HAPPY NEW YEAR! A Veterinarian’s Perspective…

It’s that time of the year again! Time where I take stock of what I’ve accomplished over the past 365 days, and, more importantly, time to hold myself accountable for what I’ve left undone.

In other words, it’s time to list my New Year’s resolutions.

2014 brought a remarkable number of changes in my life. Foremost, I took a 5-month hiatus from working — the first time I’ve had that much time off from employment since I was 14 years old.

I also made a major geographical move back to New York and currently live not to far from the town where I grew up. Along with the move, my husband and I are also first time homeowners and we’re “enjoying” all the perks that come with such responsibility.

Most recently, I commenced working at an entirely new hospital on Long Island, and am currently in the midst of learning a completely new foundation upon which I must practice my craft.

The changes I’ve endured were nowhere on my radar at this time last year, so I’m tempering my expectations for 2015 with a heaping dose of reality. I won’t attempt to predict where or what it is I’ll be doing this time next year, but it’s still important that I take the time to examine my career goals and set up a plan of action for the next 12 months.

Resolution #1

I will actively seek opportunities to promote awareness of veterinary specialty medicine.

When I’m asked what I do for a living, invariably I will answer, “I’m a veterinarian.” Most people understand what a vet does, but I know if I tack on that I’m a veterinary oncologist, I’m bound to face some perplexed stares, uninformed comments, and a general sense of unease.

However, my lack of desire to face those faces, comprehend those comments, or deal with the unease isn’t an excuse for not capitalizing on the opportunity to educate people about what it means to be a veterinary specialist.

Veterinary specialty medicine is a remarkably difficult profession to endure. Referrals don’t always come easily and specialists often have to be their biggest supporters in a competitive economy where even routine veterinary medicine is undervalued.

Though owners are becoming more and more savvy about the specialty options available for their pets, there are a staggering number of people who have no idea that we are an option for treatment. Furthermore, they can be dissuaded by fear of cost or commitment; or worse, steered away from the proper specialist by another doctor who claims to offer equal services, but who lacks comparable training.

It’s only through continued education and self-promotion that we specialists will have a chance of success.

Resolution #2

I will try to put myself on the other side of the exam table more often.

I constantly struggle with trying to explain complicated oncological topics to owners in such a way they not only comprehend their pet’s diagnosis, but are also feeling empowered to make the decisions necessary for their care.

It’s easy to forget that not everyone is familiar with medical vernacular, and even when they are, they may not be so in the same way. It’s equally easy to forget that just because an owner nods their head, or says they understand what I’m saying, that it means they truly grasp the importance of the concept I am trying to pass along.

Taking just a little extra time to check in with an owner or explain something in just a little more detail could make a huge difference in their awareness of what is truly going on with their pet.

Resolution #3

I will continue to cultivate my creative side while working in a scientific field.

OK, so maybe this is a bit of a cop out since this was one of last year’s resolutions. However, actively working on this aspect of my life was so rewarding over the past year, I would be remiss to not continue to do so in the New Year.

Medicine tends to be an exceptionally dry topic at times, and I spend so much of my time studying, researching, and translating fact-based objective theory into practice. In order to be successful, I need to blend in some creativity and mesh the art and the science of veterinary medicine into a better product.

Resolution #4

I will remain cognizant of the needs of my entire patient, not just those related to its cancer.

Each pet I meet is so much more than just his or her cancer diagnosis and co-morbidities abound in the population of animals I typically see. Though my expertise is in the area of cancer care, I still possess a working knowledge of all other areas of veterinary medicine and surgery and can use this to treat multiple issues as necessary.

Of course it’s more complicated than simply stating, “I can deal with it all.” Sometimes it’s a matter of knowing whether other issues should be addressed before (or even instead of) the pet’s cancer.This may even mean sending them to another specialist better equipped to do so.

Resolution #5

I will stop adopting cats.

OK, this one is a bit of a joke. But seriously, we are now up to four kitties in our household, and if I want to maintain a sense of sanity and happiness in my home life, I am going to have to put the brakes on adding any more felines for some time.However, now that we have the home, the square footage, and most importantly, the backyard, I’m pretty sure we will be adding a dog to our family in the upcoming year!

I wish everyone and their pets a happy and healthy New Year! I’m thankful for all of the support from friends and family and look forward to what 2015 will bring!

Advertisements

Of Cats and Cancer!

I am a self-proclaimed “Crazy Cat Lady.”  If you are a faithful reader of this blog, or even an occasional visitor, I’m sure you would never guess this to be the case as the majority of the articles I write are centered on dogs.

