Class of 2015... How ya doing?

[Trilt]

I cannot for the life of me remember... What specialties are you guys going for?

pretty sure Stigma's surgery and Jayna clin path. Amusingly diametric.

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[scb44f]

P.S. taking the internal medicine class intended to prepare the LAIM residents for boards was the least delightful part of my internship (as an intern, I had duties equivalent to the residents I worked with minus the stress of boards/case reports and extra classes... So I cannot fully commiserate, but I get the gist!)

 

[scb44f]

pretty sure Stigma's surgery and Jayna clin path. Amusingly diametric.

Ahh thank you!! Good luck to you both!!

 

[JaynaAli]

pretty sure Stigma's surgery and Jayna clin path. Amusingly diametric.

Diametric, but with an occasional meeting. Phase 1 for path is general pathology, meaning essentially in-depth pathophys of things like inflammation, immunology, neoplasia, hemostasis, etc. (so many enzyme acronyms!) I just finished a chapter on wound and bone healing, which a Surgery resident here told me was on her study topic list as well.


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[SocialStigma]

Diametric, but with an occasional meeting. Phase 1 for path is general pathology, meaning essentially in-depth pathophys of things like inflammation, immunology, neoplasia, hemostasis, etc. (so many enzyme acronyms!) I just finished a chapter on wound and bone healing, which a Surgery resident here told me was on her study topic list as well.


Sent from my iPhone using SDN mobile

Yep, and interpretation of cytology/histopath images and bloodwork/urinalyses are fair game on surgery boards as well.

 

[that redhead]

Life has just been hell lately. My cases have been really sad, complicated and/or people not following my simple, basic recommendations and then want to complain their animal is no better. I feel so overwhelmed, frustrated and sad about everything.

Finally I get my weekend (had to work yesterday) and last PM was the first night of farm sitting for our friends/neighbors. She tells me to keep an eye on one of the cats (it's a long story...she shouldn't HAVE these cats but what do I even know) because there was some bloody urine or poop or something. Uhh...Get there to scoop the box and the one is posturing and producing tiny amounts of urine repeatedly. So I drive BACK into work to get some basic meds (prazosin is out of stock by some cruel twist of the universe) and have my hubs hold for poking then lock the kitty in the bathroom overnight. Still repeatedly attempting to go this AM but producing slightly more amounts and bladder has remained small throughout. But SERIOUSLY?! The damn thing is like 6mos old.

Also, we're going out of town ourselves right after Thanksgiving and I asked my sister like a month ago if she could watch the dog. She says she still doesn't have her schedule and while I know that she'd be honest with me if she didn't want to watch him, it's still frustrating and stressful and I hate feeling like I have to scramble to get something arranged for him.

I just want to crawl in a hole and never speak to anyone ever again

 

[Coquette22]

That all sucks TR. We've had some crap cases too lately, seems like the holiday euthanasia season comes earlier and earlier each year. Just a slew of nice pets with crap diagnoses combined with the usual uptick in old pet euthanasias.

Also prazosin is out of stock for you? Yikes! This is prime stressed out cat season! The boys need to be able to pee!

 

[scb44f]

The clinic I work for doesn't even carry prazosin so I feel your pain!

 

[cowgirla]

FYI, most human pharmacies carry prazosin 1mg capsules, as well doxazosin 1mg, which is a tablet.
We usually get our prazosin compounded into tiny tabs, but I've scripted out in a pinch.

 

[Trilt]

The clinic I work for doesn't even carry prazosin so I feel your pain!

I literally just ordered it for our clinic a week ago...

 

[scb44f]

I literally just ordered it for our clinic a week ago...

Yeah. I worked on getting gabapentin first.

 

[scb44f]

In other news, I bought a printer (my first one since the divorce 3.5 yrs ago) and set it up today. Either I'm getting older and am no longer tech savvy or this thing was a bitch to get working. Of course, I vote the latter.

 

[Trilt]

In other news, I bought a printer (my first one since the divorce 3.5 yrs ago) and set it up today. Either I'm getting older and am no longer tech savvy or this thing was a bitch to get working. Of course, I vote the latter.

Don't worry, printers exist in their own dimension where they are a pain in the ass regardless of tech savvyness.

 

[that redhead]

Started my new job yesterday. So many people doing so many things, all so very efficiently. A LOT of differences from my old place (in good ways) and I have a lot to learn but as my old friend/coworker said, at least I already have a good handle on the vet stuff and don't have to learn all that at the same time! Surgery time with the boss lady on Friday and I'm terrified I've forgotten what the heck sterility really means...guess we'll see if I remember how to gown myself

 

[LetItSnow]

Started my new job yesterday. So many people doing so many things, all so very efficiently. A LOT of differences from my old place (in good ways) and I have a lot to learn but as my old friend/coworker said, at least I already have a good handle on the vet stuff and don't have to learn all that at the same time! Surgery time with the boss lady on Friday and I'm terrified I've forgotten what the heck sterility really means...guess we'll see if I remember how to gown myself

Man. Sterility is an interesting topic in general.

