Why can’t we all just get along?

I’ve noted a particularly disturbing conflict within my profession I thought I would take the opportunity to address publicly. My goal in doing so is not to fuel fires, but rather to open up dialogue between the two sides and see if we can’t redirect some of the hostility towards more productive measures.

The subject of my interest is the ongoing “dispute” between the goals of veterinary specialists and general practitioners (GPs) of veterinary medicine. It’s something I’ve only become attuned to as a working professional, and never considered during the inception of my career during veterinary school and residency.

I’ve seen countless examples of veterinary specialists who are quick to blame GPs for poor referrals, poor record keeping, poor case management, and “overstepping” their boundaries. GPs are equally verbal about their unhappiness with specialist’s egos, their persistent “stealing” of cases, lack of providing follow up, expense, and inaccessibility.

The bitterness isn’t pervading, but it’s sour enough to damper at least a portion of each of my workdays, some more significantly than others.

No soul would argue the fact that GPs and specialists alike share the same passion for our profession. We chose this path not only because we love animals, but also because we love science and medicine. We each knew how difficult attaining admission to veterinary school would be and we each reveled with our first (and in some cases only) acceptance to school.

We all grew from the same seeds planted in the dark and quiet lecture halls of our respective universities. We suffered together in the sticky trenches of gross anatomy, and shared in the joys and nuisances of clinics. In the end, we each pursued varied avenues of the same profession, working in different geographical and socioeconomic areas, with some of us working as GPs and some of us pursuing further training.

We hugged vehemently at graduation. We promised, and successfully managed, to keep in touch. And we now find ourselves sharing the joys and nuisances of marriage and parenthood amid our lives as working professionals. So why, if our foundations are so solid and deep-rooted, is there such palpable hostility between the two sides?

We are taught as children that there are two sides to every story. In considering this, I know that what I can’t see as a veterinary specialist is how GPs are scheduled to see so many more cases per day than I am, back to back, in rapid-fire succession. The pressure of this must be so immensely draining.

I know that despite being a dog or cat’s oncologist, I will never have the same bond with that pet as their GP does, as they were the most integral part of their healthcare from their very first puppy or kitten exam through the illness that brought them to my exam room. Their need to maintain contact and be updated stems from a place I could never begin to comprehend. There are these and a thousand more miniscule factors, whose magnitude projects larger than I could ever consider, that make the job of a GP so taxing.

What the GP will never see is the frustration on an owner’s face when their pet arrives to see me and I have no records to indicate to me why they are there because they were not sent ahead of time. They will not understand that faxing over a biopsy report with no signalment or history or descriptive information and expecting a detailed reply as to the “next best steps” borders on malpractice. They cannot see that sending a case to see me to “get the protocol so my vet can do the treatments at their hospital because it’s cheaper” is invariably infuriating.

The rationale from GPs, that owners “hear what they want to hear” or “don’t have the money to spend on referral hospitals,” starts to wear thin to us specialists when you consider that the price of a referral is nominal, and could provide owners with the information they need to make a choice, even if that choice is to do nothing.

Likewise, the gritty abrasiveness of specialists who complain about poor referrals or speak badly about GPs who send cases without adequate records, or mismanage cases without knowing the full details of what truly transpired in the exam room, needs to stop.

This is not to say that gross negligence on the part of either party should be ignored. If a GP makes a glaring error in prescribing an incorrect chemotherapy dose, I am obligated to point out their error. If I fail to return a phone call in a timely fashion, or if I speak in a condescending manner to a GP, I deserve to “lose” the potential referral. But neither of the above mentioned arguments are helpful for either side or for our profession as a whole.

We can be frustrated with each other, but we also need to remember that we do not walk in each other’s shoes. I could never do what a general practitioner does. In fact, I realized very early on in veterinary school that I would never attempt to do so. I know it is beyond my capabilities. Nor could a GP do what I do on a daily basis. As such, I would argue that we need to co-exist peacefully and productively, with each side recognizing our limitations and our talents.

