The Wagging Tail

Oral disease affects 68% of cats and 78% of dogs over the age of three years.  Because it’s a common disease with a big potential impact on the Pet-family bond, the BARK  team has spent a lot of time researching periodontal disease over the last year.  We’ve examined the prevalence and risk factors for diagnosis as well as learned more about how often Pets are receiving dental prophylaxis and therapy in Banfield hospitals. Risk factors for periodontal disease include increasing age and small breed (Toy Poodle, Yorkshire Terrier, Maltese, Pomeranian, Shetland Sheepdog, Cavalier King Charles Spaniel, Papillion, Standard Poodle, Dachshund, and Havanese). Additionally, we’ve learned that canine periodontal disease is associated with certain cardiovascular diseases (cardiomyopathy and endocarditis).

Despite the fact that strategies for prevention of periodontal disease are fairly straightforward, Pets still suffer from the disease.  The most effective strategy is multi-faceted and includes teeth brushing at home, feeding of dental diets or treats, and dental prophylaxis performed by the veterinarian. However, client compliance with brushing is low and we’ve found that there’s a big gap between the number of Pets diagnosed with periodontal disease and those that actually receive dental prophylaxis. That gap can be as large as about 2/3 of all cats or dogs diagnosed with periodontal disease.

Why, despite the prevalence and impact of periodontal disease, are preventive strategies not fully implemented for Pets?  Why are the behaviors that people have adopted around their own twice yearly dental care not standard for our Pets?  Do Pets (especially cats) hide the pain that they may experience from periodontal disease from us?

As veterinarians do we recommend dental therapy less often than we should?  Are there factors like anesthetic risk or cost of therapy that affect your discussion of the diagnosis or treatment with clients? What factors influence your recommendations? What factors affect your clients’ compliance?

We’d love to hear what you think!

Further reading:

• BARK’s White Paper on periodontal disease

Do veterinarians practice evidence-based veterinary medicine?  In the human medical profession, evidence-based medicine (EBM) has become established and clinicians have accessible EBM tools to support clinical decision-making. 

What exactly does EBM mean to a practitioner?  EBM is the conscientious and implicit effort to apply current best research evidence to medical decision-making.  EBM should enhance clinical expertise in concert with consideration of patient needs and client circumstances.

For veterinarians, EBM is gaining momentum, but it is not widely employed in clinical practice. In addition to published research evidence, veterinarians still rely heavily upon textbooks, anecdotes, faculty expertise, and peer consultations.  Depending on the clinical question, these may be the only resources to utilize, but they are often inadequate, outdated, and unproductive.   Why has veterinary medicine been slower to adopt the practice of EBM?    Is it because there is less rigorous, controlled research conducted and published in the peer-reviewed literature?  These challenges create a gap between new knowledge and the practice of EBM in veterinary medicine. 

How can the veterinary profession close the knowledge-to-practice gap?  The gap represents a barrier to high quality care for individual patients. Where can veterinarians go to get evidence-based, synthesized information?   Who teaches veterinarians how to incorporate it into clinical settings?  The US Preventative Services Task Force (USPSTF) is well-known for providing physicians with recommendations and guidelines based on research evidence.  According to their website, the USPSTF is “An independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services.”  

Could similar guidelines for preventive care and screening be developed for veterinarians?  These guidelines would support the most efficacious screening for optimal pet care.  The BARK (Banfield Applied Research and Knowledge) team is using Banfield’s large database to generate new knowledge, in addition to critically appraising existing knowledge from a variety of sources, to create preventive care and screening guidelines for the common diseases of middle-aged and senior pets. 

Next month, BARK’s Research Medical Advisor Associate, Patrick Shearer, BVMS, PhD, will talk about periodontal disease.  Please join us, post your comments, and engage in a discussion about what we know about the disease and how as veterinarians we can promote the highest quality evidence-based dental care for the pets that we see.

• Each month thereafter, the BARK team will blog about topics such as:
• EBM and evidence dissemination initiatives in the profession
• Strategies to best apply evidence in clinical settings
• Current and future research initiatives at Banfield

Let us know if you have ideas about questions or topics that are of interest to you, especially in relationship to evidence-based medicine and getting new knowledge to our patients!

