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FYI - For Your Information
Writing about practicing veterinary medicine and practicing veterinary medicine
Question: Hi Dr. Mike:
I just wanted to write to say "thank you" for answering all the questions
that I have sent you on my cats. Your advice has been extremely helpful.
What I would like to know is -- where is your practice located? Is it in
the New York area? If so, I would definitely like to become a client of
yours. You are so extraordinarily knowledgeable and the vets here in
Brooklyn don't seem to know half the things you have answered in your
E-mails. If you do practice in the New York area, can you please send me
your address/phone number? Thanks so much.Janice
Answer: Janice-
I practice in Virginia, so that would be a long trip!
I think that it is a lot easier to write about practicing veterinary medicine than to actually do it.
This is one of the reasons that I continue to practice full time. I'm afraid I will forget how hard it
really is. I am a competent veterinarian but not an extraordinary one. Many clients have left my
practice to go to other ones because of frustrations with me, so I know that I'm not managing to
communicate effectively with everyone and I know for sure that I miss some things in practice
that seem readily apparent when I am researching them for online use.If you can find a vet you can talk comfortably with, who doesn't mind rechecks when you think
things aren't going well and who will refer your pets to a specialist when he or she is stumped
they are as good as I am "in real life".Thanks for the kind words, though. It is nice to know that the web site is helpful and that
Michal's and my work is appreciated.Mike Richards, DVM
8/13/2001Michal Remark: I think he's a genius across the exam table or the surgical table .. but I may be just a tad biased. But he's right - there are a lot of really good, caring veterinarians out there. Most of them are in the field because they care deeply for animals. Not all terrific vets are great communicators and sometimes their staff is a great asset there. The Veterinary Tech and Receptionist are there to make life easier for the Doctor, you and your pet. Find veterinary clinic or hospital where you and your pet feel comfortable and you feel that your pets medical needs are being met.
Veterinary Medicine as a business and Borzoi Skin and diet, Collie Heartworm med questions
Question: Dr. Richards,
I received an education in Northridge, CA, for Animal Health
Technology and have been professionally & privately training all
breed basic dog obedience for 18 years. I moved from the West
to the East coast 2 years ago; where I find most veterinary practices to
be lacking in many areas, i.e., sanitation, technology, modern
equipment, etc. Making appointments to see specialists at teaching
universities should not take $300.00 to walk through the door, or
3-4 weeks to wait for an appointment opening. While millions of pets
are destroyed each year in shelters, an incomprehensible
number die while awaiting their turn to receive care too.
Emergency medicine should not have to be the only option to
treating an ill animal, after business hours of vets, when an owner
is willing to pay for the expertise of a specialist, no? Comments?I am the owner of a 5 year old Borzoi and 8 month old Rough Collie.
Both dogs are well-mannered, neutered, purebred males.
I am writing to you now concerning "Justice," my Borzoi.
Although I have directed sight hound rescue teams for decades,
and am abundantly familiar with their unique dispositions and needs,
"Justice" presents perplexing symptoms at times, which have
not proven to be fatal, yet have required ongoing treatment and
close monitoring.Typical for his breed, he is a poor eater. His appetite is not
consistent, but (luckily) his weight does not fluctuate. His exercise
is minimal, due to his aloof nature, preference to relax, age and
my work schedule. He has not been given any medication for
any chronic illness; however, he has been treated with Flagyl
on 3 different occassions (during his five years of life), after testing
positive for Giardia. WHERE he is picking this parasite up is
beyond me! Perhaps he is no longer symptomatic after drug
therapy, but the parasite remains lurking within his system.....?
He is and always has been an indoor pet, never exposed to filth,
contamination or disease (that I'm aware of). His vaccinations
are all current, including that for Lyme. I maintain my own and
my pets living quarters meticulously; carpets & rugs are cleaned
regularly, dog beds and toys are washed, outdoor urine spots are
bleached, feces are picked up shortly after being eliminated.
Although it's contagious, he never caught (or infected) Giardia from
the Collie, because the Collie has never tested positive. Both
dogs are given purified or "Brita" water to drink. They are never given
access to toilet or tap water.He is allergic (breaks out in hives) to many OTC grooming (bathing)
products, as well as Primor. Currently, his coat is full, but lacks
lustre and his skin is flaky. Due to his tendency to become
gassy after being fed most reputable brand name dog foods,
as well as having diarrhea and/or producing loud stomach gurgles,
and having loose stools, it has been recommended to me (by a Vet) that I feed
him a combination of Hill's Science Diet ID dry kibble mixed with canned ID,
2x daily. Considering the sensitive digestive tract of a
Borzoi, I thought this diet would be worth a try.I began this expensive diet in May of this year. Initially, "Justice"
ate the food with great enthusiam, his bowel sounds resoved and stools
returned to normal, until he was DX'd with Giardia again.