We all entered the profession from our passion and love of animals and science. It seems we could all do with putting our egos aside and keep in mind the real goal: promoting and maintaining the health and wellness of our patients. On that, we’re still all on the same page.

Just as we were on day one of Gross Anatomy.

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Why being an optimist sometimes pays off…

Trixie’s owners sat stone-faced across from me in the exam room. They were a middle-aged couple filled with worry about their beloved 14-year-old tabby cat, referred to me for evaluation of a tumor in her chest. Trixie was like a child to her owners – this became evident within the first few minutes of the appointment when they would finish each other’s sentences while describing how she played fetch with her toys or how she begged for food like a dog or how they picked her out from a litter of 7 other kittens at their local animal shelter. Their tone became solemn as they described how Trixie developed a slight cough over the past few weeks, which did not resolve with treatment with antibiotics and anti-inflammatory medications.   Her primary veterinarian performed radiographs (x-rays) of her chest the week before their appointment with me and saw a suspicious area within the cranial (front) part of her chest cavity. She was very worried about a tumor as a cause of the chronic cough, and so she referred Trixie and her owners to the oncology service at my hospital for further testing and treatment options.

 

Prior to meeting with Trixie’s owners, I reviewed her radiographs and saw exactly what her veterinarian was troubled about. I too was concerned about what I saw on the films. There was an irregular mass located in the normally tiny space between the left and right topmost portion of Trixie’s lungs, sitting just in front of her heart. From a purely logical standpoint, the odds weren’t in Trixie’s favor. She was a geriatric cat, and some statistics suggest more than 50% of pets over the age of 10 will develop cancer. I knew the most common types of tumors that would grow in the chest included lymphoma, thymomas, tumors of the thyroid or parathyroid glands, or even tumors that spread from another area in the body, none of which were options offering a good long-term prognosis. The mass was also quite large, which added another negative for Trixie, due to concern it could be invading into regional blood vessels and/or nerves. I also knew chest tumors could often cause fluid to build up within the space around the lungs, which further restricts expansion of these vital organs, causing a reduction in ability to oxygenate blood, which could ultimately prove fatal. Despite all of these undesirable outcomes, I also knew we didn’t have an actual diagnosis of cancer, which meant there was a chance the abnormality seen on the radiographs represented something completely benign, and further testing was necessary in order to provide an accurate prognosis. As I always tell owners, nothing makes me happier than to tell them their pet actually doesn’t have cancer and I was really hoping to be able to do that for Trixie.

 

I sat before Trixie and her owners and explained my concerns about the possible causes for the mass. My recommendation was to perform an ultrasound of the mass to try to better clarify its location in relation to other organs within the chest, to gain some information as to whether the mass was attached to any vital structures, and most importantly, to try to attempt to obtain a sample of the cells comprising it using what is known as a fine needle aspirate procedure. No matter what I said, Trixie’s owners remained absolutely grim and teary-eyed with concern over her welfare. Nothing I could offer would console them there could possibly be a good outcome. They asked me many questions about the different types of cancer it could be, and expressed they were not likely to pursue surgery or radiation therapy or chemotherapy, should those treatment options be recommended based on the outcome of the ultrasound.  However, after much deliberation, they wanted to know more about what the mass was, and they agreed to perform the scan.

 

Trixie was positioned on her back and a small region of fur was clipped away from the side of her chest. The radiologist swabbed a small amount of bright blue gel along the bare skin and changed a few settings on the ultrasound machine.   He gently placed the probe on her side and we both stared attentively at the screen, while swirls of blacks and whites and shades of gray appeared at first in a rather haphazard manner, then slowly taking form into more recognizable structures: the rhythmic beating of her heart, the bright contrast of a rib bone, the rippled shadows of the lung tissue, and there it was, the mass itself, sitting right in front of the heart and between the lungs.   Knowing the typical ultrasonographic appearance of tumors, I anticipated seeing a solid form of gray tissue, but instead I found myself staring at a screen filled with blackness, surrounding by a thin rim of brightness. At first none of the images made sense, but after a few seconds, I turned to the radiologist and we both exclaimed our thoughts at the same time: “It’s a cyst!”

