VetInfo Digest

 February 2005

Table of Contents:

Observations

Questioning Evolution

Advice

Grief

Thinking about Thinking

Aggressive Pets

Life's Mysteries

This Month's Note:

I suspect that some of you think that TierCom, Inc., the parent company of the VetInfo Digest and www.vetinfo.com web site, at least resembles a real business. You might envision an office and a staff on duty during regular work hours. In reality there are two computer stations, one in my home and one in Michal's home. Our workforce is supplemented when necessary by Moe, my wife, who handles the mailing of the VetInfo Digest and Susan, our receptionist, who sometimes handles phone calls from people looking for me, as well as helping to fold, stamp and transport the VetInfo Digest newsletters. We have a long standing policy of refusing phone consultations, so please don't hassle Susan about that! Moe and I are full time veterinarians in a small rural practice. Michal is an artist at heart but has been unable to work on her craft for some time due to persistent health problems. She handles the organization and design of the web site whenever possible. Together we own the corporation we initially named TierCom, Inc., before we realized we needed a name that gave a better idea of what we do. So in the vernacular, TierCom, Inc., "trades as VetInfo". We started our company in 1996, went online in 1997 and we survived both the boom and bust of the early dotcom world.

I thought that this month we would try to cover the things that we have learned by providing an online information service pertaining to pet health, some of them medical, some philosophical and some simply practical advice for anyone using a computer these days. When reading this, remember that Michal answers all the mail to our web site that goes to its general address and I answer mail addressed specifically to me. Some people who aren't subscribers seem to be able to find my e-mail address but Michal handles most of the general e-mail and gets most of the hard questions.

Observations

There are a few things that Michal and I have noticed over the years on a pretty consistent basis. One of these is that most of you have competent veterinarians and some of you have absolutely outstanding veterinarians, willing to go way beyond normal boundaries to help you with your pets. I find this most reassuring because some of the mail we have gotten over the years can only be explained by serious judgment errors or just plain lack of caring by veterinarians involved. Thankfully these vets seem to be a very small minority - and I have to remind myself that I have had cases in which I didn't do well, either.

We have also noticed that many of you are not getting enough information about your pet's care to understand what happened. It is hard for you to tell if your pet got good care or bad care because your vet didn't have enough time to adequately explain the pet's problems, his or her explanations were hard to understand or you were struggling with one or two bits of information you didn't understand and missed everything else. I am always willing to try to help you understand what your vet said but there are lots of times when it is better to get the information from your vet, directly. I have some suggestions for accomplishing this without really messing up your vet's busy schedule:

• Most vets have e-mail now. Ask your vet's receptionist if your vet accepts questions from clients by e-mail about pet care. Some vets won't do this but many will. I was very interested in a set of message board postings on a veterinary site about whether vets should give out their e-mail address. A few of the vets felt that a small percentage of clients took extreme advantage of this service but most felt that it was a good avenue for exchanging information at an easy pace for the veterinarian and the client.
• If your vet doesn't have e-mail there is a chance he or she will respond to written questions sent by fax or by regular mail. We do both of these things for some of our clients.
• Finally, some vets set aside a certain time during the day when they will answer questions. I know of a vet who leaves the last half hour of each day open for returning telephone calls and others who try to return calls between certain hours during the day. You will have more success getting a response from a vet who works this way if you talk to the receptionist and let him or her know who you are and what your question is and remember to be available during the time your vet returns calls or work out a good alternative time with the receptionist. My receptionist spends a good part of her day talking to telemarketers, drug salesmen and other folks who can't get through her to talk to me. If a client calls and won't say who they are or why they want to speak to me, she assumes they are a telemarketer and prevents them from reaching me. You will always have a better chance of getting through to your vet if you are polite to the receptionist and able to state clearly what you need from the vet.
• Don't ask your vet questions about your pets unless it is really urgent when you see him or her at a restaurant or other place where people go to relax and get away from the pressures of work. Movie theaters, restaurants and places like this aren't good for consultations. I usually don't mind answering questions in the grocery store or places like that but it can be a problem if I'm in a hurry. Everybody needs some down time and your vet will appreciate you for recognizing their need to relax for a little while.