Now, once again, he has lost interest in this food, and has to be
prodded to eat it. FYI: Although there is a vast age difference
between my dogs, they do not eat each other's food. He has completed
his ten day therapy with 'metro' and a recent stool sample was tested
(negative) for Giardia. I have noticed that while his coat is 'full,'
he is shedding excessively, and there are small isolated spots of
dark pigmentation appearing on his front legs. Being
a survivor of Melanoma myself, I am curious as to what these
spots are, or could be...................? "Justice" is a sable colored
dog, with dark eyes and black paw and nose leather. There has
always been dark areas of pigmentation in his mouth, on his gums."Justice" has been tested three times for Heartworm, all tests
were negative. In May 2000, I noticed a build up of fluid underneath
his lower jaw and his chest area, between his two front legs. He
'appeared' swollen and heavy -- he has never had Torsion/Bloat. The only
explanation I was able to get for this condition was after having
a complete CBC ran. The CBC revealed very low Protien, Albumin
and BUN levels. The edema resolved (quickly) with a high protien diet
(cooked hamburger in addition to the new diet of ID). A "slight"
heart murmur was also comfirmed (which was detected by a
different Vet early on in this dogs life). Q: Does this one episode,
in your opinion warrant a chest x-ray and/or EKG?Also, do you believe a dog needs to be tested for Heartworm annually,
prior to giving it preventative tablets or, should one test suffice and,
if negative, be able to suffice ongoing annual treatment? I cannot get
two doctors to agree on this topic. FYI: "Justice" was born and raised
on the West Coast, where Heartworm is not prevelant, and was
therefore not tested or given preventative tabs during hs first 3 years of
life. He has been tested annually since our move 2 years ago, resulting each
time with negative findings. According to his weight, I administer
"Interceptor Tabs" for prevention, during the months of July through Dec.
Q: It's my understanding that the most recommend Heart Worm
Prevention for a (Rough) Collie is "Filarabits," which must be administered
daily. DO YOU AGREE? Is it really necessary for my two dogs to be given two
different types of Heart Worm Prevention therapy, or could the Collie
tolerate Interceptor without incident? I know that "Ivermectin" can
not be tolerated by Collies.Any time I add something new to "Justice's" diet, he becomes
spoiled by the palatability of the new ingredient, and turns his nose
up at his regular diet when the hamburger, broth, rice, whatever, is
no longer made available to him. While I'm aware that keeping
sight hounds in good weight is a task in itself, "Justice" has never
has a problem with weight. It's his desire for human food that
keeps this pet from wanting to eat his dog food. Q: What is it about
pumpkin that seems so popular to give dogs these days? While
most dogs prefer the same diet daily, "Justice" appears to become
bored with any given food given to him on a regular basis. Knowing
his stomach gets upset easily, I am careful about what and how often
I make changes in his diet. Q: Do you believe a steady diet of
ID supplies enough of a nutritiously BALANCED diet for this finicky
eater, of 120 pounds? Hill's says yes, but of course they would.
If not, what kind of diet would YOU recommend? Gone the Lamb
and Rice, Chicken and Rice, Beef and Rice, and even Puppy food
(for higher protein) routes with him ... he dislikes baby food, is given no
'treats' or faddish grocery store products. I steer clear of wheat and
soy for allergy purposes. Supplements: what, if any, supplements
do you believe a dog of this age and status should be given? For your
consideration, I will tell you that aside from a little Flaxseed Oil or
I've been told by most Vets that if a dog is feed a completely balanced
diet, it should need no supplements; they are considered by many to
be a good items to spend money on, needlessly. Agree/disagree??"Justice's" temp is now normal, his most recent Giardia test was
negative, his color and pulse are normal, his urine looks and smells
pungent, but it's clear, not cloudy or containing blood. His stools
appear normal (no diarrhea or constipation), there is no vomiting
or panting, no excessive thirst or lameness; there are no signs of obvious
illness, but I am concerned about his disinterest in food/eating, spots of
dark pigmentation that have developed (age spots? injury? lack of nutrition?
melamona?), even though they are not "raised or causing him to itch."
I am further concerned about dermatitis in the form of a light red rash that
exists on his abdomen (doesn't seem to bother him either!). I don't
suspect mange or mites, as there are a few pustules resembling
black heads present in the same area. He does not have fleas and
no flea eggs are visible. Both of my dogs wear Preventic (tic control)
collars. He had acne as a pup ... should a scraping be done of
this area to check for potential fungal infections? Would a giving him
a bath with NIZORAL be harmful to a dog, since it's RX'd for humans?He has no tumors or open lesions, does not lick or bite at himself.
Q: Would you recommend testing for diabetes, Cushings or Cancer?
Would you suspect any form of autoimmune system disorder? At this
point, if a specialist is going to be seen, would you recommend an internist,
dermatologist, both or neither?!Finally, after going over my 'son' with a fine tooth comb, the
only other abnormality I can report to you, is an odd cough that
he has, which is not chronic or produce phlegm or blood. It is
intermittent, and has the sound of a 'choke' at the end of it.
