Translate This Blog

Thursday, January 26, 2017

Realistic Dog Model To Replace Cadavers

I came across this article last year, but never got around to writing about it.  It's pretty cool!

A company, SynDaver, has created realistic dog models for veterinary schools.  The intent is to replace cadavers used in veterinary studies, as well as live animal surgeries.  Here is a quote from the article:

The synthetic cadaver is made of water, fiber and salt. Each cadaver is anatomically correct and features lifelike fat, fascia planes, bones, muscles, ligaments, joints and all body systems.
The skinless dog not only mimics the feeling of living tissue but breathes, has a heartbeat and can be programmed to simulate various diseases and medical complications. The skin even bleeds when surgical cuts are made, since the cadaver has a circulatory system.

I would be very curious to try one of these out myself!  I love the idea, and agree with the concept of trying to reduce procedures done on living animals.  However, a surgery on a model, no matter how sophisticated, can't duplicate the feel and circumstances of a living animal.  Is it close enough to be comparable for training purposes?  I don't know, and I'm hopeful that it would be.  

Similar models are used in human medicine, so this may be something that would be very useful for veterinary students.  If nothing else it's a great step in the right direction, and shows how far technology has come, as well as where it can help us in the future.

Monday, January 23, 2017

The Growth Of Corporate Veterinary Medicine

A few weeks ago a small bombshell hit the veterinary community.  Mars, Inc. announced that they were buying Veterinary Centers of America (VCA) and their subsidiaries.  And this has fueled strong discussions and great concern in the profession in the US.

To anyone not in the veterinary field the significance of this will likely be lost so let me give some details and perspective.  Mars is the largest privately owned company in the world and spans every continent. The company was started by the Mars family and is still  run by that family, now in the fourth and fifth generations after the founders.  Most people know them for their candy products, such as M&Ms, Snickers, and other classics.  But over time they have bought up many other companies, gaining access to their product lines.  To get an idea of the incredible number of human and animal products they make, head over to the Wikipedia entry on them.

Several years ago Mars bought all controlling interest in Banfield Pet Hospitals.  This is a national veterinary chain, primarily based in PetSmart stores, currently with over 900 locations across the US.  Last year Mars bought BluePearl, a chain of specialty and referral clinics with over 50 locations, and Pet Partners, a smaller corporation with over 50 vet clinics.  This month they announced the purchase of VCA, which gives them nearly 800 clinics around the country.   VCA also owns Antech Diagnostics, which is the largest veterinary diagnostic lab in the US, serving a majority of veterinarians across the country.  By the end of this year the Mars company will own nearly 2000 veterinary clinics as well as a huge diagnostic laboratory.  This is unheard of and unparalleled in the history of veterinary medicine.

Historically a veterinary clinic has been owned by one doctor or a small group of partners.  Over the last 20-30 years we have seen a rise of large corporations such as Banfield and VCA, as well as smaller regional or local corporations that may have anywhere from a dozen or two to a hundred or more.  While the two biggest companies gain most of the publicity and concern, there are many other smaller corporations out there (such as Pet Partners, now owned by Mars).  But even with these companies the vast majority of veterinary practices are owned as a single location and not a conglomeration.  Though Mars will own a large number of clinics, larger than any other company in history, they will control only about 6% of the practices in the US. 

In my experience veterinarians as a whole are very strong-willed, independent people.  When I was going through school we knew that the majority of the people graduating would go on to be owners or partners of a small animal clinic.  This is still the case, but the patterns are changing.  Historically it was almost an expectation that after practicing for a while a vet would buy into that clinic or open their own.  But the younger generations of vets are less interested in being business owners, and are more interested in flexible schedules and quality of life outside of work.  The younger vets simply don't want to have to work the 60+ hours per week that generations past saw as normal.  I can't blame them.  This shift is in part due to generational differences, but are also because the profession is skewing highly female and many of these doctors want the freedom to raise families without having to worry about running a business.  While there are certainly still many vets who want to have a clinic of their own, and can run them successfully even with kids and a spouse, we are seeing fewer vets who want to go this route.