A number of people have written to me to ask if their vet is doing the right testing or the right examination procedures for the symptoms their pet is exhibiting. After reviewing a great number of veterinary records over the years it is apparent to me that most of you have good veterinarians -- but that all veterinarians, even very good ones, sometimes need help. Don't be shy about asking for referral to a specialist when it seems necessary. In a small number of cases it is apparent that the veterinarian involved in a case isn't doing a very good job. This appears to happen for several reasons and it might help to think about these a little in order to be able to recognize them.

Some veterinarians are just working too hard to take the time to research and think about the occasional truly difficult case that comes along. They look for the common problems and generally do a good job recognizing them but won't reconsider this approach when diagnostic tests or treatment efforts don't support their assumptions. Sometimes it is possible to nudge these vets into doing a better job simply by asking the right questions, scheduling a recheck examination to discuss how your pet is doing or by asking for referral to a specialist if the vet doesn't have any more ideas for diagnosing or treating the case.

There are a few veterinarians who just don't care enough about the job they're doing anymore. One sign of this is irritation or even anger when you ask them questions. Clients have the right to ask questions about their pet's health care. I read an article recently on behavioral patterns among employed vets (those working at a clinic but not owning it) which stated that 15% of associate vets have lost interest in the profession and are working because they haven't come up with a better plan for supporting themselves. If your vet just doesn't seem to care that might really be the case! You have to take the initiative in this situation and insist on seeing a different veterinarian in the practice or moving on to another veterinary hospital if you have to see this person.

If your vet discourages you from seeking the best care for your pet or from asking questions you should find a new vet unless you are really certain that he or she is an excellent vet and that it is worth putting your complete trust in their skill. All vets, even very good vets, get off on the wrong track at times. This can be a bad situation if a vet isn't willing to talk about other possibilities or think about them seriously. Michal is convinced from her correspondence online that a number of veterinarians are condescending to women and that some are just condescending to everyone. Since we don't have any good ideas for teaching vets not to do this we suggest changing vets when it is apparent that your vet believes that you are not intelligent enough to help make decisions about the health care of your pets.

Finally, there are a lot of pets who have problems that are very difficult to diagnose. There are hundreds of case reports of diseases or disorders that have only been recognized in one pet, or a handful of pets. At university practices and other high powered practices around the country pets die without a conclusive diagnosis possible before or after death. Despite the fact that science has provided us with a great deal of information about pet health there is at least as much we don't know about yet. In addition, no one knows all the information available or has access to all the information that is available. Sometimes you just have to live with the fact that it wasn't possible to provide help for a pet or even to know for sure what happened, despite that fact that your vet made his or her best effort.

For those of you who are in business or perhaps just deal with people on a routine basis, I have one important observation on human nature. People will complain even if you give them your best effort and you give it to them for free. We get letters of complaint about our site on a fairly routine basis and we get scorching e-mail from people on occasion. All over information that we, with your help, provide for free. I used to worry about the people who complained about pricing or service in my office almost constantly. It caused me to work towards the lowest common denominator client. It is amazing how easy it is for veterinarians to just assume that they have no clients interested in really good care for their pets and to simply stop offering the best options -- things like kidney transplants for pets in renal failure, hip replacement for dogs with hip dysplasia, radioactive iodine therapy for cats with hyperthyroidism, MRI examinations for dogs with spinal disorders. These types of procedures are expensive but they are often the best possible alternative for the pet. Two things have helped me overcome this tendency --- a client who told me she was disappointed that I could only tell her of two places that did kidney transplants when she found five in her first effort on the Internet and all of you folks striving to find the best possible information for your pets. Don't let the complaints get you down -- it isn't the people who will complain about free advice or free treatment that matter. You can't make those people happy and listening to them just makes it harder to do a good job for the people who really do want your best efforts and who appreciate them.

