Diagnosis: idiot!

From the VBB mailbag, I bring you Dr. Happyvet's tale of woe:

Joe Doglover has a dog named Mutt. Mutt has had a few health problems for a while, so Joe takes Mutt to Dr. Happyvet.  Using her powerful diagnostic skills, Dr. Happyvet determines that Mutt suffers from “sickdogosis,” and requires continued treatment.   Treatment is prescribed, but sadly the Mutt does not improve, as Joe either decides not to treat Mutt, or forgets to give the medication. Instead, Mutt gets worse. 

Chart review reveals that sickdogosis  has been noted three times in the file. The last time Mutt was seen, sickdogosis was "discussed extensively with owner". Specifically, a treatment plan was laid out, with appropriate diet and medication sent home. Prices to further work up sickdogosis at external labs were relayed to the owner - the record contains copies of these estimates. A few articles regarding possible underlying diagnoses, additional medical treatments, management methods and possible outcomes of sickdogosis were sent home with Joe on multiple occasions. These articles were discussed while sitting next to Joe, and relevant points were highlighted in front of him. A summary was written on another sheet of paper and given to Joe, with a copy retained for inclusion in the medical record.   

After a while, Joe stopped coming in, and there were no additional updates on Mutt. A few weeks later, a records transfer request arrives at the clinic. Reason given?  "Dr. Happyvet is incompetent for failing to recognize that Mutt had sickdogosis."

          I don’t want to live on this planet anymore.

Oh, Cable Guy!

So, this isn't meant as a "poor me" post, or a husband bashing post, or anything other than a "take a minute and think about this" post. 

I'm a full-time small animal veterinarian. My husband works for a large cable company as an installer. We both work our butts off to be good at our jobs.  

I was paying bills the other day and realized: 

• I spent 4 years in graduate school to be able to do what I do. My husband was on the job trained. 
• I graduated with ~$115K in loans (all from grad school). My husband has none. 
• I paid for my school. My husband's company paid him to attend school. 
• I pay for my health insurance, have my own retirement plan since my clinic does not offer one, and get no money for continuing education, uniforms, dues for professional organizations, etc. My husband gets full medical, dental, vision, retirement plan, weekly paid training sessions, a work vehicle, and paid for uniform shirts. 
• I work, on average, about 60-65 hours per week. If there are emergencies, I have a patient in hospital that needs care, or we are busy, it's significantly more than that. My husband works about 50 hours a week. 
• I do not get any paid time off for sick days or vacation. He accrues paid time off every week, and is guaranteed sick days. 

So, all of this adds up to a significant difference in the bottom line, right?

Well, I suppose it does.....the past few months, he's made more than I do. 

In essence: with less training, less debt, fewer hours, better pay, and better benefits, it makes more sense for me to go work for a cable company than it does for me to a be a practicing doctor. Kinda makes me stop and think - next time I have a bright eyed young person look up at me and tell me they want to be a vet, too... It's sad.

Walk softly & carry a large tranquilizer gun

This story from the remote VBB outpost known as VBB Ambulatory Service illustrates part of the problem our farm-call colleagues have every day. Small animal vets may recognize the archetypal Mr. Nopay in this dramatization of a routine inquiry by phone:


VBBAS: Good morning, VBB Ambulatory Service.  How can I help you?

Mr. Nopay: I wanted to make an appointment for spring shots for my horse.  How much will that cost?

VBBAS: That depends upon what vaccinations your horse needs.  How old is your horse?

Mr. Nopay: He's three.  Is it too late for his boosters?

VBBAS: Do you mean annual vaccinations?

Mr. Nopay: No, his boosters.  The other veterinarian said I needed to make an appointment for his boosters.

VBBAS: Okay.  When was this?

Mr. Nopay: I don't think I should have to pay to start over.

VBBAS: When was your horse last vaccinated?

Mr. Nopay: The veterinarian gave him the five-way when he was six months old.

VBBAS: Has your horse received any other vaccinations?

Mr. Nopay: My horse doesn't like men.  That's why I thought I'd try VBB Ambulatory Service.

