I’m part of the problem. Are you?

A recent suicide of another veterinarian once again sparked a burst of concern regarding the mental health of those of us entrenched in this profession. As an isolated event, this news is nothing short of tragic. What is equally as concerning is how this heartbreaking news is an alarmingly repetitive part of our community. In the past few years, we’ve lost far too many outstanding colleagues who felt the only way to relieve their pain was to take their own life.

Statistics describing the emotional status of the “average” veterinarian are shocking. Suicide rates for veterinarians are double that of dentists and physicians and six times higher than the general population. A recent survey indicates as many as one in six veterinarians had considered suicide. Nearly seven percent of male vets and 11% of female vets reported “serious psychological distress” in an online survey.

There’s a disturbing pattern where every few months another veterinarian ends their life – and the magnitude of response on part of those of us in the profession is astounding. We express anger and frustration at pet owners, practice owners, corporations, and the lenders of our student loans. We share information about the rigors we endure on a daily basis with the hope of emphasizing we are just as much a “real doctor” as a human MD.

We are quick to expose the darker side of veterinary medicine, partly in solidarity and partly to educate the public about our concerns. I’ve participated myself, having written several articles on the detrimental impact compassion fatigue has on our profession. There are only so many times we can tolerate being accused of being “in it for the money” or “heartless” before we shatter.

The saddest part to me is despite the commonality in our cause, thus far, we’ve been ineffective in our endeavors. The statistics remain as abysmal today as they were several years ago and fundamentally, veterinarians continue to kill themselves.

When I learned of this most recent suicide, like many of my peers, I felt compelled to express my outrage in written form. But I paused before typing any words. My silence stemmed partly because I knew I’d never be any more eloquent than those who already stated their piece about the tragedy. But a greater portion of my silence arose from a gnawing sensation that exclusively pointing my finger outward was inaccurate. I’d always avoided looking inward and never really asked myself, “To what end do I contribute to the problem?”

To best explain the impetus for my altered point of view, I need to provide a bit of background. After spending nearly eight years in private practice, I recently transitioned to working in academia. It’s been a remarkable change, as my focus has shifted from seeing cases as a primary veterinarian to training students how to become successful veterinarians and teaching house officers (residents) how to become remarkable veterinary oncologists.

While overall the pace is much slower than what I’ve grown accustomed to in private practice, our oncology service is capable of seeing a good number of new consults and rechecks each day and the cases we evaluate tend to be more complex in nature than what I’ve faced previously. I’m also no longer tasked with directly communicating with clients and referring veterinarians. This is the responsibility of the house officers completing their residency. While these individuals possess a solid core of knowledge in oncological principals, the fundamental thing they lack is experience. They are here to learn and grow as specialists, but they aren’t there yet. That’s a huge part of my job – shaping what type of oncologist they will become over time.

Despite all of their spectacular qualities, house officers lack the breadth of experience necessary to be as efficient as a board-certified specialist. They are exceptionally intelligent and motivated, but are fundamentally more methodical in their thought processes than I’d ever be. They are not yet proficient in understanding risk of treatment (or not to treat as it may be.) They will express anxiety about scenarios I’d never consider, simply because my experience over the years has afforded me a sense of self-trust and knowledge that their concerns are unfounded. They need more time to process data and discuss outcomes.

The same is true for our radiology department, where house officers perform all of the assessments of our x-rays, ultrasounds, and CT scans. We face the same struggle with the residents we ask for surgery consultations, who are also trainees lacking the same level of experience as the board-certified service chiefs who back up their plans. Every blood sample or cytology slide we submit will be first analyzed by someone learning to become a specialist. While all house officers at an academic institution are supported by someone like myself – an experienced board certified expert, the frontlines are managed by people who are only just learning how to become the authority.

Beyond my responsibilities to the house officers, I’m also tasked with teaching veterinary students how to be good doctors. I must take the time to belabor pathophysiology and anatomy to ensure they have a strong foundation for clinical work. I have to constantly monitor their progress and remember the fundamental aspect that they lack pattern recognition not because they are not good at what they do, but because they haven’t seen that pattern just yet.

