Thursday, October 11, 2018

Love


"I've been spending the nights with him on the living room floor, by his favourite spot. I keep worrying he's going to stop breathing, so I'm not sleeping much. I know his time is coming soon. I didn't want to bring him today because I'm so worried you're going to say I have to put him down." Mrs. Gagnon's eyes were red rimmed and her voice trembled as she said this.

I looked down at Edwin, an elderly black cocker spaniel. He was wheezing a bit, but at first glance he did not appear to be on his last legs. I crouched on the floor and offered him a liver treat, which he happily took, wagging his little stub tail. As I dug around in the treat jar to get another one I thought about Mr. Wilson who had taken the day off work to sit with his cat Parsnip while he was being treated for complications from diabetes. Parsnip would be in all day and Mr. Wilson would be there the whole day too, reading a little, patting Parsnip and generally just being there with him. I thought about Mr. Wilson because Mrs. Gagnon reminded me of him. She reminded me of him because they were both here for the same reason: love.

I am in a very privileged profession. What other professionals are you primarily motivated to visit because of love? Family doctor? No. Lawyer? Ha. Accountant? Double ha. Dentist? Triple ha. The list goes on. In fact, the only other similar profession I can think of is pediatrics. I have often joked with my kid's pediatrician that I practice furry four-legged pediatrics, or he practices hairless two-legged veterinary medicine. For sure many veterinary clients (and parents of children?) are also motivated by a sense of duty, a desire to do the right thing or even feelings of guilt, but the basic driver is usually love.

This is where the conversation can become awkward around people who don't have pets. Love? Really? Isn't that a bit overblown? Too sentimental? A sign that they are lacking human love? No, no and no. Forgive me if I am, as the saying goes, preaching to the choir, but the following is for the benefit of the occasional non pet owner (can I call them muggles?) who stumbles on this blog and thinks, "wtf?"

Part of the problem is language. English is a wonderful, rich and expressive language, but it has some gaps. We have an exhaustive list of words to chose from when it comes to describing and naming objects, but rather less when it comes to relationships and emotions. Think for example about the word "uncle". In English this can describe your parent's brother, or it can describe the random dude your parent's sister was briefly married to. It can even sometimes describe an older male family friend. There are many languages that have distinct titles for each of these, but may not have separate words for all the different kinds of car shapes or shoes styles or couch configurations. I'll let you draw your own conclusions regarding what this says about our culture.

In any case, so it is with the word love. There should be more words to describe all the kinds of love. Does your love for your parents feel the same as the love you feel for your spouse? Or your children? Or your siblings or best friends? They are all closely related emotions, but they are not the exact same. So it is with the love many people feel for their pets. If we're stuck with this one word, "love", then it has to be big and it has to be inclusive. Comparisons between the different flavours of love are not useful. Sure, in a "Sophie's Choice" nightmare scenario all of you would chose to save your child at the price of losing your dog or cat (or almost all of you... most of the time...), but that is never a real life choice.

With respect to it being sentimental, yeah, I suppose it can be. So what? Isn't the appreciation of much of what makes life worth living often somewhat sentimental? Good music, movies, art and literature all make use of emotional response to draw you in and involve you. Loving and appreciating the company of a pet is broadly similar. Can you imagine a world where sentiment was banished and everything had to be cold and practical?

And as to the love people feel for their animals indicating the need to fill a void, this has been amply proven false for the majority of cases. There certainly are many lonely people who find solace in the company of their pets, but pet owners represent the widest cross-section of society, including many of the most gregarious and outgoing "people people". In fact, my experience has been that the more capacity a person has to love an animal, the more capacity they often have to love people too.

Both Edwin and Parsnip did ok. I won't say that it was the power of love that made them better, but it certainly didn't hurt either.

"We can judge the heart of a man by his treatment of animals."
-Emmanuel Kant


Thursday, September 27, 2018

Dr. Goliath Inc.


It may be a cliche to say so, but change is inevitable. In few aspects of life is this as true as it is in the world of work. Every job and every profession is changing, and the pace of that change is accelerating. In veterinary medicine we have seen great technological change and we have seen an enormous change in our understanding of many diseases. We have also seen the profession change from being male dominated to female dominated in a single generation. These changes are evident to most pet owners, but today I want to talk about an equally important change that is occurring behind the scenes. I want to talk to you about the creeping corporate takeover of veterinary medicine.