VBBAS: When was your horse last seen by a veterinarian?

Mr. Nopay: I hope you're better than the other veterinarians.

VBBAS: Who is your regular veterinarian?

Mr. Nopay: Well, I use Dr. Doesitall for my dogs, and he gave my horse the five-way, but now my horse is afraid of male veterinarians.  He is very rough.  The last time he vaccinated my horse he broke the pasture fence.

VBBAS: Was this last spring?

Mr. Nopay: No, when he gave him the five-way.  He said I need to make an appointment for a booster, but I didn't want to make it with him because after the last time my horse is afraid of male veterinarians.

VBBAS: Did your horse receive any vaccinations after the first shot?

Mr. Nopay: No, that's what I've been trying to tell you.  Dr. Doesitall doesn't travel with a technician.  Do you have a technician?

VBBAS: We can schedule the appointment on a day when the technician is with me.

Mr. Nopay: You shouldn't need one.  My horse is very well-trained.  He works at liberty.  I've taught him to rear.  Have you ever seen a horse rear at liberty?  He's so beautiful.  I'll have to show you the photo I used for my Christmas cards last year.

VBBAS: Let me make sure I understand.  Your horse received his first five-way when he was six months old...

Mr. Nopay: Yes.  Do you do castrations?  Dr. Doesitall doesn't do castrations.  Neither does Dr. Newgrad.  Dr. Deathwish wanted me to bring my horse to his hospital, but his hospital is expensive and my horse is afraid of men, anyhow.

VBBAS: I see.  Yes, I perform castrations.

Mr. Nopay: My horse only has one testicle.  Would there be a discount?

VBBAS: Actually, I don't perform cryptorchid castrations in the field, but we can talk more about that when I come out to your farm.  Now, your horse needs all of his vaccinations, and it sounds like he will need both the primary and the boosters because he didn't receive the full series originally.  I can work up an estimate for you so there won't be any surprises when I arrive for the appointment...

Mr. Nopay: Last spring Dr. Newgrad didn't bring her tranquilizer gun.  Do you have a tranquilizer gun?

VBBAS: ...Let me give you the phone number for Dr. Wild.

Mr. Nopay: But he's a man.  My horse doesn't like men...

One of these things is not like the other..

So, one of our DBB is a big fan of Sam's Yams. Are you familiar with them? They are dried sweet potato slices. They are really expensive. You may have heard that vets aren't actually raking it in right now... so, you know, I figured maybe I could recreate these slices of heaven for DBB using the tools I have on hand in my kitchen - the oven, a knife, and some sweet potatoes. How hard can it be?

Well, it turns out it doesn't seem to be that hard. I read this article and I'm hoping that I can give this a try later today. I just have to get some sweet potatoes. But anyway, when I got down to the bottom, there was one of those "more articles like this" sections. Here's a screenshot:

One of these things just isn't the same...

Dude. The one on the right.  WTF?? Not about sweet potatoes! Not about food preparation or storage! Not in any way similar to the original article. Also, not particularly enlightening, if you go there and click through.... but honestly I wouldn't bother.

Anyway - anyone reading this ever made home-prepared dried sweet potato slices for his or her pooch? Any other healthy snacks your DBB loves? VBB Home Base could use some inspiration. Drop me a comment, or tweet@me!

Not cheaper by the dozen!

Sitting in my office, I can hear the receptionist out front on the phone with a caller. This is what I heard just now:

[ring, ring]

