NY Times article on vet med profession

[LetItSnow]

Most shelter spays are performed through a keyhole incision and take a shelter vet 10 minutes (on average).

Nephrectomy is performed through a much larger incision, requires much more extensive dissection, takes much longer, and has a different set of complications. So I do believe it is much more invasive.

So what complication rate is acceptable for elective procedures on healthy animals in shelters, then?

(Though, I take it the larger portion of your point is really the future effect on the animal, not the procedure itself?)

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[bunnity]

I would want to at least give it a shot to have two living kitties instead of two dead kitties... granted I have never done a nephrectomy so I'm sure you know more than me about the surgery aspect

 

[cdndvm]

So what complication rate is acceptable for elective procedures on healthy animals, then?

I'm not sure there is a published 'acceptable' complication rate for elective procedures. I can tell you that my complication rate for spays and neuters is far <1%. A different surgeon may have a different complication rate depending on their patient population and skill. Most shelter vets I know do thousands of spays and neuters per year and rarely have a complication.

In this circumstance (nephrectomies) I don't think it is the complication rate (or surgical morbidity) that makes it 'unethical'. Its the fact you are putting a healthy patient through a big surgery and predisposing that patient to potentially early stage kidney disease because it only has one kidney. Additionally, implanting the kidney in the donor is not walk in the park...

Incidentally, In the scenario you described with the trauma cat that needed a nephrectomy, that would not be considered an elective procedure.

 

[LetItSnow]

I'm not sure there is an 'acceptable' complication rate for elective procedures. I can tell you that my complication rate for spays and neuters is far <1%. A different surgeon may have a different complication rate depending on their patient population and skill. Most shelter vets I know do thousands of spays and neuters per year and rarely have a complication.

In this circumstance I don't think it is the complication rate that makes it 'unethical'.

Incidentally, In the scenario you described with the trauma cat that needed a nephrectomy, that would not be considered an elective procedure.

I don't believe that was my post (the trauma cat).

I guess I just find the "complication rate" portion of the argument odd, because it's entirely subjective. The nephrectomy may be more complex, more invasive, and have a higher complication rate .... but a spay is invasive and has a complication rate as well. I'm not saying it's the same as the nephrectomy - that's not my point. It stands to reason that you're suggesting that there's a point somewhere in between the two procedures where it goes from acceptable (the spay end of the spectrum) to unacceptable (the nephrectomy end of the spectrum).

That seems pretty subjective.

 

[cdndvm]

I don't believe that was my post (the trauma cat).

I guess I just find the "complication rate" portion of the argument odd, because it's entirely subjective. The nephrectomy may be more complex, more invasive, and have a higher complication rate .... but a spay is invasive and has a complicate rate as well. So it stands to reason that you're suggesting that there's a point somewhere in between where it goes from acceptable (the spay end of the spectrum) to unacceptable (the nephrectomy end of the spectrum).

That seems pretty subjective.

I dont want to get hung up on the complication rate being the crux of my argument, because its really an adjunct. As far as invasiveness is concerned, I 100% think a nephrectomy is more invasive then a spay (for reasons I've already outlined).

 

[LetItSnow]

I dont want to get hung up on the complication rate being the crux of my argument, because its really an adjunct.

Fair 'nuff!

 

[bunnity]

One of our lecturers put it really well I think:

"The most common cause of death in dogs and cats is...
Shelter euthanasia of healthy animals due to overpopulation."

As a future shelter vet (and really, I hope all vets have that fact in the back of their minds) I have to think of "lack of space" as every bit as much a pathology as kidney trauma. Or cancer or heart failure or endocrine disease or anything else that kills cats and dogs. So I guess I don't see much difference between taking a kidney out of a shelter cat due to be PTS from kidney trauma (surgery will make it adoptable) versus a shelter cat due to be PTS due to lack of space (guaranteed adoption post surgery). I think the first one makes us feel good as vets and the second one makes us feel weird, but I think from the cat's perspective, it will experience the same thing... a big surgery, some pain, and then a lifetime in a loving home.

 

[Abnerrs]

This thread is srs

 

[bunnity]

This thread is srs

haha feel free to chime in people!

Like I said before, I totally respect the other side of this argument, and I would love to hear what other people think.

And in reality, this situation will probably never come up for any of us!

 

[LetItSnow]

This thread is srs

*shrug* I think it's nice to hear a different perspective.

 

[Abnerrs]

Oh no. I'm totally for different perspectives. I was commenting on the super cereal vibe in here.

 

[lexypanini]

Dialysis is a whole different ball game - another procedure I'm not sure we should be offering to veterinary patients.

On a different but related note, I am curious to to see why you don't think dialysis should be offered. It seems to me (but I do have very limited knowledge) that it seems like a good thing to be able to help a pet live longer. I would love to know your reasoning for it and I am truly just curious and do not mean to be confrontational.

 

[bunnity]

On a different but related note, I am curious to to see why you don't think dialysis should be offered. It seems to me (but I do have very limited knowledge) that it seems like a good thing to be able to help a pet live longer. I would love to know your reasoning for it and I am truly just curious and do not mean to be confrontational.

I don't want to speak for anyone else, but dialysis involves putting a huge catheter in the patient's neck. Then the patient is hooked up to a machine and has to sit still for about 3-6 hours while their blood is processed. Since cats are so small, at any given time during the procedure they are missing a significant amount of their blood (I think our machine holds 67mL minimum). So the procedure itself is rough and has to be done every 1-2 days. Besides that, the patient is uremic most of the time unless you are dialyzing aggressively every day (at $800 a pop) and they feel really awful, plus they get the uremic complications like uremic lung, GI ulceration, etc. If the patient is anuric they can't drink and they get fluid overloaded just from fat breakdown and that makes it hard for them to breathe. So basically, it's really unpleasant for the cat and it is not something that is sustainable long term either from a quality of life or a financial perspective.