He can go days with out doing it, and some days he coughs 2-3
times in one day. The cough is not necessarily after eating -- he
coughs/chokes while completely at rest. I know his moaning is his
way of telling me he's content, happy and not worried. I am sure
he is not moaning as a result of being in pain. He is not arthritic or
Dysplastic. I would give my life to save his - I want to "moan"
back at him. :)Thank you for reading this dissertation. As my initial letter to
you, I apologize for being wordy, but tried to lay some foundation
from which you can provide me insightful answers. I eagerly
look foward to your replies and engaging in an ongoing dialogue.Regards, Vox
Answer: Vox-
Veterinary medicine is a business. Veterinarians want to provide excellent
care and it is necessary that they make a profit. I know, personally, two
veterinarians who have been forced out of their practices by an inability
to produce adequate income to support themselves, despite the fact that one
of these vets was probably the best diagnostician I have ever known. She
did care a great deal for her patients and she often chose to lose money
rather than to see them receive less than optimum care, but in a
competitive market, she could not, or would not, charge enough to cover
these losses. It took me three years in practice to learn that I had to
make a profit. I might not ever have learned, except that I accidentally
chose an accountant who had a knack for teaching inept businessmen the
basics of making a living. Understanding that basic concept, veterinary
medicine is a business which must provide a profit, is where the answer to
your questions begin.Veterinary medicine is approaching a crossroads. In order to provide truly
state of the art care a great deal of investment needs to be made in many
practices across the country. This has to be compensated for by increased
fees. There simply is no other way for the veterinary practice to provide
these services and remain financially viable. I only know one veterinarian
whose practice salary comes close to the average salary for a human
physician in her line of work. Most vets work for salaries that are roughly
1/4th those of physicians practicing in similar fields. It is becoming
quite difficult for new graduates to practice veterinary medicine and repay
college loans and start families. This is putting a great deal of stress on
the profession and I truly believe that it is coming to a breaking point. I
think that the only viable answer, long fought by veterinarians and
veterinary clients alike, may be pet insurance. There isn't any other way
that I know of to provide high quality care and keep the average price for
that care in the range that pet owners can afford. The only other option I
can think of is simply to give up on high quality care for pets and go to a
standard in which really ill pets are euthanized rather than treated. There
is a real fear among veterinarians of seeing our profession go down the
road of insurance and ending up in the managed care nightmare being
experienced by humans but the other options even less appealing.There are major variations between practices all over the country. It is
possible to find very good and not very good veterinarians practicing in
close proximity. I do not know if Western U.S. practices are better than
Eastern U.S. practices but I suspect that overall, they are probably
similar but that services and prices vary a great deal from one small
region to the next. In areas on which rapid growth is occurring, practices
are newer and more likely to have equipment and facilities near the state
of the art. In areas in which growth is slow, or non-existent, buildings
and equipment tend not to get upgraded much.I do not know where you are on the East coast, but in Virginia, litigation
and legislation have made it difficult to provide emergency care outside of
an emergency veterinary hospital setup. Veterinarians do not have high
liability when it comes to the value of most of their patients. However,
veterinarians have very high liability when it comes to injuries suffered
by their clients from the teeth or claws of their pets. When a dog bites
its owner in a veterinary hospital, the owner can, and sometimes does, sue
the veterinarian for negligence in controlling the dog. I used to provide
almost all of the emergency care for my practice at night, working alone,
with the client as assistant. This is the only way that emergency care can
be provided in a rural setting (and probably many urban settings) by a
small practice, at a reasonable fee. If I had to pay an assistant to be at
the practice or come in on call, the cost of the emergency visit would
skyrocket. On the other hand, there have been several six figure lawsuits
over dogs biting their owners. So do I risk the health of my practice for
the health of a pet or do I refer the owner to a staffed facility? At this
time in my career, I send them to the emergency veterinary clinic, most of
the time. It may not be what the majority of my clients want and it is true
that the majority of my clients are not going to sue me even if their dog
does bite them in my office, but in a situation where one client could cost
my practice nearly a million dollars, the small minority sets the tone.