Further Reading: Click on the links below for two articles on EBM that recently appeared in the Banfield Journal. The current edition of the Banfield Journal can always be viewed online at www.banfield.net/banfield-journal. 

• Banfield Journal May-June 2009
• Banfield Journal July-Aug 2009

“Holiday Puppies” are a common present at Hanukah or Christmas. Shelters routinely brace for the surrender of these dogs a few months later. And while dogs are relinquished for a variety of reasons, one of the most preventable is “behavioral issues.” Here are some simple tips you can give to your clients at the first visit with their new puppy that will help mitigate some common behavioral issues, smooth the transition of the new family member and ensure a lasting bond.

Feel free to copy the tips below and distribute to clients:

Contented Confinement: I suggest that every dog should be trained to accept confinement in a portable kennel as early in life as possible. (Prepare her now for boarding or hospitalization later.) For “gone to work” confinement, the ideal setup is a portable kennel connected to, or inside an indoor “exercise pen” with newspaper or fake grass as a toilet. This setup is safe for 8-10 hours at a time and limits the puppy’s access to everything it might do wrong. The best way to introduce the closed kennel is to pair every entry into the kennel with a toy containing a fresh dab of peanut butter. If the puppy cries later, first do a “Needs Analysis” and if elimination, exercise and other needs have been met, it will be necessary to let the pup learn that tantrums don’t work.

Chew Training: A few chew toys inside the kennel during confinement teach the puppy that these are his items to chew. Other times the owner should actively put these chew toys in the puppy’s mouth and praise any chewing.  Start with very easily chewed toys such as Greenies and work up to compressed rawhide that has one end soaked in water to soften it up.  Booby trap unacceptable targets with mouth wash or underarm anti-perspirant.

Reward Based Elimination Training:  Punishing house soiling teaches, “Don’t eliminate when he’s watching!”  This approach makes proper training more difficult because the goal is to BE THERE outside to praise correct elimination.  When home, begin with confinement in a closed kennel which inhibits elimination.  Take the pup out every few hours when awake, and no food or water inside the kennel overnight.  If the puppy does not eliminate, just put her back into the kennel and try later.  She will learn the way to get freedom, play and other rewards is to eliminate in the right place.  Make her urine or feces so valuable she won’t want to waste it indoors.  When she routinely asks to go out, she has earned her indoor freedom.

Leash Training:  After successful elimination, suggest the owner take the puppy for a walk as reward.  This habit of rewarding elimination on the owner’s property reduces the future need to bring baggies on walks.  If an outdoor walk isn’t possible, suggest an “indoor walk” i.e. hold the leash INSIDE the house during post elimination play periods.  This is a positive leash association, and makes it easy to catch the pup if mouthing something inappropriate, or if about to eliminate again.  In the evenings, use the leash to tether the pup next to people to bond, and to prevent sneaking away to trouble.

Following these simple steps will go a long way in making the “Holiday Puppy” a permanent member of the family.

The present economic climate provides a challenge for veterinarians. We strive to provide the absolute best medical care to our patients, and we also strive be sensitive about the affordability of that care. Kristi Reimer, the editor of Veterinary Economics, wrote an excellent article on the matter: Affordability vs. Excellence, Do Veterinarians Have to Choose?  She asks, “Is there a way to maintain excellent medical standards, charge appropriately for them, and still be a compassionate veterinarian who’s accessible to the majority of Pet owners in the community?”

The answer is “Of course!”  We need to be offering the very best we have to every client and every patient at every visit.

The veterinary team and the Pet’s family have the same goal of restoring or maintaining the health of the Pet.  I believe we even have the same financial goals.  We want our clients in sound financial health so they are able to return again, and they want us in sound financial health so we are here when they need us.

Instead of offering “good/better/best” medical plans and “bargaining” with our client until we meet in the middle, consider offering the very best and using the treatment plan as an open dialogue.  Be transparent about what is absolutely mandatory and what is optional for your patient’s well-being and return to health and why each component is important.  You may be surprised with what your client will allow you to do when they understand why each portion of the treatment plan is important.  However, even a gazillionaire is not going to toss money at you for stuff they think you threw in just for the heck of it.

