VMDiva

It disheartens me to see my alma mater struggle during the recession, especially when a portion of its economic strife is not under the school’s control. The Commonwealth of Pennsylvania has slashed its funding to the veterinary school so severely the school has been forced to eliminate numerous faculty positions as well as entire departments. It is evident these cuts affect the public and veterinary students as the repercussions funnel down to them. I have great concern for the future of Penn Veterinary Medicine, especially when the future is partly controlled by bureaucratic decisions.

Veterinary student debt is a common topic and I certainly don’t want to harp on something most veterinarians know about. With budgetary issues at the forefront, it only flows that student tuition will continue to rise.  At Penn Vet, the current cost of tuition for PA residents is $32,902. The current tuition for non-residents is $40,058. That doesn’t even cover cost of living during those four years. With debt soaring, students shouldn’t have to deal with another tuition hike. They shouldn’t be sitting on top of one another in class either. Class sizes are always increasing but have significantly risen in the past few years.

The public will ultimately be hurt by these cutbacks.  The Matthew J. Ryan Veterinary Hospital has eliminated its neurology and special species departments and rumors swirl about the elimination of more departments. Pet owners will need to go elsewhere for some types of specialized care, sometimes miles away from home.

Perhaps most concerning is the elimination of the Center for Infectious Disease Research, highlighted in the CNBC article. “Established to study diseases with the potential to move from animals to people (or vice versa), the center’s loss is “stunningly myopic” in the era of swine flu, [Dean] Hendricks said.” Veterinarians do not merely care for sick pets. They play a critical role in protecting public health by researching and preventing zoonotic disease and inspecting the US food supply though the USDA.  A slash to infectious disease control measures will put the public at greater risk for zoonotic disease and could affect our food supply.

An appalling case of animal abuse occurred near my alma mater this week and it sickens me. The local news reported a 33 year old Philadelphia father, surrounded by his small children, decided to teach his young pit bull a lesson after the puppy nipped at him. His solution involved dousing the animal in alcohol and setting him on fire. The man’s children reported the incident to school officials. The dog has apparently survived but has a tenuous recovery from severe burns to his face and neck.

This type of cruelty stirs a nauseating anger that grows the more I think about it. Pennsylvania Animal Cruelty laws state “It is a Misdemeanor in the first degree if a person: “Kills, maims, mutilates, tortures or disfigures any dog or cat, whether belonging to himself or otherwise; or administers poison to or exposes any poisonous substance with the intent to administer such poison to any dog or cat, whether belonging to himself or otherwise”  This is punishable by a fine of not less than $1,000 and/or imprisonment for up to 2 years.” This particular suspect is facing many other charges such as child endangerment and arson.

Remove children from the situation and this guy (or a similar perpetrator) could get a slap on the wrist. A $1000 fine is insufficient for this type of malicious disregard for life. Imprisonment up to 2 years is reasonable, but very rarely do the courts drop the hammer on animal abusers. This confuses me given the known ties between animal cruelty and domestic violence. It has long been understood that animal abusers often graduate to domestic violence. Regardless of personal beliefs about treatment of animals, it would be prudent of the courts to look at “gateway abuses” critically. I wonder how this man responds to his small children when they misbehave.

We need to seriously consider the way we handle perpetrators of heinous acts of animal cruelty. Anger management, domestic violence classes, and compulsory prison sentences should be mandated. Psychological evaluations could help prevent future abuses and should be incorporated. Perhaps the courts should even  require community service in an animal shelter. A small fine for first time offenders equates to a slap on the wrist and does nothing to prevent further abuses of both animals and people. Drop the hammer. Please.

A recent article in the Wall Street Journal made me evaluate how my own pets affect my relationships. The article highlights how distorted priorities can lead to marital problems and dysfunction in the family. My husband knew what he was getting into when he married a vet, so I almost get a free pass when it comes to me lavishing my pets and treating them like the infallible monsters they are. With my own pet-to-husband balance in check (I admit to the occasional argument on who cleans the litter), I mulled on the ways my pets affect everyday life.

