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Tag: clinical

  • The Doctor debate

    Yes or no?
    Yes or no? Image ©iStock.com/benstevens

    One of the big discussion topics within the veterinary profession at the moment is the RCVS consultation on UK-qualified vets adopting the courtesy title of “Doctor”, or “Dr”.

    Given that the consultation closed on February 16, I may seem a bit late to add my two pennies’ worth, but I didn’t really know how I felt on the matter and wanted to assess the justifications before assuming a position on one side of the fence or the other.

    Reasons for and against

    There are valid arguments for both sides – and while those against the use of “Doctor” invariably shout louder with their opinions, there is an undeniable majority (at least across the veterinary student body) in favour of the change. In fact, a poll on the Association of Veterinary Students’ (AVS) Facebook page found 97% of respondents were in favour of adopting the title.

    The suggestion is that use of the title would bring vets parity with doctors and dentists in the UK, and also with veterinarians in the US, Australia, New Zealand and parts of Europe. It has also been suggested the change would see an increased respect for vets and help highlight the level of training required (which is of similar length and breadth of doctors and dentists).

    Post by The Association of Veterinary Students [AVS] (UK & Ireland).
    Those against the idea argue that human surgeons do not style themselves "Doctor" (due to a historical quirk that differentiates them from physicians) and so, as veterinary surgeons, we already are on a level playing field with our human counterparts. However, as those less surgically minded are quick to point out, vets are not just surgeons; we are GPs, radiographers, anaesthetists, midwives etc, and so our skill set expands beyond those constrained by this historical quirk. Additionally, in the US, vets are termed "veterinarians" rather than "veterinary surgeons", which makes this historical quirk inapplicable if the argument is simply down to semantics. Instead of achieving parity and clarity, some claim it would actually cause more confusion as vets are neither medical doctors or PhD holders (unless they have indeed spent another few gruelling years at university), although the relevance of this in a clinical situation is questionable – are clients or farmers really going to be too fussed about whether you have a PhD if you’re calling yourself "Doctor"? They’re probably more interested in whether or not you can heal their dog or calve a cow. To this end, giving vets the option to use the title may cause further confusion as not all veterinary professionals will necessarily take it up. So should we have this option, or should we stick firmly to an "all or nothing" approach to ultimately achieve true coherence and unity?

    A matter of trust

    I feel the reasoning with regards to increasing respect for vets and highlighting their level of training is weak – most people outwith the veterinary field actually think we undergo more training than we do (how many times have you been asked if you train for seven years?), and I don't believe respect comes from having a couple of extra letters before your name. Respect must be earned through demonstration of skill and – perhaps more relevantly – client trust. It is this aspect of trust I believe to be the most important justification against the use of the title, and perhaps the one that might just tip the balance for me to fall into the "against" crowd. [caption id="attachment_4659" align="alignright" width="300"]Rather than trying to force this respect, would we not be better off preserving the relationship and earning respect through trust? Image ©iStock.com/JackF Rather than trying to force respect, would we not be better off preserving the relationship and earning respect through trust? Image ©iStock.com/JackF[/caption] It is said the client-vet relationship is often far better than the patient-doctor relationship, with vets often getting to know their regular clients as well as the animals they bring in. Many clients see their vets as friends and so trust their judgement and take heed of their advice (how many times do you hear the question "what would you do if this were your dog?” ?). Rather than developing trust towards a friend, adopting the title "Doctor" may actually form a barrier (however unintentionally), causing an immediate distance between professional and customer due to subtleties such as the client feeling less inclined to be on first name terms with the vet. This would be the cost of the "respect" the title holds. Rather than trying to force this respect, would we not be better off preserving the relationship and earning respect through trust? My gut reaction to the suggestion was yes, of course I’d call myself "Doctor" given the choice – but I began to think a bit more carefully when the strong opposing statements had a substantial backbone to them. And then, on a very personal level, I remembered that I am "blessed" with a unisex name and, as such, always sign emails with a definitive MISS in front of it. For an entirely un-veterinary related reason, I might consider keeping the Miss/Ms just to avoid turning up at an interview to a confused look before the employer realises their mistaken assumption (yes, this happens more times than you would think). Alternatively, in an increasingly female-dominated profession where males may still be considered (however wrongly) to be superior, those two letters in front of my name may cause sufficient confusion to gain an interview I may otherwise have been denied based on gender... but that’s an entirely different debate.

  • Sterile pyogranulomatous cysts are worth bearing in mind

    Interdigital cyst
    An interdigital cyst in the paw of an English bull terrier – image by Nottingham Vet School (CC BY-NC-SA 2.0) via Flickr.

