Do the clothes make the doctor?

Veterinary medicine is a dirty job. I’m not talking about unethical behaviors or illicit activities. I’m speaking in a very literal sense, referencing the countless pungent, projectile bodily eliminations, oozing wounds, parasite-infested hair coats, and traumatic injuries we encounter on a daily basis.

All of our patients are adorable, but many of them have hygiene standards on par with a college freshman living away from home for the first time. It doesn’t help that animals notoriously enjoy repulsive activities like rolling in dead things, eating their own poop, and sticking their noses in places they shouldn’t.

As such, veterinarians tend to dress for the part. At the end of the day, we know at minimum that we’ll be covered in a shaggy covering of fur. On the worst of days we’ll have changed our clothes several times before heading home.

Scrubs are the collective uniform of choice for veterinarians, especially prevalent amongst emergency doctors and surgeons. Otherwise, their clothing is typically kept on the “way casual” spectrum of style. Depending on the clinic, lab coats may be the norm, or they may be shunned.

For those attending to our large animal or equine species, practicality often overshadows fashion sense, with “durable” and “waterproof” being the foremost important adjectives for their outfits.

When it comes to dressing for work, I tend to sway in the opposite direction from the “norms” of my profession. I happen to like wearing nice clothes and shoes (and handbags and accessories). I don’t care much for designer threads, but I do appreciate wearing pretty things, including dresses, skirts, heels, costume jewelry, etc., and I enjoy coordinating my outfits with my moods or with the season.

I’ve never ascribed to the idea that my career choice would doom me to a life of drawstring scrub pants or roomy sweatshirts. But this doesn’t mean I spend a fortune on clothes. I’m much too frugal for such behavior, and I’m a realist about the grubby nature of my job. Yet I still struggle to look my best, even while attempting to mask the piquant scent of anal glands that have been inadvertently expressed into my hair.

I’ve had a few owners comment that they think I’m the best-dressed veterinarian they’ve ever seen. Rather than come across as a compliment, I’ve found their tone judgmental, suggesting my clothing somehow imparts a lack of credibility, or even a sense of mistrust about my capabilities.

Do people care how their doctors dress? Does the attire of a medical professional influence a patient’s confidence of their knowledge? Could something seemingly as innocuous as clothing make one doctor more or less credible than another in the eyes of their patients?

A study by a University of Michigan Health System team attempted to answer those questions by examining the influence of physician attire on patient opinions, including trust, satisfaction, and confidence

The study, cleverly titled “Understanding the role of physician attire on patient perceptions: a systematic review of the literature—targeting attire to improve likelihood of rapport (TAILOR) investigators” compiled data from a comprehensive international review, from studies and other sources, on physician attire. In all, the data they reviewed came from 30 studies involving 11,533 adult patients in 14 countries.

Results from the study showed patients preferred their physicians dress formally and not casually. Male and female physicians who wore suits or a white lab coat were more likely to inspire trust and confidence in their patients.

Fashion takes a back seat when it comes to emergency, surgical, or critical care, where data show clothing don’t matter as much and patients prefer to see such doctors in scrubs.

Age and nationality also played a role in patients’ perceptions. Europeans and Asians of any age, as well as Americans over age 50, trust formally dressed physicians more than their casually dressed counterparts. Americans in Generation X and Y tended to accept less-dressy physicians more willingly.

Whether the results of the study translate to veterinary medicine is unknown. I suppose we have more interesting things to research about animal care than whether it makes a difference how a pet’s doctor dresses. Personal experience tells me an owner’s expectation for how their veterinarians dress is less stringent than for their human counterparts.

Despite a lack of evidence-based information and my own personal experience, I choose to take the results of the TAILOR study to heart and plan on continuing to wear my nice clothes to work. I know it’s important to constantly present myself as a professional, and part of that means I need to continue dressing up for my job.

And I’m not ashamed to admit I’m a firm believer that looking down at my feet and seeing a darling pair of shiny new shoes helps negate any minor aggravations I encounter during the day.

Is your veterinarian too competitive?

