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.

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.

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.

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