Is it ever ok to not be nice?

Sometimes it’s hard to be nice.

We all deal with annoyances and irritations in our lives. That person who cut you off on the expressway—completely out of line! That woman who talks loudly on her cell phone while you’re in line at the grocery store —absolutely mind numbing! The wailing toddler, the failed Wi-Fi connection, the extra long red light when you’re in a hurry, all add up to make your day much more debilitating, especially when you’re already overwhelmed with responsibilities.

Fortunately, such issues tend to be minor and never life threatening. We encounter them, process them, and move on. Learning to be nice, even when you don’t want to be, is an unfortunate part of adulthood.

It can be surprisingly tricky to distinguish the inconveniences from the truly distressing. You question whether you are acting out of immature, whiny, and selfish needs or because you have something truly worth griping about? It requires a remarkable amount of maturity to determine when it’s appropriate to stay silent and when it’s necessary to stand up for yourself.

Professionally, I struggle with this when my clinical obligation to my patients conflicts with my ability to be a “nice” employee who keeps owners, co-workers, and other veterinarians happy.

It’s not nice for me to criticize owners who refuse to euthanize pets suffering in pain from their cancer. It’s awkward for me to chastise the untrained doctors who oversee chemotherapy administered by inexperienced individuals without proper safety equipment or monitoring in place. I shouldn’t expose cases where vets have ignored basic principles of surgical oncology so extensively they actually increased the risk of tumor spread rather than reduced it.

It’s not nice to tell the owner who chooses herbal treatments rather than chemotherapy that I feel they have wasted their money. It’s impolite to call the vet who only took one x-ray of a dog’s lungs before performing a complicated tumor removal and tell them how unacceptable that was. It’s frowned upon to argue with the person who doesn’t want to treat their 12 year-old dog with cancer because that is akin to “torturing a 95-year-old human with chemotherapy.”

Though much of what I do is certainly rewarding and worthwhile, on days where my patience is worked to its barest thread, my emotional capacity is stretched to the brink of snapping, and it’s exceedingly difficult to be nice and not behave as listed above, at those times I force myself to remember that at minimum, I can be fair.

When I’m frustrated by an owner who chooses herbal remedies for their pet’s cancer, rather than the treatment plan I outlined, I remember their choice is still made out of a want to help their animal battle its disease.

When I roll my eyes at a veterinarian who took the single x-ray, I remember similar cases where I’ve been told the owner could only afford the less expensive diagnostic test so they could pay for the life-saving surgery.

When an owner declines treatment for their elderly pet, I recall how I felt watching my mother endure chemotherapy and understand how personal experience could influence their opinion of anti-cancer treatment for their animal.

When do I cross the line from explaining the potential reasons behind apparently incompetent medicine to making excuses for it? When is it acceptable for me to outwardly rant about insensitive and rude owners rather than allow my concerns to simmer internally? Am I a whistleblower or am I exhibiting childish dissatisfaction? Am I ever allowed to not be nice?

I’m not sure of the correct answer and it’s a constant struggle for me to determine when to speak up and when to “let it go.” There’s a lot to be said for being a professional work in progress.

What helps sustain me is remembering that even when I’m not so nice, I am fair. That’s been enough to carry me through the toughest of days thus far. It will likely take me far into the future of my profession as well.


What’s new for treating lymphoma in dogs?

Lymphoma is the most common cancer diagnosed in dogs and cats. It’s also an extremely common cancer in humans. This represents a unique opportunity where people can potentially benefit from treatment options developed for pets, and vice versa.

In people, lymphoma is usually classified as Hodgkin-like (HL) or Non-Hodgkin-like (NHL), with NHL being the most common form. Diffuse large B-cell lymphoma (DLBCL) is the most common form of NHL in people. Though many different forms of lymphoma exist in dogs, the most common form we diagnose in canine patients is similar to the DLBCL seen in humans.