To these younger vets a corporation can seem very appealing.  They can get a good salary, have a degree of flexibility with their work schedules, and simply never have to worry about taking out loans (on top of the ones from school) to start a clinic.  They get to simply be a vet for their life, which is all that many of them want.  A corporation, especially the larger ones, gives them the structure and freedom to have this lifestyle.

I've been following discussions on the Veterinary Information Network (VIN) and other sites.  While there are some people who shrug and don't care about the growing Mars hold on our profession, there are others who are significantly worried about it.  Here are some comments I've seen online.

"My big concern with the acquisition is this: Who owns our profession now? I would argue that as of the drying of the ink on the Mars VCA deal veterinarians no longer have a profession. Now Mars Co which is in essence just a very wealthy family (who so far as I know are not veterinarians) are going to be substantiatively guiding our profession. We are now going to take our professional direction from the kings of candy. We have entered the new future of veterinary medicine not as a profession but rather as a trade in which each veterinarian is now a production unit." 

"Essentially, if there is one player who owns a significant portion of the market, they will be able to dictate the conditions of how you practice, what your treatment recommendations would be, what products you use, and who you refer to."

"There will be little room for dissent once the vertical integration is established. How are you going to say no when the other 75% of practices in your town are effectively owned by the same entity? There has always been the ability to move to another practice if you did not agree with management or philosophy of your current place of employment. This luxury may not be as available in the future."

"I would like to see my clients have choices. I would like to have choices about where I am able to refer clients for advanced care. Unfortunately the only emergency facilities around me for hundreds.....yes hundreds of miles are VCA or are in the process of becoming VCA."

"I don't like feeling like I'm speaking for everyone, but in my case it doesn't matter that Mars/Banfield bought VCA - it could be VCA buying Banfield and Blue Pearl. It could be Apple, or Google, or GM, or Lockheed Martin buying VCA and Banfield. My problem is not with who is doing the buying, but the buying and consolidation under one (albeit big) roof is happening - and veterinarians aren't going to be driving the company."  

"While it may be true that Mars will control less than 10 %of the veterinary hospitals in the nation what I see on a local scale is unmitigated Monopoly."

"While I cannot discuss my prices with my local practice owners, the VCA's and Banfields are more than able and in my experience willing to price fix a geographic area. Combine that with limited exit strategies to sell my practice, the increased cost of drugs, health insurance etc on a unit basis due to economies of scale ......I can tell you I am concerned.....very concerned. I can tell you that when individuals ask me if I would make the same decision to pursue veterinary medicine as a career today as I did twenty some years a tech and then as a doctor. The answer is no...emphatically no."

"I find the corporate takeover (though limited at this time) of our profession a tragic occurrence for future Veterinarians. As corporations control more of the profession we will become more of a cog in the machine and easily replaceable. I always looked at practice ownership as the means to improve my financial position in life as owners do make more money than employees. If this trend continues that will no longer be an option for future veterinarians to better their position and, at least to me, it seems to severely limit their financial future. Is Veterinary medicine doomed to become the "second" family income and no longer an option as the primary family income?"

 But not everyone is so "doom and gloom".

"In the 10+ years I've been on VIN I've been reading threads about the certain and imminent doom of the profession at the hands of Banfield and VCA. Here we are 10 years later and they still have only 6.5% of the market COMBINED. I think we have the best of both worlds as a profession. The profession has a enough economic upside to be seen as a desirable asset to large companies, yet the vast majority of it is privately owned."

"Mars is not the boogey man, they are a large company interested in profit that pursues other successful companies within their areas of interest and expertise. Personally I think smaller private equity firms are going to have a bigger impact on our profession's ownership over the next 20 years than one corporate player. No one talks about those deals though because they are invisible. (the clinic's name doesn't change)."