 Although many cancers occur with equal frequency in both species, most of the information I present describes dogs, and even when I use specific cases as examples, I often talk about my canine patients, leaving felines out of the discussion.  Why is there such a disparity between my passion (cats!) and the topics I write about (mostly dogs)?

 Truthfully, though cancer occurs as frequently in cats as in dogs, and the most common cancers we treat in dogs are the same as in cats, there is far less information available for cats as compared to dogs, and outcomes tend to be much poorer in our feline counterparts.

 One reason for this is cats tend to hide visible signs of illness until their disease is significantly advanced.  Compounding this is the signs cats eventually show are incredibly non-specific.  The top two signs cats with cancer will show include inappetance and a behavior change (such as hiding).  Yet, cats may show either because they are seriously ill or because they are unhappy with something going on in their environment.  How does the average pet owner discern the difference and know when to seek veterinary advice?

 Consider a diagnosis of lymphoma; the most common cancer in both dogs and cats.  Dogs tend to present with palpably enlarged external lymph nodes owners detect while petting them, where cats tend to develop lymphoma within their gastrointestinal tract, and enlargement of external lymph nodes is rare.  This means dogs are typically diagnosed in a relatively asymptomatic phase, whereas cats will be showing signs related to their gastrointestinal tract.

 As an example, Duke is a robust 7-year-old tabby cat who up until a week ago Saturday, was behaving absolutely normally.  However, on that particular weekend evening, this otherwise food motivated feline missed his evening meal and when his owner went to look for him, she found him hiding under her bed.  She recognized his signs as abnormal and brought him to the emergency service for evaluation.

 Duke’s exam was relatively unremarkable, however further diagnostics showed he had a large amount of fluid within his abdomen, multiple enlarged internal lymph nodes, and a large mass encircling a portion of his intestine.  Further testing confirmed Duke had lymphoma.

 Less than one week passed between Duke showing any signs of illness to me telling his owner without treatment he would likely succumb to his signs within a few short weeks, and with treatment we would hope to see him survive anywhere from 6 months to 2 years.

 Unfortunately, Duke’s diagnosis of lymphoma could easily be replaced with any number of cancers afflicting cats including mast cell tumors, intestinal adenocarcinomas, injection site sarcomas, and even many non-cancerous conditions (e.g. diabetes mellitus, a foreign body, etc.).

 With any cancer, we feel the more advanced the disease is, the less successful the treatment will be.  This may be one simple reason why a diagnosis of cancer is so devastating for our felines; by the time they are diagnosed their disease tends to be extensive.  For those cases where we have treatment options, there are several other hurdles particular to cats I think are worth mentioning.

 Consider the necessary literal “capturing” of cats required to bring them to a veterinary appointment.  Dogs are typically used to going for walks and car rides, and even those anxious about visiting the vet are still initially easily duped into traveling without much protest.  Cats must be caught and transported in carriers, and for some, this seemingly innocuous act may preclude the option of treatment altogether.

 Next, consider the medications prescribed to prevent or alleviate side effects from treatment, or even some of those used as chemotherapy for specific diseases, are most commonly made in oral forms.  The administration of oral medications can be an impossible task for some owners, which can make treating adverse signs or certain forms of cancer impossible.

 Cats undergoing treatment with chemotherapy are prone to decreases in appetite, and developing a very picky appetite.  This causes a great deal of anxiety in some owners, and can even lead to premature cessation of treatment, due to the perception the cat is not thriving while on treatment, despite the effects not being life-threatening.

 Each of these factors (among may others too lengthy to record in one simple article) contributes to some of the frustrations I experience regarding cats and cancer.  I’ve often joked I should form a support group for owners of cats with cancer as their needs truly are so different from their canine owning counterparts.

 As a cat-centered person, I feel I’m more likely to embrace the challenges of treating felines.  Or perhaps the challenge of the treatment is what makes me love them so much more. My goal in writing this is to stress my lack of writing about cats represents nothing more than a bias in available information within veterinary oncology.

 Fortunately, I know my feline patients will never take this personally, as so accurately stated in one of my favorite quotations about kitties; “As anyone who has ever been around a cat for any length of time well knows, cats have enormous patience with the limitations of the human kind.”

We go together… Like surgery and oncology!

Certain combinations are indelibly etched in our minds as cohesive partnerships. For example, can you think of peanut butter without contemplating jelly? I challenge you to hear the word “ying” and not think of “yang.” If someone says “tequila,” I’m guaranteed to think of a lime. Don’t judge — I’m sure you have your own particular groupings you’d never think to separate.

When it comes to veterinary medicine, the specialties of oncology and surgery are an example of equally inseparable grouping.