This is just another business reality.Giardia can be a difficult parasite to control in some patients. At the
present time, it is thought that fenbenazole (Panacur Rx) is a better
medication for control of giardia than metronidazole. This medication is
dosed at 50mg/kg/day for 3 to 5 days, based on the average advice. Some
veterinarians advise splitting the dosage and giving 20mg/kg every 8 hours
for 3 to 5 days. It is also possible to mistake other intestinal protozoans
for giardia or to confuse mobile spirochetes with giardia organisms,
particularly if the examiner is mostly looking for motion in the stool to
make the diagnosis. Most protozoans do respond to the same medications but
spirochetes may require antibiotic therapy other than metronidazole, such
as tylosin (Tylan Rx) or lincomycin (Lincocin Rx). There can be
intermittent diarrhea problems with spirochetosis, which might give you the
impression that treatment for giardia is working when the actual problem is
something else. It can be helpful to treat all the dogs in a household,
even if only one is symptomatic (this is especially true for giardia).Diet can be helpful in controlling digestive problems but it is hard to
figure out in advance which diets will help with a particular patient. Low
fat diets help some dogs, low or high fiber diets help other dogs and
easily digested foods, such as the i/d (tm) you are using, help a different
group. It is sometimes necessary to make adjustments and use a new diet
when another approach was working but is no longer helpful.The skin pigmentation changes may be due to chronic skin irritation if some
of the skin problems you are seeing are due to bacterial skin infection,
flea bite sensitivity, allergies or if there is a problem like an early
lick granuloma on the front legs. Basically, any irritation that goes on
long enough can cause the skin to become darkly pigmented in dogs. The
other common cause of darkening skin is hormonal disease in dogs. The two
most common hormonal problems leading to skin pigment colors are
hyperadrenocorticism (Cushing's disease) and hypothyroidism. Growth hormone
disorders and sex hormone imbalances cause these problems more rarely.I would be really worried about a hypoproteinemia and would want to find a
cause for it. Inflammatory bowel disease seems pretty likely with the
overall history but liver disease and kidney disease can both cause low
protein levels. Intestinal parasites, usually hookworms, can also cause
this problem but that does not seem likely with the history you give.I don't test dogs annually for heartworm disease when they are on one of
the monthly heartworm prevention medications. We test every two years. I
would go to a longer test interval, perhaps every three years, but this is
a legal gray area in veterinary medicine, since the American Heartworm
Society recommendations are to test at least every two years and deviating
from established practice standards leaves a practice vulnerable to both
law suits and regulatory questions. We do test dogs that are on the daily
heartworm prevention medications yearly because these medications are not
nearly as reliable and can potentially be dangerous to a pet with heartworm
microfilaria in its blood stream. During the time that daily heartworm
prevention medications were the only option, we usually had between five
and twenty dogs, every year, who developed heartworms while heartworm
medications were being administered by the owners. We have had about 10
dogs total develop heartworms since ivermectin and milbemycin became
available and half of them are dogs that the owners were administering
non-approved ivermectin products to.We use ivermectin (Heartgard Rx) in collies on a regular basis. We use
milbemycin (Interceptor Rx, Sentinel Rx) in collies on a regular basis,
too. We have had no problems with either product and they are considered to
be safe for use in collies. I would not recommend the use of a daily
heartworm prevention medication for any patient starting on heartworm
prevention at this time.Pumpkin is a good source of fiber. I do not know of any other reason to
advocate its use.It would be a good idea to do a skin scraping of the abnormal areas of the
skin to rule out mites and to check for yeast. A skin biopsy is a
reasonable choice if skin scrapings are not helpful, although it would
probably also be reasonable to try a course of antibiotics to rule out a
pyoderma, if it is possible to do that and not cause digestive tract
problems. Ketaconazole INizoral Rx) shampoo is safe to use on dogs but 4%
chlorhexidine shampoo is less expensive and is as effective, or more
effective, in studies of yeast infections.If I had to pick a specialist at this time to refer a patient with
Justice's history to, I'd opt for a dermatologist first and then consider
an internal medicine specialist if necessary. I think that seeing a
dermatologist is a good idea with the changes in skin pigment, the dullness
of the hair coat and the overall history. While I tend to lean towards a
problem like bacterial pyoderma, the hormonal diseases like
hyperadrenocorticism (Cushing's disease) certainly seem possible.Finding the cause for an intermittent cough can be difficult but when
starting with a patient with an audible heart murmur, it seems like a good
idea to try to rule out heart disease first. X-rays are are a good initial
test, since they help to determine if a lung problem is present, too. While
lung problems are less common, I have occasionally been surprised to find
an obvious cause for a cough relating to the lungs on an X-ray, such as
cancer, emphysema, collapsing trachea, or something similar. Heart problems
are also visible on X-rays in many cases. If there is no sign of heart
disease on an X-ray, such as pulmonary edema or heart enlargement, it may
not be necessary to do more. I am not a huge fan of ECGs unless there seems
to be an arrhythmia present. I think that cardiac ultrasound gives a better
understanding of what is happening with the heart.I hope that this helps some in your decision making. I really think it is
possible to find some relief for the skin problems. I think it is important
to find out why the low protein levels occurred, if possible, and that if
you can find the answer to this you might also know how to treat the
overall digestive problems. This is going to take some patience and
persistence on your part.Mike Richards, DVM
10/31/2000
Shelter situations and outbreaks of disease
Question: I currently volunteer at a local animal shelter where we have "lost"
quite a few dogs to kennel cough over the past few months. An aggressive treatment
used to try to prevent the cough (in addition to a Bordetella vaccination
upon arrival) is the use of approx. 500 mg of Vitamin C per dog/day depending
on age/weight. Of course, we also bleach out wards after an outbreak but
that doesn't seem to help for very long. Is the Vitamin C doing any good and
is there anything we could use to increase immunity or to try to prevent
further outbreaks? Should the dosage of Vitamin C be changed? Apparently,
improving air circulation in the wards would only be possible if we had
$90,000 to spare but we don't.
Answer: D-
I don't think that Vitamin C is likely to be helpful in this situation.
Vitamin C can help white blood cells that absorb bacteria do their job a
little better but it would be surprising if that benefit was enough to
allow them to control the infections. I tried to search for more specific
information on this and could not find any, though.Unfortunately, in shelter situations the vaccines do not help as much as
they might if dogs could be vaccinated a couple of weeks prior to arrival.