"I think we're all going to be just fine, and I say this a practice owner surrounded by corporate practices. They were private clinics before (with the exception of a Petsmart Banfield) and now that they are corporately owned that just provides an extra differentiator ("locally-owned practice") for me that wasn't there before. In any case it's counter productive to think that veterinary practice owners-- uniquely among American small business owners--ought not to have to contend with corporate competition."

"A few years ago at a dinner party at a friends house, another guest was some big, mucky muck who ran in house seminars for Mars. It was his only job; setting up and conducting management seminars all over the country for Mars. He had a second home in Italy, so I gathered it paid well. We sat next to each other over dinner. He was fascinating and I gained a great deal of respect for how Mars operated. This might have been before Mars bought Banfield....I want to say Mars was always a financier of Banfield....but this would have been around 2002-3. Anyway, I've always been impressed with whatever mars has done. They look like they know what they're doing."

"It's easy to blame Banfield because it's corporate and ubiquitous, but as said above, you will find plenty of questionable things happening at private practices as well - but it seems like if a doctor in private practice does questionable things, it gets blamed on the doctor. If a doctor does something questionable at Banfield, then Banfield gets blamed - not the doctor."

As you can see there are some pretty passionate views on these events.  Many people are genuinely worried for themselves and the profession as a whole, and some see this as the worst thing to have ever happened.  Others simply aren't worried.

So what's my take on this?

First, I certainly don't subscribe to the opinion that all hope is lost and the profession is ending.  I think that there are pros and cons to corporations owning veterinary practices.  These companies often have better negotiating and purchasing power which allows them to manage costs more easily and give higher salaries and better benefits than a privately owned practice.  There is more lateral and upward mobility for the veterinarians.  They provide some consistency and guidelines for practicing vets.  But they can be limiting in flexibility for an individual doctor.  Sometimes the leaders can be unfeeling because they don't have a good understanding of day-to-day challenges.  Change is often slow and difficult, unlike a private practice owner who can suddenly decide to buy a new chemistry analyzer.

I firmly believe that no veterinary practice is going to be perfect for everyone.  I've seen privately owned clinics that are far stricter on dress codes, behavior, and medical choices than either VCA or Banfield.  I know that vets who want their own practice or more independence will not be happy with a corporate environment.  Doctors who only want to practice and never want to be owners or partners will be happy to turn over all business responsibilities and worries to someone else.  A place that is a perfect fit for one person may be only manageable for another and be complete misery for someone else.

Our profession is changing, and doing so pretty rapidly.  The demographics of who attends veterinary school has altered dramatically in the last 30 years.  Within the last 60 years we have moved more and more from a rural to a suburban and urban outlook, with an increasingly smaller percentage of new graduates choosing to go into large animal medicine.  The growth of the internet has seen a noticeable shift towards clients purchasing medications and preventative products online rather than buying them from the local vet.  I would say that the internet has been a bigger problem for all kinds of businesses than any large corporation has.

In the US corporately owned veterinary practices aren't going away.  But I don't see them becoming so large and all-encompassing that they wipe out the traditional privately owned practices.  Just as there is room for chain restaurants and "mom and pop" ones, there is room for private and corporate veterinary practices.  In fact, I think having both available gives veterinarians more choices about where they want to work.

