Knowing When It is Time to Say Goodbye

As I was leaving work last night, I got a call from a friend and client who needed to have a serious conversation about his dog’s current quality of life and what the right decision to make is.  My friend has had his goofy, wet kiss giving, fun loving chocolate lab since he adopted him at the age of 8 weeks in 1999, when my friend was 24 years old and single.  His dog is now nearly 15 years of age and my friend 38 years of age and married…the long history and life together through those years so filled with transition and change cannot be overstated, the bond between them so strong, words cannot describe it.   My friend’s wife who he met 10 years ago has also formed a deep bond with this Labrador, such that she felt she needed to be present at our discussion as well.  When he proposed to her years ago, he had done it by bringing her breakfast in bed, followed by having the dog bring the ring in its box over to her and drop it on the bed next to her, a testament to how strongly this dog is engrained in the fabric of their lives.

The frustrating part of my friend’s dog’s situation is that at nearly 15 years of age, a very advanced age for a 90 pound chocolate lab, is the dog’s spirit is still there: he wags his tail, eats and drinks with gusto, gets excited every time his beloved owners come home…but his rear limbs are failing him.  Stricken with a combination of degenerative spinal disease and degenerative joint disease in his hips and knees, walking to even go outside to eliminate is a struggle multiple times per day.  Simply getting up to walk to the door to go outside is hard enough, but posturing to urinate and defecate is even more difficult.   Anti-inflammatories and joint chews have helped alleviate his discomfort and sustained him for the past year, but their benefits are rapidly providing diminishing returns.

What compounds the problem, is that alternative treatment modalities like acupuncture, therapy laser, and glycosaminoglycan injections require regular visits and are thus off the table because of the toll that the trip to and from the clinic takes on the dog given his physical limitations; and stress levels such a trip creates at his advanced age.  Nutritional management and anti-inflammatory medication is therefore all we can offer the dog, and with only those modalities at our disposal, we are rapidly losing ground in battling the progression of his disease.   Seeing this is heartbreaking for his owners, yet they are torn to make the decision to humanely have him euthanized because his spirit, his mind, and his love for them remains so abundant.  He does not seem willing or ready to give up, but his body is far less able.

When the death of a pet has occurred because of disease or injury, so severe that medical treatment failed or disease or injury manifested too quickly for the pet to have gotten access to veterinary care on time, parting is not as devastating for owners, as such an event was not their choice.  The most heartbreaking side of pet ownership occurs when quality of life is compromising and deteriorating yet not fatal, and it becomes the responsibility of the pet owner to decide when it is time to humanely say goodbye.  While as veterinarians we are able to guide pet owners as to when the decision for humane euthanasia is justifiable and even perhaps in the best interests of the pet, we cannot make that decision for them in these subjective cases.   In light of my friend’s situation with his chocolate Labrador, the purpose of this post is to help pet owners decide when it is the appropriate and the most humane option to elect euthanasia.

In that regards, the first thing one must do in the case of an ailing geriatric pet is observe the 4 basic necessities to maintain reasonable quality of life, the ability to: 1.) breathe, 2.) eat and drink, 3.) urinate and defecate, and 4.) ambulate.  If the pet can do each of these things without severe debilitation or distress, then usually quality of life is adequate.   Let us apply this rule to my friend’s Labrador retriever.  In his case, he breathes fine, eats and drinks well, but he has pain and distress when attempting to ambulate and urinate/defecate, meaning that 2 out of the 4 basic criteria for reasonable quality of life are compromised.  Based on this, I advised my friend and his wife that this at the very least put their dog in the category where humane euthanasia is a justifiable decision, perhaps even the most humane option with increasingly less medical alternatives available to him.

Put in this perspective, the decision will be no easier for the good people that I write of today, but it gave them a more certain perspective to be confident that in the coming days or weeks, that they will make the right decision in the best interests of their beloved companion.  While there are difficult times ahead of them as they will likely inevitably have to make that heartbreaking decision to say goodbye to their dog, they will be poised to do so with more clarity than guilt.

There is rarely an easy path around these types of situations, and for those of us who love animals and will always have pets in our homes, we will all likely inevitably face with the same tough decisions.   I hope this post can give my readers more confidence and clarity if ever they are faced with similar quality of life decisions.

Dr. Roger Welton is the President of Maybeck Animal Hospital and CEO/Chief Editor of the veterinary information and blog online community, Web-DVM.

Veterinary Advice Online? Does That Really Exist? Should Pet Owners Really Be Seeking Online Veterinary Advice?

The internet is deeply engrained in the fabric of global life.  Whether it is social media, shopping, getting directions, getting our news, or simply entertainment, the internet has become the first place we often look.  But veterinary advice online?  Does that really exist?  If so, is it a good idea to get veterinary advice online?

It has actually been going on for much longer than people realize.  Veterinary advice sites have existed since the late 1990s when the internet was first steaming ahead in its popularity.  I created my first veterinary advise website called AskDVM.com in 2003 ( the domain still exists, but hyperlinks to my most recent and ambitious creation, Web-DVM.net…more on this, below).  My first site was a lot like the other few others that existed back then, with a simple prompt that enabled the user to submit a question to the veterinarian – me – for a one on one consultation for a fee.  In order to make the site more user friendly and multidimensional, I added a “Pet Tip of the Day” to the site where people could log on to the home page and get a new piece of free general advice with regard to nutrition, training, therapy, etc.  Later I added a “Pet of the Week” and by doing this, I was amazed how often people returned to the site, not really to ask me a question, but just to get a glimpse of my daily advice or enter their pet to win pet of the week.

Eventually, seeing how successful the new sites were in offering up their news and links for free in exchange for the users having to tolerate ads placed as unobtrusively as possible throughout the site, it dawned on me that the same would likely apply to veterinary information.  Internet surfers seemed perfectly willing to accept a few ads for the trade-off of getting quality information and content in other areas of the information superhighway, so why should veterinary information be any different?  And so, the Web-DVM (http://web-dvm.net) was born.