I mean, I practice good sterile technique for open surgery. We use all the latest neato toys 'n stuff - disposable gowns, massive draping of multiple layers, Ioban draping (my nursing staff LOVE these since they redirect liquids away from the pet so the pet doesn't recover from surgery with a soaked back) - full gown/glove/cap/mask/booties ... etc. All that jazz. You walk into our operatories and it's like a scene from a movie with more blue than the ocean.

But I keep wondering how much of it is truly necessary.

In my perfect world where I have all sorts of free time and unlimited funding, I'd love to dive in more deeply research-wise to when sterile technique is actually needed, to what extent it's necessary, etc. There's a lot of opinions in the literature, and a lot of the research is procedure-specific, or speculative, or flawed. Kinda amazing what we don't really know.

 

[Coopah]

Man. Sterility is an interesting topic in general.

I mean, I practice good sterile technique for open surgery. We use all the latest neato toys 'n stuff - disposable gowns, massive draping of multiple layers, Ioban draping (my nursing staff LOVE these since they redirect liquids away from the pet so the pet doesn't recover from surgery with a soaked back) - full gown/glove/cap/mask/booties ... etc. All that jazz. You walk into our operatories and it's like a scene from a movie with more blue than the ocean.

But I keep wondering how much of it is truly necessary.

In my perfect world where I have all sorts of free time and unlimited funding, I'd love to dive in more deeply research-wise to when sterile technique is actually needed, to what extent it's necessary, etc. There's a lot of opinions in the literature, and a lot of the research is procedure-specific, or speculative, or flawed. Kinda amazing what we don't really know.

Apparently there was a study done in the seventies where there where several trials of nonsterile technique used, I heard of it second hand so I don't have the specifics but the rate of infection was like 1%. So I have no idea how much we're helping with the sterility but it's an interesting concept.

 

[LetItSnow]

Apparently there was a study done in the seventies where there where several trials of nonsterile technique used, I heard of it second hand so I don't have the specifics but the rate of infection was like 1%. So I have no idea how much we're helping with the sterility but it's an interesting concept.

Well, I'd argue there's a huge difference between 1.0% and 0.1%, right? I mean... I <personally> don't want 1 out of every 100 procedures I perform to have a perioperative infection complication (plus whatever other typical complications might occur). It doesn't sound like a high number until you start thinking about the number of procedures you (might) perform.

But it's still an interesting point, because every add'l bit of protocol we put in place costs money, whether it's in terms of time or materials. So there's at least a reasonable discussion to be had about cost/benefit of incremental reductions in complication rates.

In the human world, and more and more the pet world, that's a discussion people are afraid to have - we're becoming so incredibly risk-averse (at least in the U.S.) that almost NO risk is tolerated - one of the contributing factors in outrageous costs of medical care.

 

[Coopah]

Well, I'd argue there's a huge difference between 1.0% and 0.1%, right? I mean... I <personally> don't want 1 out of every 100 procedures I perform to have a perioperative infection complication (plus whatever other typical complications might occur). It doesn't sound like a high number until you start thinking about the number of procedures you (might) perform.

But it's still an interesting point, because every add'l bit of protocol we put in place costs money, whether it's in terms of time or materials. So there's at least a reasonable discussion to be had about cost/benefit of incremental reductions in complication rates.

In the human world, and more and more the pet world, that's a discussion people are afraid to have - we're becoming so incredibly risk-averse (at least in the U.S.) that almost NO risk is tolerated - one of the contributing factors in outrageous costs of medical care.

Yup valid points, I just want to look it up to see what the actual numbers are because you have me curious

 

[LetItSnow]

Yup valid points, I just want to look it up to see what the actual numbers are because you have me curious

Stuff like this just INTERESTS me. I've had a lot of discussions with my MD sister about human medicine's perpetual push for "what can we do" rather than "what should we do." She works in pediatric intensive care cardiology, and some of the cases she shares with me ... she just anguishes over the fact that she regularly has to pour thousands upon thousands upon thousands of dollars worth of care into patients that have essentially zero chance of survival (or at least any reasonable quality of life).

That's getting away from the sterility issue, but there's some overlap there in that everything we do to improve sterility costs <something>, and we frequently don't sit down and take the time to think about whether that cost makes sense. We just leap to "hey, it gets us a lower complication rate, so we should definitely do it!"

 

[Skimble]

Apparently there was a study done in the seventies where there where several trials of nonsterile technique used, I heard of it second hand so I don't have the specifics but the rate of infection was like 1%. So I have no idea how much we're helping with the sterility but it's an interesting concept.

I recall being told in class that there was a study regarding scrubbing prior to gloving and it really didn’t make any difference.

 

[LetItSnow]

I recall being told in class that there was a study regarding scrubbing prior to gloving and it really didn’t make any difference.

Be interesting to read if they included cases of needle penetration, glove breaking, etc. Or if the study only included procedures without glove failures. There are pretty good studies showing a pretty high rate of glove puncture, also demonstrating that most of the time surgeons are unaware of it.

And, gloves are also intended to protect the surgeon (obviously way more important in human medicine).

There are studies demonstrating that brush scrubbing is contraindicated. But we're all still taught to do it.