Most dogs that enter shelters are exposed to Bordetella bronchiseptica
bacteria pretty quickly. It takes several days (at least four) for the
vaccine to provide protection against the bacteria. So dogs develop the
infection before the vaccine has time to work. In addition, there are a
number of causes of kennel cough other than Bordetella, including
parainfluenza virus, adenovirus and canine herpes virus. Any of these may
be the source of problems in your shelter.When disease problems get established in a shelter it is pretty difficult
to get rid of them. You are absolutely correct that building design,
especially ventilation, plays a big role in contagious disease
transmission. Shelters usually don't have the financial resources to hire
architectural firms with a good understanding of infectious disease
transmission and can't build to their specifications, either. So most
shelters deal with some form of respiratory disease nearly continuously.If dogs are dying, it would be worth having some post-mortem examinations
done to determine the cause. You may actually be dealing with canine
distemper. It can closely resemble tracheobronchitis, especially early in
the disease. Inappetance, diarrhea, eye discharges and neurologic signs, if
present, would make distemper even more likely. It may be possible to
arrange post-mortem examination through a state diagnostic lab or a local
veterinary hospital may be willing to do the exam and collect samples for
examination by a pathologist.Bordetella is killed by most common disinfectants. Chlorine bleach diluted
1:30 is probably the least expensive for use in shelters. Trying to keep
the amount of moisture down in the shelter helps a lot but it is very hard
to balance keeping the place clean against keeping the moisture down.I wish that I knew of a really good solution to the type of problem your
shelter is experiencing. It really would be a good idea to try to determine
if distemper is present, if possible. Reviewing sanitation procedures might
reveal a way to cut down on transmission of the disease even in a shelter
working hard to maintain cleanliness.Mike Richards, DVM
7/16/2000
Dental care
Question: Dr. Mike
Your response helped...alot. Missy is doing much better, she is more active
and wants to play alot. Her breathing is also very good and her tongue is a
nice shade of pink. I think her problem now is teeth. I am going to attempt
to brush them every night (short time at first). The vet wants Missy to take
1 ml of antirobe acquadrops 2x a day for 5 days each month to keep infections
down in her teeth.
know you can't spend alot of time writing to everyone numerous times, but
if you could just answer these last 2 questions: (1) How do I best take
care of Missy's teeth if the vet is reluctant to clean them. Is there
anything out on the market or at a vet's office that will help? A friend
told me there was some type of enzyme that you put in your pets mouth at
night and it will keep placque from forming. Missy seems to have alot of
saliva and licks alot, so I am sure her teeth are bothering her....also, she
eats now but not alot (as she did before)....of couse, I am no longer feeding
her people food either, and I am not sure she is not content with dog food.
(2)
Are there any foods out there that are acceptable to pets with kidney disease
and heart failure? Is cottage cheese ok? Ground beef and rice? Or are all
people food off limits?Thanks....Sharon
Answer: Sharon-
Clindamycin (Antirobe Rx) is helpful in controlling gingivitis and
periodontal disease in pets. There are recommendations to use this
antibiotic in the manner your vet has advised, in order to help with
periodontal disease in pets, in conjunction with teeth cleaning. It may be
necessary to use clindamycin for a longer period, initially, when teeth
cleaning is not possible. Usually it will help a lot, but not always. There
are several products on the market that help cleanse the teeth. There are a
group of products with "CET" as part of their name that are enzymatic
cleansers. CHX Gel (tm) is another product that contains chlorhexidine and
is helpful. Using dilute chlorine bleach (dilute it 1 part chlorine bleach
to 9 parts water) is also acceptable as a rinse to apply to the teeth. If
you can gradually work up to teeth brushing that might help, but teeth
brushing works best to keep teeth clean after tartar has been removed by
your vet.Low sodium diets are helpful for heart disease, so when you add foods to
the diet of a pet with heart conditions it is best to avoid high salt food
items. Kidney disease makes both high salt and very low salt diets a
problem, so it is a little hard to balance these needs. Avoiding things
like potato chips or beef jerky treats is a good idea, though. Otherwise,
if treats are kept to less than 10% of the diet they are unlikely to cause
problems. If Missy likes carrots they make a good treat. I prefer ground
beef and rice over cottage cheese but both are probably OK in small
quantities. Trying to use lower protein choices, whenever possible, is
best. The rice is a carbohydrate and it reduces the protein level compared
to feeding straight hamburger, which is why I like that combination better
than straight cottage cheese. If you think along these lines it will help
you choose good quality treats for Missy.Hope this helps some. Please feel free to ask questions when you have them.
Mike Richards, DVM
7/16/2000
Pet Health Insurance
Question: I am wondering what you think of veterinary insurance. In your opinion, would it make practical sense for us to look into insurance for veterinary care?
