VMDiva

The diversity of my appointment schedule never ceases to amaze me. From the blissfully smooth to the guilt-inducing no-money client, I fluctuate between joy and stress throughout my day. One hair-pulling situation involves the disabled pet owner of two small fluffy dogs who routinely appoints her caregiver the task of bringing the aging beasts to me for exams. Following the visit, I then call the owner to discuss my findings, diagnosis, and plan. I’m struck with minor annoyance by having to repeat the entire appointment over the phone but can understand the owner’s absence.

The real trouble arose when I realized the owner and caregiver have a palpable distrust of each other. The caregiver revealed the owner doesn’t want her present at the exams. The owner called before an appointment to ask that I not tell the caregiver too much. The caregiver tells me the owner fails to give medications as prescribed and refuses to follow recommendations. The owner assured me she gave the medication and the dog is still no better. I’ve found myself in the middle of a owner/caregiver/dog triangle and needed to find the fastest way to the best outcome for my patients.

I’m tasked with placing the dogs’ health at the forefront while still adhering to the wishes of their owner. Now, I’m no fool and realize owners lie to me about giving medications, diets, and who knows what else on a regular basis. I rarely have foreknowledge of the impending lie. I tend to believe the caregiver’s story  because there is no rational reason for her to lie about the owner lying. The owner, with her impaired faculties, probably believes admitting to her lack of compliance will result in relinquishment of her pets. Despite this, I refused to cut some back-exam-room-deal with the caregiver to reach the treatment plan these dogs need. The owner has exclusive right to chose as long as she adheres to anti-cruelty statutes. So instead, I’ve employed my straight talker tactic.

I asked the owner pointed questions about completing courses of antibiotics and reasons she wished to pursue XYZ courses of action. We spoke candidly about quality of life and her ability to provide adequate medical care to her pets. I built trust and after we had a rapport, I reiterated the importance of all the things we discussed and planned. I cannot control whether she does them or not which is a lesson in patience and understanding only time teaches.

And I haven’t forgotten to document, document, document!

Anyone else out there find themselves in a similar situation? How did you handle it?

It’s internship season which always makes me wonder: Is life after an internship so radically different from spending your first year in private practice? I decided to forgo an internship, mostly for financial and marital reasons. Kudos to my husband who tolerated my indebtedness for four years of vet school. This year’s new veterinary graduates are faced with a decision that has educational, financial, and personal implications: Pursue an internship or full-time employment? About 40% of new veterinarians are entering internships upon graduation, leaving the remainder to *fingers-crossed* find strong mentorship at a private practice. New graduates have the base knowledge needed to develop a list of differential diagnosis but have yet to learn the the art of recognizing nuances of disease in practice, delivering bad news, and having confidence in their abilities.

In an academic setting, influences from specialists and the constant inundation of “ivory tower” medicine can easily persuade students to pursue additional training after graduation. Many of my classmates pursued an internship with knowledge they would never pursue a residency. But why? I argue many new graduates lack confidence in their knowledge and instead find themselves leaning on an internship as a crutch, that stepping stone between student and independent veterinarian. It’s not wrong to feel insecure but it warrants recognition for what it is. I’ve heard many reasons for pursuing an internship from: inexperienced, not ready, want more emergency training, not sure about specialization. Most of these reasons boil down to fear.

I felt fear and, admittedly nausea, on my first day of work as a veterinarian in private practice. I don’t regret my decision to forgo an internship. Within months I felt at home, climbed the steep learning curve, and blossomed into the veterinarian I am today. Interns earn a pittance, work double the hours of a private practitioner, and defer loan payments for one more year all the while accruing interest. I challenge new graduates to honestly explore the reason for pursuit of an internship because that path is wrought with challenges.  If the pursuit is for more education and career advancement – go for it! If it is fear of primary case responsibility and decision making – take the brave step, find a mentor in private practice, and jump!

How do you remove dried snot from painted walls without damaging the paint? You can’t. At least that’s my experience with my chronic snotting, snuffling, sneezing, snorking cat. Winston has successfully plastered my walls with copious amounts of mucous with a holding power rivaling the largest tube of gorilla glue. If you have one of these snorkers in your house, there is hope!

