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Surviving Veterinary Medicine
Fear Free® is Only the Beginning with Dr. Mike Petty
April 3, 2020


Narda Robinson, host (NR):  Surviving veterinary medicine.  Be smart, be bold, be creative and be your own boss.  At the very least find a practice where you can do what you do in the most positive way that gives you the space to practice medicine as you see fit. Because at SVM we set a higher standard for medicine than what you learned in school  I’m your host, Dr. Narda Robinson, veterinarian, osteopathic physician, and leader of the VetMed Revolution™, calling for safer, gentler, and more effective medicine for animals and their people. 

So we started out, I was saying about Fear Free® and you know before the world started coming apart I was thinking about you know that the Fear Free® piece is just the beginning. I mean and it should last through, but if you’re treating them in a very conventional manner that seems to antagonize or negate that, so that was that second idea that I had, it’s not truly Fear Free® if it’s not the pain free and the integrative medicine piece. That makes everything consistent. 

Mike Petty, guest (MP): Right, right.

NR: But of course even to diagnose the cruciate we recommend is that you shouldn’t have to do a painful orthopedic exam. I’ve seen, maybe it’s different now at the university, where they don’t have three or four people holding down the dog and forcing their joint into all kinds of ranges of motion, but it seems like that would have to shift given the people that are involved in Fear Free® now.

MP: Yes, and I really agree with this and I have said, you do not have to make them holler to get your point across that there’s an issue. I will admit that there are some times there are clients that are incredibly skeptical and you do need to palpate to the point until the dog reacts, not scream, just to let them know that there’s an issue going on. Otherwise they’re like oh yeah you’re just saying this. They’re few and far between, but you know I’ve done it for the dog’s benefit basically so they agree to treatment.

NR: Right, I agree. I’ll do that too. With a human you can show that, but the times, which are not few, where I’ve heard that they spent a half-hour or an hour trying to see, was there really a positive drawer test on that animal, it’s like you’ve been working that ligament, what are you doing to it?  I mean it’s such a fundamental shift needs to happen to really incorporate Fear Free® principles deeply that there is much more to do, and more to encourage and especially when there’s more hands-on assessment and massage throughout the patient’s day and all that. But anyway so that was the second iteration and then we have this coronavirus thing which places this heavy blanket on everything that’s going on and sort of shifts us into more survival mode rather than optimizing the patient experience so there’s so much going on it’s hard to decipher. 

MP: Right right.You’re not going to convince anyone to get certified for Fear Free® right now. Because, trying to decide how to stay alive.

NR: Right. I mean we’re all fearful. 

MP: Yeah. But you know, it’s kind of interesting, I’m looking ahead to my appointment calendar for the next 3 weeks and people are not making appointments for vaccines and such which I think is probably okay, unless they have a dog that’s at risk. But you know what is filled up? My acupuncture schedule–they are all coming in. They know what it’s like here, they know that we swoop them into a room, that they never see any other clients, they never even see any other dogs and cats. My front end, it’s like they’re the gatekeeper. No, you need to stay in the room because we have another dog coming. We don’t cross dogs. We don’t cross dogs and cats. The people that have come to me regularly are still coming in. They’re still making the appointments.

NR: And isn’t that great. Thank you for reminding me because that gets me back to where I was saying that integrative medicine should be first line care. I mean we can get away from this overdose of technology and surgery and cost escalation and everything. Certainly those things are needed, but shouldn’t be the norm. And I think over the past several decades, especially with human medicine as well, more and more high-tech, more and more tests, it pads the bill, and then it dissociates or depersonalizes the practitioner from the patients, and in our case, the clients as well. If you don’t have a drug armamentarium, and of course now with all the drug shortages and opioid restrictions, it’s like this is the time for Integrative Medicine. 

MP: Right, it really is. But people have to understand integrative medicine, but not all the herbal supplements, and you’ve got to be careful with the proprietary herbal supplements. 

NR: Right.