The site officially opened in 2007 after taking one year to personally write all of the disease/medical articles myself, as well as personally design, edit, and regularly update the site.  Over time, I added canine and feline breed profiles, nutrition and training information and links, discount pet medication affiliates, this blog, and most recently, an online symptom checker where a pet owner can go through a series of medical history questions to get a list of possible disease that may ail one’s pet (along with a comprehensive article that details each disease in terms of description, diagnosis, and treatment).

Through all of this, however, while the site has grown exponentially with mostly free resources, it has never lost its original purpose, that is, if after sifting through all of these free resources, if one still wishes to consult one on one with a veterinarian, one may do so.  However, it is not only just with me, but a whole team of veterinarians who log in 24 hours a day, 7 days a week to answer questions.  In fact, I only log in to answer questions occasionally these days, generally focusing more on providing quality and informative content for the site.  When submitting a consultation for a veterinarian to answer, the user pays only if satisfied with the veterinarian’s answer, so satisfaction is 100% guaranteed.

A recent study indicated that 38% of pet owners have turned to the internet when a pet is sick or injured, before calling their vet.  The question is, is this the right thing to do?  Is my Web-DVM.net and other sites like it unethically capitalizing a growing market of internet addicts?

While I cannot speak for other sites, with regard to Web-DVM.net, no answer is no.  I will start by telling you why this is so, but also give you tips to properly use the internet for ancillary information to help care to your pets.

The company I joined forces with in an affiliate relationship to provide me the large pool of licensed vets necessary to offer 24/7 advice, Pearl.com, have the same philosophy with regard to offering internet information:

1.) It is not meant to replace the pet and pet owner’s relationship with the hands on veterinarian, but be used for times when a pet owner may wish to get a second opinion or fresh perspective on a case or lab data associate with a given case.  As such, while our veterinarians may suggest possible causes for a given problem, perhaps some additional testing that may add more useful information on a case, or simply recommend some husbandry and/or nutritional changes, they are prohibited from diagnosing or directly recommending medical treatment for a given condition.

2.) If the pet is in a life threatening situation or condition, the pet owner is strongly advised to not use our service and get the pet to a hands on veterinarian immediately.  In rural or remote areas where 24 hour emergency veterinary care may not be available, we will offer the best advice we can without breeching the prohibitive diagnostic and medical treatment tenant.

3.) Not only are we not directly diagnosing or making medical treatment recommendations, we likewise are also are not selling products for the purpose of self treating your pet.

With regard to how you should utilize Web-DVM.net and other veterinary advice and information websites, you should generally follow the same rules in reverse:

1.) Do not seek to replace your veterinarian with an online veterinary who cannot see or hear your pet.  What you observe and convey by typing online may be very different from what a trained veterinarian may observe that is actually seeing the pet.  For example, dogs with back pain will often yelp when picked up, which is commonly mistaken by owners for abdominal pain.  Likewise, pets often arch their backs when they have abdominal pain, making pet owners commonly mistake abdominal pain for back pain.  Making it more confusing, pets will often vomit from back pain as readily as they will vomit from the various things that may cause abdominal pain.

2.) If your pet is in a life threatening condition, labored breathing, listless, unable to walk, etc., stay off your computer and find a vet ASAP.

3.) Avoid sites that offer herbal or magical cures for sale that your vet somehow does not know about.  Most of these sites are not unlike the travelling charlatans of times past that offered people magical elixirs of life and vitality that were not only useless, but all too often toxic.

Lastly, make certain that whatever online ask a vet service you choose to use actually uses verified, licensed veterinarians.  Web-DVM.net‘s online veterinarian affiliate Pearl.com, for example, puts the veterinarian through an extensive verification process, starting with verifying credentials such as state veterinary license, followed by giving the veterinarian random test questions to not only test their knowledge, but be certain that the veterinarian is answering in a manner that is consistent with the aforementioned ethical boundaries.

As with most other aspects of life, there are a lot of valuable pet care and veterinary resources to be found on the internet.  However, also as in most other aspects of life, there is a lot of misinformation out there, as well as quacks happy to take your money without a care of what happens to your pet.  Enjoy the benefits of the internet where you can, but always be careful to verify the source and integrity of information and recognize and avoid those who are out to cheat you out of your money.

Dr. Roger Welton is the President of Maybeck Animal Hospital and CEO/Chief Editor of the veterinary information and blog online community, Web-DVM.

Why yearly heartworm screening when my dog is given heartworm prevention year round? (and other commonly posed heartworm prevention questions)

This is a question that is commonly posed to me in clinical practice, and to be fair, a fair one.  If you are giving your dog year round heartworm prevention, why do we still ask you to have your dog get a heartworm test once a year to renew the heartworm prevention prescription?  If you live in an area where the mosquito vector responsible for transmission of the disease is seasonal, why the recommendation for year round heartworm prevention?  Why treat at all if you live in a region with no mosquitoes? Below are the answers to these questions.

1.)    No treatment is 100%.

While heartworm preventives are highly effective in preventing heartworm disease, not one single heartworm preventive can claim 100% efficacy, even in controlled settings where product is regularly administered vigilantly. 

2.)    While as in other aspects of life, we all strive to be perfect in giving our pets their medications in a timely manner, not one single person can claim to be perfect.

Heartworm preventives are only effective in killing the infective stage of larvae that infected mosquitos inject into the dog’s bloodstream when feeding.  If even a few days late in administering the heartworm preventive, if a dog is infected, the larvae may have already reached a stage of development that the preventive medication will not kill; and thus, continue to develop into adult worms despite continued timely preventive administration.

As such, I see about 1-2 cases per year of heartworm positive dogs whose owners had previously  purchased 12 months of heartworm prevention and religiously administered product, but in hindsight usually recalled a particular month when they may have been late.

3.)     Although in temperate climates where the temperature regularly drops below freezing in the winter months naturally culling mosquito populations, unseasonably warm weather will commonly lead to pockets of mosquito blooms, thus making transmission of heartworm disease still possible during less mosquito prone months.

4.)    In dry climates like Arizona and Nevada, it is true that mosquitos – and therefore incidence of heartworm disease – are uncommon to see.    

However, anywhere or any time there is the right atmospheric condition, however brief, combined with fresh, standing water (lakes, ponds, puddles, irrigation ditches, etc.), it is possible to have mosquito blooms.  According to statistical data compiled by the American Heartworm Society, Arizona reported 462 cases of heartworm cases in 2001.  With significant ongoing development and irrigation systems necessary to provide water increase in size and scope, it is likely that number is currently higher and poised to rise.

