One of my favorite client recommendations involves the use of a small, spiral-bound notebook (or a handy PDA, depending on your taste) and a pencil (or a set of quick thumbs). Keeping a log is so simple...and bears such magnificent fruit when carefully employed.
In case your veterinarian has never suggested it, you should know that many chronic, episodic or as yet undiagnosed pet diseases are amenable to the invaluable assistance offered by the low-tech tool that is journal-keeping.
Diabetes (all varieties) Cushing’s disease Allergic skin disease Seizure disorders Inflammatory bowel disease Addison’s disease Cardiac diseases
The list would be longer if it wasn’t so early in the morning, but these are the most common disorders for which I strongly recommend my clients keep a log.
It’s a bit different for each individual disease but the basics are the same. In your journal you report on...
Medication doses and frequency Feeding or other home care details Symptom presence, duration and description Veterinary visits, findings and recommendations
All this is recorded by date, of course, with some disorders requiring specific times of day.
Here’s where your veterinarian comes in. Your job is first to ask your veterinarian which details are most important to record. For example, seizure disorder pets may require the observation and recording of the different phases of the seizure and their timing. Diabetics will most definitely require details on insulin doses, blood glucose measurements, etc.
Next up is the issue of how to present your findings. Some of you will anally graph and chart your findings. Others will simply ensure it’s legible and easily digestible by your veterinarian (doesn’t count if no one can understand your scribblings, right?). Doesn’t have to be pretty––just needs to be understandably organized and basically intelligible.
See how easy it is?
Believe it or not, this simple task will help your veterinarian immeasurably. It’ll help guide a diagnosis, if the disorder’s provenance is as yet undetermined. It’ll make medication dosing more targeted and efficient. It may even save your pet’s life.
Oh, and one more thing...it’ll definitely endear you to your veterinarian.
Ever wonder at all the “stuff” your veterinarian carries in his/her hospital? Sometimes it seems the products and foods are literally dripping from the well-stocked walls, the melamine shelving teeming with pet-themed goods––sometimes even in the exam rooms. You’d never expect to see so much for sale at your human doc’s place, right?
After yesterday’s post on euthanasia costs––and a couple of client interactions on the price of products––I got to thinking about this topic.
You could say that we veterinarians didn’t go to to school to become retailers, and many veterinarians would agree. To me, the proliferation of products in our workplaces is kind of demeaning to veterinary medicine––somewhat akin to what’s happened to the pharmacy profession.
Explanation: It hurts me to see licensed pharmacists scanning toilet paper at the pharmacy counter. So much so that I feel the need to apologize every time I ask my Target pharmacist to scan tampons or hair ties along with my meds.
I definitely don’t want my profession downgraded to such a status. Sure, I squeeze anal glands and clip toenails, too, but I can tell myself that’s still a whole world away from selling collars, leashes and kitty litter along with more defensible veterinary products like Frontline and Heartgard. Nonetheless, many veterinary hospitals defend a ginormous range of product sales as a “full-service” approach.
Perhaps my problem is more that I’ve always been such a horrible salesperson. During one horrible summer between college and vet school when the veterinary assistant jobs were few and far between, I even sank so low as to take a job selling Rainbow vacuum cleaners. I lasted two days, so unfit was I for such a detail.
There’s always been one exception to this rule for me. If I’m selling something I truly believe in and would buy with no reservations, I excel at sales. Hence, my top-salesperson’s status at the Joan and David store while in high school. Despite my youth, I could sell shoes I adored with perfect aplomb, surprising everyone with my hefty bonuses and pre-college savings (which I spent almost immediately on my Wellesley winter wardrobe).
Excelling at this narrow brand of salesmanship is why I’m convinced that I can handle the retail aspects of veterinary medicine. After all, I can breezily recommend products and services I’d happily purchase for my own pets.
It’s second nature for many of us, really. Veterinarians usually love playing the well-versed informant, the one who tells you which great restaurants to try and where to get the best prices online for X, Y or Z. This personality-type drives our veterinary “salesmanship,” whether we’re selling you on something we can provide or not.
But is this drive ultimately what’s best for our industry as a whole? Sometimes I think it is...and sometimes I believe it goes too far, as when we’re willing to stock far more goods than we could ever credibly believe in.
Whether we like it or not, every profession sells. the question is: By doing so with increasing reliance on food, product and drug sales, are we ultimately selling our services short?
What do you think? Is it distasteful to see products cramming every nook and cranny? Or are you relieved to know you don’t have to go elsewhere to stalk your pet stuff?
Here’s a killer topic. It’s one veterinarians hate to handle due to its sensitive nature and accusatory undertones. And yet it’s worth raising, especially since someone else did so in a nationally syndicated pet health column last month.
The issue is this: Why should veterinarians charge their “faithful” clients for euthanasia? After all, it’s painful enough to have your pet euthanized. No one should be handed a bill on the cusp of such an event, right?
That’s the paraphrased version. And here’s the good doc’s response:
“In the days before dehumanizing, money-driven ways took precedence over common sympathy and decency, a vet would never charge a regular and responsible client for euthanasia. Now the service is usually tacked onto a body disposal or cremation fee, the latter being reasonable. But as a business courtesy, if not on the grounds of professional etiquette and ethics, I think veterinarians should not charge their faithful clients one dime for euthanasia.