I think there is certainly a place for dialysis in situations like acute ethylene glycol toxicity where it's a one-time treatment that saves their life and allows them a normal life expectancy. I think it is pretty gray territory when you're maintaining an animal on dialysis in hopes of a transplant or that they will regain the ability to urinate post acute kidney injury. I think it's definitely unethical to maintain a chronic renal failure animal on dialysis long term because it is so stressful on the animal and in between they will be feeling awful.

Curious to see what cdndvm has to say

 

[lexypanini]

I don't want to speak for anyone else, but dialysis involves putting a huge catheter in the patient's neck. Then the patient is hooked up to a machine and has to sit still for about 3-6 hours while their blood is processed. Since cats are so small, at any given time during the procedure they are missing a significant amount of their blood (I think our machine holds 67mL minimum). So the procedure itself is rough and has to be done every 1-2 days. Besides that, the patient is uremic most of the time unless you are dialyzing aggressively every day (at $800 a pop) and they feel really awful, plus they get the uremic complications like uremic lung, GI ulceration, etc. If the patient is anuric they can't drink and they get fluid overloaded just from fat breakdown and that makes it hard for them to breathe. So basically, it's really unpleasant for the cat and it is not something that is sustainable long term either from a quality of life or a financial perspective.

I think there is certainly a place for dialysis in situations like acute ethylene glycol toxicity where it's a one-time treatment that saves their life and allows them a normal life expectancy. I think it is pretty gray territory when you're maintaining an animal on dialysis in hopes of a transplant or that they will regain the ability to urinate post acute kidney injury. I think it's definitely unethical to maintain a chronic renal failure animal on dialysis long term because it is so stressful on the animal and in between they will be feeling awful.

Curious to see what cdndvm has to say

Thank you for your thoughtful response! What about peritoneal dialysis--it seems less intrusive (bloodwise at least). Is it not as effective? Does it the pet feel just as awful and is it just as expensive? I am really enjoying reading everyone's responses and learning more about the different ethical points.

 

[kakurubird]

I'm not quite sure where I fall in thinking on all of this (still processing myself), but does the ethical-ness/justification of doing the kidney transplant change for you guys based on the concurrent otherwise health/age of the cat?
I guess what I have a hard time with is the bad part of surgery and the recovery (which to me seems like it would be more for the nephrectomy/transplant than a spay, based on all the drugs human-transplant patients have to take, but I don't really know much more than what's been said on this thread--so the recovery could not be as bad as I picture it?) when all the patient knows is the bad now and can't think through to the good that will come after recovery (unlike a human patient who can mentally process that, yes, I feel bad right now, but it will be worth it in X amount of time). (I mean, as far as I understand a cat's/dog's cognitive processing skills.)

 

[hygebeorht]

honestly, who cares? Firstly - these rankings mean nothing. They're based on research dollar and have nothing to do with the level of education students receive. Secondary, does it really matter that veterinary medicine is included under health vs. medicine?

I think we have more important things to worry about.

While I agree that the rankings mean nothing, and that we have more important things to worry about, schools do care about the rankings. I was just called (again) by one of my alma maters begging for a donation. Aside from the infuriating fact that this is a wealthy private school and they're demanding donations from an alum (me) who makes less than 8k a year, they flat-out told me on the phone that they were trolling for cash because it's the number of alumni that give, not the amount, that helps their score on the US News list.

If this is something that schools are focused on, we shouldn't ignore it. They are devoting resources to maintaining their ranking that should probably be used elsewhere. It's not totally irrelevant.

I suppose by that reasoning, we should probably not contact US News, because if pre-vets and students show they care about the rankings, then schools have even MORE impetus to focus on climbing the ranks.

I was annoyed that vet med isn't listed under medicine, but it's a minor annoyance. Just one of those "well, that's how the world is I guess" things.

 

[cdndvm]

I don't want to speak for anyone else, but dialysis involves putting a huge catheter in the patient's neck. Then the patient is hooked up to a machine and has to sit still for about 3-6 hours while their blood is processed. Since cats are so small, at any given time during the procedure they are missing a significant amount of their blood (I think our machine holds 67mL minimum). So the procedure itself is rough and has to be done every 1-2 days. Besides that, the patient is uremic most of the time unless you are dialyzing aggressively every day (at $800 a pop) and they feel really awful, plus they get the uremic complications like uremic lung, GI ulceration, etc. If the patient is anuric they can't drink and they get fluid overloaded just from fat breakdown and that makes it hard for them to breathe. So basically, it's really unpleasant for the cat and it is not something that is sustainable long term either from a quality of life or a financial perspective.

I think there is certainly a place for dialysis in situations like acute ethylene glycol toxicity where it's a one-time treatment that saves their life and allows them a normal life expectancy. I think it is pretty gray territory when you're maintaining an animal on dialysis in hopes of a transplant or that they will regain the ability to urinate post acute kidney injury. I think it's definitely unethical to maintain a chronic renal failure animal on dialysis long term because it is so stressful on the animal and in between they will be feeling awful.

Curious to see what cdndvm has to say

This is pretty bang on from my perspective. I just consider hemodialysis inhumane because of what the patient has to go through. Furthermore, once you've got a patient that is in need of dialysis, they're usually profoundly ill and you are reaching for hemodialysis as a salvage procedure.

Having done peritoneal dialysis on a number of patients, its not all that its cracked up to be. Its very invasive, extremely costly and not nearly as effective as hemodialysis. The last dog we did peritoneal dialysis on (ethylene glycol toxicity) ended up in anuric renal failure, had a 25K vet bill and didn't leave the hospital. Every time we do it I think to myself: never again.