5.)    Most veterinary grade heartworm preventives also have potent killing capability for the most common intestinal parasite worms. 

Worms such as these are ubiquitous nationally and can infect people, especially young children, immune suppressed individuals, and the elderly.  Treating with heartworm prevention helps to prevent these harmful parasites as well.

6.)    With the advent of “all in one” preventives like Trifexis that offer protection from fleas in addition to intestinal parasites and heartworm, there is the added benefit of keeping homes free of fleas as well by keeping your pet on year round heartworm prevention.

So there you have it, no heartworm preventive is 100%, no owner no matter how responsible is perfect in timely administration of heartworm preventive, mosquito blooms and heartworm infection still happens in regions cold winter months during unseasonably cold weather, mosquito blooms and heartworm infection in dry climates occur under the right set of conditions, and year round prevention with modern “all in one” products also protect the pet (and its family) from common intestinal parasites and fleas.

Lastly, once a canine is infected with heartworm disease, it is too late for preventives.  Treatment for heartworm disease is expensive, potentially toxic, and sometimes fraught with complications.  It is a lot less expensive, far less traumatic for the pet, and safer for the human family to just administer year round treatment, while engaging in once yearly screening.

Dr. Roger Welton is the President of Maybeck Animal Hospital and CEO/Chief Editor of the veterinary information and blog online community, Web-DVM.

Don’t Tell Me You Cannot Afford Vet Care After You Spend $3000 on a Pure Breed Pet

I recently have written about how pet ownership should not be a privilege of the well off and wealthy.  In my previous most recent blog post, I also wrote about costs of veterinary care seemingly being poised to outpace general inflation and wage increases of the average pet owner, along with precautions pet owners must engage in if they are to deal with this new reality of pet health care.  However, it is hard for me to have sympathy for a person who goes out and spends $3000 on a pure breed pet, then cries to me that they have no money to afford even basic health care for the animal.

The most troubling aspect of this all too common scenario is that the breeds that people tend to sink the most money into are the ones that have the most health problems.  In dogs, it is Boxers, Sharpeis, German Shepherds, and English Bull Dogs to name a few.  In cats, it is Persians, Himalayans, Siamese and Ragdolls to name a few.  These and other pure breeds often cost the owner a small fortune and carry the most unwanted disease predisposing genetic baggage.

Of course, when these pets ultimately get sick, partly because of their genetic predisposition to disease, partly because after the expensive purchase of the animal the owners have no money left to provide even basic well care for the pet; guess who they ask for a discount, free care, or payment plans to provide treatment?  Then after I refuse, suddenly I am the bad guy in their minds for not working for free or refusing to set up a payment plan that I know I will never collect…been there, done that too many times to know how things turn out.  That’s right; I end up somehow being the cause for the dilemma created by their bad decisions.

But although my clinic had to do away with billing plans as our accounts receivable started reaching astronomical proportions, we do offer interest free payment plans from third party medical lenders like Care Credit that people with even fair credit worthiness can get approved for, as well as accept all major credit cards.  But of course, all too often, these people that were bent on spending $3000 on a pet, not only have no money to pay for vet bills, but they also have no credit worthiness for any kind of medical lending plans.

So please put this in perspective.  A person has very little money, poor to non-existent credit, yet spends $3000 on a pure breed pet that is likely to have more health problems than the average pet.  Really?

Now, I will still maintain that pet ownership should not only be a privilege of the well off and wealthy, but people also have to be accountable to make financially sound and common sense decisions.  Want a pet?  No problem.  Go to the local shelter where they are giving them away for a nominal adoption fee, complete with parasite and heartworm screening, full complement of vaccines, and spay/neuter.  Still bent on a pure breed pet?  Be patient, they come through shelters all the time, or one can easily find a pure breed rescue online or through local retail pet stores and veterinarians that engage in work for these organizations (my hospital works with Italian Greyhound, Scottish Terrier, German Shepherd, and Labrador Retriever rescues, as well as a host of feline rescues).

If you know or are related to people like this that are talking of buying expensive pure breed animals with money they don’t have, nor have the means to properly care for them, please, talk some sense into them.  Spread this post as far and wide as you can, share it with others, shout it from the roof tops.  While it may be hard to believe, this story lines occurs day in and day out, and those of us with better sense than that must do our best to guide those that do not.

Dr. Roger Welton is the President of Maybeck Animal Hospital and CEO/Chief Editor of the veterinary information and blog online community, Web-DVM.

Protect Your Pets Against Rising Health Care Costs

I was inspired to write this blog post after I was informed this week of my clinic’s reference laboratory’s across the board fee increase of 5%. The stated reference laboratory, Antech, is the lab to which we send out of house laboratory diagnostics, from blood work profiles, biopsies, and EKGs, to x-ray imaging consultations. Antech offers the most competitive pricing for these services in the veterinary industry and yet, even they are posting a rather significant fee increase this year. As a consequence, since Antech bills us monthly for laboratory services, we in turn must increase laboratory fees to our clients by the same percentage.

Such is the nature of our profession…what we charge for veterinary care is for the most part dictated by the fees we are charged in course of performing our veterinary medical services. Whether we are talking about surgical materials, prescription diets, medication inventory, or the cost of servicing our medical equipment, these costs must necessarily be factored into our fee structures; and unfortunately over time, these fees go up, not the other way around. What’s more, they have been trending in recent years to increase annually at a rate of 4%-6% per year.

What this means for pet owners, is that the cost of veterinary care will likely reflect similar increases over time. While we pride ourselves in offering one of the noblest of professional services at a fraction of the cost of analogous human medical services, from a fiscal perspective, veterinary hospitals are no different than any other small businesses; and our fees must thus cover our own incurred costs to stay in business.