At first glance, the connection between the two may not be apparent. Surgeons are often stereotyped as arrogant, cold, egocentric, and harsh. They are the “carpenters” of bodies, who willingly carve flesh and bones in an effort to impart a detached and impersonal “quick fix” to a problem.

Oncologists, conversely, are perceived as continuously compassionate and endlessly optimistic, possessing traits necessary to somehow deliver devastatingly harsh news while simultaneously maintaining an outlook of hope and inspiration.

Whether these stereotypes are true or not isn’t the important debate. What we do know is that the adage “a chance to cut is a chance to cure” is especially pertinent for oncology cases. When it comes to the majority of cancers I treat, when I’m able to recommend a patient’s tumor burden be reduced using some form of surgical excision, their survival time is likely to be significantly increased no matter the diagnosis.

When feasible, and medically indicated, my preference is to have tumors surgically removed before attempting to treat them with any of the other weapons I have in my treatment arsenal, such as chemotherapy or immunotherapy. Furthermore, in many cases I recommend the oncologic surgery be performed by a board certified veterinary surgeon rather than by the pet’s primary care doctor.

The advantages to utilizing a veterinary surgeon for complex tumor removal are innumerable. The foremost being that they possess extensive training in, and have access to the tools necessary to practice, the fundamental principles of surgical oncology (SO).

Some of the basic tenets of SO include (but are not limited to):

  • Careful pre-surgical planning of the removal of skin and subcutaneous tumors such that any remaining scar tissue could be potentially incorporated into a post-surgical radiation field should excision be incomplete. This includes understanding how to orient a scar such that radiation therapy can be delivered without extensive damage to healthy tissue. Poor planning can lead to disastrous outcomes for pets.
  • Performing a thorough exploration of the entire anatomical cavity from which an internal tumor is removed (e.g., a full abdominal exploratory surgery for cases of removal of an intestinal mass). In order to accomplish this, a surgeon must create an incision long enough to permit adequate access to the region they are examining. All too often I see a patient diagnosed with an abdominal tumor with a surgical incision only a few centimeters in length. This immediately raises concern that the veterinarian who performed the procedure was unable to adequately assess all of the anatomical structures in the abdomen and may have missed other organs that should have been biopsied.
  • Using a different set of surgical instruments, gowns, and gloves during closure of the skin or a body cavity following tumor removal. If these objects are not changed, it is theoretically possible to (inadvertently) physically transfer tumor cells attached to the objects’ surfaces from one site in the body to another.

Primary care veterinarians often indicate that owners are reluctant to seek consultation with a board certified surgeon because of concern for expense. I challenge those doctors to encourage reluctant owners to consider the value of information they could obtain from meeting with a surgeon.

I also challenge veterinarians to disclose any limitations they may face in their ability to perform oncological surgeries (e.g., not having the resources necessary to change surgical instruments when necessary), their comfort level with the procedure in question, and to be familiar with the results of studies indicating the outcome for pets with certain tumors can be improved when a board-certified veterinary surgeon, rather than their primary care veterinarian, performs the procedure.

I challenge owners to think about whom they would rather have performing a complicated oncological surgery on their pet: a person who performs that particular surgery once every other month versus one that performs that surgery twice or more per week.

Lastly, I challenge the specialists to 1) present owners with all available options, not solely the “ideal” plan, 2) continue to train general practitioners in the proper way to approach oncological surgeries, and 3) uphold the medical and surgical standards to which they were trained in the first place.

Oncology and surgery go together exceptionally well. I’m fortunate to have worked alongside, and to personally know, some of the most outstanding veterinary surgeons in the field.  And yes, I happen to be married to one as well…  I can’t work to the fullest of my capabilities without the help of these amazing individuals, and likewise I’d like to think they couldn’t be as successful managing their cancer cases without my input.

We may not mix as palatably as chocolate and peanut butter, but we’re pretty darn close in our ability to create an outcome that’s nothing short of amazing.

For more information on how to find a board certified veterinary surgeon near you, visit the American College of Veterinary Surgeons.

For more information on the field of veterinary surgical oncology and why seeking a veterinary surgeon for your pets oncological surgery is important, visit the Veterinary Society of Surgical Oncology.

Communication Breakdown or Comedy Show? Veterinarians See It All…

The five crucial components to a veterinary visit include recording a patient’s vital signs, taking a complete medical history, performing a comprehensive physical exam, recommending laboratory tests, and discussing the utility of other ancillary studies. You might be surprised to learn that the most useful of those five pieces of the diagnostic puzzle has nothing to do with fancy machines or expensive laboratory tests.