I recently attended a veterinary conference lecture that focused on these cats by Cynthia Stubbs, DVM, DACVIM. We all know snot-nosed cats can prove difficult to manage for both veterinarians and pet owners. Once the appropriate diagnostics are performed to rule out some of the more easy to treat issues, many pet owners are faced with the choice of advanced and often expensive diagnostics. While I still strongly recommend performing a vast array of diagnostics to get to the heart of the disease, many times cats suffer from difficult to diagnose rhinitis and sinusitis that can be exacerbated by respiratory infections. There is a probable association between chronic snorkers and chronic infections with herpes and calicivirus. Both herpes and calicivirus attack nasal and upper airway mucosa, causing chronic inflammation that can lead to nasal discharge and destruction of the delicate nasal bones that sit inside the nasal passages. This correlation has lead Dr. Stubbs to pursue both palliative and curative treatments.

Dr. Stubbs suggested one such treatment involves giving affected cats intranasal bivalent vaccinations against herpes and calicivirus. The intranasal delivery is purported to increase local mucosal immunity and therefore decrease the inflammation in the nose. Dr. Stubbs reported some cats needed only the vaccine on an every 3-6 month basis for near complete relief. The off-label use of the vaccine does not confer any immunity to panleukopenia, so Dr. Stubbs recommended also giving the traditional subcutaneous trivalent FVRCP vaccine. In addition, Dr. Stubbs bravely uses the anti-inflammatory antibiotic doxycycline along with the NSAID piroxicam to provide additional symptomatic support. Word to the wise: Non-liquid forms of doxycycline are known to cause esophageal stricture in cats and piroxicam should not be used in cats with kidney disease.

I am planning on trialing the intranasal vaccine in my own snorker. We’ve tried multiple antibiotics – no small feat given Winston is a perceptive, neurotic, inflammatory bowel disease cat. Nothing has alleviated his six years of nasal congestion. I will certainly follow-up in future postings.

Diagnostics Performed in Nasal Discharge in Cats

• Complete physical exam
• Complete bloodwork, urinalysis, Felv/FIV testing, +/- coagulation testing
• Blood pressures, particularly if nasal discharge is hemorrhagic
• Nasal cytology, culture, and biopsy
• Viral detection tests
• X-rays, CT scans, Rhinoscopy
• Nasal Flushes

Common Diagnoses In Nasal Discharge in Cats

• Dental disease – very common
• Rhinitis/Sinusitis – very common
• Nasal foreign bodies
• Cancer
• Nasopharyngeal Polyps
• Infection: Bacterial, Viral, Fungal, Parasites – common either as primary or secondary diseases
• Trauma
• Hypertension or bleeding disorders

Apparently only one. At least that’s what the civil court said in a recent civil complaint against my practice. Let me give you some history.

Mrs. Notesta brought her young cats to our clinic years ago, well before I worked there. At the time, she declined Felv/FIV testing saying, in what typically amounts to a “never”, she wouldn’t test today and that she’d have to think about it. Thankfully, the veterinarian at the time noted this in the record. She declined testing the other 2 cats as well. Fast forward to eight years later when one of Mrs. Notesta’s indoor only cats, Lucky, becomes very ill. She is seen at a local referral center where, over the course of a couple of days she deteriorates and is euthanized. Lab results revealed she had Feline Leukemia Virus (Felv) and it was believed this lead to her death. Felv is not curable or even treatable, leaving cats with a compromised immune system and more likely to develop cancer. Fortunately, none of the other cats in the home were infected.

Mrs. Notesta wrote a letter to the hospital with accusations of negligence and malpractice because her cat was never tested for Felv. She contends that, because Lucky wasn’t tested, the hospital is liable for all medical bills incurred at the referral center, loss of salary for her time off, and other bills accrued during the cat’s illness. Despite having copies of the records with multiple documented refusals and repeated telephone conversations with the practice owner, she announces she will pursue a civil suit against the practice to recover her expenses.

A couple of issues come to mind with this situation:

1. Had the original veterinarian not recommended testing or failed to document her refusal, would Mrs. Notesta have a case?