I just recently realized how disruptive the cats are to our sleep during their recent month of confinement. Both have been banished to the basement due to Winston’s inappropriate elimination (before you think I’m mean, it’s a finished basement with all the kitty amenities). With the cats safely locked away, there was no more waking up in the middle of the night to ax-like paws digging into my sternum. No more 3am howling in triumph after killing the toy mouse for the 1000th time. No early morning meowing alarm clock nervous we’d forget to feed him breakfast. I must say, I’ve been sleeping quite well.

In addition, the cats definitely affect the relationship with my in-laws. My father-in-law is dreadfully allergic to cats and despite my cleaning, vacuuming, dusting, and sterilization of the house, his visits can only comfortably last about 2 hours despite allergy medications. Summer visits lend themselves to sitting outside but winter visits result in trips to the movies or going out for dinner. I have no plans on ridding the house of cats in the future so I guess I have agreed to awkward visits.

I’m wondering how your own pets affect your day to day and extended relationships?

I’ve gotten a number of questions about Angels’ Eyes, the oral product that proclaims to rid little white dogs of their unsightly red-brown tear stains. Small breed dogs and brachycephalic cats commonly experience epiphora, or excessive tearing. Products like Angels’ Eyes promise to rid a pet of its tear stains with a daily oral supplement. I typically consider such claims nothing more than another gimmick. However, it seems as though this product might actually work for little Fluffy. I researched the miracle product and was surprised to find the secret ingredient is Tylosin.

Tylosin is a macrolide antibiotic commonly used in food animals but can also be used to treat campylobacter and mycoplasma spp infections among others in dogs and cats. It is also used as an anti-inflammatory to treat colitis, much like metronidazole. It is in the same drug family as erythromycin and azithromycin (Z-Pak). The company claims the product kills yeast, which they mistakenly call a bacterial infection, that are responsible for producing red pigment. Tylosin actually kills the bacteria that, when interacting with the yeast, cause the formation of pigment and subsequent stain.

I have some major issues with this product:

Tylosin tartrate is labeled by the FDA for OTC use in food animals. When it comes to use in dogs and cats, the FDA notes federal law restricts this drug to use by or on the order of a licensed veterinarian. This drug should not be sold OTC for pets. Period. Loopholes in the supplement labeling system allow companies like the manufacturers of Angels’ Eyes to sneak around FDA regulations with the disclaimer: These statements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure or prevent any disease. This disclaimer does not make the act of dispensing this drug legal, it merely allows the manufacturer to make the product without going through the expensive and arduous process of FDA approval. Because the FDA typically has bigger fish to fry, companies like this cruise under the radar.

Antibiotic resistance is a problem that affects all facets of medicine. Many common antibiotics have dual use in both veterinary and human medicine. While tylosin is a veterinary only drug, drug resistance to one drug can potentially result in resistance to an entire class of antibiotic.  I am concerned there are voices on the web who say that, because tylosin is a narrow-spectrum antibiotic, resistance is not a worry. Say what? First of all, tylosin has broad spectrum coverage against gram positive bacteria. Second, if an antibiotic has activity against ANY bacteria that bacteria can become resistant. Those same voices also claim tear staining leads to eye infections. Sorry, wrong again. Staining leads to unhappy owners; Improper tear production and tear flow coupled with shallow orbits, bulging globes, and underlying pathology leads to infection.

I also have serious concerns for any use of an antibiotic to treat a cosmetic issue. This is bad medicine no matter which way you slice it. Angels’ Eyes gets my stamp of disapproval.

I was recently unpleasantly surprised with the diagnosis of a bone tumor in a young golden retriever I was convinced had a cruciate ligament tear. The ensuing conversation blindsided the pet owners and I was reminded of the importance of delivering bad news properly. I’m not the most articulate person but as I travel along in my veterinary career I have learned invaluable lessons in the delicate art of breaking bad news. Below is a short list of insights that may help an unsuspecting new veterinarian.