Answer: Pet insurance is a difficult issue. Because euthanasia is an option for pet owners who do not
have the financial means to pursue treatment for a sick or injured pet, from a strictly financial
standpoint pet insurance is not as necessary as medical insurance for humans. However, we are
starting to see a fair number of clients who do wish to see their pets treated and who will spend
a great deal of money to see that it happens. We have a few clients who simply could not
consider euthanasia even in extreme circumstances. For both of these types of clients, pet health
insurance is going to become a necessity soon. There is some competition in the pet health
insurance industry now, which I think is a good thing, too. It makes the companies less likely to
refuse to renew insurance or things like that, which have anecdotally been reported as problems
in the past. Check out the prices and think about what you are willing to spend to keep your
guys healthy and then just try to make the best decision you can.Hope this helps some.
Mike Richards, DVM
5/22/2000
A lesson in Veterinary economics..
Q: Greeting,
Great web site, we enjoy it. As a dog lover, and am owned by a german
shepherd and siberian huskey, I am very careful to be current on their
shots and exams and monthly heart worm medication. After my vet kept
raising his price for Interceptor each time I purchased it I began to
compare cost to mail order Interceptor. It required a prescription but
the savings amounted to about $10.00 per package of 6. With two dogs
this added up. I am a senior citizen on a fixed income. So, I asked my
vet for a copy of prescription to send away with my order so I could
purchase Interceptor by mail. Of course my pets will still see the vet
regularly. The vet charged $6.00 for each prescription and marked, NO
REFILL. This means only a 4.00 saving. I called around my area and the
rest of the vets say they will absolutely not give copies of
prescriptions for heart worm medicine or any medicine. This is more than
upsetting. They charge for their services and are well paid I think. A
routine exam with fecal check and blood work costs $100. per dog. Do you
have any thoughts on this? I have been told that the state Vets assn.
recommends that the vets charge for prescriptions but encourage them not
to do it at all and to discourage mail order purchases.
Thanks for your feedback and letting me get this off my chest.
Sandra
A: Sandra-
Well, I have really mixed feelings about the issues raised in your letter.
So I'm going to put the short answer in the next paragraph and then a long
explanation in the paragraphs that follow that is certain to ramble on and
require some thought and probably make some people mad at me. Please feel
free to read only as far as you feel the urge to.I think that veterinarians should not charge for prescriptions for
medications that the client picks up at the office or are given as part of
an office visit. I think it is fair to charge a fee to cover postage and
handling when a client insists that the prescription be mailed to them,
which several of my clients insist on. I do not know the practice acts or
Board of Veterinary Medicine decisions in all, or even most states, but I
would be surprised if a board actively discouraged the writing of
prescriptions for medications. It is my understanding that some states
specifically prohibit charging for writing a prescription. It would be a
good idea to call the Board of Veterinary Medicine in your state and find
out what the policy really is. In theory, these boards are for the
protection of the consumer as well as the veterinarian. In reality most of
them tilt one way or the other. You might as well find out which way the
board leans in your state.This is a lot bigger issue than it appears, though. The existence of
mail-order pharmacies is a relatively new thing and only one of the ways in
which the relationship between veterinarians and their clients is changing
right now. Veterinarians are losing their traditional ways of making money
and are in a scramble to figure out what to do about it. Some are clinging
to the old ways ferociously. Refusing to write a prescription for
medications is one way of doing that. Other vets are jumping off the
traditional ship and selling medications in catalogs, buying into
veterinary medical offices in pet store chains and forming pet health clubs.A simplified short history of the way veterinary medicine developed might
help to understand what is happening. Until the early 1980s all
veterinarians received intensive training in both large and small animal
medicine. They received training in large animal medicine because it fit
the traditional role of the veterinarian, which was to help an ensure an
adequate and safe food supply and to treat the animals with work to do,
such as horses. Of course, cars and trucks sort of eliminated the need for
beasts of burden and pets began to be perceived as animals that contributed
to the well-being of a person or family. This perception gradually grew in
strength and was bolstered by the disappearance of a lot of the farm
related work. Veterinarians could honorably specialize in dog and cat
medicine by the 1940s or 1950s but the really good years of dog and cat
medicine were the 1960s and 1970s. Good vaccinations became available for
many of the really bad diseases affecting dogs. There was enough money to
be made in vaccinations that it was possible to purchase hospital equipment
and to do complicated surgical procedures at prices that are amazingly low.
