Monday, March 27, 2017

Ethical Fatigue. The Crossroads of Vet Med and The Public Conscious Awakening.

How did we get here? How did we get to this place where we can't help all of our patients, can't acquiesce to our clients requests and can't discern why we are still so unhappy? Seems it might help when staring into the abyss, contemplating embracing it, and feeling like there is only something to gain if you do, that understanding how we got to this place that, we might need to take a step back and start figuring out these gnawing questions.

Two of my favorite rescue babies of 2016.
Thor and Weasely.
Rescued, treated, saved and adopted to a client home.
Happy, happy ending!
"Ethical Fatigue" is the new catch phrase making the rounds in the vet med publications these days. It is the evolution (and in my opinion, more clarified definition of the veterinarian's experience) of "Compassion Fatigue". Compassion Fatigue is the term adopted from our friends on the more glamorous side of the scalpel; the MD's. Veterinarians have always been seen as the slow step-child to 'real medicine'. We copycat the physicians tools, tips, tricks, medicine, even their white coats and still we can't even come up with our own names for our own unique disorders? We are, however, the profession with the highest suicide rate. Our once humble beginnings have been met by high societal pressures and unrealistic expectations.

Veterinary medicine, the once heralded career path of every bright, science-loving moderately nerdy girl shadowed by her own introverted personality who too often sought refuge and acceptance in the non-judgmental arms of animals is now the place of veterinarians who are offing ourselves at sky rocketing proportions. A huge multitude of factors have caused this. They include; huge debt loads (because a determined nerd never gives up on a dream,,, even one we cannot afford), ridiculous expectations from everyone (most notably ourselves), lack of ability to dig ourselves out of a self imposed hole (did I mention introvert?), and loss of ability to know which way to go when we can no longer navigate bad from worse. The more we feel compelled to help and invest ourselves the more we get stuck in the trap. The boa constrictor only swallows the prey that struggles.. they don't eat carrion. Those of us who invest too much can find ourselves lost in the plight and forget to save ourselves in the process. I am one of these people. A decade ago we called this "Compassion Fatigue," defined as "a state experienced by those helping people or animals in distress; it is an extreme state of tension and preoccupation with the suffering of those being helped to the degree that it can create a secondary traumatic stress for the helper." Dr. Charles Figley. (More on Compassion Fatigue here). Today it's the "ethics" that are killing us.

Garfield, deemed 'feral' at the shelter he is so afraid he hisses at everyone.
If you challenge his bluff you get this; Love, affection and gratitude.
Misunderstood, misdiagnosed, and almost missed opportunity.
This is what vets do. We see past the misleading exterior.

Befittingly vets and medical doctors do not share the same exact burden with respect to patient care. We both deal with loss, long hours, stress of managing a balanced life and patient demands.... BUT, (there is a BIG BUT here), we veterinarians lack much of the team support and resources that human medicine provides. There is often no one else to lean on in vet med. We carry cases, often difficult, multidimensional, multi-specialty cases that one person with one lifetime of general medicine cannot manage. We also live in this conflicting dichotomy of purpose. Pets are in some cases the lifeline companion to our clients lives. The only thread holding them to life and happiness. This is an immense burden to shoulder, often made worse by the too often financial constraints these clients have. They need their pet desperately but they cannot afford what these pets need on a day to day basis, never mind the inevitable illness or disease. In other cases these companions are seen as annoying costly burdens that people all too easily unload as 'disposable'.

Ethical fatigue in veterinary medicine exists for reasons that human doctors rarely see or experience. (OK, I shouldn't speak for others). In veterinary medicine no one who needs insurance has it. Very few can afford the expensive tests, treatments and tlc needed to save the dire cases. The patients at the fringe live with families on the brink. They too often collide at the vets office. The vet was once the sanctuary for the meek, weak, and huddled masses. In the old days, before debt, McMansion's, fast food, and corporate take overs there was room for everyone to get help. I miss those days. I miss them desperately. I am left to decide whether I can always maintain "Standard of Care" as I try to offer assistance to everyone who needs it. I will not sacrifice that little girl I once was for a payment, an excuse about having 'overhead' and alienating yet one more person who used to believe I was in this for more than the money. If you have become 'one of those vets' your legacy will be shrouded in a gilded casket attended by your immediate family alone. These are not the vets we wanted to be. They are the vets society, drug companies, and the Jones' next door encourage us to become.