Traditionally, in both people and animals, NHL is treated with chemotherapy using cytotoxic drugs in what is known as the “CHOP” protocol. The chemotherapy drugs in this protocol, though effective, are not specific for cancer cells, and this is the main reason for the adverse side effects seen with treatment.

The idea of using “targeted therapies” as anticancer weapons is not new, but it wasn’t until the late 1990s that this idea became a reality. Targeted therapies are designed to do exactly what their name implies: specifically target cancer cells while sparing healthy cells, thereby reducing side effects and, hopefully, also increasing efficacy.

Rituximab is an example of a targeted therapy in people; it is a “manufactured” antibody directed against a protein located on the outer surface of B-lymphocytes called CD20. After administration, one end of the rituximab antibody binds to the CD20 protein while the other end “sticks out” and signals the patient’s immune system to attack the lymphocyte and destroy it. Rituximab will bind to both cancerous and normal B-lymphocytes, but not to cells of other healthy tissues. making it a specific form of treatment for cancers (and other disorders) of B-lymphocytes, with limited toxicity to other tissues.

For humans with DLBCL, the combination of rituximab with traditional CHOP chemotherapy regimens essentially resulted in achievable cures in many cases, and this combination is now accepted worldwide as the standard of care people with lymphoma. Rituximab in combination with chemotherapy during the initial treatment of less aggressive variants of B-cell lymphoma (other than DLBCL) has also been documented in multiple clinical trials over the past decade.

Rituximab, unfortunately, is an ineffective treatment for canine lymphoma. The engineered antibody is specific only for the human version of CD20; it does not recognize the canine version of this same protein. However, the exciting results seen in people prompted intensive research towards developing monoclonal antibodies that would be effective for dogs.

After many years of study, several pharmaceutical companies have produced B-cell and T-cell monoclonal antibodies for use in dogs, and the veterinary oncology world is on the cusp of having such therapeutics available for widespread commercial use. Preliminary studies show the antibodies are safe and reasonably effective for the treatment of canine lymphoma. Studies are ongoing to determine the optimal timing of treatment, long-term benefit, and to better characterize any adverse effects.

Investigational studies examining the use of these therapeutics in greater detail are available at select veterinary hospitals across the United States. For example, the hospital where I work is one of only a handful of sites chosen to offer the T-cell monoclonal antibody as a treatment option for their patients.

If you would like to find out more information about monoclonal antibody therapy for your dog with lymphoma, please ask your veterinarian or contact your local veterinary oncologist for further information.

What’s the one thing I never knew about becoming a veterinarian?

Doctors endure a great deal of expectations. We should be kind, compassionate, and intelligent. We must be patient, efficient, and accessible. Doctors should be passionate about their craft, able to endure long work hours, possess excellent time management skills, while continually updating their knowledge.

These features are not unrealistic and are not restricted to successful individuals within the medical profession. I’m never shocked when I see those traits listed as “desirable characteristics” within a veterinary job description or on an employee evaluation form.

One trait I never anticipated I would need to possess to be a successful doctor is being an effective leader.

I’ve always been capable of leading by example. I’ve made a concerted effort to behave professionally at all times as I’ve carried the burden of someone whose words and actions are heard and observed not only by my colleagues, but to a community well beyond the walls of my exam room. But I never felt this translated to me being a true leader.

I perceived the doctors who breeze into the hospital and effortlessly assign responsibilities, unstressed about potential conflicts or concern about perturbing another person’s schedule, as the most effective leaders. Their effortless demeanor, ability to delegate tasks, and, most importantly, their ability to have people respond to their requests, were, to me, signs of the epitome of leadership.

With this as my defining point, I’ve always felt uncomfortable with taking on a leadership role. Innately, I feel terrible when I delegate tasks, especially when I recognize an inkling that the person I’m about to ask to help me is less than enthusiastic about what I am asking them to do.

The sticky part is, my job requires me to constantly ask for help. I can’t make it through an appointment, a procedure, or an encounter with an owner on my own. My job requires me to be only a small part of a team approach to my patient’s care. This is true whether evaluating a pet for a routine recheck exam or when stabilizing a critically ill patient in the ICU.

