Why seeking a veterinary specialists could just mean the difference between life or death for your pet

I’ve recently returned from the annual forum for the American College of Veterinary Internal Medicine (ACVIM), held in Nashville Tennessee.

For those not familiar, the ACVIM (www.ACVIM.org) is the non-profit organization dedicated to the education, training, and certification of veterinary specialists in the fields of small and large animal internal medicine, as well as cardiology, neurology, and oncology.

This was the third conference I’ve attended this year. Each time, I’ve returned feeling renewed and invigorated about being an oncologist. I’ve felt more confident in my career path and my knowledge base. I’ve felt assured I’m doing the best job I can do, and that I was adequately adhering to my responsibility to keep current in my field. Sadly, within just a few short days of arriving home from each occasion, I’ve found my enthusiasm become re-routed as I tackle events that completely question my faith in the public’s perception of veterinary specialty medicine.

I’d barely arrived home when my husband excitedly told me the wine store near where we lived was having it’s grand opening that afternoon. Though I am an avid lover of animals, I also really enjoy wine, so I was equally enthusiastic about the event.

Within a few minutes of our arrival at the store, we met two gentlemen who struck up a conversation with us about a baseball game we all were watching on the large flat screen TV. My husband and I have an unwritten rule that we will not voluntarily bring up our profession in social situations unless asked directly, as inevitably the tides of conversation will change and then simply become monopolized by animal talk. So we happily discussed the game, the wine store, and things to do around the area with our newfound friends.

As is so often the case, it somehow came up in conversation that we were both vets and immediately the topics shifted from discussing pitching stats and the merits of beer flavored with Old Bay, to questions about our new friend’s pets, breed specific illnesses, and then once they found out I was an oncologist, stories of their dogs who were previously diagnosed with various tumors and their outcomes.

I listened intently as one owner recounted the events surrounding the death of his older Golden retriever. He accurately recounted how his dog became acutely weak and inappetant one morning, with no premonitory signs of illness. His owner knew enough to know the behavior wasn’t normal, but figured his dog had contracted a stomach bug or ate something he shouldn’t have. He diligently brought him to his primary care veterinarian for evaluation that same day. That’s when the story took a disheartening turn for me.

Turns out his dog’s signs were not due to a simple virus, but rather a bleeding tumor along his spleen. Given the age, breed, and presentation of his pet, the most likely diagnosis was an aggressive tumor called hemangiosarcoma. However, other possibilities existed. The only way to know would be to perform an immediately life-saving surgery and remove the spleen and submit the tissue for biopsy.

The owner recalled the story with the following chain of events: 1) the primary care veterinarian diagnosed his dog with a bleeding tumor that had a > 90% chance of being a type of cancer, 2) that he would live only 3 months with an immediate life saving surgery, 3) the life saving surgery needed to be done at a specialty veterinary hospital and would cost no less than $10,000, and 4) the dog had a less than 50% chance of surviving the surgery. He ultimately elected for humane euthanasia.

As he told the events of his pet’s death to me, I could feel myself struggling between a strong sense of sadness over the sudden loss of his beloved companion and a growing sense of frustration and anger towards the misconceptions he had about what may have been the outcome for his dog.

Yes, there is a strong likelihood of a diagnosis of splenic hemangiosarcoma, but I will stand by my conviction that so many dogs are euthanized prior to surgery, that we actually do not know the true prevalence of benign vs. malignant splenic tumors.

Yes, if the diagnosis is splenic hemangiosarcoma, the prognosis is considered very guarded with surgery alone, but chemotherapy following surgery can be effective in prolonging survival.

Yes, the surgery is expensive, but likely would range between about 1/3rd to ½ the amount quoted by the primary veterinarian.

And yes, though the dog was quite ill at the time of diagnosis, the survival rate for splenectomy surgery is far higher than 50%.

At the time, I silently agreed with the owner as he told the story, as nothing I would say or do could change the events of what transpired with his dog. But I made a mental note that although I am only one small voice for my profession, I have the potential to be a proverbially powerful one. Therefore I put forth two main suggestions for our profession at this time:

I sincerely urge owners to seek referral to a specialist when offered, but also consider asking for a referral when they want to learn more about their pet’s health.

Likewise, I urge primary care veterinarians to discuss cases with your local specialists to be sure, as frontline consultants; you are providing the most accurate information to owners.

