The AVMA responds to continuing discussion of animal welfare

The three-orientations framework of animal welfare assessment¹ mentioned by Dr. Kipperman in his March 1 commentary² is a useful tool that can assist in evaluating outcome measures with respect to animals' health and function (health, growth, and productivity), affective state (contentment, pain, and suffering), and natural living (comparisons to wild or free-living counterparts). Outcome measures have largely been interpreted through use of the five freedoms,³ which focus on the avoidance of negative welfare states, and more recently via the five domains,^4,5 which accommodate and encourage consideration of positive states and focus on attainable goals. Even though objective data can be obtained with respect to both positive and negative states of animals' welfare, there is a subjective component to the analysis of that data. What conclusions are drawn can be highly influenced by the ethical views and values and the personal and professional experiences of the evaluator.

Tightly held ideologies in combination with a narrow spectrum of relationships and experiences can result in a skewed view. In his commentary, Dr. Kipperman appears to focus on what he believes to be the veterinary profession's and, by extension, the AVMA's preoccupation with physical health; however, divergence happens in both directions—it is equally possible to overemphasize the psychological aspects of animals' welfare. Dr. Kipperman appears to be most interested in that aspect of welfare in his evaluation of animals' housing systems and their management.

Intensive systems, such as conventional cages for laying hens, do provide limited space and restrict animals from performing evolutionarily important behaviors⁶ (eg, perching and dust bathing); however, they also provide a highly controlled environment that protects hens from a range of health and injury problems that may be encountered more commonly in more extensive systems, such as aviaries and barns (eg, injurious pecking⁸ and keel bone deformation⁹). In other words, although more extensive housing systems can help support the mental health of animals, which seems to be key to Dr. Kipperman's support of them, they can also create more challenges for animals' physical health. As veterinarians, we must guard against bias in our frame of reference, understand the trade-offs¹⁰ that exist with respect to various approaches to animals' housing and management, make recommendations that maintain and improve both the physical and mental health of animals as much as possible, and never assume that we can't do better (ie, be willing to change our approach when change is indicated). In addition to being based on sound science, our solutions to welfare challenges need to be practical, acknowledging both social acceptability and economic realities; otherwise, they become a nice theory with no reasonable chance of acceptance and implementation.

When it comes to welfare-related questions, veterinarians are uniquely positioned to get past the “narrows.” And, when we support animals' good welfare, we often also see positive impacts on what those animals provide for us—whether that be companionship, food, work, or something else. But, if veterinarians are serious about assuming a leadership position in this highly complex and emotive field, we all have to be able to step out of our comfort zones and move away from our ideologies. Are we ready to do that?

Martha Smith-Blackmore, dvm

Chair, AVMA Animal Welfare Committee Boston, Mass

Lori Teller, dvm

Member, AVMA Animal Welfare Committee Houston, Tex

Gail C. Golab, PhD, dvm

Director, AVMA Animal Welfare Division Schaumburg, Ill

More on conflict of interest

An editor's note¹ in the May 1, 2015, letters section of the JAVMA indicates that the Liaison Committee for Medical Education, the accrediting agency for medical education programs in the United States and Canada, allows deans to serve as members. With 155 medical schools in the United States, I believe it is unlikely that medical school deans have the opportunity to know each other well enough that serving on the Liaison Committee together would represent a conflict of interest. In contrast, with only 30 US veterinary schools, veterinary deans have many opportunities to collaborate and form friendships. This was certainly my experience during 14 years as dean of the School of Veterinary Medicine at the University of Pennsylvania.

Robert R. Marshak, dvm

Newtown Square, Pa

Selecting for the future

New veterinary graduates are the pillars on which the profession's future rests. Therefore, student selection is critical, requiring attention to both quality and inclusiveness. In light of this, it was interesting to read the recent JAVMA News story¹ reporting on the 2015 Association of American Veterinary Medical Colleges' annual meeting, which included presentations on the persistent lack of veterinary student diversity and calls for colleges to adopt more inclusive student selection procedures. I agree that improvement can be made in both areas.

Nonacademic criteria are used when assessing veterinary college applicants, but in my experience, undergraduate grades are still the main entrance determinant. Although a strong academic record may be a fair predictor of future scholastic success, selection processes that overwhelmingly value academics over other factors are insufficient to address diversity. To assess applicants' personal characteristics, interviews are indispensable and should evaluate psychosocial disposition, interpersonal skills, communication skills, creativity, and leadership. Interviewers should be trained in basic sociological principles and interrogation techniques, and interview teams should incorporate veterinary practitioners as well as members of the public, including human behaviorists.

Over the past years, cuts in state support for higher education have, along with other factors, pushed veterinary college tuition up severely. Consequently, veterinary colleges are increasingly financed by debt taken on by students. An unintended consequence is the disproportionately heavy financial burden on low-income students who must spend a greater proportion of their resources on education, compared with their better-off compatriots. As a society, we need to think harder about how to narrow the gap between the bottom and top of higher education's socioeconomic ladder. Economic and racial fairness are not entirely separate issues. Being well-off or poor or from a majority or under-represented group has no relevance to intelligence and motivation.

