Do What’s Right

Last night at the North American Veterinary Conference I was sitting with a group of wonderful veterinary students, and we were chatting about practice and whatnot, when all of a sudden it occurred to me that I was the senior veterinarian in the group. As in, the things I was saying were now the Pearls.Of.Wisdom from on high, and the idea that I’ve been doing this long enough to have wisdom to impart is simultaneously horrifying and delightful. Wow, I’m the wise one! Good Lord, I’m the old one.

I was talking about my first days of practice, when I was with a group that had proclaimed that all veterinarians must give a whole bunch of vaccines, because vaccines prevent disease, so the more you give, the better you are practicing. This is where we were at in 2002, and it was an ugly scene. As you know, all vaccines are not created equal. Now we have AAHA and AAFP guidelines that define “core” versus “non-core” and “not recommended”, excellent, evidence-based rules that take into account efficacy, likelihood of reaction, and the individual pet. But at the time, those concepts were still kind of nebulous, so the concept was more along the lines of, “more vaccines = more medicine = good.”

Translation: Cats getting FIP vaccine whether or not the vaccine actually worked, dogs getting Lyme vaccine whether or not they lived in an area that had Lyme disease. FIV vaccine, regardless of whether we were messing up future FIV testing. We were expected to do it, because that was considered good medicine.

But it didn’t feel right.

I was the lowest producing vet in my area, in terms of the money I was generating. I talked to clients about the risk and the benefit, and in cases I deemed appropriate, I might give Lyme. I didn’t give FIP. According to the medical algorithms at the time, I was practicing bad medicine.

I spent a lot of time on the phone trying to justify my decision to my superior. He felt I was practicing poor medicine. I felt the exact opposite. He had been out a lot longer than me, and saw a lot more things than I did, but I stood my ground, shaky as it felt at the time. I knew what was right by my clients, so no matter how much my superior protested, I practiced for them and not for him.

It was considered quite contrarian at the time.

Untitled

After a year and half or so of neither of us budging, I quit. I quit my job rather than compromise myself. Again, a move that seemed provocative back then, when practitioners had more of an expectation of loyalty from their employees. I went to a place that told me I could practice the way I felt was appropriate, and I took a few key staff members and clients with me.

I didn’t know at the time whether or not I made the right decision, but I made the one that allowed me to sleep at night. And then two things happened:

1. Tides turned on the vaccination deal. The medical field came around to the same conclusion the rest of us had reached some time before, which is, “more does not equal better.” Vaccination must be determined on an individual basis, tailored to the pet. Now that person who had made me feel like a chump for two years was on the defensive, and all those pets I had dissuaded from an unnecessary treatment sought me out at my new clinic.

2. The practice I had been at before I quit, the one that performed quite mediocre in terms of revenue, was recognized in a group of 400 practices as having the highest client loyalty in the nation for the year. The area I practiced in was economically depressed. My clients weren’t wealthy, but they cared, and they knew I was working with them to do what was best. And at the end of of the day, there was no greater recognition I could ever receive than that. Me, newbie Dr. V, the one who put the needle back in the fridge and said no, had more people who kept coming back than all the others out there with more experience, better skills, more knowledge.

And trust me, I really did not have a clue what I was doing, so don’t take it as a boast about my amazing vet-fu. I was shaky and insecure and I had a ton of stuff I was horrible at, like most new grads. I never lied about my skills. I referred a whole lot of stuff I wasn’t ready to handle. I said no to what I couldn’t take on. I put aside that mask of bravado you’re told you should have as a doctor, and decided to just be perfectly honest.

It’s exactly what they tell you not to do.

But it felt right.

And my clients all knew it, intuitively. They forgave every deficiency because they trusted me to be upfront with them, no matter what.

Time moves quickly. I’ve done a lot since then, and made good choices and bad choices and gotten to the point where I’m perfectly comfortable in my practice; I know what I know and what I don’t and I don’t worry about how old clients think I am because it doesn’t matter. But that one lesson has never changed, and I know now never will. It’s so easy, and we screw it up so often under some auspice of ego or “promote confidence” or whatever the practice management du jour mantra is.

Apollo, the minimally vaccinated, wet food only counterculture hippie of the house, is doing gangbusters at 14. He’s outsurvived Nuke, Mulan, Emmett, and sadly, probably Koa too.

I was in a lecture today with Dr. Alice Wolf, a world renowned expert on feline medicine. She stated without preamble that yes, adjuvanted vaccines have a higher risk of inducing cancer in cats, laid out the evidence, and said this is a risk she considers unacceptable.

Adjuvant, for those who don’t know, is something that is added to a vaccine to enhance the body’s immune response by acting, essentially, as an irritant. In some cases, estimated to be 1:10,000, that inflammation turns into a horribly aggressive form of cancer. While documented in many species, it is most prevalent in cats, to the tune of about 20,000 cases a year. Manufacturers, realizing this was an unintended consequence, have responded by producing alternative vaccines without this added product. They may be more expensive. They may need to be boosted more. But they are, in Dr. Wolf’s opinion and that of many others, the superior choice.

