SPF has gone to the dogs! In this episode of Cone of Shame, Dr. Andy Roark shares tips on how to protect your pet – especially those of the short-haired variety – from the sun.
Care
7 Things MDs Can Learn From Veterinarians
My daughter and I have chronic illnesses that took a long time and many doctors to diagnose. We’ve met some outstanding doctors and others that have frustrated us and dismissed our suffering.
I’m a veterinarian, and during this journey I’ve learned many things from the physicians we’ve met that have helped me be a better doctor for my patients. I’ve also thought a lot about how physicians can learn to be better doctors for their patients from veterinarians. Here’s my advice to human doctors:
1. Listen to your patients (or their caregivers).
You have a huge advantage over veterinarians, since most of your patients are able to speak to you directly about their symptoms and concerns. Yet, if you don’t listen to or dismiss your patients’ concerns, you lose this advantage. A good history will get you to the diagnosis sooner, almost every time. Listening to your patients validates their experiences and instills trust in your care. Veterinarians rely heavily on the observations of pet owners.
2. Don’t forget a comprehensive physical exam.
Yes, it’s admittedly more awkward to do a physical exam on a person than a pet, but it’s still important. Many times veterinarians find something highly significant on a physical exam that the pet owner had not noticed or not realized was a problem.
3. Think big picture.
Specialists in both human and veterinary medicine are becoming ever more abundant. The knowledge they have in their disciplines is deep and remarkable. However, many times it is helpful to step back and look at the whole patient, not just one or two body systems. Veterinarians in general practice often care for our patients from 6 to 8 weeks of age to death, and that breadth of knowledge of our individual patients helps us tremendously when choosing diagnostic and treatment options.
4. Don’t rely exclusively on initial test results.
It’s fine to reassure your patients when the initial tests you’ve run are normal, but that doesn’t mean your patient isn’t sick, just that it will take more work to get to the diagnosis. Fewer than 5% of our patients are covered by insurance, so we often must stop after the initial round of testing due to the pet owners’ financial limitations.
Our lack of a diagnosis does not mean the pet’s clinical signs aren’t real or that the pet is not sick. In these situations we empathize with our clients and help alleviate the pet’s clinical signs, which is much more compassionate than assuming patients’ undiagnosed illnesses are “all in their head”, as people with chronic illnesses have heard from their physicians far too often.
5. Learn to say, “I don’t know”.
The last line of the Veterinarian’s Oath is: “I accept as a lifelong obligation the continual improvement of my professional knowledge and competence”. This assumes we don’t know it all and we never will. Besides having to learn about multiple species of animals, veterinarians often don’t have access to the latest diagnostic tools or treatments, so saying “I don’t know” rolls off our tongues pretty easily.
I’ve found many physicians have a tough time saying, “I don’t know”, but I respect immensely the ones who do. Even better is when a veterinarian or a physician follows “I don’t know” with “I’ll help you find out”.
6. What you see in the exam room is not the whole story.
Many pet owners apologize to us and are embarrassed when their pet’s limp disappears or the cough is non-existent in the exam room. Yet, veterinarians know that the adrenaline rush pets experience when visiting us masks many of their clinical signs, and we reassure pet owners of that fact.
We encourage pet owners to video their pets at home when they are experiencing clinical signs so we get the full picture. Don’t discount what your patient is telling you because you don’t see evidence of it in the exam room. Ask how the symptoms are impacting your patient’s daily life. If your patient has a short video or picture, take the time to review it together.
7. Remember the zebras.
Yes, we’ve also heard the saying, “When you hear hoofbeats, think horses, not zebras” during our training. Common diseases and conditions (horses) are more likely to explain patients’ symptoms than uncommon diseases and conditions (zebras).
Veterinarians could be called upon to treat any kind of animal, so we might be more open to “zebras” than physicians – if our patients can be so varied, surely the diseases and conditions they suffer from can be as varied. You too could have a “zebra” come into your exam room one day – don’t miss it!
The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.