 

[Minnerbelle]

Agree with bunnity about the dialysis. I would never advocate to put an animal in chronic renal failure through dialysis. But I do think there's def a time and place for hemodialysis in carefully selected cases of toxicities and such. My understanding is that in an early case of ethylene glycol tox well before the onset of azotemia, the prognosis is pretty good with just 1 dialysis session and the patient can very well walk out with a bill of <$2000-3000. I would never fault someone for not going through with it (in the cases in which the above applies) but I don't think it's crazy to do it either. Anuric/oliguric AKI with something like lepto would be a gray zone for me in terms of how much I'd advocate for it...

Just out of curiosity, what do you think about PD for something like a bladder rupture? Is it over-rated?

But more back on topic. I actually agree for the most part with juliedvm when it comes to differences between human and vet med, and how vet med is for the vast majority of cases "fluffy's fixer" and what the implications of that are in general. And i can't say I'm all that upset about us news classifying vet med as "health" rather than "medicine" or whatever... (I'm sure it had much more to do with logistics of how they were publishing the rankings than a slight to our profession or anything) But I also don't see why we can't consider vet med "medicine." No, vet med and human med aren't equal in a lot of ways... And the level of care and attention to detail in vet med definitely pales in comparison to human med in a lot of ways. But... We still do perform PE's, run bloodwork, take rads and whatever other diagnostics, make diagnoses and treat patients (however inferior it may be in some cases to human med). Is that not medicine?

 

[cdndvm]

Agree with bunnity about the dialysis. I would never advocate to put an animal in chronic renal failure through dialysis. But I do think there's def a time and place for hemodialysis in carefully selected cases of toxicities and such. My understanding is that in an early case of ethylene glycol tox well before the onset of azotemia, the prognosis is pretty good with just 1 dialysis session and the patient can very well walk out with a bill of <$2000-3000. I would never fault someone for not going through with it (in the cases in which the above applies) but I don't think it's crazy to do it either. Anuric/oliguric AKI with something like lepto would be a gray zone for me in terms of how much I'd advocate for it...

Just out of curiosity, what do you think about PD for something like a bladder rupture? Is it over-rated?

But more back on topic. I actually agree for the most part with juliedvm when it comes to differences between human and vet med, and how vet med is for the vast majority of cases "fluffy's fixer" and what the implications of that are in general. And i can't say I'm all that upset about us news classifying vet med as "health" rather than "medicine" or whatever... (I'm sure it had much more to do with logistics of how they were publishing the rankings than a slight to our profession or anything) But I also don't see why we can't consider vet med "medicine." No, vet med and human med aren't equal in a lot of ways... And the level of care and attention to detail in vet med definitely pales in comparison to human med in a lot of ways. But... We still do perform PE's, run bloodwork, take rads and whatever other diagnostics, make diagnoses and treat patients (however inferior it may be in some cases to human med). Is that not medicine?

In my experience, ethylene glycol toxicity that is caught and aggressively treated with 4MP prior to the onset of azotemia have decent to goo prognosis without hemodyalisis so I wouldn't jump to dialysis in this patient right off the bat anyways.

In the case of the ruptured bladder - No i wouldn't employ PD... I would take the patient to surgery and fix the bladder. The azotemia will resolve with diuresis and fixing the problem.

 

[Angelus9]

We are not human doctors. Veterinary medicine is nothing like human medicine

No, but you ARE doctors. I would never say that the surgeon who performed a complicated (and successful) colic surgery on my horse was not a real surgeon, or, well, there are endless examples. Perhaps many (most?) vets don't do this type of work, the way many (most?) human doctors just see patients in their offices and tell them to eat less & exercise more. Guess they don't do much and I shouldn't consider them real doctors.

Griping about the fact that we are grouped in a Health bracket vs. Medicine bracket is petty and unproductive.

Strongly disagree. It's standing up for your profession, which is most certainly Medical.

 

[VMCASSTAFF]

Hey Guys... just for reference, and to put the NTY article in perspective, please see the following response from the Association of American Veterinary Medical Colleges (AAVMC). AAVMC is the Association the runs VMCAS:

http://www.aavmc.org/Events/?id=52

 

[Trilt]

Hey Guys... just for reference, and to put the NTY article in perspective, please see the following response from the Association of American Veterinary Medical Colleges (AAVMC). AAVMC is the Association the runs VMCAS:

http://www.aavmc.org/Events/?id=52

It's been discussed quite a bit on this thread already.

 

[Nekkid]

One of our lecturers put it really well I think:

"The most common cause of death in dogs and cats is...
Shelter euthanasia of healthy animals due to overpopulation."

As a future shelter vet (and really, I hope all vets have that fact in the back of their minds) I have to think of "lack of space" as every bit as much a pathology as kidney trauma. Or cancer or heart failure or endocrine disease or anything else that kills cats and dogs. So I guess I don't see much difference between taking a kidney out of a shelter cat due to be PTS from kidney trauma (surgery will make it adoptable) versus a shelter cat due to be PTS due to lack of space (guaranteed adoption post surgery). I think the first one makes us feel good as vets and the second one makes us feel weird, but I think from the cat's perspective, it will experience the same thing... a big surgery, some pain, and then a lifetime in a loving home.

Some pain? A nephrectomy is waaaaay more painful than a spay. I think dead is dead and alive post painful surgery is better, but it is one of the more painful surgeries to recover from.

 

[VMCASSTAFF]

I think the feeling of deception is directly related to who you choose to get your information from. I can only recommend that you carefully weigh all the information out there. The AAVMC's reply to the NYT article (http://www.aavmc.org/Events/?id=52, i think, pretty clearly explains how information on both jobs and debt can be misconstrued when presented out of context.

