What You Might Be Missing When You Pick Convenience vs. Quality in Pet Health Care

A recent segment of the Today show focused on the growing trend of walk-in health care clinics for people. These are the ubiquitous “Minute Clinics” found amidst local pharmacies or the 24-hour “No appointment necessary” offices where people can, at the initial fleeting sign of a sniffle, ache, or strange skin rash, show up and request immediate care for their ailment.

The report indicated that more and more people are pursuing the option of convenient care because of a perception that their primary care doctors are inaccessible during evenings, weekends, or holidays. However, with a bit more probing, evidence revealed the issue wasn’t that people couldn’t get in to see their doctor. The issue was they couldn’t get in to see the doctor when it was more appropriate for their own personal schedules.

I paused to consider the message put forth and what this suggested regarding American society’s awareness of the importance of their own health compared to the quality of life for their physicians, and (as usual) how does this information about human healthcare relate to my life as a veterinarian?

Few people would disagree with the notion that if you’re truly sick you should not be working. You should be at the doctor, or resting and healing your body, or both. Unfortunately, this simply just isn’t an option for many people trying to sustain themselves in our “Work to Live” society. It’s terrible to think people are so financially strapped or so worried about their job security that they literally can’t afford to take a sick day to go to the doctor when they are ill.

The flipside to the American status quo is that if people are unable or unwilling to miss work to visit the doctor, or their jobs are too important to take time off when sick, the natural expectation is that their physician should work second shifts or provide weekend or holiday hours to care for them when they are not working. Otherwise, doctors run the risk of losing patients to walk-in clinics with more convenient hours, even when this means the care offered may be impersonal and subpar.

As a doctor who also happens to be a human being, I support the notion that physicians should not be expected to work until midnight or be available every weekend or holiday, simply because their patient’s job or financial situation doesn’t allow them to take time off to take care of themselves. As a human being who also happens to be a doctor, I understand how difficult it can be to miss work because I’m sick and need to take care of myself and how it would be much more suitable to schedule my own appointments when my day was finished.

Most pet owners have a primary care veterinarian they will see for routine healthcare and preventative medicine, or for when their pets are sick with a non-life threatening condition, or even for emergency care. These same doctors recognize the importance of providing evening and/or weekend appointments to accommodate the restricted schedule of the average owner. Yet for smaller and personal veterinary offices, it’s completely unrealistic to expect them to remain open every hour of the day, 7 days a week.

You may be fortunate enough to live in an area where you have access to emergency veterinary hospitals which operate after hours and on weekends, or, in some cases, that are open 24 hours a day for the times where primary care vets are not available or able to squeeze your pet into their already overbooked appointment schedule.

The gray area in veterinary medicine opens up when we consider those hospitals where the policy is to simply get the case through the door with the “Minute Clinic” mentality. At first glance, it all seems like a win-win, as pets receive the care they need in a timely and efficient fashion. What may not be immediately evident is the great deal of pressure “convenient” healthcare puts on pet owners, and how that trickles down to potentially less effective care for their animals.

This Minute Clinic mentality can be especially problematic in “tertiary referral” hospitals where veterinary specialists such as myself work. Obviously, when life-threatening illnesses affect animals, or when access to specialized diagnostic and therapeutic equipment is required to save a pet’s life, accessibility is paramount.

But what about cases where waiting a day or so would not affect the clinical outcome but is more opportune for an owner, or for their perceived urgency regarding their pet’s care? What about the times when seeing the case on an urgent basis actually means fewer options may be available in the long run? Does the perception of “I can have it for myself, therefore I demand it for my pets” really play a role in the veterinary profession?

I’ve had countless referrals that “needed” to be seen that day, where owners show up without their medical records, without results of previous diagnostic tests, and without the right information to indicate why they are even sitting in my exam room in the first place.

The lack of a previously established client-patient relationship at such offices could at a minimum mean spending owners’ money on repeating tests that were already performed, to the more serious error of putting forth a quality of medicine that is less than ideal, all the way to the worst case scenarios of grievous errors in medical care that could further harm the patient or even lead to their death.

Accessibility doesn’t always equal good medicine, and convenience doesn’t always equal compassion. This is important to keep in mind not only when considering decisions about your pet’s health, but also the next time you don’t feel well and have to decide about whom to entrust with your own wellbeing.

In both cases, it may just serve you well to pause to consider the bigger picture and take time to heal properly rather than settle for the most convenient option for your care.

