Hope and Mother's Day 2023

Hope. When there is everything, and nothing, there is still hope.

A long time ago there was a girl who was afraid. Of all of the things she was this one thing dominated. It was what propelled her, crippled her, and reminded her. It was the beast she lay victim to for all of the days. It was the affliction her mother had and her mother before her. It was everything and nothing. It was, and it was what she let it be.

It was like this for a very long time. A lifetime, and then, a lifetime more.

It took a long time to recognize the part of her she didn’t have to be. She knew that there had to be more to this journey. The one she woke up to everyday to repeat the whole pattern again. But when you carry a beast so big, and so heavy, it is hard to raise your eyes above it. Maybe fear is the antidote to hope, she thought. And, maybe hope was the cure for her fear? And with that it began; the daily ritual of pulling her bootstraps up and raising her chin above the horizon, just to see if maybe out there somewhere there was another option to her fear. Maybe there was a place she could leave it? Just to rest its weary head for a while. Maybe, it was as tired of her as she was of it? Maybe, they could exist without each other? The shell without the cortex. The cure without the disease. Maybe, if she could grow big enough and strong enough, she could outgrow its need for her, and with all things that persist long enough, her need for it? Maybe? Just maybe?

What happens is that time works its magic on you and you grow comfortable with even the most horrible. You get used to each other to a degree that makes it hard to coexist without each other, even when the other half is a cancer. A bad marriage arranged on the most horrific of terms. Life is like that. It will kill you if you let it. Leach you to anemia just to see what the reserve tank has in it. Medicine, the art of molecular life in the grips of another life, the host with its many moving parts all required to work in tandem even when they have opposing agendas, is also just like this. A dance, a tango set to a music you cannot always chose. You try to lead but you know the tempo might change and there may be feet stepped on as you tip-toe across the floor.

Isn’t life like this for all of us? The calculations of actions you make silently within to try to make it through life with as little turmoil, pain, and scarring as possible. At what point do we learn that if you don’t have one side of the coin it's impossible to know the other. Maybe with age there is wisdom and the ability to excise the fear so you can live with just the hope?

Today is Mother’s Day. The day that we all celebrate the origin of our existence on the double X chromosome in our own DNA. For me, May 14 is the day my mother died. On this day at 4:14 pm in a little stone house not too far from my own, my mom was given her last breath. I say this as it marks a date, impermeable, and in-excisable that is the pivot point to which the calendar resets, and a life without another starts. It is that day changed so much within me. There is a book to write about her, and her impact upon me. A book that sits waiting for the time and the distance to write it without it eating me up. Consuming me like the fear that swallowed her and kept her trapped within.

Today I remind myself that there is life after another life passes on. I cannot call her life gone. She is never gone. She is here all around me reminding me to always have hope. To always see the beauty and the joy in the life that exists even if you have a difficult time seeing through the tears. Today I talk about hope.

This morning I opened my eyes before the sun came up. The sky crept from black to the darkest of blue. A grey-washed out kind of blue. Smeared in its blurry shadows. Quiet, heavy, and slumbered with a fog that keeps all of the earth’s tiny souls safe in their beds. The first rays of sunshine wake up the world and to this awakening the first chirp can be heard. It is my time to be alone and feel as if the world will remind me that I am never really solitary. One little chirp. Just a call in the almost-darkness to awaken the rest. I turn on my Merlin app, and start to record. I now know that this tiny rooster call is an American Robin. Maybe being afraid, and trying to replace it with hope is about seeing the bravery in the darkest of places and still singing?

here's this mornings first recording; (and try the Merlin app. You can listen and identify all of the birds. It's amazing, and you will part of something that is alive around you that you never felt before. And maybe it can help us all remember that we are all mothers to each other?). 

I made a video the other week about all of the clients I see who come to me having to lay their pet to rest after disease, and age, and all of the many afflictions that life can wear you down from. They always ask me the same thing, without fail; they ask, “this must be the hardest thing that you have to do as a veterinarian?” And I always reply the same way… “No. You loved your pet so much that you made them a part of your family. They were loved every moment of their lives. How lucky they are for that, and I know they are so grateful to have been yours.” That is the hope in the face of fear. That is the beauty in the face of death. Maybe losing someone you love is about remembering the hope they brought you everyday you were together?

With hope springs gratitude eternal. Is there anything we wouldn’t give for that?

Happy Mothers Day to you all. (regardless of what your chromosomes or current children roster looks like)..

 

And P.S. go out and foster, adopt, and live life with someone else… pets count as kids these days,, so we are all moms here. Maybe there is life outside of the one you are living right now where hope springs eternal? And, maybe its time to go look for it? Let’s all look for hope in the love that reminds us we are all mothers.

More on my mom here.

The Ross House. My Mom's Decorating and The Things She Treasured.

The First Christmas Without My Mom.

The Sensuous Bean.

And to identify the songs in your back yard; Merlin app information here.  

Blocked Cats; My Cause and My Advice

A "blocked cat" in vetmed terms is a cat who cannot pass urine normally, or, at all. "Blocked" refers to urinary bladder blockage. A blocked cat is a medical emergency and should be treated as such.