A few miles from my home, there are two small farms located on the same road—one along the West side and one along the East side. They exist on a small stretch of the street, with not more than a tenth of a mile or so separating the two.

Both farms sell fresh produce, flowers, and locally prepared food and craft items in the summer and fall months. Both currently offer pumpkin picking, corn mazes, and family-oriented activities, such as hayrides, pony rides, and bounce houses in celebration of Halloween and all things wonderfully autumn.

Though farms are not particularly unusual here on the Eastern portion of Long Island, it is peculiar to find two in such close proximity to each other. Especially when both are practically exactly the same in appearance, what they offer, and price. It’s a mystery to me how two exceedingly similar ventures successfully exist within less than a tenth of a mile of each other.

Of course I lack an understanding of specifics related to truly how successful each farm is. I don’t actually know whether they are rivals or are co-owned by the same individuals. I lack the proper background in marketing or economics that could afford me the ability to fully comprehend the “whys” behind how two seemingly competitive endeavors can willingly co-exist peacefully and profitably when all surface data suggests the results should be the opposite.

What I do know is that in some geographical areas, the same scenario exists for veterinary clinics. There may be several located within a short radius, or even on the same road, just as the farms near my home. Experience tells me that, unlike the idyllic farms I’ve described above, competition amongst neighboring vet hospitals can be fierce.

Competition isn’t necessarily a bad thing for veterinarians. It forces us to strive to deliver the highest quality of medicine possible. We can’t be comfortable with being average when there are above average clinics located just a few miles away. We need to be able to offer owners something more significant than our neighboring counterparts. It also helps keep costs down and prevent inflation of prices for services.

But competition can create negativity as well. Competition can lead to inappropriate bad mouthing of peers. It can cause strain amongst staff members. It makes job security a questionable commodity. And competition can create an inappropriate sense of entitlement.

This inter-clinic competition extends to the level of a referral hospitals, such as where I see my appointments. Our doctors are board certified in specialty areas of veterinary medicine. We possess advanced diagnostic equipment on par with that available at human hospitals. We have specific areas of expertise that distinguish us from primary care veterinarians. In theory, specialists already possess the necessary “edge” over our competitors because what we have to offer is only available at our hospital.

Yet specialists struggle with competition with primary veterinarians. Troubled economic times, skepticism of how others practice, inflated personalities, lack of perception of value of referral medicine – each contribute to veterinarians (and owners) wanting to keep things within the confines of their comfortable exam rooms.

I wasn’t prepared for this angle of medicine during my veterinary school and residency training. In the confines of the ivory tower of an academic institution, I was sheltered from these concerns. I also naively assumed everyone simply got along with each other and when cases became complicated or were better suited for treatment at a specialty level, a referral would be made.

The real world dictates this idealist view occurs far less frequently than I’d hoped. I still find it shocking when I witness competition motivated by what appears to be selfish goals rather than what is in the patient’s best interests. I’m not speaking of owners who decline referral for personal, emotional, or financial reasons. The situations I speak of are far more complex in nature, and rooted in a more worrying aspect that such rivalry can bring.

I still uphold that competition can be good for veterinarians. But we need to keep our fundamentals in check and always ensure we are first doing no harm and are always doing the right thing by our patients and clients.

Assuming the owners of the small farms near my house are doing the right thing, shouldn’t veterinarians be able to do the same?

Rescue me!

Lymphoma is a frequently diagnosed cancer in dogs. It is a cancer of lymphocytes, which are a type of white blood cell normally tasked with fighting infections. There are many different forms of lymphoma in dogs, with the most common type (multicentric lymphoma) bearing close resemblance to Non-Hodgkin’s lymphoma in people.

The recommended treatment plan for multicentric lymphoma in dogs is a 6-month course of a multi-drug injectable chemotherapy protocol. This treatment plan is extremely effective at achieving remission, which is a term used to describe when a patient no longer shows any visible, detectable evidence of their disease.

Remission rates are greater than 80%, and survival times can be extended well beyond what would be expected without any treatment.

