A year ago, my husband gave me a telephone number and said his insurance company now had phone consults available. 24/7, from the privacy of my own home, I could call in and get “seen” for ear infections, get a prescription for Ambien for travel, even get marriage counseling, should I desire it. I only used it once, but I was amazed that at 10 pm I could just call and talk to some random person and 15 minutes later pick up a prescription at the 24/7 Rite-Aid. I’m not going to lie, I think it was pretty cool.
For the past five years, I have said the same thing over and over to people in the veterinary profession: telemedicine is coming. How are we going to handle it? And over and over the response has been the same: no it’s not. This is only half true: it’s not coming from inside the vet profession.
But it is coming, as this piece from dvm360 goes into. And not just Vet on Demand. I’ve been approached about 10 times in the past year to sign up to be a telemedicine/internet consultation vet, and I always say the same thing: I am bound by my state practice act’s definition of valid client-patient relationship, which says that I must examine an animal in person to establish that. Anything outside of that and I’m breaking the practice act, which is why my FAQs are so clear on the topic.
Veterinarians make excellent points as to why telemedicine for us differs so much from telemedicine for people:
Doctors get a lot more out of history than we do. People can describe symptoms they are experiencing; pets cannot say, “I have chest pain radiating down my arm”. Veterinarians rely much more heavily on physical examinations.
Human medicine is incentivized to keep people out of the clinic to keep costs down, since general practitioners are already in short demand. Vets aren’t that slammed. Come on in.
And while we are perfectly content to say “This is a terrible idea,” others are not, and are trying to reap the benefits of it. People with background in restaurateurism see a chance to make a few bucks and throw an app together, paying a vet some pittance like $5 to put their license on the line. Why not? They don’t have anything to lose. They get around it by saying things like, “oh, we’re offering general advice, not specific diagnoses,” or take the old Miss Cleo approach:
For entertainment purposes only. Riiiiight.
This is from the VetonDemand website. I dunno guys, sure sounds like diagnosing to me. (By the way, my favorite saying is a lump is a lump is a lump. No biopsy, no diagnosis, unless the lump was a tick or a piece of sticky kibble.) That’s wasted $$ right there.
To sum up: individual veterinarians are bound by their state practice acts in terms of whether or not diagnosing over the net is legal, and it’s all over the place in terms of who can do what. This is reason enough for people to fold their hands together and say, “See, it’s not going to work.” I disagree.
My husband called the human telemedicine line to ask about a cough, and they refused him antibiotics and told him to get a chest x-ray. They were clear in their limitations. I think there are opportunities for veterinarians to use telemedicine to our advantage in responsible ways:
consults for pre-existing clients
Online ER consultations in coordination with local clinics for things like post-op questions: “My pet’s incision looks puffy, can it wait or should I come in?”
With clearly defined limitations and expectations, it has its place. Truth is, most of the time the answer is, “It could be x, y, z…you should be seen,” but that’s still better than what I see happening now.
I don’t have all the answers, certainly, but I think it’s a huge mistake and a missed opportunity for the veterinary profession to not take this on proactively. It’s not a matter of if, it’s when, and if we pass up our ability to drive the bus then two restaurant entrepreneurs from Nashville are going to take the wheel instead, and we probably won’t like where they take us.
I love technology. I think we can use it, we just need to be a little creative and stop digging in our heels like those old guys who still- STILL- insist on fax over email for sending records over. Give up, man, the world is moving on.
What do you think? Would you use a service like this if you could?
As you may or may not have heard, the internet was abuzz last week with a series of alarming headlines, such as:
PURINA IS KILLING DOGS
CLASS ACTION LAWSUIT AGAINST DOG-KILLING BENEFUL POISON
And as these things tend to do in today’s internet age, the story has taken on a life and momentum of its own, just like last year’s “Eukanuba is killing dogs” story that ended up fizzling out and the “New parvo strain is killing dogs” story that also ended up fizzling out. Remember those? No? They were huge at the time, until they realized there was no actual evidence to support the claim and WHOOSH gone, not that it seems to matter these days.
I take lawsuits with a big huge salt-lick sized grain of salt, because once you’ve seen what people do in court rooms you gain a grim view of human nature. One veterinarian I know of lost a court case alleging intentional infliction of emotional distress for a phone call that never happened, because the plaintiff was able to bring in several family members to perjure themselves and say they heard the harassing call that never took place.
