Veterinary care in the food animal industry

The article¹ in the January 1, 2011, issue of JAVMA relating to the profitability of having farm personnel versus veterinarians treat left displacement of the abomasum (LDA) in dairy cattle raises some interesting points. Certainly, the use of certified veterinary technicians in food animal practice is an issue worthy of exploration. Unfortunately, the study ignores important aspects of real-world dairy practice and downplays the critical responsibility veterinarians have to educate clients about humane animal care.

The study used a statistical model to show that having farm personnel treat dairy cattle for LDA is more economical than having a veterinarian do so. However, the model does not take into account a veterinarian's ability to identify and triage surgical candidates. A displaced abomasum is as much a symptom of metabolic disease as a primary condition. Many cows are too sick to undergo any surgery; others may need adjunct treatment. If farm staff operate on poor candidates, they will have poor results. In addition, this model incorporates the cull slaughter value of surgical failures at $600. Very few surgical failures (which usually have metritis and peritonitis and have been treated with antimicrobials) are worth $600. Often, they are dead, which necessitates a substantial carcass disposal cost because of environmental concerns. Decreasing the cull value for dairy cows with an unfavorable outcome dramatically increases the cost of surgical failure and lowers the economic value of having farm personnel treat LDA. By choosing to ignore these practical concerns, the authors appear to bias the results in favor of a conclusion that allows a discussion of the use of certified veterinary technicians in practice. Although that discussion is interesting, the study overlooks the importance of the veterinarian-client-patient relationship (VCPR), the future of the veterinary profession, and the humane treatment of livestock.

Although the study presents an academic evaluation of the economics of health-care delivery related to treatment of LDA, I worry that its results will be taken at face value by dairy managers to make on-farm decisions, without regard to any missing data. If veterinarians imply that it is reasonable, cheap, and humane for farm personnel to perform LDA surgery, then farm managers will implement that policy. I find it ironic that the same issue of JAVMA contains an article² on “The veterinarian's role in animal cruelty cases” and cites the November 2009 AVMA Policy on Animal Welfare, which states that “The AVMA considers it the responsibility of the veterinarian to educate clients regarding humane care and treatment of animals.” I wonder whether it is truly humane to suggest that farm personnel with no training in anatomy and often no ability to even read instructions practice a surgical procedure on cows, particularly when it may take 50 cows for them to get good at it. Our veterinary profession has an obligation to show leadership on humane treatment of animals. If we do not, then others will do so for us.

Lastly, I find it disturbing that the authors state that the consolidation of farms requires a reinterpretation of the VCPR. I do not believe that the implied future veterinarians whom the authors note “… are unlikely to be familiar with the animals through regular and timely visits” can truly have a valid VCPR. If a veterinarian really wants to provide quality advice on neonatal health, maybe it is necessary to be there in the calving pen early in the morning before the pen has been cleaned for the consultant's visit. Doing multiple LDA surgeries provides that opportune time to start the discussion on nutritional management of transition cows, whereas simply providing a cheap surgical solution to a metabolic problem merely buries that correctable situation out of sight and mind. Perhaps for the benefit of consumers and the welfare of the animals, we should not surrender our oversight of food animal health care.

Stephen C. Major, dvm

Green Mountain Bovine Clinic PC West Chesterfield, NH

The authors respond:

Thank you for your interest in our article. We agree that veterinarians are a critical part of food animal health care. However, we disagree with many of your assertions.

You indicate that changing the cull value for animals in which left displaced abomasum (LDA) correction fails may change the economic outcome. We included two sensitivity analyses to evaluate the robustness of the model to input changes. The indifference curve allows readers to use their own input values to evaluate effects on expected economic outcomes. Given the probabilities in this model, it is not until the difference in the value between a favorable outcome (cow remains in the herd) and an unfavorable outcome (cow is removed) exceeds $2,800 (eg, value of a favorable outcome = $1,500; value of an unfavorable outcome = −$1,300) that the expected economic advantage shifts to veterinarian-delivered LDA correction.