Here is how I treat a blocked cat, and, why/how these cases often come to find me.

Stripes. Presented blocked and unhappy about it.

The typical scenario for a blocked cat presentation is this;

• Cat is in and out of the litter box, 
• Often crying, meowing, and/or, in distress 
• Little to no urine is being produced

Client and blocked cat show up at vet office or ER. Cat is examined and owner is asked to produce a $2,000 deposit for care. Most struggle to afford this. Many cannot. Therefore, they call me for help.

Here is a look at how I manage blocked cat cases with financial constraints at my veterinary practice.

Almost all cats can be diagnosed without diagnostics (outside of the above mentioned physical exam and history).  I DO NOT RUN DIAGNOSTICS IF IT WILL AFFECT A PATIENTS ABILITY TO RECEIVE TREATMENT. This is a practice that has become all too common place and the systemic practice of economic euthanasia to allow for diagnostics is unethical and warrants state board and AVMA scrutiny and policy changes.

KEY POINT; This should be provided in documentation after the examination is done. At each client documentation/signature request the client MUST get a copy, and, there MUST be current patient status listed. A client has the right to deny diagnostics and still receive life saving care. The egregious practice of turning away clients if they will not meet a practices proposed standard of care, and the corresponding costs associated with them, is also in need of AVMA and state board examination. We allow the euthanasia of patients because we reduce them to property status when it suits our prejudice and financial gain discretion. A blocked cat is typically young, otherwise healthy and free from any other medical conditions. They may present looking, and feeling, bad, but, they are treatable in almost 100% of these cases IF UNBLOCKED.

Urine, rally bloody, from a recently unblocked cat

I am going to describe the typical blocked cat cases that I see, and, how I manage them. Almost all of these are owned by people who have financial limitations. I am also providing challenges to the typical way an ER manages these cases to help highlight areas we can help allocate resources to as I call it, “get out alive.”

                First challenge; diagnostics are not needed to diagnose. Short of a very obese cat a competent physical exam AND thorough history will diagnose the majority of these cases. Why does everyone run diagnostics? Why, again, are we not talking about the client’s budget at the beginning of spending their money?

                Second challenge; diagnostics, regardless of their findings do not influence the care needed. ALL of these cats need to be unblocked immediately. In some very rare cases there are some patients who should not be treated, or, have a poor prognosis regardless of treatment. (i.e. geriatric cats with comorbidities, fractious, feral, unknown rabies history, cats we will not be able to safely manage fluids/urinary catheter on, loss neural function, etc). These patients/clients deserve to be notified before treatment, or estimates, are provided. Futility* medicine should be as ethically bound as economic euthanasia defaults, and over padded invoices that prohibit care ability because finances have been drained in the diagnostic phase.

I would like to provide users with a step by step approach to their cats care. Challenge the suggested treatment protocols to save clients from economic euthanasia

Next challenge; vets do not talk to clients about managing financial resources to allow for the expected stumbles in this disease process.

Challenge; talk about whole pet care, not point of care emergency. Who else talks to clients like I do? I say, once we start treating we are all committed to a positive outcome. This is NOT based on financial ability. It is based on needed patient care. Vet med withholds this until it is perceived that clients are dry and then we offer euthanasia as the only affordable option.

Challenge; these cats are typically young (under 3-4 years old) and otherwise very healthy. We are over-euthanizing young, previously perfectly healthy cats simply because we have priced them out of care. These cases have been around for decades. Decades where we treated them at minimal cost and saved the majority of these cats. Why are more cats dying now? We priced people out of care while better educating the public on this disease. That is unethical. This needs to be challenged.

Challenge; why do we run blood work on ALL of these cats? And then tell owners that ALL of these cats blood work looks bad, because, well simply they are sick, they are critical and they do look bad. What were we expecting the blood work to look like? We do it to make money, and, we do it to CYA, and we do it because someone made us believe it was a liability otherwise? It’s time to challenge pricing pets out of care while we CYA.

Challenge ALL of these cats in my experience go back to perfectly normal blood work indices after their obstruction is removed and they are given time to recover. They do not start out in kidney failure although all of them have blood work that looks like kidney failure while they are blocked and present for care. Vets use this to their advantage when discussing euthanasia, or repeating blood work. It is deceitful.

In cases of financial limitations (this is decided up front at the first visit/interaction) we have an ethical obligation to discuss what we expect, what we have seen to be true, and that this is not a one and done fix. We need to start with a whole cat case approach, not a singular point in time under emergency induced emotional duress and take clients for a one and done as much as we can get them for and to-hell-if the cat is euthanized along the way approach. We know better, even if our clients don’t.

Challenge; This ridiculous, archaic practice of not having vets discuss money (see equally ridiculous reasons here)

Challenge; most ER vets are unblocking without general anesthesia between cases. We can do it so quickly that the charge given to the owner is exorbitant. In many cases we can unblock a cat in the same time it can take to pass an i.v. catheter.

Challenge a line item list of how a cat is unblocked is not provided to the client.