The veterinarian was able to prove the call never occurred using phone records, and the case was overturned on appeal, but not before the plaintiff called in the local consumer advocate, got the clinic on TV, and had to endure months of people coming into the clinic and yelling at the staff. The damage was done.
CC by MikeMccaffrey on Flickr
Filing a lawsuit is easy. Anyone can do it. I can sue the guy across the street tomorrow if I want to. I’ve never met him or interacted with him, but I could, just because. Winning one, proving damage- that’s another story.
Here’s a hard truth: a lot of dogs die every day, and much of the time we don’t know why because people don’t have the money to spend getting a definitive diagnosis on a 15 year old dog who has been vomiting. So they look to the obvious thing: the food! and never actually learn that the dog’s had a percolating abscess in the liver, or a hemangiosarcoma that metastasized, or any one of a number of things that happen. If 1.5 billion bowls of Beneful got eaten last year, it’s a given some of those dogs will die because that happens in life not because their food killed them; but they’re the easy target.
Here are my own FAQs based on the questions I’ve been getting this past week:
1. Is it possible that Beneful has a problem?
Sure. It is possible the case has merit, but until we see the actual proof I can’t say much about it. Given the fact that the suit mentions “propylene glycol” as an antifreeze analogue (it’s not), it seems to be one more tired rehashing of the whole ‘I can’t pronounce it so it’s bad’ argument people like the Food Babe have made so popular recently. Possible? Yes. Likely? I can’t say I have seen any evidence of it. Dr. Weeth has an excellent analysis here.
Were you to believe every “this kills dogs” claim on the net in the last 10 years, you’d have to have given up the following entirely:
Febreze, Swiffer, Iams, Eukanuba, Purina, any commercial dog food, Trifexis, ice water, vaccines, corn, anything with toxins, preservatives, moldy food resulting from lack of preservatives, veterinary care, Advantage, life as we know it.
2. Don’t you believe this poor man?
I believe that the man who filed this lawsuit believes in his heart that this is what killed his dogs. My heart goes out to him for his losses, it truly does. People want accountability for sad events and that is understandable. That still doesn’t prove that the food had anything to do with it.
3. What about melamine? Is your memory so short that you think pet food companies are flawless?
Here’s the thing about the melamine incident I want everyone to remember: Do you know how that story was discovered?
-It was not one person with a Google account and a phone book opened to “law offices.”
-It was not the FDA or companies testing dog food (melamine isn’t something normally tested for.)
-It was individual veterinarians who noticed a pattern, did some digging, talked to each other, and pursued an answer. I watched it happen, and it was incredible. There are some smart vets out there.
I can list about 3 major food problems off the top of my head that veterinarians figured out, and based on their experiences I would agree that not all pet food companies are forthcoming or proactive when it comes to potential issues (none of those companies I am thinking of, by the way, is Purina or any of the other big name companies. They were boutique ‘premium’ brands.) Yes, it happens, but the answers come with careful analysis by trained scientists, not lawyers.
4. If I feed Beneful, should I change my food?
Food is kind of like religion: people get really worked up about it. Each food has its place in the market, and if you’re the type to obsess over food labels and ingredients (nothing wrong with that! I do!) you’re probably purchasing a different category of dog food anyway, right? But this food has its place too, even if it’s not in your house. For plenty of people it’s been working fine.
I say the same thing about this that I do any food: if your personal individual pet is doing fine on their food, I wouldn’t change a thing. If he isn’t? Well, let’s talk. So yes, you should always report weird symptoms to your vet and tell them what the dog is eating (it is one of many, many data points.) Most of the time it is not the food. On occasion, it is.
Any questions? Then carry on. I have to catch up on Walking Dead.
Disclaimer: This post was NOT sponsored by Purina, Nestle, Big Pharma, or Corporate Shills. In fact I’m losing money writing this because I could be working on another project I actually get paid for. Information in this blog post is for informational purposes only and should not substitute for mass hysteria generated by your regular inflammatory website.
About one year after I graduated vet school, I took routine screening chest radiographs of my senior Golden, Mulan. I looked them over, frowning at a small, mottled spot near her sternum.
“She has cancer,” I thought. It’s not an unreasonable conclusion to come to with Golden Retrievers. Before I panicked, I asked my colleague to look at the x-ray, and she agreed it looked suspicious. I was devastated.