In my quest to improve my professional skills, I came across an organization called “The Veterinary Leadership Institute.” On their website they address some of the struggles veterinarians face with specific regard to leadership.

“Medical proficiency alone is not enough for veterinary professionals to effectively respond to the changing needs of an increasingly diverse society with the skill and competency necessary to succeed in their evolving roles. To reach their potential, veterinarians also need emotional intelligence, communication skills, cultural awareness, professionalism, the ability to work in teams, conflict resolution strategies, and the understanding that multiple approaches may be employed to resolve challenges.”

After I read this description, I became increasingly confused. I could easily tick off the listed attributes on an imaginary checklist of how I approach my work. But I’m not a good leader and I don’t like taking on a leadership role, so how is this possible?

I started to scrutinize the behavior of doctors I previously categorized as effective or ineffective leaders and found many could be divided into one of two groups. The “we-ers” and the “do-ers.”

The “we-ers” appeared to be in control and were the ones I felt were the greatest leaders. They often used verbal commanding statements such as:

“Can we change the antibiotic from injectable to oral?”

“Can we call the owner and let her know the pick up time?”

“We need to be better about sending owners home with discharge statements.”

“We-ers” consistently use the word “we” in a passive manner, making the question being posed seem outwardly less like an order and more like a group activity. “We-ing” deflected a sense of accountability from a single person to several.

What I noticed was that despite their seemingly calm and cooperative exterior and ability to designate assignments, the “we-ers” had no intention of participating in the aforementioned requested task and were simply telling other people what to do.

The “do-ers,” on the other hand, asked for help but participated in the situation as equals with whomever they were requesting help from.

“Do-ers” made definitive and direct statements:

“Change Fluffy’s antibiotic to capsule form.”

“Call Fido’s owner and let her know he is ready to go home.”

“Remember to send discharge statements home with owners.”

Though I admired their ability to “get stuff done,” the “do-ers” never struck me as leaders.

I then read an inspiring quote stating that “the difference between managers is leaders have people follow them while managers have people who work for them.” Managers are akin to my “we-ers,” while leaders are the “do-ers.”

I realized that those who are a good proportion of the people I looked up to as leaders could actually be more accurately described as “we-ers”; glorified managers who gave order and had people do their work for them, but who lacked the ability to inspire those around them.

The “do-ers” who were more apt to fade into the background were the ones who truly fit the actual definition of a leader much more effectively than the “we-ers” ever did.

Though I still have a terribly hard time when I ask others for assistance, I now recognize this doesn’t make me any less of a leader than a person who can more confidently take on that role.

It may mean I’m a less efficient “do-er,” but the good news is I have plenty of room for improvement.

And I’m very happy to “do” more to better myself in that capacity every day.

How to have a life, while saving lives…

Lately I’ve felt a bit overwhelmed. I’ve carried a nagging, overriding sense of anxiety, particularly regarding work-related assignments, deadlines, and expectations.

I wish for the weekend to hurry up and arrive, and then spend my days off worried because I didn’t accomplish my “to do” list.
Obligations are piling up, with their ceaseless associated expectations, responsibilities, and stress. My enthusiasm for my career has diminished, and even those activities I typically engage in for leisure, such as writing, have become a chore.

I searched for information on I how to more appropriately cope with the pressures I’m facing, and came across the “Eisenhower Principle,” which is a systematic and methodical approach to time-management skills and tackling projects.

In a 1954 speech to the Second Assembly of the World Council of Churches, former U.S. President Dwight D. Eisenhower quoted Dr. J. Roscoe Miller, president of Northwestern University: “I have two kinds of problems: the urgent and the important. The urgent are not important, and the important are never urgent.”

The key to successfully implementing the Eisenhower Principle is to accurately distinguish whether a task is urgent or important. Doing so requires having a working definition for each term.