In the triad of owner, primary care veterinarian, and specialists, don’t we owe to it to the one thing we all share in common? The voiceless companions dependent on our care would never ask for anything more than this.

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Why I think “Yelp” reviews for doctors are bad news!

Press Ganey, a little-known company based out of South Bend, Indiana, is the leading provider of patient satisfaction surveys for human hospitals and physicians.   These surveys are used on both small and large-scale levels to evaluate the performance of doctors, providing leverage for compensation (or penalty, as it may be.)

 

Hospitals and doctor’s offices can use the information generated from the surveys to gauge where their employees stand with regard to the opinions of their clientele. Government offices will also use the information from these surveys to evaluate how to dole our reimbursement for certain programs such as Medicare. Higher scores translate to more revenue.   Lower scores lead to budget cuts and salary decreases.

 

The company’s website remarks “everything we do is driven by our unwavering focus on helping our clients transform the patient experience.” Patients answer questions about their providers with the goal of making the sum total of their healthcare more enjoyable and efficient.   Doctors then learn what they do well, and what areas they can improve upon. Sounds like a proverbial “win-win” situation, right?

 

Unfortunately, physicians raised concern that it’s unfair to base their performance ratings solely on the results of such surveys, as patients tend to consistently score them lower when they feel they are actually practicing better, more efficient, medicine. Conversely, their scores rise when they practice what they consider subpar care, designed to placate people’s wants/needs, but not what is in their best interests.

 

Doctors feel the overriding mantra is “the patient is a customer, and the customer is always right”, moving medicine from a scientific based, to a service based profession.

 

When doctors fail to recommend additional testing, do not offer admission to the hospital, or refuse to prescribe antibiotics or strong pain medications for minor health issues, people become angry and consistently rate their doctors lower. When physicians suggest persistent knee pain may be related to a patient being overweight, they are subsequently scored poorly.   When they tell a parent their smoking could be contributing to their child’s worsening asthma, it is received as an insult, causing poor results on the surveys.

 

Doctors claim their survey scores are reliably higher when they prescribe antibiotics or narcotic medications for patients where they truly feel those treatments are not warranted. Even worse, doctors are moving towards placating patients with these unnecessary prescriptions with the specific intention of achieving higher scores for fear of loss of job security and/or pay cuts.

 

When I discovered this phenomenon, I immediately wondered “Could this somehow relate to my career as a veterinary oncologist?”

 

At first glance, I would answer that no, I am exempt from such issues. Superficially, I do not feel as though I’m working towards the goal of achieving any specific rating or score from my clients. Whether a client agrees with my recommendation or not, it doesn’t influence my decision to make it. I take pride in my profession, with the noble foundation I’m here to protect and help animals at all times.

 

The sad part occurred when I really began to dissect the differences, and I discovered that unfortunately, I’m not exempt from the madness.

 

In looking at the examples set forth by disillusioned doctors, I too, could easily recall cases where I’ve felt forced to treat a pet with antibiotics because an owner would not agree to a test to examine for infection.

 

I could offer up instances where I’ve reduced the dosage of a particular chemotherapy drug because an owner has asked me to do so out of fear of a poor reaction from their pet.

 

I’ve agreed to add on appointment after appointment, even when I’ve felt on the brink of exhaustion, just to keep my hospital managers happy and my job secure.

 

I’ve seen appointments where owners do not bring their pets along, knowing it really is not in their best interests, but also knowing I need to keep everyone happy, including my bosses.

 

Conversely, I can think of many instances where I’ve definitely made owners upset with a refusal to prescribe a particular medication or with my brutal honesty about their pet’s diagnosis and prognosis.

 

I’ve lost clients to other oncologists because I’ve stopped offering treatment for their pet when I think their quality of life is poor.

 

I’ve even had one owner be angry with me when my prediction that their dog would likely succumb to it’s cancer within a few short months and their pet was alive and well over a year out from it’s diagnosis.

 

In some instances, what I’m describing has no particular relevance to the activities described by the human doctors above. In many others, the parallels are astonishing. I wonder how many of my colleagues would have similar stories to tell?

 

The most interesting aspect of doctors being evaluated on a ratings based system is that the most satisfied patients do not appear to be the healthiest patients. A study looking at the results of surveys for physicians reported the most satisfied human medical patients were also the ones who spent the most money on their healthcare and prescription drugs. They were more likely to be admitted to the hospital, incur the largest healthcare bills, and also the most likely to die. If the most satisfied and happiest patients truly had the best doctors, wouldn’t they be healthier in the long run?