 

[Lissarae06]

I think the feeling of deception is directly related to who you choose to get your information from. I can only recommend that you carefully weigh all the information out there. The AAVMC's reply to the NYT article (http://www.aavmc.org/Events/?id=52, i think, pretty clearly explains how information on both jobs and debt can be misconstrued when presented out of context.

We have already discussed this earlier in the thread but here goes. The AAVMC points out that the low starting salary is skewed because of internships and residencies. Doesn't that also apply to the employment percentage?

 

[VMCASSTAFF]

We have already discussed this earlier in the thread but here goes. The AAVMC points out that the low starting salary is skewed because of internships and residencies. Doesn't that also apply to the employment percentage?

Absolutely. The case here is reporting methodologies. No one is particularly wrong here, but please consider the following:

We (AAVMC) conduct our survey at a different time in the life-cycle of a graduate or soon-to-be graduate. AVMA conducts their 2-6 weeks PRIOR to graduation, AAVMC conducts our survey up to 6 months after graduation with dramatically different results.

But to answer your question, yes, the survey results ARE different in both salary AND employment percentages because of the various survey methods used.

 

[bunnity]

Some pain? A nephrectomy is waaaaay more painful than a spay. I think dead is dead and alive post painful surgery is better, but it is one of the more painful surgeries to recover from.

Anywhere that is doing kidney transplants is going to have a board certified anesthesiologist giving boatloads of pain meds (seriously, I have never seen analgesia like the stuff they do here) but yes, point taken.

 

[StartingoverVet]

I think that to some owners it is emotionally exactly the same as losing a person. I think the research into grieving bears that out. .

I think this is a really important point. The emotional devastation of losing a pet for many people is no different than a child, and as for a parent/friend is often much worse because of people's less complicated, purer love for animals. There is no debate on this. Ask any psychologist about it.

Society still frowns on people being excessively emotional over the loss of a pet, but that doesn't stop people from having those emotions.

I personally do not understand the reasoning in this argument at all, and it depends a lot on the doctor and owner/patients involved.

Basically, society still values a human doctor way higher, they have a lot more funding, having more research/drugs/procedures available, but practicing medicine is practicing medicine. I would say that we are probably 3 or 4 decades behind. We probably practice medicine on animals similarly to the way it was done in the 70s in human med. Were those doctors not the same as current doctors? I don't buy it.

 

[StartingoverVet]

I'm not quite sure where I fall in thinking on all of this (still processing myself), but does the ethical-ness/justification of doing the kidney transplant change for you guys based on the concurrent otherwise health/age of the cat?
I guess what I have a hard time with is the bad part of surgery and the recovery (which to me seems like it would be more for the nephrectomy/transplant than a spay, based on all the drugs human-transplant patients have to take, but I don't really know much more than what's been said on this thread--so the recovery could not be as bad as I picture it?) when all the patient knows is the bad now and can't think through to the good that will come after recovery (unlike a human patient who can mentally process that, yes, I feel bad right now, but it will be worth it in X amount of time). (I mean, as far as I understand a cat's/dog's cognitive processing skills.)

But for an animal that is going to be euthanized, I still think a short recovery is worth having an 8 or 9 or 10 year good life in a good home (because let's face it, anyway paying for a kidney transplant is probably going to be a great home for the donor cat).

We had a lecture from the clinician doing renal transplants here.. I wish I could find it (I can look further later), but my memory is that the donor cats do extremely well.

And as for the statement that transplants shouldn't be done at all. I find that highly subjective. Many human doctors I know feel that as well, so there is that.... but someone has to decide on the trade-off between quality of life and doing a treatment and life span, and I am pretty sure that is not the dvm, and it is going to vary in individual cases, and I am highly suspect of anyone making a blanket statement as was made earlier in the thread.

 

[cdndvm]

But for an animal that is going to be euthanized, I still think a short recovery is worth having an 8 or 9 or 10 year good life in a good home (because let's face it, anyway paying for a kidney transplant is probably going to be a great home for the donor cat).

We had a lecture from the clinician doing renal transplants here.. I wish I could find it (I can look further later), but my memory is that the donor cats do extremely well.

And as for the statement that transplants shouldn't be done at all. I find that highly subjective. Many human doctors I know feel that as well, so there is that.... but someone has to decide on the trade-off between quality of life and doing a treatment and life span, and I am pretty sure that is not the dvm, and it is going to vary in individual cases, and I am highly suspect of anyone making a blanket statement as was made earlier in the thread.

If veterinarians aren't making these decisions, then who? The client, who typically has no concept of the ramifications associated with major medical decisions (like in the case of hemodialysis)?


Veterinarians should 100% be making these decisions. Clients rely on our medicinal expertise to guide them in making ethical, humane choices for their pets. Regardless of your position on transplants, as a veterinarian you should be taking ownership and a leading role in major treatment decisions. It's your job.

 

[DVMDream]

If veterinarians aren't making these decisions, then who? The client, who typically has no concept of the ramifications associated with major medical decisions (like in the case of hemodialysis)?


Veterinarians should 100% be making these decisions. Clients rely on our medicinal expertise to guide them in making ethical, humane choices for their pets. Regardless of your position on transplants, as a veterinarian you should be taking ownership and a leading role in major treatment decisions. It's your job.

