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VetInfo Digest November 2005

Table of Contents:

More than One Problem

How Much Medication?

Is Anyone There?

When not to see your vet

Alternative Medicine

Drawing the line on Vaccines

Thoughts on Specialists

This Month's Note:

Veterinarians do some things that frustrate pet owners. Some of these things are the result of laws or regulations governing veterinary medicine. On the other hand, some are simply customs in the veterinary community or are the result of a practice style that is hard for a veterinarian to change. Veterinary clients themselves are the cause of a few of these problems, as well.

This month's VetInfo Digest is an attempt to explain a few of the misconceptions, problems and communication difficulties in veterinary practices. Knowing some of this background information may be helpful when you need to discuss a problem with your vet. In some cases it might even help you avoid the problems altogether.

Some Pets Have More than One Problem

Veterinarians tend to want to diagnose a single cause for illnesses In young veterinary patients it is not uncommon for a single disease to be the cause of multiple clinical symptoms. In many instances in which more than one disease organism or process is occurring correction of a single cause will still result in a reasonable cure rate since the elimination of one problem often makes it possible for the pet's immune system to handle other problems that are present. These factors tend to encourage the bias towards searching for a single disorder or disease that is causing all of the symptoms rather than considering the possibility that more than one disease or disorder is present.

As pets age it is much more common for more than one disease to be present. Chronic illnesses involving the kidneys, liver, heart or other organs are not uncommon in older pets. When another illness occurs it will often exacerbate any chronic disorder that is present. This can lead to difficult diagnostic challenges for the veterinarian. The need to consider the possibility of a second, third or fourth disorder affecting the pet increases with age.

If you have an older pet and you find yourself thinking that there just has to be something else wrong after your vet has made a diagnosis you may not be wrong. If your pet continues to exhibit symptoms that bother you even though a problem seems to be partially responding to treatment, ask your vet if there is a possibility that a second illness is contributing to your pet's symptoms.

How Many Medications is Enough?

Most veterinarians want to dispense one or two medications rather than three or four medications, whenever possible. Most pet owners have some difficult administering medications and generally prefer to keep medication administration to a minimum. Some diseases really require multiple medications for best treatment, though. Chronic renal failure and liver disease are two examples.

It is pretty common for me to get e-mail messages asking if a vet is doing enough when a pet has kidney or liver disease. Most of the time there are treatments that might help that aren't being administered for these conditions. It would be reasonable to use five or six medications at the same time for kidney or liver disease and there is definitely evidence to support the superiority of using multiple medications if they are administered properly. This, of course, is the rub.

There are several studies that show that pet owners don't give medications as directed as much as 75% of the time. Most veterinarians also see a tendency for pet owners to burn out if they make a huge effort to treat a disease early on and do not see discernible evidence that the medications are helping. Lots of times clients quit using medications even when it is obvious they are working. When clients stop using medications it sets up a conflict with their vet. It is not uncommon for vets to simply avoid this conflict by refusing to dispense more than two or three medications, even though they know that other medications might be helpful.

You may have to convince your vet that you are willing to give multiple medications over the course of the day if that is what is optimal for your dog or cat's medical conditions. If you ask your vet, "Isn't there more that can be done?" be sure that you really want to do more if the answer is yes.

Does Anyone Watch My Pet at Night?

Most veterinarians who hospitalize pets do not have staff members on site twenty-four hours a day. In many instances there is no one at the hospital from shortly after closing time until shortly before opening hours the next day. It surprises me that many veterinary clients have no idea that when a pet is hospitalized in a veterinary hospital the odds are better than 50% that no one will be there to watch over them from the time the veterinary office closes until the next morning when it reopens again. Some veterinarians do schedule hospital checks at night but there is not continuous surveillance at most veterinary hospitals.

For some time I have felt that it is best for veterinary patients to be at home with their owners or referred to a 24 hour care facility when hospitalization is truly necessary. I have had some lively discussions with other veterinarians about this issue. Some feel that a pet is still better off in a secure cage overnight after a surgical facility than running around a household. Others think that making sure the pet is examined the next day is worth taking a small risk at night. Still others think that pet owners expect their pet to come home without any sign of bleeding, drowsiness or post-surgical pain and that the only way to ensure that is to hospitalize them.