This all equates to an inherent slowness of the process and I must set boundaries as to what our service can reasonably accomplish each day. I have to restrict our schedule to include a specific number of rechecks and new appointments. I need to be cognizant of what I’m asking our staff to accomplish, because even a slight overload could very well surmount available resources. But the caseload far exceeds those restrictive numbers and the waitlist for an appointment with our service is a month long, which is tantamount to eternity for a worried owner with a pet newly diagnosed with cancer.

Here is where I’ve recognized I’m failing to support our profession, and worse, potentially contributing to its failure.

I’m the first to sort out how to squeeze in one more consult. Or to add on a few rechecks. I never want to disappoint pet owners. I’m compelled to help all the newly diagnosed patients. My wants frequently come at the expense of the very people I’m tasked with training. The model I’m setting forth to my trainees is to put owners and their pets first, even to the point of driving yourself down.

I’ve taken my own obligations and passed them along to my apprentices. I expect house officers to see another new consult, even when they’ve been assigned their “maximum” daily load. I ask them to stay late to talk to owners of cases presented on the emergency service whose pets are diagnosed with cancer because I think it’s the right thing to do. I expect students to be one time for 8am rounds, even when they have complicated treatments to accomplish on their hospitalized patients and lack the experience and confidence to ask for help.

While I’m assured my intentions are pure, I’m not accomplishing anything more than setting these fresh-faced doctors, and doctors-to-be, up to fail. I’m telling them this is the “normal” way to approach their profession, yet these are the very attributes I’ve condemned as being the cause of compassion fatigue. Is it fair for me to expect them to share my obligation to fit in the case, talk to the owner, and appease the referring veterinarian? Why am I ok with adding strain to people who already feel stretched thin, years before they’ve even achieved their board certification and have the ability to make such choices for themselves? If I can’t teach them to set boundaries now, when will they learn how to do so in their professional life?

How can I be angered at the status of our profession yet so obviously contribute to the issue at hand? How many others are behaving the same way as I am? How can I rectify sending the mixed message of “take care of yourself and your mental health, but please stay late and see one more case?”

Veterinarians know there’s a problem. We will never control what pet owners say or do and there’s little we can do to control for the debt required to graduate vet school. We will never shut down Dr. Google or eradicate the piles of misinformation surrounding animal health and wellness.

But we can control what we ask of ourselves and our colleagues. And while we may never control the expectations of others, we can teach each other to recognize our limits and be okay with saying no. This is especially those of us tasked with instructing those coming up through the ranks on how to be successful doctors.

It just might be the only way we protect ourselves and the future of our profession.

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I’m here to make cancer less scary…

A few weeks ago I was asked to be formally interviewed as a means to introduce me to the surrounding community. NC State takes an active role in promoting recently hired faculty and as the new kid on the block, it made sense it would be my turn to spend some time describing myself and my goals to the community.

As much as I enjoy writing and and publishing posts online for the virtual world to read and examine, if I’m being honest I’d tell you, I detest having my picture taken and I really dislike talking about myself. There’s a huge disparity between publishing written information and posting pictures of my cats and really delving into the more sensitive issues on a “face to face” basis. But I recognized the goal of the assignment was far more important than my personal hang ups and agreed to sit down and talk about veterinary oncology and my choice to leave private practice and work in academia.

The goal here isn’t self-promotion – it’s to promote awareness of veterinary oncology. To let pet owners know there are specialists available who are experts in the diagnosis and treatment of cancer in companion animals. To assure them that the diagnosis of cancer doesn’t equal “there’s nothing we can do.” Pet owners should know the goals of veterinary oncology are not the same as human oncology. While the two disciplines are certainly intertwined, the approach to each case is vastly different. We promote quality of life, not life at all costs.

My wish is everyone facing a diagnosis of cancer in their pets would at least be offered the opportunity to talk to a veterinary oncologist. While a consultation doesn’t equal committing to a treatment plan, you will never be able to make the most informed decision unless you are presented with all the facts.

And the best person to help you make that decision is a veterinary oncologist.