Friday, January 20, 2017

The High Cost Of Becoming A Vet

I haven't written about veterinary education costs in quite a while, and unfortunately there has been no improvement in the situation.  It is still extremely expensive to become a vet and salaries still remain very low, resulting in some significant challenges and hardships as young, new vets struggle to try and repay their loans while maintaining a moderate lifestyle.
Dr. Julie Funk, an Associate Dean and Professor at Michigan State University, recently wrote an article about this issue.  Here are some choice quotes. 
"A 2013 national survey of DVM graduates found the average debt for students was as high as US$162,113. This is similar to the average educational debt of $180,723 accrued by physicians in 2015. However, physicians have much higher lifetime earnings than veterinarians, making it easier for them to manage their debt.
It is true at the beginning of their careers, salaries for veterinarians and physicians are quite comparable: Veterinarians get, on average, a full-time starting salary of $67,136 annually. Physicians, who pursue residencies for advanced specialty training under supervision, soon after graduation, earn an average first-year salary of $52,200.
However, this changes over the years. The lifelong earning potential of physicians improves significantly in comparison with veterinarians. Over a period of time, the overall median salary of a physician gets to $187,200, whereas that of a veterinarian remains at about $88,490.
The situation is worse for women. Female veterinarians, on average, will not even break even on their educational investment until they are well past the age of 65 (or older)."
That last statement is particularly troubling since in the US 75-80% of veterinary classes are female.  How bad is it that they aren't likely to even break even on their education costs until they retire around 40 years later???
The future for veterinary students is not promising, as Dr. Funk points out later in the article.
"As a result of the growth in the colleges of veterinary medicine, more seats are available. (What is decreasing, however, is the applicant-to-seat ratio.) Two new colleges are seeking accreditation, while the existing ones are boosting class size. This expansion is happening in the face of the 2013 Veterinary Workforce Study that estimates that there is an excess of veterinary labor nationally.
High tuition, low wages, an oversupply of veterinarians and more seats to study veterinary medicine are strong signals of a veterinary education market bubble."
What these facts indicate is that's there are more people entering the field, yet on a national average there are more vets than are needed.  Colleges are increasing the number of students they accept and new schools are being built, yet there is no need to expand the number of newly graduated veterinarians.  In the end this may very well result in a glut of veterinarians, which could cause lower wages as employers can pick new hires who are willing to work for less and those new hires will accept it because there are fewer job opportunities.
For most of us veterinary medicine isn't just a job, it's a calling.  I started wanting to be a vet when I was nine years old, and that's typical of most of us in the profession.  When your heart desires something so strongly it becomes hard to resist and look at the reality of the situation. 
The veterinary colleges and national organizations have had numerous discussions, debates, panels, and reports over the last 10 years or so, but so far all I've seen is more of the same information and confirmation of previous information.  For many years we keep seeing the outcome of these various studies as "Yep, debt is worse, salaries are no better, the problem is literally a crisis, and it's not getting better in the near future."  Well, we know that by now.  What we're lacking in the profession is a consensus of how to solve this crisis.  Maybe we should be shrinking class size rather than expanding them.  Maybe we should be closing schools rather than opening new ones.  Perhaps if there were fewer vets entering the workforce we would see salaries rise as competition increased. 
Some have suggested looking at a model where an undergraduate and graduate degree are obtained at the same time.  Currently virtually everyone first spends an average of four years obtaining a Bachelor's degree, then another four years for their veterinary doctorate.  Much of that undergraduate education is spent on classes intended to make someone well rounded but that doesn't have anything to do with the career.  I took two semesters of calculus in college, but I couldn't tell you what I learned or how it might be useful.  I can guarantee that in 20 years as a vet I've never had any cause to use the information in those classes.  As much as I enjoyed my literature and history courses they really have never applied to my career.  If the first 2-3 years of college were strictly pre-veterinary courses and then the last 3-4 years were on veterinary education itself you could reduce the time to become a vet by about two years.  That means two years of tuition and other expenses that you don't have to pay, and don't go into debt over!  Make the education year-round without summers off and some have speculated that you could become a vet in as little as five years!  There are pros and cons to this proposal, but it's one being considered.  Unfortunately I don't think it would be accepted by the majority of veterinary colleges or the veterinary licensing entities, so something like this in the US is probably a long way off.
I know that it's very depressing and disheartening, but I honestly can't recommend this as a good time to go into veterinary medicine.  Student debt load is quickly increasing while at the same time starting salaries are stagnant or even decreasing.  These horrible facts are not likely to change in the next few years.  I know that young people with a passion to be a vet will read these words and potentially despair.  Yes, the future is a little bleak if you haven't actually become a vet yet.  If someone still chooses to follow that dream I would strongly encourage them to be VERY good at budgeting, realize the huge amount of debt they will have coming out, and even consult a professional financial planner.
I'm just glad I graduated 20 years ago when it wasn't nearly as bad as it is now.

