A conversation with an administrator at a local animal shelter the other day reminded me just how un-progressive veterinary medicine is here on Long Island.  First, a little background information: A couple of years ago, I agreed to perform some spays and neuters for the town shelter at a reduced rate.  Basically, we were doing them for free.  Our monetary compensation for these surgeries barely covered the costs of all the administrative paperwork that goes along with any operation.  Since I refused to lower my standards of care for the shelter animals, I ended up eating the cost of pre-anesthetic blood testing, pain killers and intravenous fluids for every single shelter dog and cat that ever came through here.  In my mind (at the time) it was a small price to pay for doing the right thing.  The real payoff, however, was the prospect of gaining a new patient/client.  The new adoptive owners would come to the hospital to pick up their freshly neutered pet and realize how wonderful our facility was compared to their current animal hospital of choice.

So how well did that pan out?  Not so well.  It turned out that more than 75% of the animals we received from the shelter did not have an owner yet.  The shelter wanted to get the animals spayed and neutered before adopting them out.  So we never had an opportunity to meet or speak with most of these new owners.  In the end, we performed several hundred surgeries (costing us tens of thousands of dollars in labor, medication and supplies) and gained …about eight new clients.  It was not a mutually beneficial arrangement, so we stopped receiving these dogs and cats from the shelter.

Fast forward to 2010.  I met with a shelter administrator who want to know if I would be interested in renewing my contract with the county.  Here is how our conversation went:

“Actually, I may want to do some dog spays for you this summer.  I’m learning how to do laparoscopic spays at the University of Georgia and…”
“Let me stop you right there.  Another veterinarian approached us with the same thing last week. We’re just not interested.”
“What do you mean?”
“We just don’t want to get involved with something so new.”
“Minimally invasive surgery is hardly new.  This is the new standard of care in humans and some veterinarians have been doing it like this for years.”
“We just don’t want to get involved.”
“So you’re turning down an opportunity to get a more progressive, more expensive, less invasive, less painful surgery done at …at the same price to you?”
“Well, what’s involved? Do you still remove the ovaries?”

At this point it be came very apparent that judgment had been passed on the procedure without knowing a single thing about it.

“Yes, both ovaries are still removed.  That’s what makes a spay a spay.  Typically, the uterus is left in.  This can be done with two or sometimes one small incision.”
“OK. I see… Well, we talked to our other veterinarians and they all said that laparoscopic spays were not a good idea for our dogs here.”
“Which veterinarians said this?”
“I’m not at liberty to say specifically.  Just the veterinarians who do our spays for us.”
“They’re wrong. This is just another glaring example of how backwards veterinarians are around here!”

Yup, I said that out loud.  What I managed to hold back were my thoughts of how many swollen, infected and painful surgery sites I have seen on patients spayed via the shelter over the past few years.  A shameful display of high-volume, low-cost negligence.

“Well maybe we’ll change our minds.  Things may change in six months if everyone starts to jump on the bandwagon with this laparoscopic stuff…”
“Unfortunately that will never happen.  You don’t just decide one day to start doing laparoscopic surgery.  You need to get sufficient training, then you need to invest in $10-30,000 of equipment.”
“So you just wanted to practice on some shelter dogs?”
“For lack of a better word, yes. Every dog I spay for you has a greater than 50% chance of being euthanized once you bring her back to the shelter.  I figured you might want to do whatever it takes to get them up and ready for adoption as quickly as possible.”
“Yeah, well …we just can’t let you do that.”

No situation has bothered me more than a recent clash between my consulting dog trainers and some other veterinarians on Long Island.  Responsible owners of several puppies have enrolled for Puppy Kindergarden (socialization) classes -but their veterinarians have advised them not to bring their puppies until they are “fully vaccinated.”  Perhaps these other veterinarians are afraid of losing their clients to me (the puppy classes are at my facility).  More likely, these veterinarians have just proven that they simply do not understand the importance of early socialization or the real-world risks of infectious disease transmission between healthy dogs.

Here are the facts:

• Behavior problems are the #1 reason why dogs are surrendered to animal shelters.
• This, in turn, makes behavioral issues the number one cause of death for dogs under three years of age.
• The overwhelming majority of these behavior problems can be either corrected or prevented in the first place.
• The socialization period of dogs ends at around 12-14 weeks of age.
• Most puppies will not be “fully vaccinated” until they reach 16 weeks of age.
• The risk of death from Parvo or Distemper infection is far less than the risk of death due to a behavior problem.