I took Mulan to the local specialty hospital, where an intern I knew from vet school patted me on the back while the resident internal medicine specialist pursed his lips sympathetically. He grabbed his ultrasound machine to prepare for a guided biopsy. Before starting, he asked the radiologist to stop by to give his thoughts as to what this strange radiographic feature might be.
“What are you looking at? That? That’s normal sternum,” he said, sipping his coffee with the mildest of eye rolls before strolling out of the now-silent room.
I knew just enough to be dangerous but not enough to actually come to the correct conclusion. Along the way I dragged two other very educated colleagues with me through sheer force of conviction. Mulan lived another 4 years, by the way.
Data and Interpretation
Lots of people have asked me about the controversial results from the Truth about Pet Food’s crowdsourced food safety study. I haven’t said anything, because I couldn’t think of anything to say. It’s the same response I have when people send me this picture over email and ask me what this lump is:
The correct answer is, “I need a lot more information before I can tell you that.” Which is about how I feel about the significance of this study.
As veterinary nutritionist Dr. Weeth points out in her excellent response, scientists kind of live to nitpick and poke holes in one another’s work. It’s necessary to allow criticism because there are so many ways one can go wrong with a project- from the way the study was designed, to the implementation, to the data interpretation. It was the persistent nagging of the science community that led to the eventual discrediting of Wakefield’s autism/vaccine research paper, the public health implications of which we are still dealing today, up to and including 19 people who were sickened with measles at The Happiest Place on Earth.
Without being allowed to evaluate the entire research process, we have no way of knowing how valid the results are. A pretty infographic does not science make. Nor does protesting “it’s not junk science” mean that it isn’t.
What We Know
I’m hopeful that the full set of data will be made public, including methodology. Until then, all we can do is go by what we have been told.
Dr. Gary Pusillo of INTI services, who has the misfortune of being out of the country while all of this debate is going down, was in charge of the testing process. Thixton writes that he is a board certified veterinary nutritionist, which in theory is fantastic because it means that he would have the background in both veterinary medicine and nutrition to not only perform the studies, but interpret the results. There’s only one problem: he’s not. (Nor does he in any way present himself as one, by the way.) A board certified veterinary nutritionist is a veterinarian who is also a diplomate of the American College of Veterinary Nutrition. You may think that’s irrelevant, it’s just semantics, but it’s not.
Credentials are a big deal, as I’m sure Dr. Pusillo himself would tell you were he around. I would really love for Dr. Pusillo and Dr. Purejav to have been available to answer questions while we’re all begging to know what the heck they did, and I’d love to hear more about how they determined “risk.” They may be the most qualified people in the world, but for right now, all I have is an infographic and a consumer advocate’s word that they’re the best.
Dr. Pusillo is a PhD who provides forensic science services, which actually sounds really cool and I would love to hear more about it. I have no reason to doubt that he is an excellent scientist. He probably knows tons and tons about how to test a food for specific substances. What he may or may not know is whether or not those substances matter clinically.
Data Collection vs. Interpretation
Let’s assume that the data collection was carried out perfectly. Data collection is only half of the equation- you still have to know what to do with it. You can have all the answers in front of you and still not know the question. The scientists Thixton contracted with are out of town at the moment, so who are we going to ask to help us interpret things?
Given who’s around right now, who could interpret the limited data we have through the filter of what matters?
Or a board certified veterinary nutritionist, who can tell you about nutrient analyses and why dry matter comparisons without calorie content is useless. Both of them have some big reservations about this project.
They know more than I do about such things, which is why I defer to their interpretation. Little things mean a lot- for example, when you say “bacteria are present” what do you mean? Does that mean live bacteria were cultured using sterile handling procedures to eliminate environmental contamination? Or did the test just look for bacterial RNA, which could come from dead bacteria that were killed during processing and therefore prove that production works as advertised? I don’t know, but that would sure make a difference.
When the company you contract with to run your tests asks for their name to be dissociated from any press surrounding you, there’s one of two conclusions: 1. They were not happy about how their data was manipulated in the interpretation stage and didn’t want to be associated with bad science; 2. Big Pet Food Cabal. We may never know. *shrug*
A victory for food safety
I like to look at the bright side of things, and for reasons I can’t fathom, what I’ve found to be the biggest findings of the study are barely mentioned.