Sadie's first selfie
Half a century ago when veterinary medicine was simple, agrarian, and cheap these were less relevant. Now, based on student debt, some White Tower mandated governance of "Standard of Care" (most notably supported by billionaire drug companies reminding us that if we aren't with the times we either lose our clients, lose our patients, or lose our ass in state board reviews), the consequence of trying to be everything, worrying about everyone and somewhere reminding ourselves that we went to vet school because we cared got shoved out the door with the bath water. We have lost ourselves. We gave it up to a school we really couldn't afford. A profession that expects perfection and supplies only Kleenex, and clients who can no longer afford us, AND/OR no longer trust us. We even lost them. The last vestige of friendship in the cruel world of bottom lines and profitability.

I think it is bullshit. I do. I didn't go into vet med to make a million dollars (although I think this term is considered 'chump change' in any circle of any real business person acumen), I came to make a difference. I cared about the lives of animals and wanted to make them better. Not the few that could pay for my services, but every single one who came to me. I think, fear, and worry that the ethical dilemmas that we are facing is more aptly the subconscious yearning we are trying to suppress.

Mumford,, beaten, tarred and abandoned with
his adoptive mom who loves him more than anything.

I came understanding and accepting the ethics. (Maybe I am alone?) But the ethics don't scare me, and they damned sure am not walking away or giving up because of them. I am just not letting them decide my, or anyone else's fate. The ethics of vet med are the reason we have so much work left to do.

An AVMA study determined that the most common ethical dilemmas veterinarians face are;
  • Every pet in private practice is attached to a human being. Human beings come in all shades. Adoring; perhaps even to the point of hoarding to abusive, neglectful and cruel. How do you know which one you are about to meet? You don't. Those that reside at the barbaric end of the spectrum can take many visits to distinguish, and even then in many cases it is too awful to begin to imagine, and yet we have to. We don't want to be held culpable if we forget to look for the vile in our clients. Your ass is always on the line and often you don't see it coming. You need a team, at least for the benefit of different fresh perspectives. You also need emotional support when the judgement's are passed.
  • Pets are property. It is as non-sensible as it gets. Respect, cherish and provide for your patients as if they are family, but in the end they have almost no rights and they can be euthanized at any time. I saw a very sweet older found dog last week. She was as kind and endearing as they come. She was also too cachexic (sick) to be ignored. We started emergency treatments on her at arrival. All were done without owner consent and without security of reimbursement. I treated her because she needed me and she was so pitiful. She also captured the heart of my sister, our hospital administrator. When the owner came to claim her we pleaded that she stay with us for continued treatment. The owner declined. My sister pleaded that we intervene. "I can only offer help. I will follow up with Animal Control but remember if I push too hard he will just have her put down. I'm sorry." We found out she was euthanized after they claimed her.
  • Expectations. Veterinarians work incredibly long grueling hours, day after day. Vacations, complaining and shying away from areas of medicine that make us uneasy (like surgery for many) is both shunned upon and shamed. It is one of the trademarks of our predecessors we have to let go of. We are not the same people our veterinary ancestors are, (and I'm not even sure it made them happy either?). There has to be some acknowledgement in maintaining a healthy mind, body, soul and striving for balance. 
  • Euthanasia. The one place we receive the greatest amount of gratitude is also the one place that we are reminded (almost daily) that we are applauded and regaled for ending suffering. If every pat on the back was a genuine heart felt "thank you" for ending a life you learn to be comfortable and safe there. Think about that. Think about how reward based behaviors influence delicate hurting souls. 
  • Everything in this superficial material based world is about money. At least for the tv producers, malls, and magazines. If you don't have the biggest, the shiniest and the most exclusive designer whatever you haven't quite made the grade yet. I am also incredibly fed up with this side of medicine. The side that shames clients who cannot afford us, and berates them for "not thinking about and being prepared for the emergencies beforehand." There is no place for a cold unkind hand in veterinary medicine. There's enough of that out there in the world already. (For more on this see Why Your Vet Won’t Give You Credit blog.)
  • Toxic Workplace. You are either part of the solution OR part of the problem. Like every tragic case you try to save knowing that it might all be for naught you either try to ameliorate for the sake of your patient and your emotional stability, OR, you walk away damaging both. Be brave, as you already are (I mean who else whispers love songs and sweet nothings into pets ears as we are passing them into another place?). Be the gentle hand of compassion inwardly and outwardly. You can save every patient (at least from being worse off), you just can't convince every human.

Belle, spayed with the generosity of the Good Sam Fund
I have a busy, over extended vet hospital. We have a huge following and we do more than we have to. We do it all from a genuine place of dedication to the pets and families of our community. I know the practices around me also do more than they have to. I know some of them provide help that is very (almost crazy) affordable. They have there reasons and they make sacrifices to do so. I applaud them and I am grateful to them, (even if I have to have the too often uncomfortable conversation about the emergency consequences to not being encouraged or reminded to spay their dog. I do many emergency pyometra's because of this).