Properly socializing puppies and protecting them from infectious disease do not have to mutually exclusive.  Can I guarantee that no puppy will ever get sick at on of my classes? Of course not.  But this is not just a random gathering of puppies at a local dog park.  All puppies that enroll in our puppy classes are carefully screened to minimize the spread of disease among classmates:

• New puppies must have spent at least 14 days in the home of their new owner.
• Puppies must have received at least one round of Distemper-Adenovirus-Parvo vaccine following a complete physical examination by a veterinarian.
• Puppies must have received an intranasal vaccination for Bordetella-Parainfluenza.
• Puppies must have a documented fecal examination with a negative result.
• Puppies must be free of any obvious clinical signs of infectious disease, including coughing and sneezing.

If veterinarians continue to ignore the facts and insist on a complete vaccination series before puppies are allowed out of a home quarantine …they will be directly responsible for increasing the population of shelter dogs.  It’s time to live up to our Veterinary Oath and actually use our scientific knowledge and skills for the benefit of society through the protection of animal health, and the relief of animal suffering…

I’m not alone in this fight against antiquated vaccination vs. socialization viewpoint.  Here are a couple of expert links:
http://www.vet.purdue.edu/animalbehavior/forms/pc_letter_vacc.pdf
http://www.avsabonline.org/avsabonline/images/stories/Position_Statements/puppy%20socialization.pdf

Here are some highlights of the owner’s rant:

“I brought my dogs to you because I thought you’d be better than my last vet.  You did a good job with my other dog, but I’m questioning you about this one!”

“How much is it gonna cost for you to look at my dog?  You already took $1000 from me and now I’m broke.”

“So you’ll be able to look at my dog and tell me what’s wrong, right?”

“My wife worked for a doctor and she told me that those tests you charged so much for only cost about $10.  It’s ridiculous that you mark it up so much! You don’t need to charge me for any additional tests you run.”

“Doesn’t the fact that I already spent $1000 there mean anything?”

Here are my responses, directed to only to this owner in particular, but to all veterinary clients out there:

1) Question me all you want.  A good veterinarian doesn’t mind being questioned.  I have always welcomed second opinions from a specialist to confirm my diagnosis.

2) I did not “take” $100o from anyone.  I did perform a number of important and informative diagnostic tests.  Costs were discussed and consent forms were signed along the way.  I charged a fair amount for the procedures done and have spent a fair amount of time explaining and interpreting all of the results with the owner.

3) It’s certainly possible that I can reach a diagnosis for the dog’s current condition based on physical examination findings.  However, the physical exam is often just one piece of the puzzle.

4) My laboratory bill would be much much smaller if all of my tests only cost me $10!  I will readily admit that there can be a substantial markup on some diagnostic blood tests, but not the 10x markup that this client was suggesting.  Besides, the charge for any individual test is not based solely on the wholesale cost of the test.  If a client wants to figure out what tests need to be run, draw their pet’s own blood samples, ship them to the lab, and then interpret all the results …then I could just have a small fixed markup on the test itself.  The fact is, clients don’t pay for the test per se.  They pay for the sample collection and interpretation.  Otherwise, it’s just a bunch of meaningless numbers.

5) I appreciate any and all business from my clients.  I have told my staff in the past “Treat each client as if they are giving you your paycheck -because they are.”  It doesn’t matter if you spent $100 or $1000, my commitment is to the well-being of the patient.  However, money previously spent at the hospital is for services already rendered.  It can’t be used to “buy” any freebies or discounts on future services.  If I discount a client’s next bill by $100 because she spent $1000 at the hospital last month …doesn’t that just mean that I over-charged her by $100 last month?  Am I crazy for thinking this way?

The following article was sent to me by a client this morning.  Good to finally hear that action is being taken against some of these people…

By BARBARA LEONARD

MINEOLA (CN) – Queens-based pet dealers use bait-and-switch tactics to sell unfit dogs, and violate charities law by “purport(ing) to engage in animal rescue activities,” New York Attorney General Andrew Cuomo says.