We have a number of clients who want us to hospitalize pets when the pet has diarrhea, vomiting, any possibility of bleeding or any other condition that might lead to soiling of the house or might require nursing care from the owner. Even at the owner's request we won't leave animals in the hospital at night except when there appears to be no alternative. I know of two veterinarians in my area whose hospitals have burned down with patients in them and I know of a number of incidents in which pets died while being kept in a veterinary facility overnight from conditions that might not have been fatal if someone had been present to check on the pet at night.

My best advice for covering this conflict is simply to ask your vet is someone will be there at night to watch your pet if you are asked to leave it overnight. If not, ask about taking your pet home or transferring your pet to an after hours clinic at night, such as a local emergency clinic, so that it is watched throughout the night.

When it Might Not be Best to See Your Regular Veterinarian

Veterinary clients often want their veterinarians to be available for emergencies twenty-four hours a day. Realistically, this isn't possible, although some veterinarians make a really determined effort to meet this standard. At one time in my career I was one of those vets. After a few years I found that I was often too tired to think really well and that I was putting off continuing education and even keeping up with journals and other sources of information. This wasn't good for me and it wasn't good for the majority of my patients. There is no question that it is comforting in an emergency to deal with someone you know and trust but there are other considerations.

When I do see a pet on an emergency basis at night I don't have the support of my staff, which means there is no one to help with restraint of the pet, no one to monitor anesthesia if it is necessary or to tend to necessary nursing care. These things increase the risk of mortality, they increase the liability for the veterinarian and they even increase the risk to the client of an injury.

If the pet goes to an emergency center the staff is there to meet the needs of the pet and the veterinarian providing services. The equipment for emergency care is usually available and often the veterinarians have additional training in emergency or critical care medicine. These benefits are balanced by the tendency for emergency clinics to charge more for their services and to be very busy at times. Overall, though, there is little question that from a purely medical or surgical standpoint most pets are much better off being seen at an emergency clinic than by a veterinarian working alone.

"Alternative Medicine"

Lots of clients want to talk to me about herbal, homeopathic or other "alternative" treatments when I am working on their pet. I have no problem discussing these alternatives and we use a small number of therapies that most vets would consider to be outside the mainstream of veterinary medicine in our practice. Despite this, it is not uncommon for a client to ask about a treatment that I have not even heard of.

To answer a question adequately I have to have time to research the suggested treatment and to formulate an opinion of its use. This is no problem for chronic conditions but it isn't something that I can always afford to do during a regular office visit for a pressing problem. In these situations I may have to work quickly enough and with enough concentration that it is detrimental to ask about forms of therapy I'm not familiar with right at that moment. To avoid this problem it is probably best to choose a veterinarian who uses therapeutic methods that you favor and then to trust that vet, at least until there is time to research a problem. If you are already in the midst of an emergency, let your vet work with the methods that he or she is most familiar with because the odds are better your pet will have a good outcome if the vet following protocols that have been successful in the past. There are a number of suggested treatments for various conditions that I have researched and do have an opinion on. When these alternative treatments seem to work I try to use them. When it is apparent they aren't likely to work I usually make no effort to stock them or use them. If your vet is familiar with a therapy, knows the pros and cons of that therapy well enough to explain them and doesn't want to use the therapy you should listen carefully before ignoring the advice and using a treatment, anyway.

Sometimes a client really wants me to endorse a form of therapy that I feel won't work for the treatment of their particular pet. I usually try to explain why I think the treatment should not be used but some clients press quite hard for a detailed response. We do not schedule our office visits with this type of discussion in mind and it isn't always possible to provide time for a good discussion. If this happens to you and you feel a strong need to discuss alternative therapies with your vet, schedule an appointment to discuss the alternative therapy. This is usually sufficient to ensure that your vet will be reading up on the therapies you are interested in and trying to come to some conclusion about them prior to meeting with you.