The troubling aspect of this is that the wage increases of the average pet owner are not currently keeping pace with the current rate of fee increases. Understandably frustrated pet owners will sometimes speculate that these increases are due to veterinarian greed, but with a few exceptions, fee increases are not driven by veterinarian greed, but by in large, the industry’s own ever increasing business costs. In fact, veterinarians from a career standpoint are currently fairing little better than other professions, with average veterinarian wages having actually on average declined since 2010, while student loan debt burdens have increased as clearly illustrated in this article:

http://veterinarynews.dvm360.com/dvm/Breaking+News/Starting-salaries-for-veterinarians-trend-lower/ArticleStandard/Article/detail/742446

The reason I am sharing this information is not simply to frighten pet owners, but to create urgency for pet owners to prepare to deal with the cost of veterinary care as it seems poised to steadily increase over the next several years. The solution is twofold:

1.) Engage comprehensively in preventive wellness care by taking advantage of the area of veterinary care where costs can be more successfully controlled and kept in check. Follow veterinarian recommendations for optimal nutritional to maintain good health and prevent disease. Take part in our wellness programs that are pivotal in early disease detection and reward participation in good well care. Wellness programs are becoming increasingly common in veterinary clinics, and in addition to rewarding participation in wellness programs with significant discounts, they are pivotal in early disease detection and prevention of disease. When routine dentistry is recommended, do not wait. Routine dental cleanings are not expensive when dental disease is minimal; it is oral surgery for dental extractions and antibiotics that drive up dental care costs when disease has reached a severe state. Promoting good preventive well care in this manner will drastically reduce health care costs in the life of the pet.

2.) Give strong consideration to carrying pet insurance. Americans have a major aversion to pet insurance, with only 3% of pet owners carrying it for their pets, compared to 50% of pet owners carrying it in Europe. I would speculate that Americans likely avoid pet insurance in large part because of the sour taste many of us have in dealing with our own health insurance companies, but if the average pet owner is going to be able to sustain quality health care for his/her pet, that mindset is going to have to change in coming years.

That stated, not all pet insurance companies are created equal, and there are many out there that put profit before ethics and what is best for your pets. You must do your research and read reviews, while getting important feedback from veterinarians. Following years of experience observing the integrity and quality of veterinary pet insurance companies, there is one in particular whose policies I have found to be the most favorable to the patient and pet owner of any pet insurance company since the inception of the industry, called Trupanion. Other veterinarians may be aware of other pet insurance companies from whom they have gotten good client feedback from. The point is, your veterinarian is a great source for information on quality pet insurance, so be sure to ask before choosing any one particular company.

So…while I will reiterate that my intention in writing this post was not to frighten everyone with the notion that veterinary costs will be unaffordable tomorrow, recent trends indicate that costs for veterinary care may well continue to outpace wage increases of the average pet owner in coming years. Engaging in preventive wellness care and carrying good quality pet insurance for your pets are the best tools to protect your pets against ever increasing costs of treating unexpected illness or injury.

Dr. Roger Welton is the President of Maybeck Animal Hospital and CEO/Chief Editor of the veterinary information and blog online community, Web-DVM.

Why/How Do Cats Purr?

The purr is one of the most distinctive features of our feline companions, yet many cat owners and feline enthusiasts do not really know how and why cats do this.  To be quite honest, even us veterinarians do not completely understand the reason behind purring and the physiological mechanism that enables feline purring, but we do have some level of understanding I will be sharing in this article that will shed some light on this feline anomaly.

Kittens begin to purr as early as two days old.  It exists in this early phase of life as a connection to Mom that seems to signal contentment, letting Mom know everything is okay so she can turn her attention to one of several other kittens that may be in greater need of her attention.  It also seems to contribute to the bond between Mom and kitten, as kittens and Mom will often purr simultaneously when in the midst of affectionate interaction.
As the kittens progress into adulthood, we commonly observe that cats will still purr as an expression of contentment, but purring may also occur during times of injury or stress.  In this context, purring seems to be a self-soothing tool that cats may use as a sort of coping mechanism.

As far as how cats purr, that is not quite as clear, but here are a few facts that we do know.  In contrast to the meow which is a vocalization that only occurs on exhalation (expelling air), the purr is a sound which is made on both inhalation (inhaling of air) and exhalation.
Purring emanates through the larynx, a structure that is commonly known as the voice box.  This we know because cats that suffer from laryngeal paralysis lose the ability to purr.  Where it becomes a little bit more mysterious is what differentiates the meow sound that would be more akin to the “voice” of the cat, versus the rhythmic, almost percussion-like sound of the purr.

The answer to that seems to lie in the feline’s internal laryngeal muscles, which control the opening of the glottis (the vocal folds and spaces between them), but exactly how that happens still remains a bit of a mystery.  The trigger is hypothesized to come from a rhythmic/repetitive neurological mechanism of the central nervous system known as neural oscillation.

The cat’s purr is one of the most unique characteristics of feline and to many who love having cats as companions and family members, one of the more enjoyable feline traits.  Like the kitten with its Mom, our cat’s purr to let us know they are enjoying a treat, snuggling, getting pet or brushed, or simply enjoy having us nearby.  Like the kitten with its Mom, cat purring enhances the human feline bond.

Dr. Roger Welton is the President of Maybeck Animal Hospital in West Melbourne, FL and founder/CEO of Web-DVM.net.

Pets Increase Health, Longetivy in People

With over 60 % of Americans owning pets, collectively pouring approximately $41 billion a year into pet care, it is abundantly clear that pets are a major aspect of the fabric of American life.  So while we know full well how much we love our pets and consider them members of our families, many do not know that the love and money we pour into our pets is also a great investment in one’s health and longevity.

Statistically, in a study conducted of 4000 cat owners over 10 years, the Minnesota Stroke Institute found that people has a 30% lower chance of dying from heart disease.

Similarly, dogs have been shown to reduce stress, cholesterol, and even blood pressure.  Stress not only leads to physical manifestations of disease, but stress also creates anxiety and reduces overall quality of life.  Therefore, it naturally follows that if one effectively lowers stress, then overall health and quality of life are generally better.

The benefits of pet ownership for the elderly cannot be overstated.  One study observed increased neural activity in the brains of seniors while they walked or interacted with their dogs.  Increased neural activity means a more active and functioning brain, making pet ownership a possible way to manage conditions that lead to decreased brain activity, such as dementia or Alzheimer’s disease.