Cuomo says the husband and wife’s two businesses, Imported Quality Guard Dogs and the Animal Rescue Unit, “engage in deceptive business practices and false advertising” and violate “the Pet Lemon Law.”

Defendants Robin Schulder and her husband, Perry Reich, falsely claim to be dog breeders, make “numerous misrepresentations” about their animals, and falsify health records of the dogs, Cuomo says. He adds that Schulder practices as a veterinarian without a license, and makes improper use of the title “veterinarian technician.”

Cuomo says his office has received 13 complaints against the couple and their companies. Consumers also have complained to the New York Better Business Bureau, the agriculture department and the American Society for the Prevention of Cruelty to Animals.
The couple operates more than a dozen Web sites that lure consumers with empty promises, such as “all our babies are born in our home,” according to the complaint.

The sites list puppies with pictures, names, weight, sex, age, price and availability, but Schulder delivers a “markedly different” dog, according to the complaint.

Despite their claims, Cuomo says, the couple resells dogs they bought from third parties.

“Numerous customers purchased animals that suffered from illnesses ranging from parvo, coccidian, mange, acute respiratory infection, pneumonia and life-threatening hypoglycemia,” according to the complaint.

Some consumers pay up to $3,000 in veterinary bills “trying to nurse the animals back to health,” but one dog died and two had to be euthanized because of severe medical issues, according to the attorney general.

Cuomo says the couple delivers dogs with visible defects, including deformed limbs and blindness, as well as signs of illness such as coughing, sneezing, bloody stool or vomiting.

When consumers demand reimbursement for veterinary care or try to return a puppy, Cuomo says, Schulder becomes verbally abusive, “lashing out at them with vicious obscenities, and blaming them for their dogs’ illnesses or death.”

Cuomo says that Schulder once answered the door holding a large kitchen knife, and when a veterinarian diagnosed a puppy with congenital blindness, Schulder insisted that the consumer had dropped the puppy on its head.

Cuomo adds that one of their Web sites claims: “‘Some of our puppies are imported from our family-owned kennel in Europe.’ This is an outright lie. Respondents do not have a family-owned kennel in Europe.”

They claim their “No-Kill Animal Shelter” has rescued dogs throughout New York’s five boroughs and has “over 2,000 supporters and donators,” but Cuomo says they “have been unable, however, to produce any records whatsoever identifying any dogs they have rescued, and admit that their ‘animal rescue charity,’ the Animal Rescue Unit Inc., is inactive.”

Cuomo seeks an injunction, accounting, restitution and civil penalties.

While most dog trainers will charge by the hour or by the lesson, his company charges one price for the life of the dog.  If everything I ever need to know I learned in kindergarten …even kindergarten lasted for more than a handful of 30 minute lessons.  Same thing applies to dogs.  And yet dog owners continue to attempt to rehabilitate their humping, jumping, runaway canines in 4-lessons-for-$150.  But what about the well behaved pooch who just needs some finishing work? Maybe those dogs and their owners really do only need a handful of lessons to get the ball rolling.  So can a premium dog training company offer that as an option without diluting their brand or contradicting the values they preach to their premium training clients?

After our conversation, we agreed it could be done, as long as it was marketed smartly and tactfully.  It worked for other companies: Nobu has Nobu Next Door.  Georgio Armani has Armani Exchange.  Saks Fifth Avenue has Saks Off 5^th.  Even Porsche once sold the 924.

Could that model ever work for a veterinary hospital?  I sure hope not.  Low-cost veterinary care –unless subsidized by some sort of private or public funding –is often low-quality veterinary care.  Ask any doctor if they can maintain their level of patient care if their operating budget is slashed by 50%.  High profit medical care is only sustainable if there are profits to support it.  Even if doctors donated their time, there are still many other costs to consider: experienced (and well-paid) support staff, medications, laboratory testing, patient monitoring equipment, needles, syringes, fluids, etc…

Let’s look at a simple example of two different veterinarians in the same town who are charging vastly different prices to spay your cat.  One may charge upwards of $275 and the other may quote less than $75.  (These numbers are not entirely made up –I’ve seen this in both the San Francisco Bay are and the New York City Metro area.)  For argument’s sake, let’s assume that both doctors possess the same surgical experience and skills.  What then makes up for the difference?  Can the cheaper veterinarian offer pre-anesthetic blood testing, intravenous fluids, and pain killers at that price?  Is the less expensive hospital utilizing the same level of patient monitors, and are they paying an experienced anesthetist to monitor the cat while the doctor has his hands inside?  On the flip side, how can you know that the more expensive doctor is doing all these things?  The best you can do is ask.