Questioning Evolution

I guess that the simplest way to start this next paragraph is to note that people just don't always think before they sit down and write an e-mail to us. One of Michal's favorites: being asked to sex a big fluffy seated black cat from its picture. My most amazing e-mail started out "my dog has been sitting in the same position in the same chair for three days. He hasn't gotten up to eat, drink or even to go to the bathroom and he doesn't even look at me when I talk to him..." I think you can figure out that this dog was beyond my ability, or anyone else's ability, to help.

Personally, I am also amazed by the people who start their e-mail with a line like "Are you a real vet? No real vet could be so stupid as to recommend ____ (fill in your personal least favorite drug, treatment, etc.) And then go on to ask a detailed question and finish with a line like, "I know that you offer advice to subscribers but since this is such an important topic I figured you'd answer me for free."

Many people who are smart enough to use computers and to send e-mail still don't seem to be able to process what they are reading. I have received a number of e-mails over the last few years from people seeking advice about human health care issues. Things like "I have a red spot on my elbow that hasn't gone away in two years...." Apparently the fact that there is "Dr." in front of my name registers with them, but the fact that I'm a veterinarian never does.

Michal frequently gets mail from people who are apparently so panicked about a pet's condition that they forget all sense of reason and sit down at the computer to look up something like how to stop arterial bleeding and send an e-mail to ask that question. No matter how fast we respond to e-mail it isn't fast enough if there is a critical emergency. There are times when there is simply no substitute for calling your own vet for immediate advice and/or care or for knowing exactly where the closest emergency veterinary clinic is and going there immediately.

Advice

Our first and most important piece of advice is back up your data, if you want to keep it. Really important stuff should be backed up on removable media and stored in another location. We have survived a number of virus attacks, spyware attacks and system crashes by keeping this most basic piece of advice in mind. Of course, this does include medical records and other information pertaining to your pet!

Our second most important piece of advice is that only a fraction of what you read is grounded in real science (from any source) and that the Internet has at least as much bad advice as good advice -- and probably more bad advice than good advice. To some extent this even includes what we produce. One of the major faults of providing information online is that a critical element of health care, the physical examination, is left out of the process. In addition, the whole story is often not available to us, either. When someone writes and tells us the symptoms their pet is experiencing, then tend to emphasize the ones that concern them. When they talk about how they were treated by their vet, their friends, other pet owners, etc. we get only their side of the story. Never forget that there really are two perspectives, at least, in most encounters between a veterinarian and a client. Never ever forget that anyone with a point of view, right or wrong, can buy a domain name and set up a web site. You should confirm information as best you can before relying on it!

This is Michal's perspective on the above advice:

Much of what I do every day is try to comfort and clarify regarding what is going on with treatment of a reader's ill pet and why. I refer to our pages (Vetinfo) for Dr. Richards' explanations on any topic, I list the differentials for symptoms, the topic pages that will be helpful. If we do not have anything on a disorder I do a web search and try to find a well written explanation of the disease or disorder and refer to that page. I never refer to personal web sites , only to medical. I don't feel qualified to asses the information on a personal web site no matter how well written or intended.

Take the time to think clearly about your situation in an emergency. If it takes an hour to get to the nearest emergency veterinary clinic (EVC) you can't waste much time locating your own vet. If you are very reluctant to go to the EVC but recognize that you have little time to make a decision, take the phone book and your cell phone and call your vet while you're on the way. If you are able to contact your vet and make arrangements to meet with him or her before you get more than halfway to the EVC you can always turn back. Don't make the mistake of assuming that you can tell your pet is only going to live for 45 minutes and it takes an hour to get to the EVC so you aren't going to go (you'd be surprised how many clients do this). I can't tell with precision how long a pet will be able to hold on despite severe bleeding, respiratory difficulties or other life threatening situations. It is worth giving your pet the benefit of the doubt and heading for help.