What are the three most common concerns I hear about pet food safety?
pathogens of most dire human significance, specifically Salmonella and Campylobacter
pentobarbital contamination (implying euthanized rendered carcasses in pet food.)
Why were these not mentioned in the risk report?
Because they weren’t found. They did look for all of these products. All twelve tested foods were clear of the three biggest worries in recent memory to pet food safety. That’s something, don’t you think?
I’m an optimist. Let’s look at the bright side of things, what do you say!
So let’s review here: I like asking questions. I have no problem questioning consumers, colleagues, my own professional leadership. I think concerned consumers are good consumers, and I applaud anyone who is invested enough to care about what goes into their pet, be it food, drug, or plant. I have chosen not to work in the employ of companies in the field specifically so I can feel free to say what I want without worry about my job or advertisers.
That being said, I think we also have to take the Occam’s razor approach to life and assume at some point that companies are telling the truth when they tell us they aren’t actively attempting to kill our pets. There are problems, some big and some small, and those are worthy of being addressed, but if you can’t accept at the end of the day that they are generally trying to do the right thing, then we may not ever be able to come to an understanding. As part of a profession that deals with this type of distrust on a regular basis, there comes a point where you have to say, “If you’re going to insist I’m out to harm you no matter what I say then I probably should just leave now.”
So let’s end on a high note: a toast, to those who care. I think everyone’s here arguing for that reason even if the conclusions are different. Salmonella free appetizers for all.
A week ago, I decided I was going to stop drinking caffeine. Now if you know me at all, you know I adore coffee, more than almost anything else in life. If you cut my arm, skinny vanilla latte would pour out. The decision to give up my biggest vice was not an easy one by any means, but at the end of the day, health trumps pleasure, and I figured there’s always decaf.
I did what everyone tells you not to do, and just stopped cold turkey. Big mistake, everyone.
8 am: I felt a little sluggish, but not too off. This is totally manageable.
10 am: I felt really sluggish, like I was about to fall off the kitchen barstool; a sober drunk. I am still mostly coherent, though, so I figure I can continue to tough it out. My children look on in confusion.
noon: I felt a little twinge in the back of my temple, just a tiny blip of a possible headache. I take 2 Advil. Ah yes, the infamous caffeine headache. It’s not too bad, though.
3 pm: An small but bloodthirsty miniature barbarian horde has invaded my head. They have taken microscopic pickaxes to my sinuses and are attempting to harvest my eyeballs through the back of my orbits. Paralyzed by exhaustion, I am unable to tell anyone of my predicament as I am systematically destroyed.
Here they come.
5 pm: My husband finds me slumped on the bed in the fetal position, moving centimeter by centimeter in slow motion because every time a wave of movement jolts the marauding horde in my cranium, they get angry again. He has no way to tell that this is what is going on; as far as he knows, I have the flu, or allergies, or I ate some bad Greek yogurt. In a feathery voice, I whisper: “Make me a cup of coffee, if you would.”
I admit defeat, and give the barbarians their drugs.
7 pm: Feel fine.
If you are not someone who experiences headaches, you have my complete and utter envy. While my caffeine withdrawal headache was nasty (I have since elected for a more subtle weaning-off process), I used to suffer migraines as well and those would pretty much put you out of commission in a blinding stroke of agony, nausea, and an unending mantra: please let me go unconscious please let me go unconscious. And despite the misery and despair you are experiencing, to the outside you simply look like someone who doesn’t feel that great.
But what about dogs?
At 11 pm, recovered but now fully awake from my late night caffeine jolt, I started thinking about dogs and headaches. As veterinarians, we aren’t really trained in the idea that dogs get headaches, so therefore they don’t exist. Well, pain in the head is not a disease, it’s a clinical sign of a disease process, such as dehydration, brain tumors, or any number of other problem that both dogs and humans do get, so it’s not unreasonable to think they might get head pain as well. They get other kinds of pain, after all. But objectively speaking, we have no idea whether or not a dog gets a headache because there’s no way for them to describe it as such.
I suspect they do get them. Have you ever seen a dog with a hangover? I have, sadly, in the ER. It’s not funny, it’s actually very sad that someone would knowingly intoxicate an animal, but the morning after they really do look like every college kid on a Sunday morning. Whatever it is they are feeling, it’s not super awesome.