There is also the question of career diversity. Companion animal practice is the choice for most new veterinary graduates, at the expense of other sectors such as food animal practice, public health, and governmental and corporate practice. A way to steer veterinary students toward underserved areas is through a differentiated curriculum² that contains elective concentrations or tracks with distinct practice themes.³ As an enticement, colleges could use private money to support tuition discounts, bursaries, and scholarships in exchange for contractual agreements from students willing to make a set commitment (eg, 3 to 5 years) in an underserved practice sector. Inevitably, societal demands will change over time; thus, colleges would have to adjust their student selection processes accordingly.

As a supplementary feature, dual-degree programs (ie, programs leading to a veterinary degree combined with a doctoral, master of science, or master of public health degree) that incorporate advanced education and research in areas of societal need could be expanded. Stipends derived from research grants, together with tuition waivers, can be provided for the doctoral and master degree portions of dual-degree programs.

Veterinary college diversity is unlikely to improve without financial support. Colleges should establish private endowments dedicated to bolstering inclusiveness. Goaloriented philanthropic fund-raising would be necessary to achieve this. Change does not happen merely because we say it should; it takes leadership and determination. We have the power to improve diversity if we have the will. Creating a more equitable system of education may be the veterinary profession's biggest challenge.

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

Blacksburg, Va

Questions diagnosis of acute large granular lymphocytic leukemia

We read with interest the recent article by Suter et al¹ describing allogeneic hematopoietic cell transfer in a dog with acute large granular lymphocytic (LGL) leukemia.¹ This certainly was a pioneering technical achievement in the field of veterinary oncology and translational medicine. However, we had several questions about the way the diagnosis was reached and the expected prognosis.

According to the report, the diagnosis of acute LGL leukemia was made by means of cytologic evaluation of peripheral blood and a bone marrow aspirate along with flow cytometric immunophenotyping. But, we were curious about the severity of clinical signs. This is critical because LGL lymphocytoses are generally indolent diseases discovered incidentally during testing for other conditions.² In a review² of 25 dogs with LGL lymphocytosis, the 3 dogs with acute LGL leukemia all were euthanized within 1 day to 2 weeks because of rapidly progressive disease. In contrast, the other 22 dogs had persistent LGL lymphocytosis that was subclinical or did not require treatment (9 dogs) or was responsive to prednisone with or without chlorambucil (13). Fourteen dogs were alive > 1 year after the diagnosis, and 5 were alive > 2 years. Importantly, LGL lymphocytes in dogs in that study² were morphologically similar to those described by Suter et al.¹

We were unsure how aggressive the disease process was in the dog described by Suter et al, given that the initial clinical signs were acute vomiting and diarrhea and that the dog was bright and alert 5 weeks later, without any physical examination or serum biochemical abnormalities and with resolution of the lymphocytosis and no hematologic abnormalities other than mild thrombocytopenia. Also, although the dog had continuous thrombocytopenia that ranged from moderate to marked, Cavalier King Charles Spaniels have well-documented hereditary macrothrombocytopenia that is not associated with clinical signs.^3,4 The macroplatelets noted on blood smears and adequate to increased megakaryocytes on bone marrow evaluation of the dog in the report by Suter et al¹ could have indicated regeneration associated with thrombocytopenia resulting from an extra-marrow cause or, more likely, hereditary macrothrombocytopenia secondary to a β₁-tubulin mutation.⁴ Furthermore, the mild anemia cannot be definitively interpreted, because no reticulocyte count was reported and the Hct was within the range expected with anemia of chronic or inflammatory disease.

The authors state, “Considering that bone marrow involvement was minimal, the most likely diagnosis was acute LGL leukemia of splenic origin.” Yet, there was no description of any cytologic, histologic, or immunohistochemical evaluation of the spleen or results of a PCR assay for antigen receptor rearrangement (PARR). Histologic evaluation of the spleen would have been important to document a mitotic rate compatible with acute lymphoid leukemia, and PARR may have been useful to prove clonality and differentiate from reactive LGL lymphocytosis.

There is a paucity of information about LGL lymphoproliferative diseases, but what is published suggests many patients can survive without clinical signs for years with either limited chemotherapy regimens or even no treatment at all. We do not mean to diminish the effort that went into developing the treatment protocol for this dog, and this report provides proof of concept to justify evaluation of this treatment in a larger cohort of patients. We simply want to stress great caution in interpreting the clinical success obtained in this first patient.

