Researching low-cost alternative treatments

I applaud the work of Cooper et al¹ in developing a protocol for managing urethral obstruction in male cats that does not involve urethral catheterization. The veterinary profession needs a great deal more of this type of work. In school, all of us are taught how to provide the highest level of care to our patients. In practice, however, we sometimes find ourselves in need of a less expensive option, particularly when caring for the pets of low-income clients. Sometimes, an alternative plan is needed simply to care for elderly and fragile patients that cannot tolerate anesthesia or invasive protocols. The recent recession, unfortunately, means more pet owners will need these alternative plans.

Organized research is needed to encourage the use of successful alternative practices and to discourage the use of harmful or useless ones. Such research may actually uncover practices that are an improvement over current standards of care. A prominent example of this in human medicine involves human rabies postexposure prophylaxis. Reduced availability of human rabies vaccines in 2007 led the Advisory Committee on Immunization Practices of the CDC to examine how human rabies exposures might be managed if a major shortage occurred. Such a shortage never materialized, but the Advisory Committee on Immunization Practices discovered that a full series of five rabies vaccines was not needed for a healthy person and that four was sufficient.² This has now become the new standard of care, saving people time, money, expense, and the risk of an adverse vaccine reaction.

My own clinical experience has shown me that aural hematomas may, in some cases, be managed with repeated aspiration and pressure bandaging, rather than anesthesia and suturing. I have offered this alternative to clients who declined the standard care for financial reasons or in cases when anesthesia might have been risky. The results were generally cosmetic, and the procedure was cheaper and associated with less bleeding and, perhaps, less pain than the conventional approach. Over time, I have come to wonder if this low-intervention procedure should be offered in most cases. Research could help answer this question. I am sure all of us can tap into our clinical experience and come up with similar research proposals.

I propose the AVMA or American Veterinary Medical Foundation maintain a list of clinical scenarios for which research into low-cost alternative treatments is needed. I believe it is our responsibility as a profession to do such research.

Emily Beeler, dvm

Redondo Beach, Calif

More on diversity in veterinary medicine

I would like to respond to three letters to the editor^1–3 published in the December 15, 2010, issue of JAVMA that address the topic of diversity. First, it is my firm belief that any measure that takes racial or ethnic status of veterinary school applicants into consideration during the application process is wrong and should be soundly rejected.

Second, I do not believe that quality must be sacrificed when diversity initiatives are pursued. On the contrary, it is my position that if diversity can be achieved through recruitment of underrepresented racial and ethnic groups and not through racial preference at the time of admission, then there is no reason to think that quality need be sacrificed.

Third, if Ms. Kovacs is suggesting, in saying “[t]here must be an affirmative response to remove [historical institutional] barriers and to adopt practices that result in fair and equitable decisions,” that “affirmative action” should be used, then I reject that idea as unfair.

Fourth, I am concerned that the Joint Task Force on Diversity of the Michigan Veterinary Medical Association and the College of Veterinary Medicine at Michigan State University misinterpreted comments in my own letter to the editor⁴ as critical of diversity. In truth, I do not oppose increasing diversity within the profession; rather, I question whether the methods that have been suggested to achieve diversity are fair to all.

Fifth, I am confused as to the task force's intended meaning when it suggests that “[o]nly veterinarians who are truly competent in a multicultural society will reach the full potential of their medical training. …” If they are talking about adding classes to the curriculum to enhance veterinarian-client communication across cultures, I agree with that and wish I had had such courses available when I was in school. However, if they are talking about admission quotas to match the diversity of veterinary student classes to that of society, I reject that idea as unfair. Besides, if we are so concerned about the veterinary profession matching society, why are we ignoring the male veterinary student gap that now exists?

Lastly, the task force suggests that diversity initiatives be considered in all veterinary medical associations. As president of the Haggis-throwing Veterinary Medical Association, I would state that diversity is not an issue in our organization and that all are welcome. I suggest that this should be our profession's position as well.

John S. Parker, dvm

Novi, Mich

Factors related to recovery in a cat treated for lidocaine intoxication

In a recent clinical report¹ describing the use of a lipid emulsion to treat lidocaine intoxication in a cat, the authors describe substantial improvement in the cat's clinical appearance prior to initiating any treatment other than supplemental oxygen administration. Lidocaine has a very short half-life, and most lidocaine intoxications in my experience require no treatment other than, perhaps, nonspecific short-term care. I am surprised the authors did not discuss the possibility that the simple passage of time was a factor in, if not entirely responsible for, the patient's recovery.