Important activities are those that allow you to achieve personal or professional goals and are associated your own values and aspirations. Think: Writing the book you’ve promised yourself you would start, taking a trip to Europe, learning to ski.

Urgent activities demand immediate attention, are usually associated with achieving someone else’s goals, and are of a narrow focus. Think: Returning specific phone calls and e-mails, responding to deadlines, paying your bills on time.

Urgent tasks instill a sense of reactivity—we must handle the problem not right now, but five minutes ago! We often approach urgent issues in a defensive, rushed, and hurried manner.

Important tasks are often sidelined for the urgent ones. Yet we are inundated with the message that we need to cultivate the important tasks to make us feel most fulfilled.

The Eisenhower principle is simple: Each action you are handed is assigned to one of four categories:

Important and urgent: e.g., crises, deadlines, and problems

Important but not urgent: e.g., relationships, planning, and recreation

Urgent but not important: e.g., interruptions, meetings, and activities

Neither urgent nor important: e.g., time wasters, pleasant activities, and trivia

I’ve had success applying the Eisenhower principle to my personal endeavors. However, I find it nearly impossible to adhere to the guidelines in my professional life. In veterinary oncology, urgency is the overriding, pervading theme.

It’s cancer; therefore a diagnosis must be made immediately. It’s cancer; therefore testing must be accomplished as soon as possible. It’s cancer; therefore therapy must be instituted at the earliest point of intervention possible. Waiting is not an option, even when I truly believe it’s in the patient’s best interests to wait.

I am expected to feel the same way about the diagnosis as the owner/primary veterinarian/etc. does, but this isn’t always the case. In fact, in some instances, all this perceived urgency does is lead to further complications.

Appointments are booked without ensuring the proper diagnostic equipment is available, or cases are scheduled to see me when they should be sent to surgery first. When we rush to set up an appointment, I may not have all the pertinent referral information and recommend repeating tests simply because I lack the data. Biopsy results are pending, yet owners are calling to be seen immediately so I can provide treatment options. I face these scenarios on a daily basis.

My goal should be to spend time on the important but not urgent tasks. I need to cultivate growth within my marriage and in my relationships with my friends and family. I need to divert more attention to my hobbies and my passions. The remainder should theoretically fall naturally into place once the foundation is put down.

However, it’s extremely difficult to excel at the important aspects of my life while simultaneously supporting a career where urgency abounds. I must put the needs of others above my own, whether those needs are urgent, important, or neither.

Perhaps this is a consequence of choosing a career in medicine—a profession where I am entrusted to provide care and compassion towards others at all times. The needs of the person or animal experiencing illness are the only thing in the world that matters to them.

You would think the President of the United States would feel more pressure than a veterinary oncologist, but Eisenhower’s famous quote implied he had no trouble keeping the urgent separate from the important.

I bet he never sat across from a distraught owner of a pet newly diagnosed with cancer.

“I thought it was just a little limp…” Part 4: Chemotherapy options for canine osteosarcoma