Wednesday, January 18, 2017

Poisonous Plants To Keep Away From Pets

Recently contacted me about an infographic they have on their website which lists nearly 200 poisonous plants, how toxic they are, which parts or toxic, and which species to keep away from them.  Honestly, this is one of the best summaries I've ever seen, so I'm sharing it here.  Please pass this around to your friends and other pet owners.  If you're having a hard time viewing it, click on the original link above.

Saturday, January 14, 2017

What To Do With FIV Positive Cats

A few weeks ago I received the following email:
We just had a stray cat euthanized because he had FIV and the vet recommend this because we couldn't bring him in with out cats and we couldn't keep him outside to spread the disease and he would have been hard to adopt out because of the FIV and he was a fighter.  He was sweet to us but had been in fights with area cats.  I am feeling extreme guilt over this.  Did we do the right thing?  It seems like we did what was best for us and maybe not the cat.  I am devastated and am feeling like a horrible person.
I've had this exact same situation come up a few times in the past.  It's never easy to handle, and always a tough decision.
Feline immunodeficiency virus (FIV) is very similar to HIV in humans.  In fact, some veterinary researchers on the disease have collaborated with HIV researchers and vice-versa.  The virus can lay dormant in a body for years and become active at any time.  Once it activates and affects the body it proceeds very similar to AIDS in humans, suppressing the immune system, lowering white blood cell counts, and making the patient much more susceptible to infections.  When the virus starts along this path there really isn't anything we can do.  We don't have a wide range of antiviral drugs in animals like there are in humans, so essentially a diagnosis of FIV is a ticking time bomb and an eventual death sentence.
Once a diagnosis of FIV is made, the cat may live a few more weeks or several more years.  There is no way to predict what their lifespan will be.  But we know that they won't live as long as an uninfected cat and will be more prone to health problems.  At some point in the cat's life the virus will lead to its death.  Unfortunately there is currently no treatment or cure for FIV, so once a cat has it they are infected for life and are at risk of spreading it to other cats.
So what do you do when a cat is diagnosed?
I 100% feel that these cats need to be isolated indoors.  If you allow them to continue to roam outside they are most likely spreading the virus to other cats and therefore giving more animals a death sentence.  When they are "fighters" as in the email above this is much more likely, and every time it fights with another cat it is probably passing along FIV.  If a cat can be kept indoors they can still live a good life until they become seriously ill, and I've known many FIV positive cats who have lived more than five years indoors before succumbing to the disease.  So I don't think that a cat with FIV but no symptoms automatically needs to be euthanized.
Some people can't keep the cat inside for various reasons.  Maybe they have other cats, and there is certainly a risk of passing FIV to the ones that person already has.  Some outdoor cats won't tolerate being kept inside and will be destructive with scratching and spraying.  So there are certainly situations where that cat can't be kept in the home.
What do we do then?  We can't keep the cat inside, but we can't let it outside to be a vector of infection.
As harsh as it may sound, the best option is often humane euthanasia.
Stop and think about it.  Is keeping that cat alive worth having a dozen more cats develop FIV?  While it sounds pretty cold and unfeeling I do believe in this situation we have to look at the greater good and the potential for the most harm.  It is a bit of an ethical dilemma, but I personally think that gently ending the infected cat's life to prevent infection in 20 other cats is justifiable.  It's not easy, but it's the best option in a bad situation.
With a stray cat kept outside a person also not know when that animal becomes sick.  A cat with active FIV may slowly die a miserable death somewhere in the woods or under a porch.  Do we leave them outside to have this eventually happen, or do we give them a quick, peaceful death before they suffer?
I have euthanized a few FIV positive cats in the exact situation described in the email.  I haven't enjoyed it but I also haven't felt guilty about it afterwards.  I don't think any pet owner should feel bad about making this choice, even if it's not ideal.  In the words of Spock in Star Trek: The Wrath of Khan, "The needs of the many outweigh the needs of the few, or the one."