If you need to write someone to ask for help, say the consumer support department of an appliance manufacturer, don't start the letter out with "I think your appliances are terrible and I'll never buy another one..." Think about what you really need or want and ask politely for help. Don't take away the incentive to write to you and resolve the problem and then ask for help resolving it. If you really are angry with your veterinarian but you need information from him or her or need to talk about what happened when a pet died remember that many veterinary hospitals have a hospital manager now. Often it is easier to talk to this person and let them serve as a middleman to relay your concerns to the veterinarian. I have found that I can sometimes resolve problems I'm having with a specialist or referral hospital by going through the hospital manager so I know this approach can work.

Ask for a copy of your pet's medical records, at least once, to get an idea how seriously your vet takes their care. It isn't possible to tell everything about a vet from their medical records but you can tell a lot from them. If you can't tell what your vet did on the last ten visits by reading the record then the odds are your vet can't tell, either. If the records aren't legible to you the odds are high they aren't legible to your vet, either. My own handwriting is atrocious and I learned very early on that I had to keep records on my

computer in order for them to have any long term value. Some vets don't have this problem so there isn't anything wrong with hand written records when they are legible. If you ask your vet for your pet's records and you get a computer printout that lists all the transactions at your vet's for your pet's life but has nothing else written on it, please do me a favor and ask the receptionist if the printout is a joke. I'm serious. I get more of these printouts than you can imagine when we ask for a pet's records or when clients who are traveling bring "records" with them. If your vet doesn't care enough about the request for records to provide real medical histories you have to wonder how seriously they take the rest of their job. If your vet provides you with a complete medical history of your pet it is a good sign that they take the rest of their job seriously. Like all "rules of thumb" this one isn't perfect, it's just a start.

Grief

One thing that Michal and I have both noticed is that a number of people write us in an effort to get over grief associated with the loss of a pet. People write to us from all stages of grief: anger, remorse, guilt. Some are seeking revenge or to avenge the death of a pet. Some people write with quiet acceptance of the death of their own pet but with the hope of passing on some piece of information they feel might make another person's pet live or that might help to alleviate another pet's suffering. There is a glaring need for veterinarians and their staffs to become better at counseling people about approaching death in a pet and to help with grief after a pet dies. This is not something veterinarians will ever be able to do long term for a person but having some community resources they could refer deeply hurt pet owners to would also be a big help. Hopefully, as pets become better recognized as contributors to and participants in our mental and psychological well being these resources will become available. If you have had a good experience in your own community with someone who helped you cope with grief over a lost pet, let your veterinarian or his staff know. They need the help in locating resources.

The Delta Society maintains a list of support services for grieving pet owners at this URL: http://www.deltasociety.org/dsn000.htm

Michal's take on this issue: I have become a very able grief counselor because people are not able to express their fear and sadness except in an e-mail to a stranger or because everyone around them is treating them like a fool because they have lost a beloved pet not a human and need to get over it. Some of these people I talk to for weeks and then off and on for months. It's OK, I'm glad to be able to help them and saddened that they don't have the personal support systems they need.

One of the most difficult aspects of grief is the long period of deterioration that sometimes occurs when a pet has a chronic illness such as cancer or kidney failure. During all this time there are things to do to help the pet but nothing that will cure her. There are good days and bad days. On the good days it is hard not to control the hope that the problem is gone and on bad days it is difficult to decide whether this is just a bad day that will give way to another string of good days or if this is the bad day when there won't be one more turn around. Almost everyone hopes their pet will simply go to sleep one night and not wake up so they don't have to decide whether euthanasia is appropriate.