Remission, unfortunately, does not equate with a cure. Cure would imply that treatment resulted in complete eradication of all of the cancer cells from the dog’s body. Remission indicates the disease is no longer detectable, but is still present.

Ninety-five percent of dogs treated for lymphoma will experience disease relapse (i.e., “come out of remission”). The timing of when this happens is variable.

Relapse typically manifests with the same clinical signs as were shown during the initial diagnosis. For example, if the initial signs of disease were enlarged peripheral lymph nodes that reduced to normal size during treatment, at relapse the lymph nodes would enlarge again.

If the patient was initially administered the multi-drug protocol mentioned above, this is usually considered the most successful plan in re-inducing remission once relapse occurs. The main exception to this recommendation would be a dog who experienced relapse in the midst of, or within a few short weeks of completing, the protocol. In those patients, rescue protocols are more appropriate and effective choices.

There are a many different rescue protocols for canine lymphoma. Amongst veterinary oncologists, owners are surprised to hear there is no one universally agreed upon “next best” way to proceed. Rescue protocols vary in terms of success of inducing remission, expected duration of remission, number of trips to the oncologist for treatment, chance of side effect, and cost.

Many owners are willing to treat their dog with lymphoma with chemotherapy once. Far fewer will embark on additional treatment once relapse is detected. The variables listed above also influence owner’s decisions about how they would next like to proceed.

For some, cost of treatment is not an issue, and efficacy is their primary goal. For others, the price tag associated with the drugs limits what they are able to pursue.

Even when finances do not play a role, aspects of treatment related to the emotional and time commitments required for appointments influence what an owner is, and is not, capable of.

When dogs with lymphoma experience relapse of disease it is a devastating reminder to owners of their pets’ vulnerability. It means their dog will not be a part of the 5% who are cured. It means revisiting the idea of continued chemotherapy. It means additional obligations they may be unprepared for. And it means genuinely facing their pet’s mortality, which is something they may have deeply buried during the time their dog was in remission.

From a clinician’s perspective, relapse evokes a similar set of emotions. These are owners and animals with which I’ve journeyed through diagnosis and six months of treatment. I’ve learned much about their lives, their families, and, of course, their dogs. When a dog comes out of remission, despite knowing the odds were never stacked in my favor, it still feels like a professional failure.

Once lymphoma resurfaces, it’s a harsh reminder that it was always there, lurking beneath the surface of a pet that otherwise behaves exactly the same as a healthy pet. Though I try to stress that relapse is simply an outward manifestation of the dog’s cancer and that there are many options available to re-induce remission, I remind owners that just because we can do something doesn’t mean we have to do anything.

Relapsed cases remind me that the palliative nature of veterinary oncology is a double-edged sword. I afford pets that have cancer with the chance to live longer and happier lives, which fulfills my goals to be an advocate for animals. But I cannot cure them because I must administer doses of drugs at levels designed to maintain a good quality of life during treatment rather than invoking a cure.

This is a bittersweet compromise I make as a veterinarian, who more than anything, must always ensure that I first do no harm.

I’m pretty excited to let you know…

I was invited to write an article for NextAvenue.com again. The topic this time was when older parents and their adult children disagree about treating a pet with cancer.

It’s a dilemma I’ve run into numerous times as a veterinary oncologist, and something I never gave much consideration to before actually experiencing the discourse firsthand.

My perspective, from the opposite side of the exam room table, is an interesting one.

If you’ve experienced similar situations as a veterinarian, parent, or adult child of a parent with a pet with cancer (or other health issue) and would be willing to share your story, please do so below.

You can read my article here:

http://www.nextavenue.org/when-older-parents-and-their-kids-disagree-about-a-pets-care/

 

Lung tumors in pets

Lung cancer is the second most common cancer in both men and women (not counting skin cancer). In men, prostate cancer is more common, while in women breast cancer is more common.

Lung cancer accounts for just over 25 percent of all human cancer deaths and is the leading cause of cancer death among both men and women. Each year, more people die of lung cancer than of colon, breast, and prostate cancers combined.