• Consider how the cat’s medical care would have evolved had veterinarians known she was Felv positive. Perhaps she would have received more aggressive antibiotic treatment when infections were evident. More aggressive treatment early on may have staved off inevitable illness a little longer.
• Would Mrs. Notesta have pursued expensive diagnostics and treatments at the referral center had she known the cat was Felv positive and likely suffering complications of endstage Felv? Probably not. Even if the cat was not tested, testing would not have necessary affected the overall outcome. In the above scenario, is the hospital responsible for her bills if it failed to recommend testing?

I don’t know the answers to these questions but I sure look forward to hearing your opinions

2. How many times should you ask an owner about a specific diagnostic or treatment modality, especially if they say “I’ll have to think about it?”

• The civil court judge  in this case ruled that one instance of documentation of the owner’s refusal for Felv/FIV testing 8 years ago was enough even though there were multiple documented refusals. The lawsuit was dropped, the owner paid her bill to the practice, and we haven’t heard from her again.

I think one additional inquiry about testing is warranted from a medical standpoint, if not a legal standpoint, especially if the owner left the conversation with “I need to think about it.”

3. Can clients construe repeated questioning about testing be construed as bullying?

• Maybe. It depends on your approach and the client. If a client senses you’re uncomfortable pressing for an answer they usually become uncomfortable themselves. If a client says no, a reasonable response is “Well, if you ever change your mind and want to do that test let us know” or at an annual visit “Are we still holding off on that heartworm test like we did at your last visit? I certainly recommend the test for Fluffy.”

I am not legal expert and can rarely predict which way the court will rule, but I think veterinarians are probably “safe” recommending testing one time for diseases like heartworm and Felv/FIV provided the recommendation is recorded. Informed owners are key; It’s not enough to merely suggest a test but to explain why that test is important. I talk about heartworm disease in depth at least once, typically at a puppy’s final vaccine appointment. I still recommend testing to owners who have repeatedly declined heartworm testing for their dogs. I also discuss the long term affects of Felv/FIV with new kitten owners prior to recommending testing. I am sure to mention testing twice (if needed) and recommend the test strongly for all strays and all never-previously-seen cats.

Perhaps my approach is overkill, but I feel confident that when Mrs. Notesta writes me a letter, I have myself adequately protected.

Recent comments on my posts have touched on one of the most pervasive yet least talked about subjects in veterinary medicine: Burnout. There were no courses in vet school on how to deal with this topic. I suppose we are expected to suck it up and deal with it. That doesn’t sit well with me as I see excellent veterinarians bail on their careers, families, or worse, lives, in response to the stress this profession brings.

Burnout has many causes. Veterinarians typically work long hours. Very long hours. Those hours are changing, fortunately, for small animal veterinarians and a small subset of large animal veterinarians. Long hours alone can lead to mental fatigue but then take into consideration emergency care. The long hours topped off with calls in the middle of the night lead to physical fatigue. Yawn. For the practice owner, life is even more harried. Owners are balancing veterinary medicine with business decisions. In their “down time” they are making financial decisions for the practice, handling upset clients, and managing personnel. It can easily consume all of an owner’s waking hours. Maintaining a proper work to life balance is critical in keeping your sanity.

Next is the issue of stress. Every veterinarian has different stressors. For some it is dealing with difficult clientele who demand so much of your time you fall behind schedule or sit on the phone for what seems like hours waiting to leave at the end of the night. For others it is dealing with compassion fatigue. As acclimated to pain, suffering, and death vets become, we are never quite comfortable with it. The mental toll this takes is not always apparent until you find yourself lying awake at night thinking about a case. I still have patients who break my heart and I admit to tearing up over them. Compassion fatigue alone can be enough to lead a veterinarian to burnout. This phenomenon is common in all medical professions. And for other vets, stress comes from balancing the desire to provide optimal care with an owner’s financial considerations. Rare is the vet who hasn’t heard, “I can’t afford any of that. You’re going to let my pet die. If you cared you’d give it to me for free.” These difficult situations are only magnified by the aforementioned physical and mental fatigue.

Any job can cause burnout if the work environment is toxic. Viral personalities, unyielding bosses, unreasonable hours all lead to discontentment. As stress and angst grow at work, small issues become magnified and soon become large issues. In these cases, if the practice is stagnant and unwilling to change, you’ve got to make the change yourself. Quitting your job is no flippant recommendation. It should always be considered carefully as the grass is always greener.