Receptionist: Hello, VBB Animal Hospital, how can I help you? [pause] Yes, we do boarding. [pause] Absolutely we do. Hang on let me see - yes, there's room that week. [pause] How many cats? NINE cats? Well that would be $22/cat/night. Yes. Yes, that's $198/night inclusive. No, there's no group discount. So have we seen these cats before? [pause] Oh you just moved to the area a year ago, I understand, but has any veterinarian seen these cats before? [pause] Well, we can't board them unless they are up to date on their vaccines. No, no. We cannot sell you the vaccines. Yes, even if they are indoors only, they can't stay here if they aren't up to date on their vaccines. [pause] Well they would need an examination so the veterinarian is sure they are healthy and free from infectious disease and parasites, and then they would need vaccines, and if you hang on I can get you an estimate - ah, yeah, that's what I thought. Well, pets are expensive. I know. I'm sorry. [pause] Actually I do know. Actually I take off one day a week to watch my grandson exactly because daycare is so expensive. But, the cost of daycare isn't really something that we take into account when we set our fees. [pause] You might have better luck finding a petsitter to come to your house. [pause] I don't know what else to tell you. [pause] Well you have a nice day too, maybe someone can call you at work and curse you out for doing your job. Thanks for your inquiry. Goodbye.

[slams down phone]

Is it any wonder people burn out in these jobs?

The Readers speak!

2. OK, one reader speaks. The rest of you slackers, feel free to chime in any time. Our reader Jenna commented so eloquently on our previous post, we obtained permission to repost her remarks here as a separate blog post. 

   
   

   From Jenna:

   It's convenient to blame the current generation's parents for encouraging to follow their dreams, no matter how unrealistic, or the current generation, for expecting "someone", whether that be the government or Mom and Dad to bail them out. 

   You are on the brink of retirement. What do you have to say to someone like me, who graduated over a decade ago? I am NOT part of this new generation, nor am I of their parents' generation. I'm from the group stuck in between, the practice owners who are still paying back loans they once thought were reasonable and manageable. 

   I paid for my first year of veterinary school with savings I'd earned in a job I'd worked for half-a-dozen years before I applied to veterinary school. Unfortunately, I reside in a state with an expensive in-state veterinary school. I graduated with loans around the national average for the year that I graduated. After working for other people and doing my best to absorb all I could from my mentors, I set up practice in a rural community, figuring if I were good, I'd always be able to make a living in large animal practice. 

   I didn't anticipate the economy tanking. 

   I didn't foresee a hefty percentage of my clients leaving the area or losing their homes. 

   I didn't see all those farms being sold for development and paved over to build yet another shopping center or McMansion development. 

   I didn't expect veterinary schools to increase the number of new grads to a point that the number of practicing veterinarians would balloon out of control. 

   I didn't plan on those new grads starting their own practices when they couldn't find jobs. 

   I didn't guess that a huge percentage of those new grads would come from wealthy backgrounds, so they'd own nicer equipment (digital x-ray, etc.) than I could afford unless I overextended myself on credit, equipment that impresses clients but doesn't actually improve outcomes. 

   I had no clue those wealthy young grads would prefer "boutique" work, offering only the profitable, 9-5 services like lameness and "alternative therapies". 

   I didn't know the "retired" large animal veterinarians in my area had never actually given up the predictably profitable portions of practice (basically excluding illness and emergencies) or that a sizable number would come out of retirement when the stock market crashed. 

   I didn't realize the small animal veterinarians who had "retired" from large animal practice were selling vaccines and dispensing drugs to their "good" clients without ever setting foot on farms. 

   I didn't have an inkling I'd lose such a huge percentage of my routine work to lay people (e.g. tooth fairies), internet sales, and human chiropractors and physical therapists. 

   I never suspected that my colleagues, my fellow veterinarians, would find themselves so desperate for a source of income that they'd engage in race-to-the-bottom pricing in order to attract clients, any clients, even temporarily. 

   I banked on my clients' loyalty, only to find that if there are 10 practices working in an area that formerly supported 3, after a certain point this benefits only the clients, not the veterinarians... and after another, later point, this benefits neither group. Everyone loses.  

   Sure, I'm still a good veterinarian, but I am very, very tired of this profession. What does anyone have to say to people like me who did what we were supposed to do: work hard, pay back student loans in full and on schedule, all while providing full-service veterinary care? All this, and I bought a home I could actually afford, and as a result have never missed a mortgage payment.
   I'll soon be closing my practice and going on to a job as a non-practicing veterinarian. I've practiced just long enough that I will remember the good times without forgetting they were far in the past, in a practice climate far different than what I see in 2013. 