About the Author
Dr. Michaele M. Oberbroeckling received her DVM from the Iowa State University College of Veterinary Medicine in 1994. She is currently an associate veterinarian at VitalPet Kings Crossing Animal Hospital in Kingwood, Texas. Her daughter has a form of dysautonomia (Postural Orthostatic Tachycardia Syndrome). She also has dysautonomia, along with Sjogren’s Syndrome. These conditions are not actually rare, but can take months to years to diagnose. Learn more at: www.dysautonomiainternational.org and www.sjogrens.org.
How My ER Visits Made Me a Better Vet
In this article we are going to get a little bit personal. Not telling you the color of my underwear personal, but close. In the past month or so I have had two run-ins with the hospital (human hospitals.)
One was a scheduled elbow replacement that just took place, the other was a very unscheduled hip dislocation about a month before. The hip dislocation took me to the emergency department, while the replacement took place through a scheduled operating room intake. Don’t worry, we are past the time when you need to send me bouquets (fruit baskets accepted year round, though.)
Both of these got me thinking about the differences between human medicine and animal medicine and made me consider how I could take the positives and negatives from my experiences and make my clinic a better place for patients.
For better and worse, the two fields are very different. I have nothing but respect for human nurses, PAs, LNAs, PAs, MDs and the rest of the field. Both of my hospital experiences weren’t especially new to me, but now that I have been out in the field longer I try to look at things from the perspective of my own clinic and patients. I also tend to stay away from the ER, so this was only my second visit there ever. I look on the bright side of these hospital visits and become a better vet because of them.
The first thing that happened when I arrived at the emergency room was that I was asked what was wrong. I knew that I had dislocated my hip because I heard it, felt it and could easily evaluate that it was in the wrong place.
Our animals don’t have this advantage which is why fast, gentle and complete physical exams should always be the first thing that we do. The second thing to do in many situations is pain medication. The speed with which I get pain medication to my patients is light years faster than often happens in the human field. I want every patient that enters my clinic in pain to have the benefit of a very fast resolution. Their pain is hidden better than ours, but directly related to their fear.
I tried to imagine how I would feel if I didn’t know what had happened and couldn’t speak the same language as my nurses and doctors. I was able to reason out what was happening, but if I took only my pain and eliminated the ability to think about a plan for the future I can only imagine how scared I would have been. This is the angle that my patients are coming at me from, and it must always be the forefront of our minds as veterinarians.
Veterinary medicine is much more hands on than human medicine- and let’s be honest, you would rather put your hands on fur than a human as well. Other than vitals, often we go entire visits without our doctors touching us. We typically see physicians for each specialized field, while your veterinarian encompasses all of those fields. My orthopedic surgeon has never felt my spleen, while hardly any pet goes through my clinic without a complete abdominal exam. My surgeon can also rebuild and replace bones in a way that I could not.
It is often said that specialists have knowledge which is one inch wide and one mile deep, while general practitioners have knowledge one mile wide and one inch deep. In human medicine, each field is very specialized. Your veterinarian likely has a wider breadth of knowledge, but must refer you elsewhere for very specific problems.
Now let’s talk about hospitalization. At my ER visit I was in the hospital wearing the clothes I was going to ride my horse in. Once I got fixed up it was 1:30 am. All I wanted were PJs and to take my contacts out. I can guess that when our dogs wake up from surgery all they want is their favorite toy and a soft bed.
When I needed something, I could just hit a call button. I could tell my nurses exactly what I wanted. I could tell them my pain score, if the medicine was working, how well it was working and what needed to change. These are all things we need to try and predict for our patients since they don’t have the benefit of a call button.
Did you know that we monitor all of these things in pets too? We don’t have questions to ask them, but we watch parameters like heart rate, position in the cage, ear position, pupil appearance and breathing to monitor pain. We use the results of studies to create a generalized approach in our patients, then monitor them as individuals. We make sure that pets haven’t rolled over on a surgical area and have soft beds. We get the benefit of our patients not talking back with the downside of them not being able to tell us how they feel.
A couple of months ago while I was at a vet meeting my husband called because my dog had peed on the floor. She is very well trained and not prone to that type of thing. I questioned if she asked to go out and he said she hadn’t made a peep. I clarified that if she walks to the far end of the living room and back twice with her ears in a certain position it means she wants to go out. He justifiably told me I was crazy.