If you enjoyed this article, take a look at: Evaluating the Value of Veterinary Medicine

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Why I don’t worry about quality of life sometimes…

When faced with a diagnosis of cancer, invariably the most consistent concern owners have is being assured of maintaining their pet’s quality of life. Though they may have trouble with articulation, and stumble over word choice, I know they wish to select a treatment plan that refrains from inflicting pain or adverse side effects while simultaneously providing a prolonged lifespan over what would be expected without any additional intervention.

 

I fiercely agree quality of life for animals undergoing anti-cancer treatment is important, but I’ve also come to appreciate the attention that must also be focused on the opposing side of the spectrum: We must give credit and recognize the importance of the quality of their death.

 

What defines dying with quality? What exactly are we are hoping to provide or maintain during this time? How can veterinarians and owners ensure pets are able to die with dignity and respect, worthy of the unwavering companionship they provide during their lives?

 

To me, a quality death means an animal dies without pain, distress, or discomfort. They die while they are still self-sufficient and ambulatory. And they die without fear and without suffering. If death is a likely consequence of their disease, every effort must be taken to maintain an animal’s dignity and preserve their pride.

 

To fully understand quality of death, I think we need to clarify the definition of what we mean by palliative and hospice care as these terms relate to animals. Many people use the terms interchangeably, when in truth, the meanings of these terms are quite different.

 

Palliative care refers to care designed to maintain an animal in a state of self-sufficiency, where we infer (based on both quantitative and qualitative factors) animals are enjoying the things we would define as indicators of a good quality of life. Palliative treatment, by definition, is not designed to prolong life. However, as cures are rare in veterinary oncology, when we successfully palliate adverse signs associated with cancer, we afford pets the ability to live out their remaining time with their disease as more of a “chronic condition”, which often translates into potentially longer survival. Palliative care is active, ongoing, and a huge focus of my career as a veterinary oncologist.

 

Hospice care occurs when death is pending. There are no further heroic gestures, treatment is ceased, and the focus is on relieving pain and suffering related to disease. Hospice care allows for the patient and their family to be supported through the process of dying. Hospice care is also active and ongoing, but instead of maintaining quality of life, we are now compelled to provide a quality of death.

 

In veterinary medicine, and specifically within the specialty of veterinary oncology, there is a remarkably narrow and blurry gap between what constitutes palliative care and hospice care, further confounding our ability to understand the concept of quality of death.

 

As an example, consider a dog diagnosed with an inoperable oral melanoma tumor. Without treatment, their expected lifespan would be anywhere from a few weeks to maybe a month or so before they would become so debilitated from their disease that we would recommend humane euthanasia. Without euthanasia, the dog would quite literally waste away and, eventually, they would likely die from dehydration and malnutrition.

 

Most dogs presenting in such condition will already be experiencing difficulty ingesting food or water so they may not satisfy my criteria of being self-sufficient. They are likely to be in pain from either the physical presence of the mass, or invasion of the tumor into surrounding bone or muscle. Again, failing one of my main standards for having a quality of death.

 

In some cases, the lifespan of a dog with inoperable oral melanoma can be extended with additional treatments such as radiation therapy and/or immunotherapy.  These actions would not be expected to result in a cure, but would rather be expected to provide temporary palliation of signs, with death being a near inevitable consequence at some point in the future.

 

Let’s say the chance of success of the treatment is 30%, and the chance of some impacting side effect is 25%, and the chance of eventual death is near 100%. Considering an owner’s (and their oncologist’s) priority is to make sure their pets do not undergo adverse consequences from the options we have for attacking their cancer, how do we decide whether to focus on palliation or hospice care? Do such figures allow us to be comfortable with providing further options, or should we focus truly on the quality of death that is imparted by excellent hospice care?

 

For some owners, simply hearing me say, “There is nothing more I can do” will be enough for them to draw the line and end their pet’s life. Others will need to know they’ve exhausted every option before “giving up” on their beloved companion, trying second, third, and even fourth line protocols, with the hope that something could be successful.

 

People never hesitate to tell me they think my job has to be hard or that it must be sad, but likely they underestimate that the absolute hardest and the hands-down saddest part of my profession is discussing with owners when I feel that we are at the crossroads between palliation and hospice care for a particular patient. The second most stressful part is feeling confident that I am the one best equipped to make that decision for the pet.

 

Our concern for the quality of life for animals with cancer prevails, sometimes surprisingly even to the detriment of achieving our goal of helping them live a longer life. I argue an equally important effort needs to be made to maintain their quality of their death. And attention should be paid to both ends to make sure we’re maintaining our responsibility to the legacy they leave us during this most difficult of times.

