Efforts to control pet overpopulation and its impending consequences have been ongoing for at least the last 45 years. Since the opening of the first public spay and neuter clinic in 1969, veterinarians and animal shelters have taken a tremendous stride in reducing such negative effects as; staggering euthanasia numbers, urban stray populations and public health threats.
Yet despite these achievements it’s still a daily battle to gain compliance with some pet owners.
For some it’s a concern over the pet’s safety and risk involved with anesthesia. Even though advances in veterinary medicine offer the safest possible anesthetic gasses and the risks involved with unaltered pets far outweigh those associated with surgical complications.
Others claim it’s too much of a financial burden. There are many options, not only in our area, but across the U.S. for people to access financial assistance through spay and neuter programs. Government programs, local humane shelters, rescue organizations and even some veterinary offices will offer discounted rates to pets in need. Could it be that pet owners aren’t aware of such benefits? Or is it just another excuse to procrastinate an act they simply don’t consider to be important.
Yet still there are a surprising number of people who insist on waiting until after the first heat cycle or even breeding to consent surgical sterilization. I think this idea is considered an old wives tale, but remains in practice although most people don’t know where the concept originated from. It’s likely that no one will truly know where it came from, but there is one very plausible theory. Before the invention and use of certain surgical instruments veterinarians might have had more difficulty finding and removing the small uterus of a young dog. But after a first litter those organs would much easier to locate. Regardless of the reason behind such an absurdity, the facts are clear. Studies have proven that female dogs spayed prior to their first heat cycle are up to 70% less likely to develop cancerous mammary tumors later in life.
I think in this day and age it’s easy for us as professionals to overlook or even assume that our clients are educated about pet alteration. The only responsible approach would be for us to assume they are not.
We need to help our clients feel comfortable with our surgical protocol by offering pre-surgery blood work, advanced monitoring and the safest available anesthetics. Take the time to address their concerns. Put those fears and off the wall ideas to rest by offering sound education in the matter.
Information about free or reduced spay/neuter programs should be made available for clients struggling with a financial hardship. A lobby corkboard is a great place for displaying details about assistance programs or spay/neuter clinics. It also offers those clients wishing to donate funds information about what organizations you support.
It’s crucial for everyone to remember we are still very much in a pet overpopulation crisis. Adoption efforts can only do so much to reduce the number of unloved and uncared for animals living on our streets. The only way to get ahead of this dilemma is through spaying and neutering. If we expect to win in this war we’ve got to hold our ground on the battlefield.
Dr. Amanda Donnelly is a second-generation veterinarian with a diverse background in small animal practice, emergency medicine, business management, industry, speaking and consulting. Dr. Donnelly owns ALD Veterinary Consulting in Tampa, Florida. She works with veterinarians who want to grow their business and have their team look forward to coming to work every day. See more information below post.
For as long as I can remember our profession has discussed client communications that enhance client compliance. So, what have we learned and what’s changed? Well, the competitive landscape and profession has changed dramatically since I was a kid working in my dad’s small animal practice. But what hasn’t changed is that clients still make decisions about care for their beloved pets in large part on the relationship they have with the veterinary team. When this relationship is based on trust and a sense of family, pet owners are more likely to come in, agree to services and refer their friends. Unfortunately, gaining the trust of clients is harder now because of competing distractions (think Internet, low cost alternatives, less discretionary income) clients face. Moreover, clients often feel overwhelmed with all our recommendations for high quality care and think “does Chloe really need this?” And it certainly doesn’t help when television shows like the recent 20/20 episode air negative claims about veterinarians making unnecessary recommendations.
As I reflect on my 15 years in clinical practice and consider my observations working with clients, I believe there are 2 secret ingredients to successful client communications and enhanced compliance with treatment recommendations. They are Authenticity and Confidence. Confidence without authenticity leads to pet owner mistrust and skepticism. Authenticity without confidence may result in confusion and inaction. Look at the following aspects of your communication and consider how authentic and confident you and your team are when making recommendations.
A note from Rebecca: I will be taking a break next week for Christmas. My next post will be on December 30th. Merry Christmas everyone!