    I recently saw a very large, and very friendly bull mastiff that presented with what appeared to be typical interdigital cysts. These had been chronically recurrent and previous histopathology indicated a pyogranulomatous reaction.

    However his lesions responded poorly to three weeks’ of cephalexin antibiotic therapy and, in fact, he developed several lesions on his other feet.

    Cytology revealed mild bacterial colonisation, and it occurred to me this might be an immune-mediated reaction (his blood work and TSH/T4 were all within normal limits) – and, hey presto, we got a rapid clinical response to steroids.

    In spite of being under control he has also developed an acute erythematous otitis externa, so I think a food trial is my next line. Watch this space…

  • Helping the hounds of the homeless

    Homeless man with dogs
    Image ©iStock.com/artefy

    The homeless come with a certain stigma – particularly those with pets at their side.

    Should we be concerned for the welfare of those animals, whose owners cannot afford to feed themselves so surely cannot adequately care for a companion?

    Of course we should.

    However, instead of claiming these pets should be removed from their owners, Ruby Shorrock (a fourth year vet student at the University of Glasgow) took a different approach.

    Being homeless can be extremely isolating and lonely. For some of these people, their dog is their only companion, and can often be the only thing keeping them going. A dog can also provide a connection to home, and so the reluctance to give them up is understandable.

    Despite this, many shelters refuse to accommodate dogs and so the help available can become increasingly restricted for homeless dog owners.

    In light of this, Ruby founded Trusty Paws, a non-profit organisation that hosts free clinics and provides preventative care for hounds belonging to the homeless. The clinics involve a free health check (a clinical examination performed by veterinary students, supervised by a qualified vet), microchipping, flea and worming treatment and vaccinations. Dog food packages and other supplies such as leads and dog coats are also given out at the clinics.

    The Trusty Paws Clinic logo
    Trusty Paws: a vaccination clinic for dogs belonging to the homeless, run by fourth year vet students at the University of Glasgow.

    There have been three Trusty Paws clinics in Glasgow so far, with several grateful clients being able to benefit from the supplies donated and the services provided by the students. Everyone involved is delighted with how the clinics have been received.

    Plans for 2015 include registering as a formal charity and organising public fundraisers. The Trusty Paws team also intends to tackle the problem of local shelters and hostels not allowing dogs.

    Trusty Paws relies entirely on donations and sponsorship and the response to requests for both has been exceptional. The concept has really taken off and looks to gain popularity and success in the future.

    The work of Trusty Paws is a fantastic way of not only actively ensuring quality care for homeless pets, but also raising awareness within the community to tackle public perception. If these misconceptions can be eliminated, others will be willing to accept that pets are a huge part of the lives of homeless people too and, perhaps, be encouraged to help the situation instead of avoiding eye contact with that person sitting in a doorway on a rainy evening.

  • Aggression as an unusual presenting sign of hypothyroidism

    Aggressive dog
    Image ©iStock.com/YuriyGreen

    I’ve not long come across a case of a middle-aged dog that had suddenly become unaccustomedly grumpy and started snapping at its poor owners.

    This was uncharacteristic, as it had no previous history of behavioural problems. There were no other obvious clinical signs – perhaps it had become lazy of late, but there was nothing to put your finger on.

    I recalled having attended a CPD event a while before when the speaker mentioned hypothyroidism leading to aggression. I thought this was worth a punt, and low and behold it had a very high thyroid-stimulating hormone level and very low thyroxine result. Our friend is now on thyroid supplementation and is much happier, although at the time of writing some two to three months into therapy, it was not completely better.

    So, it may be worthwhile considering a blood profile when presented with signs of aggression in middle-aged dogs.

  • Top tips from the reception desk

    Communication is key. Image ©iStock.com/DenGuy
    Communication is key.
    Image ©iStock.com/DenGuy

    As I’ve done quite a few clinical tips now, I thought it would be interesting to ask our receptionists what their top tips from the front line would be.

    Sara, one of our excellent branch manager team, says communication is essential. Passing on as much information as possible to the clinical team can sometimes be challenging if presented with a very worried or upset client on the phone.

    Sara also says remaining calm is key, and she always does her best to reassure clients and ensure the patient turns up at the right surgery at right time.

  • It takes two to tango

    Argentinian Tango dance duo German Cornejo and Gisela Galeassi. Image: Fuentes/Fernandez

    Before the full force of third year hit, the first week back at vet school started with everyone catching up on tales from their summer holidays.

    Before long, it was like we’d never left and the four months of freedom seemed to fade into a distant memory. However, one particular topic of holiday gossip that I have been dwelling on is extramural studies (EMS).

    Everyone had undertaken some form of EMS over the summer, whether it was just a week or two, a solid two months, clinical, preclinical, large or small animal – there is a lot of room for variation in our placements, but I was still surprised to hear of how different some of my friends’ experiences had been, despite doing theoretically similar placements.

