Choosing a career beyond private practice

We applaud the recent calls for improved student awareness of the breadth of opportunities in the veterinary profession.^1,2 Veterinary colleges provide excellent comprehensive education in clinical medicine and surgery, but in our opinion, often do too little to promote careers other than those in private clinical practice.

The Virginia-Maryland College of Veterinary Medicine has been offering veterinary education and training beyond private practice through its Center for Public and Corporate Veterinary Medicine for nearly three decades. The college curriculum is differentiated into several clinical practice tracks, along with a track in public and corporate veterinary medicine that is taught cooperatively with government agencies and commercial organizations. During orientation and throughout all four years of their veterinary education, students are counseled about the breadth of veterinary career opportunities. The Center for Public and Corporate Veterinary Medicine also serves as a resource for practicing veterinarians wishing to change careers.

Many veterinary colleges offer dual-degree programs (eg, DVM-MS, DVM-MPH, DVM-MBA, and DVM-PhD). These combinations greatly expand career opportunities for veterinary students and can lead to an extensive range of career options.

We agree with Dickerson et al² that “[f]urther efforts to highlight the diverse and fulfilling career opportunities available to veterinarians are needed.” All recent studies on the direction of the veterinary profession and projections of workforce needs indicate that not only are there critical unmet workforce demands for veterinarians, there are many complex societal forces and global trends that will require veterinarians to work across disciplinary and professional lines. Failure to meet these challenges will result in an ever-declining role for veterinary medicine in global society.

Although modest progress is being made, we suggest that even greater progress would be possible if veterinary colleges were more willing to make career training beyond private practice a genuine priority, both for veterinary students and for veterinarians exploring new opportunities. To do so, we further suggest that now would be a good time to revisit the idea of centers of excellence, as recommended in the Pew Report,³ whereby colleges of veterinary medicine would collaborate and share resources to provide a more complete spectrum of veterinary medical education.

The status quo is not sustainable. Substantial changes are urgently needed if our academic institutions and their graduates are to make optimal contributions to society in the future.

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

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

Valerie E Ragan, dvm

Center for Public and Corporate Veterinary Medicine, Department of Population Health Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Tech Blacksburg, Va

Hypofractionated radiotherapy in dogs with oral tumors

We are concerned that the report by Riggs et al,¹ “Outcomes following surgical excision or surgical excision combined with adjunctive, hypofractionated radiotherapy in dogs with oral squamous cell carcinoma or fibrosarcoma,” does not represent long-standing standards for the treatment of subclinical disease in dogs with oral tumors. Compared with total adjuvant radiotherapy doses of 54 to 60 Gy cited for comparison,² the 32- to 36-Gy total doses reportedly used in this study are subtherapeutic and would not necessarily be expected to yield long-term local control. When treating microscopic disease, where the target is primarily normal tissues and the intent is long-term local control, the use of 8- to 9-Gy fractions has been shown to exponentially increase the likelihood of irreversible late complications in normal tissues.³ Thin bones such as the maxilla and mandible are at particularly high risk for developing late effects, and the potential for osteoradionecrosis in thin bones is mediated by fraction size.⁴ In addition, Riggs et al reported that radiotherapy doses were delivered with a single radiation portal, which will result in overtreatment of normal tissues superficial to the tumor, further increasing the likelihood of irreversible late effects. The standard of care is delivery through at least 2 and preferably multiple portals for homogeneous tumor dose distribution and normal tissue sparing. The occurrence of late adverse effects in the study was not evaluable, given the low number of dogs in the radiotherapy group. Still, long-term survivors treated with this protocol could be expected to have unacceptable risks for both tumor recurrence and irreversible late complications in normal tissues.

The authors acknowledged that finely fractionated definitive radiotherapy protocols resulting in higher total doses may result in better local control. Their concern that the requirement for daily anesthesia, the higher risk for reversible acute radiation toxicoses, and the higher costs for definitive radiotherapy would deter many owners from proceeding is reasonable. However, palliative radiotherapy at many institutions costs upwards of $2,000, itself not an insubstantial expense. Safe, rapidly acting sedatives and anesthetic agents are widely available, greatly reducing risks associated with daily anesthesia.^5,6 Finally, none of these concerns (anesthetic risk, adverse effects, and cost) offset the concerns that the low total dose is subtherapeutic if the goal is long-term tumor control and that the high fractional doses may cause irreversible late complications in normal tissues even if long-term local control is achieved despite the subtherapeutic dose. The appropriate radiotherapy options for patients with subclinical disease postoperatively are either finely fractionated definitive adjuvant radiotherapy delivered to a total dose approximating normal tissue tolerance, or observation followed by palliative treatment of gross disease when the tumor recurs. Four weekly fractions of 8 or 9 Gy would be appropriate at that time.

Nicholas Rancilio, dvm, ms

Gregory Almond, dvm, ms

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

Jeannie Plantenga, dvm, phd

Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, Ind

Kevin G Ware, dvm

The Veterinary Cancer Center, Norwalk, Conn

The authors respond:

We thank Drs. Rancilio, Almond, Plantenga, and Ware for their comments on our study.¹ Our intention was not to compare various radiotherapy protocols for adjunctive treatment of residual disease in patients undergoing surgery for oral squamous cell carcinoma and fibrosarcoma, nor to specifically advocate the use of a coarsely fractioned radiotherapy protocol over other protocols described in the literature. As alluded to in our discussion, we acknowledge the risk of late radiation toxicoses following delivery of a coarsely fractionated, palliative-intent protocol, and we ensure that these risks are explained at length to clients whose pets are embarking on such a treatment protocol. Given the results of this and other studies, the radiotherapy protocol described is no longer used for dogs with incompletely resected oral fibrosarcomas at our institutions, despite its previously documented efficacy for appendicular sarcomas in dogs.^2,3 However, we would argue that with careful patient selection and client education, there may be an indication for adjunctive, coarsely fractionated, palliative-intent radiotherapy protocols in the treatment of dogs with incompletely resected oral squamous cell carcinomas. Importantly, 19 of the 39 (49%) dogs with oral squamous cell carcinoma in our study were geriatric (≥ 10 years of age), and for dogs in this demographic group, long-term disease control may be of lower priority than it would be for younger dogs. Therefore, in those instances when comorbidities, logistic factors, or financial constraints may preclude use of a finely fractionated radiotherapy protocol, our results may support the use of a coarsely fractionated protocol as an adjunct to surgery to extend survival times of dogs with incompletely resected squamous cell carcinoma (median survival time after surgery, 2,051 days with coarsely fractionated radiotherapy vs 181 days with excision alone).¹ Furthermore, at a time when gold standard radiotherapy protocols for treatment of tumors in dogs are poorly defined⁴ and many protocols lack corroborating level 1 evidence,⁵ we would argue that reporting of all results for recognized radiotherapy protocols in dogs represents a valuable contribution to the otherwise sparse literature in this field.

Julia Riggs, ma, vetmb

Willows Veterinary Centre & Referral Service, Shirley, England

Vicki J Adams, dvm, phd

Vet Epi Abbey Farm Cottage, Ixwoth, England

Joanna V Hermer, bvm&s

Taverham Veterinary Practice, Norwich, England

Jane M Dobson, ma, dvetmed

Jane F Ladlow, ma, vetmb

Queen's Veterinary School Hospital, Department of Veterinary Medicine, University of Cambridge, Cambridge, England

Suzanne Murphy, bvm&s, msc

The Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush Campus, Midlothian, Scotland

Call for community animal hospitals

A recent JAVMA News article¹ discussed West Texas A&M University's plans to spend $22.8 million on a building for veterinary education, research, and workforce as part of a new $90 million commitment to the state's agricultural industry. I'm wondering, however, why the university would not, instead, build several veterinary hospitals throughout the region that would be staffed and run similar to the way community hospitals for humans are. Depending on the community, those veterinary hospitals could have as much or as little equipment as the community deemed necessary. To my mind, this would solve a lot of the current problems that veterinarians, new and old, are experiencing, by putting concerns about debt and cash flow on the community and taking it off veterinarians. Veterinarians working at these hospitals would be employees of the community animal hospital, just as if they had gone to work for a corporate practice in an urban area. The existence of such community animal hospitals would allow interns from Texas A&M University, and possibly neighboring states, to experience veterinary medicine, supervised by a senior veterinarian, in a real-life setting. And, the hospitals could include apartments for the interns, or members of the community could offer lodging, with the hope that a bond would be forged that would bring veterinarians back to the community animal hospital.

If we are to solve the problem of staffing rural veterinary practices, we must get beyond the traditional paradigm under which a veterinarian is expected to be the owner of the building and equipment, the office manager, and the practitioner, all while beginning a career deep in debt and fresh out of school. One way to solve this problem is to shift the business risk to the community that wants to have a local veterinarian. The community could even sell shares in the hospital if need be, but making sure the community has a vested interest would seem to be a great way to ensure a veterinarian could be employed there.

Fred Philips, dvm

Rushville, Ind

Issues with pet diets

The recent JAVMA News story “Unusual pet diets may be linked to heart disease”¹ reports that the US FDA's Office of Foods and Veterinary Medicine is studying possible connections between certain diets—particularly grain-free diets—and dilated cardiomyopathy in dogs and indicates that the Cummings Veterinary Medical Center “is warning people that they should tell a veterinary cardiologist if their pets have heart disease and eat foods that are homemade, raw, or vegetarian or that are made by small companies.” In my opinion, the article paints an unfair, negative picture of certain types of pet foods and a certain section of the pet food industry.

Clearly, the ongoing debate about the safety of certain types of pet diets is not going to abate in the near future. However, many underlying and confounding factors can potentially play a role when specific diets are linked to disease, including the quality and variety of ingredients and the source (eg, homemade vs commercial), preparation (eg, cooking temperature), and processing (eg, raw, freeze-dried, dehydrated, or pasteurized) of the diet. Bacterial, fungal, and parasitic contamination may contribute, as may contamination with metals, thyroid hormone, pesticides, herbicides, aflatoxins, and mycotoxins. Ingredients not listed on the label may be included in some diets, taurine requirements for dogs are different from those for cats, and genetic predispositions and potential interactions between foods in the gastrointestinal tract must also be considered.^2–6

An objective approach is needed when educating owners about various diets, and practitioners should seek expert opinion and advice, rather than warning against certain types of diets or manufacturers. Each pet can present unique needs or challenges when attempting to identify an optimal diet.

W. Jean Dodds, dvm

Santa Monica, Calif

Debt and tuition

The Veterinary Debt Initiative, as described in the recent JAVMA News story “New aim of debt program is helping veterinarians thrive,”¹ fails, in my mind, to address the elephant in the room: the biggest single factor contributing to veterinary student debt is the staggering cost of tuition at veterinary colleges. I recently visited The Ohio State University College of Veterinary Medicine and was shocked to learn that tuition for out-of-state students was $71,000 per year.

By and large, veterinary students don't lack needed financial planning resources or crucial information about how to balance their finances. Their problem is not having parents rich enough to pay the tuition needed to enter the field of their dreams. The rising cost of veterinary school must be addressed to protect the diversity and longevity of the veterinary profession.

Diana Care, dvm, mph

Sumrall, Miss