 

Truthfully, patients, whether two-legged or four-legged, are not the best equipped to judge what is best for their health. This isn’t to say you shouldn’t be an active participant in your pet’s care, rather the best outcome would be expected when the veterinarian and owner work together in an open and honest forum.

 

We should be able to practice our craft with the knowledge we are the best equipped to make recommendations for the care of our patients, free from worry about a negative review for not making a particular recommendation.

 

Lets save the “Yelp-like” reviews for our entertainment and dining preferences, and not our doctors.

When making a decision about your pet’s healthcare, are your interests clouded by your own bias?

To describe animals as essential family members is somewhat of an understatement. Most of the pets I see are considered “children” to their pet parents, or “siblings” to their human counterparts. The unconditional love we receive from our pets is something nearly unexplainable to those without companions. This bond is the essential force that sustains my ability to practice the craft I’ve devoted myself towards.

 

Yet this same strong bond can create exceptional struggles and create many challenges when it comes to issues related to the healthcare of pets. Specifically, people tend to project what they understand about their own medical issues and care on their pets, sometimes to the detriment of the care for their beloved companions.

 

After seeing thousands of appointments over the years, I am certain everyone’s goal (whether owner, veterinarian, or otherwise) for patients with cancer is exactly the same: to maintain a good quality of life without causing harm, pain, or suffering and with the greatest potential for longevity as possible.

 

In exceptionally rare instances, an owner will tell me they would be ok if their pet would experience undue side effects or discomfort from treatment if that would mean they would live longer than if they did not.

 

It’s difficult to guide owners through such decisions without feeling as though I’m being too pushy or forceful. It’s equally difficult to not feel as though I’m acquiescing to their concerns too quickly.   I’m there to listen and to offer advice and recommendations, but I simply cannot remove the personal feelings from the equation.

 

As an example, for the vast majority of dogs with appendicular osteosarcoma, the primary recommendation will be amputation of the affected limb. This is the single most effective way to remove the source of pain for those dogs, and there are surprisingly few contraindications to this procedure and few pets that are considered poor candidates for the surgery. Even for large breed dogs or those who are overweight, or old, or arthritic – I will still generally recommend amputation for the pet because my primary concern is to relive their pain.

 

Many times owners will struggle with this decision, with the focus of their uncertainty stemming from concern their pet would not “do well” without their limb. They are concerned because the animal is too old or has trouble walking or that they would not be able to do the things they enjoy doing such as swimming or fetching.

 

Despite attempts to reassure them and to focus on the need for immediate relief of discomfort, I’m continually surprised at the number of people who simple will not consider this option for their pet. There are plenty of times I simply cannot convey that their pet is crippled with pain at that time or that they would likely never fetch or swim again with a leg riddled with a tumor.

 

I received a phone call earlier last week from an owner updating me on her dog who was previously diagnosed with osteosarcoma. Initially the dog’s family was certain they would not amputate his limb because he was a 14-year-old large breed dog. Their first appointment was with our radiation oncologist to discuss a palliative course of radiation therapy, designed to provide temporary pain relief, but spare their dog’s limb.

 

After meeting with the doctor and listening to his take on this disease, they ultimately changed their minds completely and decided to amputate their pet’s limb and follow this with a course of chemotherapy with our service. Their dog sailed through surgery and treatment with only very minor issues, truly never missing a step over his protocol.   Though we recommend routine follow-up with our service, his owner worked at a veterinary hospital closer to her home, so all of those exams were done locally.

 

The dog’s owner called this week to update me on how he was doing, nearly 8 months after finishing treatment and almost one year since surgery.

 

The news at this time wasn’t good: it sounded as though the dog developed spread of the cancer to a bone within the spinal canal and was showing signs of difficulty walking. However, the main point of the call was to let me know how grateful they were towards myself and the radiation oncologist for providing them with accurate information and statistics about their dog’s chances with surgery and treatment.

 

They were able to do their nearly impossible task and set aside many of their own pre-conceived feelings and emotions and listen to the suggestions we made which were truly offered up in their pets best interests.