MP: I say this to people all the time, if I don’t know what’s in it, I’m going to tell you to stop using it, because sometimes people come to me as a second opinion and they’ve been to a TCM doctor and it’s like I don’t know what  “man walking along a trail” something-or-other is, you know? I mean it’s like they have these weird names and no idea. I recently had an extern here from Michigan State University. We got cut short because Michigan State pulled all externs, even though I said she’s probably safer in my clinic than anywhere else, but they pulled all externs. But one of her questions the first day here was, everyone says you can’t make money at acupuncture, and just after one week she said, yes, you can make money at acupuncture. Maybe it’s not going to be the million-dollar practice but you know honestly some of these million dollar practices, you really have to question what they’re doing and why they’re doing. There’s a specialist in our area, he just retired, but every time someone goes to him they say I just walked out of the door, I was with him for 20-25 minutes and my bill was $1,500-$2,000 whatever. You know they run every test known to man, and I try to warn people before they go but they think that maybe it’s sour grapes on my part that they’re going somewhere else or whatever, and then they come back and say, oh my God. 

NR: So this is a specialist, a more conventional practitioner type?

MP: Yeah. Yes.

NR: Wow, you can sell your soul and not sleep at night or do whatever. I mean the things that sustains you and me is connection to people and being honest and transparent, and doing love based work for veterinary care. 

MP: Right.  And as I always say I’m never going to be rich being a veterinarian but I’m never going to lose sleep and I’m never going to feel bad about what I’ve recommended and done. 

NR: Right, right. I mean in terms of the financial success and all that, we have several people that, several of our instructors that we see twice a year that are actually hiring. They get so busy with their rehab and acupuncture and in the whole integrated medicine thing that they are always looking for more staff and usually try to keep it with the scientific group, but sometimes there’ll be a need in an area, and even with the Chinese medicine maybe practitioner at first, they see what the scientific approach has and then they’re pretty soon converts, and are learning the actual mechanisms for what they were doing. 

MP: Right, right.

NR: So let me see, I have somewhere here, well, I have Fear Free® principles and was going to go through that. Would you like to discuss Fear Free®? I’m actually part of the way through first level certification.

MP: Yes, so we can talk about that.  I’ve completed third level and it’s building blocks. And throughout each level I see things that’s like, yes, that’s common sense, or no, I never really thought about that before. For example one of the things that I never really considered before was that pets that take treats from you way over enthusiastically are often very scared.

NR: Wow, I must not be there yet.

MP: I never really thought about that before, but now that I have, I’ve looked at it.  Everyone should go through that and if you have a predominantly cat practice I recommend getting a Cat Friendly practice certification as well. Because there are extra things that you’re going to learn there that you’re not going to learn in Fear Free®. This isn’t a promotion of Fear Free® or Cat Friendly, but I just can’t remember the last time that I had a cat try to nail me for anything. It’s just astounding, just really astounding, how well it works. My extern said, oh you’ve got a cat coming in for acupuncture, and I said yes, it’s got some back issues, and it’s got some sinus issues, and she said, what are you going to do with the sinus issues? I said I’m going to fill it’s face full of needles. And she’s taking a picture cuz she said, I didn’t think you could do that.Yes, you can. The cat is calm enough, it’s been here enough, they understand it’s not a big deal. 

NR: Right.

MP: I know before Fear Free® but when I first learned acupuncture, it was touch and go with cats getting needles into them but just not anymore. 

NR: So what kinds of things did the Cat Friendly practice certification teach you that were new at that time to you? 

MP: It’s been a couple years and I’ve done Fear Free® since then, so I might confuse a few things, but they really stressed the importance of the physical setup, no junk on the counters for the cats to try to hide behind, or accidentally knock over and scare themselves, letting the cat wander around the room, minimize the number of times you walk in and out of the room, put the cat in the room–explain to the client you’re going to be sitting in here for 10 or 15 minutes. It’s not because we’re busy, it’s because we want the cat to get bored, and then go into the room and then the cat’s like oh something new, something curious, and try to go into the room anticipating everything you might need in terms of vaccines, literature, whatever, and bring it all in there. Because what upsets cats is opening and closing that door, who’s this coming in, is it a new person, is it a new person I have to be on guard about.  So every new person that comes in, they have to reset, re-evaluate, is this now a dangerous room or not. And that has really helped a lot.

NR: I can see where that would. Have you seen evidence where that is being introduced into veterinary schools? 

MP: It’s Fear Free® in vet schools. Cat Friendly is not really getting into it and I think that it really should.

NR: Absolutely.  And I think the most common thing I say to myself when I’m going through there, I mean, I do the same exact thing as you do like I knew that but not everything, but a lot of things I’ve done and taught with the acupuncture course but to have it said. I always think I’m at such the far end of the field in terms of being sensitive and empathetic with animals, and to have this program that has become so widespread actually say these things in a systematic manner like a codified manner. And that so many schools are, at least seemingly, adopting it. Now that’s what’s amazing and probably hugely due to Marty Becker’s influence and just everybody buying in and it’s really astounding to me that it’s out there and I do think, yeah, it should be part and parcel of everything. 