Practice groups consisting of locally owned hospitals with a few satellite clinics have been around for a long time, and the larger ones may blur the lines with corporate practice, but I'm not talking about them today. What I'm talking about started in 1986 when Veterinary Centers of America (now Veterinary Clinics of America, or VCA) was founded in California and began buying private practices and practice groups across North America one by one. VCA now owns over 800 animal hospitals directly in 43 states and 5 provinces, and it operates another approximately 1000 (!) under it's Banfield brand name, which it acquired in a 2017 merger. VCA is a publicly traded company listed on the NASDAQ stock exchange (under the cloyingly cute stock symbol "woof"). Other corporations include National Veterinary Associates with over 400 clinics and Vet Strategy with close to 100 clinics.

Winnipeg is always the last place for any trend to hit. We were the last to get Starbucks, the last for the microbrewery revolution and we are the last major market to be targeted by corporate veterinary medicine. Up until very recently all the practices in Winnipeg were locally and privately owned. Then two years ago a large corporation began to buy clinics, owning four now and with a rumoured fifth deal in the works.

Change can be good, change can be bad and change can just be change. On the good side corporations bring deep pockets to the profession that make it easier to upgrade to the newest technology and to present sparkling, professionally decorated practices, but with ample respect and affection for my colleagues who now work for corporate, I am going to argue that this particular change is on balance bad.

The fundamental problem is that large corporations solely exist to make money, to satisfy shareholders and investors. Of course small private practices also have to make money, but the difference is that if my clinic has a bad year financially we tell ourselves that it was bad luck, or the weather, or the economy and we'll hope for a better year next year. In contrast, if revenue drops in a corporate practice, management from Los Angeles or Toronto or wherever will put pressure on the veterinarians they employ to meet quotas, or else. Some corporations track very specific metrics like the number of xrays a veterinarian should take relative to the amount of respiratory disease they see. The corporations do not dictate the management of specific cases - that would actually be illegal - but they will set general benchmarks for numbers of specific tests and procedures and they certainly make specific financial goals clear to their employees. On one hand more tests can be "good medicine" and it can be hard to argue against precautionary "just in case" xrays for a cough, for example, but on the other hand this does diminish your pet's doctor's freedom to use their professional judgment and make sensible decisions without having to worry about what management is going to say about their numbers at the end of the quarter.

Another problem is vertical integration. Mars Corporation has recently bought a controlling interest in VCA. Mars is massive. It had $33 billion in sales in 2015, and only a fraction of that was chocolate bars. It is now the world's largest provider of pet health products and services. In addition to VCA it owns  Royal Canin food, with their prescription diet line, and a whole series of non-prescription pet food brands, such as Pedigree, Whiskas, Eukanuba, IAMS, Nutro and more. It also owns the largest chain of veterinary specialty and emergency centers, the second largest veterinary laboratory company, one of the largest veterinary ultrasound companies, and the number one canine DNA analysis company. Oh, and a chain of 130 boarding and doggie daycare facilities. All that's missing from their portfolio is a pharmaceutical company. The fear here is that veterinarians will be increasingly required to use only the products and services under the same corporate umbrella rather than picking and choosing from all the options based on their professional judgment of their patient's needs. I mostly love Royal Canin foods, but only mostly. I would not tolerate being told that that is the only prescription diet I can offer my patients.

At the end of the day the important relationship is the one between you and your pet and your veterinarian. Who your veterinarian works for is hopefully not all that relevant most of the time. It's just sad for us within the profession to see the freedom and independence we enjoyed gradually be eroded. And it's sad to think about the coming generations of veterinarians who will have less opportunity to enjoy the sense of pride that comes with owning your own practice and making all your own decisions.

Thursday, September 13, 2018

Sneak Peak


The advance review copy arrived today! I'm told that the official public release will be April 23.

Surgery For Dummies


When I came up with the post title I thought it was cute and absurd. The 'For Dummies' series of  books may have a breathtaking range, from ASVAB For Dummies ('Armed Services Vocational Aptitude Battery' - yeah, I have no idea either) to Zoho For Dummies, which is apparently a suite of cloud computing applications, but surely there would be no Surgery For Dummies. Ha ha, right? Well... it turns out that there actually is a Weight Loss Surgery For Dummies book, as well as Cosmetic Surgery For Dummies. One hopes these are written for the patients, not the surgeons.

