Sunday, November 7, 2021

Dog Owners Recount DCM Heartbreak in FDA Comment Docket

     September 21, 2021, the FDA CVM hosted a virtual Listening Session on the Oversight of Pet Food. In addition to the live, recorded session of oral presentations, a comment docket was opened for public submissions and closed 11:59PM EST on 10/25/2021.

In total, the docket has 137 published entries. Broken down by topic:

  • ~20 pertain to the use of 4D (dead, dying, diseased, down) meat in pet foods
  • ~12 are on the subject of transparency and access by the public to FDA (and/or AAFCO) meetings
  • ~12 are in regards to various other issues or general opinions of the FDA
  • Nearly 100 are about diet-associated (non-hereditary) dilated cardiomyopathy (DCM)

Of those, a handful are from concerned pet owners, advocates, and veterinary professionals. The vast majority, however, are the heart-wrenching personal stories of affected pet owners and their dogs, including those deceased, those continuing to battle, and those recovered. These pet owners represent only a minuscule fraction of the over 1100 complaints submitted to the FDA (as of 7/20/2020) and yet they are a poignant reminder that this issue is more than data, statistics, research papers, and debates between academia and industry. 

There are real dogs, real people, real families, and such real heartbreak underlying this investigation. Many of them have called on the FDA to take more action towards this issue.

Tuesday, October 19, 2021

What's in a DVM?

 

 What's in a DVM?

Are not those whom we call doctor, for any given species, just as competent?


    Veterinarians, much like physicians, dentists, pharmacists, nurses, and others, are healthcare providers. Veterinarians and physicians, particularly, are two sides of the same coin, providing roughly the same scope of services to two different populations of patients: humans and non-humans. But what exactly happens in a DVM curriculum? How does it compare to an MD program? What exactly is the scope of veterinary medicine? Given the frequency with which veterinary professionals seem to find their status as medical professionals undermined, answering these questions is prudent. Let it be emphasized that the purpose of this article is not to disparage any other healthcare profession or to imply the superiority of another. Rather, the aim is to highlight the rigor that is present in both programs and illustrate that veterinarians are just as much medical professionals as any other practitioner, prompted by shared experiences across the profession where our competence, qualifications, and education are routinely questioned.  

Undergraduate

    Both pre-veterinary and pre-medical students complete the equivalent of ~four years of prerequisite coursework at the undergraduate level. These prerequisites typically include a standard general curriculum (English, communications, history, etc) as well as specific STEM upper-division electives such as biochemistry, physiology, anatomy, cell biology, and the like. Once completing those prerequisites, students must apply to their respective programs, a process which entails submission of transcripts, multiple application essays, standardized testing, and letters of recommendation from professionals in the field.

Graduate (DVM, VMD, MD, DO)

    In order to become a licensed professional, students must complete four years at an accredited institution. The AVMA (American Veterinary Medical Association) and COE (Council on Education, US Dept of Edu) are responsible for accreditation of veterinary colleges, whereas the LCME (Liaison Committee on Medical Education) oversees accreditation of medical colleges. The curriculum must be a minimum of four academic year equivalents and include a minimum of one year of hands-on clinical training for a veterinary program. Veterinary programs are increasingly incorporating clinical experiences into earlier phases of the curriculum, but historically, the 4th year is reserved for hands-on clinical experiences in a teaching hospital. For MD programs, there must be 130 instructional weeks (one academic year is roughly 30 weeks). In the “required clinical experience” section, it is stipulated that the faculty of the medical school define the requirements. Traditionally, the 3rd and 4th years are clinical years in an MD program.

Didactic coursework, or “classroom” material, is very similar for the two disciplines. Both accreditation standards highlight the need to foster a lifelong commitment to learning. Consider the excerpts from the standards below:

 

Veterinarians

“an understanding of the central biological principles and mechanisms that underlie animal health and disease from the molecular and cellular level to organismal and population manifestations.”