None of us use brushes where I work (including our surgeons for orthopedic work); just Avagard lotion, glove, and go....

 

[DVMDream]

Be interesting to read if they included cases of needle penetration, glove breaking, etc. Or if the study only included procedures without glove failures. There are pretty good studies showing a pretty high rate of glove puncture, also demonstrating that most of the time surgeons are unaware of it.

And, gloves are also intended to protect the surgeon (obviously way more important in human medicine).

There are studies demonstrating that brush scrubbing is contraindicated. But we're all still taught to do it.

None of us use brushes where I work (including our surgeons for orthopedic work); just Avagard lotion, glove, and go....

So interesting. We scrub brush and then glove for surgeries. I do gown for all abdominal procedures, but for simple mass removals, cat neuters and dog neuters I don't wear a gown. I do wear a cap and mask for all procedures. Except dentals... dentals I only wear a mask and only for my own protection.

I have noticed once that I must have punctured my glove because when I took them off my finger was covered in blood. I placed pet on antibiotics as a "just in case", probably really not necessary but definitely felt better having something as a "just in case". Especially since it was an abdominal procedure. I don't really feel like flirting with peritonitis.

I punctured my glove another time but I noticed and immediately changed them. So didn't do antibiotics for that one.

 

[Coquette22]

As a very small sample size....
At my previous clinic, every thing got eirher convenia, penicillin or TMS perioperatively, and when they briefly tried to stop doing that, post-op infections shot up. Generally, spays and neuters were done with cap and mask, Avogard and gloves, no gown, single drape, needles from cold sterile and a spool of chromic.* (Anyone see why I might have left?)

Current practice is AAHA, so gowns, caps, gloves, full brush scrub, etc. I don't use booties but my shoes are dedicated surgery only, I do mask and eyewear for dentals for my own protection. Single fenestrated drape, though we have quarter drapes if needed. Cat neuters I'll just use gloves though.

*I rarely did surgery but when I did, I gowned, brush-scrubbed, gloved, used a new pack of suture and didn't use antibiotics and mine did fine.

 

[that redhead]

Man. Sterility is an interesting topic in general.

It really is. Old habits die hard as they say

Where I was, no one scrubbed at all, just "sterile" gloved (the package was sterile...when it was opened, a while before surgery even happened, and who knows who might have touched it to move it/etc.) Patients were clipped on the surgery table with disgusting clippers that were cleaned occasionally. People bare-handed cat neuters. Disposable drapes were reused for months. There wasn't a gown in the entire practice, never mind a cap or mask. Anecdotally, I had a handful of surgical site infections and I know I doubt I hit 100 procedures. Was some of that related to my slower surgical time as an inexperienced surgeon? Probably

I agree that some degree of what we're taught and what is practiced in the specialty hospitals is likely unnecessary and the cost must be outrageous for what you describe. But I sure feel a lot better about being in a place where at least people seem to care about a basic level of sterility (and patient care overall, but that's another story...)

 

[LetItSnow]

But I sure feel a lot better about being in a place where at least people seem to care about a basic level of sterility (and patient care overall, but that's another story...)

Yup! Don't misunderstand me - I care about sterility, and I'd go nuts practicing in the situation you described at your previously practice.

I just think the lengths we go to often don't have much actual evidence to support them, and in some cases have evidence to suggest they aren't best practices - and we could do a better job considering the cost of those versus the (sometimes imagined?) benefits.

Some of the stuff - like the Ioban - has incidental benefits. Our techs love the Ioban since it redirects fluids away from the animal, which helps keep post-op temps up, which is good for the patient and makes my nursing staff happy. But some stuff - like booties - doesn't have a ton of evidence to support it (especially if you use shoes that stay in the hospital 100% of the time), may have evidence to oppose it, and just costs money with little to no benefit.

Dunno. I just find it all pretty interesting.

 

[that redhead]

Some of the stuff - like the Ioban - has incidental benefits. Our techs love the Ioban since it redirects fluids away from the animal, which helps keep post-op temps up, which is good for the patient and makes my nursing staff happy.

That sounds pretty cool - I'd imagine it's even more awesome at an ER place where you probably go into a lot of bellies regularly.

 

[LetItSnow]

That sounds pretty cool - I'd imagine it's even more awesome at an ER place where you probably go into a lot of bellies regularly.

I personally do less and less surgery all the time. When I started here I was at one of our 'satellite' ERs (standalone, ER-hours only) and did a lot of cutting. Now I'm more and more (probably 80% of my time now) at one of our 24-hr referral facilities (with IntMed, Sx, etc.), so most of the time I turf surgical cases to a surgeon. I still occasionally cut things that are either easy (a gastrotomy or some "just ate it yesterday" FB) or time-sensitive (GDV) or when the on-call surgeon is already occupied at our other referral facility.

I did a facial mass removal yesterday. Kinda laughed, because I can count on one hand how many "mass removals" I've done ... ever. But it was quiet on ER, the mass was bleeding, and it just seemed easiest to take it off and be done. Usually it's pretty tough to argue that 'mass removals' are emergent.