MP:  And 5 years ago Fear Free® didn’t exist but it’s everywhere. And it seems like it’s been here forever but it’s just become so quickly an integrative part of veterinary medicine. Marty told me the number of veterinary schools but I think something like 18 or 19 of them require Fear Free® certification before their students can graduate.

NR: Wow, yeah I know he’s sort of run down those statistics to me too. That sounds about right. But it’s still then to me, it’s and you’re going to do what?  It’s like thinking of the dog and the considerate approach and the gentle handling. You’re going to do what to me? You’re going to cut my tibia?

MP:  Right, right. Exactly. I know, and as you know in human medicine, that if you’re going to perform some invasive procedure you have to outline all the alternatives, or you can get in trouble.

NR: True.

MP: That’s not true in veterinary medicine. You can say nope, we’re going to do a TPLO and not even tell them there’s an alternate surgery or that maybe rehab might fix this, or whatever. I’ve never heard of anyone getting sued for not explaining that. So Michigan has been the last state that’s required continuing education in order to get your license. It’s kind of sad, but at least we’re finally there and they have basically three required classes, one of them is opioid training, which to me is stupid because we don’t dispense opioids. The other two were record keeping and legal. I was just so disappointed with it after 2 hours of taking those online classes and paying money for them, the only thing that I came away with that I didn’t realize beforehand was that if you lose your license or you get slapped on the wrist, that the licensing board alerts all the other states.  That was the only thing I learned. Everything else, it was like how to keep records and all this other stuff, but yet there was no ethical stuff on it. The ethics of law should’ve been in that class, like you need to be thinking about this, you need to be doing that. It was more how to cover your ass in case someone came after you. That should be mandatory.

NR: Right. Yes well, and then how would we change that? How do you change laws? How do you influence? We’ve talked about vet boards and sort of the politics of being on a vet board or not. But like you say, people aren’t being given other alternatives, and I feel like they are not adequately informed about what the risks of TPLO or any surgery are. With human medicine, it’s not ideal but at least you can read the information. You’re supposed to be told about what could happen.

MP: Right.

NR: And that you’re the person signing up for it so you should be able to know what you’re getting into. But when I talk about non-surgical approaches to pelvic limb lameness, cuz I think a lot of them are not cruciate issues, and I’ll talk about that in a lecture and I have slides full of risks and bad outcomes from the TPLO.

MP: Right.

NR: It amazes me even that there’s so much bad stuff associated with it.

MP: And yet it’s worth how many millions? Right.

NR: Right. So that needs to be addressed for sure. And I’m going to do that in an upcoming podcast. 

MP: Great.

NR: I think with Fear Free® they do recertifications?

MP: Yes. I haven’t reached that point yet but yes you have to re-certify at a certain point. I did all mine within the past year. I’m quickly approaching it.

NR: Yeah, because I just found it interesting. I brought a cat a few years ago into a local practice where a cardiologist was going to be setting up and just to get an echo or something on a cat and they said they were Fear Free® certified. I went in and there was a TV in the waiting room. Me and my cat were the only people there and the TV was on, blaring some game show. So it’s like this is stressful, this is very bad acoustic input. What really stuck out to me at that time too, when I went back and we’re preparing to see the cardiologist and they were examining the cat, taking a temperature, I don’t think in a Fear Free® manner. And then they said, well, okay, I think we’re done torturing the cat, which is a common thing that you hear. And it’s like that was very offensive to me, that word. 

MP: Right.

NR: It just seemed to violate the ethos of Fear Free® to me.