Dr. Donnelly is a graduate of the College of Veterinary Medicine at the University of Missouri, Columbia. She has an MBA from Baker University in Overland Park, Kansas and also holds a certificate in Veterinary Practice Administration from the AAHA Veterinary Management Institute (VMI) at Purdue University. Dr. Donnelly is Past-President of VetPartners™ and the author of the book 101 Practice Management Questions Answered available from AAHA.
A member of the National Speakers Association, Dr. Donnelly is a frequent speaker at national and international veterinary conferences. She was the Practice Management Speaker of the Year for the 2007 and 2013 NAVC.
ALD Veterinary Consulting, LLC
3008 Partridge Point Trail
Valrico, FL 33596
A couple of years ago, I wrote about the question of whether or not surgery was better than medical management for dogs with cranial cruciate ligament (CCL) disease. Here was my conclusion at that time:
As is almost always the case, the evidence is not of the highest possible quality or unequivocal, but this does not exempt us from having to draw conclusions and make recommendations to our clients. My interpretation of the available evidence is that overall, cruciate ligament disease causes significant arthritis and loss of function when untreated. For most dogs under 15kg, conservative management (primarily restricted activity for 3-6 weeks, achieving and maintaining and appropriate body weight, and possibly physical therapy and pain medication) can achieve acceptable comfort and function. In larger dogs, significant arthritis is inevitable and dysfunction is extremely likely without surgical treatment. No single surgical technique is clearly superior, so the choice of specific surgery should be determined by the judgment of the individual surgeon and the needs of the owner.
A recent research article has added an important piece of evidence concerning this subject, and while supporting the value of surgery it does weaken somewhat the case against medical treatment for large dogs.
Wucherer, KL. Conzemius, MG. Evans, R. Wilke, VL. Short-term and long-term outcomes for overweight dogs with cranial cruciate ligament rupture treated surgically or nonsurgically. Journal of the American Veterinary Medical Association 2013;242(10):1364-72.
The authors interpretation of the results supports the argument that both surgical and nonsurgical treatment can be successful, even in overweight large-breed or giant-breed dogs, but that surgery appears to provide a better outcome.
Overweight dogs with CCLR treated via surgical and nonsurgical methods had better outcomes than dogs treated via nonsurgical methods alone. However, almost two-thirds of the dogs in the nonsurgical treatment group had a successful outcome…
Overall, I agree with their conclusion, though I would probably place less confidence in it than the authors do.
Forty overweight large-breed or giant-breed dogs with unilateral rupture of a CCL were recruited and randomized to either medical therapy alone (a weight loss program, individualized physical therapy, and daily use of a nonsteroidal anti-inflammatory medication) or medical therapy plus surgical therapy (TPLO). Outcomes were assessed at 6 weeks, 12 weeks, 24 weeks, and 52 weeks after the beginning of the study.
There was a high rate of drop out (5 digs by 6 weeks, 11 dogs by 24 weeks, and 17 dogs by 52 weeks). The majority of these dogs (11/17) dropped out due to CCL rupture in the opposite leg, and there was no overall difference in dropouts between the two groups (9 in surgical group and 8 in non-surgical group).
Both subjective outcome measures (surveys of owner perception of their dogs’ pain and lameness and pain scores generated by the investigators) and objective outcome measures (body weight, body fat, body condition scores, and several measures generated by force-plate analysis) were evaluated at the beginning of the study and in the dogs still participating at each follow-up point.
No adverse effects were reported for the weight loss diet, the NSAID therapy, or the physical therapy. A few minor complications associated with TPLO surgery were reported at rates consistent with those reported in other studies.
The weight loss program did result in decreases in body condition score and percent body fat for both groups, and there were no significant differences between the two groups. Interestingly, while total body weight did decline slightly for both groups, the decrease was not statistically significant for either, and there was no difference between the groups.
Subjective measures, both owner and investigator assessed, improved significantly for both groups. There were no differences between the groups in the subjective outcomes assessed by the investigators. The surgery group had significantly lower scores for pain severity and interference than the non-surgical group only at the 52-week evaluation. Some differences between the groups in visual analog pain scale assessment by owners were reported, but how many measures were assessed and which ones differed were not reported, and no statistical analysis of these differences was reported, so it is difficult to assess this outcome measure.
Of the several force-plate measures assessed (5 or 6 measures; it isn’t clear from the paper), only one differed between the groups, and this difference was significant only at two of the four assessment points (24 weeks and 52 weeks).