But yeah, check out the Ioban. You might like it.

 

[cheathac]

I personally do less and less surgery all the time. When I started here I was at one of our 'satellite' ERs (standalone, ER-hours only) and did a lot of cutting. Now I'm more and more (probably 80% of my time now) at one of our 24-hr referral facilities (with IntMed, Sx, etc.), so most of the time I turf surgical cases to a surgeon. I still occasionally cut things that are either easy (a gastrotomy or some "just ate it yesterday" FB) or time-sensitive (GDV) or when the on-call surgeon is already occupied at our other referral facility.

I did a facial mass removal yesterday. Kinda laughed, because I can count on one hand how many "mass removals" I've done ... ever. But it was quiet on ER, the mass was bleeding, and it just seemed easiest to take it off and be done. Usually it's pretty tough to argue that 'mass removals' are emergent.

But yeah, check out the Ioban. You might like it.

Is getting burned out in emergency med as easy as I have read? I see a lot of job openings for 3 days on 4 days off type of thing that doesn't seem all that bad, but those 3 days could become pretty rough I would think. I've not really had much experience with emergency, but it seems interesting. Will probably have to wait until 4th year to see if I actually like doing it or not!

 

[that redhead]

Now I'm more and more (probably 80% of my time now) at one of our 24-hr referral facilities (with IntMed, Sx, etc.), so most of the time I turf surgical cases to a surgeon.

That seems to be the trend with our local referral places. There are still the stand alone, ER-only shops but the places I tell people to go to have the in-house specialties alongside. I consider myself really lucky to have a ton of places to refer things to very nearby, almost all with more than one option. Unfortunately, I think that sort of convenience has made the older generation of vets (and a lot of "old-timey" clients) grumbly because they say the newer vets just want to turf everything accordingly. But why not offer a specialist if there's one 5mins away and you get better medicine for it? Humph.

 

[DVMDream]

But why not offer a specialist if there's one 5mins away and you get better medicine for it? Humph.

$$$$$$$$$$$$$$

Owners want you to do specialist work for at least half if not a third to a quarter of the price. Oh and don't make any mistakes either or have any complications occur because they'll sue.

 

[LetItSnow]

Is getting burned out in emergency med as easy as I have read? I see a lot of job openings for 3 days on 4 days off type of thing that doesn't seem all that bad, but those 3 days could become pretty rough I would think. I've not really had much experience with emergency, but it seems interesting. Will probably have to wait until 4th year to see if I actually like doing it or not!

Well, I've never worked anything but ER so it's hard for me to compare our burn-out rate to GP or other specialties, yanno?

Here's a longer answer than you probably want.

I feel like the fairest answer is that ER work is for some people and not others, just like anything. If you can handle high-stress cases and not let it get to you when they don't go well, you'd probably do fine. Some people just don't like that pressure. And, yanno, 90% of the cases are boring anyway - one vomiting dog after another.

The schedule has ups and downs. Yeah, you only work 13 or so shifts a month, but keep in mind that many/most of them will be overnight. So one of those "4 days off" you end up sleeping a lot of the day, being all out of sorts that evening, trying to sleep that night to get on a regular schedule, etc. It just messes with you. And that's if your 3 days 'on' are in a row. If they aren't ... it doesn't end up being as much true functional time off as it sounds like. And, you work holidays and those are almost always crappy on ER. So the schedule is more attractive on paper than in reality for most of us.

You get pretty cynical working ER. You hear GPs talk about their awful day because they had to euthanize 2 things, and you try to remember the last shift you DIDN'T euthanize 2+ things and you can't. (I did only 7 on Dec 24th this year which was a record low for me for xmas - the previous year I'm told by my techs I did 17. I don't remember that. I remember doing 12 2 years ago.) In fairness to GPs, they know their patients/clients better, so euths can be harder on them. But still....

Flip side, you get to work with cool cases, you learn to make quick decisions, you get comfortable with critical animals that a lot of docs aren't comfortable with, and you get some super satisfying saves from time to time. I had a non-ketotic hyperosmolar hyperglycemic case tonight that was a super fun challenge. Na > 180, serum osmolality 411, glucose 680, temperature 107.8F, marked tremoring or seizuring on presentation. Nothing would touch the tremors until I gave in and put him on a propofol CRI. And correcting a Na over 180 isn't trivial (there's not even consensus among Criticalists and IntMed docs about precisely how you should; add in the time constraints that owner finances put on you and it can be an unmanageable challenge). GP docs will certainly deal with those critical cases, but (for most of them) not as often, and not as comfortably. You rack up your stack of 'cool' cases pretty quickly working ER.

Other flip side is frustrating clients: Once they're gone, I never have to see them again (usually). I feel bad for some GPs who have their regular 'bad' clients. What a headache going to work knowing that client is scheduled to come in today.

We're paid pretty well, but in my opinion, not <nearly> well enough in the face of the mountain of evidence about just how bad this job is for your health. It's been well known for years that shift workers are more prone to metabolic disease, but more recently evidence is accumulating for very scary mental health effects, including a higher rate of, and earlier evidence for, alzheimer's disease and dementia. Personally, I think that for people who (supposedly) believe in evidence-based medicine, we are pathetic for not taking that more seriously and doing something to mitigate it: either paying ER staff (CVTs as well as DVMs) more for fewer hours, or finding other ways to manage it.