 

More information on the American Veterinary Medical Association’s stance of hospice care:

https://www.avma.org/KB/Policies/Pages/Guidelines-for-Veterinary-Hospice-Care.aspx

 

 

If ever there was a tumor that would fool me, it would be a mast cell tumor on a dog…

Mast cell tumors are the most common cancerous skin tumor seen in dogs. Mast cell tumors are tumors of mast cells, which are immune cells normally functioning in allergic reactions. Mast cells contain various chemical mediators that are released upon some sort of external stimulation. I typically use the example of a mosquito bite on your skin: Mast cells release chemicals in response to the substance injected by the mosquito, and this causes the development of a pesky, itchy red bump. Mast cells are also involved in anaphylactic reactions to things like peanuts or shellfish. In these instances, mast cells are releasing their chemicals on a more “global” scale in the body, causing swelling of airways and lowering blood pressure, which can even lead to death.

 

Cutaneous mast cell tumors in dogs can be extremely challenging as it seems no two tumors behave alike, even in the same dog. Some dogs develop a single tumor during their lifetime, which is surgically removed, and never have any evidence of recurrence or spread. Other dogs develop multiple tumors in their skin at the same time, or develop one tumor every year like clockwork, while some others may experience regrowth of a tumor soon after surgery, and spread of the cancer through their body at a rapid rate.

 

Among many variables, the biggest predictor of the behavior of a cutaneous mast cell tumor in a dog is something called the histological grade. The grade of a cutaneous mast cell tumor can ONLY be determined through a biopsy. There are currently several grading schemes for mast cell tumors; the most commonly used is the Patnaik scale, which designates tumors as grade 1, grade 2, or grade 3. Grade 1 tumors are invariably benign in their behavior, and are generally considered cured with surgery. On the other end of the spectrum are grade 3 tumors, which are considered invariably malignant, tending to recur following surgery and spread to regional lymph nodes and internal organs with a high frequency and can be rapidly fatal. In the middle fall grade 2 tumors, which can be a diagnostic and therapeutic challenge for oncologists. Most grade 2 tumors behave like grade 1 tumors, however some grade 2 tumors behave in a very aggressive fashion. As a veterinary oncologist, these are my most difficult cases as it can be very hard to predict which grade 2 tumors will “behave badly”.  A newer scale, which classifies mast cell tumors as being either “High grade” or “Low grade” was recently developed. This grading system can better predict outcome for dogs.  I personally like it when a biopsy report grades the tumors on both the Patnaik and the “High/Low” scale in order to give me the most information possible.

 

Mast cell tumors are treated in many different ways and when I meet with an owner, I spend a great deal of time talking with them and developing the best plan of action for their pet.  In my experience, there’s usually a lot of different ways we can approach a pet’s treatment, so it’s important to make sure owners understand all their options and that we are all on the same page.

 

I’m often asked by owners and their veterinarians about the oral chemotherapy drug available for treating mast cell tumors in dogs.  There are two drugs that fit this description, and both are in the family of receptor tyrosine kinase inhibitors (TKI’s) are currently licensed for use in dogs: Palladia ® (toceranib phosphate) was the first drug to be approved by the FDA for treating cancer in animals, and approval of Kinavet ® (masitinib) soon followed.

 

Receptor tyrosine kinase inhibitors (TKI’s) are targeted anti-cancer therapies. This class of drugs has caused significant excitement in the human cancer field. The most widely known receptor TKI for people is Gleevec ® (imatinib mesylate), a drug that has revolutionized the successful treatment of human gastrointestinal stromal tumors and chronic myelogenous leukemia.   Both Palladia ® and Kinavet ® are multi-receptor TKI’s similar to Gleevec ® that target mutated receptors involved in both cellular proliferation and tumor angiogenesis (blood vessel growth) pathways.

 

Specifically, mutations in the receptor tyrosine kinase known as KIT occur in 20-30% of grade 2 and 3 canine mast cell tumors. Palladia ® and Kinavet ® successfully target mutated KIT receptors in mast cell tumors. Palladia ® is indicated for the treatment of grade 2 and 3 recurrent mast cell tumors, with or without lymph node metastasis. Kinavet is licensed for the treatment of recurrent (post-surgery) or nonresectable Grade II or III cutaneous mast cell tumors in dogs with no previous treatment with radiation therapy and/or chemotherapy except corticosteroids.