Documentation on the procedure and the time necessary to unblock is not provided. This should be provided before treatments are given AND confirmed before invoice is given. 

Challenge; Removing a urinary catheter before 72 hours, or before the urine is running diluted and clear is setting the patient up to reblock. I would argue that we use time based estimates which are always egregiously too short thereby setting the patient up to reblock. Veterinarians should expect, and do, the cat to reblock within a very short period of time. We make more money with the cats failure. The ethics of this should be challenged. If clients cannot afford to keep a patient in the hospital they should be allowed to be transferred to a primary care facility, i.e. their normal veterinarian (even if they do not have 24 hour care), and/or allowed to go home with the intravenous catheter AND urinary catheter in place to be monitored at home. Challenge; I have never seen this happen. In all cases these are removed by the ER facility. These critical goods are paid for and owned by the client. Removing them without consent is a breach of consensual care and a done to the detriment of the patient.

We should all expect that a cat that has blocked once, will soon block again. How many times can the client pay for this? We should be addressing this at the first visit. We should be using the clients ability for the expected treatment course, and not the typical one time financial hit. We require a deposit for care, and that deposit is typically exhausted within the first 12-24 hours leaving cats to be discharged before they are ready, and setting the client up for a repeat obstruction within days to weeks. Where a small percentage of cats are treated on the first obstruction many are not on the second. Further the trauma of the blockage compounded by the passing of a urinary catheter causes excessive damage to the patient urethra. I would argue that the removal of a urinary catheter prematurely causes an increased chance of reblocking and therefore makes the veterinary team responsible for re-current obstructions that frequently occur within days. 

The inflammation from BOTH the blockage AND the urinary catheter always needs more than 12-24 hours to resolve.

Challenge; a client pays for the goods and services provided to the patient. Why then do vets insist on removing these? At least we should unblock and transfer elsewhere to provide these patients a longer fluid therapy plan. We need to be documenting and insisting these cats continue care elsewhere. Even if this at the owners home, if it cannot happen at a veterinary facility.

Although not ideal we keep cats in our vet hospital for 3-5 days even though there is no overnight care.

These cats need fluid therapy AND urinary catheterization for 3-5 days.

Unblocking a cat at my clinic; Client call to front desk with any of the above clinical signs is sent immediately to the Charge Tech. They immediately notify a veterinarian of the cat being blocked. If the cat is an existing patient we direct them to go to the ER immediately, or come to us. Upon arrival we immediately  examine to confirm bladder is large, painful and no urine will pass. Do not squeeze too hard. Bladder can rupture. This is always a surgical emergency, financially constrained clients will not be able to afford this.

Treatment tree looks like this; 

•  cold laser therapy of prepuce. Will reduce inflammation and allow some sediment to pass.  
• massage penis to remove calculi. May allow urine to pass, 
• attempt to place/pass a urinary catheter. Catheter selection matters, avoid tomcats and red rubbers, try Tom Tiddle, 3.5 french. Lots of lube! 
• Start i.v. fluids as fast as able. These cats die from dehydration causing cardiac fatality.
•  If unable to pass Ucath, try to relieve urethral obstruction with olive tipped syringe and 20 ml saline to retropulse obstruction back into the bladder. Lots of lube 
• If unable to olive tipped syringe decompress bladder with 22 gauge needle. Remove as much urine as able. I leave needle in bladder and switch out 20 ml syringes until bladder is soft. Warning, bladder rupture is possible.  
• Continue laser, massage and retropulsion with olive tipped. In almost all cases you can feel obstruction move as these are done. 
• Attempt to place Tom Tiddle and suture stopper to prepuce. If able;
• Flush bladder with sterile saline to remove as much debris, and blood as able. 
• Place collection back onto Ucath 
•  Start iv fluids. We use NaCl for ivf therapy 
• If a higher degree of difficulty in passing ucath take lateral caudal ab xray to look for bladder stones. This may indicate a cystotomy is needed.

Challenge; it is easier to unblock a cat then spay a large, fat dog. Why then is this done at 4 plus times the cost to the owner?

Why is it ethical to be charging so much just because this is an emergency? I would also challenge that these cats are easier to treat than a big aged dog spay, Which we do routinely and charge for at a fraction of the cost, because people can find this surgery at almost every veterinary facility. Where there is competition there is a lower price point. Further a spay is (typically) elective.

At home care after urine is clear; the following are my patients; 

• Teach owner how to palpate for the urinary bladder. 
• Place patient on a steroid to encourage drinking water and reduce inflammation. 
• Feed a wet food only urinary diet. Add water to each meal. The diet should be a urinary prescription formula and it should be used for the rest of the cats life. 
• Encourage water intake with a fountain,. 
• Encourage play. 
• Reduce stress in any and every way possible. 
• Monitor litter boxes lifelong. New litter options are being produced to help guide clients in detecting and monitoring for possible issues. 
• Use anti anxiety medications like gabapentin. 
• Or, long term medications like fluoxetine. 
• Use analgesics like transmucosal/dermal buprinex. Pain medications will help these patients quality of life. Reduce stress and reduce likelihood of recurrent stress induced cystitis, further reducing chances of reblocking. 
• Give sq fluids at home for days to weeks post op. Fluid kits are available on Chewy.com

We need to develop ways to allow in home care and supervision. Pawbly.com can help.  Start a savings account for the next urinary issue. If necessary discuss a PU surgery as the next treatment option. See VetBilling.com for pet savings plan options. 