MP: Right, and I absolutely hear you. We had to borrow some ear medication from a clinic near us and it’s a huge clinic, it’s a 7 doctor practice. We have a dog that’s the nicest dog in the world, the owners do everything for it, had a sarcoma on it’s mandible, had to get a partial resection, you can do anything to this dog except touch his ears. So one of the things that when he gets an ear infection there’s this product called Claro, you put it in once, it lasts for 2 weeks, it’s great for the dog.  Well, we didn’t have any so we borrowed some. Long story short, I returned it and I had to wait about 15 minutes just to return it but I was in the waiting room for this facility, they had a TV going, it was probably not only distressing to the animals, it was probably distressing to the clients because it was Judge Judy and there was a veterinarian that was getting sued. There are dogs cowering in the corner, you could roller skate in the lobby, this place is so huge, but they have it set up so people, they have the lights turned off at one end so everyone’s crowded together and I’m just watching the intake people and the dog is scared,  it was a Golden Retriever. It gets up, the first thing it does is shake, it would only shake its head and there’s obviously some kind of pain mid-back and then I watch the dog and it has what looks like a cute butt wiggle, but it’s really just the back legs moving cuz the hips are too painful and it goes in and I said well I’ve just diagnosed a cervical thoracic issue and hip dysplasia on this dog and no one has noticed. And this dog is going to go out with it’s heartworm pills. And maybe I’m getting off the Fear Free® topic but I think this whole clinic attitude has to change. It’s like that person that watches the dog come through the front door and takes it to the exam room and does the discharge is every bit as important as the veterinarian and in terms of seeing things that are wrong, evaluating the dog. Cuz that dog it’s going to go into an exam room, it’s just going to stand there and the veterinarian is not going to have a chance to see it walk around.  And the owner doesn’t realize there’s anything wrong until it starts crapping in the house because it can’t use the stairs, and then it’s too late. 

NR: Right, or any number of things can happen, or they’re leading the dog behind their bicycle by the neck and all kinds of things with this undiagnosed pain. So I’d like to review the Fear Free® concepts just because taking a dog like that and if we reinvented, or recreated, or reimagined veterinary medicine how it really should be, then as you’re saying that dog that you’ve described comes in and the receptionist is aware of what a painful dog looks like. I mean the signs of that, and so that’s one. I mean these are things that should be discussed among the group around the practice. ln your practice if that happened what would have been the outcome?

MP: My receptionist would have made sure that there was a pain survey attached to the file, she doesn’t have to say anything, and just by the fact that there’s a pain survey attached to it, my technician now knows someone saw something, or maybe the client said something, but I have to give this and then we’re going to talk about it. And then they’re going to fill that out and it’s going to have a value. Then I’m going to go in and say wow, you’re telling me your dog is in pain by the answers you’ve given.

NR: Right right.

MP: And I think that’s the other confounding fact that a lot of veterinarians encounter is they go in and say, well do you think your dog’s in pain, and they’re going to say no and then if you say anything else you tell them they’re an idiot and they don’t know their dog. So you need to use these surveys as tools to say wow, your dog’s in pain because you’re telling me.

NR: Right. And also I think that what I like to suggest is that the veterinarian watch the client and animal come in from the parking lot so you can see the dog, you know if there’s time, but that way you can you can watch the interaction between the person and the animal, you can see the gait. Having a situation like you have where you’re not mixing animals and it’s not crowded and they’re not fighting or scared, but that there’s a way to assess them not only in a static way but movement and interaction.

MP: Just an observation. Because the second we put ourselves into the situation, it changes the outcome so just an observation is the best. I try to peek at animals that are walking down to the exam room around the corner, and if I can’t then we’ll try to walk the hallway, and if that doesn’t work, then let’s pretend we’re all going home by going out to your car because that’s when they show stuff.

NR: Right, right. Just even having some of the main Fear Free concepts up here even starting with communication so there’s common behavior signs of fear, anxiety, and stress in cats and dogs. So if we take that expanded view of signs of pain or dysfunction or restriction, all those things, and so they have here the obvious signs, cowering or crouching, lowering or flattening of the ears, growling, hiding, hissing, lifting the lip or snarling, tucking the tail, and trembling. This is where Fear Free® is coming from but those could be signs of fear I suppose, anxiety and stress, but why is that happening? There’s behavioral things, expectations or fears of that but there’s physical reasons  like I’m hurting as well. 

MP: Right, or last time I was here it really hurt and I don’t want to do this. I lecture all the time about how come these puppies love coming to see us, they’re willing to take the vaccine, they’re willing to do everything, and then they get spayed or neutered and they never want to come back because we did a crappy job of taking care of them when they were here getting spayed or neutered.

NR: As you were saying that I immediately thought of first-year veterinary students that come in, this is the dream of their life, they worked so many years to get there, and I mean I remember the high of the acceptance letter, even being afraid to open it, and and you know it’s the pinnacle of your to get into vet school, to start vet school, and they’re so enthusiastic and they’re learning anatomy and the neuro stuff ,at least of CSU, I mean they’re so excited, they’ve got it, they look at cases. And then you see by the second year, that’s come all way down and it’s a very different emotional makeup even by second year.