   The young people in my life will never be veterinarians, if I have anything at all to say about it. 

   And yes, Lindsay, veterinarians have a suicide rate double that of other high risk professions (law enforcement, military, physicians). I've already lost two colleagues to suicide.

   
   Jenna, we at VBB central feel your pain. A number of us are in the same situation! I remember my mom telling me "they can never take away your education, and that's your most valuable asset." I'm not sure that's true anymore in this economy!

back in the trenches

It's not all politics around here. Yeah, the AVMA is annoying lately with their whole "let's spend $80K on finding out whether we really need a new logo and if so what it should be like" thing. Yeah, there was an article in the NY Times about our profession & its economic issues, and I'm sure that you, dear readers, have noticed that we VBB have strong feelings about these matters. That said - there's more to life, and as we struggle to keep our heads above water and pay down our loans, we are kicking butts and taking names - and sometimes seeing patients.

I had a client call me today to find out whether or not Fluffy needed to continue his medication. Before calling the client back, I went into our trusty EMR and looked up Fluffy's history. I noticed that Fluffy is on Optimmune, and has been on Optimmune for 3 years now. I further noticed that the last several labels printed out for Fluffy's Optimmune all contained the statement "DO NOT DISCONTINUE - CALL FOR REFILL BEFORE RUNNING OUT - THIS IS A LIFELONG MEDICAL TREATMENT!" So, I banged my head on the desk a few times before making that call. It didn't help.

I've been treating a million-year-old Small Fluffy White Dog that belongs to a million-year-old dementia patient. The client's caregiver comes with the dog & the lady to our appointments, thank goodness. Last week I saw the SFWD on a recheck four days after her previous visit which had been with a colleague. When my colleague saw SFWD she'd noted lumbar pain, hind end pain, generalized weakness, and a high white count. She'd started methocarbamol & amoxi/clav. Apparently this hadn't worked so well because when I saw SFWD she was pretty flat. Dehydrated, not eating/drinking, not walking, not standing unassisted, and temp in the range of 104 F. Euthanasia was not on the table that day - you know, this dog is the demented old lady's only real family left, and the demented old lady was not capable of understanding the kindness it would be to release the dog from her suffering, it seemed to me. Certainly the caregiver wasn't about to consent. So, I did some hemming and hawing and ended up giving fluids, and sending SFWD home with mirtazapine and Zeniquin on top of the rest of the stuff. Imagine my surprise to find out today the dog is doing great! Eating, drinking, walking around normally. I just wish I could be sure - is she really better, or is this the sweet spot before they find her dead in the kitchen or something?

Today I also saw a young adult longhaired mutt cat. She was presented by a woman claiming to be the mother of the actual owner, who was a 12 year old girl. The girl was not there. The woman stated that her daughter said the cat had bumps on its skin. She further stated that they had used a Furminator on the cat four months ago, and she'd "been like this ever since," where "like this" equals "practically no hair on the caudal half of the cat." To make a LOOOOOOOOOOOONG story short, there were no significant findings on any of our diagnostics, and a trichogram revealed growth-phase hairs that were broken off rather than normally tapered. The owner did state that the cat had a history of food allergy. In despair, I decided to give 10 mg of Depo-Medrol. I had a discussion with the owner in which I explained that I really wasn't sure what was going on, but that hopefully in the event of allergic or inflammatory condition the steroid would help. Of course I also explained that if there were in fact a fungal, parasitic, or infectious condition I had not uncovered, the cat could get worse. The owner looked at me for a moment and said "ok, sounds good. Either she will get better, or she will get worse. If she gets worse, I'll bring her back for more tests. Right?" "Yes. Either she will get better or she will get worse. I realize that sounds bad...." We all laughed. It was really nice to have an understanding client for a change. I put a lot of pressure on myself to always figure it out up front, to always be right, never make a mistake, etc. This cat just did me in and it was wonderful that the owner was understanding. Here's hoping kitty improves.