 

Exciting information from preliminary clinical trials indicate both drugs may also have activity against cancers other than mast cell tumors, making them attractive options for patients who previously may have had little or no opportunity for treatment. Published information is not currently available about the use of Palladia ® in cats, however preliminary studies indicate this drug is safe to administer to cats, and we have personally successfully used Palladia to control a variety of cancers in our feline patients as well.  I receive a lot of calls about using these drugs “off label” and I will warn owners and their vets that just because they are oral medications and they can be given at home, they are not necessarily less toxic or less likely to cause your pet any side effects as the drugs we administer in hospital.  I do worry that because of their ease of administration, there’s a lot of misuse of these drugs going on.

 

TKI’s are a unique form of anti-cancer therapy for animals. They are available as oral tablets designed to be administered either daily or every other day at home by the owners, rather than being given intravenously at the veterinarian’s office as we do for most other chemotherapy drugs. Initially (and this will vary from doctor to doctor) I recommend patients receiving these drugs are scheduled for monthly rechecks with comprehensive physical exams and labwork for the first 6 months of therapy. Rechecks are sometimes reduced to an every other month basis, depending on the patient’s status. Treatment is continued for 12 months or longer, depending on tumor control. Again, it’s important to keep in mind that the major toxicities seen with TKI’s are adverse gastrointestinal signs rather than hematological toxicity as seen with other traditional chemotherapy agents.  Therefore once again, ease of administration should not preclude sound medical reasoning for their use.

 

If you or your veterinarian feels your dog could benefit from treatment with a TKI, please consider referral to a veterinary oncologist to discuss the pros and cons to treatment with this family of drugs so further diagnostic and therapeutic options can be discussed.
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What’s the most commonly uttered phrase in veterinary school? The answer may surprise you.

There are several phrases one is guaranteed to hear on nearly a daily basis in veterinary school, ranging from “What a cute puppy!” to “That’s really gross!” to “Have you seen my rectal thermometer?” These expressions are commonly uttered as students cross from lecture hall to lecture hall, or wander down the corridors of the teaching hospital, or even as they wait in line at the coffee cart. But perhaps the most frequently encountered saying, guaranteed to spew forth from the mouths of even the most articulate students, is “Will this be on the test?”

Whether agonizing over the details of a recent lecture, watching an instructional video of how to halter a cow and lead it safely from it’s stall, or sifting through infinite piles of notes, concern centers on what is necessary to memorize for testing purposes, and what can be discarded as unimportant.

Admission to veterinary school is difficult. It’s estimated that only about 40-45 percent of applicants will be accepted and enrolled. I’m sure the ratio of people who aspire to become veterinarians to those who actually pursue application to school is equally skewed in a negative direction.

Not only is it challenging to commit to and finally achieve the elusive acceptance letter, one must then consider the exceptional rigors of the curriculum itself. Veterinarians must become proficient in the diagnosis and treatment of multiple species over their 4-year tenure of learning, while our human counterparts, given the same time frame of education, are only expected to focus on learning about a single organism (i.e., human).

The upshot of all of this strain is that veterinary medicine is an extremely competitive field. To even be considered a candidate for admittance, students must not only achieve high grades, they must also possess vast experience working within the veterinary field, hold excellent letters of recommendation, and even maintain a great deal of volunteer experience. The aggressive nature of the admissions process and the stressors associated with the curriculum tends to select for individuals who are exceptionally driven.

For many students, the competitiveness doesn’t stop once they’ve entered the halls of the vet school. Constant pressure to maintain an excellent GPA along with stellar co-curricular activities are necessary evils for individuals looking to pursue post-graduate training with an internship and/or residency program — or nowadays, even to secure a job in general practice.

For some, this translates into an irrational and unhelpful focus on tests and grades, rather than an assessment of ability to exist and thrive in the “real world.” The very act of the constant questioning of “Will this be on the test?” illustrates the poorly focused attention of even the most stable of students.

When I look back with the hindsight of several years of work experience and think about what it truly means to be a veterinary specialist in clinical practice, I now see that those facts I spent hours agonizing over are often quite meaningless. More so, I now recognize there were several voids in my educational process that I would now consider essential aspects of the career we need to be teaching to students.

In all my time spent poring over textbooks and class notes, you may find it surprising to know I was never trained on the proper way to tell an owner their pet had a terminal diagnosis. I was never examined on my ability to discuss how to pick and choose diagnostic tests when owners do not have unlimited funds to spend on testing. No one ever assessed my ability to maintain composure while simultaneously calming a distraught owner, or to manage an overbooked schedule when my first appointment runs 20 minutes late.

I wasn’t taught how to speak to co-workers when I felt they treated me poorly. I wasn’t primed on how to negotiate a contract or ask for a raise. I never learned the true meaning of hospice and the myriad of difficulties associated with end of life care.