In general, I love ER work. But I'm debating moving away from it because of the health risks associated with it. I get paid great - but not well enough to give myself diabetes and suffer dementia at 60. I think we are dramatically undervaluing overnight workers when you consider the impact to their/our health.

That seems to be the trend with our local referral places. There are still the stand alone, ER-only shops but the places I tell people to go to have the in-house specialties alongside. I consider myself really lucky to have a ton of places to refer things to very nearby, almost all with more than one option. Unfortunately, I think that sort of convenience has made the older generation of vets (and a lot of "old-timey" clients) grumbly because they say the newer vets just want to turf everything accordingly. But why not offer a specialist if there's one 5mins away and you get better medicine for it? Humph.

Ya! I have pretty mixed feelings, and I haven't sorted through them. On the one hand, I think it's great that we have specialists who can deliver a higher level of care in a particular field for clients who want (and can afford) it for their pet. And wow - I learn so much from our IntMed / CritCare / Sx docs. On the other ... I have just as much of a romantic attachment to the idea of vets as "treat everything, do everything" doctors as anyone else does. And I like variety. And I like cutting (most of the time). So I don't like the idea of being more and more focused and less and less diverse.

For better or worse, that's where we're headed as a profession. It will be a super long transition - there will always be people who can't afford referral or don't want it, and there will be places for decades where referral just isn't available. But more and more in larger metro areas that's where things are going.

$$$$$$$$$$$$$$

Owners want you to do specialist work for at least half if not a third to a quarter of the price. Oh and don't make any mistakes either or have any complications occur because they'll sue.

I don't think that's necessarily a bad thing. I mean, I've done procedures for owners who declined referral because I could cut some corners, not charge the 'specialist' surgeon's fee, and turn a $3500 procedure into a $2000 procedure. If it's that or euthanize, hey, why not.

With regard to liability, I think it's just a matter of document, document, document. Document it three ways to Sunday that you recommended referral, that you informed the client of a worse prognosis under your care, etc. Not much they can do lawsuit-wise at that point.

 

[that redhead]

On the other ... I have just as much of a romantic attachment to the idea of vets as "treat everything, do everything" doctors as anyone else does. And I like variety. And I like cutting (most of the time). So I don't like the idea of being more and more focused and less and less diverse.

Very much with you on that - the variety my day brings is a big part of why I enjoy GP. I think a lot of the time nowadays, it's CYA more than anything.

 

[cheathac]

Originally I wanted to do research and/or lab animal because I've had negative experiences with GP (doctors were rude, not a good working environment, nasty clients). However, I've had some of my professors/faculty talk to me about GP. They see that I really love the problem solving and putting it all together aspect (we are doing CBC, chemistry, UA, etc in a problem based learning class we have). The idea of owning my own clinic and having more jobs available geographically is pretty appealing, as well as making a higher salary starting out to pay off student loans. I probably won't make up my mind until 4th year where I'm actually "practicing" the medicine anyways, but the opportunities are fun to look into.

 

[DVMDream]

I don't think that's necessarily a bad thing. I mean, I've done procedures for owners who declined referral because I could cut some corners, not charge the 'specialist' surgeon's fee, and turn a $3500 procedure into a $2000 procedure. If it's that or euthanize, hey, why not.

With regard to liability, I think it's just a matter of document, document, document. Document it three ways to Sunday that you recommended referral, that you informed the client of a worse prognosis under your care, etc. Not much they can do lawsuit-wise at that point.

I don't think it is necessarily a bad thing either. However, it gets a bit difficult to fit in some of these more specialized procedures as a GP. Things that are time sensitive... like GDV's, pyos, some foreign bodies, etc... I can't just jump up and cut. I am the only Dr. present seeing patients every 30 minutes (sometimes more frequently) and we are only open until x time. If I decide to do something after hours (which a pyo or foreign body might be able to wait for but a GDV would not be able to) then I have to keep staff late and that costs the clinic $$$. So most of these types of things, I end up punting to ER. There is no way I am stabilizing the above you discussed with the hyperosmolar, hyperglycemic, hypernatremia... that requires some really close attention and I don't have the staff for that (a lot of times it is me and a single tech). (By the way, serious applause on that case... hypernatremia is mind-numbingly difficult to deal with).

As for the liability bit, pay attention to the cases that go through your state board. The state board here are picky as all hell. You could document that 5,000 different ways to Sunday and if they feel you did anything less than "gold standard" you WILL get some kind of reprimand. Usually a fine and CE, but basically they are forcing us to more and more refer to a specialist because I am not going to be risking my license with some of that. Sucks a bit because that is driving vet med to be more like human med, but I think give it another 10 years and we will be there anyway. Heck, in 10 years, animals may no longer be seen as "property" and as more like real "children" with all the complications of insurance and increased liability, etc, etc.