Wednesday, January 11, 2017

Predator Birds And Small Dogs

Here's a question that in over eight years of blogging I haven't been asked!
We saw a bald eagle fly over our house the other day.  We've also seen hawks and owls.  My concern is our 13 lb dog's safety.  I was wondering if she wore a piece of clothing outside if that would somehow make her look less like an animal they would want to pick up.  I was just looking online and found this page that mentions different products that are on the market.  Do you know if any of these products are helpful?  At the end of the article it said eagles can only pick up 4-5 lbs but other places I read much larger.  Would love to know your thoughts.
When you think of a large raptor such as a hawk or eagle, you wouldn't think of them as a potential concern for your pets.  After all, that's just Hollywood, right?  You might think of it happening in a movie such as The Proposal (Ryan Reynolds & Sandra Bullock) but not in real life.  Isn't it a myth?
I'm sorry to say that it's not.  While rare, birds of prey will occasionally try and take off with a small dog.  I've had at least one client who lost a small dog to a hawk.  So this is one that is definitely not a myth.
Bald eagles prefer fish over small mammals, but other kinds of eagles may have more variety in their diet so it depends on what is native to your area.  Hawks and owls do prefer small mammals, but will eat just about anything they can get their claws on.  Since some of the larger raptors feed on rabbits, which can weigh 4-6 pounds or more, a dog about that size certainly isn't safe.  I don't have information on exactly how much weight a large predatory bird can carry, so I'm not going to try and hazard a guess.  Keep in mind that they don't always carry their prey away, and sometimes will kill and eat it on the same place.
What can a pet owner do?  The link above is pretty interesting, and I think those products have some potential.  It's the first time I've ever heard of them so I can't say whether or not they are effective, and I've never known anyone to try them.  But if I had a small dog in this situation it sounds like it probably wouldn't hurt to give it a try.  I would be slightly skeptical that a reflective surface would always work, as I would imagine it being less effective on a very cloudy day.  But the dog probably wouldn't look like prey with this on, so that's a good thing.  If we're merely going by whether or not it looks like prey to a raptor, you might achieve a similar effect with a colorful shirt or jacket designed for dogs.
I do recommend being aware of the types of high level predators you might have in your area, and for birds I would be cautious with any dog or cat under 15 pounds.  Ones under 10 pounds are more at risk.  If you know you have hawks, eagles, and owls in the area I wouldn't let your dog go outside unsupervised, and if you are in a very rural area you may consider only ever taking your dog out on a leash.  A raptor isn't likely to try and kill or capture a dog when a human is a few feet away, and if for some reason it did happen you'd  have your dog on the leash, preventing the bird from flying away with him or her.
Those of you who have small dogs living in the same area as raptors, I wouldn't panic.  These predators tend to prefer hunting without humans nearby, so most dogs will be safe.  The risk exists, but even then the incidents of this happening are very rare.  I still recommend taking some precautions because you don't want to lose your dog to a situation like this.

