VMDiva

Every now and then I need to remind myself what it’s like to owner a pet without all the knowledge I’ve accrued as a veterinarian. I often find myself diagnosing a limp, finding lumps, and grasping at lymph nodes when I am in the company of my friends and family. That auto pilot is awfully hard to turn off!

Several weeks ago I allowed myself to immerse in the unbridled joy of being a crazy cat lady as I shopped for a kitty staircase for Winston, my debilitated old man. I purposely failed to divulge my career status to the very enthusiastic and obviously crazy cat man who assisted me in my purchase. It was so awesome to just enjoy being a pet owner without the expectation of expertise. Dipping my toes into the non-veterinary pool was so refreshing I’ve decided to plunge wholeheartedly into my reflection and reconnect with my clientele.

If you’ve followed my posts in the past, you’ve realized I’m an all-or-nothing gal; I hate it or I love it. This personality trait proves challenging for a little emotion called empathy. I’ve outlined some of the pet owner quirks that, frankly, drive me nuts and paired each with an empathetic thought process that keeps my sanity and helps me practice better medicine.

I am trying to better connect with clients while alleviating self-induced irritation. Win-Win!

1. Any Nervous Dog or Cat Has Been Abused

I encounter at least one pet owner a day who believes his pet was abused prior to adoption. The default thought process of an owner is this: “He cowers so he must have been beaten. He barks at men so he must have been abused by one.” If every nervous pet I see was truly abused, every neighbor is a suspect animal abuser.

There’s certainly no harm is believing Fido was beaten under previous ownership but it really chaps my hide when an owner allows this perception to foster bad pet behavior. The perceived abuse provides a scapegoat for their animal’s aggressive behavior and lack of training. Instead of reinforcing good behaviors, owners unwittingly allow the biting, writhing, pain-inducing creature to wreak havoc on me and my staff.  All the while they reinforce the behavior with coddling and praise under the notion that discipline equals abuse!

Empathetic Moment: Human nature, lack of understanding of animal behavior, and compassion drive owners to these conclusions. Submissive behaviors and failure in appropriate socialization most likely account for a majority of these fearful “abuse” cases. However, the truth is abuse does exist and dismissing the idea altogether is a disservice to the pet and owner. Educating owners to the variety of behavior types and teaching them to acclimate their pet to new situations is key.

2. What Breed Do You Think He Is, Doc?

Who cares?!? Okay okay, owners care about their mutt’s constitution. I hate this guessing game because it sets me up for a discussion about a subject I find irrelevant and, it seems, I never tell the owner what they want to hear. Not many owners are keen on me telling them their “Labrador-mix” is actually a Pit Bull. After I’ve offer my best guess, I’m told the groomer/friend/neighbor  has told them it’s an insert-name-here-a-poo and they agree with them over me. *face palms*

From a veterinary standpoint, does it really matter? Nope. The genetic diversity of a standard mutt generally equates to less inherited diseases and medical problems overall. Do owners still want to know? Yep. Some owners seem so fixated on figuring out the amalgam of breeds they even throw money away on those dreadfully unreliable doggie DNA tests.

Empathetic Moment: Why is it so important for owners to know what breeds their dogs are? Knowledge of your pet deepens your emotions and creates a greater bond! I will continue to play the guessing game and call your new rescue a labrashepacockadoodle, but I still refuse to recommend those DNA tests!

3. My Groomer Said/My Breeder Said….

It’s like nails on a chalkboard. The Dr. House part of me begs to ask, “Oh? And where did your groomer attend vet school?” Of course, I’d never. Okay, maybe once but only in the right circumstance.

Now, don’t hang me by my toes yet, all ye breeders and groomers. You folks are often advocates for the pets you care for and for that, I’m grateful. Some of your advice is excellent! But some, particularly pertaining to vaccinations, is woefully inaccurate and not rooted in science. I dread refuting bad advice and fear that if not worded just-so, I’ll come off pretentious and judgmental.

Empathetic Moment:  How are pet owners to tell the difference between good and bad advice? Veterinarians should welcome questions regarding alternatively sourced information handed to the client; sometimes the only way we find out what type of misinformation is out there!

The best pet owners hunger for knowledge and desire the best for their pets. Veterinarians must educate pet owners with reliable and scientifically-based information or they might just get their information from unreliable sources. I don’t want my clients to rely on Drs. Google and Wikipedia exclusively for their veterinary information.