 

[LetItSnow]

I don't think it is necessarily a bad thing either. However, it gets a bit difficult to fit in some of these more specialized procedures as a GP. Things that are time sensitive... like GDV's, pyos, some foreign bodies, etc... I can't just jump up and cut. I am the only Dr. present seeing patients every 30 minutes (sometimes more frequently) and we are only open until x time. If I decide to do something after hours (which a pyo or foreign body might be able to wait for but a GDV would not be able to) then I have to keep staff late and that costs the clinic $$$. So most of these types of things, I end up punting to ER. There is no way I am stabilizing the above you discussed with the hyperosmolar, hyperglycemic, hypernatremia... that requires some really close attention and I don't have the staff for that (a lot of times it is me and a single tech). (By the way, serious applause on that case... hypernatremia is mind-numbingly difficult to deal with).

As for the liability bit, pay attention to the cases that go through your state board. The state board here are picky as all hell. You could document that 5,000 different ways to Sunday and if they feel you did anything less than "gold standard" you WILL get some kind of reprimand. Usually a fine and CE, but basically they are forcing us to more and more refer to a specialist because I am not going to be risking my license with some of that. Sucks a bit because that is driving vet med to be more like human med, but I think give it another 10 years and we will be there anyway. Heck, in 10 years, animals may no longer be seen as "property" and as more like real "children" with all the complications of insurance and increased liability, etc, etc.

Sure, but "not having time" (or staff or ... etc.) is a completely different reason for not doing a procedure than an owner declining referral because of cost. If you can't do the procedure you can't do it and that's all there is to it. Nothing wrong with that, and GPs transfer those cases to us every day. If an owner declines referral and you just plain can't do it ... then you just have to say no, and that's on the owner. I've certainly turned down owners for a variety of things ranging from euthanasia to surgical procedures, and I'm sure you have too. But I think it's ok for an owner to ask for a lesser standard of care - I mean, if all we're going to offer people is "gold standard" or "too bad" ... that seems like pretty bad medicine from a population perspective.

Maybe your state is different than mine in requiring gold standard care, I guess, but out here that's certainly not the case. Our board expects you to recommend appropriate care, but if a client declines it ... that's on the client. I've read a <lot> of board actions in our state, and I can't recall a single one that was leveraged against a vet who did less-than-standard-of-care but had documentation that they recommended 'gold standard'. There were definitely some cases that I felt were unfair against the vet, but none because of something like that. And the vast majority of license action cases I've read (again, in my state - that's the only place I've really read any) were really legitimate. Persistent poor care without good recommendations, drug issues, some facilities issues, things like that.

I don't think it's board action that will drive us to be more CYA and whatnot as much as changing liability laws will. At least, up here in MN. If down there your board is really punishing people for recommending gold standard care but then delivering less when a client rejects the recommendation .... well, that's screwed up.

 

[LetItSnow]

Originally I wanted to do research and/or lab animal because I've had negative experiences with GP (doctors were rude, not a good working environment, nasty clients). However, I've had some of my professors/faculty talk to me about GP. They see that I really love the problem solving and putting it all together aspect (we are doing CBC, chemistry, UA, etc in a problem based learning class we have). The idea of owning my own clinic and having more jobs available geographically is pretty appealing, as well as making a higher salary starting out to pay off student loans. I probably won't make up my mind until 4th year where I'm actually "practicing" the medicine anyways, but the opportunities are fun to look into.

I think you just have to dip your feet in all the various things that interest you and go from there!

I'd bet there is some pretty deep problem solving to research and lab animal medicine; at least in some contexts.

 

[DVMDream]

Sure, but "not having time" (or staff or ... etc.) is a completely different reason for not doing a procedure than an owner declining referral because of cost. If you can't do the procedure you can't do it and that's all there is to it. Nothing wrong with that, and GPs transfer those cases to us every day. If an owner declines referral and you just plain can't do it ... then you just have to say no, and that's on the owner. I've certainly turned down owners for a variety of things ranging from euthanasia to surgical procedures, and I'm sure you have too. But I think it's ok for an owner to ask for a lesser standard of care - I mean, if all we're going to offer people is "gold standard" or "too bad" ... that seems like pretty bad medicine from a population perspective.

Maybe your state is different than mine in requiring gold standard care, I guess, but out here that's certainly not the case. Our board expects you to recommend appropriate care, but if a client declines it ... that's on the client. I've read a <lot> of board actions in our state, and I can't recall a single one that was leveraged against a vet who did less-than-standard-of-care but had documentation that they recommended 'gold standard'. There were definitely some cases that I felt were unfair against the vet, but none because of something like that. And the vast majority of license action cases I've read (again, in my state - that's the only place I've really read any) were really legitimate. Persistent poor care without good recommendations, drug issues, some facilities issues, things like that.

I don't think it's board action that will drive us to be more CYA and whatnot as much as changing liability laws will. At least, up here in MN. If down there your board is really punishing people for recommending gold standard care but then delivering less when a client rejects the recommendation .... well, that's screwed up.

Often times it is a mix of I can't do it and owner won't go for referral. Sucks but what else am I to do?