At my first job, I worked with an old timer who always criticized how long it took my pets to wake up from anesthesia. “Look how quickly mine wake up!” he’d crow proudly. 20 minutes after a spay they were up and pacing. Mine were usually out for at least an hour or two. Eventually I decided to take a look at the differences in technique, and the main difference was this: I gave a lot more pain medications. My pain protocol back then was an eye-roller to many, but is now standard in many hospitals. My patients weren’t taking too long to recover, they were sleeping because their pain was being managed appropriately and they were comfortable.
If you could please stop playing the bongoes over there, that would be great.
If you talk to your typical veterinary anesthesiologist or oncologist, many of them will tell you that most people- vets included- tend to underestimate the amount of pain a pet experiences, assuming if a pet is not howling in pain they are OK. The more we learn, the more we are realizing the effect of pain on health, and how much more we can do to alleviate it. We are getting better about that as a profession, and I’m glad to see more and more vets adopting aggressive pain management protocols for everything from cancer to arthritis, but at the end of the day we can’t really manage a symptom we don’t know exists.
So to answer the question: Do dogs get headaches? I hope not, but I suspect they might. Poor dogs. Good thing Brody’s not hooked on caffeine.
Know your dog or cat. Know what is normal behavior and what is off. And if you suspect something is wrong, trust your instincts, and get them to a vet. Subtle signs can mean big things going on.
Today I’m showing Part 2 of the Ask Dr V series. I believe, though I haven’t checked it against the itinerary, that I should be on my way to the Ngorongoro Crater as we speak. Unless a chimp shoved me off the mountain earlier in the week, in which case these pre-published videos will be on a whole new level of macabre.
Which, by the way, my shade would find utterly hysterical.
Before I left, I spent a few minutes answering some of the great questions you submitted for the Ask Dr. V segments. I was on my way to a PTA meeting and had a few minutes to kill, so I figured why not. This was way more interesting, by the way.
Do you have a clear understanding with your petsitters or boarding facilities when you leave on a trip? Would you want them to make that call for you?
I’ll be picking questions to answer in the Ask Dr. V section over here. You can send in your questions via the contact form. Questions will be selected at my discretion.
That’s Spike from Iams, who is mulling over what he might want to ask.
As always, if your pet has an immediate health concern, please see your regular veterinarian. I will answer questions about general health topics, but I will not select any questions that have to do with your specific pet’s health.
Most difficult class in vet school?That’s a toss-up. Clinical pathology was a bear, but so was neurology. The first because of the topic, the second because of the teacher.
Did the dogs get any of the cat litter chicken breast?
Nope. It was immediately tossed, much to Koa’s chagrin. She really wanted it (as you could see, I didn’t realize until watching the video that she was pacing like Jaws!)
What was the biggest animal you have treated & what for? And the smallest & what for?
I see you sneaking in 2 questions there! Biggest I have personally treated was a horse, but I watched someone else work on an elephant in school). I was treating it for, I don’t know, some horse thing. It was over 10 years ago so my memory is fuzzy.
The smallest was a mouse with an upper respiratory infection.
The most exotic was a chimpanzee.
Have you ever met a dog that truly watches television? ;0)
Just yours! 😀
I had a family vet growing up who always remembered our family’s pets (and later mine) and remembered us. I never figured out how he did it, but he always said the most soothing things and knew exactly what memory to bring up to make me feel better…Do you experience this kind of connection with any of your regular clients? Is it rewarding to you?
I do with several of my regular clients. It is a wonderful experience. It’s few and far between, though- a lot of people simply aren’t looking for that depth of relationship with their veterinarian.
Do people ever ask you what type of dog (or pet) to get? How do you answer such a question?
I would actually like that if more people did ask! They usually don’t and end up getting something that is a terrible match for their lifestyle (like the couple in a tiny but immaculate apartment who got a Weimaraner and then got upset that the dog was destructive when he got bored.)
I would ask them what their lifestyle is like, and what they are looking for in a pet. Then I would give them some suggestions and maybe a list of some rescues to talk to.
What is your grossest exam room story?
Hmm, probably the severely matted Chow who was in for a “skin infection”. Once we started cutting off the mats, we found infection all right. Secondary to the fleas and maggots. Handfuls of them.