 

The swirling blackness on the screen was no mirage. It represented fluid, which meant the ominous mass seen on the radiographs was nothing more than a large liquid-filled sac known as a cyst.   Cysts arise when the cells lining various structures within the chest cavity begin producing excessive amounts of fluid, which accumulates slowly, similar to a water balloon, and over time, this can cause compression of the surrounding organs. To be absolutely sure of the diagnosis, we elected to introduce a small needle into the structure and withdrew some of the fluid. It appeared colorless and without cells, confirming our diagnosis. Trixie did not have cancer!

 

When I told her owners the great news, they were so relived and thrilled; they once again started tearing up, but this time out of sheer happiness.   We discussed the different ways to manage her cyst, and since Trixie wasn’t really showing any clinical signs associated with her diagnosis at this point, we did not need to intervene at this time. Rather we would be able to monitor her condition with repeat imaging tests to assess growth of the cyst over time. Although her owners were overcome with emotion, and although I felt so happy to report her prognosis was now excellent for long-term survival, like a typical feline, Trixie seemed otherwise unimpressed with the day’s events, and she scowled at the three of us from the depths of her pet carrier, gently thrashing her tail from side to side in protest of her lack of breakfast.

 

Trixie is a good example of why it is important to take the extra step to pursue additional tests to confirm a diagnosis, even when there is a great deal of suspicion an animal’s signs are due to cancer. When I discuss various additional diagnostics with owners, sometimes it is a struggle to communicate the reasoning behind my recommendations, especially when they may perceive the tests as redundant or unnecessary or invasive. Experience allows me to have just enough breadth to recognize many non-cancerous conditions mimic cancer and it is my goal to be able to provide owners with all available options and I can only really accurately do this when I am certain of a diagnosis. In my opinion, this is especially true when owners are not inclined to pursue definitive treatments for cancer as I strongly feel they should make such a decision with as much information as possible.

 

Trixie continues to do well, an although she may cough from time to time, I am happy to report she remains cancer-free and continues to provide her owners with joy and companionship, and the occasional tail thrash on the days she has her recheck appointments. I don’t take it personally though – we all take it as a sign of her continued good health and we look forward to her visits each month.

An ounce of prevention could be worth a lot in the bank…

Preventative medicine. What do these words mean to you?

 

As doctors, we tend to think of preventative medicine in a very concrete way. It’s the underlying mantra behind our recommendation for routine physical exams, labwork, imaging tests, and screening tests. We want to perform these check-ups when patients are well in order to detect risk factors prior to the development of significant disease.

 

There’s a great deal of evidence to support the benefit of preventative medicine for people. One study indicated over half of the deaths in the United States in the year 2000 were due to preventable “behaviors and exposures.” This included deaths from cardiovascular disease, chronic respiratory disease, unintentional injuries, diabetes, and infectious diseases.

 

It would seem, therefore, preventative medicine would be our best defense against illness. Yet, nary a few months go by before another study is published indicating preventative exams, lab tests, or diagnostic procedures are no longer being recommended as they provide no apparent benefit to patients.

 

As an example, the results of a recent meta-analysis of 52 different studies indicated annual pelvic exams were “unnecessary” for women. Results showed the exams provided no benefit for diagnosing women with ovarian cancer, uterine cancer, or vaginal infections early enough to save a woman’s life or preserve her fertility.
When I heard the results on our local news station early one morning, I immediately reacted with anxiety, anger, and concern, shouting irrationally at the television screen, while my husband stood bewildered at my outburst. When the media puts forth such medical information without a supporting net for the fallout, I can’t help but bristle in response.