Yes, it is our job to educate the client on all possible treatments, side effects of treatments and potential outcomes from the various treatments. It is our job to explain how the treatment will affect their pet as well as any potential complications that can arise from the various treatment options as well as our prognosis with each of the treatments. It is NOT our job to make a final treatment decision... it is the owner's job to ultimately decide what to do for their pet once they have been provided all of the treatment options and information from us. We are not supposed to be making decisions for owners, only guiding them and explaining the options as thoroughly as possible for them. In the end, it really is the owner's decision as to which treatment their animal will receive and hopefully as the vet you were able to give them enough information and guidance for the owner to feel comfortable with the decision that they have made (even if you may disagree with their decision).

 

[cdndvm]

Yes, it is our job to educate the client on all possible treatments, side effects of treatments and potential outcomes from the various treatments. It is our job to explain how the treatment will affect their pet as well as any potential complications that can arise from the various treatment options as well as our prognosis with each of the treatments. It is NOT our job to make a final treatment decision... it is the owner's job to ultimately decide what to do for their pet once they have been provided all of the treatment options and information from us. We are not supposed to be making decisions for owners, only guiding them and explaining the options as thoroughly as possible for them. In the end, it really is the owner's decision as to which treatment their animal will receive and hopefully as the vet you were able to give them enough information and guidance for the owner to feel comfortable with the decision that they have made (even if you may disagree with their decision).

This just isn't the reality of how medicine is actually practiced.

I'll give you an example. You have a 16 year old cat with end stage renal failure. A little old lady owns this cat, and she loves it more then anything. The cat has a number of comorbidities that are exacerbating its renal disease (hyperthyroidism that you've managed, and HCM that is not clinical at this time). The cat is dehydrated and severely azotemic. You could offer hemodialysis for this cat, and this little old lady with an unlimited bank account would do anything to save it, but should you? Is hemodialysis in the patients best interest? By your argument you have to give them every option available to them...

Your job is to advocate for your patient. Yes you provide owners with medically reasonable options, explain those options so they have a clear concept of their choices, but in the end your recommendations are based on what you feel is best for the patient. When you enter practice you will be faced with the prospect of completely disagreeing with what an owner wants to do (convenience euthanasia is a good example). Does that mean you have to do it? Absolutely not.

Here is another example that is reasonably common: an owner brings a blocked cat into you. You provide the owner with their options - from gold standard therapy to euthanasia. The owner decides they want to do nothing and just take the cat home. What do you do? You know that cat is going home to die a miserable death, do you just shrug and let them leave because you gave them all their options and they made a decision you don’t like? Sure you could call the humane society and have them try and rescue the cat, but maybe its a Sunday and they're not open until Monday... then what? I would tell these people that leaving with their cat and doing nothing is not an option; they have to make a decision: treat the cat or euthanize it. Was that wrong of me?

In practice things aren't so clear cut.

 

[DVMDream]

This just isn't the reality of how medicine is actually practiced.

I'll give you an example. You have a 16 year old cat with end stage renal failure. A little old lady owns this cat, and she loves it more then anything. The cat has a number of comorbidities that are exacerbating its renal disease (hyperthyroidism that you've managed, and HCM that is not clinical at this time). The cat is dehydrated and severely azotemic. You could offer hemodialysis for this cat, and this little old lady with an unlimited bank account would do anything to save it, but should you? Is hemodialysis in the patients best interest? By your argument you have to give them every option available to them...

Your job is to advocate for your patient. Yes you provide owners with medically reasonable options, explain those options so they have a clear concept of their choices, but in the end your recommendations are based on what you feel is best for the patient. When you enter practice you will be faced with the prospect of completely disagreeing with what an owner wants to do (convenience euthanasia is a good example). Does that mean you have to do it? Absolutely not.

Here is another example that is reasonably common: an owner brings a blocked cat into you. You provide the owner with their options - from gold standard therapy to euthanasia. The owner decides they want to do nothing and just take the cat home. What do you do? You know that cat is going home to die a miserable death, do you just shrug and let them leave because you gave them all their options and they made a decision you don’t like? Sure you could call the humane society and have them try and rescue the cat, but maybe its a Sunday and they're not open until Monday... then what? I would tell these people that leaving with their cat and doing nothing is not an option; they have to make a decision: treat the cat or euthanize it. Was that wrong of me?

In practice things aren't so clear cut.

I agree with everything that you have said ... except I have been in the last scenario, not as the vet but as the tech dealing with the owner directly... except switch blocked cat to severely dehydrated, anemic, parvo puppy.... the owner wanted to do nothing (she paid for the exam) and just wanted to, "take the puppy home and give it pedialyte and god would take care of it."... we told her multiple times... that is not an option and that she needs to decide something (we even offered euthanasia at no charge) but her response, "No! You are not killing this puppy god will take care of it." What do you do? You can NOT legally take the puppy away and keep it and the owner was not going to do anything... we had to let her leave and we informed her that since this is now considered cruelty that we would be contacting animal control... but really... what else can you do... we knew that puppy when we saw it was probably less than 24 hours from death, but we had no choice, you can not legally take their pet away (this of course might be different depending on where you live.)

Or how about this: A guy brings in his 7 year old Bichon that has newly diagnosed diabetes.. the dog is not in really poor condition and starting it on insulin and monitoring it should help it. But this guy is "too busy" and can not afford the continual care that is required for a diabetic animal and decides to euthanize..... do you agree? I know the vet that was in charge of this case did not, but what are you going to do? You can't let the dog live with unmanaged diabetes. It is something that can be simply managed but the owner doesn't even want to try. Do you refuse to euthanize because you don't agree?

While we might not think it is the *right* thing to do for the first pet to give the cat in your first scenario hemodialysis but if you don't mention it and that owner finds out about it... you could get sued for simply not offering a treatment. So while you or I may not see it as a good idea, the client may disagree and when it is your career on the line... sometimes the client wins, which is unfortunate.

