You spin me right round baby, right round?

Medicine is full of peculiar terminology; the language spoken by doctors is unfamiliar to non-medically trained individuals. Even those of us entrenched in the healthcare field become bogged down by confusing acronyms, four and five syllable words, and bizarre pronunciations.

Earlier this week I found myself contemplating an example of “curious medical lingo”. While standing in my everyday position in the ICU amongst my peers, listening to the emergency doctor discuss details about each of the hospitalized patients, I suddenly questioned, “Why do doctors call this process we are participating in ‘rounds’?”

Doctors participate in a variety of rounds on a routine basis, including bedside (“cageside” for veterinarians) rounds such as those listed above, morbidity and mortality rounds, grand rounds, teaching rounds, journal club rounds, tumor board rounds, and research rounds.

You may have called your veterinarian to ask a quick question and been told; “The doctor can’t speak with you now. She’s in rounds.”

If you’re a fan of medical drama television shows, you’ve probably heard one of the main characters barking out the order; “We’re rounding in five minutes!”

Rounds can be lengthy or terse, boring or captivating, have an audience of one or thousands. But the word “rounds” doesn’t seem to have anything to do with what truly transpires during these happenings.

Rounds do not typically occur in the actual shape of a circle. While “rounding,” no one is generally contorting themselves into orb-shaped structures. And when we are in rounds we are not entertaining ourselves with a myriad of curved spheres.

So where did the expression “rounds” arise, as it relates to medicine?

Legend tells us the term was first coined in 1889 in the hallowed hallways of the medical school of Johns Hopkins University. Sir William Osler, a preeminent clinician and teacher who was also the first Professor of Medicine and Physician-in-Chief at Hopkins, is credited with introducing the concept of rounds to his students.

Prior to Osler’s tenure, the typical medical school curriculum consisted primarily of only instructive courses. Students merely observed senior physicians, who themselves were tasked with performing all examinations, diagnostic tests, and therapeutic procedures on patients. Time spent with actual “hands-on” learning was minimal to none.

Osler’s philosophy towards medical school education contradicted the established status quo. He insisted students could only accurately learn the art of human interrogation and examination by being the ones who actually spoke with and examined the patients themselves.

Osler told his students, “Listen to your patient, he is telling you the diagnosis,” emphasizing the importance of obtaining a thorough history as it relates to diagnostic acumen. Osler’s words were powerfully echoed over 110 years later by my favorite veterinary school professor, who taught me that “90% of the diagnoses you will make will be achieved based on your ability to talk to an owner and perform a comprehensive physical exam.”

The contribution to medical education Osler was proudest of was his creation of clinical clerkships. Here, the third and fourth year students worked directly alongside him in the hospital, simultaneously examining admitted patients in small groups.

The hallways of the medical school at Johns Hopkins were circular shaped. So while doctors-in-training were participating in Osler’s daily didactic endeavors, they needed to physically walk along the circumference of the circle in order to stop at each patient’s bed and perform their evaluations. Hence, the birth of the term “rounds” as it relates to medicine.

Rounds are an excellent way for doctors to disseminate knowledge to one another. However, inherent to the verbal flow of information is a considerable flaw, which is most pronounced during shift changes among attending doctors who are caring for the same patient.

Whenever one doctor rounds with the doctor taking over the care of that patient, there is as equal an opportunity for teaching and learning as there is the chance for information to be relayed incorrectly or lost in the shuffle.

The good news is that mistakes are rare. The bad news is that mistakes, though rare, can be quite impacting for patient care. All it takes is omitting a key lab report finding, inaccurately recalling a patient’s vital signs, or forgetting to relay that an owner is expecting a call that evening with an update to create a severe complication. Rounds are the ultimate test of communication skill and thoroughness for most doctors.

Though the shapes of the ICU where patients are kept vary, and the layouts of our lecture halls and tables that we sit at for our meetings change, the fundamental philosophies of medical rounds vary little from institution to institution.

Rounds are an integral part of my day and beyond. Rounds are how I disseminate information to my fellow doctors, technicians, and house officers. And rounds are a constant reminder that I must be completely up to date on not only my own patients but also all of those in the hospital where I work, in order to provide the highest quality of care.