The board out here strongly has an "if it has come to us, we're going to find something wrong with it mentality"... basically don't get sent to the board out here because you can do everything right and they'll dig for something to charge you for. Does this mean I never do less than gold standard? Of course not, people can't afford that, but it sure doesn't instill confidence into trying planning D on a possibly complicated case or jumping into a surgery that I haven't done before.

 

[KCgophervet]

Originally I wanted to do research and/or lab animal because I've had negative experiences with GP (doctors were rude, not a good working environment, nasty clients). However, I've had some of my professors/faculty talk to me about GP. They see that I really love the problem solving and putting it all together aspect (we are doing CBC, chemistry, UA, etc in a problem based learning class we have). The idea of owning my own clinic and having more jobs available geographically is pretty appealing, as well as making a higher salary starting out to pay off student loans. I probably won't make up my mind until 4th year where I'm actually "practicing" the medicine anyways, but the opportunities are fun to look into.

I think you just have to dip your feet in all the various things that interest you and go from there!

I'd bet there is some pretty deep problem solving to research and lab animal medicine; at least in some contexts.

There's definitely problem solving to be done in lab animal medicine. It can get even more problem-solvey in some cases since a lot of the reference ranges aren't super well described in certain lab animal species (similar to zoo/exotics med). There's the experimental uses on top of that as well that adds another layer of complication. For example, I was just working on a diabetic monkey case (experimentally induced diabetes) that was having some troubling clinical signs. The monkey had received islet cell transplants and it turns out the lab was overdosing the immunosuppressive medications, some of which have a known side effect of causing diabetes due to islet cell toxicity. And the lab was confused about why the islets were dying . We had to figure out what was going on and what was causing the clinical signs while stabilizing the monkey plus thinking outside the box to find the cause. It was a good case (and the monkey is doing fine now and we have the diabetes well controlled). We also had to figure out how to manage a bladder surgery model in a baboon (a surgery that is performed typically in kids for a certain disease process). Had to get creative to find a way to keep a urinary catheter, an abdominal penrose drain, and a subrapubic catheter intact and in place in a patient that has hands/fingers and can(and will) pull all of that out. Ended up putting on a jacket and securing an upside-down E-collar to the bottom of it to make a skirt that they couldn't reach around to pull out the catheters. Looked ridiculous but it worked.

Granted all of this has been in non human primate patients, and while the medicine can get more interesting in the larger species, the vast majority of lab animals are mice. My predecessor actually discovered a new strain of Bordetella in our mouse population that was causing problems for a lab that was studying respiratory diseases. That was definitely a huge problem to solve and then she helped the senior vets come up with a way to eradicate it from our population (since it wasn't being screened for at the vendors). Different kind of problems to solve, but still.

So, don't rule out lab animal just because you want to do some problem solving

 

[LetItSnow]

Often times it is a mix of I can't do it and owner won't go for referral. Sucks but what else am I to do?

Yeah, definitely awkward situation. I know when I'm in that situation, I just throw it in the owner's lap. "Well, I can't accommodate that request. Here's the only way *I* know for you to get it done. What would you like to do?" Might be awkward, but you just have to hold your ground, right?

The board out here strongly has an "if it has come to us, we're going to find something wrong with it mentality"... basically don't get sent to the board out here because you can do everything right and they'll dig for something to charge you for. Does this mean I never do less than gold standard? Of course not, people can't afford that, but it sure doesn't instill confidence into trying planning D on a possibly complicated case or jumping into a surgery that I haven't done before.

Your board blows.

I dunno, that sounds like a difference from our board. I have absolutely no worries when I deliver less-than-gold-standard. Maybe I'm overly optimistic, but I've read a lot of board cases and never seen one like that where it's been a problem.

I've only had one <real> interaction with our board (when I reported an abuse case). They were super to work with. Complimentary, even.

 

[DVMDream]

Yeah, definitely awkward situation. I know when I'm in that situation, I just throw it in the owner's lap. "Well, I can't accommodate that request. Here's the only way *I* know for you to get it done. What would you like to do?" Might be awkward, but you just have to hold your ground, right?



Your board blows.

I dunno, that sounds like a difference from our board. I have absolutely no worries when I deliver less-than-gold-standard. Maybe I'm overly optimistic, but I've read a lot of board cases and never seen one like that where it's been a problem.

I've only had one <real> interaction with our board (when I reported an abuse case). They were super to work with. Complimentary, even.

I'm moving to Minnesota.
















Not really, it is too cold and I just bought a house.

 

[LetItSnow]

Not really, it is too cold and I just bought a house.

Cold? COLD? What are you talking about? It got above zero today!

 

[DVMDream]

Cold? COLD? What are you talking about? It got above zero today!

I mean, it is 67 degrees here. Just a very minor difference.

 

[that redhead]

Originally I wanted to do research and/or lab animal because I've had negative experiences with GP (doctors were rude, not a good working environment, nasty clients). However, I've had some of my professors/faculty talk to me about GP. They see that I really love the problem solving and putting it all together aspect (we are doing CBC, chemistry, UA, etc in a problem based learning class we have). The idea of owning my own clinic and having more jobs available geographically is pretty appealing, as well as making a higher salary starting out to pay off student loans. I probably won't make up my mind until 4th year where I'm actually "practicing" the medicine anyways, but the opportunities are fun to look into.