Read all about my new job at NC State College of Veterinary Medicine and veterinary oncology by clicking here

If you want to be a veterinarian, you better like people!

My advice to anyone aspiring to be a veterinarian? Get used to talking to people.

Pursuing a career in veterinary medicine is tough. Just considering the process of applying to veterinary school is daunting. There are numerous standardized tests, the need for superior letters of recommendation, and the stress associated with composing the perfect personal statement of why you’re choosing this particular path. Individuals must have top notch grades, possess a wide breadth of animal-related work experience, and be well-rounded in their extra-curricular activities.

Plenty of worthy applicants are denied admission based due to a lack of available spots. The competition is palpable, and is potentially one of the biggest detriments to the vocation. The aggressive nature of the application process selects for individuals who excel academically. All too often, such individuals lack critical attributes such as comfort with public speaking or interpersonal interactions.

It’s no mystery that veterinary medicine requires a love for animals and science. Whether pursuing small or large animal practice, or a career as a wildlife or zoo vet, or even biological research, individuals are driven by a passion to preserve the health and welfare of animals.

What is often overlooked is the extent to which veterinarians must work with people. Though driven by a passion for helping animals, those working in the profession will be always be surrounded by owners, other veterinarians, technicians, assistants, co-workers, practice managers, owners, etc. who each require time, energy, and attention.

Every pet that steps through my exam room is attached to at least one human being. My interactions with animals comes easy, but those with people come less naturally. Further complicating my particular scenario is that as a veterinary oncologist, I meet people at an extremely emotional time in their lives. I possess no formal training in grief counseling or psychology. My education regarding “bedside manner” comes entirely from personal experience, both as a patient myself and over my years of worming in the field.

I may be walking into my third canine lymphoma consult of the morning, while the people I’m meeting with have never even considered their dog could be diagnosed with cancer. I have to be able to connect with those individuals despite having to repeat facts multiple times within the same work day.

I could be running a half an hour or more behind on appointments, or lack appropriate support staff, or simply not feel well and am still expected to complete my daily roster of appointments with the same amount of kindness and care as I would on a less busy or emotionally tolling day.

The animals I work with never consider my credentials or bedside manner, but I will constantly be judged by their owners on my knowledge, compassion, and ability to make them feel as though their dog or cat is the only pet I am seeing that day. I’m cognizant of how owners acutely remember every word I say and every interaction I have with them and their animal, even when doing so exceeds my reservoir of compassion and my abilities are worn thin.

The best advice I could give would be to learn how to be comfortable speaking to people and in front of groups of people. Learn about how people learn and process information. Discover new ways to listen to people. Observe and record their behavior. Consider ways to keep yourself interactive, even when you don’t feel as though you want to. There will be so many times during your career as a veterinarian you will want to withdraw, but be forced to continue to talk. You won’t always be comfortable doing so, but you need to find sooner rather than later if you’re able to push through your comfort zone.

Attempting these activities is especially important if you’re a particularly shy person. While studying, and memorizing facts will afford you the academic qualifications, what will carry you through this profession as a career will be the way you interact with other people. The more you practice these tasks, the more comfortable you will become with the process.

Is a cure for FIP on the horizon?

Feline infectious peritonitis (FIP) is caused by a mutated version of a feline coronavirus that transforms from a benign, minimally pathogenic virus to an aggressive and deadly version. Feline infectious peritonitis (FIP) is a devastating diagnosis for a cat owner as the disease is considered 100% fatal.

FIP is considered an incurable disease and the mainstay of treatment has focused on providing comfort and supportive care to affected patients. Since FIP is a deadly disease, there have been many efforts to develop effective treatments for it, with disappointing results.

However, progress is being made in developing new therapeutic options for FIP in cats. Researchers at Kansas State University devised a new antiviral treatment, which led to full recovery in cats experimentally infected with FIP who were treated at a stage of disease that would otherwise be fatal.

The antiviral treatment works by blocking the replication of the virus, a process required for it to survive within an infected cat. Six out of eight cats treated with the antiviral had resolution of fever, ascites, and low white blood cell counts, and returned to normal health within 20 days or less of treatment.