Be honest and forthright.

I am not a fan of the question “What would you do if he was your pet?” While I offer my opinion when solicited, I always note that I have a bias. That bias is what makes me a veterinarian. My job is to cure and treat disease, alleviate pain, and want to find the diagnosis. If you think an animal is suffering, kindly say so. Veterinarians sometimes better recognize the signs of pain, discomfort, and failing quality of life.

Get to the point. Repeat.

When delivering bad news to an owner, like the diagnosis of a tumor, it is tempting to talk about normal results and how the animal arrived at this point before giving the diagnosis. It just doesn’t work. Most people are perceptive enough to sense something is dramatically wrong and their minds begin racing as soon as you don’t say everything is okay. I find the most effective way to deliver the blow is with a soft voice, caring personal tone, and preface the entire conversation with “I’m afraid I have some very bad news for you, it appears as though Fluffy has a tumor in his abdomen that looks as though it has spread to his chest. I know this is a lot to handle but I’d like to discuss it with you.”

Further discussion at that time is completely dependent on the owner. Some owners want to discuss all options then and there. Others need time to digest the information and will need to call or visit later. Determining what the owner needs is a skill a vet develops over time. Too many times I have tried to plow through a discussion of what we do next only to realize the owner hasn’t moved beyond the word “cancer”. Once you deliver the news, summarize the findings again. In a state of shock, owners may remember only a fraction of what you tell them.

Don’t Use Euphemisms

It may be tempting to sugar coat findings to try to spare emotions but you will do a disservice to your patient if you fail to adequately explain the dire situation to its owner. A gentle apologetic tone prevents you from sounding too calloused. For suddenly deceased pets, using terms like “moved on”, “passed on”, and “no longer with us” are not definitive for a reeling mind. Use the terms “death” and “died” at least once in conversation and supplement the conversation with the other terms.  For the terminal diagnosis, terms like “life-ending”, “end-stage”, and “not recoverable” are warranted. In addition, “uncomfortable” does not mean the same thing as “suffering” to most owners so choose your descriptors wisely.

Offer Follow-Up

Once you’ve delivered the news, acknowledge there will be more questions. Suggest owners write them down, sleep on it, and call you the next day with questions. Make yourself available for a consulation appointment as some owners prefer speaking in person.

Be Compassionate

You’ve just rocked someone’s world. Remember what it is like to be confused and stunned. Don’t be afraid to reach out and hug a client in need.

Here’s a little public grievance for my friends at Pfizer Animal Health: Stop jacking up the cost of veterinary medications on a quarterly basis and pricing my clients out of treatment!  There, I said it. Pfizer, creator of wonderful drugs like Convenia and Zeniquin, has been increasing the cost of its medications exponentially since early last year. I grimace as I prep owners for the financial shock when these medications are indicated. Don’t even get me started on the price of Rimadyl and Clavamox.

Perhaps the recession hit the drug giant hard and their financial loss is being passed along to distributors and veterinarians. This is capitalism in action and money makes the world go round, yada yada. My problem is not with profit, but the repetitive precipitous increases in cost that get passed on to my clients. It’s not that the price is rising, it’s how fast and how much the price is rising each time. In some instances, the price rises nearly $0.10/pill every quarter. That sounds like small potatoes until you take into account that’s $10/quarter and $40/year on every bottle of medication we dispense.  I recently wanted to prescribe 10 days of Zeniquin to a large German Shepherd for an ascending infection arising from a nail bed. Cost to owner would have been about $150. Yikes! Talk about seeking an alternative drug therapy!