Most of the time I can genuinely say in these circumstances that there is a day when it becomes clear that your pet has given up the fight and euthanasia is appropriate. Not all pets have the ability to communicate this time or perhaps some just can't or won't give up, though. When this happens you have to accept that you can't identify the exact right time to choose euthanasia. You just have to make the best judgment you can, with your vet's help and then work as hard as you can not to second guess yourself. These are a few questions that sometimes help when making this decision:

• Will curing the current problem bring your pet's comfort level back to a point where it is acceptable? Sometimes I know that I can completely eliminate a cancer, for instance. If that cancer is growing in a dog who also has severe degenerative joint disease and heart failure, will putting the pet through a major surgery really improve its life enough to justify the surgery even if it is successful? You have to think this through carefully.
• Am I capable of handling nursing care for a severely debilitated pet? If your vet can provide a treatment plan that will keep your pet alive but will require real commitment on your part, do you have the time, resources and ability to provide the care or commitment necessary? If you can't it is best to be honest with yourself about the situation.
• Is my vet prejudiced by my pet's age? I know several vets who won't even discuss expensive options for health care for older pets. They think that the client should spend their money more wisely by getting a puppy. From a strictly monetary standpoint this might make sense but it's your money and if you think providing a few more months of good quality life for your 20 year old cat or 15 year old dog is worthwhile you have to go with your feelings, not your vet's. Michal's take on this: I usually suggest a second opinion or referral if it looks like the vet isn't doing anything or has been wasting a lot of time. Older Dogs are often a problem here -- the vet says nothing can be done - old dog. That can be 9-10 years in a breed that lives to be 14-15. The reader is upset and wants help and help for the dog. Sadly that is not uncommon. I don't like it a bit. Of course you know how I personally feel about geriatric dogs. (Michal has a history of adopting little geriatric dogs)
• Are you thinking about life from your perspective and not your pet's? This is the flip side of the previous question. Realistically, pets don't have really major incentives to live a month or two longer at any cost, as humans sometimes do. Pets don't have to get their affairs in order and they don't have to put things right with a family member they have wronged or been hurt by. They probably aren't capable of having an overwhelming goal like seeing a loved one get married or attending a grandchild's graduation. People will sometimes live with uncontrollable pain or through tremendously debilitating illnesses in order to leave their loved ones a little better off. I know that pets would do this for us if they understood there was a need but fortunately they don't. It is OK to let them go before they suffer just for us.

Thinking about thinking

Americans, on the average, are terrible at science and possibly even worse at math. We also seem to lack the ability to objectively analyze history or medicine or most other topics. I am not thrilled with the new emphasis on teaching children to know standard facts through state and federal testing but neglecting the much more important aspects of education --- how to find information, how to evaluate that information and how to think rationally about the application of information. This is the process that is necessary for people to understand how to help their pets and how to solve most other problems, as well.

I know that this next section is tantamount to picking on some of you but I can't write an article about what I have learned from the experience of writing online without including some of this. There are certain things that people write to me about quite frequently that require suspension of reason to follow. The first of these is that medications, particularly antibiotics and heartworm prevention medications, have ruined the health of large numbers of pets and should be avoided. It should take just a few minutes to think about this realistically using just one example: in the Civil War fought in the United States, the death rate from disease far outstripped the death rate from battlefield wounds. Even in WWI, when the value of proper sanitary procedures was pretty well known, the death rate from disease surpassed the deaths from combat. Then penicillin and sulfa based antibiotics were discovered and in WWII the death rates from disease dropped dramatically and death rates from disease have continued to drop in every war since. Antibiotics went from a new discovery to worldwide acceptance in just a few years. In modern war deaths from all things other than combat typically account for about a third of soldier deaths in war zones and death from infectious disease is a small portion of that third. If antibiotics didn't work or existing medications did work prior to antibiotics, how else can you explain the change?

There is a similar situation with vaccinations. There is no question that vaccines harm a small number of pets. There is also no question that they save the lives of a much larger number. Vaccines should be used appropriately. To deny that they have contributed to the well being of pets is to forget about the huge number of dogs who died when parvovirus hit in the early 1980s, to forget about the huge numbers of people affected by polio and to forget about worldwide devastation from smallpox. There is a reasonable chance that the Americas would still be in the hands of native Americans if there had been a smallpox vaccine and widespread use of it back then. All things can be misused but when this happens it is best to focus on the misuse rather than on the vaccine or medication.