PU surgery.

Here is a video from my YouTube channel on unblocking a patient of mine. More videos can be found there. Link here

How do I get these patients treated for about $1,000 (and, yes, even I admit this is too costly for many people), I invest in my clients AND patients care. We start with a goal. We talk about options. Every single option. They are all weighted equally to reinforce that we are in this together. From start to finish. If none of these seem acceptable to the client I ask, "what will it take for me to help your cat?"

We start there.

If you have a cat, particularly an adult (greater than 1 year of age), indoor, neutered, male on a dry food diet (particularly a grocery store brand) you need to ask your vet what would happen if your cat blocked? Would they refer you to an ER? If so. how much might this cost? Be prepared before this happens to you. Please follow my blog, my Jarrettsville Veterinary Center Facebook page, my YouTube channel for more on this, and other pet care issues. Please also stay tuned for a step by step guide to managing your cats emergencies, especially if you do not have an emergency pet care fund with at least $2,000 in it, as we are working on it now.

For more help you can ask our pet care professionals for free at Pawbly.com

References;

CareCredit. Hate Talking About Money? You Are Not Alone.

*Futility Medicine; 

UW Dept Of Bioethics discussion.

Medical Futility Is Commonly Encountered In Small Animal Medicine.

 

The Sensuous Bean

Bollo's

I go to a particular coffee shop a street away from my apartment. It isn’t perfect. Not the perfect replica of the one I have spent the last 20 years trying to replace, but, it’s good enough. I feel a sense of belonging there. Silly, I know to find a sense of belonging in a $3 cup of coffee delivered to me in a tiny chit of a chat to make room for the other paying customers behind me. But it’s enough. Enough to feel warm within. Enough to call me back to every morning. Enough to find solace within, and comfort around. 

Gillies.

Most days it's just that. A large cup of black coffee; strong, dark, bold, intoxicating. I breathe it in. That first hello. Steam from its surface filling my foggy head with wakeful inspiration for the days needful wanting. 

Today, standing in line, I thought I saw her. She is always near. I can always feel her around me. But she has never appeared to me in human form until today. Today she was working far behind the counter in the small staff area half hidden from the line I waited in. Today she was there, standing back toward me, hair down, filling the monster coffee grinders just out of my view. And just for a second, the briefest of seconds, I saw her. I knew as my heart overrode my heads sensibilities that this was her. Her hair was long, straight, just past the shoulders, as it always was, with the tinge of silver her box color couldn’t confiscate. She was standing tall.  Taller than she had been in the last few years when the weight of the painful burden of her bodies betrayal had permitted her. Today she was 50 again. Time had slipped two and a half decades. Oddly, or poetically, this is the same morning our clocks had been pushed forward an hour. She worked quietly. I could only see a part of her from the back. Just enough to tell my heart that she was still among us. She had decided to hide in a coffee shop. She must have known I would settle upon this one. It’s deep, sensuous allure calling me in. The cry of a baby to its mom. It’s how we just sense the other needs us. 

Sensuous Bean

I know she turned around at some point. I know she did, but there was no face my mind could correct itself into seeing. Just the back of her. When it was her. The rest I don't need, and, so, I let her stay. 

No, I countered. It's not her. She never wore black. And yet between the coffee and the crowd I was content and comforted to just know she's near.

I spent the best part of 12 years sitting here studying.
Bollo's. My corner

The Tipping Point. When There Is More Behind You Than In Front.

The tipping point.

There is a place, a moment, a collection of revelations, where you realize, bring to your own attention, that you are looking back, (horrifically in some cases even attempting to relive, revive and recollect the exact details of what was before), more than looking forward. 

That place where there is more behind you than in front of you, and not only is that the truth, but worse, your preference defers to back versus ahead.

Gracie. Just rescued. Her mouth was soo diseased the smell would knock you over.
All of her teeth had to be removed. This is her waking up.
She was a different (soo much happier) cat 24 hours later.
The degree of neglect she came to us with was pitiful and compelling.

In the misery of many a childhood moment I would sit, close my eyes and imagine the magic that lay ahead. Too often the allure of what might be. What I could salivate over. Some lustful moment. A momentous accomplishment dreamt of but yet to be fulfilled. A far away land with all of its exotic flavors. I got by, (a theme song from my favorite Grateful Dead anthem), because I projected forward. Those invisible carrots of motivation lay just at the tip of my tongue. Propelled me forward through what turned out to be some pretty traumatizing growing up. 

At 50ish I have realized that the carrot has shape shifted. It no longer hovers above calling. It lays beside me waiting. The small dirt-dusted, blunted, jaundiced nut in a collection resembling a sickened nest of eggs to ride out the Winter. 

The snowdrops and the crocus.
They remind me to believe in beginnings,, even after all of the endings.