Rising prices mean changing treatment plans to accommodate an owner who doesn’t have $150 to spend on medications. I will write a prescription for antibiotics so owners can get them for a better price at a local pharmacy. However, there are only a finite number of medications, particularly broad spectrum antibiotics, available to treat these common conditions so options are limited for a serious infection.  I lament providing the “suboptimal” treatment because, quite frankly, drug companies like Pfizer can’t put a cap on their prices for more than four months.

This one’s for the girls. Recent discussions on my friend Dr. Khuly’s blog, Dolittler, have compelled me to beg, plead, and grovel for you to please have your female cat or dog spayed. A recent discussion about a pregnancy gone awry topped with an article released from USA today about attitudes toward sterilization of pets have burdened my heart with the age old problem of pet overpopulation and unnecessary suffering. Despite advocacy to have pets spayed or neutered in a push to curb pet overpopulation, a staggering number of animals acquired last year have NOT gone under the knife! Granted, some animals were too young for surgery at the time of the survey but 24% of respondents who hadn’t altered their pets stated they “hadn’t gotten around to it” while another 14% stated they “didn’t feel it was necessary.” Irksome at best, but potentially a red flag for a bigger problem: Lack of proper communication and education between the veterinary profession and pet owners.

Top Five Reason to Spay

1. Pet overpopulation
An estimated 4 to 6 million unwanted and stray animals are euthanized in shelters every year. The world, quite honestly, doesn’t need anymore dogs and cats to add to the mix. There will always be pet overpopulation (I’m not so naive to believe the problem will ever go away) but every person can do his/her part by making sure the cycle ends with their pets. This is NOT to say responsible breeding should be outlawed or discouraged. I guesstimate responsible breeders (AKA not puppy mills, not backyard breeders, not accidental breeders) minimally affect the overall pet population.

2. Pyometra
An all too common affliction of older dogs is a condition known as pyometra, or an infected uterus. This is a life threatening condition that can lead to sepsis and death if untreated. A uterus filled with infection can rupture in the abdomen leading to peritonitis. This condition is 100% preventable with a spay. Spaying your pet as a youngster is significantly less expensive than emergency surgery years down the road, so you’ve got no room to complain about cost.

3. Mammary Cancer
Mammary cancer develops commonly in unspayed females later in life. About 45% of mammary tumors are malignant in dogs, whereas around 90% are malignant in cats, and dogs have a much higher number of complex and mixed tumors than do cats. Spaying dramatically reduces the risk of mammary cancer in both dogs and cats. In dogs the risk has been reported as 0.5% when spayed before the first heat, 8% if spayed before the second heat, and 26% if spayed after the second heat. For a listing of scientific findings check out SkeptVet.com’s summary of research regarding companion animal mammary tumors.

4. Unwanted/Unplanned/Poorly Planned Pregnancy
I’ve heard the “I just want her to have one litter” line too many times. She doesn’t need to have a litter. Period. In addition, accidental breeding can result in a size mismatch and a possible dystocia (read: stuck puppies) during labor. Raising a litter of puppies or kittens is expensive when you consider all the time, effort, or finance that goes into caring for them for 8 weeks. The bitch or queen should be examined following labor. The puppies or kittens will need to be examined, dewormed, and vaccinated prior to being sold or adopted. Lack of planning or foresight can set the unsuspecting owner back a pretty penny.

Dolittler describes a case of at best, egregious ignorance in pet owners who “married” two dogs, missed all the signs of pregnancy and labor, and allowed their poor Maltese to have a dead puppy in her uterus for 24 hours – a move that may have ultimately lead to the dog’s death. “Back yard breeders” must be discouraged. Back yard breeders are folks who decide they want to breed their dog, know little about doing it properly, and typically do it with dreams of profit. It seems as though those breeders always seem to find the sickliest, poorest-doing dog with multiple congenital and genetic problems and breed her. And don’t even dream of those dogs having been vaccinated. I actually had one couple ask if a puppy would come out of their Chihuahua’s “who who”. That’s biology 101 folks. If you don’t know where babies come from perhaps you should avoiding breeding. That applies to both dogs and people.