In children with autism, one study done in Australia observed that the presence of animals can be beneficial for encouraging social interaction with other children.  Specifically, the study indicated that social interaction was 55% more likely with autistic children in the presence of animals compared to toys.  The study also concluded that the children were twice as likely to smile when in the presence of animals.

So there you have it, our furry friends do not just give us unconditional love and companionship, but also offer the added benefit of helping us to live healthier, longer lives with better quality.  There really is no end to the gift our pets are to us, and how lucky we are to have them in our lives.

Article Sources:

http://animal.discovery.com/pets/live-longer-with-a-pet.htm
http://www.huffingtonpost.com/2013/02/27/animals-autism-pets-asd_n_2776373.html

Dr. Roger Welton is the President of Maybeck Animal Hospital in West Melbourne, FL and founder/CEO of Web-DVM.net.

Help Me Help You

Before I elaborate further on today’s topic, let’s first discuss compliance. By definition compliance from the perspective of medicine means: willingness to follow or adhere to a prescribed treatment course and/or regimen. In the field of veterinary medicine, many factors can affect compliance, such as: the ability of an owner to medicate a fractious or uncooperative pet, financial constraints to pay for medicine or treatment, a disorganized owner that is prone to forget treatments, a dismissive owner that disregards the veterinarian’s recommendations, or a pet’s intolerance (allergy or GI disturbance) to a given medicine, to name a few variables. While a few cases this week reminded me of just how much compliance affects our ability as veterinarians to succeed in improving the health of our patients, whenever I am faced with compliance issues, I am reminded of a seminar I once attended that was put on by Pfizer Pharmaceuticals a few years ago.

They were discussing a new product line that is an antibiotic that only requires one injection, as its anti-bacterial activity lasts in canine and feline tissues for 17 days. The Pfizer rep then marketed this new product line as the only antibiotic that virtually guaranteed 100% compliance, then proceeded to show us a slide of a pretty woman with a big smile on her face, holding her cat, with an arm around her big dog. He asked us, “Which species in this picture presents the biggest challenge to achieving 100% treatment compliance?” As veterinarians, we all know that from a general standpoint, felines tend to be more difficult to medicate than dogs, so most of us said cats. He then clicked his power point presentation and placed a big red circle around the woman. This is not to insinuate that women present our biggest challenge to compliance, it just so happens that the biggest challenge to treatment compliance is the human owner; and the human in the picture happened to be a female.

This part of the presentation really got us chuckling, because we quickly realized that far and above the other challenges to treatment compliance in veterinary medicine, it is the pet owner that brings the pet to us for health care in the first place that is our most common obstacle in attaining compliance. It also proved to us just how powerless we really can be in the health care of our patients, as all we can do is prescribe medication, advise preventive strategies, and make lifestyle recommendations, but as soon as the pet owner and pet step out of our clinics, the patient’s health care is 100% out of our hands, and 100% in the hands of the owner.

A study in 2011 conducted by the large prescription pet food company, Hills, detailed owner compliance statistics by comprehensively surveying pet owners throughout the country. The results were very eye opening:

1.) 17% of dogs do not receive regular heartworm screening.
2.) 52% of dogs are not kept on monthly heartworm preventive medication.
3.) 82% of cats do not have yearly well visits (exam, stool analysis, and vaccines).
4.) 65% of dogs and cats do not have preventive dental cleanings.
5.) 82% of dogs and cats are not fed therapeutic diets to manage disease when recommended.
6.) 67% of dogs and cats do not participate in senior screening/early detection programs.

A separate study conducted by veterinary pharmaceutical, Zoetis, revealed that:

1.) Fewer that 33% of pet owners will give pet medication at the correct time intervals.
2.) Only 30% of pet owners give antibiotics to completion as prescribed by the veterinarian.

In my recent blog post, What Wellness Reveals, I discussed the incredible diversity and amount of preventable and treatable disease detected on routine wellness visits in just one week. I also discussed how failing to provide well care for pets can lead to poor quality of life and decreased longevity for the pet, but potential dangerous, even tragic consequences for its human family members. While participation in wellness visits is very much an owner compliance issue, I will not revisit the importance of compliance with wellness visits today, and recommend you check out that post if you have not yet read it.

For today, I would like to focus on two cases I saw this week that were hallmark examples of owner non-compliance drastically affecting treatment success. While these cases were standouts in my mind, please bear in mind that these are only 2 examples of many non-compliance related issues I faced this week.

The first case was a recently diagnosed diabetic cat that I had prescribed insulin for after the diagnosis was made. I advised as always that, while the initial insulin dose is determined by body weight, we must closely monitor the blood glucose in the early phases of treatment in order to adjust insulin doses as the patient physiologically adjusts to receiving insulin derived from another species. Doses are frequently changed in the first few weeks, making our initial dosing calculation more a general guideline than anything we can rely on long term.

The first blood glucose re-check was supposed to be one week later, but I did not see the cat again until 2 months later when she came in on emergency in the midst of a grand mal seizure brought on by severe hypoglycemia (low blood glucose). Her blood glucose at the time was 25, meaning that she was likely just moments away from insulin coma and possibly death. Thankfully, we were able to treat her in time to stabilize her and she survived the episode. The kitty’s owners are very nice people who love their cats and I really felt for them that day, as they learned a very tough lesson about the importance of compliance.

The other case that stands out from a compliance perspective was a little dog that has battled skin problems for the past 4 years, and for the past 2 years, has virtually lived with a cone on his head as, otherwise, he would chew himself to oblivion. The cause for his severe skin disease is always apparent, as one swipe of a flea comb has always revealed 20-40 fleas in one comb through, and every time I show the flea comb teaming with fleas to the owner, he always acts very surprised. Yesterday’s visit was no different.

While I had to treat the severe skin infection and inflammation that was in front of me, like each of the last 5 occasions that I have seen this dog for the same problem, I told the owner that all the antibiotics and cortisones in the world will not clear this skin problem until he gets serious about controlling fleas. I advised veterinary grade flea control for not only the patient, but for all the other pets in the home (1 other dogs and 5 cats). I also advised that he hire a professional service to have the home and yard treated as well. Will he comply this time? For the sake of the pets, I certainly hope so, but I am unfortunately not optimistic.