The fact is that we get very attuned to nonverbal communication from our pets. I never want crying in pain to be my first indicator that I need to intervene on behalf of a patient. It is important that I look for other silent signs to help them before they are in a high degree of pain.
Now that I am on the mend I have the benefit of stepping back and looking at the positives and negatives from my visits. While they made me less able to do intense physical labor for a while, I am hoping that they also improved my skills as a veterinarian. While I am always attuned to my patients’ needs and wants while they are in my clinic, it is helpful (though not actually very fun) to view it from the other angle.
The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.
Dr. Anna Dunton-Gallagher is a 2011 graduate of Ross University School of Veterinary Medicine. She completed her clinical year at the Virginia Maryland Regional School of Veterinary Medicine and then settled back into her hometown of Rutland, VT to practice. She loves wellness pet care, pain management and her clients. When not at work she enjoys spending time with her pets, snowboarding and horseback riding..
I Like Big Guts and I Cannot Lie
I heart science. It’s a huge part of why I’m in this field. I like that there are causes and effects and rules and explanations. I’m a total fangirl when it comes to evidence-based medicine and I geek out over a good math equation. I have also developed a passion for emergency medicine and triage. It’s like a big puzzle, and if I collect all the vitals and information I need and if I ask all the right questions, I can put it together to form a picture that can explain it all.
I am not a touchy-feely or emotional person. I like rules and structure and logic. So it should come as no surprise that one of the most difficult lessons I had to learn in Veterinary Medicine was how to listen to my gut.
We were in the early evening hours of a Saturday shift when a woman brought her dog in for an “emergency” check-up. (In other words, she just hadn’t taken the time to schedule an appointment, and had enough money that she wasn’t worried about the emergency fee.) The ER was swamped – it was summer, and right around the time when everyone was getting home from the beach or the barbecue and finding that their dog had eaten something it shouldn’t have. It was warm and beautiful outside, and I was stuck only halfway through my 12-hour shift, freezing my butt off in the hospital air conditioning.
“Can someone go triage this dog and send it home,” my coworker hollers. Patience was running thin, and the last thing we needed was yet ANOTHER person using our ER for their walk-in annual exams. “I’m on it,” I reply.
I guide the woman and her dog – a 10-year-old MN Pointer – into an exam room. The woman tells me the dog has slowed down a bit. “How long has this been going on for?” I ask. “Oh, the past year or so, I’d say,” she replies. “I think he has arthritis.” I ask some stock questions while I assess the dog’s vitals. Heart rate, respiratory rate, respiratory effort, mucous membranes, capillary refill time, temperature, and femoral pulses are all within normal limits. Weight is stable. The owner reports no vomiting, diarrhea, acute lethargy, or changes in appetite, water intake, energy, or behavior. All I can get out of her is that he’s “slowing down”.
In my head, I think “You waited a year to come in on Saturday night emergency hours for this?!” Instead, I bite my tongue, explain to the owner that her dog appears stable, and offer her an appointment on Tuesday. The woman declines and insists that since she’s already here, she wants to be seen. I let her know it will be a long wait and that a doctor will be with her as soon as possible.
“Did they make an appointment?” my coworker shouts as I emerge from the hallway of exam rooms. “Nope,” I say as I roll my eyes in obvious annoyance. “Why not?!” she asks with the frustration and exhaustion apparent in her voice. I round her on what’s going on with the dog, then leave the case in her hands as I am already running 20 minutes late to lunch (as usual).
I decide to dedicate my precious lunch break to making a return at the store across the street. As I trek in that direction, I feel my heart start to race and my knees start to shake. I attribute it to the fact that I’ve had coffee and nothing to eat since 10 am and brush it off. However, as I wait in line at the returns desk, I notice I’m sweating – the kind of sweating you do in an interview or when you’re meeting your significant other’s parents for the first time. I shift my shopping bag to my other hand and wipe my damp palm on my scrub pants.
I am no stranger to anxiety, but this is different. I’m getting that sensation you get when your boss says “Can I speak with you in my office?” and you start to panic and wrack your brain trying to figure out what you did and whether or not you’re getting fired. I feel nauseous and I’m thinking about bailing on this line because I’m suddenly feeling desperate for fresh air.