You also suggest two factors that should have been further evaluated in this study: triage of affected patients and the delivery of humane care. In most cases, herd personnel provide the initial recognition that an animal is deviating from normal. If herd personnel are unable to triage successfully, poor results will likely be observed. However, in a direct comparison of LDA correction delivered by herd personnel or a veterinarian,¹ the range for success rate of herd personnel—delivered LDA correction (62% to 88%) was almost identical to the range for success rate of veterinarian-delivered LDA correction (61% to 87%). These results suggest that the experienced herd personnel included in the study triaged cows for LDA correction at a skill level similar to that of veterinarians. In this study,¹ veterinary school anatomic training (or lack thereof) was not demonstrated to be an important factor.

We believe it is critical for veterinarians to play a primary role in advising, developing, and monitoring protocols and training employees to ensure animal well-being. However, the data indicate that the specific parts of these protocols, including LDA correction, can be successfully performed by herd personnel. Correction of LDA is a technical skill, similar to artificial insemination. Just as we don't expect individuals performing artificial insemination to be reproductive physiologists, the data suggest it is not necessary for individuals performing LDA correction to be veterinarians.

Our report provides economic data to describe one of the reasons producers are substituting on-farm personnel for traditional veterinary tasks. We believe this trend, if continued, will jeopardize the veterinarian-client-patient relationship. Technical skills provided by veterinarians are being replaced through the use of skilled herd personnel and improved technology. A veterinary team approach incorporating credentialed veterinary technicians is one opportunity for maintaining technical services at a cost that economically competes with the cost of providing those services through herd personnel, while ensuring a veterinarian-client-patient relationship. A paraprofessional model has been incorporated extensively throughout human and companion animal practice; it is time a similar approach is examined in food animal health care. If veterinarians want to remain valuable to their clients, they can't wait for multiple LDA repairs before discussing management changes. Veterinarians must find their value in preventing the LDAs from occurring. Only in this way will dairy producers choose to continue to include veterinarians in the oversight of food animal health care.

Darren W. Remsburg, dvm

David T. Galligan, vmd, mba

James D. Ferguson, vmd, dacvn, dact

Section of Animal Production Systems Center for Animal Health and Productivity School of Veterinary Medicine University of Pennsylvania Kennett Square, Pa

Integrating animal, human, and environmental health

In a recent letter to the editor of JAVMA, “The effects of human activity on animal species,” Dr. William Skaer offers a strongly worded challenge to “… question [how] current industrial agricultural and urban practices … are affecting all of the animal species on the planet.”¹ His challenge serves as a timely reminder of the under-represented ecological component of the One Health Initiative proposed in 2007 by then-President of the AVMA Dr. Roger Mahr to “… enhance the integration of animal, human, and environmental health for the mutual benefit of all”² and to “… facilitate collaboration and cooperation among colleagues in veterinary medicine, human medicine, and environmental sciences.”³ As concerned individuals who have variously represented and practiced in veterinary medicine, human medicine, environmental science, education, and policymaking, we urge the AVMA and its One Health partner the AMA to more overtly integrate environmental contributors to human and animal disease in their reporting. Much has been learned about zoonotic conditions such as rabies, H1N1 avian influenza, West Nile virus infection, salmonellosis, bovine spongiform encephalopathy, toxoplasmosis, and others. Thanks to research funding from the likes of Paul G. Allen and the Bill and Melinda Gates Foundation, more is being learned every day in places like the School for Global Animal Health at Washington State University. In our region, the WWAMI Program teaches medical students from Washington, Wyoming, Alaska, Montana, and Idaho about cross-species contagion and animal models for human health conditions. The aspect that seems lacking is the overt and routine integration of ecological health in the human-animal-environment triad that comprises the One Health Initiative.

To be sure, the effects of climate change in specific regions may be accounted for in articles about vector-borne illnesses, but the relationships among human-caused pollution, unsustainable use of resources, environmental degradation, loss of habitat, endangerment and extinction of species, interdependence within ecosystems, and human illness have not been made sufficiently clear, as Dr. Skaer suggests in his letter.