The investigators also created a composite measure of “successful outcome,” defined as achieving both a specific force-plate measure that was >85% that of a normal dog and a subjective, owner-assessed improvement in lameness and quality of life >/= 10%. The dogs in the surgical group had higher “successful outcome” scores at all assessment points, but this only reached statistical significance at 24-week evaluation.
Strengths of the Study
Overall, this was a well-designed study. The use of both subjective and objective outcome measures, random assignment of treatment, an aggressive and consistent medical therapy program, and partial standardization of surgical treatment all reduce the risk of bias, confounding, and other error in the study. The consistency of several reported variables (such as surgical complication rate) with those reported in other studies increases the confidence one can have in the results. And the attempt to verify compliance with the weight loss aspect of medical therapy is an important part of any study employing this therapeutic approach.
Limitations and Caveats
A significant limitation is the lack of blinding of owners or investigators to treatment group. While blinding would be difficult, and possibly unethical due to the need for a sham surgery component, the lack of blinding introduces significant risk of information bias, particularly in the subjective outcome measures.
There was some individualization of surgical procedure and physical therapy treatments employed, which means not all subjects had the same treatment. If some techniques used work better than others, or if the selection of technique to be used is associated with the likelihood of a good or bad outcome, this could generate an erroneous impression of the differences between the surgical and non-surgical treatment groups.
The biggest limitation of the study was probably the high dropout rate. In general, dropout rates greater than about 20% are considered to severely compromise the data, and the overall dropout rate was 42.5% in this study. Though the number of dropouts were evenly distributed between the two groups, this does not mean the dropouts did not introduce bias into the results. If those patients who dropped out, most because they developed a second CCL rupture in their other leg, differed in terms of their underlying disease or response to treatment from the subjects who stayed in the study, this could have significantly altered the findings.
Also, as the authors themselves point out, the dropouts caused a significant loss of power in the study (though no power analysis is presented in the report), and this could lead to a failure to detect a difference between the groups. Overall, the dropouts significantly weaken the confidence we can place in these results.
This study does provide some support for the contention that overweight, large-breed or giant-breed dogs have better long-term outcomes when treated with both surgery and non-surgical therapy rather than with non-surgical therapy alone. However, the limitations in these data are great enough that the case for preferring surgical intervention is not strong. The non-surgically treated patients had overall very good outcomes that, at most time points and by most measures, did not differ significantly from the patients who received surgical treatment. Additional evidence would be required to make a strong statement that overall surgery is superior to aggressive medical therapy.
While it is reasonable to tell dog owners that there is some evidence their pets will benefit more from having surgery than not having it, we must also inform them that most dogs will have a good long-term outcome even without surgery. And it is important to emphasize that even with surgery, aggressive management of weight and physical therapy are important elements of comprehensive and successful treatment. For those owners who cannot afford surgery, or those patients who are not good candidates, there are still effective therapies that can be offered.
In last week’s post, we were discussing how to best connect with your introverted clients. This week, we will be talking about how to connect with those hard to forget extroverts.
Understanding your clients and what makes them “tick,” will make all the difference when it comes to owner compliance.
We can spend all the time we want creating new programs to get clients to bring in their cats or commit to better dental health for their dogs, but until WE take the time to CONNECT with our clients, these types of “programs” will not be successful!
Connecting with your clients is not difficult and is as simple as asking yourself two questions about each of them.
Question 1- Are they extroverted or introverted?
Question 2- Are they people or task oriented?
What do these extroverts need from you?
If you truly want to increase owner compliance then this is by far the best way to do it!
I challenge you to try this for the next 60 days and see what happens.
I bet you will be amazed in the difference you see with your clients. Heck, you might even find that some of those difficult clients are not quite as difficult to deal with now that you have a better understanding of what makes them tick!
Are you up for the 60-day challenge? Please let us know right here and right now-we would love to hear what you think!
You can follow my weekly blog at www.catalystvets.com
Now that the appointments are more spread out I have plenty of time on my hands to catch up on long overdue cleaning and organization projects. With the busy days of summer coming to an end, I'm finding myself in a bit of a slump. Sure everyday is different and you never know what you're day will bring, but this time of year always seems to be sort of humdrum and tedious.