This is where your relationship with your client becomes important.  Clients who trust your integrity and medical expertise will know when you say something is mandatory or even ideal, when you really believe it and when you are probably right.

Sometimes, clients ask for help finding ways to afford the treatment their Pets need.  We may have payment plan options, charity information or other helpful resources available.  However, keep in mind that our clients’ financial situations are none of our business unless they choose to make them our business.  We are no more equipped to guess about the level of care they can afford than we are to guess about the strength of the bond they have with their Pet.  If we are focusing on the financial aspects of a case at the cost of focusing on patient care, we will convey that to the client whether we mean to or not.  

Recommend the very best for your patient.  Explain to your client why the components of the treatment plan you propose are important.  You know your patient is getting the best care you have to offer, your client is well cared for and you are being fairly compensated.  Win-win situations are possible for the patient, the client and the veterinary team, and are worth striving for with every case.

No question about it – these are trying financial times. Fortunately, the stature of the family pet has never been higher, and more than 80 percent of pet owners DO NOT intend to spend less on their four-legged family member in 2009. The American Pet Products Association (APPA) expects pet spending in the U.S. to increase 5 percent this year. In spite of a serious recession, that’s amazing! The APPA predicts the biggest beneficiaries of this year’s growth will be the veterinary care and pet food categories. Dogs and cats must eat, and pet owners have a propensity to bring their pets in for veterinary care.

The ever-present challenge for veterinary professionals is to demonstrate the value delivered. According to a PiperJaffray study of 248 companion animal practices, “While we were impressed with overall growth expectations, we would highlight that nearly 70 percent of the clinics we surveyed believe pet owners are deferring some treatment this year.” The BNResearch PetPoll 2008 concluded that “…with household budgets getting tighter due to the economy, clinics can expect more scrutiny and questions related to the cost of veterinary services. If pet owners do not understand the value of the services they are receiving, hospitals are at risk of facing both unsatisfied and lost clients.” Clearly, it’s never been more important to clearly explain the value you deliver.

So, how do you communicate value?

• See patients and clients on-time. Your client’s time is valuable and finite
• Articulate the comprehensive physical exam as conducted
• “Show and Tell” clients what you see, hear and feel
• Spend adequate time with clients, and probe for pet health questions
• Cliché, but true, a picture is worth a thousand words. Show Me!
• Demonstrate the cost of non-compliance:
  • Obesity likely results in osteoarthritis, shortened longevity, expensive NSAIDS and lab tests
  • Periodontal disease only worsens without veterinary intervention. The systemic risks are significant (see Dr. Glickman/Purdue CVM study of 60,000 dogs linking gum disease with heart disease)
  • Heartworm disease, as well as other diseases, is MUCH less expensive to prevent than to treat

Dogs and cats don’t know or care that the economy is weak. Their health care needs remain unchanged. As Dr. Marty Becker has said, “Your job is to be the spokesperson for the pet’s best interest.” Your oath is to protect human and animal health. Be the pet’s advocate, and everybody wins!

Too many cats and kittens is currently a major concern to the shelter community.  Data shows that 70,179 cats and kittens entered Colorado shelters in 2008, with 34,619 being adopted, a mere 5,175 reunited with owners and 24,619 euthanized. Only by working together can we improve these statistics.  Clearly, there is a lot to do. This blog describes some efforts to attack the problem. Your feedback is welcomed.

First, let me say that it helps the Dumb Friends League (DFL) and the shelter community to have positive working relationships with Banfield, The Pet Hospital, as well as other large practices.  Locally, it helps that we have a strong partnership with the Denver Area Veterinary Medical Society.  All of us working together benefits the pets and people we serve.  Here are a few examples:  

Have you noticed the beginning of an advertising shift related to the image of the cat?  This is no accident. Two years ago, the DFL and the Hawaiian Humane Society brought together a group of about 50 stakeholders that included industry, academia, marketing, other nonprofit leaders and the veterinary community.   They came from all over the country for two days of brainstorming on how to “rebrand Felix”—in other words, to change the perceived value of the cat from negative to positive in everyone’s minds.  The intended result is that more cats will receive regular veterinary care, better quality food and be kept safely indoors—plus more will be adopted from shelters. A similar effort started about the same time in California.  Shortly thereafter, the two groups formed the national CATalyst Council.  Jane Brundt, DVM, is its chair. I am a member.  Syndicated columnist and radio host Steve Dale is a member, as are others with national clout.