From the vantage point of the examination room where veterinarians see s pet perhaps once or twice a year, we can only do so much. We can prescribe treatment, advise husbandry and life style changes, and promote wellness, but in the end, it must be the pet owner that complies with our recommendations and implements them. Since it is you the pet owner that ultimately most important factor in treatment compliance, I leave you with a quote from 90s iconic move character, Jerry Maquire (Tom Cruise) as he pleads with his client (Cuba Gooding Jr.) to work with him: “Help me, help you.”

Dr. Roger Welton is the President of Maybeck Animal Hospital in West Melbourne, FL and founder/CEO of Web-DVM.net.

Pet Companionship Should Not Only Be a Privilege for the Financially Well Off

I had an experience this week that has really gotten me thinking about the gift of loving a family pet; and how that joy should not be a privilege reserved only for the financially well off.  It was Tuesday afternoon, and a colleague and friend of mine, the surgical spet at the local veterinary emergency and specialty hospital called me with the case of an 8 month old pit bull puppy that had gotten hit by a car and sustained a serious fracture of its femur (thigh bone).  The family who owned the puppy did not have the funds to afford the services of a spet, as many don’t.  The services of this spet and that referral center generally can be quite costly, so it is not uncommon for my general practice to get calls from them to see if we could take on a case at less cost.

But this case was a bit different…these folks not only could not afford the emergency referral center, they could not afford any level of care.  The referral center even had to absorb the cost of the x-rays to get the diagnosis.  They told my surgeon friend that they could raise $500 within 48 hours to put toward the repair, but that was it.  There was not adequate credit worthiness for consideration for any medical financing plans, and $500 would cover 1/3 at most of what it would cost to surgically repair a fracture like this in my practice.  What’s more, without any prior relationship with this family, we really had no certainty that they would even come through with the $500 anyway.

I discussed the matter with the other associate veterinarian in my practice, and we decided to use a combination of rescue fund money that we raise through candy machine sales and private donations, the $500 the owners would hopefully come through with, and apply some discounting of the surgery and ancillary care.  In the end, we managed to get the surgery done for this puppy and its family.

The puppy is still in the hospital as we oversee his initial rehabilitation phase, and when the family came to visit him yesterday, I was both elated and saddened.  The puppy was wagging his tail and reveling in the love of his family; the two boys, each 12 and 14 hugged their beloved puppy as if he had been resurrected from the dead, and the mother sat in the corner sobbing from happiness.  She told me that this was her first dog and never understood how much love she could have for a creature like this, and that when he got hurt, she was overwhelmed with grief at his suffering that they did not seem to have the means to have fixed, and her fear of losing him was something she would have never expected.  She gave me one of the biggest hugs I have ever received from a non-family member, and from a person I had just met at that.  The puppy still has a long way to go to get through this, but I left my practice yesterday feeling a mix of happiness for this family that my practice was able to offer hope for what previously seemed a hopeless situation, and sadness because responsible pet ownership like so many other things in our society, seems to be gravitating to a paradigm where the love and companionship of an animal is becoming a gift only to be enjoyed by the financially well off.

I look at this financially challenged, but tight knit and loving family that absolutely love their dog and the dog that clearly loves them back 100 fold.  Should people like this have to be shut out of the joy of loving such a creature because they do not have much money to care for him optimally?  Should this dog be denied the love of this family because they do not have much money?

Before discussing this further, let me be clear that there is a clear distinction between families like the owner of the aforementioned puppy; and people that just make bad choices.  There are those like the former example that rescued the puppy and fell in love with him in the process; and those like the latter would make the decision to spend $3000 on a full breed English Bulldog and leave no money left over for its veterinary care…for a breed that is known to have constant health problems that need to be addressed.  While I feel for the dogs owned by these types of people who take no consideration for the fact that spending $3000 on a dog that will likely need constant veterinary care knowing full well that they bought the dog with money they did not have; I have little sympathy for their ridiculous choice and the consequences that choice reaps.

But it is the people whose hearts go out to dogs or cats in need, whether the animals are death row pound animals, or were found on the side of the road starving, wet and cold; who want to take these pets in to care for them, love them, and make them members of their families; that I really feel for.  And I wish that things could change so that these kind and generous people whose only flaw is poor economic status; could enjoy the love of animals, both given and returned; as this is a joy that would extend to both the animals and the people alike.

The question is, how do we get there?  Veterinary hospitals cannot get in habit of giving services away.  As small businesses, such behavior will lead to financial jeopardy and eventually disaster.  And one of the things any veterinary hospital must avoid.is getting tagged as being the hospital that give services away or allows owners to make payments on services…because then the darker side of human nature kicks in, where abuse of kindness starts to happen, and every hard luck, sob story, real or imagined case begins flowing into your hospital expecting pro bono services and/or payment plans that 50% of which pet owners will not ultimately follow through on.

There really is no one answer to this dilemma, and we will never be able to fix this issue100%, but we can make it better by approaching the problem from many facets.

1.) From the veterinary profession, every general practice should put together a rescue fund to use in times such as these, where there is legitimate need and sincere intent, as best can be ascertained by the medical team through questions, queries, observation, and to be used only when all medical financing options have been attempted and declined.  I know there are at least a few veterinarians that follow my blog, so I advise all of you to set one up immediately, and tell all of your vet friends and colleagues to do the same.  For all the veterinary technicians that follow my blog, let your veterinarian employers understand the importance of a medical fund, and have them read this post.  Money for our fund comes from candy machine sales, an occasional car wash, and direct donations into a donation box we have on the reception desk.  The generosity of pet owners cannot be overstated…it is always so pleasantly surprising to see how much people are willing to give to help others that are less fortunate.