I also work around practices that charge up to $3500 for this emergency surgery. If you end up at one of these most of my clients can't afford it. The ethics of this are death due to economic euthanasia. The ethics of vet med are overwhelming.  We have overpriced ourselves out of accessibility and now we are blaming our unprepared clients for it.. even though we couldn't afford ourselves either (we don't admit this).


I have had to change both who I am in front of clients and how I practice medicine. I had to. I was going to want to swallow the abyss if I didn't. It was my ethical obligation to that little girl inside of me who finally got out of vet school.

Every client interaction starts with a deep breath. A moment of affirmation that "I am ok. I can do this and I have steps and plans in place if I need them." I start with an internal pep rally and knowing that I have a medic on the side line. I also have a team who supports me. I built this. It is as integral and important as having a firm understanding of veterinary medicine. I can manage a case on a shoe string. I don't back away from them and I never forget who I serve. I serve my own 14 year old rose colored glasses self AND my patients. My clients may have their own priorities in a different order, but all they have to do is care about their pet and we can make miracles happen out of thin air. By about now many of you might be wondering how I can possibly keep the lights on and the staff paid with this business plan? I make it work. We have a Good Samaritan Fund. We post like crazy on Facebook. I am honest, transparent and determined. I also never say no.. Well,,,, I never say no if I know that the client has no other options, I can help their pet, and that I will be ok with the outcome regardless of the roll of the dice. I go into every situation with a plan for a back up plan. I also remember where I came from. I grew up in a tiny town where the vet lived above the practice and routinely got calls at 1 am, often in the form of a hard knocking at the front door. He would get out of bed, help his clients and patients and never once complained, (he is a far better man than I). He worked 40 years like this. He retired with enough money to live the way he always had and he left a legacy behind more honorable than the fecals, rectals, and c-sections could have amassed by themselves.

Recipients of our Pet Food Pantry donations.
Every vet knows what the difference between right and wrong is. It is not that we don't understand NOR know which side of the ethical dilemma to stand on. In case you aren't sure here's where I start. What will ultimately help my patient most? I start here. I don't allow pessimism or the easiest answer to influence me. You have to be strong enough to live by these. You also have to be willing to lose clients because of them and be proud of who you are despite of all of this. You have to protect yourself from the abyss. You also need help to make things happen. Turn to your team. Lean on them. Build a community that reflects who you are. And most importantly never walk away from who you are. It is after all, ALL THAT YOU REALLY EVER HAVE.

Every client has my email address. The clients with critical cases also have my phone number. If I am asking them to invest more emotionally and financially in their pet, place more trust in our dedication to them AND their pet then I have to be ready to give it back equally. I am available as I would want my vet to be. I have never had a client abuse this (OK, one did he was a psychopath it wasn't my fault). I have had my share of abusive, demanding, neglectful clients, and I have fired them all. I cannot provide what they want, demand, or they were bullies who intimidated and I will not subject my team to them. There are boundaries. I provide ultimatums. But, we work very hard providing help and assistance and warnings. I am not going to ever let another person nudge me into wanting that abyss.. that is not going to happen,, there is enough of a fighter within the introvert to protect this. I had to learn that too.

Maybe we aren't alone if we collectively refuse to be shoved into the corner where only the abyss waits?


Proudly displayed at the front desk.
This little shoe box saves hundreds of pets every year.

So where do I see the debacle with Ethical Fatigue? I see that compassion is who we are. It is the BEST part of who we are. We do not surrender it and we do not run out of it. The ethics? well, I think we already know the answer to these questions.. we just don't have to comply. We all have a voice, a choice, and a skill set. Walk away. State who you are and embrace the differences between the person you grew into being. We all make mistakes, but we are not damned to repeat them.

Here's some of my crazy public displays of opinion and preference. Here are the ways I avoid making ethical mistakes;
  • A savable case is offered every option. CareCredit first, third party billing (yes, I assume some risk they may not pay, but almost everyone does), and then if all else fails the Good Sam Fund mounts a campaign to raise funds. 
  • We have a network of rescues and volunteers to help foster or adopt cases. Some cases are with us for months or years. They become a part of our clinic. Our mascot. Our cause. Our promotional pet of the month. They are a daily reminder of who we are, and are not. 
  • I ask for help, a lot and often. I now have a team on standby. They are my private reserve National Guard. They are also the support staff to my team. I have a team who helps our team. They are the most devoted amazing people and I am reminded that I am not alone, my quest is not in vain, and my community has faith in each other. 
It really is this simple. There are endings decided by fate. Medicine is like that. Immune to reason, fairness or pleas for mercy. But, there are happy endings more often than not anytime a client will let us try. How often have you labeled a case as that? They let us try. We all worked together. Not me, vs, for them, but for the we in together. That's where medicine came from. The humble place where value was exchanged in chickens, thank-you's, apple pie, and owing each other a favor simply because we are neighbors.