Tuesday, January 3, 2017

Case Management--Anxiety, Fear, Then Relief

As I've mentioned before, most vets (and medical professionals in general) really do worry about their patients.  I know that I do.  It's not uncommon for me to fret over a case for days, especially if it's complicated or doesn't go well.  Most of the time it's not my fault if things go bad, but I will worry anyway because I'm my own worst critic.
One of the surgeries that I occasionally do is to correct "cherry eye".  For those not familiar with the disorder, it is common in certain breeds (English bulldogs, Shar-peis, Shih-tzus, and cocker spaniels are the most prone) and results when the tear gland under the third eyelid becomes inflamed and prolapses.  This causes a very obvious red, fleshy bump on the inside corner of the eye.  If untreated there is a risk of chronic inflammation and damage to the gland, which is responsible for the majority of tear production in the eye.  We don't want to remove the gland because we would decrease the tear film and cause dry eye problems.  The only real fix is surgery.
The most common method, and the one that I do, involves making an incision on either side of the gland, forming a pocket under the tissues, placing the gland within this pocket, and then closing the edges over the gland with sutures.  Because the eye is so sensitive we use very small suture material, typically about the thickness of a human hair or smaller.  While the surgery is typically successful there is about a 20-30% "failure" or recurrence rate even with the best surgeon.  The gland can re-prolapse because the suture breaks, the technique was poor, the tissues fail to heal, or the inflammation is too persistent.  Most of these reasons have nothing to do with the doctor, which is why the failure rate is so high compared to other surgeries.
I've been performing this procedure for all of my nearly 20 years in practice and have become pretty proficient with it.  Though I haven't specifically tracked the numbers I would say that my recurrence rate is around 20-25%, right within expectations.  Even so, I really hate it when one of my patients has a relapse and I worry about whether or not my technique was correct or if somehow I had failed as a surgeon which led to the failure of the surgery.
A couple of months ago I had that happen.  About three days after the surgery the client called to say that it had prolapsed again.  I had her bring the dog in and it looked like the suture had broken.  We would have to repeat the surgery, and I said that I'd give her a $100 discount on the second procedure due to the inconvenience.  Even though it didn't look like it was my fault, I worried about it, and started to doubt myself.  I promised that the next time I did this type of surgery I would be even more careful with my steps and method.
That opportunity came in late November, with a shar-pei puppy who had both glands prolapse.  When I did the surgery I was extra-careful about my incisions, suture placement, knots, and generally everything that I could potentially control.  The surgery went well and the patient looked great post-operatively.  I was very hopeful that this one would be successful but I remembered my last case.
About 10 days after the surgery I came in to work and there was a note for me that the client had called and I should check the medical records.  My heart dropped into my stomach and my first thought was "crap, one or both of the eyes failed and relapsed".  I first saw the note around 8:15 am.  I didn't actually look at the record until around 5:00 in the afternoon.  I had time to do so, but was worrying about it the whole day.  I just knew that the client was calling to say that it had happened again and perhaps be angry that it had done so.  I always tell my clients two or three times what the rate of failure is, but that doesn't always stop people from being upset when it happens.  I dreaded what I would see in the notes.
As the day went on I started thinking and worrying even more, to the point of being a bit sick to my stomach.  I doubted my abilities, and even started thinking that maybe I should stop doing this particular surgery if I was going to have a high recurrence rate.  Maybe I should be referring them out if I wasn't going to get it right the first time.  Maybe I should never have attempted it in the first place.
So I finally steeled myself, gritted my teeth, and pulled out the medical records to read the notes from the previous day, preparing myself for the worst.
The client had called to ask if they could take the Elizabethan collar (e-collar or cone collar) off.
That was it!  The client wasn't reporting any problems, only asking if it was okay to stop using the e-collar!
I breathed a deep sigh of relief and called the client.  The dog was doing great and the eyes were perfectly fine.  There was no sign of any problems or any recurrence and his puppy was acting like nothing had happened to her.  We talked about taking the e-collar off and watching her for any other problems.
I had worried for nothing.  I spent almost nine hours being anxious for no reason whatsoever.  I had doubted my abilities when my personal success rate in these cases is right in line with the profession.
That's not uncommon for me and many of my colleagues.  Most of us care deeply to the point of doubting ourselves if something doesn't go exactly right.  It's easy to forget all of the "good" cases when we are presented with a "bad" one.  Many of us worry ourselves sick for things that are beyond our control.  Because of this veterinarians have a high rate of clinical anxiety and depression.  It's not easy having someone's beloved pet depend on you for their life and health.