2.) Pet owners need to be educated about what a minimal standard of care for their pet means, how it protects not just the health of the pet, but also the health of their family.  They need to understand that pets are like murphy’s law: whatever can go wrong, will go wrong…they get injured and sick, and there must be a means to provide the necessary veterinary care when needed.  There are methods people can implore to attain these means, such as what I call the $50 rule: putting aside $50 per month per pet in a separate savings account.  This should be done automatically with that account used only for the health needs of the household pets.  Most people no matter how financially strapped, can part with that amount of money each month, which works out to only $12.50 per week.  That amount of money will likely cover the general yearly wellness and grooming needs of the pet, while leaving some put away for a potentially expensive injury or illness.  People should also be educated about pet insurance, where reputable companies like Trupanion are offering reasonable premiums to cover large veterinary bills (up to 90%) in times of unexpected injury or illness.  I will be educating the owners of the puppy whose story I told, of all of this at the time discharge.  But this information cannot just come from veterinarians: it must come from everyone.  We all know people who own pets, genuinely love them, but do not have the financial resources to properly provide for their health care.  You must take the initiative to educate them that there are ways to plan and prepare to provide their pets necessary health care.  They must also know clearly that failing to meet the health needs of a pet, puts their human family in jeopardy as well.

3.) Breeders of pure bred dogs and cats must do home inspections of prospective puppy/kitten buyers, as well as ask tough questions to ascertain of the prospective buyers would be getting themselves in over their heads.  No matter how responsibly bred a dog or cat may be, pure breed animals carry a lot of genetic baggage that came with the selective breeding necessary to achieve the status of being a distinct breed.  If a breeder determines that an English Bulldog, for example, is likely too much for a prospective buyer to handle financially, he/she should perhaps advise they get a healthy mutt for free at the pound.  The genetic variation that mutts have tend to make them healthier, harder dogs that do not require as much health care.   

4.) Prospective adopters of pets must also take personal responsibility for the pets they choose to adopt.  As I stated, a premeditated purchase of an expensive dog one cannot afford is inexcusable, but in impromptu rescue situations where people are just looking to do the right thing, they deserve our compassion and guidance.  Despite that, these folks may only see love and empathy for the pet they have taken in, and fail to see the bigger picture of the pet being a responsibility of a life that needs regular wellness care and will inevitably need health care in time of injury or illness.  We have to reach out to these people, get beyond their hearts, and reach out to their more practical side, and decide on strategies to afford the care that their beloved new pet deserves.  If you are one of these people, take heed and start making the changes right away.  I love people with big hearts, but if there is not a big wallet to go with your big heart, then you need to let a little realism creep in and get prompted to start responsibly and effectively preparing for a rainy day.

To maintain a society where pet guardianship does not become yet another joy in life partaken by only haves and not by the have nots, it must be a team effort to make a difference, where we all do our parts.  From veterinarians setting up rescue funds to people being kind enough to donate to those rescue funds, to breeders and friends of pet owners taking the time to educate pet owners who are financially challenged to make easily implemented and practical preparations to properly provide for the health care needs of their pets; there is a role each and every one of us can play in caring for one another, and one another’s furry family members.

Dr. Roger Welton is the President of Maybeck Animal Hospital in West Melbourne, FL and founder/CEO of Web-DVM.net.

What Wellness Reveals in Pets

I hear it time and again.  “Fluffy doesn’t need to go to the vet because she is so healthy, nothing is ever wrong with her.”  Or lately, I’ll also hear, “I only have to take her to that place for cheap shots.”  Such is the increasing mind set of many pet owners, and as a result, the value of the yearly wellness visit is diminishing from their point of view; and pets and their families are suffering the consequences.

Each year since 2008, well visits are decreasing steadily each year.  Part of the reason for this trend is the rise of the new discount shot facilities, and as I call them, shot wagons (vans that pull up to pharmacy, pet store, and now even gas station parking lots to give shots to pets).  I will not spend too much time on these type of places (for more on these places, please see my post: The Shot Wagon: The Bottom of the Veterinary Barrel).  I will mention that they have capitalized on the concerning economic climate of the past several years, and devoted their services to plugging pets with every vaccine under the sun (whether pets need them or not – more on this later on) and offer them at cheap prices.  The cheap prices come from the fact that they typically use cheap, poor quality vaccines; as well as not giving a physical examinations, not engaging in stool parasite screening, and often without even recommending a heartworm screening for dogs.  Their profit is based primarily on the the number of shots they can dole out in the shortest period of time.

But it is more than just these discount shot places that have led to the decrease in wellness visits.  The whole mid set of our Americans has changed since the great recession.  Rather than seek out the best quality for price they simply seek out the best price with less emphasis on quality.  Rather than than accept the veterinarian’s focus on the importance of wellness visits, they rationalize forgoing them because Fluffy looks great.  Why would they waste money on a well visit for a healthy pet?  The impact of this change in pet owner paradigm cannot be overstated…and is all too often devastating for the pet, and even a serious danger to the human family.

Pets Suffer Silently

The natural tendency of animals is to hide signs of pain or distress.  Showing weakness of that kind in the wild leaves them susceptible to predation, getting chased from territory, or getting their food taken.  Dogs and cats are no different.  Cat are especially good at hiding signs of pain or illness.

So when you are so convinced that Fluffy is so healthy, remember these facts:

– 1 in 3 dogs and cats carries a preventable parasite, some of which can infect people, while reducing the health and longevity of the pet.

–  1 in 4 dogs and cats over the age of 4 has painful and health diminishing periodontal and gum disease. 

– 30% of dogs and cats over the age of 7 have hypertension (high blood pressure).  Hypertension could be an early sign of preventable but serious disease if left unaddressed, but by itself can damage the eyes, heart, liver, and kidneys, while leaving the pet prone to dangerous blood clots.

– Heartworm disease in dogs in on the rise at a time in history that it has never been more preventable.

Here are perfect examples of serious disease I caught on routine wellness visits that the owners were certain their pets were in perfect health just this week:

– 1 case of early stage congestive heart failure in a dog

– 10 cases of advanced dental and gum disease.

– 3 cases of intestinal parasites found on routine stool analysis.

– 11 cases of flea infestation.

– 2 cases of hypothyroidism in dogs.

– 2 cases of Cushing’s disease in dogs.

– 1 case of feline diabetes.

– 1 case of feline hyperthyroidism.

– 1 case of heartworm disease in a dog.

– 10 cases of obesity.

– 3 cases of ear infections (2 dogs, 1 cat).

– 1 case of ear hematoma (blood and fluid swelling in the ear flap) in a dog.

– 5 cases of osteoarthritis (4 dog, 1 cat).