In order to ward of the seasonal blahs I plan to spend some of the spare time focusing on educational opportunities. Maybe I'll finally finish that Purina Health Champion course I've been playing around with for the last 4 years. Although the slump can be quite boring at times it really is a convenient time to advance in learning new skills and techniques.
I've also put some thought into a couple upcoming special projects to improve staff communication. At our last team meeting we proposed the idea of organizing some in-house mini workshops to encourage cross training and integrated learning throughout the clinic. By working to ensure all team members are on the same page we can better serve our clients and patients.
I don't believe there's any doubt the key to compliance is a well educated staff. If you don't understand something or believe in it, how can you recommend it to your patients?
This year one of the goals I set for myself was to tackle OSHA. I wanted to make sure that we were up to snuff on compliance and that my staff knew how to keep themselves safe. Of course the mere mention of "the 'o' word" sent chills down the spines of each and every member of my staff and, if I'm honest, I had my own internal reservations about what a monumental task this was going to be.
I am pleased to announce that most of the formalities of establishing an OSHA compliant practice are almost done and now the task of enforcing the rules sets in. Because OSHA compliance is such a dreaded task for so many owners and managers I thought I would share my journey with each of you. It will either give you courage and hope that achieving this goal can be done or it will solidify (the typically shared feeling) that I was nuts for taking on this regulatory monster.
The first step was to determine what OSHA compliance meant for our practice. It varies from industry to industry and so I had some sorting of information to do. I needed to determine what was required for veterinary practices and what we lacked. We needed all the major stuff: an emergency evacuation plan, MSDS binders, secondary labels for our containers, and a staff training program that covered everything from personal safety, to ergonomics, to chemical hazards. That's a lot!
I had to prioritize what I felt like was most immediately needed for the staff and given that I'm in Texas and it's tornado season, I opted for an emergency evacuation plan to start with. This task was relatively simple. I need to put, in writing, a step by step protocol for the staff to follow in the event of an emergency. I covered fires/explosions, using a fire extinguisher and severe storms/tornadoes. I included who the person(s) in charge were and where the rendezvous point was. Then, at our next staff meeting I handed each staff member their own copy, went over it with them to determine if anyone had questions and posted a copy in a prominent place in our break room.
Emergency Evacuation Plan...check.
Gathering MSDS's was easier than I thought it would be. Our distributor provided me with a CD with all the MSDS's for products that I purchase from them. The ones that I was missing I simply found online. Then it was only a matter of making copies for each of the three main areas of the hospital, putting them in an easy to identify binder, explaining to the staff what MSDS's were to be used for and where they could locate them.
At lunch a few days later I was reading AAHA's publication, Trends Magazine. The cover read "Taming the Regulatory Beast". Ah ha! As quickly as my fingers would move I flipped to that page and got out my pink highlighter. The article discussed the basic do's and don'ts of having an inspector in your practice, what your rights and responsibilities are and so on. Near the end of the article some resources were listed to help owners and managers get started. My poor owner found a wish list on his desk within the hour for 3 items that I wanted from AAHA. The first was Philip Seibert's Manager's Guide to Veterinary Workplace Safety. This 41 page resource was The Bible of OSHA compliance as far as I was concerned. Second I wanted Mr. Seibert's training program for the whole veterinary team. I got the DVD and six workbooks. My plan was to have all current staff watch the DVD and take the test at the back of the book. All new staff would be required to watch the DVD and pass the test as part of their training as well. Lastly, I wanted the packet of secondary labels complete with a poster. Why reinvent the wheel? I just need to place those on all my secondary containers make sure they are appropriately labeled for warnings as they pertained to the chemical in the bottle.
Now I was getting somewhere.
Christmas (at least it felt like Christmas) came a few days later. I opened the box from UPS addressed to me and I did a little dance! I immediately looked at the schedule and assigned two different training sessions, dividing the staff up so that we still had coverage of the hospital and those in training could focus on the material. The DVD is a more up-to-date version of the "Right to Know" video that you are probably familiar with. Surprisingly the staff didn't make a single complaint...at least not to my face. They all passed their tests and those are filed in their personal files. Part of my staff safety training program was established. Now I needed to tackle the OSHA Bible and write my Safety Training Plan.