 

[kernel]

but her response, "No! You are not killing this puppy god will take care of it." What do you do? You can NOT legally take the puppy away and keep it and the owner was not going to do anything... we had to let her leave and we informed her that since this is now considered cruelty that we would be contacting animal control

This infuriates me, and I would have no problem telling the o that I would report animal cruelty. Obviously that isn't feasible, but the o doesn't know that.

I don't care *what* you believe. If you're sick and you "just wan't to let God take care of it," fine, have fun with that. When it comes to another life though, that decision is not yours to make. In fact, I would probably tell that to the o, verbatim.

I'm not disagreeing with anything DVMDream or cdndvm have said; in fact, I want to reiterate what cdndvm said: you're damn right I'm going to be my patient's advocate. I think many veterinarians have to deal with staggering amounts of stupidity on the part of owners. We need to make the best of these situations...

 

[DVMDream]

This infuriates me, and I would have no problem telling the o that I would report animal cruelty. Obviously that isn't feasible, but the o doesn't know that.

I don't care *what* you believe. If you're sick and you "just wan't to let God take care of it," fine, have fun with that. When it comes to another life though, that decision is not yours to make. In fact, I would probably tell that to the o, verbatim.

We reported animal cruelty... they did a welfare check the next day but no one answered... beyond that, they could not do anything else other than to check that once....

 

[kernel]

We reported animal cruelty... they did a welfare check the next day but no one answered... beyond that, they could not do anything else other than to check that once....

You did the best you could. At the end of the day, that's what counts.

 

[DVMDream]

You did the best you could. At the end of the day, that's what counts.

Yeah, it was really frustrating to be in that position though... I probably spent a good 30 to 40 minutes with this client explaining exactly what parvo is, what it does, how painful of a death it is and trying to kindly tell her that sometimes a pain free, assisted death is better than a long, drawn out painful one... but she didn't believe the puppy would die. I guess we can't say 100% that the puppy would die, but when its mucous membranes where as white as the wall and the puppy was already showing signs of respiratory distress... it is pretty obvious where things are going.

 

[RadRadTerp]

Just one small, probably controversial, point that I think was kind of thrown out of the discussion without much consideration was that someone suggested that allowing veterinarians to graduate from multiple schools outside the US did not affect the number of veterinarians entering the US workforce as much as vet schools expanding their class sizes and I kind of felt that maybe that response was a little defensive and dismissive. Both increasing class sizes and expanding the number of schools where Americans can obtain training to become practicing veterinarians in the US will impact both current and future veterinarians by increasing competition for jobs. Most veterinary students in American veterinary schools probably want to graduate and practice in the US. If more and more undergraduates want to become veterinarians and there are a limited number of seats in the US, then increasing the availability of seats by allowing more of them to be trained elsewhere has an effect on the market whether you want to believe it or not. There will always be an incentive to build outside veterinary schools if those for-profit schools know that the government will help provide loans for students to attend and because there's an overwhelming demand of people wanting to go to vet school, but I don't think everyone who is competent enough and wants to attend should attend veterinary school because we don't need to emulate the problems of the law school system.

 

[DVMDream]

Just one small, probably controversial, point that I think was kind of thrown out of the discussion without much consideration was that someone suggested that allowing veterinarians to graduate from multiple schools outside the US did not affect the number of veterinarians entering the US workforce as much as vet schools expanding their class sizes and I kind of felt that maybe that response was a little defensive and dismissive. Both increasing class sizes and expanding the number of schools where Americans can obtain training to become practicing veterinarians in the US will impact both current and future veterinarians by increasing competition for jobs. Most veterinary students in American veterinary schools probably want to graduate and practice in the US. If more and more undergraduates want to become veterinarians and there are a limited number of seats in the US, then increasing the availability of seats by allowing more of them to be trained elsewhere has an effect on the market whether you want to believe it or not. There will always be an incentive to build outside veterinary schools if those for-profit schools know that the government will help provide loans for students to attend and because there's an overwhelming demand of people wanting to go to vet school, but I don't think everyone who is competent enough and wants to attend should attend veterinary school because we don't need to emulate the problems of the law school system.

Yes, allowing US students to be trained elsewhere will obviously have an impact on the market, but the point I was making was that the seats available in overseas schools has not changed in size whereas the available seats in US schools is increasing. The international schools have not been increasing in size and often times have a difficult time filling their class (see my post where I mentioned that even though applications have been reviewed Edinburgh is still accepting late applications for international students).

The point that I was making was that even if you completely eliminate all overseas schools, you will not make a significant impact on the job saturation in the US... it will still occur and you will also now have a higher demand for students seeking seats in the US and the US schools will see this as a way to do two things: 1. Higher demand = greater tuition because when there is higher demand people are more willing to pay more for it due to the usual limited resources the occurs with a high demand. 2. The US schools will increase seats due to the increase in demand (as they are already starting to do).

The for-profit schools can build vet schools in the US as well (why does it have to be outside the US that then causes it to be a problem?)... see posts about Western, their accreditation and the lawsuit that they filed because they were refused accreditation which lead to the AVMA COE basically obeying to them. Also there are more schools being built and opened in the US... I have not heard of any new schools being built or opened anywhere else.

So, in the long run, no the international schools are not going to be the big problem... the problem needs to be dealt with at its core.... which is inside the US... US students can still go to international schools and go back to the US to practice even without the AVMA COE accrediting them .... yes, it is harder and more expensive... but people were still doing it. If you want to take care of the problem, there needs to be a cap on class size for all schools accredited by the AVMA COE (including international ones)... and even this isn't going to help much at all.