Drawing the Line on Vaccines

Some veterinarians have not adopted an every three year vaccination schedule for core vaccines at this time. I doubt that this causes much problem for dog owners but if you own a cat and your veterinarian is giving feline leukemia vaccine or rabies vaccine yearly and using any product other than Purevax vaccines from Merial it would be best to find another veterinarian, at least for handling vaccinations for your pets. Just to make sure that there is no suspicion of a conflict of interest, I don't work for Merial or benefit from any other association with them. These vaccines are the only ones that don't have adjuvents in them available for these particular infections. Since adjuvents are thought to be the cause for cancers forming at vaccine sites there is no reason to take on the risk of yearly vaccination for these infections without taking the precaution of using Purevax vacccines. If other companies produce non-adjuvented vaccines in the future I will be sure to put that information in future issues of the VetInfo Digest.

Why Won't My Vet Send my Pet to a Specialist?

Based on the email questions that I get there are veterinarians who are very reluctant to refer their patients to veterinary specialists. This problem is probably best resolved by switching veterinarians. This might sound harsh, but if a veterinarian refuses to refer cases to specialists at all I worry about whether they are afraid their work will look bad when reviewed by someone else. Another problem, which can be just as vexing for the client is when a veterinarian refuses to refer to a specific specialist or to the closest specialist. It can be hard to understand why your vet wants you to drive 200 miles to a specialist in internal medicine when there is one in the neighborhood. Sometimes there are good reasons for this practice, though.

It is important for the general practitioner and the specialist to agree in general on the type of care that is expected. It is also important that the generalist and specialist communicate well. If they really don't like each other this can present severe problems. When the closest specialist just doesn't mesh well with your vet's practice style or personality he or she may want to refer you to a specialist who is farther away. If you value the relationship with your vet it is probably better to see the specialist they prefer to work with, even if it is a little more of a hassle for you.

There are some exceptions to this rule. If you can figure out why your vet doesn't like to refer to a specific specialist you might find that it really doesn't matter all that much for your pet's condition. A dental specialist with a general practice might make your vet hesitant to refer since there is a risk that you will be "poached" by the specialist's practice. This isn't really a reasonable concern on your vet's part, though. If your vet is afraid that the specialist's charges will bother you and that disappointment over them would threaten the relationship with you, that may not concern you much, either. On the other hand, if your vet tells you that too many of his clients are put off by a specialist's personality or that the results of past referrals have been disappointing you should pay attention.

You're My Vet, I Don't Want to See a Specialist!

A few of my clients think that I refer them to specialists too often. We practice in a rural area and it is hard for me to gain expertise in some surgeries, particularly orthopedic surgeries. I refer most of my patients who need orthopedic surgery to a specialist. We make good use of veterinary dermatologists, internal medicine specialists and ophthalmologists, as well. I believe that the availability of these specialists is good for my practice and my patients.

I think that sometimes clients are confused by the goal of sending their pet to a specialist. I am a good general practitioner and I care about my patients but I will never have the concentration of knowledge concerning specific areas of care that specialists can acquire. It isn' possible to develop great familiarity with unusual skin diseases unless you are seeing mostly skin disease patients, for instance. This is true for eye problems, internal medicine problems and many other areas of care. It is also hard to acquire the specialized instrumentation necessary to provide some types of care unless those instruments will be used enough to pay for themselves. It is a rare general practice that can justify an MRI machine, an operating microscope, color doppler ultrasound or all the sizes of endoscopes necessary to be able to provide diagnostic support for all body regions. When these types of things are necessary to make a diagnosis or provide treatment I refer to specialists. This is what is best for my patients and truly caring about them requires taking the steps to make sure they get the best possible medical and surgical care.

Read the Record

My personal pet peeve about veterinarians is the tendency to give a computer printout of transactions when asked for a medical record. There is simply no justification for this practice. A medical record should enable anyone who reads it to know something about the state of a pet's health, what specific information medical decisions were based on, what treatment plan was followed, what vaccinations and other preventative health measures have been taken and perhaps even the alternatives a veterinarian considered as diagnostic or treatment options. A computerized list of transactions doesn't fulfill these criteria.