Two years ago, the DFL worked with our partners in the Colorado Federation of Animal Welfare Agencies to pass legislation that requires mandatory spay/neuters at all Colorado shelters and rescues.  Because few shelters have in-house veterinary staff, most are working with local veterinarians to comply with the law, which took effect last January.

The DFL tried another legislative tactic last year—a bill that would have required urban-area cat owners to ID their cats with a tag or microchip.  The purpose was to reduce the number of unidentified cats in shelters, thus reducing costs to municipalities of maintaining, adopting or euthanizing these pets.  Some lawmakers thought it was frivolous.  The bill never made it out of committee—but we are undeterred. We plan to introduce the bill again in 2010.  

Last year, the DFL and the DAVMS spearheaded the CHIP YOUR CAT campaign. With 100,000 donated microchips from Bayer resQ and HomeAgain, we offered cat owners a year-long opportunity for free microchip implants and wellness exams at shelters and participating veterinary clinics in our six-county area.  While only about 20,000 cat owners took advantage of it, it still represents quite a number of potentially new clients for the veterinarians and thousands of cats that now have identification, making their return home a lot more likely, if they get lost.  

Together, we are making inroads.  None of us could do this alone.  This will be a long-distance marathon, not a sprint.  It will take years, but I believe we’re on the right path to addressing our cat/kitten concerns.

On one of my very first days in practice, I faced a challenge that no classroom had prepared me for – unfriendly feedback from a colleague who did not extend professional courtesy.  I was mentally prepared to face my first surgeries, to recommend and perform diagnostics to treat a myriad of illnesses; I was not prepared for the shock of a nearby veterinarian stating in several instances to mutual clients that I performed unnecessary diagnostics and prescribed the wrong medications. (Since when are blood work and diphenhydramine not recommended for snake bite wounds?) When philosophies of practice differ greatly among two vets, maintaining professionalism can be very difficult. However, professional integrity must be maintained – not only between two general practitioners, but among specialists and referral hospitals – because we fulfill different niches and working together is best for the Pets we treat. Even if your name is being dragged through the mud unfairly and dishonestly, it’s best for our profession – and for the Pets – when we take the high road.

Differences in philosophy of practice are not always so well demarcated, and Pet owners are able to pick up on even your most subtle of facial expressions and word choices. So, it is extremely important to be aware of how you speak about your competition in front of your clients.

Never forget that towns, no matter how large, can retain a bit of the small town syndrome – everyone eventually hears about you through the grapevine. If you are positive and honest, word will travel fast – your actions will be your best referral source. Conversely, if you have the opposite reputation, new client numbers could eventually dwindle. It’s truly amazing how many clients know each other. 

Most of the time, speaking positively about my veterinary colleagues makes absolutely perfect sense.  However, what about those instances that may not be so obvious? Recently, I saw a client for the first time on a Saturday because her regular veterinarian wasn’t able to fit her in to their schedule. The client was very worried about her Pet because he had a piece of tissue hanging out of his leg! Her regular vet wanted to wait until Monday to see them. Very upset, the client emphatically stated that she would never go back to them. It would have been easy to fall into the trap of agreeing with the owner that her vet should have worked her into their schedule. Even saying something to the fact that you always work in emergencies no matter the day of the week, which may be true, is still straddling the line of professionalism. The fact is you don’t know why that vet was not able to see the Pet. What if they had a rush of emergencies already? Or the staff had the flu? We should always try to be positive about our colleagues. We can sympathize with the client about having to look for an alternative solution. The client is upset with her regular vet now, but she may forgive them, go back to them, and remember how negative you were – and then state she would never go back to you.

I actually look forward to consulting with nearby specialists. Their grasp of the newest medications from pimobendand to gabapentin usually occurs much sooner than my ability to learn about the latest meds. Research into pharmaceuticals as well as better surgical techniques creates such a huge amount of information that no one person could possibly learn it all and still practice full-time general medicine. Conversely, if specialists had to spend time performing preventive care in addition to their area of expertise, they wouldn’t be able to see nearly as many patients who desperately need them. Instead of being competition, referral practices and general practitioners work best in cooperation. 