 

Often the ability for owners to care so deeply for their pets is both a blessing and a curse for veterinarians. On the best of days it means people are able to listen and be open-minded as to our suggestions, recommendations, and opinions in much the same way they might entrust their health with own physicians. On the worst of days their attachment can preclude their ability to understand our concerns and suggestions, closing them off to opportunities for healing out of fear or anxiety.

 

Veterinary medicine is unique in this capacity. Our patients cannot speak their opinions or their concerns, so we rely on their caretakers to provide a voice and make decisions. It’s nearly an impossible task to perform so I would urge you all to greatly consider the experience and wisdom of your veterinarian. And if you are not happy with the things you hear, please seek a second opinion. It’s the least you can do for the silent, but unconditionally loving, member of your family.

 

What would you do if your dog suddenly collapsed and it could be from cancer?

Imagine taking your dog for it’s usual morning walk. Nothing seems out of the ordinary; your companion’s energy level and demeanor is perfectly normal, as it’s been for as long as you can remember. Imagine leaving for work, or to run errands for a few hours, and returning home to find your pet completely lethargic and unable to rise, breathing shallow rapid breaths, with a distended abdomen, pale gums, and an exceedingly rapid heart rate.

 

Imaging rushing to the nearest open veterinary hospital, and within moments of arriving, hearing the devastating news your pet is suffering from internal bleeding from a mass associated with its spleen, and will require emergency surgery in order to have any chance of survival.

 

Now imagine hearing the mass very likely represents a deadly form of cancer called hemangiosarcoma. And that with emergency surgery, this disease is typically fatal within 2-3 months, and even with aggressive chemotherapy after surgery, survival is extended to only about 4-6 months. While trying to wrap your head around this information, imagine hearing there is a smaller chance the bleeding results from a completely benign tumor that will be cured with surgery alone. And there is no way to know whether your dog has a cancerous or benign tumor before making the decision to go to surgery. What do you do when all you can think is “My dog was completely normal this morning when we went for a walk”?

 

Hemangiosarcoma is a fairly common cancer diagnosed in dogs. It arises when mutations occur in the endothelial cells lining blood vessels. The most common primary sites of tumor development include the spleen, the right atrium of the heart, and the skin. The liver is also a common site for a tumor to form, and also a frequent site for metastases from other locations. Hemangiosarcoma occurs more commonly in older dogs, especially larger breeds such as Golden retrievers, German shepherds, pointers, Boxers, and Labrador retrievers.

 

As hemangiosarcoma tumors grow, rapidly dividing endothelial cells try to form blood vessels and vascular channels, but their growth is erratic and abnormal, and tumors are fragile and prone to bleeding. If bleeding occurs while a tumor is small, or the cancerous vessels can be repaired, dogs will usually be asymptomatic. Once a tumor reaches a critical size, bleeding will typically be more severe and dogs will show signs related to massive internal blood loss. In most cases, owners have no way of knowing their pet is afflicted with this type of cancer until it is very advanced and they are literally faced with a life or death decision about how to proceed.

 

The statistics surrounding a diagnosis of hemangiosarcoma are fairly abysmal. It is estimated over 80% of affected pets have microscopic metastases at the time of diagnosis, therefore even though the surgery to remove the immediate source of bleeding is life-saving, it is generally not curative. Chemotherapy can prolong survival, but typically only for a short duration.  Even when dogs are diagnosed with hemangiosarcoma “incidentally”, meaning tumors are discovered before dogs show signs of bleeding, the average survival time with surgery alone is about 6-8 months.   The unluckiest dogs have visible metastases in multiple organs at the time of their diagnosis. Survival times for those dogs may only be on the order of a few short weeks.

 

What I find most problematic is there is little information to help determine whether a splenic mass is cancerous or not before a tissue biopsy is obtained, so owners are forced to make a decision about pursuing emergency surgery without having all the information they might need to feel completely educated about their choice. Although most splenic tumors are ultimately diagnosed as hemangiosarcoma, other types of cancers can occur within this organ, many of which carry a more favorable prognosis than the odds I’ve listed above. I’ve also seen dogs “diagnosed” with hemangiosarcoma within their spleen, with spread to their liver, based on images obtained with an ultrasound, yet biopsy showed the masses in both organs were completely benign.   Hemangiosarcoma is uniquely challenging for this exact reason: owners are forced to make major decisions with limited evidence-based data to feel comfortable they are truly making the “right” choice for their dog.

