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 8/13/2001

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