I decided to stick with Surgery For Dummies, even though it now seems slightly less cute and absurd. My point was to highlight that there is no great mystery to surgery. A lot of surgery is much simpler than you might have thought. For many lay people surgery may seem like the pinnacle of a veterinarian's (or medical doctor's) specialized skill and knowledge, but I'm here to tell you that I could easily teach any of you the basics of the majority of the surgeries we do, and that I could teach you that with lessons that would fit on an index card. A small index card.

Basically most surgery can be boiled down to one of two processes - either you are removing something, or you are repairing something. The latter can be far more complex, but it actually only accounts for less than 10% of surgeries in a general practice. Most of the time you are removing something and that is usually not terribly complex. You could be removing testicles (neuter), ovaries and uterus (spay), a lump, a foreign object, or a stone, to give the most common examples. Here are the steps:

(NB: We are assuming the patient is already appropriately anesthetized.)
1. Use a scalpel to cut a straight line in the best place to find the thing you want to remove. Avoid cutting through blood vessels, but if you have to, tie them off with suture so they don't bleed.
2. Find the thing you want to remove.
3. Identify the blood supply to this thing and tie it off.
4. Remove the thing.
5. Sew up the cut or cuts you made. Depending on how deep the cut was, you may need to sew a few separate layers.

That's it. If you cut-and-paste those five steps, they'll fit on an index card.
If you have to cut into an organ to find the thing, such as a foreign object in the stomach or a stone in the bladder, then step 3 will be slightly different:
3. Cut into the organ containing the thing in the same manner as Step 1.

And the sewing is really just that - sewing. The thread (suture) may be special and we usually tie the knots using instruments, but the knots themselves are often just square knots. It's not hard.

All that being said, there are however two very important additional factors to consider before you dive into this. Ok, three if you count the fact that you need a license. And you should count that.

The first factor is that in order to "find the thing" and "identify the blood supply", and all that stuff, you do need to know the anatomy. Surgery is basically applied anatomy. (And, by the way, medicine is basically applied physiology.) Anatomy may seem complicated, but it's really just a lot of memorization. It helps to have a good visual memory, but it's not essential. And honestly, to perform a spay for example, you don't need to know the anatomy of the brain or the elbow or the lungs - just the abdomen and even there you don't need to know the name and location of every blood vessel running into the liver, you mostly just need to know what's right around the ovaries and uterus. Also, as soon as you start doing it, remembering becomes easier and easier as anatomy is something concrete that you can hold in your hands and see (unlike, say, the names of Prime Ministers you might have been forced to memorize in history).

This leads me directly to the second aspect, which is that it takes practice to become good at this. Duh. But this applies to veterinarians too! Regardless of how thoroughly a vet student has memorized the anatomy and the five points on my index card (or whatever notes they have from their surgery lectures), it will take them a ridiculously long time to perform their first spay. And they will be terrified and they will have to ask questions and get help and they will not be confident. At least one hopes that they will not be confident, as they shouldn't be, not yet. One of my classmates even fainted during their first surgery. Whump - hit the floor. They went on to become a fine surgeon. Eventually. With practice.

So learn the anatomy, keep the index card handy and practice, practice, practice under the supervision of someone who can swoop in should things go sideways, or you pass out. (And get a veterinary license.) And then you too can be a surgeon.



Thursday, August 23, 2018

Vets Gone Bad

Image result for quack
I recently participated in a brief Facebook conversation with some of my colleagues about the highest rated program on National Geographic Wild. I have not seen it, but I have certainly heard and read a lot about it. I may have the name wrong, but it's something like "The Appalling Dr. Pol".

Off stage, Vetography lawyers: "You can't say that! You know it's not called that. We'll get sued!"
Me: "Come on, get real. Nobody reads this blog." 

People appear to love this guy despite the fact that he is manifestly a quack.

Lawyers: "OMG!!"

You would be hard pressed to find a veterinarian who feels otherwise. But I'm not going to talk about the show or the details of his practice. I only mention him because his story is a useful illustration of the weakness of the professional disciplinary process.

One the hats I wear is as Chair of the Peer Review Committee (PRC) of the Manitoba Veterinary Medical Association (MVMA). I've been Chair since 2011 and sat on the PRC as a committee member reviewing complaints for about ten years before then. Veterinary medicine is like most other professions in that it has been accorded the right to self govern and self regulate.The reason professions are permitted to do this is that the government recognizes that only those who actually do the work are in a position to determine what is appropriate and what is not, and which errors are avoidable and which are not. Lay people are also appointed to the PRC to make sure that the public interest is kept in mind and that it doesn't evolve into an "old boys and girls club".