And after writing this article I know a little more about a pretty interesting guy named Dr. Osler, who not only impacted human medicine but, obviously, veterinary medicine as well.

He’s someone I’d love to have had the chance to round with myself.


Why you should put off reading this article until tomorrow…

On the art of procrastination, Mark Twain said, “Eat a live frog first thing in the morning and nothing worse will happen to you the rest of the day.”

Fortunately, Mr. Twain wasn’t actually asking you to make a slimy, green amphibian the staple source of protein for your most important meal of the day. His take-home message was much less literal and, happily, much less nauseating in its significance.

He’s suggesting that if you are able to complete the most overwhelming, difficult, and repulsive task on your to-do list at the inception of your day, all of your other designated assignments will seem much less daunting in comparison.

I’m generally a very productive person at work. I can juggle an overbooked appointment schedule with a myriad of meetings (some pre-planned, others impromptu), all while taking and/or returning multiple phone calls, e-mails, text messages, etc.

In between appointments, you’ll find me completing writing assignments, working on continuing education lectures, and reading articles on current studies in veterinary oncology. There’s always a topic to research, a blog to write, or a case to catch up on.
Despite my endless capacity for multi-tasking and my passion for writing, and re-writing, and re-re-writing my list of daily tasks I want to accomplish, I’ll admit a big secret:

I’m really, really bad at eating the frog.

Invariably, the task I deem to be the most challenging, demanding, and time-consuming chore on my extensive list of planned daily activities will be the one I put off the longest to complete.

Rather than getting down to business and forcing myself to eat the frog, I’ll add on additional assignments, obligations, and chores to be able to justify pushing the one thing I don’t want to do off for as long as possible.

I will become unexplainably lost within a textbook for hours, I will pre-write discharges for cases set up with appointments three days from that moment, I will clean and reorganize my desk over and over again, and, on occasion, I will become entrapped in the vortex of viral videos depicting cats knocking things off tables.

My frog varies with the day. Sometimes it’s putting off writing a lengthy summary for a complicated case. Other days it’s working on rounds presentations for the hospital staff. But typically, the most repellent frog-eating duty I face is setting aside the time to call an owner and deliver bad news.

People assume veterinary oncologists give owners devastating news on a routine basis. Cancer is a term that conjures up nothing less than the bleakest of skies and the most dubious of horizons. These misconceptions mean it’s actually never easy for me to tell strangers what I do for a living.

Most individuals are genuinely surprised when I inform them that my job is far less dramatic than what they expect. In fact, I’m far more often the hero rather than the villain. My emphasis is on the fact that I’m the one who often imparts hope to owners who have already been given the devastating news of their pet’s diagnosis by a different doctor.
There are times, however, when I am the person responsible for disclosing unfortunate news. Sometimes this relates to confirming a suspected diagnosis of cancer in a pet referred for further diagnostics. Other times, I’m there to inform them that their beloved pet’s disease has spread within their body, and that our carefully planned and executed treatment plan was unsuccessful in controlling disease. And in others, I’m calling to tell an owner there’s simply nothing more we can do.

Our nature as doctors is to impart healing to our patients. We never wish to be the bearer of anything other than stellar examination and laboratory results and proverbial clean bills of health. Doing so is akin to our admitting defeat.

We chose this path because we love science, medicine, and maintaining and restoring health. Along with those positive attributes comes the great responsibility of disseminating information, both the good and the bad.
In some instances, I put off eating the “bad news” frog because I want to be sure I have set aside an adequate amount of time to have the difficult talk with the owners. Those discussions shouldn’t be pinched in between appointments when my mind is preoccupied with dozens of other things.

In others cases, I’m too attached to the pet or the owners (often both) and worry I won’t be as objective in my delivery as I should be and my bias will influence my speech.

I stall on eating the frog because I know it will be hard and uncomfortable for me. I know it will take time and there will be questions and I won’t be able to read facial expressions or know what is being comprehended.

Most significant is I know that when I eat that frog, I know I am likely to cause another person to feel pain. No matter how temporary, it is not in my nature as a doctor to wish to willingly and purposefully make another person (or animal) hurt.

My complex emotional state boils down to a very primitive survival skill tactic: I don’t want to deal with eating the frog because it’s difficult.