    A number of us had embarked on our first clinical placements, and although we’re all at the same stage of our studies and therefore should be able to get involved during veterinary placements to a similar extent, the truth is somewhat different.

    Just among my friends, there were experience levels at both ends of the scale, with some students having been simply told to observe consultations and others being allowed to scrub into surgical procedures.

    This wide range of experiences can be attributed to many factors, including:

    • the veterinary practice
    • how well the vet knows the student (either from previous experience or length of placement)
    • how well the staff have judged the student’s knowledge and ability based on stage of the veterinary course
    • attitude and competency of the vet
    • the individual student’s skills, experience and attitude

    I was advised by a final year student last year to undertake the majority of my clinical EMS at one single practice if possible, because by getting to know the vets well (and vice versa), they’ll be able to judge your level of competency better and encourage you to get more involved. I can now begin to appreciate this advice more, having listened to the anecdotes from my friends.

    ems-quote2The practical teaching we receive at vet school is just not enough to be able to adequately develop and refine essential clinical skills that will be needed everyday in general veterinary practice. The solution to this is EMS, and we are constantly being told that we, as students, need to take responsibility for our own learning and ensure that we get the most out of EMS by getting involved. And I whole-heartedly agree – we can’t be spoon-fed forever and need to be proactive in gaining the right type of experience.

    However, you could be the most enthusiast student in the world and read up on cases every night, and yet still be very limited in what you are allowed to do. While getting the most out of a placement is up to us, it takes two to tango, and we need the vets’ support too in order to enable us to do this.

    I know taking on students and teaching or letting them practice techniques can be time-consuming and inconvenient, but we need to gain experience somehow. At some point during their training, all vets would have had to see practice and learn in the same way, so is it not just a way of giving back to the profession?

    I can also appreciate that some people are just not natural teachers (after all we’re training to work in a vet clinic, not a school), but a little bit of patience and some advice can go a whole lot further than just ignoring a student.

    It may sometimes be inappropriate for a student to be asking questions or trying things out – in the consultation room in front of the client, for example – but these situations can be fine when approached the right way. I was lucky enough to stand in with vets that would always try and get me to see/hear/feel things. If they found something interesting in the consultation room, they’d always explain to the client that I was a student and ask if they minded me having a look. This seems far more reasonable to me than telling a student they are to observe only.

    Another approach I experienced myself was the vet taking the animal to the surgery room to take blood samples and allowing me to perform my own clinical examination (having not actually been in the original consultation).

    As mentioned previously, there can be many factors involved in getting a “good” clinical placement. It also depends how busy the surgery is – if there are four clients waiting to see the same vet, it’s understandable for the vet to whizz through them without having much time for questions or explanations (whenever this happened to me, the vet apologised for not explaining, even though she really didn’t need to!).

    I have to agree there are advantages to going back to a veterinary practice you know. I did work experience for three years before university at the practice I did my EMS at this summer, and definitely felt welcomed as part of the team, which can be difficult at an entirely new practice.

    Yes, it is our responsibility to find the balance between getting involved to gain experience and not interfering with consults, but we also need vets to help us a bit too. Undertaking EMS is the only way we will prepare ourselves for the future, and we’re extremely grateful for the vets that encourage and help us every step of the way (partly why most vet students are pretty good at baking). I think it’s just a case of finding the right practice for both you and the vets you’ll be learning from.

  • Ask the editor

    Jordan and her fellow stewards "hard at work" at BEVA 2014.
    Jordan and her fellow stewards “hard at work” at the 2014 BEVA Congress.

    As a student steward at the British Equine Veterinary Association (BEVA) Congress, my responsibilities included helping set up the trade exhibition, handing out welcome packs at the registration desk and escorting speakers to the appropriate rooms. However, we were also able to sit in on lectures and act as the legs for the microphone whenever there were any questions.

    The congress provided a great opportunity for networking and meeting other students from across both the UK and the world, as well as many veterinary professionals from every corner of the globe.

    One of the lectures I sat in on was a Q&A session, “Ask the editor”, about publishing clinical research. A particularly sensitive topic was the process of peer reviewing research papers. The main point of discussion that interested me was the huge variation in quality of reviews depending on the reviewer, especially when veterinary schools were brought in to the argument.

    As someone with no experience of research, the general impression I got was that one of the issues with peer reviewing is many reviewers are practising vets who – having done a veterinary degree rather than a research-based degree – are never taught specifically how to write a paper, and therefore aren’t taught how to review one either.

    And then came the inevitable “well perhaps that should be introduced to the veterinary curriculum”.