Dr. Samuel Hahnemann wrote the majority of his work on homeopathy, the method of treatment he founded, by about 1811. If it had worked well does it make sense that its use wouldn't have spread as fast as that of antibiotics? Do people really believe that physicians and veterinarians could suppress effective therapies for over a hundred years, even if they wanted to? There are conventional pharmaceuticals that don't work that have been around for a long time -- because there isn't anything that really does work or because the medications that do work carry large price tags or great risks. When safer or less expensive medications are produced for problems they generally spread quickly. When there are safety risks in excess of those reported early on it generally takes just a few years for these to be well known. Homeopathic medications are safe. It's just extremely unlikely that they actually do anything. To date, there is no credible evidence from well constructed scientific studies for benefits of true homeopathic medications, at least according to the alternative medication section of the National Institute of Health.

Veterinarians have a hard time saying "I don't know what's wrong with your pet." I'm not sure why, because it should be pretty obvious to anyone who thinks about it for a minute or two that no veterinarian will ever know everything. People seem to have a hard accepting that a good veterinarian could say "I don't know what's wrong with your pet." This makes the problem with vets worse. As long as your veterinarian is willing to do everything he or she knows how to do to find a diagnosis and is willing to refer your pet to specialists when that doesn't work, there should be no problem admitting that he or she is uncertain about what is wrong - for the vet or the client. Along these lines if you seek a second opinion remember that the second vet isn't perfect either -- think about who might actually be on the right track before blindly accepting the second opinion.

Aggressive Pets

Neither Michal or I are behaviorists. We have both spent a lot of time reading about behavioral issues and I have spent a lot of time working with aggressive dogs in our practice. We get a lot of questions about aggression. We have only three guidelines to follow.

• Try to be sure that there isn't a medical cause for aggression, especially when it is a new behavior in a pet who has not shown signs of aggression in the past. Dental problems, back pain, arthritis and a number of other medical conditions can lead to chronic grumpiness or snapping when a pet is moved or disturbed. Especially in older pets it is reasonable to try pain relief medications even if there is no sure sign of a painful condition.
• If aggression is recurrent and if children or unsuspecting adults are involved you have to provide security for them. This may mean keeping the pet completely and securely separate from the children at your home, finding an alternative home -- something that should be done only if the circumstances are such that this is not an irresponsible act -- or considering euthanasia. No treatment program or medication for aggression is completely successful and dogs, in particular, are capable of seriously harming children and even adults.
• Work with a knowledgeable behaviorist if at all possible. I am biased, probably, but I think that a board certified veterinary behaviorist is the best choice. Unfortunately, there aren't enough of them to service even 1% of the need. Other options are members of the International Association of Animal Behavior Consultants - www.iaabc.org. or the Animal Behavior Society - www.animalbehavior.org. It takes time, effort and sometimes medication to get control of an aggressive pet but control can be achieved in many pets with a serious effort.

Life's Mysteries

And finally, the answers to the two questions that seems to pop up repeatedly on every bulletin board I have seen about pet health and in our e-mail, as well:

• No one knows why dogs eat poop but it makes the most sense that they eat it because they find its taste appealing for reasons humans can't understand.
• No one knows why cats like to eat grass but it isn't because they have upset stomachs. At least not all of them.

We thank you for your support. Especially those of you who disagree with us about some issues, like homeopathy, school testing, the existence of evolution or feeding raw meat diets!

We are happy to simply agree to disagree.

The VetInfo Digest is published by:

TierCom, Inc.

P.O. Box 476

Cobbs Creek, VA 23035.

The opinions expressed in this newsletter are those of Michael Richards, DVM., author.

Copyright 2005, TierCom, Inc.