“understanding of normal function, homeostasis, pathophysiology, mechanisms of health/disease, and the natural history and manifestations of important animal diseases, both domestic and foreign.”




“Instruction in both the theory and practice of medicine and surgery applicable to a broad range of species. The instruction must include principles and hands-on experiences in physical and laboratory diagnostic methods and interpretation (including diagnostic imaging, diagnostic pathology, and necropsy), disease prevention, biosecurity, therapeutic intervention (including surgery), and patient management and care (including intensive care, emergency medicine and isolation procedures) involving clinical diseases of individual animals and populations. Instruction should emphasize problem solving that results in making and applying medical judgments.”



“instruction in the principles of epidemiology, zoonoses, food safety, the interrelationship of animals and the environment, and the contribution of the veterinarian to the overall public and professional healthcare teams.”



“opportunities for students to learn how to acquire information from clients (e.g. history) and about patients (e.g. medical records), to obtain, store and retrieve such information, and to communicate effectively with clients and colleagues.”

“opportunities throughout the curriculum for students to gain an understanding of professional ethical, legal, economic, and regulatory principles related to the delivery of veterinary medical services, personal and business finance and management skills; and gain an understanding of the breadth of veterinary medicine, career opportunities and other information about the profession.”




“Opportunities throughout the curriculum for students to gain and integrate an understanding of the important influences of diversity and inclusion in veterinary medicine, including the impact of implicit bias related to an individual’s personal circumstance on the delivery of veterinary medical services.”

“knowledge, skills, values, attitudes, aptitudes and behaviors necessary to address responsibly the health and well-being of animals in the context of ever-changing societal expectations.”

Physicians

“content from the biomedical, behavioral, and socioeconomic sciences to support medical students' mastery of contemporary medical science knowledge and concepts and the methods fundamental to applying them to the health of individuals and populations.”

“includes content and clinical experiences related to each organ system; each phase of the human life cycle; continuity of care; and preventive, acute, chronic, rehabilitative, and end-of-life care.”




“instruction in the scientific method and in the basic scientific and ethical principles of clinical and translational research, including the ways in which such research is conducted, evaluated, explained to patients, and applied to patient care”.


“incorporates the fundamental principles of medicine, provides opportunities for medical students to acquire skills of critical judgment based on evidence and experience, and develops medical students' ability to use those principles and skills effectively in solving problems of health and disease”



“ instruction in the diagnosis, prevention, appropriate reporting, and treatment of the medical consequences of common societal problems.”



“specific instruction in communication skills as they relate to communication with patients and their families, colleagues, and other health professionals.”

“prepares medical students to function collaboratively on health care teams that include health professionals from other disciplines as they provide coordinated services to patients. These curricular experiences include practitioners and/or students from the other health professions.”

“medical ethics and human values both prior to and during their participation in patient care activities and require medical students to behave ethically in caring for patients and in relating to patients' families and others involved in patient care.”


“opportunities for medical students to learn to recognize and appropriately address biases in themselves, in others, and in the health care delivery process. The medical curriculum includes content regarding the following:
- The diverse manner in which people perceive health and illness and respond to various symptoms, diseases, and treatments
- The basic principles of culturally competent health care
- Recognition of the impact of disparities in health care on all populations and potential methods to eliminate health care disparities
- The knowledge, skills, and core professional attributes needed to provide effective care in a multidimensional and diverse society”




    Side by side, it’s easy to see how comparable the curriculum requirements for the two programs are. While it would be incredibly time consuming to detail the exact curriculum for the many accredited degree programs for veterinarians and physicians, I can readily speak to the education I’m receiving. If a medical student (or recent graduate) would like to add their experience to this article, please reach out and I would be happy to include it as well (caitlin@docofalltrades.net). 