 

When you examine the “bones” of the study, the American College of Physicians essentially is saying, skip the pelvic exam, but you still need to routinely test for cervical cancer. Though the conclusion I read was, “You still need to see your doctor regularly for preventative testing”, the media’s take was skewed towards, “Skip the exam and question your doctor if they suggest performing one.”

 

My first concern was women would hear the results and interpret them to mean, “You don’t need to make an appointments for an annual exam anymore – it doesn’t do anything.”

 

I then wondered how the perception of the results of such studies translated to veterinary medicine. If the (inaccurate) message put forth is preventative care is unnecessary and unhelpful for people, how can veterinarians ever attempt to convince owners of the importance of preventative health care for animals?

 

I am certain one of the main reasons we are unable to cure the majority of our veterinary cancer patients is because we diagnose and initiate treatment when their disease burden is large.

 

Animals are hard-wired to hide signs of illness or pain, and will often only just begin to give an indication they are sick only after their disease is quite advanced. Even the most astute and loving pet owner can easily miss the very early signs of disease.

 

Regular physical exams and a better ability to screen patients for risk factors indicating predispositions to cancers would lead to earlier diagnosis and a better chance for cure. We could also test breeding animals for susceptibilities to cancers and remove them from programs.

 

Prevention of disease could ultimately be less costly than diagnostics and treatment instituted at advanced stages. A 2007 study by the American Veterinary Medical Association (www.avma.org) supports this concern.

 

This study showed that although there was a consistent rise in spending on veterinary care for pets over a 5-year period, the actual number of veterinary visits per pet during that same time frame declined. Many interpreted the results to mean that owners were spending more money only once their pets were sick, rather than on their routine visits that could have prevented the larger expenses in the long run.

 

Lastly, bringing pets in for more wellness exams it will force veterinarians to place more emphasis on the lost art of the physical exam. On of my best mentors in veterinary school drilled into students that 90% of success in obtaining a diagnosis comes from the history given by the pet owner and the physical exam. Despite this, veterinarians consistently seem to rely much more significantly on the results of labwork or imaging tests to tell them what’s wrong with pets.

 

Think about it this way: If one year in the life of your pet equals seven years of your own life, and you skip your pet’s yearly checkup, it’s the equivalence of missing seven years of preventative care for yourself.

 

Imagine not going to the doctor or dentist for seven years.   Would you not be surprised to learn you had “issues” with high blood pressure, were slowly gaining weight, or had a “bit” of dental disease at that time? How then can anyone be surprised when diseases are detected at such advanced stages in pets when routine care is avoided? And how can we be surprised when treatment options are limited and cure rates are low?

 

Keep up with the wellness visits for your pets – they really are an invaluable aspect of their overall health! And you may just be able to afford your companion with a chance for a cure they would not have had if you waited until they were actually sick from their disease.

Why your doctor may not be telling you what you need to hear about your cancer prognosis.

Owners typically seek consultation with a veterinary oncologist for one of three reasons:

They are interested in obtaining a definitive diagnosis and performing recommended staging tests to establish options for further care

They have a solid understanding of their pets’ diagnosis and are definitely interested in treating their pet’s cancer

They are searching for more information about their pet’s diagnosis and are interested in knowing what can be expected as the cancer progresses.

Naturally, there is a great deal of overlap between the different motives, but central to each learning what their pets’ prognosis will be.

Though most of us associate the word prognosis with survival time, the actual definition of the word is “the likely course of a disease or ailment.” Obviously, the latter description encompasses much more complicated aspects than simply how long a pet will live.

The behavior of some cancers is fairly predictable. Pets with lymphoma tend to become extremely ill as the disease progresses, dogs with hemangiosarcoma will typically experience a massive bleeding episode, and cats with oral squamous cell carcinomas usually stop eating from pain directly related to the tumor. Though I’m confident in my ability to foresee what will happen in those cases, it’s very difficult to pinpoint the exact time frame when the illness, bleeding, or anorexia will be fatal.