Lung cancer is typically diagnosed in older patients, with two-thirds of individuals being age 65 or older. Less than two percent of all cases are found in people younger than 45.

American Cancer Society estimates for lung cancer in the United States for 2015 are:

  • About 221,200 new cases of lung cancer (115,610 in men and 105,590 in women)
  • An estimated 158,040 deaths from lung cancer (86,380 in men and 71,660 among women)

Contrary to the disease in people, lung cancer is very rare in dogs and cats. The average age of dogs with primary lung tumors is approximately 11 years and the risk of developing lung cancer rises after the age of 13.

In cats, the average age at diagnosis is about 12 years, with most cats being more than 5 years of age. In both dogs and cats, no consistent breed or gender predisposition is found.

Pets with lung tumors often show adverse clinical signs, including a chronic non-productive cough, difficulty breathing, lethargy, and weight loss. Other less specific signs include fever, lameness, and, in cats, vomiting. Many pets are incidentally diagnosed with primary lung tumors while undergoing routine chest radiographs (x-rays) taken for other purposes.

Fluid may build up in the space around the lungs (pleural effusion) secondary to tumor cells invading into the lining surrounding the lungs or into lymphatic vessels. This can cause a pet to show signs of significantly labored breathing, which is a medical emergency.

Cats can experience a unique presentation of lung cancer where the primary tumor spreads to the bones of the digits (“toes”). In fact, some feline patients are diagnosed with the bony lesions prior to being diagnosed with a lung tumor.

If a diagnosis of lung cancer is suspected, computed tomography (CT) scans of the chest are recommended to better delineate the size and location of the tumor. CT scans are also more sensitive than radiographs for picking up metastatic tumors within other lung lobes, enlarged lymph nodes, and other intrathoracic abnormalities that may be present.

Surgery is the treatment of choice for solitary, non-metastatic lung tumors in dogs and cats. Complete removal of the entire affected lung lobe is typically recommended. Though this procedure sounds intensive, complications are rare and most pets do very well afterwards following a brief recovery period.

Thoroscopic procedures, where specialized cameras and surgical instruments are inserted through ports located within tiny incisions into the chest, are less invasive, and useful for removing smaller tumors. At the time of surgery, any visible lymph nodes should also be biopsied to determine stage of disease.

Once the tumor is removed it is submitted for histopathology and biopsy. This will provide information as to the exact cell of origin of the tumor, as there are many different potential primary lung cancers.

Most information regarding prognosis for animals with pulmonary tumors is derived from the behavior tumors of epithelial cell origins, otherwise known as carcinoma tumors. Typical expected survival time is about one year after surgery.

Prognostic factors are characteristics of the patient or their tumor that can influence the outcome (usually measured as survival time) in either a positive or negative way.

Prognostic factors for dogs with pulmonary tumors including stage of disease, the presence of adverse (i.e., unfavorable) clinical signs prior to diagnosis, size of the primary tumor, location of the primary tumor within the lung, and histological grade of the tumor, which is based on features the pathologist will evaluate under the microscope.

Chemotherapy plays a large role in treating lung cancers in people. Based on this information, there are many theoretical advantages to chemotherapy’s use in pets. However, because the tumors are so rare, studies are lacking regarding proving its benefit for dogs and cats.

I recommend treatment with a drug called vinorelbine. This is an injectable form of chemotherapy shown to provide a partial response to treatment in a very small number of dogs with lung tumors. Metronomic chemotherapy is also a reasonable, theoretical treatment option.

The role of other typical treatments used in people with lung cancer, including radiation therapy, interventional radiology, and regional chemotherapy remains relatively unexplored for veterinary patients.

Because lung cancer is so common in humans, many people are aware of how serious a diagnosis it is. Though there are many shared characteristics in the disease between animals and people, it’s important to keep in mind that in both cases, though not curable, it is often a very treatable type of cancer.

If you’re facing a diagnosis of lung cancer in your dog or cat, please seek consultation with a veterinary oncologist who can provide you with all the information you need to make the right decision for your pet.