Suddenly, the Pointer comes to mind. THERE’S SOMETHING WRONG WITH THE POINTER. My stomach drops and it all clicks. There’s something wrong with the Pointer and my body knew it before my brain did. I rush to pull my cell phone out of my scrub pocket and call my coworker. “Has the Pointer left?” I hold my breath as I wait for her answer. “No,” she replies with a question mark lingering at the end of her words. “The doctor just went in, why?” I can finally exhale. “Good, ok. I don’t know, I just had a weird feeling, I was gonna ask you to make them stay.”
I hurry back across the street, feet heavy and goosebumps covering my arms. I rush to the break room, where I jump onto the computer and pull up the dog’s medical record. My stomach drops and my teeth clench as I see the title of the SOAP: “Splenic mass.”
Later, I approach the doctor who saw the case to apologize for my failure to triage the patient appropriately. Turns out the doctor had felt the mass on abdominal palpation, then taken the dog for an ultrasound to confirm the location. The mass had not ruptured or started to bleed, and the patient was stable and scheduled for surgery early the next morning. It was all going to be fine, but I couldn’t help but think: What if I had sent that dog home and that mass had ruptured between now and the appointment on Tuesday?
Years later, I still rely on vitals and objective information when I triage pets, but now I also listen to my gut. On more occasions than I care to admit, my gut has been wrong and made me overreact and look like a crazy person who has no idea what she’s doing. But on several occasions, it has also come to my rescue and told me to get a doctor involved immediately even when the normal vitals and BAR presentation are telling me otherwise.
Veterinary Medicine is not just a science, it is an art. If we rely only on facts and figures, we miss out on the power of instinct and intuition, both of which are crucial in the way we practice medicine. I would rather overreact a thousand times than miss one critical patient, so I plan to continue to listen to this gut of mine – It is a tool, just like my calculator or my stethoscope, and learning to use it has made me a significantly better Veterinary Technician.
The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.
6 Steps to Make Your Pet’s Nail Trims Easier
Nail trims can be a scary experience for some cats and dogs. That’s the last thing we want! With time, patience and a LOT of treats, you can get your pet on board with nail trims. In this episode of Ask Dr. Andy, Dr. Roark reveals some simple steps to help make nail trims easier.
1. Get ready to give a BUNCH of treats.
2. Prepare for this to take some time and effort.
3. Start by simply handling your pet’s feet.
via GIPHY
4. Click the nail clippers near your pet so they adjust to the sound.
5. After a few days, simply try placing your pet’s nails in the clippers.
6. When your pet is ready for a nail trim, stick to the tips!
For more nail trim tips, watch the full episode of Ask Dr. Andy below:
Subscribe to the Cone of Shame channel on YouTube for more videos from Dr. Roark!
The Biggest Myths about Vets and Nutrition
I’m a big believer that most “black and white” statements about nutrition are oversimplified, frequently to the point of being inaccurate; and that the longer, grayer story is really the better one.
While I could (and just might) write an entire series based on this introduction, today’s long-overdue post addresses a mostly inaccurate statement that is frequently made by those offering pet nutrition advice online, and even occasionally by veterinarians. I’m referring to the myth “veterinarians don’t know anything about nutrition.”
Nutrition Education in Vet School
First, some truths. All graduates of US veterinary schools, no matter when they graduated, have nutrition integrated into their curriculum, whether it was a required course labeled “Nutrition 407” or whether it was sprinkled into other aspects of medicine, it’s in there. Some nutrition knowledge is also requisite to pass examinations for veterinary graduates to practice in the US.
I’ll be the first to agree that some veterinary institutions don’t provide enough nutrition training; however, even those institutions have curriculum that incorporates critical thinking, research, and the importance of continuing education. To maintain licensure to practice, veterinarians are required to complete a certain amount of continuing education each year, and there are many options available for veterinarians to either brush up on nutrition or pick up where vet school left off. It’s just a matter of making an effort to do so. There really isn’t a good excuse for a veterinarian to be ignorant when it comes to nutrition.