Unbeknownst to me the tipping point hasn't evolved into a concession, rather a gentle acceptance that the To-Do list, my collective life accomplishments still yet ephemerous, need to be fast-tracked. That list cannot be allowed to outlive me, good intentions, or fate deciding.

Perhaps other people spend their autumnal time reflecting on the amassed possessions as some aging dragon in her liar of pillaged treasures? Perhaps not having children to leave a better life to isn't the motivation to dying with assets left behind? Or, perhaps even more disturbingly I recognize my stash will outlive me. I will not be able/chose not to, exhaust it before the timeline draws to a close. Perhaps this is the tipping point? that place where your efforts tip to giving back versus gaining more? Perhaps that's what aging, retirement, exhaustion and a worn out body brings to your peace of mind as the collective cacophony of a chaotic world swirls around you?

My Raffles kitten. She was given up on because her sibling came up positive for rabies.
Four months of quarantine and she is mine.
Life for me works like this. These needful souls find me.
I am as much grateful for them as I am for the fate that brings them to me.

Maybe that's why I am so much happier in the looking back than the drive to accelerate forward?

Oh, that's right, today is Tuesday. I must get dressed and go fight those diseases and dragons for another good day of deeds in the small animal vetmed trenches. I'll rest tomorrow and save a carrot for the slumber another day. 

Raffles watches as Birdie wakes up from her spay surgery.

Tipping points too often get me confused between tipping and pivoting. I don't know if I can recognize one versus the other any longer.

There is a real-life plight in vetmed these days. Those of us who grew up in the trenches, took on a place of our own, led or our community practice for a few decades, sunk our whole lives into. We are at a place now where we have to decide how to exit. Do we take the big cash out from the guys who might as well have a Hamburgler face on. Their shifty eyes, smooth talking and thick gravid unexplained check books? Or, do we try to find some new grad willing to take the reigns and care for the next generation of pets the way our previous generations of vets did? Is that even possible?

Hamburgler holding the American icon hostage

Me, I am at a place where the box has to be rethought, reinvented and repurposed for the greater good and not the singular cash out retirement/burnout plan. Me, I'm pivoting before the tip pulls me under.

Hand Holding Anxiety. When You Love Too Much It Costs.

 Hand-holding vs. confident and competent?

Izzy takes a ride with Allie.

It occurred to me that as much as I hope to practice for the latter I see a lot of the former. Maybe I attract it?

Maybe I market it,,, albeit unknowingly.

Questions about intentions from the newest rescue we are helping.
This little one is about 10 weeks old and was rescued from a dump in deep Kentucky.
She had an ultrasound and some questions about the size of our position pillows.

The issue is not that one is better, or worse, than the other. The issue is that I am not as adaptive as I hope to be, or know others hope me to be. The issue is that I am too sensitive, too driven and too insanely compelled to practice for the benefit of the patient and forget to tailor my delivery to the client.

 The real issue is that I forget I am merely an extension of the leashes many avenues, and not the patients only resource to recovery. 

Teddy. TPLO surgery last Wednesday.
All sweetness and a pinch of Border Collie anticipation.

Yesterday was an example of this. Yesterday was Lilly. A bubbly, bouncy curly ginger girl who has had multiple trips to the ER and multiple trips to my clinic for her waxing waning intermittently, self-described as "violent" vomiting and diarrhea. She is owned by two doting millennials. The kind that the vet journals remind me to both recognize and cater to. They are the new generation of my bread and butter. They love their pets in place of having children and they will both spend for them and advocate for them. These are the couples with sets of pet outfits, all personally monogrammed with the family crest, one for each member. One for each holiday, each gathering and always captured in holiday post cards. They have vacations designed around "pet friendly" parameters. They are new parents who jump and take notice at the first sign of illness, discontent, or dismay. They are what I want every pet parent to be, not withstanding the narrow age bracket to remind me I still live in a rural place where people on farms still refer to all species with a prefix denoting "farm use." (The labels can literally kill you around here).

Skylar, also a TPLO surgery Wednesday.
The eyes, they always get me.
I spend a significant amount of my work day reassuring.

Lilly's mom arrived in her work clothes. A clean, dark, pet hair free, (I cannot remember the last time I had one of those outfits, likely never) pencil skirt, with mid-heeled black leather shoes,  and a tight fitting ruched shirt to match. She must work in an office where professional image matters, I think. I have yet to ever live that life,,, (and, yes, there is a side of me that is jealous about that). Compared to my professional attire which included; poorly matched scrubs, upper and lower hemispheres, and not-at-all comfortable, (nor supportive) sneakers with the laces untied dragging behind me swinging to and fro collecting hairball tumbleweeds as they traversed. I was reminded of the hazards by everyone I passed and still was too tired, too painfully arches in agony, to correct them. I have considered adding slippers, or Crocs, (I cannot believe I am here), to my wardrobe as the days get soo long I am reminded my body is decaying. Lilly's mom was intense, apologetic and fretful. Her dog is just over a year old and she has been to the vet a dozen times for the same thing. She is also, in quiet, subtle undertones, worried about the current place her vet bills lie and what the road ahead will look like to for retirement account if she stays on the current path for another decade.