Phil Seibert is the go-to resource on OSHA compliance specifically for veterinary practices. His easy to understand guide spells everything out and even gives a comprehensive list of what needs to go in your safety training manual. It only took me two days to get it done. The next step is going to be presenting it to the staff, ensuring that they read it and then have them sign a training checklist that states they understand all of the policies and procedures in the manual. This will also be filed in their personal folders.
Now my training program is in place and the enforcement part begins. Keeping the staff on their toes regarding safe practices will no doubt be an exhausting task at first, but I hope that in time it will become routine. Two added benefits to having a safety program in place: I have a leg to stand on. I can deliver the same training to everyone, every time and it's in writing. So if there is a disciplinary issue with regard to safety I can back up my verbal requests with a written document that the employee signed off on as having received and understood. Secondly, I can show a good faith effort to an OSHA inspector that our practice is absolutely striving for safety and compliance.
I don’t know about you, but I only want the very best of the best working with me. It can be challenging to find those people, and when you do, what can be done to ensure that they stay with you? First, I think we need to understand that this generation of workers is not one to stay in the same job for a number of years. So despite our best efforts, some people may decide to seek different opportunities anyway.
I do believe there are some things though we should be doing in our practices to make sure the best people are going to stick around for as long as possible.
The inspiration for this post is Daniel Pink’s terrific book “Drive” that I highly recommend. He has found that there are essentially three things you MUST be willing to give to employees in order for them to be their best and give their best at work and those are:
Autonomy, Mastery, and Purpose
Having semblance of control over our lives is a basic human need. Researchers have found a link between autonomy and overall well-being. The opposite of autonomy is control and you probably know what it is like to work for a micro managing controlling boss-no fun!
Pink discusses some of the many ways you can provide autonomy for your employees-
Interestingly enough, Pink cites a study from Cornell University that studied 320 small businesses- ½ of which granted workers autonomy, the other ½ relying on traditional top-down management. The businesses that provided autonomy grew at 4X the rate of the control oriented businesses and had one third of the turnover.
One can only master what they do when they are engaged in their work. According to Gallop research, more than 50% of employees are not engaged at work, and nearly 20% are actively disengaged. Compliance used to be all we needed from our teams, but that is no longer enough. With animal hospitals on every corner, we must have an engaged team if we are going to stay competitive and grow.
Training programs need be in place to help people master what is expected of them. It is not fair to them, us, and certainly not to our patients to put people in situations where they have not been adequately trained or coached. Mastery is something that takes time. Hiring a veterinarian just out of school and expecting them to practice like a seasoned veteran is not only unfair but can also be demoralizing to them.
Research by renowned psychologist, Dr. Anders Ericsson, shows that it takes 10,000 hours or 10 years of disciplined practice to be considered an expert in any area. I am not saying give someone 10 years to do things well, but do remember mastery takes time and effort.
Going back to human nature, people want to be part of something bigger than them. A wise sage once said “without vision the people perish.” We cannot expect the best people to follow us when they do not know where we are going. Your hospital’s vision acts as a guiding star for where you want to be going. Not only is having a vision essential, your leadership team must be discussing it at least every 21 days for it to stick.
We, as a profession do meaningful work each and every day, but do you share your vision with your team? One of our customers has as their vision to be a hospital that practices academic level medicine in a private practice setting- what a great vision to tap into and inspire their team to be part of something great.
Autonomy, Mastery and Purpose are really not difficult to provide to your team but they will take effort on your part. I personally think it is well worth the time and effort to do whatever you need to do to keep yourself surrounded by the best people you can.
What systems do you have in place to ensure that your best team members are receiving the most job satisfaction they can?
To follow my blog weekly, please got to www.catalystvets.com.
Client compliance and overall clinic success come from consistency of message, according to Dr. Mike Paul. He says this includes a practice's standards of medicine.
CVC rolls on in San Diego and the dvm360 team is hitting the lectures. Here Content Director Marnette Falley reports three points for ensuring compliance from Drs. Mike Paul and Ruth MacPete.
