the adjustments with the rest of the family.  But I think it was a great fit for Tucker and my father.

Margaret, I hope you can see some of the parallels between your situation and mine.  Sometimes the best thing for your pet is to be with someone other than you.  Not because you don't care, but because the situation is tough for your pet.  In the end only you can decide if you truly made the right decision.  I'm also not a psychologist so I can't help analyze your motivations.  But it doesn't sound like you made the wrong choice.

Monday, October 12, 2015

Beautiful Eyes

Recently I saw a cat with the most amazing eyes.  I wish the following picture really did them justice.


Oh, and my tech wasn't choking him.  He was a very sweet cat, but wouldn't stay still and look into the camera, so she had to hold his head in this position in order to take the picture.

This condition is called heterochromia iridum, and happens in many different species, including humans.  It is a harmless condition and can affect part of an iris or the complete iris.  I've seen it in many dogs and cats over the years, but never quite this spectacular.  Certainly worth sharing!

Friday, October 9, 2015

Veterinary Life + Tech Week = No Rest

As I've posted about several times, my whole family is involved in community theater.  It's a really fun hobby and I've been involved in everything from Shakespeare to farce comedies.  My wife and I do two to three shows per year, and are currently about to open on our latest one, The Crucible by Arthur Miller.  It's a classic story with some incredible language.  I have a relatively small role, that of Thomas Putnam.  Here's a photo of me (on the left), having grown out my beard for the show.


While acting is fun, it can be quite a stressful time when combined with my regular job.  This week we've been in "Tech Week", or as it is often called, "Hell Week".  For those of you who aren't thespians, this is the period just prior to the first performance where you rehearse every night in full costume to try and work out the kinks, lighting, sound, and so on.  It is a lot of work but it is important to get everything as perfect as possible before we have an audience.  My problem is that I've been doing it after a full day at work.

I leave for work about 8:15 in the morning so that I can get to the clinic before 9:00.  I work until 7:00 in the evening, and lately have been busy enough that I haven't been able to take much in the way of a lunch break.  Typically I'm eating lunch while writing up medical notes and calling clients.  I leave work and go directly to the rehearsal, getting there around 7:30.  The show has about a three hour run time, so with a break at intermission and discussions with the director I'm not getting home until after 11:00.  

Take a 10 hour work day, add three and a half hours of acting, throw in driving time, and all this week I've been spending a total of nearly 15 hours away from home.  By the time I get home at night I'm absolutely exhausted.  At the end of this week I will have done that for five days in a row.

I'm looking forward to Monday, which I have off work and where I won't have anything to do with the play.  I will definitely be sleeping in that day!

Saturday, October 3, 2015

Come On, Halloween! Get Anatomy Right!

It is getting close to one of my favorite times of the year.  I love Halloween!  It was always a fun event growing up, and I've always loved costumes and spooky themes.  I get really excited when the Halloween decorations start to crop up in stores, and start making regular trips to see what new things they have each year.  And don't even get me started on the fun of specialty Halloween Stores!

This year I noticed far more animal skeletons than I've ever seen before.  As a veterinarian as well as a Halloween enthusiast, this was a double bonus to me.  However, I noticed some problems.....

It starts out well enough, with some cool skeletons and skulls.




 I'd have fun displaying these all year!  But then I noticed some anatomical issues on other skeletons.



Do you see the problem?  Can anyone tell what's incorrect about the cat and rat skeletons?  It's the ears!  A skeleton is made of bone, and the ear flaps (pinnas) are cartilage.  Therefore you will never see the ears on any skeleton.

Okay, this bothered me a bit, but I understand that it is harder to quickly identify the skeleton without the ears, at least for a layperson.  So I was willing to let this slide since the rest was so cool.  But then I saw the skeleton that sent me over the edge.


Please tell me you see the problem!  Spiders don't have endoskeletons!  THEY DON'T HAVE BONES!  There are no leg bones, spine, or ribs on an arachnid!!!!  Spiders are supported by exoskeletons, which is basically their entire body.  

Here's what such a thing actually looks like.  The two left objects are shed exoskeletons, while on the right is the live spider.  


A dead spider wouldn't look like the Halloween decoration!

I know this is a minor issue to most people, and I'm probably one of the few that even notices this.  My wife has had to hear my rants every time we see the spider skeletons in stores, and she patiently lets me get my frustrations out.  But this really does bother me!  I don't expect complete scientific accuracy in a holiday decoration, but at least don't be so glaringly wrong!


Wednesday, September 30, 2015

Leptospirosis Cases Increasing. Should You Vaccinate?

I can't think of a more controversial vaccine than Leptospirosis.  Many people, especially certain breeders, think that it is dangerous and should never be given.  But the disease is potentially fatal and can be transmitted to humans.  So what should you as a pet owner do?

First, let's understand what "lepto" really is.  Here's a summary from the Centers For Disease Control website:  

Leptospirosis is a bacterial disease that affects humans and animals. It is caused by bacteria of the genus Leptospira. In humans, it can cause a wide range of symptoms, some of which may be mistaken for other diseases. Some infected persons, however, may have no symptoms at all.

Without treatment, Leptospirosis can lead to kidney damage, meningitis (inflammation of the membrane around the brain and spinal cord), liver failure, respiratory distress, and even death.

That sounds pretty serious, doesn't it?  And it really is.  While we don't see the disease often, it is very serious when it crops up.  Why don't we see it appear as frequently as it used to?  Because we've done such a good job of vaccinating against it.  But it's still out there, and in increasing numbers.

Again from the CDC's website:

The bacteria that cause leptospirosis are spread through the urine of infected animals, which can get into water or soil and can survive there for weeks to months. Many different kinds of wild and domestic animals carry the bacterium.