Any vet worth their weight in prednisone will tell you it’s the patient’s history and current physical exam that are the most crucial contributors to answering the proverbial question of “What’s going on with Fluffy?”

Veterinarians are trained in the art of obtaining a thorough medical history in school, where we’re exposed to a variety of interrogation techniques during our curriculum. The most important aspect ingrained in us, above all else, is to avoid asking closed-ended questions.

For example, when faced with an owner who is worried about the way their pet is breathing, instead of asking “Does Fluffy pant?” which can be answered with a simple “yes” or “no” response, we should inquire “Describe Fluffy’s breathing.” The latter allows for further probing, establishment of trust between the doctor and client, and, ultimately, a more open dialogue.

The goal of asking open-ended questions is to allow owners to not only give as much information as possible as to what they perceive is happening to their pets, but also to empower them to feel as though they are an active participant in the process.

It all sounds wonderfully productive in theory. However, at least once a day I find the tactic of asking open-ended questions about as successful in helping to achieve a diagnosis as attempting to communicate anything to my husband during Sunday night football. In other words, it just doesn’t work.

Here are three very typical scenarios where open-ended questions literally, without fail, detonate within my exam room:

Scenario #1: “The Disagreeable Husband/Wife Team”

ME: “How is Fluffy’s breathing?”

HUSBAND (with a slightly blank look): “She’s breathing fine.”

WIFE (looks at husband with shock and horror): “Fluffy’s breathing much harder than ever before. Especially at night. Sometimes it wakes me up and I can hear this noise, like it’s coming from deep in her lungs. It’s very raspy and loud.”

ME (struggling): “So Fluffy breathes harder at night? Tell me a little more about this. How long have you noticed this going on?”

HUSBAND (with a complete blank look): “I don’t know what she is talking about. Fluffy breathes the same way she has her whole life.”

WIFE (shooting daggers from both eyes that are designed to shred her husband’s soul): “Well with as much attention you pay to me, I’m not surprised you haven’t noticed that Fluffy breathes so poorly. She’s been doing it ever since last Thursday, right after Dr. Intile called us with the news about her cancer.”

ME (continuing to struggle): “So Fluffy started showing signs of labored breathing after she was diagnosed with her tumor on her paw?”

WIFE (interrupting my statement and still addressing her husband in an escalating loud voice): “I can’t believe you didn’t notice her breathing! She’s practically gasping for air, while you sit there and ignore her!!!”

ME (hands pressing into forehead): “Moving on…”

Scenario #2: “The Strong But Silent Type”

ME: “How is Fluffy’s breathing?

SST: “Fine”

ME: “It says here you brought Fluffy to see your primary doctor because she was coughing? Tell me more.”

SST: “She does cough”

ME: “When did you first notice the cough?”

SST: “A while ago”

ME: “When you say ‘a while ago’ do you mean a few weeks or months? Any idea how long it’s been going on?”

SST (Pausing): “For a while”

ME (hands pressing into forehead): “Moving on…”

Scenario #3: “The Busy Mom With 3 Children Under The Age Of 4”

ME: “How is Fluffy’s breathing?”

MOM: “Declan put that down! Do not put that in your mouth! Do you know you are in a VET HOSPITAL with TONS OF GERMS?! Madison, if you don’t stop hitting your brother, you will not get any ice cream! Sophia, sit down! I’m sorry — what did you say?”

ME: “Wow, looks like you have your hands full! Let’s try this again. How is Fluffy’s breathing?”

MOM: “Fluffy pants a lot. I noticed it back in — Declan stop going through the garbage and do NOT feed that paper towel to Fluffy! Madison and Sophia stop screaming right now! Here’s mommy’s iPad. Why don’t you watch some Elmo” Turning back to me, “I’m sorry, what did you say?”

ME: (hands pressing into dents that are now permanently located along my forehead) “Moving on… and could I please get my stethoscope back from little Declan’s mouth?”

Despite the communication difficulties, the bottom line is that each of the aforementioned are in the exam room because they love their pets and they want the best information available to help them make a decision about how to pursue their care. But making sure the information flows freely in both directions, from owner to myself and vice versa, can be challenging, to say the least.

It’s an understatement to say we could all stand to benefit from working on our communication skills every day. Likewise, no one single communication style will work for every owner, despite what my mentors in vet school taught me.

I’ve found that when faced with any one of the situations above, I have to accept it’s just one of those times where the “rules” don’t apply, and we all simply need a break from being open-ended.

Instead, a closed ended-question can be just the thing to help move the consult along and help get me to the actual answer of “What’s going on with Fluffy?” so I can move along to the next appointment, and start the adventure all over again!