It was 730 pm. We close at 8. I had fit her in after her call at 630 pm begging to be seen for her dogs "vomiting and diarrhea all over the place for the last 3 days." I had been in the clinic all day, 12 hours, and I was,,, done. Toast. And I know it.

I was exhausted. And now I have Lilly in front of me, with her worried mom,, and I am asking myself if I can see just one more case today? I remind myself silently that this, this profession, this day, and yes this moment,, is not about me. There are times, many times, and many days like this, where I am a bag of bones with untidy shoes, urine/fecal stained scrubs and a belly soo dehydrated and hungry I cannot adequately focus, nor separate myself from the clock calling me to close. I had arrived at the clinic at 8 am. I have not had a meal of any sort, nor sat down, nor taken a break to clear my cluttered head. There were 11 surgeries today. Two of which were my own pets. (Let's talk about how difficult that is). Then pile it on top of a day like this. I remind myself there won't be anything left of me to cremate when the burner expires within. I know this. I push my nose deeper into the ground and flex all fours to plow on. 

"Lilly's exam looks fairly normal." I reply. Lilly is now cowering behind her mom. She is drooling with anxiety and really wants me to go away. Pet hair free and upright on her kitten patent leather heels she asks me, "Why does this keep happening? And, how do we stop it?"

It's 745. That answer could take another 12 hours. 

Gunner, using the almost infallible tactic of,
"I'm too cute to ask to participate in an exam" ploy.

"Well, we have never gotten her a diagnosis. We are always treating the emergency and never investigating the in between times that might be leading her to this." I reply.

It's 750 pm. I sit down. I have to. I look up and meet her moms eyes. This was not the answer she wanted.

"Again, thank you for seeing me today. For fitting me in."

"You are welcome. I know you are worried." I suspect she is also worried about needing the ER, having to repeat an overnight stay. The x-rays, blood work, and ultrasound. Never mind the barium study. All of these have been done. And all were normal. 

"Maybe it would be helpful to keep a journal?" I suggest. Something for us to better understand what is happening between her visits? She is a normal weight. Normal size, normal coat. A picture of a healthy dog, but,,,, (bracing myself here),,, she is nervous. Mom is nervous. Is everyone in this household nervous? Stressed? How much exercise does she get? There is a direct correlation between dogs who play, act, and remain happy independent of their parents. I suspect she is a single pet in a perfectly doting home and maybe this isn't beneficial to her gi tract?

I suspect too much love is not what her inner self needs to grow up feeling confident, calm and content with the world she lives in. Good news is there is not an expensive diagnostic for that... just some difficult conversations and a few transitional anti-anxiety medications.. and,, "have you considered another dog?"

Pumpkin is waking up for a mega-dental extraction dental..
very common in older dachshunds.

Lilly is like so many cases I see everyday. I am never sure how problematic a medical problem is when I am not sure that the environment is influencing the clinical signs. Can you love a dog too much? Yes, when you complicate the problems with perception, actions and off setting the balance every life needs. That balance of allowing your pet to be who they are and not needing to live in the shadow of who you are and what you expect them to be. Feeding; the dilemma of feeling desperate to have your pet be happy with their meals, eat as much as you think they should be, and not buckling to offer them anything they find interesting,, too often poor quality, and too often ever changing as we chase the palatability compulsion. When I was in Ukraine rescuing dogs and cats I had a Romanian vet remind me that I needed to chill about the constant feeding concerns for the 12 animals we had transported in the car for the last 20 hours. He reminded me "that in the wild dogs might not eat for days." I wondered to my exhausted, cooked self if that included the stress of a tiny cage shoved in a tiny car running from wars? I loved those animals so much it will be the PTSD I never can shed about that broken place with all of its too many heartbreaking tales.

Saving The Soul Of Veterinary Medicine by Mark Helfat

 Saving the soul of veterinary medicine

An appeal to practitioners to sustain small, independent clinic ownership

February 15, 2023 (published)

By Mark Helfat

Photo by Scott Nolen

The author, Dr. Mark Helfat, snuggles his dog, Simply Irresistible Giselle.

Last June, I attended my veterinary college reunion (45th!) in Ithaca, New York. Over three days of perfect weather, old memories and old acquaintances were revisited and renewed in all their youth and splendor.

Before, during and since that glorious weekend, I have enjoyed ample opportunity to ponder my veterinary career with all its twists and turns, what-ifs and why-nots. I have spent many moments reflecting on our profession — where it started for me and where I see it now.

It saddens me to conclude that veterinary medicine is quickly losing its soul. I choose this word "soul" because, for me, it denotes a life-sustaining spirit, an inner force of sustenance, a vibrant, glowing core.

For four decades plus, I have viewed veterinary medicine as a singular profession. As practitioners, we treat animals and care for owners. Yes, "we care for owners." Our patients do not arrive on their own. The hand of a human is at the end of a leash or upon the handle of a carrier. Our veterinary-client-patient relationship, our VCPR, relies as much upon the C as it does upon the P. And the C and P don't have a chance of finding fulfillment and the finest care with the V unless a sound foundation of trust has been established.