Sometimes I can’t help but feel that my deficiencies have actually grown with time, but it’s likely only because I’ve been exposed to more and more situations that have made my inadequacies stand out.

I’m not suggesting the didactic portion of veterinary school is worthless. Obviously the basics of form and function, anatomy and physiology, and function and dysfunction must be taught and committed to memory. However, when the concern is placed on quantifying things related to detail rather than the bigger picture, I’m afraid of exactly what we are losing along the way.

So for those of you considering veterinary medicine as a profession, whether you are young and in pursuit of this as your first career, or older and coming to the decision after soul-searching and trading in your existing job for a new path, my best advice is to gather as much practical experience as possible not only prior to applying, but also maintain as much hands-on work as you are comfortable with during your time at school.

Exposure to practical experience in the field is the best way to garner ways of communicating that you think will work, and the ways that don’t work. It will help you learn how to have those difficult discussions, and what types of things you may face on a daily basis. Moreover, it may be the thing that helps you know whether this profession is really the right choice for you.

These things may never show up on an exam, but they will be an integral part of your day-to-day life as a veterinarian.

I can think of no better preparation for the biggest test you’ll face as a veterinarian: The day you become the doctor instead of the student.

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Evaluating the value of veterinary medicine

Back in veterinary school, I was faced with the decision about what exactly I wanted to do after graduation. It seemed there were two paths I could choose from: one would lead towards becoming a general practitioner and one would lead towards becoming a specialist.

Unlike some of my peers who knew exactly what they wanted from the minute they entered the clinics, the decision wasn’t simple for me. Each option had proverbial pros and cons and benefits and drawbacks. I wasn’t entirely sure how to proceed.

Career indecision wasn’t really a new concept for me. Although I’ve wanted to be a veterinarian for as long as I can remember, the “kind” of vet I wanted to be evolved as I aged.

As a very young child, I wanted to be a vet who treated only puppies and kittens. I’m not sure exactly when I discovered this idealistic notion of what a vet did was not even close to being true, but once it did, I know my goals started to change a bit.

As a “horsey” kid growing up on Long Island, I spent my pre-teen years dreaming of being a racetrack veterinarian. After realizing the thoroughbred racing industry wasn’t nearly as akin to the glamorous world of the Black Stallion novels as I once thought, once again I found my romantic notions of veterinary medicine shifting.

I spent time contemplating a career as a zoo vet or a conservationist, but as is true for so many things in life, things eventually came full circle, and by the time I was accepted to veterinary school, I decided I would be a general practitioner and spend my days treating companion animals.

This was, of course, before I knew what specialty veterinary medicine entailed. Once I started vet school, I was exposed to a caliber of medicine not unlike what is available for my own health. Specialty medicine appealed to my intellectual side and my creative side. After a few years I knew it was the path I wanted to take.

I struggled with what would be the ideal specialty for me to pursue. Truthfully, oncology was the farthest from my mind. One of my biggest concerns was the astronomical amount of finances directed towards saving the life of only one dog or cat was compared to what could be spent towards helping so many animals in a shelter or rescue organization.

It’s not unusual for owners to spend $5,000 or even $10,000 when treating a pet with cancer. Some owners will spend $20,000 or more on pets treated with surgery, radiation therapy, and chemotherapy. Or course I recognize this is not even close to an option for the vast majority of people, but for a small group of pet owners, there is literally no price to be put on their pet’s healthcare.

I’ve been thinking a lot about the disparity in the different “fields” of veterinary medicine. Some racehorses are worth millions of dollars as unproven yearlings and there are immense expenses related to their veterinary care. I routinely recommend treatments costing several thousands of dollars for a single animal, knowing I’m not likely to cure them of their cancer, but I’m typically able to extend their lifespan by months to years. Even “routine” veterinary care for dogs and cats can run into hundreds of dollars per visit to the vet. Yet there are so many pets in shelters who may never be afforded the chance for advanced treatment should it arise, or worse yet, are put to sleep for lack of space, or for a treatable, but expensive, medical condition.

As veterinarians, I think we each struggle with the reality we simply cannot save every animal and I still battle with the financial aspects of my chosen career more often than I would like. Maybe it’s more pronounced in a field such as oncology, but it’s not at all exclusive to my chosen specialty.

Is it wrong for an owner to spend the same amount of money on one pet that could be used to help so many more? Everyone will have his or her own convictions when answering this question. Until you are in the position of having to make that actual choice, I think it’s best not to respond at all as your answer could be very surprising under different circumstances.

Just as my career goals changed over time, so may an opinion on the “value” of a pet, especially if it were your own animal you were making that decision about.

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