Mr. Twain’s words are certainly insightful, and I’m not here to argue against the concept that attacking formidable obstacles makes us stronger individuals and gives us perspective to understand that a lot of times the “big things” are just small things with more elaborate surface structure.

But I think there’s something to be said about ensuring you’re good and hungry before sitting down to eat the frog.

It’s not something you want to face on a full or queasy stomach. Otherwise, you might not be able to finish the task to the best of your abilities.

And no one else wants to deal with your leftover frog when they have their own to savor themselves.

What’s up with supplements for cancer?

Many owners administer herbal supplements to their pets with cancer with the hope that these alternative therapies will afford their pet a therapeutic edge in fighting the disease.

The amount of information suggesting the beneficial effects of various herbs, anti-oxidants, “immune boosting treatments,” and dietary supplements is astounding. The appeal of using a substance that is “natural” and “non-toxic” to disease is inarguably real.

What most owners fail to recognize is that herbal medications are not subject to the same regulations by the Food and Drug Administration (FDA) that prescription drugs are. Owners are also unaware that carefully worded claims to efficacy are not backed up by scientific research in the vast majority of cases, despite the plethora of supportive material listed on product inserts or on websites.

Legally, herbal supplements are considered “foods” and not “drugs.” Therefore, the FDA has minimal regulatory role over their production and advertising.

The FDA acts to ensure that there are no overtly misleading claims made by the manufacturer, and also mandates that it is illegal for a product sold as a dietary supplement to be promoted on its label, or in any of its labeling material, as a “treatment, prevention, or cure for a specific disease or condition.”

Dietary supplements do not need approval from the FDA before they are marketed. Except in the case of a new dietary ingredient, where pre-market review for safety data and other information is required by law, a firm does not have to provide the FDA with the evidence it relies on to substantiate safety or effectiveness before or after it markets its products.

A recent investigation was conducted by the New York State Attorney General’s office examining the integrity of various herbal supplements via DNA analysis of their ingredients. Results astonishingly showed that 4 out of 5 herbal products were found to contain none of the herbs listed on the ingredient label.

From the press release from the New York State Attorney General’s office:

Overall, just 21% of the test results from store brand herbal supplements verified DNA from the plants listed on the products’ labels — with 79% coming up empty for DNA related to the labeled content or verifying contamination with other plant material.

… 35% of the product tests identified DNA barcodes from plant species not listed on the labels, representing contaminants and fillers. A large number of the tests did not reveal any DNA from a botanical substance of any kind. Some of the contaminants identified include rice, beans, pine, citrus, asparagus, primrose, wheat, houseplant, wild carrot, and others. In many cases, unlisted contaminants were the only plant material found in the product samples.
Though the results of the investigation are concerning, one could argue a lack of accuracy in product integrity would do little harm other than waste the buyer’s money. As a veterinarian, what I worry about is whether what’s actually present in the supplement could be detrimental to my patient’s health.

Could these non-listed ingredients cause a severe allergic reaction in an animal? Could these additional ingredients interact negatively with a previously prescribed conventional treatment? Are they really safe?

I’m not arguing against using natural substances to treat disease. In fact, one of the most common chemotherapy drugs I prescribe is vincristine, a drug derived from the periwinkle plant. Aspirin was originally produced from salicylate containing plants such as the willow tree. And on a personal account, ginger is a definite anti-nausea remedy for my own occasionally sour stomach.
But I also know that many natural substances can be extremely toxic for pets. There are many species of poisonous wild mushrooms; botulin toxin (aka “Botox”) is natural, but can be deadly for animals; and yes, even the vincristine I prescribe routinely to my patients can be deadly if proper dosing is not maintained.

I’m concerned that owners are wasting their money on supplements touted as cure-alls for their pets. I worry that these substances could actually be causing harm to my patients because of unknown ingredients that interact negatively with prescribed medications or with that animal’s particular physiological constitution. And I have concerns that the average consumer isn’t aware of the lack of regulation of these substances, which is the impetus for writing this article.

Be sure to speak directly with your veterinarian in reference to your questions about supplements and their potential role in your pet’s healthcare. And be sure to let your pet’s doctor know about any supplements, vitamins, and other over the counter remedies you may be administering to your pet. An open dialogue is essential for making the best decisions about your furry companion’s well being.