4. We Left Our Last Vet Because Fluffy Didn’t Like Him

New clients who reveal they’ve left a practice because the pet was unhappy with the veterinarian immediately ring alarm bells in my head. This equals one of two things in my book: (a) the client is either using the dog/cat as a mouth-piece to voice disapproval of the care and service provided at another veterinary hospital, or (b) she simply does not understand animal behavior.

All puppies and kittens enjoy visiting the hospital during those first innocent check-ups. Gradually the smartest of the patients, Labradors and Goldens excluded, catch on that maybe this veterinary hospital thing is not so much fun. Do clients really expect their pets to like vaccinations, blood draws, rectal exams, and nail trims?

Empathetic Moment: It is crucial to avoid labeling new clients as “high maintenance” or “difficult” because they were unhappy with service elsewhere.  The new client may have a legitimate reason for leaving disgruntled. A preconceived notion may change the tenor of the appointment.

This initial conversation opens the door to conversation about expectations for Fluffy’s care at my hospital. Meeting a client’s expectations will not only leave the client satisfied but will also, hopefully, establish a long-term relationship of care.

Empathy is perhaps innate, perhaps learned, or even both. No matter, I’m striving to practice mine everyday!

Burnout is one of my favorite topics due to its pervasiveness within the veterinary profession. Even though I know the signs of impending tribulation I still find myself, from time to time, creeping toward that all too familiar overworked and stressed out volatile breakdown. That’s why, last week, I unplugged from VMDiva and took a week off of work for my first ever Staycation.

I know veterinarians who pride themselves in their anti-vacation stance. They’ve worked 60 hours a week for years and forgot how to unwind. They wear a badge of honor for taking just one or two days off a year, thinking somehow working themselves into the ground is admirable. That’s just stupid. A veterinarian’s practice and home life will suffer when she reaches burnout. Fatigue and stress manifest as strained relations with family and lack of motivation at work. A veterinarian will practice better medicine with a well rested body and mind. Stressed professionals lose patience and passion, rush appointments, and *gasp* may even have poorer performance.

I used my staycation to accomplish my to-do list of tasks I never have time for. We all have those lists which always get put off until tomorrow. My husband and I upgraded our kitchen and planted our annuals. I even had some dental work done. And some argue, is this really relaxation? For me it is.  Simply unplugging from the daily stresses of sick animals, sad clients, and work-related financial stress uplifts the weary soul. Studies show, too, that getting chores and house projects finished actually lowers cortisol levels. No work AND crossing off tasks on the to-do list: Relaxation!

I started work this week feeling rejuvenated and hopeful. A week at the homestead was exactly what this doctor ordered. Stave off burnout; Use your PTO!

Last weekend was filled with calamity for the Koehl family. I contained my excitement for the first grilled burgers of the season, a big deal here in the north east, until the afternoon of house projects came to an end. I got the burgers on the grill and the macaroni and cheese on the stove all the while dreaming of that first bite into the mouth watering juicy beef patty. On my way to flip the burgers, I repeated the habit I’ve had for years by walking out the back door and pushing the storm door closed so my feline frenzy didn’t push it open. Hey, they get excited about burgers, too. Only this time, as I pushed the door closed the glass shattered in my hand.

Ruh roh.

Initial synaptic reports indicated I was going to die. As the blood dripped on the floor, visions of crippled exams and banishment from surgery filled my mind. Rational thought took over…err…eventually…and I notified my husband of the 1 cm laceration on my palm. That evening taste of summer ended with burnt burgers, soggy mac and cheese, and a lot of kitchen clean-up. I’ll spare those details. I decided to craft steri-strips from waterproof tape and declared myself on the mend.

The next morning, aside from pain, I felt tip top. That is until my husband woke up declaring he had a plank in his right eye. We, like so many of my clients, decided to see how he did through the day and applied lubricant eye drops and homemade remedies. Hours later he decided the pain in his eye was too severe to endure until Monday and we found ourselves at an Urgent Care Facility.

I paid the fee before he was taken back. As my husband was examined I chatted with the receptionist. Our conversation went as follows:
” You guys busy today?” “No, we’ve only seen about 12 people.”
“What kind of stuff do you see here?” “Rashes, UTIs, colds.”
“That’s interesting. Hey, let me ask you a question. What happens when people come in here for urgent care and they can’t pay the exam fee?” She grimaced and shook her head. “We won’t see them.”