My philosophy of medicine includes providing the best possible care for my patients, and that means cooperating with my small-animal colleagues, local specialists and referral hospitals. It also means that I will respect my colleagues’ reputations in front of my clients (and I hope they’ll do the same for me!). When we show professional integrity, we raise our profession to a higher standard and ensure the best quality of life for the Pets we treat.

Each summer of veterinary school, I made it a point to work within the veterinary field. I knew it was important for me to become intimately involved in small animal veterinary medicine for the clinical experience in the “real world.”For me, that meant working within a small animal facility because I knew that is what I wanted to do when I graduated. That has always been the vision of myself as a veterinarian.

My first summer, I worked in Ft. Walton Beach, FL, at Reed Pet Hospital. Dr. “Rog” (Roger) was a recent grad with his practice attached to his father’s practice. In other words, a built-in clientele!

I was Dr. Rog’s first and ONLY employee that summer. I played receptionist, vet assistant, kennel help and administrative assistant. I ordered his supplies, made appointments, called clients and assisted during surgery and all in-house appointments. Though this was after my first year of vet school, I learned to connect-the-dots of what I had learned so far! Seeing the anatomy in a live Pet during a spay was pretty cool. Seeing disease connected to that very small pituitary gland (that I could never find during anatomy tests) made it all real. Dr. Rog took great delight in me being his student and explaining everything to me in detail. I know now that was the perfect first summer job!

After my second year of vet school, I worked in Fontana, CA. Mainly because the Olympics were being held in LA that year and it was an easy way to convince my parents I should go. I stayed with friends and quickly found a job between two vet hospitals with one owner. That summer, I was actually the voice and words for a veterinarian new to the U.S. His English was still developing. When clients did not understand him, he would motion with his hand, “You tell, you tell.” I quickly learned to be his interpreter and tell clients what he wanted to do with the Pet, what tests he wanted to run and why. This was perfect since second year we began to learn pathophysiology of diseases in clinics. All those viruses, bacteria and disease processes were still fresh in my mind. And because of this, I was able to help this doctor with his patients. At the other hospital, the veterinarian was well into his golden years. But I learned by watching how to do a really efficient spay. He could do them in his sleep. I often think he did. He didn’t pause at everything that bled nor freaked out if the Pet was in heat. He methodically went about the surgeries. I learned by watching him how to keep cool in these situations. And I took a page from his book: “If something is bleeding in there, go find it. It’s not an infinite galaxy, just the insides of a dog or cat.”

After third year – what we called the preceptorship summer – I worked in Elk Point, SD. Don’t ask me why. But, thank goodness it was summer time. Why? This was a mixed animal practice. I sure am glad I didn’t have to chase cows, be chased by cows or go pull piglets in subzero weather! The owner of this practice took a student each summer. We were his relief help. He would actually allow me to go on farm calls alone, work the greyhound track as the vet-on-duty and perform surgeries. Ok, this was over 25 years ago and it was in South Dakota. Don’t try this at home! That summer, I learned what it was like to BE the doctor on a case, do the exam on a Pet, advise of the client of potential diagnoses and what needed to be done. I pulled calves and sewed up lacerated horses (another reason I am in small animal medicine). I learned how communication with clients was really the key to being able to care for the Pet or animal. Didn’t really matter how smart you were – they knew you were a doctor (almost) but, could you talk to them? Did they really feel that you cared for their Pet?

Every summer, veterinary students should work within the field of veterinary medicine. There is nothing like those wonder years. Seeing what you have learned in school and making the connection. I learned something from each veterinarian I worked with. The biggest lesson: communication. Second: trust your instincts. Third: I don’t like to be chased by cows.

I think most people, when they find a stray animal that is in need of care, is injured or unwanted, immediately turn to their veterinarian for help. I’m sure many of you provide medical treatment and housing until the owner or a new home is found. More than likely, your hospital has to absorb the costs, too, not to mention your team members having to volunteer their time.