MP: Right. I don’t know how to fix that but I will say that when I I got trained in rehabilitation I think one of the things that kept it exciting for me was the fact that we’d have a half hour of lecture and a half hour of hands on. It just made it so real. I remember my first year in veterinary school, this is the honest-to-god truth, had this veterinarian, he was a very personable guy, he’d done work in the Peace Corp and everything else. We had this huge auditorium with a stage, and we’re sitting there, and here comes a technician or an assistant that leads a young cow into the stage and he takes a dehorner and shows us what it’s like to dehorn a cow, and the blood goes squirting 20 feet across the stage, and he says, don’t worry it’s a long way from the heart. And you know, it was such a turn off and it’s like, do I want to be doing this? I think veterinary school has the potential to go bad in many different ways. I think there’s a lot of good stuff that has come out especially with the millennial generation. I think it has made us be introspective about things we do. I think there’s a lot of bad stuff. As I heard one person say recently, we’re now killing mosquitoes with flame throwers instead of trying to fix problems. I think one of the really wonderful things with the millennial generation is we are being introspective, is this proper, is this right, should we be doing this. Sometimes the answer is yes we should be, but sometimes maybe we can do it a different way. And I think the veterinary schools really need to take a look at that. And I’m hoping that as these generations come in, that they’ll insist on this change. A classmate of mine refused to do surgery in the surgery labs, and we were horrified, you know that she refused to tow the party line. But you know what? They let her do it. They let her go by observing and she was there, they said okay you’re the anesthetist and just have to watch everyone else doing it. And that was kind of like the beginning. I’m surprised they didn’t kick her out but they let her stay and they let her graduate despite that. And we need more and more of that.  Do we really need to do this? And I think it’s swung too far in that they’re doing no surgery on anyone. And students are expected to go ok, you’re the first time I’ve ever cut an animal and you’re a client’s dog. That’s maybe not right either. A friend of mine, who’s a veterinarian, took her daughter down to Costa Rica just so she knew how to spay a dog before she graduated.

NR: I think that’s probably one of the ideal things is going on those spay neuter, practicing in a low income area. I know I wouldn’t have gone to vet school if I had to kill an animal for my education so that was the 90s by then. I think we’ve talked before about having to kill a dog in medical school or not being able to continue. But yeah, you’re bringing up those things about moral injury and I think that that’s part of the mechanism of the destruction of the happiness and idealism in vet school are incidents like that.

MP: And this all circles back to Fear Free®. I mean it really does. If we can’t have that kind of empathy for ourselves in treating our patients, how can we have empathy for the animals?

NR: Absolutely. I guess I’m a little surprised that that’s not explicitly stated, I mean only being halfway through level 1, does it come up later?

MP: No, I don’t think it does. We could probably fix that.

NR: Right. And so just going on with those common behavior signs. Just to take a more critical perspective from a pain practitioner, integrated medicine practitioner, so avoiding eye contact, okay, again that could be fear, anxiety or stress. What if that animal has a headache and they can’t lift their head up, so there’s that, there’s blinking slowly or squinting, dilated pupils, showing hyper-vigilance, an inability to settle, again I would say for these things, pacing, panting, freezing, lifting paws, pain should definitely be on that differential it’s not just fear, anxiety, and stress. 

MP: Right and I know with my conversations with Marty Becker that’s what he has said, he has ignored that side of the issue too long, and that’s why he is really making a huge effort to include pain as part of the whole fear, anxiety, distress evaluation.

NR: Right. So then we get into gentle control. It’s how the veterinary team comfortably and safely positions the patient to allow the administration of veterinary care with minimal restraint. How do you know what’s a comfortable and safe position for that animal unless you’ve evaluated that animal, what your hands tell you with this touch gradient, maintaining continuous hands on touch with the patient throughout the entire procedure. Your hands should be able to be giving you all this information, not only in a systematic myofascial palpation, but just as you’re touching the animal you can feel the respirations and the stiffness in the body, areas of tenderness or tension, so that will amplify your ability to do gentle control. What’s going to be comfortable for that animal? How can you do that touch gradient and be doing some myofascial release or some massage while you’re doing that, that’s actually helping that animal relax cuz you’re helping with the pain?

