Monday, February 29, 2016

Getting Tutored

In a straw poll veterinarians stated that their favorite The Far Side cartoon was the one where a dog being driven to the vet brags to his friend, "I'm going to the vets to get tutored!".
This is funny several ways, but the way that is relevant to this post is that it highlights the confusion around the terminology. Even well educated clients will approach the subject cautiously, "I guess it's time to get Fred... is it spayed, or neutered?".

For my lay readers, neuters are for males and spays are for females. At the risk of sounding unprofessional, a handy mnemonic is that the word neuters contains the word "nuts". Which brings me to the next area of confusion: the widespread misunderstanding of what this procedure actually entails. I'll focus on neutering and leaving spaying for another post lest I blather on too long.

So, the technical term neuter is actually orchidectomy. "So doc, you're taking out his... orchids???" Yeah, so that's why we don't use that term at all. A more descriptive term is castration. Large animal veterinarians routinely and happily call it that. The companion animal world is different however. Picture a sweet little old lady with her tiny fluffy white poodle sitting primly on her lap. He has a blue bow at the base of each ear and smells faintly of peaches. Now picture me saying, "Yes, Mrs. Butterworth, it's time to castrate Baby." Moreover, there are people who think that castration means cutting the penis off. Yikes! Yes, there are such people who believe such things. And no, we never do that (except in very special circumstances in cats who have frequent urinary obstructions, but I digress).

What do we do then? We do this: we surgically remove the testicles (remember? neuters contains nuts?). Sometimes I'm asked why we don't just perform a vasectomy instead. This is because reproductive control is only one of the reasons to neuter. In many cases we would also like to remove the ability to produce testosterone in order to eliminate the risk of testicular cancers and chronic prostate infections later in life, as well as to help curb marking behaviour, roaming and male-on-male aggression. You'll note that I wrote "help curb". Too often people use neutering as a substitute for training. It is not. 

Now I'm going to wade into a controversial area. Virtually all cats are neutered. The exceptions involve people who have had their own olfactory nerves removed. However, not all dogs are neutered, at least not at the traditional six months of age, and - here is the controversial bit - this might be ok. There is evidence now that breeds of dogs that are prone to cruciate knee ligament ruptures (typically large breeds) may be at increased risk if they are neutered before their bodies are fully mature. This might mean waiting until 18 or 24 months for some breeds. There may be other risks associated with early neutering in some dogs as well. This is a complex area of ongoing research, so please (please please) speak to your veterinarian first before making any decisions based on what you have read here or elsewhere on the internet. A lot of what we do has evolved from boilerplate "one size fits all" recommendations to a discussion of options tailored to the risk/benefit ratio specific to your pet. And this is a good thing. A confusing thing, but a good thing.
I guess that was more like toe-dipping rather than wading...

Finally, I'm going to leave you with this:
This 100% for real. And endorsed, it seems, by Kim Kardashian. Yes, finally there is help for the owner who wants to neuter their dog, but has an unhealthy attachment to the appearance of his scrotum. Unfortunately it's not the help these people actually need.

Comes with a nifty bumper sticker though!


Thursday, February 18, 2016

The Ineffable Weirdness of Dentistry

A routine part of small animal practice is recommending dental work and then having the pet owner react as if you have just recommended Spanish guitar lessons for their dog or a set of encyclopedias for their cat. Some people view veterinary dentistry as evidence that we've gone too far in treating pets like people. These people (thankfully increasingly a minority, but a very annoying one) put it in the same category as pink leather jackets for chihuahuas and spa days for cats.

This can even be true when you show the client gum lesions that are exuding pus. Guaranteed if you showed them lesions exuding pus anywhere else on the body they would be horrified. They would expect immediate curative action. But not so for the teeth.

Why is this?

In part it is because the teeth are generally not visible. That being said, I would like to note that sometimes the same people will then go on to show me a minuscule lump somewhere deep in the dog's groin or be genuinely concerned when blood tests reveal a more minor issue in an internal organ that is definitely not visible.

Another factor is that animals do not show dental pain. This sometimes results in the reverse problem wherein the client will absolutely insist the cat isn't eating because his teeth are bad. There are 968 common reasons for a cat not to eat and that is not one of them. It is a very uncommon reason for them not to eat. But the pain question is also only a partial answer as many other conditions that are not painful elicit far more interest from the dental skeptical clients.

So then, what is my theory?

My theory is that we must blame the weird history of the human dental profession. Objectively speaking teeth are part of your body. Actually, subjectively too. Teeth are part of your body: objectively, subjectively, factually. Agreed? Why then is it the only part of your body to have an entirely separate profession devoted to its care? It turns out to merely be an accident of history. We could have just as logically ended up with a separate profession focused on our fingers and toes. "I'm off to the digitist dear!"