It's an interesting job but it's also a stressful job. Standing in judgment of your peers can feel like an onerous responsibility at times. A more subtle stress though is the knowledge that the worst offenders are getting away with it and that we are only seeing a skewed sample. This is because the process is necessarily complaint driven. Clinics are inspected for equipment, record keeping, sanitation etc, but nobody swoops in and looks over your shoulder to see how you are handling a case. There aren't the resources to do so and it would be pointless as you would be on your best behaviour when observed. The legislation states that for the PRC to investigate a complaint it must receive the complaint in writing. That's it, that's all. So we sit and wait for letters to arrive, our hands otherwise tied.

Think for a moment about your GP. Is he or she "good"? If so, how are you assessing that? Do you know enough about medicine to understand what is proper medical practice and what is not? Honestly? No, more likely, when you say that your doctor is good, you are saying that he or she is nice, and listens to you, and seems to care, and doesn't keep you waiting too long etc.. You have no real idea if the right test has been run and even if it was run, whether it was interpreted correctly. Your doctor could easily be incompetent and it would be very difficult for you to tell. Consequently you probably would not complain about your doctor to the College of Physicians and Surgeons, even if you had a poor health outcome. However, if you encountered a rude doctor with terrible bedside manner and had that same poor outcome, chances are higher that you would complain, even if he or she did everything right and the bad outcome was due to bad luck.

And so it is with veterinary medicine too. In all the complaints I have seen, the great majority have been due to poor communication by the veterinarian rather than poor skills or knowledge. Those of my colleagues who are a little more awkward around people, or perhaps are short tempered, but are objectively quite competent attract far more complaints than those who are charming and charismatic, but are objectively less competent.

The good news though is that given enough time, eventually the charming quacks trip up badly enough or often enough that they are unmasked and professional discipline can take action. As Churchill said regarding democracy, it's the worst system, except for all the others. Dr. Pol has been disciplined, albeit lightly.*




* And another more recent successful disciplinary case against him was reversed by a higher court in a ruling that effectively questioned the scope of authority of regulatory bodies. It doesn't impact us here, but it is interesting/frightening nonetheless.


Thursday, August 9, 2018

Bee Med


One of the most fascinating aspects of this profession is the range of creatures veterinarians treat. Personally I have cared for animals from as small as a hummingbird to as large as a bull moose, although I will confess that both were while I was still in vet school. In my own pet practice the range is somewhat more restricted, running from mice to mastiffs. But my colleagues out there will attend to the full spectrum, from bees to whales. Whales, ok, you can probably picture that. Sort of. But bees? Surely I must be exaggerating or joking. I am not.

I am aware of at least three conferences this year that featured sessions on honey bee medicine. The Honey Bee Veterinary Consortium now has 345 American veterinarians listed in its database and there is also a British Bee Veterinary Association with a cool website (britishbeevets.com), as well as a Veterinary Invertebrate Society. The latter appears to be more focused on spiders and lobsters, but it is certainly interested in anything which creepeth or crawleth or buzzeth.

Ok, you can get the obvious jokes out of the way now. You must have a very tiny xray machine! It must be hard to give it a pill without getting stung! How do you take its temperature?! Har har. Nope, nope and nope. Bee medicine is like the medicine of many other food producing animals and is directed towards diagnosis and treatment of large groups at once rather than individuals. Dead bees are tested and then, if appropriate, something is prescribed for the entire swarm.

What has changed recently and made this something more than an obscure reference buried deep in the veterinary literature is a change in the laws governing antibiotics. Since 2017 in the US, and as of the end of this year in Canada, the regulatory authorities will require a veterinary prescription for most antibiotic use in bees. And a veterinary prescription requires a valid "veterinary - client - patient" relationship. Yes, the vet will have to have a relationship with the bee (bees). He or she will have to see them and make a diagnosis before anything is prescribed. This is because in the past bee keepers were able to buy the antibiotics over the counter and misuse, largely due to lack of knowledge and training rather than actual negligence, has led to antibiotic resistance and residues appearing in the honey.