These can include, but are not limited to:
  • Cattle
  • Pigs
  • Horses
  • Dogs
  • Rodents
  • Wild animals
When these animals are infected, they may have no symptoms of the disease.

Infected animals may continue to excrete the bacteria into the environment continuously or every once in a while for a few months up to several years.

Humans can become infected through:
  • Contact with urine (or other body fluids, except saliva) from infected animals.
  • Contact with water, soil, or food contaminated with the urine of infected animals.
The bacteria can enter the body through skin or mucous membranes (eyes, nose, or mouth), especially if the skin is broken from a cut or scratch. Drinking contaminated water can also cause infection. Outbreaks of leptospirosis are usually caused by exposure to contaminated water, such as floodwaters. Person to person transmission is rare.

So anywhere that there are wild animals coming close to domesticated animals there is risk of lepto transmission.  If an infected wild animal urinates on the soil or in a water source, and your dog then drinks from that source or licks contaminated soil from their paws, there is a risk of infection.  And then if your dog becomes infected, it is a risk for anyone in your home to also contract the disease.

For my entire career (since 1997) there has been a perception among many pet owners and a LOT of breeders that the Leptospirosis vaccine was dangerous and should never be given.  I've even seen handouts from breeders that explicitly state that if a vet tries to give the lepto vaccine the new pet owner should find another vet.  This belief seems to stem from an impression that this particular vaccine has a significantly higher rate of serious reactions than any other vaccine.  Unfortunately these breeders are owners are very misinformed, even dangerously so.

A recent article in Veterinary Practice News highlights the increasing risk of lepto even in urban settings.  Here are some relevant quotes from that article

“Since 2013 in Florida, we have seen a 10-fold increase,” explains Carsten Bandt, DVM, Dipl. ACVECC, assistant professor of Emergency Medicine and Critical Care at the University of Florida College of Veterinary Medicine.

Although it was once most prevalent in regions with high annual rainfall and warm climates, current indications are that dogs with leptospirosis are found throughout the U.S.

“We are a tertiary center that sees two to three cases of leptospirosis a month in the warmer months,” said Julia Veir, DVM, Ph.D., of Colorado State University in Ft. Collins. “Our patients come from southern Wyoming and across the front range, the area from Denver north to Ft. Collins.”

“It is a bacterium that is spread from the urine of mammalian species like raccoons, mice and rats,” Goldstein said. “If a dog licks a puddle on a sidewalk, or walks in wet grass or in parks where wildlife would urinate, they can ingest the bacteria.”

“It is very rare to see a dog who was vaccinated get the disease,” Goldstein says. The first dose is two shots followed by one shot each year.

“The vaccination is effective against the four serovars of leptospirosis and may provide some cross protection against other serovars,” Dr. Harkin said.

It should be apparent that this is still a serious disease, and one that is actually increasing in incidence in various parts of the country.  Virtually all dogs are at risk for the disease, and there is no way to tell whether or not a pet is being exposed when they contact water or wet soil.  With this information in mind it should be easy to see the rationale for prevention.

But what about the often-touted idea of the vaccine causing horrible reactions?  Is it worth that risk?

This idea has no data to support it.  In fact, if you find anyone who states this as "fact", I challenge them to provide actual objective proof that the vaccine is more reactive than any other.  ALL vaccines carry some risk of causing a reaction, and rarely is that reaction truly life-threatening.  I've seen two different studies that have looked at vaccine reaction rates, and both of them showed no significant difference when comparing Leptospirosis vaccines to other vaccines.  "Well, I've been breeding for 25 years and I've seen plenty of bad reactions" is a subjective, anecdotal assessment, and is not actually any proof that would stand up in science or a court of law.  In order to prove a statement like "lepto vaccines are highly likely to cause bad reactions" you need to have numbers and statistics.  Not only does that data not exist, but the times it's been examined the numbers have actually shown that it is no more reactive than any other vaccine.

It's also important to note that there are several companies that make animal vaccines, and each company's vaccine is slightly different.  One company's vaccines may have a higher reaction rate than another company's.  In fact, my practice revised our vaccines in 2014, and the number one criterion we looked at was the reaction rate between manufacturers.  That data made us change the brand of some vaccines.  It's impossible to make a blanket statement "all lepto vaccines are reactive" when the rate of reaction varies depending on the brand.

So a breeder tells you never to give lepto because in their 25 years of experience this vaccine will almost always cause serious reactions.  Well, if we want to stick to subjective information, I can clearly state that I've been practicing for 18 years and in the veterinary field for 32 years, and I haven't seen lepto cause significantly more reactions than other vaccines.  I rarely seen vaccine reactions at all, and when I have it's to pretty much any vaccine on the market.  Lepto doesn't jump out to me as a dangerous vaccine.  

Now you have a choice....take the opinion of someone who has been breeding dogs for several decades, or take the opinion of someone with a medical degree and access to scientific journals who has been in the heart of veterinary medicine for the same amount of time.  Which opinion do you think is more likely to be informed and accurate?

Here's the bottom line for me.  Leptospirosis cases decreased after we started vaccinating for it.  In the last 20 years as we've seen an unfounded opinion that the vaccine is a problem, and therefore fewer pets are being vaccinated, we've seen a steady increase in lepto cases.  This is made worse as the population has expanded into previously rural areas and wild animals have adapted to suburban and urban life, bringing their diseases into closer contact with humans and our pets.  In the article above you can see that cases have increased 10-fold in just a few years.  We have a safe, effective vaccine that is no more dangerous than any other vaccine.  I strongly believe that this is an essential vaccine, and unless a dog has a significant medical reason that makes them unable to receive it, all dogs should have it included as part of their regular preventative care.  

And yes, my dogs are vaccinated for it.