    In my opinion, absolutely not. The format of the veterinary degree is primarily geared towards producing vets. The majority of veterinary students will have chosen veterinary school because they wanted to be a vet, not because they wanted to learn how to review scientific papers.

    BEVA 2014 was apparently a very sombre event.
    BEVA 2014 was obviously a very sombre event.

    Is the veterinary course not intensive and long enough without adding in extra skills that would be of limited use to the everyday clinician with no interest in research?

    This also brings me back to the controversy surrounding the opening of new UK veterinary schools. One of the arguments countering the “too many graduates and not enough jobs“ point is a veterinary degree doesn’t necessarily lead to a career as a vet. Some graduates opt for other aspects of the profession, such as research.

    I have to disagree – with extramural studies forming such a huge chunk of the course, it is certainly preparing students to be practising vets, not researchers. If you want to end up in research, do a bioveterinary science degree instead. That way, students aiming for a research career would get the scientific background knowledge of veterinary and research experience, without having to undertake hours in a veterinary clinic, learning practical skills they’ll never use.

    I understand some students may want to practise as vets and yet still become involved in research. However, I believe masters’ courses are available, or the option of intercalation, which would allow them to gain some research experience.

    I strongly believe not only the vast majority of veterinary students would resent a more research-based degree, but also it would produce less-competent clinicians as a result.

    Research should be an option, but not a compulsory part of becoming a vet.

  • Clinical EMS 101

    Dunce
    Vet school doesn’t prepare you for making a complete idiot out of yourself.

    At vet school, you learn some basic clinical skills and are taught how to conduct a general clinical examination to prepare you for EMS placements in veterinary surgeries. What they don’t prepare you for is making a complete idiot out of yourself.

    Before my first clinical placement I told the vets I would be working with that I had only just finished second year and had no pharmacological knowledge as of yet, non-existent surgical experience and very little understanding of small animal medicine in general.

    Luckily, all the vets in the practice were very good at judging the level of my understanding and seemed to find the right balance between patience and pushing me for answers.

    Things seemed to be going OK. I’d successfully taken blood samples and started to make sense of abdominal palpation. However, applying clinical skills taught at vet school isn’t necessarily straightforward – cadavers have a distinct lack of weapons in the form of claws and teeth, but I was coping with that reasonably well and taking note of the vets’ advice on particular techniques.

    This was until a few days in, when I found myself working with the head vet…

    In the same morning, I managed to spray penicillin all over my face while trying to administer an injection, incorrectly insert an endotracheal tube despite being 99% sure it was OK, and cover myself in guinea-pig blood while clipping nails, leaving me to wear the stained tabard for the rest of the day.

    To add insult to injury, I later misread the scales and recited the incorrect weight without thinking (it didn’t occur to me that there’s no way a fully grown border collie could weigh 10kg).

    Isolated, these incidents might not seem like the end of the world, but when they all happen in the same day in front of the head vet and when one of the clients involved is your neighbour, you do feel like shouting “I am a vet student – honest”, despite feeling like a complete moron.

    This was, however, followed by days of mini-triumph, such as inserting an IV catheter correctly for the first time or scaling and polishing a dog’s teeth myself.

    The important thing to remember is that you are inexperienced, and you just have to accept there will be days when nothing seems to go your way, get past them and carry on with your head held high – even if it is covered in yellow spots of penicillin.

  • It’s worth ruling out hypothyroidism if blood cholesterol is elevated

    Characteristic changes in the facial skin of a Labrador retriever with hypothyroidism.
    Characteristic changes in the facial skin of a Labrador retriever with hypothyroidism. Image by Caroldermoid (own work) [CC-BY-SA-3.0], via Wikimedia Commons.
    To be truthful, I have a bit of a blind spot when it comes to hypothyroidism. I often find few dogs follow the traditional textbook description of the clinical signs.

    I have seen two cases of late with elevated cholesterol, but no hair loss, unexplained weight gain, heat seeking and mucinous skin thickness.

    Both cases had blood submitted for total thyroxine (TT4) and thyroid-stimulating hormone (TSH), and both had very low TT4 levels and markedly increased TSH.

    Both cases are also improving nicely on thyroxine supplementation.

  • PCV and blood transfusions

    Red blood cells
    Image © iStock.com/Yakobchuk

    There are no specific packed cell volume guidelines as to when to transfuse an animal with red blood cell containing products.

    The decision to transfuse is based on the clinical condition of the patient and the chronicity of the anaemia.

    For example, a cat with chronic non-regenerative anaemia due to bone marrow disease may be stable with a PCV of 10%, whereas a cat with acute haemorrhage due to a RTA could be very unstable with a PCV of 15% and in need of emergency blood transfusion.