There are many overhead expenses when running any good veterinary clinic or hospital, but some loss of revenue regarding the euthanizing of one's animal patients would pay off in other ways. Imposing a bill for services during a time of intense grief and devastating loss seems impersonal and demeaning. Better to at least send the bill later, after a sympathy card.”
That, courtesy of Dr. Michael W. Fox, the veterinarian other veterinarians love to hate for his wacky, off-the-wall recommendations on pet care and business ethics in spite of his never having worked in veterinary private practice settings.
Now, it’s not that Dr. Fox doesn’t have a valid point or that his message is totally off-base. After all, none of us would deny that euthanasia is a time of incredible stress for everyone involved, a time when the financial aspects of veterinary medicine seem incongruous with our pledge to alleviate suffering and advance animal health with compassion. And there’s no doubt that it’s tremendously tricky to euthanize a patient lovingly only to turn around and hand your client a bill.
It’s also true that Dr. Fox’s implication that veterinary medicine has gone money hungry––even in the face of euthanasia––is not completely wrongheaded. It is, however, an overly simplistic interpretation of the cultural machinations that drive everyday private practice economics. That’s because the “dehumanizing, money-driven ways” our society has lapsed into...cut both ways.
Consider:
The client whose pet has been hospitalized for four days after suffering a diabetic-ketoacidotic relapse. Euthanasia ensues. The entire family is present. It’s a touching moment, as it often is. I don’t have the heart to charge the client at the moment. Six months later, I still haven’t been paid––for any of it, much less the euthanasia. When I euthanized a patient after a short bout with cancer, the owner opted for a beautiful (and very expensive) urn for her pet’s ashes. Again, I hadn’t had the heart to charge the client at the time of the euthanasia, near-hysterical as she was. When she came to pick up her pet’s ashes she hadn’t brought her wallet. Knowing how tacky it is to hold ashes hostage (as if we ever would), we handed them over along with the final invoice. We wrote off the entire bill in December after almost a year of non-payment. And if you think these scenarios are rare, you’re wrong. These just happen to be the ones I remember best for their especially high-priced ouch-factor. What about the client who you’ve only seen a couple of times? When our society is so mobile and our typical clients last two to five years (and veterinarians only last a few years at any one place), it makes it tougher to determine where to draw the line at comping costs for “faithful” client-hood. And when to let them walk away with a simple bill in the mail. And then there are clients who always seem to be bringing their pets only when they’re at death’s door. Do they deserve death concessions out of compassion? When costs for drugs, supplies, gas, equipment, etc. are rising so quickly, covering euthanasia costs for our clients will invariably mean raising costs for other services.Is it nonetheless the right thing to do? Absolutely...in a perfect world. Or when your relationship with your client is so solid that it can weather any storm––a rare bird indeed in this culture of neighborly alienation and interpersonal estrangement.
Sure, I have more than a handful of fabulous clients I've not charged for actual euthanasia services, and still it irks to read Dr. Fox’s prescription for the right way to handle a tender client interaction. Let him spend a few months at a Banfield...or, better yet, working ER...and let’s see where his compassion leads him. He might then think twice about throwing his money-grubbing veterinary colleagues under a bus.
Have you ever spied a fleshy protuberance between your dog’s toes that looked either like...
a) a fleshy welt
b) an ulcerated sore
c) a hairless bump, or
d) all of the above?
If so, you more than likely ran (fast!) to your veterinarian’s place only to be told your pet probably has a “simple” interdigital cyst (more correctly termed an “interdigital furuncle”). Your veterinarian may or may not have inserted a needle to extract some cells to send off for cytology (to ensure it didn’t scream, “cancer!”), cultured the lesion (to identify the kind of bacteria present) and/or scraped the area to investigate for the presence of demodex mites (sometimes involved). Then you spent the next month or three either...
a) plying your pet with antibiotics and/or steroids and/or mite killers
b) managing an e-collar-enabled dog about the house
c) soaking her feet in Epsom salts twice daily
d) testing her for allergies
e) testing for thyroid disease
f) attempting a food trial (in case of food allergies)
g) shampooing her feet
h) whittling down her weight
i) wiping between her toes with medicated cloths
j) seeing the veterinary dermatologist, or
k) all of the above
Or perhaps your veterinarian got fed up (or you did) and you elected to have the sucker biopsied, either by completely removing the thing––just in case––or by sticking a sharp punch right over the swelling and extracting a 6 to 8 mm-sized core of flesh to send off to the histopathologist.
According to the Merck Veterinary Manual (which every pet owner should own, IMO),
"Interdigital furuncles, often incorrectly referred to as “interdigital cysts,” are painful nodular lesions located in the interdigital webs of dogs. Histologically, these lesions represent areas of nodular pyogranulomatous inflammation––they are almost never cystic."
The cause of these lesions is multifactorial, veterinarese for “we’re not always sure but we think it’s the result of a bunch of things.” Allergies, excess weight, poor foot conformation, mites, ingrown hairs or other foreign bodies, yeast infections, etc.