What’s the Harm
I have written often about ways in which complementary and alternative medicine (CAM) can be harmful. This is not because I believe CAM is necessarily always unsafe, or that I think conventional medicine doesn’t have significant risks as well. Any therapy that is doing anything at all is likely to have potential risks as well as benefits. It simply isn’t possible to tinker with as complex a system as a living organism without affecting elements of the system one does not intend as well as those one is targeting.
However, the advantage to science-based medicine is that the risks and benefits of individual therapies are often well understood. If we have sufficient information about what an intervention does and what the risks and benefits of it are, we can then make rational choices about using it. The problem with CAM is that there is often very little information about risks and benefits and yet strong claims are frequently made that these therapies work and are safe. The lack of real, scientific information, and beliefs about safety which are not founded on reliable evidence can generate harm.
The two types of harm that can be seen with CAM therapies are direct and indirect. Direct harm is injury or illness experienced by a patient from the treatment itself. This is similar to the side effects one can see with conventional treatment. Indirect harm is the harm that comes from acting on misinformation or false beliefs even when the treatment itself is not dangerous. This usually involves the harm experienced by patients who avoid conventional therapy in favor of unproven or clearly ineffective CAM remedies.
I have put together a list of articles from scientific journals and the news media illustrating both the direct and indirect harm of CAM therapies: What’s The Harm? The name is in honor of the web site What’s the Harm, which is a collection of anecdotes illustrating the dangers of all kinds of pseudoscientific and superstitious thinking, including that behind much of alternative medicine.
This post will be a collection of links to previous posts I’ve written and links to articles elsewhere illustrating the harm CAM can do.
While generally safe if performed by a licensed, properly trained acupuncturist, acupuncture does pose direct risks, including side effects such as dizziness and nausea, infection from improper technique, and trauma from needles.
Cho YP, Jang HJ, Kim JS, Kim YH, Han MS, Lee SG. Retroperitoneal abscess complicated by acupuncture: case report. J Korean Med Sci. 2003 Oct;18(5):756-7.
Choo DC, Yue G Acute intracranial hemorrhage in the brain caused by acupuncture. Headache 2000 May;40(5):397-8.
Chung SJ, Kim JS, Kim JC, Lee SK, Kwon SU, Lee MC, Suh DC. Intracranial dural arteriovenous fistulas: analysis of 60 patients. Cerebrovasc Dis 2002 Feb;13(2):79-88
Ernst E, Sherman K. Is acupuncture a risk factor for hepatitis? Systematic review of epidemiological studies. J Gastroenterol Hepatol. 2003 Nov;18(11):1231-6.
Am J Med 2001 Apr 15;110(6):481-5
Ernst E. Deaths after acupuncture: A sytematic review. Int J Risk and Safety in Med 2010;22(3):131-6.
Iwadate K, Ito H, Katsumura S, Matsuyama N, Sato K, Yonemura I, Ito, Y. An autopsy case of bilateral tension pneumothorax after acupuncture. Leg Med (Tokyo). 2003 Sep;5(3):170-4.
Kirchgatterer A, Schwarz CD, Holler E, Punzengruber C, Hartl P, Eber B Cardiac Tamponade Following Acupuncture. Chest 2000 May;117(5):1510-1511
Laing AJ, Mullett H, Gilmore MF. Acupuncture-associated Arthritis in a Joint with an Orthopaedic Implant J Infect 2002 Feb;44(1):43-4
Nambiar P, Ratnatunga C. Prosthetic valve endocarditis in a patient with Marfan’s syndrome following acupuncture. J Heart Valve Dis 2001 Sep;10(5):689-90
Peuker E Case report of tension pneumothorax related to acupuncture. Acupunct Med. 2004 Mar;22(1):40-3.
Saw A, Kwan MK, Sengupta S. Necrotising fasciitis: a life-threatening complication of acupuncture in a patient with diabetes mellitus. Singapore Med J. 2004 Apr;45(4):180-2.
Sun CA, et al. Transmission of hepatitis C virus in taiwan: prevalence and risk factors based on a nationwide survey. Sun J Med Virol 1999 Nov;59(3):290-6
Witt CM, Pach D, Brinkhaus B, Wruck K, Tag B, Mank S, Willich SN. Safety of acupuncture: results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form. Forsch Komplementmed. 2009 Apr;16(2):91-7. Epub 2009 Apr 9
Woo PC, Leung KW, Wong SS, Chong KT, Cheung EY, Yuen KY. Relatively alcohol-resistant mycobacteria are emerging pathogens in patients receiving acupuncture treatment. J Clin Microbiol 2002 Apr;40(4):1219-24
Woo PC, Lin AW, Lau SK, Yuen KY. Acupuncture transmitted infections. British Medical Journal 2010;340:c1268.