No Excuses
All that said, I just revealed my feelings about black-and-white statements about nutrition, so I’ll also say that I absolutely have met a (very) few veterinarians who appear to have completely blocked nutrition from their memory and have no interest in learning something new. They exist, but they’re exceptionally rare. I do, however, stand behind the black-and-white statement that there just isn’t a good excuse for this. What can I say? No profession is perfect.
So, if (nearly) every veterinarian practicing in the US truly has some nutrition knowledge, how can it be that this myth is so prevalent, even to the point that some veterinarians say it about themselves?
While a study on veterinarians’ self-reported level of nutrition knowledge, comparing it to their educational records, and correlating these with how they approach nutrition in practice would be an amazing tool for improving nutrition care within US veterinary practices, and the best way to answer this question, it doesn’t exist, to my knowledge.
What I do have to offer, is my assessment of the situation, based on my own veterinary and residency training, my time spent teaching at veterinary universities, and several years of speaking with veterinarians and pet owners about their experiences. This is not a substitute for a more evidence-based approach, but it’s what we have.
The way I view veterinarians’ nutrition deficiencies focuses not on knowledge, but on communication.
Choices, Choices Choices
First, we have to go back 20-30 years to consider that things have changed relatively recently when it comes to nutrition. There were drastically fewer options for pet owners to choose from when it came to pet food, and pet food marketing was fairly simplistic. The body of knowledge about pet nutrition and diet formulation was much smaller, and internet access wasn’t a factor in people’s decision-making. Because of this, there was a tendency for pet owners to ask veterinarians for nutrition advice when it was needed, and to take that advice at face value. Easy.
Now, all of those factors have changed. Pet owners think about nutrition much more than they did in the past, largely due to the ease with which information is available now. There has been an explosion in the number of pet food options available, and along with this, some very smart marketing that has even managed to look like unbiased information has entered the pet food market.
In addition, science has progressed so that we now know much more about pet nutrition, and pet food and the internet has brought the general public a ton of information (some useful, some useless, much confusing). With all of these changes, people’s expectations of their veterinarian, when it comes to nutrition, have changed.
Pet owners are no longer asking for advice (even if they phrase it as such). They’re asking for a dialog. Rather than the basic instruction that would have been acceptable in the past, pet owners now want to know that their veterinarian recognizes their concerns and the energy that they’ve devoted to learning about the subject. They want the vet to be willing and able to engage in a conversation about it and they want to play an active role in determining the course of action.
Nutrition and Communication
Like most aspects of both veterinary medicine and life in general, having this conversation takes practice. Incidentally, it’s not something that gets talked about a lot, but one of the most important things that veterinary students in their clinical year, and new graduates, do is refine their explanations of common diseases and medical concepts. It takes time to figure out the most effective and efficient way to convey the most important information; and it’s different for everybody.
So, 20-30 years ago, veterinarians never had to be good at talking with pet owners about nutrition, because no one was asking if a grain-free diet would help their pet with diarrhea. No one was asking if a raw-meat-based diet would improve a skin problem, and no one was trying to balance a home-prepared diet using whole food ingredients. Again, black-and-white statements here- I don’t mean literally anyone, I just mean few enough people to justify not having to learn to have these conversations.
While nutrition is absolutely present in the veterinary curriculum in the US, talking about nutrition: not so much, with the exception of teaching by a few of my very proactive colleagues. It’s been up to vets to learn it on their own. By far, the vast majority of veterinarians that I talk to who’ll say that they “don’t know anything about nutrition” are actually able to make perfectly reasonable nutritional recommendations in most instances, but where they fall down is in answering the pet owner’s question about why they made the recommendation. They haven’t had the practice. It’s not a knowledge issue, it’s a communication issue.
False Information, Frustrated Vets
While the pet owner may be asking “is diet x good for my pet?” it’s not a yes-or-no question anymore. Veterinarians don’t usually recognize that exactly what and how a pet is fed can potentially say a lot about the pet owner, and the pet owner may have invested much energy in the subject and determined that diet x is the way to go. Some pet food marketing has given many pet owners some false ideas about what is and is not important in pet food, and when a veterinarian outright disagrees with the results of a pet owner’s research, it’s natural for that pet owner to be offended.