 

I’ve treated many dogs with hemangiosarcoma, and happily continue to monitor a small number of patients who are alive a year or more after their diagnosis. I’ve talked with their owners about the spectrum of emotions they experienced when deciding whether or not to proceed with the initial emergency surgery. The most common answer I hear is they just knew they had to give their dog a chance.  They felt should something happen during or after surgery, they would be content knowing they made their decision with their pet’s best interests in mind.   And they knew even though the odds for long-term survival were not in their favor, the odds for a chance to have a few more usual morning walks were great enough to warrant the risk of a diagnosis of cancer. Of course, there was always the hope the tumor would be benign, but even when hemangiosarcoma was confirmed, they were comfortable knowing it wasn’t the duration of time that mattered for them, but the time itself.

 

Whether dealing with cancer, or with any other of life’s infinitely challenges, I think we could all stand to benefit from approaching things from a “quality over quantity” standpoint. And really figure out what it means to enjoy the moment while it lasts.

 

 

 

 

 

 

What happens when pets face the additional pressure of being a connection to a deceased loved one…

As a veterinary oncologist, I see the important role pets play in enriching the lives of their owners and providing a source of happiness and sanity on a daily basis. Pets truly are family members for the majority of people I meet. But there are certain instances where I learn how pets represent more than something “average”. This is obviously something not easily quantifiable, and surprisingly, often not immediately recognizable.

 

I’ve written before about the importance of the bond between owners and service dogs diagnosed with cancer (http://www.petmd.com/blogs/thedailyvet/jintile/2013/sept/service-dogs-life-given-in-love-taken-in-love-30880). When cancer strikes one of these beloved companions, it’s particularly anguishing and certainly the effects on their caretakers are magnified.

 

In contrast to service dogs, where I’m usually able to know the role the pet plays for their family from the onset, there are other patients I treat where the ‘back stories’ of their significance to their families evolve over time.   I tend to learn about the role of pets linked to those who have passed only when owners feel more comfortable in divulging such personal information.

 

To me, the most meaningful example is pets that represent the final connection to a deceased loved one. Whether a parent, grandparent, spouse, sibling, or even a child (I swear I’ve seen it all) these are the cases that will truly pull at your heart and evoke an entirely different scenario of emotions.

 

Whenever I learn of such a story about one of my patients, I definitely take the time to pause and consider the complexity of such a case. As an individual accustomed to personal loss, I can understand how maintaining any connection to someone who has passed would be important. I also can see how the attachment could possibly complicate judgment regarding the care of the animal.
In the best scenario this means owners are better equipped to understand how aspects of terminal disease cross species. In the worst scenario, they simply cannot cope with the thought of losing the pet, as this would be the final connection to their lost loved one.

 

I think the question of how objective owners can be in such scenarios is an extremely difficult and sensitive one. The potential or actual loss of the pet can cause a resurfacing of past grief, which can be overwhelming for some people. They may be inadequately prepared to face their emotions or unable to factually understand their pet’s prognosis. The lines are so blurry when pets are diagnosed with cancer, even when they are not complicated by grief and mourning and deep senses of loss.

 

One could view this as an unfair burden for an animal to face, but ultimately, experience tells me these pets are amongst the most beloved and treasured companions I’ve ever met. Even when they initially lack the capability to understand the specifics as they relate to their pet, more often than not, owners are able to put their own emotions aside and truly care for their pet with a deeper sense of compassion and patience.

 

Such stories can truly push the limits of my emotions. It’s easy for me to become so wrapped up in the details about the story behind the animal that in some cases I’ve found myself temporarily losing sight of the bigger picture. I always need to keep in mind that as a veterinarian, my primary role is to care for animals, and to keep their health and well being at the forefront. Blurred lines or not, this rule never changes.

 

When our pets face a diagnosis of cancer, it is our responsibility to make sure they face their disease with dignity and without suffering. When they represent a connection to a deceased person, an additional focus needs to be made on honoring their original owners wishes for their care. We are all compelled to maintain their happiness, quality of life, and pride for whatever remaining time they have.

 

I urge you all to hold a special place in your heart for those pets diagnosed with cancer that also represent a connection to a lost loved one. Though they are unable to comprehend their role in the scenario at hand, they provide a remarkable sense of unconditional love that sustains over time, never asking for a single thing in return but our care.