Folks, this is just this week and its only Thursday!  The last and most amazing example of a dog suffering silently was not this week, but a few weeks ago, and is a case I will never forget.  A sweet, vivacious little 9 pound min pin mix came in, not for a yearly well visit, but because of a little diarrhea, and because his stomach seemed to be making some odd noises.  On physical examination, I felt a firm swelling within his abdomen that prompted me to take an x-ray.  The x-ray revealed that the little dog’s diaphragm (the muscular wall that separates the abdominal and chest cavities and is responsible for breathing) had ruptured, and the dog’s liver and most of his intestines were in his chest wrapped around his heart and lungs.

This type of injury only happens in cases of significant trauma, so I asked the owners if the dog had any trauma to his body recently.  The owners noted that he was hit by a car 3 years ago, but they declined x-rays at the time because the dog looked so bright, alert, and responsive.  So this dog lived with a diaphragmatic hernia – an injury that causes pain upon breathing and pressure inside the chest cavity upon eating (because the intestines and stomach were in the chest, not the belly) – for 3 years with the owners not having had a single clue.  Not only was there likely pain and discomfort with this injury, but that hernia was a ticking time bomb that the owners of this dog did not know about, that could have at any time led to strangulation of intestines , dangerous clot formations, or asphyxiation.  Had this dog had well care in the past 3 years, the injury would have been discovered much sooner, the surgery done; and the patient alleviated from pain and out of danger.

Cats Are Really Getting The Shaft

A recent study indicated that cats are really bearing the brunt of reduced wellness visits in the new paradigm of owners forsaking well care, with only 18% of household cats receiving routine wellness visits.  When it comes to suffering silently, cats are far more likely to hide signs of pain and distress than even dogs.  As a result, an unacceptable number of cats live with chronic parasitic infestations, fleas, periodontal disease, hypertension, thyroid disease, kidney failure, diabetes, periodontal disease…and a host of other ailments, with the owners not having any clue.  Parasites and fleas pose a serious danger to children, the elderly, and immune suppressed individuals.  A larval stage of a common canine and feline parasite called the roundworm, can cause irreversible blindness if children under 5 are infected with the parasite.  Still finding that yearly stool test a waste of money?

Shots Are Important, But Not All Pets Need All Shots

There are diseases that are edemic just about everywhere: rabies, canine distemper, canine parvo, canine parainfluenza virus, canine adenovirus, feline panleukopenia, feline rhinotracheitis, feline calicivirus.  We call vaccines for these diseases, “core vaccine.”  The others, feline leukemia, canine bordatella, canine leptospirosis, canine lyme disease, are regional and/or lifestyle specific, meaning that depending on the lifestyle of the pet or where in the country he/she may live, he/she may or may not necessarily need these vaccines.

By tailoring vaccine protocols to the individual needs of the patient, we are seeking to balance realistic disease risk, with making an effort to reduce vaccine frequency in pets.  While vaccines are necessary and important preventive measures for disease control, overdoing them can lead to health consequences.  In this regard, the American Veterinary Medical Association (AVMA) has established guidelines based on research that there are also several diseases whose vaccines offer 3 year protection, such as canine distemper, canine parvo, canine rabies, feline calicivirus, and feline panleukopenia virus.  Ethical, medicine minded veterinarians, therefore, tailor the vaccinal needs of each pet to its unique lifestyle, while using 3 year vaccine protocols where appropriate.

The shot wagons and discount shot facilities?  Not so much.  You see, their sole revenue structure does not come from general medical, surgical and dental services, it comes from the shots…and so they are going to plug your pet with very vaccine known to veterinary medicine and do it every year even if research proves 3 year protection.  For full service general practices, vaccines represent such a small percentage of overall gross yearly revenue, that there is little motivation to give your pet anything but what its lifestyle and current medical research indicates.  For my practice, vaccine revenue only represented 3% gross revenue for the entire 2012 calendar year.

Giving Shots to Sick Pets Can Make Them Sicker

In my practice, before giving vaccines, we give a full comprehensive examination, temperature reading, heartworm screening (dogs only), and blood pressure (on pets 7 years or older) reading prior to giving vaccines, for good reason.  Vaccines act by mimicking the disease they are meant to protect for, by stimulating the immune system to mount a protective immune response.  That process causes a temporary stress on the body, and we really need to know we have a healthy patient that can tolerate stated stress.  Plugging pets with multiple vaccines without any sort of examination is therefore a potentially dangerous gamble.

Pet Owners Think They Are Saving Money, But In Many Cases They Ultimately Are Not

By skipping well care and getting shots from a shot wagon or discount facility, once disease manifestation is so bad that the pet actually shows it and you end up in a practice like mine for treatment, not only could it be too late at that point, but if the disease is still treatable, it is often so advanced that to treat the disease, it is so much more costly than if it had been managed earlier after having been detected on routine wellness visits.

I will leave you with this last example.  Very nice lady and her husband brought one of her many shih tzu dogs into my office about 3 years ago with a swollen mandible (lower jaw).  I discovered that the dog had an oral abscess from a rotten tooth.  In addition to the abscessed tooth, the rest of the mouth was in barely better condition, with bleeding gums, severe tartar, and pus along the gum/tooth margins.  Worst of all, the infection in the mandible was so bad, that the bone had fractured – an incident we term pathological fracture.

To repair this dog’s problem, I ultimately had to perform a highly technical and invasive salvage procedure called a hemi-mandibulectomy.  I also had to pull 12 additional teeth because they were so far beyond repair, while hospitalizing the dog for 3 days to clear a secondary infection he had developed in his kidneys from the dental infection.  All said an done, the owners ended up spending $3600 dollars, whereas regular wellness and periodic dental cleanings would have cost less than half of that spread out through the course of this dog’s life to date (he was 10 years old); and spared the dog allot of unnecessary suffering.

His owners are wonderful people who meant no harm to their dog.  Like so many others, they just assumed their dog was fine…after all, he wasn’t showing any signs of pain.  Guess who now brings their dogs for wellness visits every year without fail?

Dr. Roger Welton is the President of Maybeck Animal Hospital in West Melbourne, FL and founder/CEO of Web-DVM.net.