Warren Davis, dvm, dacvim

Community Animal Hospital

Morris Plains, NJ

The authors respond:

We would like to thank Dr. Davis for his comments. We agree that there is a possibility the cat would have recovered without the lipid emulsion and that time may have played a role in the cat's recovery. However, the time course of this case makes it likely that the lipid played a role in the cat's rapid recovery. The cat was examined within 30 minutes after it had received the lidocaine overdose. Lipid administration was started 30 minutes after initial examination, and lipid was administered over a 30-minute period. However, 15 minutes after lipid infusion was begun, the cat began showing signs of rapid recovery and looked nearly clinically normal at the end of the lipid infusion. The mentation change in the cat was so dramatic and occurred in such a short time span (< 1.5 hours) that we doubt it was due to time alone. Thomasy et al¹ reported that the elimination half-life of lidocaine in cats is 1.7 hours. Additionally, that same study found that both lidocaine and monothylglycinexylidide, an active metabolite of lidocaine, were detectable in plasma 250 minutes after administration of a 2 mg/kg (0.9 mg/lb) dose of lidocaine. In fact, plasma monothylglycinexylidide concentration was still quite high (approx 0.04 μg/mL) after 250 minutes. The calculated dose of lidocaine that our cat received was 20 mg/kg (9.1 mg/lb), and it could be expected that toxic concentrations could remain in the plasma well past 1.7 hours. Additionally, for most toxic substances, patients recovering from an accidental poisoning that do not receive a specific antidote typically recover gradually and not in an abrupt fashion, as was the case for the cat described in our report. Finally, and most importantly, we were able to demonstrate, at least in this cat, that administration of a lipid emulsion resulted in no detectable adverse effects, suggesting that the emulsion may be a viable treatment option for cats with toxicoses associated with lipid-soluble substances.

Stuart C. Clark-Price, dvm, ms, dacvim, dacva

Maureen A. McMichael, dvm, dacvecc

Department of Veterinary

Clinical Medicine

College of Veterinary Medicine

University of Illinois

Urbana, Ill

Obstacles for veterinarian-scientists

I find much to agree with in the letter¹ by Dr. Eleanor Hawkins and her 10 colleagues in the JAVMA issue of December 15, 2010, but my uppermost concern was overlooked. I readily concur that substantial numbers of diplomates of the American College of Veterinary Internal Medicine and other specialty colleges, primarily in veterinary schools, are engaged in meritorious research that advances the quality and sophistication of clinical veterinary medicine and at the same time adds a unique comparative perspective to the general body of medical knowledge. My commentary does not mean to underestimate these contributions nor the importance of clinical specialties (I was a founding member and past president of the American College of Veterinary Internal Medicine). Rather, it means to direct attention to the fact that in this quickening era of molecular and genomic medicine, veterinary schools are generally ill-prepared to engage in high-impact translational research owing to a paucity of veterinarian-scientists with the training and skills needed to compete successfully for funding from the National Institutes of Health (NIH). In the training of veterinarian-scientists, I regard clinical and basic science skills as essential coequal partners.

The fact that veterinary medical research receives such a small fraction of the total federal biomedical research budget and is abysmally underrepresented in high-impact biomedical journals has little or nothing to do with bias against veterinary medical investigators or research proposals with a comparative perspective. It has everything to do with the quality of proposals, their relevance to NIH priorities, the scientific qualifications of applicants, and convincing evidence that investigators will have protected time and adequate laboratory facilities. As the letter's authors—six of the 11 with PhD degrees—correctly point out, teaching, administrative, and patient care responsibilities in most veterinary schools leave little time for highly productive research involving a substantial laboratory component, even for those with rigorous basic science training. While I believe that clinical specialty training in tandem with, or followed by, rigorous doctoral-level basic science training is the ideal path to a successful career as a veterinarian-scientist, it is a long and expensive journey that few can afford; even physician-scientists, generally functioning in more supportive and nurturing environments, are 42 years of age on average when they receive their first NIH RO1 grant awards.

My statement that the allure of specialty training opportunities may be having an erosive effect on the number of veterinary students who elect to pursue a serious career in biomedical research is based on my understanding that with the advent of so many specialty colleges, there has been a sharp decline in the number of applicants for the longer and more arduous doctoral-level research training programs. I would wager that of the > 20% of veterinary school faculty who are clinical specialists, as the authors state, only a small fraction have the training to qualify as veterinarian-scientists.