    First year, the focus was on learning “normals.” We spent hours in the anatomy lab dissecting cadaver dogs and ponies. Our systems courses covered endocrinology, musculoskeletal systems, immunology, reproduction, ophthalmology, cardiology, respiratory science, neuroscience, renal systems, and digestion. Introduction to nutrition, diagnostic imaging, animal welfare and ethics, parasitology, animal behavior, histology, embryology, and molecular biology also joined the fold. Once weekly, we met for a hands-on course to practice clinical techniques, from blood draws and catheter placement to client communication exercises. In groups of four, we collaborated throughout the year with other healthcare professional students and a faculty member to solve a problem for a local member of the community (facilitating access to care, providing resources to contact needed healthcare professionals, etc).

    Second year was like first, except recognizing and intervening with abnormals in the same systems. Anatomy became pathology. In addition to the systems courses, we had microbiology, toxicology, dermatology, population medicine, and, perhaps most exciting, surgery and anesthesia. All second year students have the opportunity to perform closely supervised spay or neuter surgery on a shelter animal prior to adoption. Another student, with supervision, directs and monitors anesthesia. Students remain responsible for the care of their patient until discharge. Much like during first year, the course practicing clinical techniques continued to meet once weekly.

    Third year and fourth year provide advanced core and elective curriculum as well as teaching hospital rotations. On breaks and vacations, students are able to schedule externships with veterinary practices and shelters. Core curriculum at this stage continues to build upon the first two years, adding additional clinical context and encouraging active decision making for disease diagnosis and treatment protocols. In the clinic, students are expected to take the lead on presenting cases, working closely with the resident and faculty veterinarians to provide the needed care to patients. This includes every stage of the process, from gathering a history with the owner, planning diagnostics, interpreting diagnostics, listing differentials, and developing a treatment plan. Students provide updates to owners for hospitalized patients, assist the veterinary nurses with hourly treatments, and write up discharges for the resident and faculty to review. 

Licensing

    Veterinary students take their NAVLE in their fourth year of curriculum. NAVLE stands for North American Veterinary Licensing Examination. It is a 360 question multiple choice exam on clinical scenarios and clinically-relevant material. Competencies include clinical practice, communication, professionalism, business management, animal welfare, and preventative healthcare. Species covered aquatics, bovine, camelids and cervids, canine, equine, feline, ovine and caprine, porcine, pet birds, poultry, reptiles, and non-feline/canine small mammals. The NAVLE was introduced in 2000. Prior to NAVLE, veterinarians were licensed through a National Board Exam (NBE) and Clinical Competency Test (CCT).

    Medical students take the USMLE (United States Medical Licensing Examination). This is a three step examination that occurs over various phases of the medical curriculum. Step 1 occurs at the end of second year. It is a basic sciences oriented systems and processes exam that consists of no more than 280 multiple choice questions. Step 2 is taken at the end of 4th year and is more clinically oriented. It happens over two days. One day is a multiple choice exam of no more than 318 questions. The second day consists of examining and diagnosing actors as patients. Finally, Step 3 is taken after the first year of residency. It is also a two day exam. Day one is 232 multiple choice questions on basic clinical science principles and knowledge. Day two is focused on diagnosis, treatment, disease management, and prognosis. It focuses on clinical decision-making, and consists of 180 multiple-choice questions and 13 virtual case scenarios.

Post-Graduate Training (Internship/Residency)

    This is where veterinarians and physicians diverge substantially. Internships and residencies are available to students and professionals of both fields, allowing new graduates or practitioners interested in specializing to work under the supervision of more experienced specialists. Veterinarians may elect to do an internship after graduation and may then further pursue residency, typically in anticipation of specializing. A veterinarian can also practice independently immediately following graduation, so long as they are licensed through the NAVLE. Roughly 30% of veterinary students pursue internships after graduation. For those that go straight into practice, many seek employment as an associate veterinarian under the mentorship and guidance of a more experienced veterinarian.  
    For MD graduates seeking to become licensed physicians, an internship or residency is a requirement. The exact requirement varies on a state by state basis, but typically those seeking license to practice medicine must have at least 12 months of post-graduate training.