Eric J. Fish, dvm

Elizabeth G. Welles, dvm, phd

Department of Pathobiology

Annette N. Smith, dvm, ms

Department of Clinical Sciences College of Veterinary Medicine Auburn University Auburn, Ala

The author responds:

I thank Drs. Fish, Welles, and Smith for their insightful comments regarding the diagnosis of acute large granular lymphocytic (LGL) leukemia in this dog. I would like to make clear that the main purpose of this case report was to emphasize that allogeneic hematopoietic cell transplantation is technically feasible in dogs with lymphoid malignancies. Therefore, when this dog was referred to the bone marrow transplant unit with a diagnosis of acute leukemia, the ultimate diagnosis was essentially irrelevant at that time. Although we agree in principle that other ancillary tests would have strengthened the diagnosis, the transplant unit was not involved in the initial diagnostic workup.

In the dog described in the report, the diagnosis of acute leukemia was made on the basis of CBC results revealing moderate lymphocytosis (7,900 lymphocytes/L), with 62% of the lymphocytes consisting of large, neoplastic lymphoid cells. After additional diagnostic testing 3 days later, which included bone marrow cytologic evaluation and peripheral blood flow cytometry, induction chemotherapy with cyclophosphamide, vincristine, and doxorubicin was begun. Therefore, the dog had been treated with a variety of chemotherapeutic drugs before being brought to the bone marrow transplant unit 5 weeks later. Importantly, the dog's clinical signs and lymphocytosis resolved with induction chemotherapy.

With regard to the flow cytometry results, the statement that lymphoblasts were identified was an error on the authors' part. The authors are aware of hereditary macrothrombocytopenia in Cavalier King Charles Spaniels, but comments regarding macrothrombocytopenia were removed during the editing process, since this was not the focus of the report.

The manuscript was written approximately 2.5 years after the transplant procedure was performed, and I believe that given the diagnostic data gathered at the time, the most likely diagnosis for this dog was acute LGL leukemia of splenic origin as described by Vernau and Moore.¹ I agree, as suggested by Drs. Fish, Welles, and Smith, that LGL lymphoproliferative diseases can be diagnostic challenges and that there are other possibilities, including LGL lymphoma (as stated in the text) or, less likely, persistent LGL lymphocytosis. In the report by McDonough and Moore² describing 22 dogs with persistent LGL lymphocytosis, only 5 dogs were alive > 2 years, whereas the dog described in our report has survived approximately 3.5 years and remains disease free and clinically normal. Monitoring will continue in an effort to assess the long-term hematologic and clinical effects of its transplant.

Steven Suter, vmd, phd

Canine Bone Marrow Transplant Unit Department of Clinical Sciences College of Veterinary Medicine North Carolina State University Raleigh, NC

Competition between private and specialty practices

The comments made by AVMA President Ted Cohn in a recent JAVMA interview¹ struck me as a breath of fresh air. He was particularly candid in his responses regarding the perceived lack of trust among elected officials of the AVMA. Although having never served in the AVMA House of Delegates and not having firsthand experience with private practice, I have practiced since 1972 and can state that, in my experience, the problem of mistrust is also present in the private practice sector. Both in the late 1970s when veterinary specialty practice was in its infancy and currently, a segment of private practice has seemed to convey the feeling that specialists overcharge, are not compassionate, or do not deliver value to the pet-owning public. In my opinion, there has at times been an inflated feeling of competition between private and specialty practices. It appears we have entered a competitive arms race in the delivery of quality veterinary care and have lost sight of the personal touch. I am certainly not qualified to offer any quick-fix solutions to this phenomenon but, like Dr. Cohn, wanted to convey my concerns regarding the future of small animal practice in this country.

Frederick H. Drazner, dvm

Animal Specialty Services of Kane County Dundee Animal Hospital East Dundee, Ill

New rules for for-profit schools should apply to everyone

A June 1 JAVMA News story¹ describes new regulations from the US Department of Education that will require private for-profit institutions, such as the veterinary schools at Ross University and St. George's University, to prepare students for “gainful employment in a recognized occupation” if they wish to continue to qualify for Title IV federal student financial aid programs. While these new regulations, which go into effect July 1, are a good first step, I believe that they should be applied to all private and public institutions, including all veterinary schools. To my mind, if the estimated annual loan payment for a typical graduate exceeds 8% of total earnings or 20% of discretionary income, then the school has failed and should lose federal student loan eligibility. Fiduciary responsibility should be paramount for all veterinary schools.

Veterinary schools in the United States have increased both enrollment and tuition in response, at least in part, to decreased public funding. Such a path is ultimately unsustainable and will inevitably result in sacrificing quality for quantity. But because students tend to apply to multiple veterinary schools, the number of applicants per school may not decrease. I agree with the comment by Dr. Peter Eyre² in his recent letter to the editor that “[c]urtailing programs and eliminating faculty and staff positions may become necessary to achieve long-term financial stability.”

Decreasing enrollment at veterinary schools would decrease the supply of new veterinarians, which, in turn, would result in higher salaries for new graduates.

Jeff A. Poland, dvm

Coshocton, Ohio