As a generally peaceful bunch, most veterinarians don’t enjoy being put in these situations, so it’s easy to see how “I don’t know” may be the easier (though incorrect) answer. Another scenario where “I don’t know” may incorrectly come up is in response to claims such as “feeding abc diet will cure your pet’s medical condition.” Veterinarians are trained in critical evaluation of information, so if there isn’t any valid evidence-based information on which the veterinarian can advise otherwise, “I don’t know” is the alternative to the full explanation of the importance of evidence-based medicine.
While I don’t believe that “I don’t know” is the right answer in either of these scenarios, when veterinarians are managing hospitalized patients and returning phone calls from worried pet owners in between running a hospital, surgeries, appointments that are never long enough, walk-in patients, and emergencies, with a little bit of perspective, it’s easy to understand how saying “I don’t know” and not having a 40-minute conversation about nutrition may be the answer that keeps the day on track.
I’ll try not to sound like a marriage counselor here, but if the problem is communication, then the solution is to understand the other person’s perspective and taking steps to accommodate it.
My Calls to Action
Veterinarians: Ask owners of pets requiring nutritional care or clients with concerns about feeding their pet to schedule an appointment to discuss nutrition. Consider that criticism of your client’s current feeding choices is indirectly criticism of your client and their lifestyle. Focus on providing background in evidence-based medicine and the medical basis for your recommendations. Point out the level of evidence that informs each idea being discussed.
Find a gentle (but honest) way to suggest making changes, and keep the focus on the fact that you both want to provide the best care possible to the pet.Contact a veterinary nutritionist if needed. Use this opportunity to develop your approach to talking about nutrition. You’ll say “umm” a lot and feel like it’s your first week in practice for a while, but it will become second-nature. Your client will leave with the impression that you care, that you listened, and that you do know something about nutrition.
Pet owners: It’s tricky to navigate pet nutrition advice. There’s a lot of it, and it ranges from excellent to terrible. Often terrible is cleverly disguised as excellent. There are resources for dog and cat owners that can help, but your vet is really the best person to help sort it out. However, understand that while “is diet x good for my pet?” sounds like a simple question, it isn’t. Not if you want an intelligent answer.
The answer actually involves your pet’s medical needs (the easy part because your veterinarian already has a handle on this); your pet’s current and possibly previous diets, and his/her response to them; and the logistics of feeding and lifestyle in your home. If you are honestly interested in your veterinarian’s opinion of your pet’s diet (you should be), it’s only fair that you give them an opportunity to give you a good answer.
Asking about nutrition as a “by the way” as your vet is leaving for her next appointment isn’t fair. You probably won’t be satisfied with the answer, and your veterinarian won’t get the chance to provide your pet with the best possible care. Just as you’d schedule an appointment with your vet if you had questions about your pet’s itchy skin, go ahead and schedule one for your questions about diet.
It’s not the easy way out (surprise), but between veterinarians’ expanding knowledge base in nutrition, more practice with talking about it, and a bit of perspective, the myth that veterinarians don’t know anything about nutrition can hopefully be put to rest.
This post originally appeared at Veterinary Nutrition Care.
The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.
About the Author
Dr. Amy Farcas is one of only 84 veterinarians board-certified as a specialist in nutrition by the American College of Veterinary Nutrition.
Dr. Farcas earned her veterinary degree at the University of California-Davis, and then completed a rotating internship, followed by a year of practicing general and emergency medicine. By this time, she’d become fascinated with biochemistry and the effects of food on the body. She returned to the University of California-Davis for her residency in small animal clinical nutrition, and then earned a Master’s degree in nutritional biology. Dr. Farcas was the clinical nutritionist and acting service chief for the clinical nutrition service at the Matthew J. Ryan Veterinary Hospital at the University of Pennsylvania before returning to California to start Veterinary Nutrition Care; a nutrition specialty practice in the San Francisco Bay Area.
Dr. Farcas is passionate about families, teaching, and food. Her work as a veterinary nutritionist allow her to combine these to help people give pets their best.