All it took was to put some of the money from the vaccinations into the
hospital equipment and salaries. Veterinarians could afford to repair sick
and injured patients at subsidized rates. For some reason it never occurred
to veterinary clients to really wonder how veterinarians could afford to do
an ovariohysterectomy for $75 when it cost $8000 for the same surgery on a
human. For many veterinary hospitals vaccinations produced 60% or more of
the profit while representing about 25% or less of the day's work. The
transfer of money from vaccination profits to cover surgical costs and
hospital costs could be looked at as a form of health insurance or a health
maintenance agreement. Unfortunately, it was an agreement that most vets
understood was occurring and most veterinary clients didn't.I think it is a true statement to say that veterinarians either have the
lowest self esteem, are the stupidest business people or are the biggest
bleeding hearts among professionals. At almost every continuing education
meeting some vet will say that a procedure is justified for the pet's
health but the client won't pay for it so if you want to do it anyway
you'll just have to eat the charges and then admits doing just that. We
work on patients with a definable economic value. It might be 20 cents for
some owners and it might be "everything I own" for others, but it is
definable. We spend a good part of our days figuring out what each of our
patients is worth to its owners. When the owner won't care for a pet
properly we often cut the fees and work on the pet anyway, just because
it's the puppy or kitten that gets hurt, not the client and it is our job
to see that the puppy or kitten is OK. At least that's what we tell our
spouses and our accountants when they ask why we do it. When we don't do
it, because it has been a bad day or because we have looked at the practice
check book recently and realize that we really do have to have $3000 to pay
a pharmaceutical company tomorrow we feel guilty. Maybe only a little, but
enough to make the job stressful. It has only been recently that the
discussion of a patient's economic value has even been allowed to surface
in human medicine. Negotiating over the value of a human life in cash,
today, in the physician's exam room isn't a day to day experience yet.So veterinarians don't make as much money as physicians. Big deal. But what
is happening to the money they do make? There was a high profit in
vaccinations. Someone always tries to figure out how to make a killing
whenever there is such an opportunity and Drs. Foster and Smith and others
have decided to do just that. Vaccinations could be sold through catalogs
because they weren't regulated by the FDA and there was a high
profitability. Clients were surprised and sometimes outraged to see that a
vaccine that their vet charged $30 for sold for $2.98 in a catalog. They
didn't think about the examination that went with it because vets didn't
charge for the exam, they charged for the vaccine. They really didn't think
about the fact that their vet only charged $300 to fix a fractured leg
because they thought it was expensive based on what they thought the dog
was worth instead of really cheap compared to what it cost to fix their
son's broken leg - especially if insurance through work paid for it and
they never had any idea what the cost was, anyway.Well, some people made a whole lot of money selling vaccines to the public.
So what was another profitable item? Heartworm prevention medications. And
here a new factor entered the equation. The pharmaceutical company spent a
lot of money figuring out how much you would spend a month for heartworm
pills for your pet. They knew the vet was going to approximately double the
price of the pills and they asked a bunch of people what they would pay for
the convenience of a once a month pill versus a daily one. Then they halved
that figure, noticed that it gave them a healthy profit and sold it to vets
for that price. People would pay it. Pricing by demand was never pushed to
the limits it has been with the monthly heartworm pills, monthly flea
products and the new pain-relievers for pets. Vets went along. After all,
they were going to make a good profit on the medications. Another
opportunity for easy money to be made. If a person only has a warehouse to
pay bills on instead of a veterinary hospital it is possible to sell the
medication for less and still make a healthy profit. Sure, there are early
fights with state regulatory boards and the FDA but the laws generally
favor consumers in situations like this and somehow that usually gets
defined as "less cost = good for consumers", regardless of other less
obvious factors. It looks good to the consumer because the consumer still
doesn't understand that where their vet is making money and where their vet
is losing money or breaking even but supplying services essential to the pet.At this time, or in the very near future, vaccination income will no longer
support a veterinary practice. It will be harder to sell big-ticket
pharmaceuticals with a high profit margin. Veterinarians are not going to
leave the profession in droves because it isn't human nature to give up on
years of training in specific job skills and look for another job. So
veterinarians are simply going to raise the fees for professional services
to the range they probably should have been all along. This is will make
emergency care and major illnesses too expensive for many pet owners.
Either pet insurance (or HMOs) will become a prominent player in veterinary
medicine or veterinary medicine will become the loss leader for large pet
stores or even possible pet pharmacies.The odd thing about this is that when it is all said and done, instead of
just the veterinarian and the client there will be a third player in some
form. The veterinarian and the client and the insurance company or the
veterinarian and the client and the pet pharmacy. Or perhaps two new
businesses -- both the insurance company and the pharmacy. Veterinary
clients will end up paying the vet more and then paying for medications
separately, which will add to the cost.It is too late to stop this process. As you point out in your email, right
now you can save money by buying your medications elsewhere. Whether you
chose to or not, many people will chose to. Ironically, I think it is good
for the veterinary profession and bad for the clients. Veterinarians will
have to face the fact that they have to charge for their professional
services or they have to chose a new line of work. They will do one or the
other. Clients will eventually be paying three or even four people for the
same service they used to get by paying one person and it will cost them
more because each of those people will want to make a living.I know that veterinary prices seem very high to many pet owners. Often,
they seem very high to me. But I know what I take home at the end of the
day in salary and I know that it is far less than people with similar
training and similar abilities who treat humans instead of pets. I also
know it is less than many other jobs in the community requiring less skill
and less dedication. I know how much worry there is associated with running
a small business and I know how stressful it is to spend the day
negotiating whether with clients over the health care of their pets. There
are many days when I question whether or not it is all worth it. I don't
know the answers. I do know that there is a lot of frustration and that
veterinarians are not always handling it well.I hope that this gives you some idea why the vets in your area are so
difficult to deal with over this issue. There is a lot of confusion and a
lot of concern about what the profession will have to do to continue to be
able to care for pets in a manner that allows most of them to get the care
they need. I don't think that their solution, charging for the
prescription, is correct, but I do understand very well why they feel the
urge to do so.Mike Richards, DVM
What constitutes stress for a pet?