Robert R. Marshak, dvm, dacvim

Emeritus Professor and Dean

School of Veterinary Medicine

University of Pennsylvania

Philadelphia, Pa

Combating the shortage of food animal veterinarians

In his recent letter to the editor,¹ Dr. Michael Fox suggested that concentrated animal feeding operations (CAFOs) have been the demise of food animal practice and that eliminating CAFOs could possibly encourage veterinary students to enter into food animal practice. I respectfully disagree that this would be an easy way to achieve that desired result.

Having practiced a long time and watched the evolution of agriculture and veterinary medicine that has occurred, I believe the decrease in food animal veterinarians is a multifaceted issue. In our area, one issue that has been of real importance is corporate consolidation and changing sales policies with an increase in direct-to-producer sales. Most trade journals have full-page color advertisements from drug and vaccine manufacturers describing the effects of their products. These products are sold to producers through direct, Internet, catalogue, or telephone sales without any veterinary involvement or advice. How can we as a profession stay relevant when we never get any opportunity to offer advice on preventative medicine or herd health? The type of advertising seen on television has been successful in portraying this profession as overpriced and unnecessary.

According to the most recent figures from the Census Bureau, we now have 308 million people in the United States, and one in seven of those is receiving food stamps. If we are to continue feeding the growing US and world population, it appears we not only need CAFOs but also need to incorporate best management practices and increase the use of technology. Our profession has the training, expertise, and knowledge to assist, but we cannot force ourselves on any industry or business that does not place a value on those assets.

At a meeting I attended some time ago, a discussion arose regarding causes of the shortage of food animal veterinarians and an older veterinarian spoke up and said that there never has been a shortage of veterinarians, only a shortage of people willing to pay for veterinary services. Having had several years to think about that statement, I believe he was absolutely correct. Until that changes, the shortage of food animal veterinarians is never going to improve.

Don Cobb, dvm

Casper, Wyo

Veterinary medical education issues revisited

A recent JAVMA News item¹ invites comments on the draft report and recommendations of the North American Veterinary Medical Education Consortium (NAVMEC).² The draft report is a distillation of three national conferences that were designed by NAVMEC to develop strategies that would prepare the veterinary profession for its future roles and responsibilities. The draft provides a number of good ideas about sharing curricular materials and pedagogical practices among colleges and schools of veterinary medicine and describes a rigorous set of core competencies for all veterinary graduates (which the accrediting, testing, licensing, and educational establishments should accept). There can be no reasoned disagreement about these necessities. However, the draft fails to provide any analyses of or recommendations for curricular design, even though the second NAVMEC conference was devoted almost entirely to exploration of models of veterinary education and a number of sturdy recommendations were made by the conference attendees. The draft does not evaluate the pros and cons of various educational practices or their effects on student learning (ie, information overload, use of technology and blended learning, case-based and problem-based learning, tracking, distributed community-based clinical education, time to graduation [eg, six years vs the conventional eight], program efficiency and college expenditures, student costs and debt, and practice readiness of new graduates). These omissions are troublesome and additional explanation is clearly warranted because the conferences were much more complete and definitive than the draft report suggests. Merely calling for more research in veterinary education affords no progress whatsoever and is unacceptable this time around. Without sufficient elaboration by the authors, the reader must conclude that a “career-ready” veterinarian is one who is all things to all species, essential core competencies notwithstanding. Considering the ever-expanding realms of medical and scientific knowledge and the many different fields within veterinary medicine, the persistent myth of the all-purpose veterinarian is both illogical and perilous; the inevitable lack of depth is the very essence of mediocrity. How is it possible to produce truly career-ready graduates in every branch of veterinary medicine without some form of differentiated education (ie, tracking) similar to the highly successful multiple, parallel curricula that have been long-established and thoroughly evaluated in colleges of engineering? Slavishly continuing to imitate the monolithic structure of human medical education is inept.

After more than 50 years of philosophizing, improvements in our system of veterinary education are long overdue, but success is by no means guaranteed. It is well known in the business world that the greatest resistance to change resides with the people most affected by it, most of whom are unable to believe in innovation until they have had actual experience of it. Contradictory though this is, it has always been the insurmountable barrier to transforming the veterinary profession. Even with inspired leadership, not much can happen without a receptive following. It is hard to change a system that won't be changed! Progress is up to us. We owe it to generations of veterinarians yet to come, and to the future good of society, to ensure that NAVMEC spurs substantial advances in veterinary medicine. But only time will tell; facts and logic can't beat delusion.

Peter Eyre, dvm&s, bsc, bvms, phd

Professor and Dean Emeritus

Virginia-Maryland Regional College

of Veterinary Medicine

Virginia Tech

Blacksburg, Va