I rarely encounter the word "trust" when studying veterinary journals, webinars and lectures. How do we establish this fundamental condition as we navigate daily examinations, treatments and client interactions? In my opinion, the sine qua non for gaining trust is forging a personal relationship — a one-on-one, caring, empathetic, honest and human touch.

Where would I look first to discover this foundation of trust; this genuine outreach of caring? With certainty, the answer is the independently owned, smaller-sized, community-based veterinary practice. The life and blood and soul of veterinary medicine lies in the long-established, solo-owner, hometown animal clinic.

So I'm sad to see that these clinics are disappearing, as corporate ownership, investment venture capital and super-sized juggernauts consume and dominate the present and future of our profession.

If you have never worked in a smaller clinic such as mine, allow me to draw a picture:

• The receptionists greet each client and pet by name — because they know their names.
• Clients never wait more than 48 hours for an appointment.
• Emergencies are seen that day.
• Appointment requests for specific veterinarians are gladly accommodated.
• There is frequent conversation in the exam room regarding family and all the accompanying health updates and milestones. There is no shortage of bad and sad news; however, we find the time and we have the concern.

More examples of characteristics from my practice that define the soul:

• The veterinary staff and non-veterinary staff have negligible turnover, with tenures averaging 10 years. More than half of the staff has been in place for 20 years.
• Financial concerns and limits are addressed case-by-case, allowing for discounted care when the pet needs immediate attention. If we know the client, late payments may be arranged.
• We see our patients from youth to euthanasia.
• We see our clients age as children to adults, and then we see their children.
• While appointments are scheduled at 15-minute intervals, they often go over — and we do not mind.
• Callbacks are made the next day for every surgery and for most visits involving sick patients.

I cannot view an episode of All Creatures Great and Small without breaking into tears. Silly, right? But the life depicted in the series — which you probably know is based on books by James Herriot, pen name of a 20th-century British animal doctor — is exactly what our profession is losing. These vignettes of a practice that is a family point straight to the profession's soul.

I do not have a Mrs. Hall who answers the office phone 24/7 and cooks all of our meals but I have loyal employees who genuinely know many of the clients as not just pet owners but as friends. The staff is not just staff. We are a family. Having known each other for so long, we truly care for each other.

Don't get me wrong. A large corporate practice will certainly check some of the boxes above, and I applaud them. However, it is my firm belief that the small, independent practice will check more — if not all — of the boxes.

Beyond the trend of large corporations buying up practices is a newer, and in some ways more terrible, trend: Many baby boomers who own solo, independent, small-town practices are reaching retirement. For various reasons, some younger practice owners also are looking to exit. But they cannot find a buyer for their established, vibrant, profitable practices. I speak to such veterinarians weekly who are now contemplating closing the doors and simply walking away.

I am talking about practices that annually gross $500,000 to $900,000. These practices have for years provided incomes that have purchased homes, paid bills, put kids through college, funded substantial IRAs and 401Ks, paid off student loans and provided a comfortable, happy existence.

At one time, these practices would be in demand. They would have associates eager to buy in. The owners might run an ad, and soon, the phone would ring. Simple word of mouth would send someone inquiring. No longer. Why? There are many theories and many new forces at work, but that is a topic for someone else. As these practices serving both small and large animals close, the impact is widespread and devastating:

• Veterinarians lose funds they had counted on for retirement.
• Longtime staff are left jobless.
• Towns lose a clinic, and the next nearest animal hospital may be far away.
• Clients are forced to start over with a new facility where wait times may be much longer.
• A community loses a pillar.
• Veterinary medicine loses another fiber of its soul.

Disclosure: I am among the veterinarians frustrated in trying to sell my practice. But my individual situation is not the problem. The issue is that this phenomenon is affecting a broad swath of clinics.

Please spare me the discussions of EBITDA, no-load and cash flow. I speak to veterinarians who have great numbers but because of proximity to another clinic, the mood of the broker, the high payroll percentage and a million other excuses, they cannot attract even a serious broker.

Is it too late? I say no!

Organized veterinary medicine has a habit of looking at other medical professions for ideas and answers. On occasion, the dental profession has been inspiring. Regarding this very topic, it lends some hope. Dentists have done a remarkable job of maintaining the noncorporate, smaller-sized, traditional community practice. In fact, they are quite successful at passing on facilities to associates and other buyers as they move into profitable retirement.

Where veterinary medicine now approaches 25% corporate ownership and is projected to rise, dentists in recent years have come in much lower, around 15%, judging from a 2021 article in Dental Products Report.

To drill down further (sorry): The American Dental Association — dentistry's counterpart to our American Veterinary Medical Association — has a formal initiative called ADA Practice Transitions (ADAPT) that addresses preserving the independent and smaller dental office. The program has a step-by-step process by which buyers and sellers are connected. Advisers are provided to facilitate the transitions. Simply put, the ADA has decided to play an active role in preserving the soul of their profession.