In 2007, Dr. Bernadette Dunham, Deputy Director of the Center for Veterinary Medicine at the US FDA, called for a “… multidisciplinary approach as we address the global health needs of humans, animals, and their environment.”² We couldn't agree more. While credible research necessarily relies on objectivity and the scientific method and a cause-effect nexus may not always be obvious, policymakers, medical practitioners, and advocacy groups owe it to our constituents and future generations to become factually informed so that broad-based, scientifically grounded, multidisciplinary solutions are possible. Thank you, Dr. Skaer, for your valuable reminder.

Gary M. Bryan, dvm, ms, dacvo

Professor Emeritus

College of Veterinary Medicine Washington State University Pullman, Wash

Nancy Chaney, rn, ms

Mayor

Moscow, Idaho

Comments on veterinary hospice

The recent commentary, “Elements of and factors important in veterinary hospice,”¹ asserts that “[v]eterinary hospice is based on the same basic tenets as human hospice …” except that “[o]ne key difference … is the availability of euthanasia for animals.” The authors further refer to “client-driven [veterinary] hospice care,” “options tailored to the needs of the client,” and “[coming] to understand … clients' wishes.” This client focus is consistent with previous articles, lectures, and materials advocating veterinary hospice.

First, the biggest difference between human hospice and veterinary hospice is that in the former, patients are able to choose hospice prior to developing or during the course of a terminal illness; the desires of veterinary patients regarding hospice must be divined by the client and the veterinarian as best they can be.

Second, veterinary hospice activists consistently emphasize clients, with less attention given to patients. The primary focus is client needs, client options, and client wishes. The authors devote a paragraph to “[m]itigation of animal suffering.” But the patient's interests are more complex than simply freedom from suffering.² For example, if a dog is drugged so as to be (presumably) free of suffering but spends all its days recumbent, that dog has little or no quality of life, compared with the dog's quality of life prior to illness. I do not believe that such a dog—if it had the intellectual capacity and voice—would choose to prolong a life with little or no quality. The choice is unlike that for humans. We have a rich life of the mind: sunrises and sunsets, music, religious faith, hope, a sense of tomorrow, and so on. That cognitive capacity is another huge difference between decision making in human hospice versus veterinary hospice.

Third, the authors refer to “natural death,” in one instance devoting a paragraph to the subject. The authors provide two lay references on the subject but neglect to cite a peer-reviewed, veterinarian-authored article on natural death.²

Finally, veterinary hospice care is an important concept. But veterinary hospice activists need to let go of the human hospice model and build their own more appropriate model. The welfare of animal patients, not the clients, should be the primary focus.

Bruce Max Feldmann, dvm

Berkeley, Calif

The authors respond:

Dr. Feldmann makes an important point that in veterinary hospice, humans must try to act in the best interests of the animal patients. This process involves extensive communication between the owner and veterinarian, largely focused on making the owner the best possible proxy for his or her pet, because it is, in almost all cases, the owner who ultimately controls how the animal will live and die. The focus of the commentary was to provide insight into all the possible elements of veterinary hospice care as well as highlight the areas that are most likely to cause dissension among the patient's hospice care team.

One of the important decisions to be made, as mentioned in the commentary, is how to determine when an animal's quality of life has declined to the point where euthanasia is indicated. The presence or absence of pain (or other immediate forms of suffering) is certainly only one factor to consider.

We would also agree that veterinary hospice needs to develop a strong identity that is broader than the philosophies of pioneer hospice practitioners and more independent of the human hospice model. However, human hospice is a strong historical and current inspiration for many clients and practitioners, and a more balanced appreciation of the positive and negative aspects of this influence will probably only emerge when veterinary hospice becomes a more mainstream focus for veterinary practices.

We thank Dr. Feldmann for drawing our attention to a reference on the issue of natural death that we had not previously been aware of.

Emily Patterson-Kane, phd

Cia L. Johnson, dvm, ms

Animal Welfare Division AVMA Schaumburg, Ill