There is indeed a minimum standard of care that every doctor should be providing.  Unfortunately, not everyone agrees on what this minimum level is –and either way, many veterinarians out there don’t make the grade.  Some just don’t care and the rest can’t afford to because they’re not charging enough.

I suppose I can blame my parents for this.  I never got rewarded for getting a 100 on a math or spelling test.  If I got a 98, I knew I’d have to answer the question “Where did the other 2 points go?”  I was expected to do a good job.  And I was punished if I did poorly.  No, they never beat me -they just gave me more work.  Since my mom’s an accountant, it was pretty easy for her to whip up a weekend’s worth of math problems for me.  And I recall some nights of memorizing sections of a dictionary.

Despite all of this, I think I turned out relatively OK.  But I still admittedly have a hard time wrapping my head around praising my staff for doing their job.  Isn’t that what I pay them to do?  If they didn’t do a good job, they wouldn’t be working for me.  About a year and a half ago, I hired a nursing supervisor to help manage my medical staff.  While I was hoping for someone to complement my “flawed” management philosophy, I ended up with a fantastic technician who expects perfection from all of her staff.  Surely there is no abundance of warm fuzzies here.

I’ve also told my staff many times that I HATE the phrase “Don’t sweat the small stuff.”  We get paid to sweat the small stuff so that our clients don’t have to.  Instead I like the phrase “The devil is in the details.” I don’t run laundromat or a shoe store -small errors and oversights can mean the difference between life and death.  All of my staff needs to understand that every single one of their decisions and actions (or inactions) can affect patient care.  Every action carries a consequence, and some consequences are more significant than others.  So if a receptionist misspells diarrhea, or a kennel assistant checks off the wrong box on a checklist, or a technician reached for prednisolone instead of prednisone …I will continue to react quickly to point out their mistakes.  If they can’t handle that, they can certainly try to find a job working for a veterinarian who doesn’t care.

That being said, I have a pretty happy bunch in the hospital and not very much turnover.  Would it kill me to say “good job” more often? Probably not, but it’s so against my nature to do that.  And wouldn’t it mean a lot more if I did praise someone when they really went above and beyond the call of duty?

Here is the problem: Most of the owners of my overweight patients don’t think their pets are overweight.  It’s not that they’re not in denial of the problem (ok, some are) -they’re completely oblivious to it.  A good portion of the owners think their plump playmates look cute when they’re chubby (I’m sure that 1600 pound guy was thinking about how cute he looked while being lifted out of his apartment by a crane).  Another group of owners readily admit to owning a fat dog but still insist on feeding table scraps and treats on top of their expensive low-calorie food (kinda like ordering a Diet Coke with your Big Mac).

Every year, i see at least half a dozen articles in various journals suggesting different techniques to talk to my clients about their pets being overweight.  All of these articles would like me to tiptoe around the issue when the owners themselves are also visibly obese.  I guess I’m not supposed to offend anyone with my medical diagnoses.   And I guess I’m a bad person for ignoring all of this advice because here’s reality as I see it:  My clients pay me for an accurate diagnosis and to be an advocate for their pets.  If I walk into a room and see a 20 pound chihuahua or a 70 pound beagle, I’m going to say something. Period.  And it’s going to be blunt.  It doesn’t matter how big or small the owner is because, honestly, I don’t care.  They can talk all they want about their weight with their own physicians.  Unless you’re covered in hair and walking around on all fours, your medical problems are completely out of my jurisdiction.

Once the problem is identified and accepted, then there’s a basic mathematical issue.  Being 5 lbs overweight may not seem like a big deal, but what if you’re only supposed to weigh 10 pounds (or 5 pounds!)?  Putting the numbers in perspective: if you have a cat whose ideal weight is 10 pounds, but she actually weighs 15 pounds …that’s like a human female being 60+ pounds overweight (if her ideal weight is 120).