I do have to admit that computerized transaction lists are at least legible. Someone with my handwriting skills has to be very careful when discussing the value of legibility for documents. I can just barely read my notes at the end of the same day, much less a year later. So I type my records into the computer management software that we use to run our clinic. It does take a little more time than scribbling on a piece of paper but I can read what I was thinking the next day or the next year and so can anyone else who gets a copy of the history. That is the point of taking a medical history and it is a very important point. It is hard to imagine the value of medical records until you have legible useful records to look at.

This is an important enough issue that I think it is reasonable to ask for a copy of your pet's medical record just to see what you get. If your veterinarian's receptionist hands you a summary of your transactions with the clinic over your pet's lifetime, there is good reason to think that your vet doesn't take record keeping seriously. In an emergency or in the case of a serious chronic illness this can be a life threatening deficiency.

Refusal to Help With Blood Glucose Monitoring at Home

There is no better way to manage the dosing of insulin for pets who are dependent on it for control of diabetes than by blood glucose measurement at home. There is no question that monitoring frequently, up to four times a day, is better than spot checking glucose levels. When veterinarians claim otherwise they are ignoring a substantial amount of data that proves these points in humans and in pets. All blood glucose monitors tested for this purpose, to date, have proven adequate for the task. There are reasons why veterinarians are reluctant to suggest blood glucose monitoring at home for all clients but no reason that I can think of to discourage owners who are ready and willing to try to provide this level of care for their pets. Based on e-mails to me, though, some vets actively resist helping their clients learn to monitor blood glucose at home.

It can be difficult, especially the first month or so of trying, to obtain blood from a pet with diabetes. With persistent effort almost all of my clients can learn to get blood. Over 50% of my clients learn to get blood on a regular basis and even more can do it at least occasionally. This is a significant portion of the clients who have diabetic pets.

If your pet is diabetic find a vet who will work with you to help you learn to monitor the diabetes at home. Use one of the new machines that only needs a small drop of blood to make this process easier. Don't get discouraged if it takes you several weeks to get good at obtaining blood and several months to really understand the value of charting the glucose measurements. Most pets will always need insulin making the effort worthwhile. You may save your pet's life if it is one of the lucky ones who can gradually be removed from insulin over time. This is an issue that is worth changing vets over.

When You Need More Information

A legitimate complaint that many veterinary clients have is that they don't get enough information about the disease affecting their pet, the diagnostic and treatment options and the medications that are dispensed to treat a condition. There simply isn't time to tell every client every detail of everything that I do for each pet during the day. We try to cover the most pertinent risks and the options for diagnosis and treatment we consider to be most applicable but we don't cover everything that could be discussed for any patient we see in a day. If we tried to do this we might be able to see one or two patients a week.

Most veterinarians make a real effort to discuss the most important aspects of a pet's problem with its owners. You can facilitate this process by coming to the office prepared to listen to your vet. If you have a pet who is ill don't bring two other pets along for the office visit because they need their nails trimmed or their yearly physical exam is due. If you can, leave children at home when you bring a pet to the vet's whose problems may require that you listen to and comprehend instructions concerning care. If you have specific questions that you want answers to, write them down and bring them with you. Try to give important symptoms or historical clues to your vet but also try to keep this information as concise as possible so that your vet doesn't get distracted by unnecessary information.

Call your veterinarian and ask for an explanation if something wasn't communicated well enough that you remember it. If you are struggling to understand information set up an office visit with your vet to discuss what you need to know. Get your vet to write down a couple of additional sources of information you can check out. And of course, don't forget that we will try to help if asked. Remember that even with all this effort there will be times when you still need to research some information on your own.

This problem is the whole reason that Michal and I started the vetinfo.com web site almost a decade ago. We felt that there should be a good source of information online about pet medical conditions, medications and diagnostic and treatment options. It is somewhat ironic that we still have this problem in our own practice, though. It just isn't possible to be certain that every client knows everything they want to know about their pet's condition and that they will continue to remember the explanations when they get home. We try hard but there are times when we fail in this aspect of our mission. We have to depend on our clients to follow up and to let us know when they need more information. We count on our clients to participate in the care of their pets so that pets get the best possible care.

Thanks for your Support!

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.