To learn more, visit the American Cancer Society’s information page on supplements: Dietary Supplements: What is Safe?

The Secret Lives of Veterinarians

There are dozens of peculiar and fascinating things about your veterinarian that you’ve probably never considered. And certainly these aren’t concepts they would ever bring up with you in routine conversation. As with most professions, the perception of a typical “day in the life” of a veterinarian differs greatly from what transpires in reality.

Here’ a list of five things I think will help you to better understand your veterinarian and provide insight into some of their typical daily struggles, some of which are just a tiny bit larger than others.

1) Your veterinarian has a lot of debt.

If you are lucky enough to have a recent graduate as your vet, you are probably thrilled with knowing they are trained in the most current available diagnostic and therapeutic options.

What you may not be aware of is that your newly minted doctor is likely saddled with a huge student loan burden that adds a tremendous amount of stress to his or her daily life.

New grads exit veterinary school with an average of $165,000 in debt. Payments on such loans can surpass those of a monthly mortgage. Starting salaries rarely compensate for this. The tenuous financial situation for most veterinarians is our profession’s worst secret.

2) Your veterinarian is a master multi-tasker.

Nearly every successful vet I know is adept at juggling at least 4 to 5 different “crises” at a time, while maintaining an air of confidence and calmness.

Primary care vets are expected to be radiologists, surgeons, gastroenterologists, dentists, endocrinologists, and often psychologists.

This can entail trying to unscramble a backed up appointment schedule because an owner showed up 45 minutes late for their appointment, while simultaneously taking the time to console a distraught owner who has just received devastating news, and disciplining feuding staff members.

We can exit an exam room after euthanizing a beloved aged companion we’ve known since puppyhood and within a minute regain our composure and move on to seeing an excited family and their new puppy coming in for its first exam.

Our capacity for multi-tasking is remarkable and, all too often, understated.

3) Your veterinarian is not an animal psychologist/communicator!

Inevitably, when someone I’ve only just met finds out I’m a veterinarian they will ask me a question about why their pet engages in a particularly peculiar activity or behavior.

Vets receive rudimentary training in animal behavior in veterinary school and we learn the basics of how to help owners cope with things like separation anxiety, aggression, and basic obedience training. For most of us, veterinary specialists who pursued board certification in veterinary behavior are our “go to people” for all things behavior related.

However, neither the general practitioner nor the specialist are able to enter the mind of your dog or cat or horse or guinea pig and tell you why it is they engage in activities you are concerned are unusual or abnormal.

Think of all the weird behaviors your friends and family members have — would you expect anyone to be able to explain them?

4) Veterinarians take their work home with them.

OK, maybe not in a literal sense. If we really took your pets home with us, it would be quite counterproductive to our livelihood; and yes, it would be very illegal. However, rest assured, we constantly worry about your pets.

As a veterinarian married to another veterinarian I can tell you that at least 75 percent of my conversations with my husband revolve around work related topics and discussions about cases we’ve seen.

We bring home the good (success stories about the pets we’ve helped feel better, fractures we’ve repaired, patients we’ve deemed cancer free) and the bad (those that became sick from treatment, those we couldn’t help, those who died).

We wake up in the middle of the night and call to check in on our cases. We work during our vacations and holidays.

We carry our work burden far beyond the hallways of the hospitals where we work and willingly bring it directly into our homes. And we envy those who can leave their work at work.

5) Your veterinarian never stopped studying after graduation.

Many states require veterinarians to maintain a certain amount of continuing education credits in order to keep their license to practice up to date. This entails attending large-scale conferences and smaller local lectures, reading articles and textbooks, and in some cases, even taking exams!

We do this because we have to, but in many cases, we also do it because we want to.

We understand veterinary medicine is an ever-changing field and that in order to offer our patients the most current diagnostic and treatment options, we ourselves must stay current on the research that offers that information.

We truly embody the definition of being lifelong learners.

Veterinarians are interesting people… when we’re not worrying about time, money, lawsuits, or inadvertently upsetting an owner.

We’ll never stop worrying about our patients though. It’s practically ingrained in our DNA.

But that’s something you probably already knew about us