Proper breeders will have their dogs or cats tested for contagious diseases, examined for general health, radiographed to see the approximate number of puppies/kittens, and are prepared for whelping/queening. They will follow-up with a veterinarian and have all puppies/kittens examined, dewormed, and vaccinated prior to placing them in appropriate homes.

5. Stop that Heat Cycle
Blood, howling, nervousness, lingering males. Need I say more.

I have followed through with one of my New Year’s resolutions! And yes, I am proud of it!

You can now follow me on Twitter: @VMDiva. New blog posts will be listed on my Twitter page. Follow along for more personal updates and get to know your VMDiva!

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!

Last night I may have gotten a taste of what it’s like to be a mother who has to let her baby cry himself to sleep. But let’s start two weeks ago, when my cat Winston decided to urinate outside the litterbox. It was not urinary “accident”. Oh no, it was a protest. He protested the delay in breakfast and, in true attention seeking fashion, urinated on the carpet at the entrance to my bedroom. I cleaned the stain, chalked it up to a one time event, and went along my way. About a week later I noticed the undeniable odor of cat urine wafting down the hallway. A nose to the carpet revealed the pungent odor of urine along the wall outside my bedroom. Despite all my veterinary behavior knowledge, I was ticked but decided to fight the urinary demon full force.

This wasn’t the first time we’ve had urinary accidents in the house. In 2006, when my new husband moved into our new home, Winston began urinating in the dining room and bedroom. After performing a medical work-up to rule out some of the common causes of inappropriate elimination (see below), I determined the stress of the move and a new family member shook his world. We scrubbed carpet, added another litterbox (actually, an underbed sterilite container filled with litter), removed lids from the other 2 boxes, and changed to unscented litter. We purchased a cat tree, toys, Feliway diffuser, and locked him out of the bedroom. And when that wasn’t enough, he even received a six month stint of Prozac. He finally began using the litterbox again, was taken off of Prozac, and the carpet in the dining room was removed. All was well until two weeks ago.

Back to last night when I decided to lock the two cats in the basement in an attempt to curb the inappropriate urination. The crying, howling, and gnashing of teeth began in protest of their new imprisonment. It killed me to hear them pawing at the door and meowing their melancholic sorrow. Alas, it had to be done. I am hoping a couple of weeks of confinement will yield a mental reprogramming of sorts. My husband’s office is in the basement so I have eyes watching Winston use the litterbox, which I am proud to report he has been doing.

Tips for Dealing with Feline Inappropriate Elimination

• Talk to your veterinarian. Many urinary accidents have underlying medical causes therefore it is important to rule them out before proceeding with behavior modification. Diseases like urinary tract infection, feline lower urinary tract disease (FLUTD), bladder stones, kidney disease, diabetes, and hyperthyroidism among others can cause cats to urinate outside the box. A behavioral issue cannot be diagnosed until all medical issues have been ruled out.
• Never punish your cat for urinary missteps. It won’t work as cats are immune to guilt.
• Have your cat spayed or neutered.
• Increase your number of  litter boxes to one more than the number of cats in your home (n+1). Uncover litter boxes as the covers trap odors and can scare skiddish cats. Place boxes in areas of accidents.
• Give your cat a smorgasbord of different litter box styles and litter types. Underbed Sterilite containers work well.
• Change litter often and clean sides of pan. Use unscented litter.
• Be sure to clean soiled carpet with an enzymatic cleaner like Anti-Icky-Poo.
• Confine your cat to a small space equipped with litterbox, food, water, and bed. Cats are unlikely to urinate where they eat and sleep.
• Enrich your cat’s environment with toys and things to climb. Cat trees work well but so does shelving. Make sure you optimize play time.
• Reward your cat for proper litterbox use. Treats work best.
• Try a feline “happy, calm” pheromone such as Feliway.
• Prevent your cat from seeing other cats outside.

I will be sure to keep you posted!