 

[RadRadTerp]

1. Higher demand = greater tuition because when there is higher demand people are more willing to pay more for it due to the usual limited resources the occurs with a high demand. 2. The US schools will increase seats due to the increase in demand (as they are already starting to do).

Just to clarify, I'm not advocating closing any schools, because the damage has already been done and that's just unrealistic.

1. Correct me if I'm wrong, but aren't most US veterinary schools non-profit? They cannot charge more just because there's more demand like a business. Universities across the US have been increasing tuition a lot lately mostly because state governments are cutting funding or the funding has not increased in relation to inflation, and training veterinarians is very expensive. It would be even more expensive if we were actually paying the real cost of getting trained as veterinarians.

2. See point 1. They increased class sizes because of decreased state funding, and also because the national veterinary organisations told the vet schools that there would be a shortage of veterinarians. It's just a shame that they were wrong.

I'm not putting all the blame in any one place, but I don't think any entity in this field of education gets away unblemished. I also agree with your point that addressing all the issues you mentioned would be better than doing nothing.

 

[DVMDream]

Just to clarify, I'm not advocating closing any schools, because the damage has already been done and that's just unrealistic.

1. Correct me if I'm wrong, but aren't most US veterinary schools non-profit? They cannot charge more just because there's more demand like a business. Universities across the US have been increasing tuition a lot lately mostly because state governments are cutting funding or the funding has not increased in relation to inflation, and training veterinarians is very expensive. It would be even more expensive if we were actually paying the real cost of getting trained as veterinarians.

2. See point 1. They increased class sizes because of decreased state funding, and also because the national veterinary organisations told the vet schools that there would be a shortage of veterinarians. It's just a shame that they were wrong.

I'm not putting all the blame in any one place, but I don't think any entity in this field of education gets away unblemished. I also agree with your point that addressing all the issues you mentioned would be better than doing nothing.

1. You are right with one... didn't even think of that... exam brain, sorry. Western is the only for-profit school in the US (I believe).

2. I don't see them stopping increasing class sizes even if state funding were what it should be mainly because of your second point in that sentence.

I think there needs to be something done with the opening of new vet schools to start with... start there for dealing with the issue then expand on to things such as class sizes.... but even AZ is opening a vet school and I know state funding to schools in AZ has been cut drastically.... the fact that they have the money to open a vet school and the money to train veterinary students baffles me... I don't see how it is possible, but somehow they are doing it.... I even had it in my mind that Midwestern University (the school in AZ opening the vet school) was a for-profit school, but I looked it up and I was wrong... they aren't.... still don't know how they plan to support the vet school...

 

[Indigo10]

I have a kind of interesting thought on this subject but it might be controversial to a lot of people. If I am wrong then that's ok, just trying to think of the situation at different angles.

Its easy to assess the veterinary situation and job market as it is now, but we have no idea how its going to pan out in the future. For example, Iowa State was the first school to build a veterinary college. If you look at their history, they went through periods of MASSIVE growth while all around them new vet schools were popped up everywhere. During the great depression, vet students were told that there was "no future" in the profession and that new graduates would never be able to find jobs. After the depression they saw another huge growth period where they increased class sizes and built new facilities to accommodate everyone. In the end the outcome for Iowa graduates was great despite the roller coaster of growth and depression. http://vetmed.iastate.edu/about/history

I like to look at history because it tends to repeat itself. I am noticing that we went through a huge period of growth right before the economy crashed. People were wanting more vets and vet students were offered 2-3 jobs upon graduation. Then the economy crashed and the word on the street was "no future" for students. We are just now getting out of this and there could potentially be another surge in growth for our industry. It's really hard to tell or asses what the future holds.

What I do know is that veterinary unemployment rate is far less then most professions at this time. My belief is that veterinary medicine is a necessity for society and choosing to go into this profession is still a smart choice for a career path. You might not be rich, but veterinarians do have the potential to make a decent living. It might be tough when you first get out of school and its understandable why a lot of people are upset about salaries, debt, and job searching. But if you continue on your path and strive towards providing the best medicine as you possibly can for your clients, I believe that you will be able to find a job and eventually get paid a decent salary for your work.

We are the new generation of veterinary medicine and we are vastly more trained and specialized then the last generation of veterinarians. Why? Because society demands better care and better technology for animals. Of course being more educated and specialized comes at a higher cost. More equipment in veterinary hospitals, veterinary teachers who are brilliant in their specific field to teach us, and diagnostic equipment that would blow the minds of veterinarians 20 years ago are becoming the norm in average vet hospitals. Heck, in 2005 the number of animals with insurance was only 50,000. In 2009, 4 years later, that number jumped to 1 million animals. Vet school is more expensive because of many reasons, but I still believe the cost is worth it and we are learning a lot more with more technology then any generation of veterinarians have seen before. With the rapid change we have seen in the past 5-10 years it is hard to say that the situation veterinary medicine is in now is going to be the same in another 5-10 years. I don't worry about finding a job when I graduate, I worry about learning all I can now to be prepared to give the best possible care to animals. For everyone that is worried that you picked the wrong profession... DON'T BE. Focus on becoming the best doctor and growing your skills all the time. Be smart about finances and your education and chances are... you will be fine.

 

[PlentyofPuppies]

Coming out of the woodwork to say that Western is a non-profit school. I don't know of any for-profit vet school in the U.S.

 

[StartingoverVet]

If veterinarians aren't making these decisions, then who? The client, who typically has no concept of the ramifications associated with major medical decisions (like in the case of hemodialysis)?


Veterinarians should 100% be making these decisions. Clients rely on our medicinal expertise to guide them in making ethical, humane choices for their pets. Regardless of your position on transplants, as a veterinarian you should be taking ownership and a leading role in major treatment decisions. It's your job.