I recently read an article describing the imprecision of human physicians with regard to their ability to provide a prognosis for terminally ill patients. Intrigued by the topic, I delved deeper, and discovered there are actually dozens of research studies centered on examining doctors’ accuracy when it comes to predicting how long terminally ill patients would survive following a diagnosis.

Turns out doctors are typically terrible at the task. Surprisingly, physicians tended to over-estimate prognosis, meaning they believed, and consistently told their patients, they would live longer than they actually did. More so, the lengthier the doctor-patient relationship, the less accurate the prognosis tended to be, leading the conclusion “disinterested doctors . . . may give more accurate prognoses, perhaps because they have less personal investment in the outcome.”

Depending on the study, results did not matter if the doctor giving the news was a general practitioner or a specialist. Positivity appears to have zero correlation with experience or level of post-doctoral training and specialization.

When considering why human physicians would overestimate prognosis for terminally ill patients, I started wondering, what are the inherent personality traits responsible for such optimism, especially in light of my experiences managing patients with terminal diseases.

Do we overestimate how we think our patients will do because of our inherent drive to heal and relieve suffering that we are willing to put aside our book knowledge and sustain ourselves on chance?

Are we so driven to succeed that anything less than remission, even in patients we know have advanced disease, would be considered failure?

If we offer a more conservative estimate for outcome, would an owner be more inclined to pursue aggressive care for their pet? Since quality of life for their pets is the main concern for most people, and in the “real world” we have to consider the unfortunate “cost to benefit” ratio, is it possible we skew towards optimism because of our hope for a chance to cure?

Do we wish so strongly to maintain a partnership with our owners and their pets we subconsciously avoid the conflict that arises out of complicated discussions about end of life care and how rapid the disease could progress?

I’m sure when it comes to prognosis, most pet owners would appreciate complete and brutal honesty, even if this would mean shocking them with how little time they may have left with their beloved companion. I can count on one hand the number of times an owner said, “I don’t want to hear the numbers”, meaning they are unwilling or unable to listen to what I think could be a realistic outcome for their pet. Typically I see this arise from apprehension or denial, rather than remarkable optimism for their pet’s outcome.

From my perspective, it isn’t easy to discuss a prognosis with owners. I never want to deliver bad news and though my skin is thicker than it was a few years ago when I was an intern having such discussions for the first time, I’m never completely comfortable “guessing” what I think could happen to their pet, and in what time frame it could occur.

An accurate prognosis can only be derived from the results of clinical studies examining hundreds, if not thousands of patients with disease. A clinician’s experience may temper such academic information, and tailor the answer more specifically for the patient in question.

In reality, the prognosis we offer may stem, at least partly, from a deeper part of our professional soul. A part designed to protect our ideals of healing and helping as we hold out for the hope of a cure, even when the statistics tell us otherwise.

 

 

 

No one wants to talk about it, but it’s something we all must face: All about euthanasia

One of the most difficult aspects of pet ownership is considering their mortality.

 

Yes, this is a heavy way to start an article. But reality tempers the excitement of picking out a new puppy or kitten, or adopting an older dog or cat, with the knowledge that animal’s expected lifespan will, in all likelihood, be far shorter than your own.   A major consideration for pet ownership is what can be done to ensure that a good quality of life is provided during all stages of their existence.

 

The loss of a pet can be unbearable for owners whose attachment far supersedes what would be considered a “typical” healthy human-animal bond. Those cases require professional help when it comes to the complications surrounding euthanasia and death. Fortunately, there are health care providers specifically trained in dealing with supporting exceptional cases of grief related to pet loss.

 

What I encounter far more frequently are owners who, despite a rational understanding that their pets are not immortal, become overcome with fear and anxiety once faced with the diagnosis of a terminal disease.