I've said this a bunch of times around these parts but I applied to vet school and went all four years through vet school being certain I was going to do lab animal. It didn't work out for me but GP isn't a bad place to be. Any job is going to let you problem solve, just like any job has the potential to give you rude or nasty people (I'm sure @kcoughli has met that one P.I who thinks their work is God's gift to the universe and heaven forbid anyone tell them they can't just change up their protocol willynilly to suit their needs...)

 

[KCgophervet]

I've said this a bunch of times around these parts but I applied to vet school and went all four years through vet school being certain I was going to do lab animal. It didn't work out for me but GP isn't a bad place to be. Any job is going to let you problem solve, just like any job has the potential to give you rude or nasty people (I'm sure @kcoughli has met that one P.I who thinks their work is God's gift to the universe and heaven forbid anyone tell them they can't just change up their protocol willynilly to suit their needs...)

Even better, I worked in his lab before vet school. SMH... but yes, those people exist everywhere unfortunately.

 

[cheathac]

I'm also looking at it from a debt perspective.... if I start out in GP I'll be making more than say in residency and if I go to own a practice I understand that a decent amount of money CAN be made.. I like the equity aspect as well. We will just see how it plans out. I did ok in my first semester... I got a 3.3 GPA but it definitely needs to be higher for a residency and the first semester at Purdue is generally the easiest so I need to step up my gain a bit more.

 

[KCgophervet]

I'm also looking at it from a debt perspective.... if I start out in GP I'll be making more than say in residency and if I go to own a practice I understand that a decent amount of money CAN be made.. I like the equity aspect as well. We will just see how it plans out. I did ok in my first semester... I got a 3.3 GPA but it definitely needs to be higher for a residency and the first semester at Purdue is generally the easiest so I need to step up my gain a bit more.

Not to push you into lab animal, but just so you know - lab animal residencies are typically paid much better than other specialties because most are paid based on the NIH post-doc scale. AKA I think all the residencies in the match this past year (when I applied) were around $45K+. Granted, not as much as GP, but not quite as bad as the typical internship/residency.

Also some of the GPA stuff can be mitigated based on where you apply and experiences and dedication to the field are looked at more (here we have a minimum GPA cut off and then we just evaluate based on CV, letters of rec, and then interview).

Just as an aside, my first semester of vet school GPA was a 3.25 and it was quite a bit higher when I graduated. I think the first semester of vet school was hardest for me just because it was figuring out vet school. So you can definitely still bring it up

 

[pooter]

I'm just gonna sit here and bask in the irony of how y'all started a conversation about ER burnout which morphed into a conversation about specialty referral and liability all while I was in the midst of my three-surgery, twice-dehisced, week-long septic peritonitis nightmare. Which we can't refer because OF COURSE NOT, WHY MAKE ANYTHING EASY?

Sometimes I deeply regret the decision to be a cutting ER doc. If anybody needs me, I'll just be over here with a mug of cocoa and a bathrobe, nursing my bronchitis while pestering our overnight doc for hourly updates.

 

[DVMDream]

I'm just gonna sit here and bask in the irony of how y'all started a conversation about ER burnout which morphed into a conversation about specialty referral and liability all while I was in the midst of my three-surgery, twice-dehisced, week-long septic peritonitis nightmare. Which we can't refer because OF COURSE NOT, WHY MAKE ANYTHING EASY?

Sometimes I deeply regret the decision to be a cutting ER doc. If anybody needs me, I'll just be over here with a mug of cocoa and a bathrobe, nursing my bronchitis while pestering our overnight doc for hourly updates.

Gross. I suggest you add some benadryl to that mug of cocoa and take a nice, long sleep.

 

[LetItSnow]

I'm just gonna sit here and bask in the irony of how y'all started a conversation about ER burnout which morphed into a conversation about specialty referral and liability all while I was in the midst of my three-surgery, twice-dehisced, week-long septic peritonitis nightmare. Which we can't refer because OF COURSE NOT, WHY MAKE ANYTHING EASY?

Sometimes I deeply regret the decision to be a cutting ER doc. If anybody needs me, I'll just be over here with a mug of cocoa and a bathrobe, nursing my bronchitis while pestering our overnight doc for hourly updates.

Man, if you're pestering the overnight doc for hourly updates, they're a) going to kill you, and b) you care too much.

I have a parvo patient in hospital that I left on a crystalloid, a colloid, metro/baytril/unasyn, cerenia, pantoprazole, reglan, fentanyl, a clinicare CRI, and a norepi CRI ...

... and I forgot about it as soon as I left the hospital until you just mentioned your nightmare septic case. Critical be damned.

 

[Coquette22]

After a nightmare bull**** mature dog spay last week where I had to call in the other doc to help me basically retie all my ****ing ligatures, she let me in on a similar surgery today since it's my day off. She can be intimidating but very helpful and I appreciated the effort. I feel so stunted in my surgical skills since old boss did so much of the surgery and I just never had chance to practice.