MP: It is hard. Dogs and cats that are food motivated, that’s very helpful, because they’re very willing to ignore certain things as long as they’re getting a treat. This Japanese company that makes these Churu tubes of cat treats just started selling them in this country, and they’re amazing.  The cats almost grab it with their hands, so that has helped a lot. But it’s a dilemma. In my practice if I’m having trouble discerning is this just fearful or is it painful all the time, I say, are you available this afternoon, are you available tomorrow, because I want to send home some Trazodone and see what your animal’s acting like. Trazodone will help with anxiety, kind of make them feel flat about whatever is going on, but the pain will still show up. When I first heard this concept, I thought, people are busy, they’re not going to go for this. People are grateful if you say, we need to do this a different day. Maybe one or two people a year will get cheesed off at me and just be like, muscle through it. I think that’s very helpful.  The other thing too is I had a neck issue, and I talked about it in my book, but that’s the first thing they did when I went in was they gave me an oral opioid cuz they could see I was in pain. So that’s the other thing that I’ll do is, is this pain, is it anxiety? I don’t want them vomiting so I usually give them something like Butorphanol, it’s going to give me a solid 15 minutes of of mild to moderate pain relief, and it allows me to go through an exam. So we go through a lot of this in my clinic. You can still tell it hurts with an opioid on board, it’s just not going to be so anxiety-provoking and it helps separate some of the anxiety from the pain. I don’t have any other really good tricks, but those are the 2 things that I do that I think really help me with my pain practice.  People appreciate it, they really do.

NR: Yeah, people appreciate that connection and being heard, and I think that oftentimes they’ll say my animal is doing this, it seems like something’s wrong and so if they go to a vet that has no concept of any of this, then that’s I think likely to be missed if they go to somebody with your type of practice. It’s just screaming at you how much is going on. One thing that you had mentioned, I think in our last discussion, was just even, do clients even have any kind of concept about what it can be like to bring their animal into a practice that attends to fear, anxiety, stress, and pain and the whole thing. So they might just think that that’s normal not to and that their animal is just asking for attention or something. When you said about giving them some medications, I mean you could also just put a couple of needles in. 

MP: Right. 

NR: It depends on the animal.

MP: RIght, right.  Sometimes I forget to do that, but there are many times I’ll do something along the top line wherever the animal allows me to do it, and I’ll just explain to the client this is going to allow them to settle down. I taught at the NAVC Institute way back when, and we had a little Intro to Acupuncture part of it and I put in Bai Hui in a Greyhound, and we were talking and the owners were there, and the owner says, I just have to say something, this is the first time that I’ve owned this dog in the last 2 years that I’ve ever seen him sit down in the presence of strangers. It does work. It really does work.

NR: It does. We know the neurotransmitters and things like that, but even fascia has become a big interest for me now, I mean just the sheets of fascia that can release with an insertion of the needle, and when you used Bai Hui,  I mean maybe you perceived some kind of lumbosacral discomfort ,but you’re you’re helping with your differential diagnosis even by doing that specific point and then seeing that response and even if that wasn’t a precipitating reason, maybe this was just an example kind of Greyhound, they didn’t come for anything in particular. So many of them have issues, especially a Greyhound, so I think that would be my preference if there was a way to do some massage or acupuncture, and maybe lavender aromatherapy. But very different than when I was in school and they’d say, oh we can’t give any pain medicine to this animal before the neurologic exam, which might even be a day away, I mean again those sources of moral injury and unethical treatment of animals.

MP: Right. And so in one of the earlier ones I talked about the neurologist that berated me because I didn’t understand what lateralizing signs were. And 2 years later I referred a dog up because it had cervical neck pain and I felt like it probably needed surgery. We’re talking early 80s so acupuncture really wasn’t an option for me then. The same person called me on the phone and yelled at me because I had dispensed Bute to this dog prior to the pain exam. How can he possibly do a proper pain exam? 

NR: Right, and “pain exam” to that person is forcing the neck into highly uncomfortable positions and making them scream. It’s not a myofascial exam. When I was teaching at the university one of the orthopedic surgeons, I said here’s a triceps trigger point, and she said,  what’s a trigger point? So a lot of them don’t have the concept of myofascial pain or anything. Just to wrap things up, sort of, I know you’ve been practicing a long time and you’re more interested in selling it at some point. So we had started with the receptionist seeing an animal come in and then for the ideal practice what would happen next for that dog with neck and hip issues? 