That didn’t surprise me as much as what came next.”Do these people ever get angry and tell you you don’t care about them and expect service anyway?” She raised her eyebrows in surprise and said, “Never.” Probing questions revealed another difference between my job and my medical counterparts. The dichotomy between the expectations in human and veterinary medicine always amazes me.

Most veterinarians occasionally face accusations of not caring about animals when they refuse service to someone who has no money. Why don’t we hear doctors accosted when they refuse service to patients without money or patients with unaccepted insurance plans? Perhaps I haven’t been listening but maybe, just maybe, the guilt pet owners feel when they are unable to care for their pets emotionally trumps their personal health concerns.

Dealing with the financial component of practice is harder than any medical decision I’ve made. Accusations of  selfishness, greed, and lack of compassion don’t easily roll off my back. I believe many of these accusations are rooted in guilt and frustration.

The truth is pet ownership a luxury. Shame and guilt felt when they can’t properly care for their animals can tip even the nicest client over the edge.  That helpless feeling coupled with compassion towards man and beast puts emphasis on caring for others over oneself and probably fuels the angry diatribes from troubled clients.

My husband was diagnosed with corneal abrasions. One trip to urgent care, two trips to the ophthalmologist, and four trips to the pharmacy later we’re on the mend. I’m grateful for the finances to ensure medical care for the entire Koehl family – Fox, Winston, and Miss Pigglesworth included!

A colleague’s recent appointment went hysterically awry when the owner misunderstood the explanation of the dog’s illness.  Upon presenting to our clinic with a “swollen nipple”, my colleague diagnosed the dog with mastitis, a painful infection of mammary tissue.  Her owners recounted the treatment plan, consented to labwork, and waited while the diagnostics were performed. When the veterinarian and dog arrived back in the exam room, one owner said, “What’d you call that problem again? Mass tits?”

Mispronunciations and misunderstandings are a staple of veterinary medicine and I rarely fault my clients for them. Refills of subscriptions, ascriptions, and scriptions fill the prescription inbox. Eyedrops treat cadillacs. Elbows are knees, wrists are ankles, their left is my right. This list goes on and on. I usually chuckle and note I should keep a list (yes, I should definitely keep a list) but a few pet peeves still get to me.

Spaded

Every veterinarian has been there.  A client requests to have her puppy “spaded” and you fight the cringe. I’ve tried gentle coaxing with, “We can certainly set up an appointment to have your dog spayed; The receptionist can set that spay up for you.” This rarely works though I find myself trudging forward on a fruitless journey. It seems as though this term is firmly rooted in the client vernacular.

If gentle guidance doesn’t fix the misnomer, this is one better left alone. The correct term for removing the ovaries and uterus is an ovariohysterectomy. The general term for the procedure is a spay. It turns out spay is an English term derived from the French term espee, the early derivative of the sharp blade used in fencing called the épée.  A spade is a tool used to dig, cut, or remove. Maybe spayed and spaded aren’t so far apart afterall?

It’s Just Fractured, Not Broke

Somewhere in the history of medicine someone decided broken and fractured were both recognized medical terms for varying degrees of bone injuries. The idea spawned faster than mosquitoes in an abandoned tire. The misconception that fractures are minor injuries with minimal bone separation and “broken” applies to bone fragments in different counties is simply…false. Fracture is the only professional term describing the traumatic separation of contiguous bone. If it’s broken, it’s fractured. Separated bone ends are called displaced fractures. Bone fragments jutting through the skin are called compound fractures. Comminuted fractures refer to bones in multiple pieces.

This one is easy to remedy. Most clients are eager to learn about things relatable to humans. They describe the fracture in detail to friends and family and some even want copies of the radiographs to wave in people’s faces. (Much like me, many people can’t refuse the opportunity to show bruises, wounds, and other injuries in a attempt to either shock or one-up people. Some time I’ll tell you about the worst blood draw I’ve ever received. We’re talking full arm bruising. I digress.) Use this opportunity to correct wayward clients.