Yamashita H, Tsukayama H, White AR, Tanno Y, Sugishita C, Ernst E. Systematic review of adverse events following acupuncture: the Japanese literature. Complement Ther Med 2001 Jun;9(2):98-104
There is little research on the risks of chiropractic treatment in dogs and cats (or on any possible benefits). However, there is clear evidence of harm in humans, particularly with manipulation of the neck. Given the limited evidence of benefit (for back pain) in humans and the absence of clear evidence of benefit in veterinary patients, significant caution is warranted.
Albuquerque FC, Hu YC, Dashti SR, Abla AA, Clark JC, Alkire B, Theodore N, McDougall CG. Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management. J Neurosurg. 2011 Dec;115(6):1197-205. Epub 2011 Sep 16.
Herbs and Supplements
Herbs and dietary supplements are among the most plausible and likely to have real physiologic effects of all CAM therapies. This also means, they are the most likely to have potential risks. As things currently stand, most of these products, particularly herbal remedies, should be viewed as drugs that have not been rigorously tested for safety and efficacy (as pharmaceuticals are) and that are not regulated for quality to any meaningful extent (again, unlike pharmaceuticals). Under these circumstances, there are unknown but potentially significant risks to using these products.
GAO Acknowledges FDA Oversight of Dietary Supplements Inadequate
Vitamins & Supplements
Mursu J, et al. Dietary supplements and mortality rate in older women: The Iowa Women’s Health Study. Archives of Internal Medicine. 2011;17(18):1625-33.
Aliye Uc, MD, Warren P. Bishop, MD, and Kathleen D. Sanders, MD, Camphor hepatoxicity. South Med J 93(6):596-598, 2000,
Angers RC, Seward TS, Napier D, Green M, Hoover E, Spraker T, O’Rourke K, Balachandran A, Telling GC. Chronic wasting disease prions in elk antler velvet. Emerg Infect Dis. 2009 May;15(5):696-703.
Angkana R, Lurslurcharchai L, Halm E, Xiu-Min L, Leventhal H, et al. Use of herbal remedies and adherence to inhaled corticosteroids among inner-city asthmatic patients. Annal Allerg Asthma Immunol 2010:104(2);132-138.
Berberine. Inbaraj JJ, Kukielczak BM, Bilski P, Sandvik SL, Chignell CF. Photochemistry and photocytotoxicity of alkaloids from Goldenseal (Hydrastis canadensis L.) Chem Res Toxicol 2001 Nov;14(11):1529-34
Booth JN 3rd, McGwin G. The association between self-reported cataracts and St. John’s Wort. Curr Eye Res. 2009 Oct;34(10):863-6.
Burkhard PR, Burkhardt K, Haenggeli CA, Landis T.Plant-induced seizures: reappearance of an old problem. J Neurol 1999 Aug;246(8):667-70
Chung-Hsin Chen, Kathleen G. Dickman, Masaaki Moriya, Jiri Zavadil, Viktoriya S. Sidorenko, Karen L. Edwards, Dmitri V. Gnatenko, Lin Wu, Robert J. Turesky, Xue-Ru Wu, Yeong-Shiau Pu, Arthur P. Grollman. Aristolochic acid-associated urothelial cancer in Taiwan. Proceedings National Academy of Sciences, April 2012. Panax ginseng: A Systematic Review of Adverse Effects and Drug Interactions. Drug Saf 2002;25(5):323-44 Drug Saf 2002;25(5):323-44
Cupp MJ Herbal remedies: adverse effects and drug interactions. Am Fam Physician 1999 Mar 1;59(5):1239-45
Debelle FD, Vanherweghem JL, Nortier JL.Aristolochic acid nephropathy: a worldwide problem. Kidney Int. 2008 Jul;74(2):158-69. Epub 2008 Apr 16.