Before the 20th century there was a division between physicians who examined sick people and prescribed primarily quack remedies and "barber surgeons" who used their sharp razors and steady hands to perform surgeries ranging from lancing boils to amputating limbs as a sideline between hair appointments. Some also had a set of pliers handy to pull teeth (as did some blacksmiths). That was the sum total of historical dentistry - yanking festering molars. Carpenters and other tradesmen made false teeth. As regulations began to gel the more ambitious of the razor wielding barber surgeons craved the prestige the physicians enjoyed and those professions gradually merged, more or less accidentally leaving tooth pulling behind and unregulated. Later on the medical colleges who began to shut down all manner of other trades that were "practicing medicine without a license" (midwives come to mind) ignored the tooth pullers because they didn't seem to be a threat and, some will darkly say, because they were of similar social backgrounds.

This has left us with a situation where in Canada medicare will pay to operate on your infected toe, but not to operate on your infected tooth. A situation where you have two incompatible sets of records regarding your health. A situation where some people see their teeth as being divorced from the big picture of their health. Arbitrary and weird. Dentistry is weird.

And for us poor veterinarians who have successfully kept the entire body of our patients under one umbrella, it is a situation where some pet owners have a different mental box for teeth than for the rest of Fido/Fluffy's body.

p.s. My dentist is great and not all that weird. I just think if he were an MD dental specialist my life as a veterinarian would be simpler.

Monday, February 8, 2016

When Darkness Overwhelms

This post is going to be a departure from my usual lighthearted (or lame attempt at lighthearted) tone. This post is going to be about suicide in the veterinary profession. Statistics are not available for Canada, but in Britain two separate studies found the suicide rate among veterinarians to be four times that of the general population.  I personally knew two colleagues here in Manitoba who took their own lives, and in 2014 a prominent and very well liked behaviour specialist killed herself, drawing some media attention to this little known aspect of the profession.

To the casual outside observer this will be unexpected and possibly even slightly bizarre news. Aren't veterinarians generally well respected? Isn't it a secure, interesting and rewarding career? Isn't it a dream job for so many people? Isn't it wonderful to heal innocent animals and get paid to play with fluffy kittens? All of that is true. Except the part about the fluffy kittens. Why then does darkness overwhelm so many of my colleagues? There are three significant reasons.

The first reason is that veterinary medicine attracts a disproportionate number of idealistic, introspective and sensitive people. Sensitive to the point of neurosis. This is true of all of the health professions, but it is more so in veterinary medicine. Some of these introspective people are more comfortable around animals than around other people. They do not fully understand that it is actually a people job that happens to involve animals rather than the other way around. Grappling with this reality can be very problematic for some. Add to this the fact that competition to get into veterinary college is extremely high and success favours perfectionists who can produce high marks. Perfectionism and idealism are fated to be brutally ground down by the chaos of reality in practice. And then their innate sensitivity lays them wide open to the second reason.

The second reason is the inherent and often surprising multi-factorial stress of the job. Of immediate relevance to sensitive people is the fact that a veterinarian is at times marinated in death and grief. There are weeks, many weeks in fact, where I perform one or more euthanasias each day. Sobbing, crying, wailing, grief-stricken people, some of whom we've known for many years, are a routine part of our day. And for those of you who think this is simply a question of overwrought crazy cat ladies or frou-frou poodle people who too much resemble their dogs, I have two things to say to you. The first is that if you have not experienced a deep bond with an animal then you are missing out on a key human experience, one shared by people from all walks of life, all backgrounds, all levels of intellect. It is one of the richest threads we weave. The second is that you have no more right to judge this than a blind man has to judge a photography exhibit. Simply trust me that these are normal people with legitimate and intensely felt grief.  Additionally, a veterinarian is expected to be competent across a range of species and a range of disciplines from dentistry to radiology to dermatology to... you name it, wedging the door wide open to so many opportunities to fail. And remember: "sensitive". Mix sensitive and failure and see what happens. And I haven't even discussed the financial stress of trying to be affordable to clients yet still be able to service sometimes enormous debt burdens and meet payroll etc.. Or the stress of being a manager when you went to school to be a vet, not a manager. Or the angry clients. Or the angry spouse because you're stuck late again.

The third reason is that we know how easy it is. How easy it is to die. Those daily euthanasias are consistently peaceful, painless, quick and reliable. One hundred percent reliable. We know the dose. We know the delivery methods. We have the drug right there. Can you see now why it happens too much?

What can you, the reader, do? You can't do much about the first or third reason, but you can do something about the second. If your friend or family member is a veterinarian, do not trivialize their stress. Understand that James Herriot is a crock and that the real job is far more complex and serious than you imagine. Offer to listen with an open heart.

And what about me? Well, fortunately I had a "happy optimist" chip deeply implanted at birth. The zombie apocalypse could roll into town and I would say, "Cool, this will make for some excellent photos!" And, "Maybe brains are better with a bit of smoked paprika?" I have painted a bleak picture when in fact most veterinarians are fine, even better than fine, but burn-out is very real and for a small tragic minority, suicide is very real too.

This post is for Terry and Craig and Sophia.