So how do we shed the pounds?  Again, I will refer to a very simple equation.  You must burn more calories than you consume in order to lose weight.  If you even eat one more measly calorie than you burn off (via breathing, walking, exercising, etc.), you will never ever ever lose any weight.  Ever.  Of course this is easier said than done, especially considering that obese people/dogs/cats have a harder time feeling satisfied after a meal and have slower metabolisms.  Yes, it’s a slippery slope.

The saving grace with treating your obese pet is that you don’t need to deal with any will power issues.  Yes, you may feel issues of guilt for putting your little friend on a diet, but I can’t help you with that.  And yes, some dogs will begin some very destructive behaviors if they are hungry and “hunting” for food in your garbage cans and cupboards -but good training and judicious use of gates and crates will help with that.  But if you just follow the simple feeding guidelines that are given to you by your veterinarian (NOT the chart printed on the back of the food bag), I can practically guarantee success -and your pets will live longer, happier, healthier lives.

One of our exhibitors at the Expo was a local rescue organization called Last Hope.  I saw at least one client take out his checkbook to contribute to them.  For Animals In The Hospital (FAITH) also had  a table set up at our event, and they collected some much-needed donations.  Another local rescue group was supposed to be in attendance, but canceled at the last minute because the members needed to attend a bigger event in Baltimore.  They inexplicably barred all of their volunteers from attending the Open House to solicit any donations, but we won’t get into that here…

Unless you live in a cave, you have at some point been asked to donate to some charitable organization.  And at least a few of these organizations are animal related.  Who deserves your hard earned dollar? Is there anyone who doesn’t?  What questions should you ask before donating?

1. Does the organization’s mission accurately represent your own values and beliefs?
2. Does the organization (and do its members) operate in a manner that meets your personal moral standards?
3. Where does the money go?  Administrative costs? Research? Directly to animal care?
4. What are the organization’s other sources of funding?
5. Is the organization legitimately registered as a not-for-profit group?
6. Do the leaders of the organization truly live by their mission, or are they there for some other ulterior or self-serving motive?

These are the few I could come up with off the top of my head, but I invite you to leave your own crieteria in the comments section.  And if you have any favorite animal charities, please post their link (or at least a name).  If you have a not-so-good rescue group, please share with us why they’re on your bad list.

But is it really the same surgery?  What do you get for the extra one or two  (or three!) thousand dollars you’ll spend with a surgical specialist?  Here’s what I usually tell my clients: “You may be able to find another general practitioner who can do this surgery for half the cost, but keep in mind that that doctor may only do this type of procedure a few times a year.  A specialist has probably done it a couple of times this week.  Surgeons are also much better trained and equipped to deal with any unforeseen complications that arise during the course of surgery.  Your pet will also be monitored overnight in most cases.”

That speech usually puts my clients more at ease about paying a stranger several thousand dollars to cut open their pet.  As veterinary medicine moves more towards specialization, more and more younger doctors (at least those lucky enough to have specialists in close proximity) will give up on trying to do everything for every animal.  But right now just about every general practitioner will perform some sort surgery during the course of their work week.  It could be limited to spays, neuters and lumps/bumps …but it’s certainly not uncommon to see a general practitioner perform a limb amputation or splenectomy or even a perineal urethrostomy.  I know of one gp in New York City who enjoys brain surgery.  What makes these doctors qualified to do these things?  It’s a combination of things: training, experience, confidence, and the right hospital resources and equipment.  But honestly (and there’s no way to say this nicely) some of these veterinarians are barely qualified to give your pet a rabies vaccine.

I have a few physician friends who are bariatric surgeons.  On their websites, they tout that they’ve done “over 700 bariatric cases” or “approximately 2500 operations overall, including residency & fellowship.”  I think it’s about time pet owners start asking their veterinarians “How many times have you done this procedure?”  It’s then up to you to decide what the magic number is.  At what point does your pet become a bona fide surgical patient rather than “practice” for an inexperienced doctor or, even worse, someone’s “experiment?”

Other questions and issue to consider: What are the most common complications with this surgery?  How will the patient be monitored while under anesthesia? How will the patient be cared for post-operatively and overnight?  What sort of pain management will be used in this case?

For more information on what it takes to become a board certified veterinary surgeon, visit: www.acvs.org/AnimalOwners/WhatisaBoardCertifiedSurgeon/