More on rigid endoscopy and laparoscopy in small animal general practice

We read with interest the report by Jones et al¹ on the economic and clinical feasibility of introducing rigid endoscopy and laparoscopy in a small animal general practice. Having trained > 300 veterinarians (most in general practice) in these techniques and having performed them in our own practice (> 3,500 laparoscopic ovariohysterectomies and ovariectomies alone) for nearly 15 years, we hope to provide additional perspective. In addition, one of us was an author on a study² evaluating patient benefits of laparoscopic-assisted ovariohysterectomy in dogs, which the authors cited.

We disagree with the statements by Jones et al¹ that “laparoscopic surgery has a relatively steep learning curve” and that laparoscopic surgery “presents specific technical challenges, including the fulcrum effect created by the requirement for insertion of instruments through small portals in the body walls … and the need for the camera to be under an assistant's control.” These challenges are encountered with multiport endoscopic and laparoscopic procedures. However, in our experience, the learning curve flattens greatly and technical challenges are reduced with the use of a single-port approach. Also, the learning curve and complication rates for most laparoscopic procedures compare favorably to those for traditional open approaches. For example, with all of the laparoscopic ovariohysterectomies and ovariectomies we have performed, we have not had any instances of bleeding from the ovarian pedicle that required follow-up surgery.

When we teach veterinarians how to use a single-port system, trainees leave the full-day session having already performed at least three laparoscopic-assisted ovariohysterectomies and one laparoscopic-assisted prophylactic gastropexy. Some also learn to perform other laparoscopic procedures (eg, biopsy, cystoscopy, and cryptorchidectomy) during their training. For those interested, we provide a second day of training to reinforce skills taught the previous day. Actual time to proficiency will vary by veterinarian.

We concur with the observation that, among other factors, effective marketing and client communication are key to the economic feasibility of rigid endoscopy and laparoscopy in general practice. In our experience, clients are less concerned about price when confident of the modality's value. We inform clients of the advantages of minimally invasive surgery and do not offer the option of open ovariohysterectomy because we believe so strongly that the laparoscopic-assisted approach is safer and less painful.

Finally, we believe four factors are critical when evaluating the potential return on investment for this modality. First is equipment price. The single-port system we use is approximately two-thirds the cost of the system described by Jones et al.¹ Second is the surcharge for using the modality versus the traditional open approach. Individual market conditions will ultimately dictate what surcharge is acceptable to clients, but in our experience, a differential of up to 20% is readily accepted. Third is frequency of use of the equipment. Jones et al¹ reported that their most common nonlaparoscopic procedure was video otoscopy, and in our experience, video otoscopy is surprisingly profitable. In our practice, we recommend it for every animal requiring otoscopy and have developed a follow-up protocol that achieves high compliance. Fourth, equipment ease of use and portability are easily overlooked but key factors in return on investment. Compact systems, such as the one we use, that can easily roll from one room to another greatly expand the equipment's availability across the practice.

Raymond E. Cox, dvm

Markee Kuschel, dvm

Deer Creek Animal Hospital Littleton, Colo

Conflicts of interest

In addition to their private practice, Drs. Cox and Kuschel operate the Center for the Advancement of Rigid Endoscopy, a provider of veterinary continuing education and surgical training.

Tuition and debt

During the past two decades, state government funding of higher education has decreased substantially, and universities have increased tuition to compensate. Among US veterinary colleges, average tuition and fees have almost tripled, from $10,500 in 1999 to $28,800 in 2016.¹ Tuition increases have outpaced starting salary growth, and average student debt has soared to nearly $144,000.² Because out-of-state students pay up to three times as much in tuition as their in-state classmates, many colleges of veterinary medicine have come to rely on out-of-state students to balance their operating budgets.

However, if tuition continues to increase at the same pace, there must inevitably come a time when numerous qualified applicants—especially nonresident and lower-income students—decide that pursuing a veterinary education is unaffordable. Tuition revenues would then decline. Thus, I congratulate the Michigan State University College of Veterinary Medicine for its decision to alter their preveterinary requirements so that students can complete them during two years of undergraduate study.³ Reducing undergraduate costs is of considerable benefit. However, to achieve sufficient tuition relief, trimming the cost of the more expensive veterinary degree program will also be necessary.⁴ Of course, this is a much more difficult task that could require cutting program and administrative costs, limiting hiring, decreasing operating expenses, and sharing educational resources among colleges, along with other possible actions.

The cost of higher education is a nationwide issue. Veterinary colleges, especially those located at land grant universities, share broad professional obligations to society that override the aspirations of individual institutions, but they rarely act in concert and finding areas of cooperation is difficult. However, averting tuition and debt crises will require colleges to collaborate, and national leadership, primarily from the AVMA and Association of American Veterinary Medical Colleges, will be essential for success. Their role should include lobbying Congress for student debt relief, ensuring oversight and accountability for collaborations among colleges, generating practical economic data, and offering grants to support college efforts, similar to suggestions in the Pew National Veterinary Education Program.⁵

It is unlikely that everyone will agree with these ideas, and too much agreement could be a sign that we have not ventured far enough. Neither is it likely that changes will happen uniformly, no matter how hard we try. However, given the gravity of the current tuition and debt problems, academia would be wise to act strategically now,³ rather than waiting to respond later, when compelled to by overwhelming external forces. By then, the problem may be too big to fix.

Skepticism is understandable.⁶ Times may change, but human nature stays the same. Nevertheless, there can be no progress without change and little success without vision, persistence, and determination.³ As Winston Churchill once said, “It is no use saying ‘We are doing our best.’ You have got to succeed in doing what is necessary.”

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

Professor and Dean Emeritus, Virginia-Maryland College of Veterinary Medicine, Virginia Tech, Blacksburg, Va

Origin of the word “veterinarian”

According to Ernest Klein's “A Comprehensive Etymological Dictionary of the English Language,”¹ the word “veterinarian” was derived from “veterinary.” Both words have their roots in the Latin word “veterinarius,” which referred to beasts of burden or draft animals and did not mean a healer of sick animals. In turn, “veterinarius” likely came from the Latin word “vetus,” meaning old or aged (the same root that gave us the English word “veteran”), which itself may have been derived from an even older word for “year” that also gave us the Latin word “vitulus” (referring to a calf or yearling) and the English word “wether.” “Vitellus,” the diminutive of “vitulus,” is the likely origin of the word “veal.”

It wasn't until 1646 that the word “veterinarian” was first used in print. Sir Thomas Browne (1605–1682) was a practicing physician in Norwich, England, who liked to coin words.² It is said that he coined 1,755 words, of which 774 are still in the Oxford English Dictionary, and that he is the 69th most often-cited source in today's Oxford English Dictionary. Browne gave us a number of familiar words, including computer, electricity, hallucination, ambidextrous, holocaust, approximate, literary, mucous, ultimate, and insecurity. And, veterinarian.

But, it was Dr. Samuel Johnson (1709–1784), who had a penchant for taking historic words and defining them, that solidified the meaning of “veterinarian” by putting the word in his dictionary.

Lester M. Crawford, dvm, phd

Georgetown, SC