I cherish each Thank You letter as a badge of honor..
I have a keepsake box to remind me why I fight so hard
and how imperative it is that I never give up.

Where do we go from here? I think it starts by taking responsibility. Our debt and our over abundant life is not our clients responsibility. If you cannot afford yourself AND be a vet then you need to find a niche, think outside of the box, be creative. If you think you can pass it onto others you better have a back up plan.

Let's remember who we were and where the success in that lay. We owe it to ourselves and our patients to provide a vet for each member of our society. There is ample provision for the clients with unlimited bank accounts, why isn't there equal provision at all levels of the income chain? Let's remember what the other side of the exam table felt like? How many of us could afford $10,000 for an osteosarcoma treatment plan? How many of us would tolerate castigation when our provider told us we should have been prepared for this?

Lady Liberty

We need more dialogue, less criticism about "poor choices" and pet ownership being a "privilege". We need to remember where we came from and what we are here to do. No excuses and no abandonment of purpose and no sacrifice of ethics in the sticky spots. All of those belong to other professions who alarmingly have no suicide rates to speak of. There is always an abyss, and there is always a way around it. It is in these small decisions, these extensions of compassion and these building of trust that the greatest reward to a profession that will never pay enough resides.

We don't take pride in the 6 month old cat neuters, we take pride in the difficult grueling surgical cases, the multi-problematic medical cases, so, why not also in the helping those who need us the most regardless of personal financial gain? You won't go under and you won't go broke, and you might also never see the abyss again. Be smart, be proactive, be creative and ask for help. It will surprise you what you get back when you give away.

For ideas in how to make patient care more accessible please see my related blogs;

How Your Clinic Can Do It All. Being Kind and Being Genuine. Weasely's blog.

Affordable Options Are Everyone's Right.

Borrowing Battery Juice. How Recharging Keeps the Motor Happy and BUILDS Your Veterinary Practice.

It isn't just high school anymore. Veterinarian Bullying and Veterinarian Suicide. How the vet clinic is the new homeroom.

My Veterinary Rescue Shaming and The Frank-Starling Law.

We Don't See You. How Vet's Became Biased and Lost Our Clients in the Process.

Compassion Fatigue blog. When the candle you are burning at both ends consumes you.

What is veterinary ethics?
This girl worked at a local vet clinic,.She intervened when this 1 year old was brought in to be euthanized
for behavior issues. She protested, convinced her boss to let her try to rehome him and subsequently lost her job.
This dog has since found a loving accepting home and is playful, happy and adored.
He is getting the training he needs and she is in search of a better job.
References;
Moral stress the top trigger in veterinarians’ compassion fatigue, JAVMA, Jan 2015, Susan Kahler.

The myth of compassion fatigue in veterinary medicine, by Dani McVety, DVM, DVM360 Jan 2017.


For help in reminding yourself what kind of vet you wanted to be a dozen plus years ago see;
  • Any James Herriott book, or If Wishes Were Horses by Loretta Gage, or, When Breath Becomes Air by Paul Kalanithi, or, The Patron St of Lost Dogs by Nock Trout, or, either book by Dr. Coston Ask the Animals or The Gift Of Pets (whose writing is as intoxicatingly poignant as it is exquisite).

Remember what your "Why" is.. Why did you want to become a vet? Why aren't you living that now? And, Why is it not feasible to move your life in that direction now? I promise none of these answers included "ethics."

For more information on me, and my vet clinic please see;

Here is our complete Jarrettsville Veterinary Center Price Guide for 2017

If you would like to follow our Facebook page you can learn more about us. If you have a pet question you can ask it for free at Pawbly.com. You can also find interesting pet facts, cases and stories at my YouTube channel and @FreePetAdvice.

1 comment:

  1. Hi Krista,

    My name is Anuj Agarwal. I'm Founder of Feedspot.

    I would like to personally congratulate you as your blog Diary of a Real-Life Veterinarian has been selected by our panelist as one of the Top 100 Veterinary Blogs on the web.

    http://blog.feedspot.com/veterinary_blogs/

    I personally give you a high-five and want to thank you for your contribution to this world. This is the most comprehensive list of Top 100 Veterinary Blogs on the internet and I’m honored to have you as part of this!

    Also, you have the honor of displaying the badge on your blog.

    Best,
    Anuj

    ReplyDelete