It’s been two weeks since Duffy’s amputation surgery, and he’s coming in to see me for a check-up, and a final discussion on what our plan for his future will be. I anxiously awaited his arrival to my examination area, recalling how when he went home two days after surgery he seemed slightly sluggish with some impressive swelling and redness over his incision site.
Duffy definitely showed some difficulty rising from recumbency and even slipped once on the tiled floor of the waiting room while being discharged from the hospital.
Before I actually saw Duffy, I heard him — or rather I heard the rapid footsteps of one of our oncology technicians pattering down the hallway, the distinct jingling of tags swinging against a collar, and the heavy panting (which I truthfully could not distinguish as being canine or human in origin). The door to my examination area opened and in bounded a massive storm of golden fur and wet slobbery kisses attached to a giant pink tongue.
“Duffy’s doing great at home,” the technician stated as she adjusted her now lopsided ponytail while simultaneously catching her breath. “I think they are leaning towards chemotherapy!”
The fact that Duffy was bouncing around the room on three legs without hesitation did not surprise me at all. Most dogs recover from amputation surgery within a short period of time. Dogs who are overweight or have significant orthopedic disease may not be quite as agile as Duffy at this time point, and can benefit from post-operative physical therapy to strengthen other muscles and joints.
As an alternative to amputation for dogs with tumors located in the lowest portions of the radius or ulna (bones of the forelimb), metacarpal or metatarsal bones (longer bones of the paws), or digits (toes), owners also have the option of a “limb-sparing” surgery. In this surgery, the affected portion of the bone is removed, leaving the limb in place.
These can be technically challenging surgeries and complications can arise, including post-operative infections and regrowth if any portion of the tumor is left behind. Owners should really only consider this form of surgery if they are willing to commit to treating their pet with chemotherapy afterwards.
I typically discuss two main chemotherapy options for dogs with osteosarcoma: pursuing injectable chemotherapy versus pursuing treatment with a newer form of treatment called metronomic chemotherapy.
Injectable chemotherapy is the most well studied form of treatment for dogs with osteosarcoma. There are three drugs that are effective for this disease: doxorubicin, cisplatin, and carboplatin. Numerically, the outcomes are similar for each drug, though it is important to point out that no one has adequately performed the perfect study comparing the efficacy of each drug in a “head to head” fashion.
We generally say the prognosis for dogs treated with amputation alone is about 4-5 months. With additional chemotherapy with doxorubicin, cisplatin, or carboplatin, survival is extended to about 12 months, with approximately 10-15 percent of dogs surviving two years.
Doxorubicin is an intravenous drug given once every three weeks for a total of five treatments. This drug is usually well tolerated but has a moderate chance of causing upset stomach signs. There is a risk for toxicity to the heart; a problem seen when dogs receive more than six lifetime dosages, which is one of the main reasons we stop at five treatments.
Cisplatin is an intravenous form of chemotherapy administered once every three weeks for a total of four treatments. Of the three drugs, it is the one most likely to cause side effects in dogs. It is an example of a chemotherapy drug that can immediately cause nausea and vomiting, so it must be administered with anti-nausea medications. This drug can also be directly toxic to the kidneys, so it must be administered with an all-day intravenous fluid diuresis.
Carboplatin is also an intravenous drug given once every 3-4 weeks for a total of five treatments. Side effects are uncommon, but it can definitely cause lowered white blood cell counts.
Metronomic chemotherapy is also known as anti-angiogensis therapy. The idea behind this form of treatment is in order for tumor cells to grow, multiply, and spread, they need to grow their own blood supply. If this process can be inhibited, then it may be possible for dogs to live with tumor cells in their body, but the cells will not grow, or may grow at a slower rate.
This form of treatment is becoming a popular treatment options for pets with cancer, mainly because these are oral formulations of drugs owners can administer at home. There is limited research in veterinary medicine supporting the efficacy of this method of treatment, however a few small studies showed potential benefit for dogs with cancers other than osteosarcoma.
I discuss metronomic chemotherapy as a “stand-alone” option, but recommend the injectable protocols initially, and then consider stating a dog on metronomic treatment once the finish their protocol. More on this form of therapy will follow in a future article.
I completed my exam of Duffy and headed in to talk with his owners. We went over the pros and cons of treatment with chemotherapy versus starting Duffy on a close monitoring program. Ultimately, they elected to start treatment with carboplatin, knowing we were ideally committing to completing all five treatments, but knowing we were going to take things day by day.
Their fears were the same as any owner starting treatment with chemotherapy, but they knew they wanted to give Duffy every available chance for long-term survival.
Duffy received his first chemotherapy as planned, and is currently feeling great at home. He’s chasing squirrels, stealing cookies from the table, and acting generally “normal” at home.
From my perspective, Duffy is a true success story. He may not be breaking any records, but I feel confident he will continue to do well and share his happiness with his family for a long time.