Lyme’s Disease

I tolerate client misinformation fairly well, but the term “Lyme’s Disease” is one I am seeing crop up on paperwork from other veterinary practices.  My skin crawls and my ears buzz when I hear a veterinary professional say “Lyme’s Disease”  further propagating misinformation and general ignorance to a highly endemic disease. If a professional can’t bother to use the correct name, how confident are you these veterinarians know the most up-to-date treatment and monitoring protocols for it?

Lyme disease is named after Lyme, Connecticut, ground zero for Lyme Disease. Perhaps I am particularly sensitive to this issue because I practice on the east coast where 9 out of 10 dogs will test positive for exposure to Lyme. Perhaps it’s because every time I turn around there is another consensus report on proper diagnostics, treatment, and follow-up on cases of Lyme disease popping up from researchers at my Alma Mater.  Or perhaps I expect the same level of attention to detail as I would give. Either way, straighten up. It’s Lyme, not Lyme’s. Read your JAVMA.

Months ago the previously prescription-only flea preventatives Advantage and Frontline became available over-the-counter at pet stores and large chains. Veterinarians were, for obvious reasons, not happy to have to compete with discount giants like Walmart. A recent trip to Petsmart reminded me we veterinary practices are still in a competitive market when I saw our prices were comparable. Other practices that have created a cash cow out of their prescription flea preventatives are not so lucky. Finances aside, I see a prominent silver lining in the change from prescription to OTC.

I see failure after failure with home flea remedies and OTC products from Hartz and Sergeants flea products. Garlic and these products are not effective. I’m sure I’ll get a backlash from the garlic crowd, but find me scientific evidence garlic does anything for your pet other than cause anemia. I digress. With a population of folks who rarely bring pets to the veterinarian, these people can never procure quality flea and tick products. From a zoonosis and quality of life view, it is critical to have pets on flea and tick prevention no matter their veterinary-patient-client relationship. The availability of Frontline and Advantage now allows all dog and cat owners to provide their pets the best prevention.

Advice to my peers: Don’t lament the loss of your cash cow and celebrate the progress in animal and human health.

I received one of the best compliments of my professional career this week when a client said he “wished his doctor was as good” as me. Wow.  His comment got me thinking: What makes me so different from his MD? Did his MD fail to engage him, encourage him to speak, make eye contact? I certainly am not that fabulous. I wondered where his MD fell short. I thanked him and told him my motto to veterinary medicine is to “Laugh so you don’t cry.” It’s important to keep it light when you can or you’ll end up crushed by the burden of the profession.

My quantum leap in thought took me back to college when I began as a biology major and a pre-medical student. That’s right. I coveted an emergency room physician position.  I had done work in an emergency room as a senior in high school and knew medicine was my destiny. Medicine was my destiny, just not human medicine. As a person who has seen both sides of the coin, I can draw some informed comparisons and contrasts.

I think the greatest agreement between the two fields comes in our education. Both veterinarians and doctors are taught how to diagnose and treat diseases all over the spectrum. From simple skin diseases to complex endocrine diseases, we learn them all. Veterinarians are problem-solvers most like ER Physicians. We must be prepared for anything that walks in the door and see a variety of cases throughout the day. Both vets and doctors (at least the good ones) must possess terrific “people skills” as medicine serves the public.

The biggest contrast between the two professions is probably directed by litigation and finances. A veterinarian’s pursuit of diagnostics and treatment is frequently limited due to cost.  I often find myself saying, “If we only can do one test, then I pick this one because….” I fantasize what my job could be like if I had unlimited access to blood tests and imaging. Bliss! Fear of litigation and the financial ability to perform diagnostics drives physicians to order a battery of tests. This is no indictment of MDs, on the contrary, I would find myself in the same situation had my career aspirations not done an about face in college!

Additionally, the high specialization in human medicine greatly contrasts with the average small animal general practitioner’s position. A specialist has a depth of knowledge in their niche that cannot be rivaled. In the span of a day, an endocrinologist may see five diabetics, two patients with thyroid disease, and several patients with obesity. My day consists of surgery, dental extractions, diagnosing heart disease, kidney disease, thyroid disease, and dermatologic disease all while managing a dog hit by a car and a rabies suspect. My breadth of knowledge adds spice to my career and keeps me fresh. The surge in veterinary specialists is slowly changing the profession’s focus but the vast majority of veterinarians still engage in the many facets of veterinary medicine.

