Question regarding a cat with pheochromocytoma

I am writing regarding the recent Pathology in Practice report¹ describing a cat with a malignant pheochromocytoma that had metastasized to the skin, left kidney, mesentery, abdominal musculature, lungs, and brain. In the description of the cat's history, the authors report that a mass had been removed from the cranial aspect of the urinary bladder that, histologically, had features “consistent with a urothelial carcinoma.” A month later, the cat was referred for further evaluation because of ultrasonographic abnormalities suggestive of possible recurrence of the mass. The cat was euthanized three months later, and a necropsy was performed. However, the authors do not describe the gross appearance of the cranial aspect of the urinary bladder and do not indicate whether samples were obtained from the urinary bladder for histologic evaluation. I was wondering whether these examinations were performed and edited out because there were no abnormal findings, or if these examinations were not performed, why not?

Lorraine K. Jarboe, dvm

Fort Walton Beach, Fla

The authors respond

We appreciate Dr. Jarboe's interest in this case. For brevity purposes, we did not elaborate on the previously diagnosed and completely excised urothelial carcinoma in the initial report. Evidence of this neoplasm was not found at necropsy. There were > 30 variably sized nodules found throughout the abdominal cavity, including a 6 × 4 × 4-cm multi-lobulated mass in the caudal part of the abdomen. The urinary bladder was not identified grossly but was thought to be encompassed within this large mass. However, urothelial tissue could not be found on histologic assessment of this lesion. We presume that the urinary bladder was located in one of the numerous other masses within the abdomen but could not confirm this histologically. The masses that were evaluated were determined to be metastases of the pheochromocytoma, rather than the urothelial carcinoma, on the basis of their immunohistochemical profile, including a lack of immunoreactivity for the urothelial markers uroplakin 2 and uroplakin 3.

Ashley Leisering, dvm, ms

Marshfield, Wis

Mario Sola, dvm, ms

West Lafayette, Ind

Remember that common conditions are common

The recent JAVMA News story “Veterinary care for all”¹ discussed ways to improve access to veterinary care, especially for owners with financial constraints. One suggestion to increase access to care was to focus on incremental veterinary care, which was described as “patient-centered and experience-based medicine that focuses on problem-solving to achieve the best outcomes in the context of limited resources.”

Incremental veterinary care is not a new concept; it is simply a recognition that although anything is conceivable, we should focus on the most probable conditions in the area, not necessarily all possible conditions. In human medicine, the term medically unexplained symptoms refers to persistent physical complaints that don't appear to be associated with a medical condition, and similar unexplained symptoms likely exist in veterinary medicine. I have found that because of the constraints we sometimes face, being in general practice has been both challenging and rewarding.

Charles Ryan, dvm, mph

Traverse City, Mich

Reassessing the “gold standard”

I would like to comment on the recent JAVMA News story¹ reporting on the Access to Veterinary Care Symposium hosted this past June by the Program for Pet Health Equity at the University of Tennessee-Knoxville.

Too often, in my mind, offering alternatives to the so-called “gold standard” for tests and treatments is interpreted as providing a low standard of care. But the gold standard only applies to a particular patient and a particular set of circumstances. Even then, finding consensus on the “best” test or “best” treatment can be difficult, and what is considered best is always changing.

Importantly, we do not treat problems in a vacuum. Rather, we treat patients that frequently have multiple problems, which generally vary in terms of treatability, and that are owned by clients, almost all of whom have some limitations on what they will allow or can afford. Thus, I don't think we should be using the term gold standard.

I believe the flowchart in the article illustrating how a practice could implement incremental care for clients with financial limitations is especially useful. At its core, the flowchart provides an outline of good medicine for all clients and patients. More choices can be added for clients with greater means.

I would encourage everyone to become familiar with the Choosing Wisely website,² an initiative of the ABIM Foundation. Among other things, this website provides lists from a variety of medical specialty organizations of recommended tests and procedures and the frequency at which they should be performed, along with lists of tests and procedures that are unnecessary and patients should refuse. It is amazing how many procedures considered to be the gold standard in veterinary medicine (most notably, routine, baseline clinicopathologic testing for young, healthy individuals) do not show up on the lists of recommended tests and procedures.

Patricia Burke, dvm

Providence, RI

Developing integrated health professionals

Approximately 75% of emerging and reemerging infectious diseases of people are zoonotic, and most have wildlife reservoirs; yet, human, veterinary, and environmental health remain essentially uncoordinated. The substantial differences among these three disciplines make coordination difficult; nonetheless, we believe that integration is needed for the one-health movement to succeed.

We envision a dual veterinary medical (DVM, VMD, or equivalent) and human medical (MD, DO, or equivalent) degree program through which veterinarians could qualify as physicians by completing the third and fourth years of medical college training. Importantly, veterinarians would need training in human anatomy and pathophysiology and human clinical techniques prior to admission into medical school. Such coursework could potentially be undertaken during summer breaks following the first and second years of the DVM program or following graduation from veterinary college.

The third and fourth years of the medical college curriculum include core courses in medicine and surgery, together with an array of elective courses and rotations on campus and at external locations. Combined DVM-MD degree students would engage in electives that offer one-health experience, such as courses on environmental drivers of zoonotic diseases. An international externship would be highly desirable or, perhaps, required.

To be licensed to practice human medicine, dual-degree candidates would need to complete a residency. However, the dual degree is not meant to produce physicians for general practice, but rather to develop truly integrated medical professionals who can assume leadership roles in global population health.

Many veterinarians who pursue careers in fields related to one health undertake additional training to obtain a Master of Science, Master of Public Health, or doctoral degree, which can be completed independently of or concurrent with the veterinary degree. The dual DVM-MD degree program we are proposing would be a unique addition to these existing one-health education programs.

There is little doubt that veterinarian-physicians would enjoy excellent career prospects; however, the additional time and financial commitments required to receive these two medical degrees are major considerations. It is noteworthy that most veterinarians spend eight years obtaining their degree (four as undergraduates and four in veterinary college). However, if preveterinary undergraduate education were limited to two years, the DVM degree could be completed in six years. Dual DVM-MD degree candidates could then be expected to earn both degrees in eight years, or the time typically taken to earn the bachelor's and DVM degrees. Even with cost savings, it would be necessary for participating colleges to provide dual-degree candidates with stipends, scholarships, tuition waivers, and travel allowances derived from educational grants, philanthropic gifts, and other extraneous income to help finance the additional 2 years of clinical education.

Integration of veterinary, human, and ecological health seems vital if the one-health movement expects to meet the future global needs of society. Combined veterinary medical, human medical, and environmental science education is one way of reaching this goal.

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

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

Robert C. Brown, dvm

Cherrydale Veterinary Clinic Arlington, Va