MP: A thorough history. The technician is going to get a more pointed history based on the pain survey because they are going to have filled that out before the technician takes a base history. And then I’m going to be doing a much more pointed history in terms of its mobility and so forth.  Let’s face it, clients think if the dog’s not screaming, it’s not in pain. So sometimes it takes a long time to tease that out of them, when did this start happening, when did he stop playing his favorite games. I’m always telling them, imagine you’re filling this out 3 or 4 years ago, what would it be like?  None of this would’ve been there. But I just thought he was old. You have to go through all that. It doesn’t take a lot of time but it does take a lot of patience to be able to go through this each and every time with a client because it’s the thousandth or ten thousandth time I’ve encountered it but it’s the first time for them. So you really need to go through it with them and have patience.

NR: Can you list off more things that you have on the pain survey?

MP: I adapted it from that canine brief pain inventory, and I just pulled the 7 questions that are the interference scores: trouble climbing stairs, trouble walking on slippery surfaces, etc. So this is not the end all and be all, this is an option to open up a conversation. Elanco has really done a good job, they hired a pain specialist, so to speak, from practically every continent on the face of the earth, and they put together this thing called the COAST, and I don’t know if you’ve had a chance to see that. It’s really nice. I’ll email you my powerpoint and maybe you can make it available on your site. What’s so genius about it is it involves every member of the team including the client in order to make a decision about not only what kind of pain there is, but what are we going to do about it, and how do we re-evaluate. It’s a really nice, nice tool. For someone like me, I don’t need it because we’re already doing some version of that, but this allows any practice that has never really considered pain to immediately slip into it. It’s cumbersome at first but like all things, riding a bike is cumbersome at first, but then you’re not thinking about it. It just starts to happen.

NR: Well that’s great. I have it up here. Principle one-there is no functional purpose  to chronic pain, there is no evolutionary advantage to it, and it serves no helpful end. Principle two-chronic pain almost always involves a degree of sensitization in the dorsal horn of pain generating site and so on. Principal three- given the nonverbal and adaptive behaviors of dogs and cats it is difficult for owners to perceive their pets’ chronic pain. What they see are mobility issues that can be described as progressive disability. Next one, chronic pain in humans controlled for other factors is considered comorbid with diminished cognition and clinical depression. And while we don’t have data for this in dogs and cats, it’s hard to imagine that some elements of this pathophysiology do not exist in non-human species. The last principle- under-recognized and under managed chronic pain can result in death via humane euthanasia perhaps years earlier than what otherwise be necessary. And that’s why you can see that the recognition and management of chronic pain is equally as life-preserving as any actions taken to handle acute and critical conditions in veterinary patients. That’s great. 

MP: Yes, it is great and Elanco paid the bill to have that thing put together.

NR: Ok, well good. So we’ll let you get back to your practice. Any words of wisdom for the veterinary student who’s about to graduate and wondering what they should do with their career?

MP: I think in today’s world veterinary students graduate with a lot of debt, and they feel that whatever track they’re on, they just have to stay the course because, heaven forbid, if I go even a month without working, what am I going to do, how am I going to pay my bills. But what we chose to do early on often sets the course for the rest of our professional career, and if you’re not happy you need to re-evaluate that. Especially talking to people like you and me and listening to these things can really set that mind up, you know I don’t have to, I don’t want to be in a spay neuter clinic, I don’t want to do this. I graduated in 1980 and it was the worst recession since the Great Depression, started in late ‘79. When I entered veterinary school there was a 99% unemployment rate one year after graduation. My classmates, 50% of them did not have a job one year after graduation. I was actually working 2 different jobs just to cobble together enough money. I guess the point is that people that are graduating right now may be finding themselves in a similar situation because you don’t know what this economy is going to do with this whole COVID-19 thing and you may have to do what you need to do to survive, but you don’t have to do it forever.  Just remember it is possible to reset, it is possible to relearn, even if you have to take a break from veterinary medicine, that’s not such a bad thing. And I think especially with so many veterinarians being female they may have babies and then they drop out of practice for a while and then they don’t want to go back. It’s all possible. Everything is possible under the sun. You just have to have the right kind of boss or mentor to help you get through that. 

NR: Good, good. And there’s more people around like us, and more options that you have like you saying you don’t need to just sign up for something that you deeply resent doing cuz it has a toll on you. Well thanks again, always great talking to you. 

MP: Great and you talked about going through some cases at some point? That would be fun.

NR: Let’s keep talking on email. Thank you. 

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