I was reading about San Luis Obispo Animal Services in California where an account for homeless animals has been established. Donations made to the “Animals in Need Fund” give animal services the ability to provide veterinary care to unclaimed Pets or those without owners. So for example, a dog brought in that was hit by a car and suffers from a broken leg, could have surgery done by a local veterinary surgeon, with the fund paying for the cost of medical and surgical procedures. The hospital team then takes care of the Pet during recovery until a new family (or the owner) is found. Integrating special events — dog walks and related fundraisers — sounds like a good way to boost the account overall.

There are probably more programs out there than I can list, but here are few others I’ve come across:
- RAP Medical Fund (NY): provides vaccines, wormings, heartworm testing, and spays/neuters. It also includes heartworm treatment, tumor removals, dentals, orthopedic surgeries and critical care
- Citizens for Humane Action Emergency Medical Fund (OH): for non-routine medical expenses for dogs and cats. Financed solely by donations.
- The CARE Medical Fund (Companion Animal Rehabilitation and Emergency Medical Fund, VA): helps the Virginia Beach SPCA provide specialized medical treatment for animals that would have once been considered untreatable by many shelters.
- LifeSaver Fund (GA): serves animals with life-threatening medical conditions whose owners are struggling financially as well as animals that have no homes or no one to care for them.
- CHAMPS Emergency Medical Fund (KY): provides medical care to animals with torn ligaments, eye injuries, rare fungal infections and many other conditions.
-  Banfield Charitable Trust Charity Bucks (Nationwide): donates funds to help offset the cost of urgent care while helping families in need provide their Pets with lifesaving care.

Visit these websites to find out more information and details about additional programs available. What’s going on in your community and how can others help?

I bet as a veterinarian you must have your days at the hospital where you had a most unusual, notable, favorite or memorable case. I’ve read a few interesting stories recently and I wanted to share a couple of them with you.

It seems a family’s Iguana had stopped eating and was brought in to be examined because he was feeling rather “grumpy,” according to the owners. The vet touched the Iguana’s tummy and felt several abnormal shapes. X-rays revealed the presence of a number of round, metallic objects. I guess Pets, like small children, will put coins in their mouths and then sometimes swallow them (I remember my younger brother swallowing a penny as a child and my dad holding him upside down by his feet to get him to cough it up, but that’s another story).

Generally the coins pass, but if there are enough of them, or if the GI tract is small (like in the Iguana), the coins get stuck. The vet used a fluoroscope to find the exact location of the coins, but couldn’t remove them with an endoscope. Although they had to be surgically removed, the Iguana went home the next day and had a full recovery. But, say the owners, he’s still grumpy. Turns out the Iguana had taken the money from a piggy bank. At the end of it all, it was the vet’s comment that made me laugh: “Maybe there was something he wanted to buy.”

Another story I read was pretty amazing. Did you hear about “Dutch” the Dachshund? He was bitten by a Mojave green rattlesnake and actually survived. The veterinarians cared for the dog 24 hours a day for about six days. It was the first time the team had successfully treated a bite from what is known as the deadliest rattlesnake in North America. Usually it’s fatal. Apparently the dog was battling the rattlesnake with another Dachshund in the owner’s backyard. The dogs killed the snake but the 10-pound miniature Dachshund became lethargic shortly thereafter. The owner was unsure if the dog was actually bitten and even after being examined by the vet, it was still unclear (there’s not much reaction at the site of the bite initially, say the vets). Antibiotics and IV medication were given as preventive measures.

Antivenin was administered but then Dutch had to be hooked up to a ventilator when the venom paralyzed his lungs. He was on assisted breathing for several days and was continually monitored to make sure he didn’t vomit while on the respirator. The vets had to manually lubricate his eyes because he couldn’t blink. They had to transport the dog back and forth between the hospital by day and the emergency clinic by night. Dutch started to improve after the owner brought in another Dachshund to see him at the hospital. Eventually, Dutch was taken off the ventilator and sent home. He lost nearly a third of his body weight during the whole escapade, has recovered significantly but still has some damage to his eyes. When he is fully recovered, the doctors will check to see if he was blinded in the ordeal.

So there you have it. We welcome you to share your experiences with us…