Perhaps our AVMA would consider a detailed study of the dental profession's trials and errors with ADAPT. Might such a program be of value for the veterinary profession? The AVMA has 400-plus volunteers from every corner of expertise, a professional staff that is surpassed by none, an Economics Division and even a Veterinary Economics Strategy Committee. I would hope that if our association studied this dental initiative and plugged in the unique characteristics of veterinary medicine, we might, in fact, construct our own program.

Considering the present disaster of our disappearing practices, I imagine that an AVMA counterpart of ADAPT could offer significant incentives to encourage and attract reluctant prospective buyers. Among such incentives, I'd suggest including the following:

• discounted sale prices (would a retiring practice owner jump at receiving 80% of practice value compared with nothing?)
• the option of a personal loan carried by the seller, with a minimal required down payment
• providing a list of reputable lenders willing to consider providing the necessary financing
• no commissions for either party (but presumably some type of service fee collected for the association)
• advisers for both parties
• a discussion with the seller of practice management options
• a program in which a prospective buyer first works at the practice alongside the owner and later buys in, either over a period of time or in whole

I would be foolish not to admit that there are impressive benefits that accompany employment at a large corporate facility:

• flexible schedule
• good pay
• health insurance
• paid vacation
• ample continuing education
• mentoring
• human resources support
• fancy, state-of-the-art equipment (read "MRI")

But all of these are standard fare for a practice owner, with the exception of the MRI. Do we all need the MRI?

Here are the benefits of independent ownership:

• being your own boss
• running a profitable business
• holding a recession-proof job
• more wealth
• paying down student debt more quickly
• creating tangible equity
• choosing your own schedule
• hiring family
• amassing a sizable IRA/401K
• becoming a community partner
• mental well-being derived from personal stability and achievement
• saving the soul of veterinary medicine

I was an associate veterinarian for six years. I have been an owner for four decades. I am much happier being an owner! I wonder how many years I would have stayed full-time in the profession had I remained an associate. Certainly not more than 20 or 25 years. And would I have found the success, stability and well-being that I now enjoy?

We are all different, and others' answers to this question will vary. However, I am not alone in lauding the advantages of ownership.

When will veterinary medicine reach its tipping point with regard to corporate ownership? If our profession continues on its present course, we may never see small private ownership again. Without new blood, our soul will slip away, never to be seen again. Just look at our friends in human medicine and their overwhelming corporatization. I contend that they lost their soul a long, long time ago.

One question to which I have no definitive answer is, "How many associate veterinarians have ever seriously considered practice ownership?" If one considers that the AVMA boasts 100,000 members, let's say that 75% are in general practice. That would give us approximately 75,000 veterinarians in general practice. If just 10% are youthful associates who have considered practice ownership, that is a sizable population that we must encourage and support.

Here is my elevator speech to our future, the saviors of our soul:

• Talk to your accountant/financial adviser about practice ownership and its benefits for you.
• Talk to some practice owners, classmates and friends in practice about the benefits of practice ownership.
• If you work at a noncorporate practice, consult the owner about the possibility of buying in.
• Reach out to the "maturing" veterinarians in your town, in your county, in your state. Ask what their exit plan might be. Don't be shy. You might gain some new friends fast.
• Attend your local and state veterinary medical association meetings and spread the word that ownership is in your future planning.
• Don't forget the drug reps as a source for who is looking to sell. They know everyone.

When I finished 15 years of volunteer service on the AVMA House of Delegates and Board of Directors, I promised myself two projects on behalf of the profession: First, write an inspiring book for veterinarians of all ages. That was easy. Within a year, I scribbled down The Happy Veterinarian. Second, and a whole lot more difficult, start a nonprofit that serves to save the soul of veterinary medicine. I founded Veterinary Practice Transition in 2020.

The mission of the organization is to encourage younger veterinarians to consider practice ownership while providing the older generation an option for selling their practice. The nonprofit offers personal loans with low interest rates, a 10% reduction/discount in the sale price, and no commissions for either seller or buyer. The effort is a work in progress. I cannot succeed alone. The profession as a whole needs to address the impending doom.

In closing, let me return to my reunion. As my classmates of '77 gathered and regaled each other with tales of conquest, I saw the immense, reflected energy of careers that served them all so well, but even more, careers that served so many others with compassion and empathy. What I also observed were veterinarians who reached out as family and friend, fostering the trust that defines the soul of our profession.

Mark P. Helfat graduated from Cornell University College of Veterinary Medicine in 1977. He owns and practices at Larchmont Animal Hospital in Mt. Laurel, New Jersey. He has volunteered for veterinary organizations and institutions for most of his career (New Jersey Veterinary Medical Association, American Veterinary Medical Association, Cornell University College of Veterinary Medicine, Virginia-Maryland College of Veterinary Medicine). Mark and his wife, Mendy, commissioned the sculpture "Shilo" that howls on the Virginia-Maryland College of Veterinary Medicine campus. The couple share their home with four beagles and many cats.

Cheers to you Dr Helfat. Here's to the rest of us working so hard to preserve the many souls vetmed is built upon.