For most of us, stress seems like the last thing that might be bothering our pets. After all, they have a home, food, medical care and our love and they don't have to drive to work in the morning to support it all. How much stress could that be?
Stress, as defined physiologically, is any stimulus that changes the physiologic state of an organism. This means that good things can be stressful, bad things can be stressful and imaginary things can be stressful, too. Most families have daily good times, daily bad times and lots of imaginary or at least perceptual stressors built into the day.
Pets depend on physical clues to judge their status in the family and to gauge the moods of their owners. When you are running around full steam in the morning trying to find the papers you need for an important meeting or your child's left shoe as the school bus arrives you are experiencing stress. Your pet, watching all of this, is experiencing stress, too. After all, you are often the major focus of their life and when you are stressed, so are they. Then you leave and they are alone. Just like people, some dogs and cats don't handle being alone well. Your pet knows that you return home in the evening, usually at about the same time. But there's always a chance you won't. How does your pet know for sure?
When your dog goes out for a walk he knows who has been there recently because he has a better sense of smell than you do. Imagine how different life might be if you walked outside and could see the recent past events at the same time you were seeing the current events. You'd be a little ticked off to see your neighbor acting like he owned the whole neighborhood, just like your dog is a little stressed to smell that Spike urinated on the fence post. Your cat might find that her aggressive "boyfriend" was out there somewhere, in similar fashion. Seeing a squirrel in the yard can trigger the instinct to hunt. Chasing the squirrel satisfies the body's need to respond but not being able to due to a fence or a leash thwarts those same needs and produces more negative stress effects.
Every day we react to stresses that are totally different from the problems our ancestors faced. Yet we do it with the same physiologic tool kit that they had. Sometimes this is like having a sledge-hammer to kill a fly. Anything that stimulates your stress responses stimulates the system designed to help you with the rigors of fighting an opponent or fleeing from a danger. If the reaction occurs because you spilled your coffee or to the sight of a poisonous snake it doesn't matter much to your body. It gets out its tool kit of adrenaline and other hormones and sets to work to fix the problem. Your pet has the same problem with its ability to react to perceived dangers. If your pet is looking out the window at an intruder on its property, it doesn't really matter if she is in a nice safe house, her body is stimulated to respond to the intrusion. Stress occurs all day, every day.
So how much does this affect our pets and what can we do about it? One of the hardest things for pet owners to do is figure out what the stressors are on their pets. Remember, your pet can hear better than you can, has a much better sense of smell, has much different visual information due to difference in their visual system and is often dependent on a family unit that doesn't speak the same language, verbally AND nonverbal. It is a tough situation to find yourself in.
Try to be aware of stimulants such as the cat next door trying to expand its territory by marking your back porch. Sometimes, just closing the curtains can help reduce stress in house pets. If there is heavy construction going on a block away, your pet might notice it much more than you do. While you can't change the situation you can be a little more understanding of your dog's urge to bark at these sounds. If you can, keep your schedule fairly regular. If you can't it might be a good idea to have a neighbor, a friend or a pet sitter stop by and check on your pet or feed a regularly scheduled meal. Being fed on a regular schedule is important to pets and doing so can make their life a lot less stressful. Try to remember that your dog is a dog and your cat is a cat. They respond to different clues about their place in the family's hierarchy than humans to. Understanding that is particularly important if you have multiple pets. Trying to make their life "fair" may actually be making it much more stressful. Dogs need a social order in which someone is top dog and everyone else has a place in line below that. Fighting that instinct to impose equality is a human trait that dogs do not appear to understand. Cats are more solitary and may need relief from constant attention from children or even a well meaning but persistent adult. Cats really like to have privacy when they urinate or defecate. Providing a litter pan for each cat in the family can relieve a lot of stress in the cats in a household. It is the little things that make life stressful. Not because they are major events but because most mammals respond to minor stresses with the same physiologic tools they react to major stresses with.
Anyone who doesn't think that pets can experience anxiety, fear, stress or pain should hang around a vet's office for a day or so. We know that all of these things are just as real for pets as they are for people. A little bit of stress relief can go a long way in maintaining health.
Heartworm medication - lapse in medication
The monthly heartworm preventatives work to kill heartworm larvae that are 45 days or
less in age and probably closer to 50 days. Since an every 45 day dose would be hard to remember and provide no leeway for error, the pills are approved for monthly use. We tell clients to give another pill if they are unable to remember if they dosed their pet and we can not help them determine if that happened based on our records (usually we can help in a single dog family but it is harder when several dogs are on the same pills in a household). We just check the dates the medication is sold and count pills from there. Administering another pill is safe if one was given at the beginning of a month because the medication is not time release. It doesn't last in the body a month it just kills all the heartworm larvae that have accumulated in the last 30 days. It is pretty much completely cleared from the body in 72 hours. Since it takes 6 months for heartworms to develop to the age they can be tested for an immediate heartworm test is not necessary prior to restarting the medication. It is a very good idea to check for heartworms 6 months or so after a lapse in preventative medications.Mike Richards, DVM
Last edited 12/31/07
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