Emery DP, Corban JG Camphor toxicity. J Paediatr Child Health 1999 Feb;35(1):105-6
Ernst E Adverse effects of herbal drugs in dermatology. Br J Dermatol 2000 Nov;143(5):923-
Fugh-Berman A Herb-drug interactions. Lancet 2000 Jan 8;355(9198):134-8
Huang WF, Wen KC, Hsiao ML. Adulteration by synthetic therapeutic substances of traditional Chinese medicines in Taiwan. J Clin Pharmacol. 1997 Apr;37(4):344-50
Kutz GD. Herbal dietary supplements: Examples of Deceptive or questionable marketing practices and potentially dangerous advice. General Accounting Office. May 26, 2010.
Lai MN, Lai JN, Chen PC, Tseng WL, Chen YY, Hwang JS, Wang JD. Increased risks of chronic kidney disease associated with prescribed Chinese herbal products suspected to contain aristolochic acid. Nephrology (Carlton). 2009 Apr;14(2):227-34.
Lawrence JD. Potentiation of warfarin by dong quai. Page RL 2nd, Pharmacotherapy 1999 Jul;19(7):870-6
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Because homeopathy has no active ingredient, it clearly cannot cause harm directly (as illustrated nicely by skeptics who regularly “overdose” on homeopathic sleep remedies). However, it is also probably the best example of indirect harm since any use of it in place of real medicine is going to provide no benefit beyond placebo effects. A recent article in the Journal of Medicine and Law catalogues a number of tragic cases of people who died due to the substitution of homeopathy for real medicine.
Freckelton I. Death by homeopathy: issues for civil, criminal and coronial law and for health service policy. J Law Med. 2012 Mar;19(3):454-78.
The What’s the Harm Web Site also provides numerous examples of people harmed by their trust in this bogus alternative therapy
General CAM Use
It is impossible to keep up with the variety of CAM therapies, but there are some that present a clear danger. And there are a number of studies looking at CAM use in general, both added to conventional care and used instead of conventional care. Though this research is by no means definitive, it strongly suggests that using unproven remedies with or in place of scientific medicine isn’t a good idea.
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Kurian Joseph, Sebastian Vrouwe, Anmmd Kamruzzaman, Ali Balbaid, David Fenton, Richard Berendt, Edward Yu and Patricia Tai. Outcome analysis of breast cancer patients who declined evidence-based treatment.World Journal of Surgical Oncology 2012, 10:118.
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Why do we insist on managing our teams instead of leading them? I believe one reason is because management is more black and white and easier than leading. That being said, managing is also a lot less rewarding!
Managers lead everyone the same way. Managers would hire the same personality type for the whole hospital if they could.
The goal in management is COMPLIANCE based on control by the people in charge. Its chief tools are extrinsic motivators. “Carrot on the stick” type of rewards are the norm. The idea of managing people presumes that people, on their own, do not have much motivation. They must be prodded to get anything done. It also presumes that once people do get moving, they need firm boundaries and guidelines or they will quickly get off task.
To sum it up, managing implies, that without bosses telling people what to do, nothing would ever get done.
Leadership is a different animal altogether.
Leaders lead everyone differently. They capitalize on hiring people with the same values but different personalities in order to strengthen the entire team.
Leaders understand that individuals have different strengths. Once they identify those individual strengths, they can then leverage them to better their hospital. Leaders understand that giving people within their hospitals some level of autonomy is essential. Leaders know their team is their most valuable asset. They do all they can to increase engagement of their team. Leaders understand that the “right” people want to be part of something bigger than themselves. They want to do a job and want to do it well.
Which is more fulfilling? For me, it is a no brainer. I would rather lead than manage. I believe that the “right” people in your hospital want to do a great job, and they will if you let them. I know there will be push back on this. Some may say, “that may be true in your business but it’s not in mine,” and I disagree. I believe if you have team members who want to be managed and not lead, they may not be the type of people you need in your hospital.
Do you feel like you are a manager or a leader in your animal hospital?
If the everyday grind of the veterinary clinic is consuming your attention you may be missing opportunities to bond with clients. Amanda Donnelly, DVM, MBA, say you should never lose sight of engaging pet owners.
Veterinarians must "walk the walk" for the benefit of team members and clients alike. Amanda Donnelly, DVM, MBA, says doctors acting as role models with respect to pet care is of great benefit to the practice.