This just isn't the reality of how medicine is actually practiced.

I'll give you an example. You have a 16 year old cat with end stage renal failure. A little old lady owns this cat, and she loves it more then anything. The cat has a number of comorbidities that are exacerbating its renal disease (hyperthyroidism that you've managed, and HCM that is not clinical at this time). The cat is dehydrated and severely azotemic. You could offer hemodialysis for this cat, and this little old lady with an unlimited bank account would do anything to save it, but should you? Is hemodialysis in the patients best interest? By your argument you have to give them every option available to them...

Your job is to advocate for your patient. Yes you provide owners with medically reasonable options, explain those options so they have a clear concept of their choices, but in the end your recommendations are based on what you feel is best for the patient. When you enter practice you will be faced with the prospect of completely disagreeing with what an owner wants to do (convenience euthanasia is a good example). Does that mean you have to do it? Absolutely not.

Here is another example that is reasonably common: an owner brings a blocked cat into you. You provide the owner with their options - from gold standard therapy to euthanasia. The owner decides they want to do nothing and just take the cat home. What do you do? You know that cat is going home to die a miserable death, do you just shrug and let them leave because you gave them all their options and they made a decision you don't like? Sure you could call the humane society and have them try and rescue the cat, but maybe its a Sunday and they're not open until Monday... then what? I would tell these people that leaving with their cat and doing nothing is not an option; they have to make a decision: treat the cat or euthanize it. Was that wrong of me?

In practice things aren't so clear cut.

Well, all I can say is I am thankful you have never been my vet.

A vets job is to inform and help GUIDE the decision. Ultimately it is the owner's, and short of abuse you have no right to withhold crucial treatment information.

You may think you know better, but that is the despot's answer in every single case. The ego to think only you know what is best for the animal is the ultimate hubris.

Do owner's make bad decisions? Absolutely, but they are theirs to make, not yours. And I guarantee, you must make some bad calls as well.

I absolutely believe in strongly advocating for the animal when necessary, but not to impose my own opinions on others as if I know better. As I said, you can believe you are doing what is right, and I can hope not to have you as a vet.

 

[DVMDream]

Well, all I can say is I am thankful you have never been my vet.

A vets job is to inform and help GUIDE the decision. Ultimately it is the owner's, and short of abuse you have no right to withhold crucial treatment information.

You may think you know better, but that is the despot's answer in every single case. The ego to think only you know what is best for the animal is the ultimate hubris.

Do owner's make bad decisions? Absolutely, but they are theirs to make, not yours. And I guarantee, you must make some bad calls as well.

I absolutely believe in strongly advocating for the animal when necessary, but not to impose my own opinions on others as if I know better. As I said, you can believe you are doing what is right, and I can hope not to have you as a vet.

You are much more brutally honest than I am... but this is the point I was trying to make.

 

[cdndvm]

Well, all I can say is I am thankful you have never been my vet.

A vets job is to inform and help GUIDE the decision. Ultimately it is the owner's, and short of abuse you have no right to withhold crucial treatment information.

You may think you know better, but that is the despot's answer in every single case. The ego to think only you know what is best for the animal is the ultimate hubris.

Do owner's make bad decisions? Absolutely, but they are theirs to make, not yours. And I guarantee, you must make some bad calls as well.

I absolutely believe in strongly advocating for the animal when necessary, but not to impose my own opinions on others as if I know better. As I said, you can believe you are doing what is right, and I can hope not to have you as a vet.

Allowing owners to dictate how you practice medicine is likely the single worst decision you will ever make. I'm thrilled that we have decided to add such an ineffective practitioner to the ranks of our profession.

 

[WhtsThFrequency]

Well, all I can say is I am thankful you have never been my vet.

As I said, you can believe you are doing what is right, and I can hope not to have you as a vet.

I'm thrilled that we have decided to add such an ineffective practitioner to the ranks of our profession.

Invoking SDN's version of Godwin's law in 3.....2.....1....

 

[dyachei]

Let's keep it civil and refrain from personal attacks as they are against the terms of service at SDN

 

[KCgophervet]

Allowing owners to dictate how you practice medicine is likely the single worst decision you will ever make. I'm thrilled that we have decided to add such an ineffective practitioner to the ranks of our profession.

This is an awful thing to say, because bad decisions can be made on either side of the white coat. There are human medical doctors who refuse to perform procedures or write prescriptions based on their personal beliefs, luckily people can generally find a different practitioner. If they were allowed to have final say in the matter horrible things could happen. Likewise, I'm sure there are some practicing vets who also make decisions that some people wouldn't agree with, but to take out the choice of the owners in the matter is a terrifying prospect. In cases of abuse and animal cruelty, it is sad and unfortunate and I think every vet should do what they can for the sake of the animal within the bounds of the law, but you can't strong arm people and just make their decision for them.

Also, there's no reason to be so harsh with your language, insulting someone here for their views on certain topics. It's just unnecessary, doesn't help your point, and ends any possibility of further rational discussion on the subject.

 

[julieDVM]

Well, all I can say is I am thankful you have never been my vet.

A vets job is to inform and help GUIDE the decision. Ultimately it is the owner's, and short of abuse you have no right to withhold crucial treatment information.

You may think you know better, but that is the despot's answer in every single case. The ego to think only you know what is best for the animal is the ultimate hubris.

Do owner's make bad decisions? Absolutely, but they are theirs to make, not yours. And I guarantee, you must make some bad calls as well.

I absolutely believe in strongly advocating for the animal when necessary, but not to impose my own opinions on others as if I know better. As I said, you can believe you are doing what is right, and I can hope not to have you as a vet.

This post demonstrates a fundamental lack of understanding of how the veterinarian client relationship actually functions.