The most common interdigital cyst (furuncle) dogs affected include Labs, Bulldogs, other short-haired or allergy prone canines, and overweight/obese dogs. But, truth be told, any pet can get one of these interdigital cysts (furuncles). For example, the two year-old German Shepherd my colleague is currently treating. The dog’s in great shape, small for his breed, and has no short hair, evidence of allergic skin disease or any other obvious predisposing factors.
These painful, nasty-looking lesions are stressful enough without the e-collar (to prevent further self-trauma to the area), the frequent ministrations and the potential side-effects of the drugs your veterinarian/dermatologist may have prescribed.
Many pet owners get discouraged, especially when treatment may go one for six to twelve weeks (!) and seek alternative (or more invasive) therapies. Here’s where you’re better off not trying one of Dr. Fox’s crazy essential oil treatments. And you’re almost always better off not opting for exploratory surgery to locate the source of the infection––not unless you’re willing to concede to the possibility of what’s called a “fusion podoplasty.”
A fusion podoplasty is a surgical technique to remove the entire web between the toes. Here’s where the interdigital cyst (furuncle) lies. And sure, removing it surgically has its benefits, but it also has its downside––especially if you approach this alternative as a quick fix that doesn’t address the underlying problem.
By removing the webbing between your dog’s toes, you may find that you predispose the foot to more troubles. Not only is the healing after this surgery a typically difficult and delayed process, it also means your dog will never have the same foot integrity as before. The webbing is there for a reason, after all. Foot pad overgrowths and a predisposition to more interdigital cysts are only a couple of problems we encounter.
All that said, your veterinarian does understand that interdigital cysts (furuncles) aren't so "simple." But they are treatable––just as long as you get to the right diagnosis early on, limit all offending factors and give medical treatment a good solid try before embarking on more drastic cures.
Ever had a pet with one of these? How long did it take to treat? Did you opt for surgery?
As if it’s not already tough enough to discuss weight loss, veterinarians get treated to a range of excuses for why their pets are tipping the scales. Broaching the “o” subject is itself an adventure, one which is commonly met with defensive postures, nervous laughs or just plain disdain.
At the outset of any conversation on the subject of extreme body mass and its ills, with fat pet as Exhibit A, I can already see my clients’ shoulders set in the universal symbol for “back up, girlfriend!”
That’s when I advance a few mollifying statements carefully crafted to set them at ease, something like...
She’s so gorgeously cute and she looks really healthy on the outside. I can understand why you love her this sweet and plump but let’s talk about what it means for her long-term health and comfort.
When I really want to say...
Wow! Miss Fatty’s blown up like a tick! At this rate, you really think those toothpick limbs can hold her up for ten more years?
Despite my mild lack of candor, what I’m really trying to do is get owners past playing the blame game. It’s my job to get the animal healthy...not to tussle with the owner over who’s at fault.
And yet for all my concessions to their human feelings, I might as well be pulling teeth for all the stress it takes to get my clients to view the situation objectively and discuss the roots of the problem dispassionately so we can move on to the solution as quickly as possible.
So you can appreciate what veterinarians are up against, here are the top ten rejoinders to my appeals for weight loss in pets:
1-But she only eats this much! (Hold your index finger about an inch away from your thumb for visual impact.)
Why is it so hard to understand that weight gain often has little to do with the total quantity of food? Come on, we all learned about calories in vs. calories out in grade school, right? If you have to feed two kibbles a day because she sleeps 24/7, then that’s what you have to do--oh, and make her move so she can earn another. (Disclaimer, obese cats require much more conservative weight loss regimens than the "two-kibble" approach.)
2-But he’s always hungry.
Many pets will always act hungry. It’s both learned behavior and instinctual for some. Imagine that your ancestors never knew where their food was coming from. Wouldn’t it be a great adaptation to be able to fill your stomach to the ripping point so you could survive on nothing for the next week?
3-But food is the only thing that makes him happy.
Yeah, because there’s something very bizarre about what you consider “happy.”
4-She’ll starve.
Really? Let’s conduct an experiment...
5-He’s so old already. I want him to live the rest of his life fat and happy.
He wouldn’t seem so “old” if he weren’t prematurely diseased from his obesity.
6-I can’t bear to know she’s suffering from hunger.
I can promise you she’s suffering already. What would you prefer, constant joint pain or half your "normal" calories?
7-He refuses to walk.
Yeah, I would too if I weighed that much. It’s a lame excuse (no pun intended). There’s always a plan for pain relief/dietary management/gradual exercise introduction.
8-It’s my family’s fault.
Sure, you may not be the one gorging him on your left over ice cream, but her obesity is still your responsibility. Call a family meeting to discuss how Fluffy will be in constant pain and die an early death if everyone doesn’t cooperate.
9-Whenever he loses weight, everyone tells me he’s too thin.
And when you lose weight everyone says you look great. When did you start listening to your mother-in-law over your veterinarian, anyway?
10-My pets have always been chunky and they’ve never died early.
How to prove an asinine negative...hmmm...
Those are my top ten. I’m sure you have more up your sleeve. Give ‘em up...