Despite the differences one thing rings true: Good veterinarians and physicians care deeply about their patients’ health.

Coming off of a summer hiatus from VMDiva, I have many updates for you. This summer proved hectic: vacation, home projects (how about a leaking roof!), graduations, parties. It’s a wonder I’m still standing. Check out all the updates from some of my previous posts and of things to come!

Snotty Cat Remedy (original post)

My chronically ill cat, Winston, was the recipient of an experimental vaccine protocol in an attempt to curb his chronic upper respiratory congestion. If you missed that post, check it out. I approached this protocol with skepticism. C’mon, a vaccine will fix a problem he’s had for six years? I was amazed that, 24 hours post-vaccine, Winston could breathe unimpeded through his nose! I’ve followed the booster schedule and am pleased to report we are 70-80% improved. The occasional snork and sneeze arises but my walls are free of snot! I’ve instituted this program at my practice and have about six cats I am currently monitoring. All have seen some improvement.

Goldie Hawn (original post)

I am sad to report I lost one of my very favorite patients a few weeks ago. Goldie Hawn succumbed to her osteosarcoma. She survived for seven months following her left hind limb amputation. I waited a harrowing three weeks for a pathology report that indicated she had “very early osteosarcoma”. I was joyful we amputated the limb correctly and devastated a young, wonderful dog was plagued with this darkness. She received chemotherapy at my Alma mater, MJR Veterinary Hospital at the University of Pennsylvania (VHUP). She did excellent under chemotherapy and, following the full course, staged clean of osteosarcoma. I hoped we had beat it. Things took a turn for the worse when she presented to our hospital severely limping on her right hindlimb. One of my associates diagnosed her with a cruciate ligament tear, a devastating diagnosis given her tripawd status. After discussing all the options, she received TPLO surgery at VHUP and recovered well.  Flash forward several weeks and she presented again, this time not looking well. She had an inoperable basketball-sized lymph node in her abdomen.

Horizons

I am now a member in training for the Pennsylvania State Animal Response Team. I will help provide veterinary care and expertise in the event of a disaster. I look forward to sharing m experiences with you!

Recent news out of Australia slammed physicians for instituting late fees for patients who show up more than 10 minutes late to their appointments. Many argue these physicians are implementing a double standard given how far doctors log behind during their appointments. Perhaps this is a double standard but I guarantee one argument you’ll hear from these physicians is the patient’s tardiness contributes to the physician’s tardiness.

I have toyed with the idea of implementing late fees for chronically tardy clients (and we all have them, usually know them by name, and plan accordingly). My practice runs on a busy 15-minute appointment schedule. A client’s 10-minute tardiness can throw off the entire block of appointments. I know a late fee would go over like a lead balloon and so it remains an idea droning in my temples every time a client shows up late on a busy night. It’s my fantasy revenge.

The facts against a late fee remain: Most clients are on-time or early for their appointments. Legitimate excuses happen. You can’t teach common courtesy.

I have found some of the best ways of dealing with tardiness are as follows:

• If owner’s are more than 10 minutes late, have front desk staff politely inform them they will need to wait because the veterinarian is seeing her next appointment. It’s unfair to clients who show up on time to have to wait even longer for their appointment.
• Squash clients who decide to “sneak” that extra pet into their 15-minute appointment. If you simply cannot fit her in without making clients with appointments wait longer, do not do it. If you do have time to look at Little Lucy’s skin condition, use the line “Fortunately I have time to see her tonight without an appointment, but just make sure to have one down the road for when we are booked solid so we make sure to address your needs.” Spin the situation toward looking out for the owner’s best interest and you’ll avoid an awkward moment. You know the saying “If you give a mouse a cookie….” Set the tone for future appointments.
• Veterinarians must practice excellent time management given the frequently unpredictable and sometimes emergency laden appointment schedule. If a two-minute recheck and a sick exam arrive at the same time, see the recheck while the technicians triage the sick patient.
• Apologize and offer a reschedule. Veterinarians run behind, mostly, due to surprise illnesses mentioned at annual examinations, emergencies, and sick patients who require admission. Once we are behind it’s very difficult to catch up and we find ourselves rushing through appointments. Sometimes it’s better to reschedule than make a client sit an hour in the waiting room with a labrador who has chewed through the leash, peed on the wall, and jumped on the counter during the wait.

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!