Final Thoughts

    Due to my interest in interdisciplinary initiatives and One Health, I’ve had the privilege of corresponding with incredible individuals across all types of medical and non-medical professional fields. Many of them have been a pleasure to connect with, and there has (almost) always been a mutual respect and admiration for the unique and valuable perspectives that each field brings to the table in terms of solving complex problems facing our world today. At the same time, I have repeatedly encountered scenarios where the competency and relevance of veterinary professionals has been questioned in terms of having a seat at the table. “You must really love animals to plan to go through eight years of school and not even be a real doctor,” said one of my best friend’s family members to me. “Can veterinarians even prescribe medications?” was asked of my classmate by a different health professional student at an interdisciplinary school activity.

“You don’t learn real medicine.”

“Dogs and cats don’t get the same quality of care.”

“If a medical issue is complex for animals, you just put them to sleep. There’s no advanced medical care.”

A list such as this could go on indefinitely with the input of my peers and future colleagues.

    Veterinarians are proficient in a clinical setting. General practitioners perform routine surgery on a weekly basis, provide preventative and wellness healthcare, dental prophylaxis, dental intervention, diagnose and treat common illnesses, and manage chronic disease. Specialists exist in all varieties: ophthalmology (yes, your pet can get cataracts removed!), orthopedics (total hip replacements are done in dogs), soft tissue surgery (I’ve assisted with a lung lobectomy), oncology (pets get chemo too!), endocrinology (both dogs and cats are frequently managed for conditions like hypothyroidism, hyperthyroidism, and diabetes mellitus) cardiology, neurology, sports rehabilitation, pathology, diagnostic imaging, internal medicine, and on.

    Veterinarians also work outside of a clinical setting. Veterinarians manage international animal trade and help prevent the introduction of foreign disease. They work at the state and federal level on disease surveillance and wildlife management. They work in research to investigate new clinical modalities and pharmaceuticals for humans and animals (the CEO of Pfizer is a veterinarian). They work in food supply safety and regulation. They work in shelters to manage not just medical care, but operations and welfare standards. This short list is not exhaustive, but hopefully highlights some of the many ways in which veterinarians contribute to society as medical professionals outside of solely the practice of medicine on non-human animals.

    The unique experiences, education, and perspectives that different medical and healthcare professionals bring to the interdisciplinary table are all invaluable. We all face shared challenges and ones that are unique to our profession. No two medical fields can be compared as identical because they simply are not. A veterinarian will never have to navigate the extensive laws and liability surrounding practice on human beings or tell someone their child has cancer. A physician will never have to learn the complex nuances of various animal species or euthanize a childhood pet. Nonetheless, the curriculum is rigorous for all of these fields and none of these professions should belittle or tear down the others. The complex and dynamic issues facing our world today require complex and dynamic solutions. Solutions that will require teamwork from professionals of all backgrounds. It is essential, then, that mutual respect, understanding, and curiosity underlay these interactions.


Thank you for reading!

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Thursday, September 2, 2021

My Dog Got Sick After I Changed Her Food.

 My dog got sick after I changed her food. 

It was my first year of veterinary school, and I started her on a diet to try and finally lose the extra weight she'd been carrying for too long. My dog loved food. The first red flag was when she had less appetite. "Well, it's a diet food," I thought. "She probably doesn't like it as much, or it's helping her stay full." 

The second red flag was a loss of energy. My dog was older, 12 at the time. "Well, she's getting up there," I thought. "She isn't going to act like a puppy forever." 

The third red flag was smaller, less frequent stools. Again, this was a new diet for weight loss. "It's higher in fiber," I thought. "That should cause bigger stools, more often, but maybe she's just adjusting." 

Finally, my dog collapsed. It was a brief episode, she was back to herself afterwards, but I was out of reasons. That night, we drove to my old workplace back home and I had her seen.