 

Even though owners may be able to comprehend their pet has a fatal disease, the tension surrounding the details of the actual “process” off loss can be overwhelming. A more frightening concept for most people is the actual act of euthanasia itself.

 

The word “Euthanasia” literally translates to “The good death.” It is simultaneously the most humbling and powerful aspect of my job.

 

The perception of what transpires during euthanasia of a pet can be clouded by experiences with the deaths of relatives or friends or even from sensational images put forth by the media. I cringe each time a television show depicts death as some remarkably dramatic flat lining of an EKG or theatrical intake of a last breath. In reality, the passing is marked with much less spectacle.

 

As difficult as it is to discuss the subject, I thought it would be helpful to provide factual information for pet owners to think about prior to the difficult choice of euthanasia and allow some opportunity for learning and discussion about an otherwise unmentionable topic.

 

The first step for most owners is deciding where to have the euthanasia take place. For some, the decision may unfortunately need to be made on a more urgent basis, but for many other situations we are able to somewhat “plan” the process.

 

Most euthanasia occurs in a veterinary hospital, however some veterinarians will travel to an owner’s home in order to provide an additional layer of comfort during this difficult time.   This can be a very helpful service for very sick or frail animals or for owners who are incapable of transporting their pets to the vet and would otherwise be limited in their abilities.

 

Owners must then decide whether they will be present or not during the euthanasia. This is often a difficult choice for many pet owners and I urge owners to think about this particular aspect of “the plan” ahead of time. From personal experience, I know that the answer to this question can be different for each individual pet, and is dependent on many different unique emotional aspects.  Take this time to consider the right choice not only for yourself, but also for your pet.

 

Although the specifics of euthanasia can vary with facility and from doctor preference, in most cases a small intravenous catheter is placed into a vein located on the lower part of one of the limbs. The catheter will be taped in place temporarily. This is to facilitate the administration of the euthanasia solution, a drug called sodium pentobarbital.

 

This drug is a barbiturate medication that at “routine” doses, can be used as an anesthetic/sedative, but at the high doses used for euthanasia, will be fatal. The drug will cause unconsciousness within the first 5-10 seconds of administration. During this time period, there is also a drop in blood pressure, along with cessation of breathing, and cardiac arrest. This occurs within 10-30 seconds of administration. There is a surprisingly brief amount of time from the initiation of injection to the passing of the patient.

 

Many times we also administer a sedative prior to injecting the actual euthanasia solution. This is to make sure the pets are calm and quiet, and able to relax in their owner’s arms or near them on the floor in a comfortable and kind environment.

 

Once the euthanasia solution is injected, I will take my stethoscope and listen for a heartbeat. Once I’ve confirmed the heartbeat has stopped, I will let my owners know their pet has passed.

 

Some owners will elect to take their pet’s home for burial. Most owners elect for private cremation of their pet, with their ashes being returned to them.

 

Veterinary hospitals typically have a contract with a local pet cemetery that provides this service. The cemetery may also offer special options for owners including viewings, witnessing the cremation, and burials with plots similar to those available for humans. Owners are encouraged to contact their veterinarian for further details, or even to search on their own for a cemetery better suited to their personal needs.

 

In most situations, owners will need to return to the veterinary hospital to pick up their pet’s ashes once they return. This can often be a very difficult thing for owners to face as they are returning to the place they will associate with the loss of their beloved companion. If needed, ask a friend or family member to accompany you, or act in your place at this time.

 

Educating yourself on what to expect at the end of life might just be the first step in coming to terms with a terminal diagnosis for your pet. Doing so doesn’t make you heartless or uncaring. On the contrary, I find it represents a commitment to one of the major responsibilities of pet ownership.

 

The process is certainly emotionally taxing and painful, but with a small amount of exploration in advance, can also be demystified, allowing for a calm and peaceful closure for owners dedicated to their pet’s care.

 

It’s the final gift we can give to our companions who never ask for anything in return.