More on the experimental treatment below, but first, a primer on FIP.

Clinical Signs of FIP

Cats with FIP show non-specific signs of illness, including lethargy, inappetance, and weight loss. They may present with persistent fever and owners can notice abdominal distension or difficulty breathing in cases where fluid build-up within body cavities (effusion) is present.

There are two clinical forms of FIP recognized in cats: the “dry form” (noneffusive) and the “wet form” (effusive). In the dry form of the disease, cats develop mass-like lesions within their abdominal and chest cavities called granulomas. In the wet form of the disease, cats show fluid buildup in these same anatomical regions. There can be overlap between the two forms; cats with the effusive form often can have microgranulomas present and cats with the dry form can develop effusion.

Diagnosing FIP

Diagnosing FIP is difficult, and your veterinarian will likely recommend several tests to determine what is causing your cat’s signs.

Radiographs (x-rays) can help determine if fluid is present within the abdominal or chest cavities. An ultrasound can show enlarged lymph nodes or granulomas within the abdomen and confirm the presence of fluid. Bloodwork may be normal, but one of the most consistent findings is an elevation of a specific protein called globulin.

There is a blood test that measures whether or not a cat has circulating antibodies to the feline coronavirus, but this test is considered of limited utility. Most cats with circulating antibodies never develop FIP. High amounts of antibody make FIP a likely diagnosis, but 10% of cats with FIP will not have circulating antibodies in their bloodstream.

If effusion is present, analysis of this fluid will show a high protein level along with a relatively low cell count. In cats with nervous system involvement (e.g., brain and/or spinal cord), MRI or CT of the brain can show changes including hydrocephalus, which is a build-up of fluid in the brain. Analysis of the pet’s cerebrospinal fluid (CSF) will show high protein and cell counts.

The most reliable test for FIP is detecting the feline coronavirus antigen within white blood cells of the affected patient by special stains.

Treating FIP Experimentally

As I mentioned at the beginning, FIP is considered incurable, with treatment consisting mainly of providing comfort and supportive care. For cats in respiratory distress from fluid buildup around the lungs or within the abdomen, removing the effusion and providing oxygen support can aid in immediate relief.

Though the experimental antiviral treatment at Kansas State University seems promising, there is concern that the coronavirus that causes FIP could acquire further mutations, rendering it resistant to antiviral treatments such as the one developed at Kansas State University. In addition, this form of treatment was only studied in cats with the effusive form of the disease; its efficacy in cats with the dry form is unknown. It is also unknown whether the antiviral will be successful in treating cats naturally infected with FIP as all of the cats in the study were infected experimentally.

Polyprenyl Immunostimulant (PI) is an investigational biologic used to lessen clinical signs associated with herpes virus infections in cats by promoting immune responses to the virus. PI also has been used to treat FIP. In a small study, three cats with the dry form of FIP were treated with PI. Two cats were alive and still receiving treatment two years following diagnosis. The remaining cat was treated for only 4.5 months and lived a total of 14 months. A larger study was done in 58 cats with the dry form of FIP. Five percent of those cats lived longer than one year and 22 percent lived at least 5.5 months.

Though PI might seem like the magic bullet for treating the dry form of FIP, there are a few caveats to consider. In the smaller study, the amount of disease present in all three cats was minimal; two had no clinical signs at their time of diagnosis. In the larger study, cats who were very ill or died within a week of starting treatment with PI were excluded from the survival analysis, likely skewing results.

As some cats with no or minimal signs of disease and localized lesions can spontaneously recover from FIP without treatment, the role of PI in aiding the convalescence in these marginally affected cats is unclear. PI is also completely ineffective in treating cats with the effusive form of FIP.

Though these new treatment options seem promising, further research is necessary to determine how successful they will be for cats affected with FIP.

FIP Prevention

Controversy exists concerning the efficacy of an intranasal vaccine to prevent infection with FIP. The vaccine it is not thought to be effective in preventing disease in cats previously exposed to feline coronavirus, but it may induce some level of protection for a cat that has never been exposed to the virus.