Note that she is not saying, by any stretch of the imagination, that all vaccines are bad and you shouldn’t use them. She is saying there is a component of one particular type of vaccine that has the potential to cause a nasty problem, and because there are better, safer vaccine alternatives, we need to use those instead.

Dr. Wolf bases her vaccine recommendations on the widely used AAFP recommendations, which can be found here. She does state, and I agree, that all kittens should be vaccinated for FELV, though whether that is boosted into the adult years should be determined based on pet lifestyle. Again, and this is key, she recommends vets always use non-adjuvanted vaccines whenever they are available. “WHO classifies veterinary vaccine adjuvants as a Class 3/4 carcinogen,” she told the crowd. “If there was an alternative, which one would you choose?”

I’m calling this now. As a client, your vet may not carry non-adjuvanted vaccines such as PureVax, but they should. This is where the tide is going. This is what is right, and you as a client should be OK demanding it, and the other you, the new vets, should as well, because you need to advocate for your clients no matter what.

Let me make it easy for you, newbies. Because you won’t be newbies for long and in another year or two you won’t care what I have to tell you.

Do what you know is right, always. And that is all you need to know.

Google+

Filed: Blog, Cats, Daily Life, Health, Picks of the Litter Tagged: , , ,
  • Kim

    Thanks for some helpful kitty info, Dr. V. From what I can tell, my vet practice follows the protocol in your link, as does the shelter from which I adopted my two cats. I’m definitely going to ask about it at their next appointment, just to get a better understanding.

    Also — way to trust your instincts! Clients pick up on a vet’s willingness to listen and work with him/her to do what’s best for the pet. Some clients have financial constraints; some (me) have a layperson’s interest in veterinary medicine. ALL responsible pet owners want their pets to live as long and healthy a life as possible. And we all appreciate a vet who clearly explains what they recommend and why. It’s why I like my cats’ vet practice. (That and both vets’ ability to turn my kitties into purr-y mush. They may like the vets better than they like me. I’ll get over it.)

    • http://www.pawcurious.com Dr. V

      Excellent. I hope everyone moving forward asks their vet what vaccines they are using- we never needed to in the past, but that’s changing.

  • carolinegolon

    As always, your veterinary wisdom transcends your field! “Do what you know is right, always. And that is all you need to know.” We should all take that to heart, no matter what industry we are in or how “experienced” we are. Great post, Dr. V.

    • http://www.pawcurious.com Dr. V

      Thanks, C!

  • Summer

    Wonderful post, as always, Dr. V! :)

    I think the next turning tide will be regarding nutrition, at least I hope so.

  • Amy Sunnergren

    Up until the 70′s all of our pets lived to old age, essentially dying of old age. Starting with the pets adopted in the mid-80′s and since, all have died of cancer. ALL. Cats at 12 and 13, while previously we had cats live to their 20′s. Same with dogs, at 12, where previously our dogs had lived until 16ish. I have been told that some of these diseases are more prevalent, but I sometimes wonder if that is true. Maybe, because people didn’t go to the vet as frequently, there simply was no report as to the cause of death. I don’t know, but I do know that I plan, if I can ever be in a position to have a dog again, to closely review the vaccination suggestion. So thanks for the news. I hope to be able to use the info.

  • Heather

    I no longer use one practice in my town due to their vaccine protocol. they always give cats the Chlamydia vaccine without discussing it with the owners. they did this to my cats when they had their one year old boosters and both cats had a severe vaccine reaction. I took my cats to a different practice who then told me that the Chlamydia vaccine caused it and they won’t use that vaccine unless there is good reason to because of the reactions it can cause.

    I really wish I could take my cats to you Dr V! you sound like my ideal vet!

  • http://twitter.com/ShihTzuGo ShihTzuCare

    I really enjoy these types of posts. I think making pet owners aware of the drugs they give their animals is a step in the right direction. I hope you continue to post news and information (in layman’s terms) so that people (like me) can stay well-informed. Thank you, Dr. V., for bridging the gap between vet and pet owner.

  • http://www.facebook.com/people/Barb-Bristol/1147604671 Barb Bristol

    As a vet tech back in the ’80′s and ’90′s, I was a true believer in the “more = better” philosophy when it came to vaccines. And my cats and dogs developed – and eventually succumbed to – a bewildering variety of cancers and autoimmune related disorders. Since 2001 (when one of my dogs developed a seizure disorder just hours after her first Rabies vaccination) I have been doing a lot of research, and I do fewer and fewer vaccines. And my pets have never been so healthy! I’ve got an 11 year old Great Dane who only retired from competing in Agility last year, for Pete’s sake. I’m not getting completely away from vaccination – I still booster puppies and kittens but it’s a lot more minimal than even the AAHA recommendations.

  • http://www.facebook.com/DawgBlogger Jana Rade

    Amen.

  • Katie D

    I really enjoyed this post since I am fresh out of vet school. It’s been really hard learning to trust my instincts as I develop into the vet I want to be.