So now vets will have to learn about "varroa mites" and "acarine mites" and "nosema fungus" and "small hive beetles" and "Israeli acute paralysis virus" and "black queen cell virus" and the wonderfully medieval sounding "chalkbrood" and "foulbrood", among many other bee ailments. Foulbrood, a highly infectious bacterial disease killing bee larvae, now affects about 25% of hives in Canada and is the main reason for antibiotic use. With correct diagnosis and careful prescription of appropriate antibiotics at the appropriate doses and times this can be managed better than it has in the past. Veterinarians to the rescue! Other veterinarians though - I'll stick to my mice and my mastiffs, and most of what's in-between. 

Thursday, July 26, 2018

The C Word


Yes, cats and dogs get cancer. And turtles, and goldfish, and budgies, and rats. Actually, especially rats. As a very general rule most diseases exist in some form in most animals. We are all really remarkably similar under the hood. Yet people are sometimes surprised to hear it. And of course they are upset to hear it. It is the most feared diagnosis after all.

But there are some things you should know about cancer. First of all, it is not one disease, but rather it is a large family of diseases. Really whenever cells begin to divide in an uncontrolled fashion it is technically cancer. Everything from that gross little warty thing on the top of Buffy's head, right through to the aggressive volleyball sized thing that caused Duke's liver to fail. When these dividing cells don't destroy important tissues or spread through the system we call it benign cancer. When they do, we call it malignant cancer. Fortunately most cancers are benign. To reduce confusion a lot of us try to avoid calling the benign ones cancer at all and will refer to them as tumours or growths, but you should always ask if you are unclear – is it benign or malignant?

The second thing you should know is that even malignant cancer is not a death sentence. In human medicine many cancers are increasingly viewed as chronic diseases that even if they cannot be cured, can be managed well enough to allow a good quality of life for a reasonable length of time. That is our goal in veterinary medicine too, with a strong overriding emphasis on the quality of life aspect. Ultimately it does not matter what label we put on the disease, what matters is what we can do to provide a good quality of life. The cancer label is not helpful – there are many non-cancer diseases that are worse than many cancers. To be sure, there are too many cancers where we have to move rapidly to a euthanasia conversation, but my point is to not view all cancers the same way as there are some that can be easily managed to provide that good quality of life for some time.

I am sometimes asked, “Aren't we just prolonging his life?” If I'm in the right mood and if I know the client well, my answer to that is, “Everytime you take a breath you are prolonging your life!” It's true. The name of the game for every organism is life prolongation, just so long as it is without suffering. An animal doesn't know how long it's supposed to live. It has no thought for tomorrow and no anxiety when I tell their human companion that we can probably only keep it comfortable for another six weeks. Each happy day for an animal during those six weeks is a happy day. It's that simple. We just want to string together as many of those happy days as we can.

The other stumbling block in treating cancer in pets is the word “chemotherapy”. Some people react quite strongly when I suggest that, as if I've now crossed a line into ridiculous territory. But chemotherapy just means drugs to treat cancer, and much like the cancers themselves, there is a huge amount of diversity in these drugs. The most common treatment for a malignant bladder cancer is the same drug we use for arthritis (a non-steroidal antiinflammatory). Used for cancer it is “chemotherapy” (oooh... aaah...). Used for arthritis it is not. Exact same drug, exact same dose. Even aggressive chemotherapy drugs that can have really unpleasant side effects in humans often have far fewer side effects in dogs (cats are a different story). And we have the huge advantage that if one of our patients does become sick on the chemo, we can just stop. At least we tried. The bottom line here is not to dismiss chemotherapy just because of the scary word. It's not for every pet with cancer, but it is for some.

And finally, I am often asked about cause. People will say, “But we feed her the best food.” Or they will ask about the lawn chemicals or the water or the neighbour's treats. The truth is that none of these have any bearing. Cancer in pets (and in people, a few uniquely human high risk beahviours excepted) is mostly due to three things: genetics, age and bad luck. The genetics is obvious as certain cancers are far more common in certain breeds. This doesn't mean that Fido's parents or siblings had to also have it for it to be genetic, it just means that the risk for an individual in that breed is higher, like playing with loaded dice. The age risk should also be obvious. As time goes on your DNA accumulates damage and errors, like an old car or old house, and some of that damage and some of those errors could lead to cancer. But the biggest factor is simply luck. The body of even the tiniest animal is inconceivably complex. When you begin to look at that complexity it is amazing that diseases and disorders such as cancer aren't actually even more common. Be thankful for what works and don't be afraid of what doesn't. Sometimes it's not as bad as you think. Be like your pet and ignore the labels and words and just work to make each day as good as possible and then enjoy that day.