So what do we do about it? More vacation, less hours? That will certainly help. Do we leave our jobs? For some that’s feasible, for others it’s not. But what are some creative ways to lessen the daily stress that tends to accumulate over time?

• Don’t sweat the small stuff. Seriously. All those little things truly add up.
• Remember there are always clients who won’t like you, won’t agree with you, and won’t listen to you no matter what you do. It’s not always easy to swallow criticism and personal attacks, but you are one in a long line of veterinarians who has been on the receiving end of a negative client.
• Focus on your favorite clients. The one’s who bring you food, remember you during the holidays, and always thank you for your time.
• Eat healthy, exercise, don’t smoke, get enough sleep. Everyone knows these recommendations. Now actually follow them.
• Stop micromanaging. Micromanagement creates more work. If the job isn’t getting done, it could be a personnel issue.
• Use your vacation time.
• Make your CE time count (especially if you can’t take vacation): If you can swing it, take one of those exotic continuing education courses to the Caribbean or Central America.
• Say no. Believe it or not, you can refuse to pick up that extra day, run a bake sale for the kids, or cover another weekend.
• Don’t be afraid to work part-time. There is no shame is cutting your hours to maintain a healthy family balance.
• Find a hobby that gets you out of the house. Fresh air does wonders for the soul.
• See your doctor. If you are experiencing severe fatigue, make sure nothing else is going on!

A Veterinary Medicine magazine article provides some good insights on approaches to puppy socialization. From the article…

The American Society of Animal Behavior (AVSAB) recently released a position paper outlining the importance of early puppy socialization, preferably before the puppy reaches 12 to 16 weeks old. Four veterinarians with extensive experience discuss early puppy socialization in a roundtable format.

Read the full article.

Changing ideas on work and life have been festering in the veterinary field for years. The now female dominated profession (80% of new graduates are women) has swung the pendulum back in the direction of family oriented work schedules. Most new graduates do not want, nor will they accept, jobs that require the 60-80 hour weeks the baby boomer generation has set forth. They are looking for a reasonable and oftentimes flexible schedule to adequately balance against family life. Baby boomers, the typical demographic for male practice owners, have had mixed receptions to this idea.  Some have acknowledged that “old way” of practicing veterinary medicine with all night surgeries and lack of sleep coupled with strained family relations is not only undesirable but sometimes detrimental. This is especially the case when a woman must consider balancing work with raising children. Others cling to the mantra “I paid my dues, so should she” or “This generation is lazy.” These ideas are preposterous. The push toward family life comes from the children of the divorced parents from the 70′s and 80′s. Perhaps this new generation sees the strain living the “veterinary lifestyle” can have on a relationship. All this being said I came to realize: It’s going to be difficult converting the older clientele to this idea as well.

I recently had a client demand, rather belligerently, that because she was such a good client she deserved another veterinarian’s home phone number so she could call on weekends. Huh? Had my customer service skills failed, I would have retorted with “Do you know your physician’s home phone number? How about your dentist’s?” Regrettably, I refrained. After mulling this over, I realized there is a population of veterinary clientele who have grown accustomed to having their veterinarian available at all times. While this may have been a necessity years ago, the advent of overnight emergency clinics and referral hospitals makes this obsolete. I would much rather have my own pets at a 24 hour care facility being treated and monitored by veterinarians who haven’t just rolled from bed. I would also much rather have a client’s pet, who is sick enough they called me in the middle of the night/weekend, at a facility where it can receive continuous supervised care. This is in the animal’s best interest.

Veterinarians too long have positioned themselves differently from other medical professionals: cramming in extra appointments, working a full day then getting up in the middle of the night for emergency calls, never refusing an emergency.  These, one can argue, are good qualities. I agree to a limit. Knowing when to defer, when to refer, and when to confer is equally important. Your family doctor does not meet you at the office at 10pm. If you call with an illness, you are sent to the well staffed emergency room ready to handle any illness. To be treated as a knowledgeable professional one must behave like one.

Veterinarians must maintain a balance between work and personal life or we will see the same high turnover and burnout that has afflicted many before us.