Choosing a Treatment Setting
Veterinarians, oncologists, and teaching hospitals
Berry was diagnosed at VHUP and there we stayed – high quality care close to home. If your dog’s lymphoma is treatable, and you decide to pursue a course of chemotherapy, you may have a choice of treatment settings: a general veterinary practice; a canine cancer specialist in his or her own practice or in a regional referral practice of specialists; or a larger, private research or teaching hospital. This chapter discusses some of the differences among these settings, some factors to consider in making a selection, and questions to ask the professional care providers in each setting as you make your decision.
Depending on your geographic location, finances and your pet’s disposition, each setting has advantages and disadvantages. Technical expertise -- the requisite technical knowledge and practical experience in treating dogs with chemotherapy -- is essential. Proximity may also be an important consideration, especially in the early phases of treatment when most chemotherapy protocols require frequent appointments. If trips in the car or to a big hospital are an ordeal for your dog, this also may affect your decision. Obtaining some or all of your dog’s treatment through a regular general practice vet may be easier or less expensive. Finally, finding a professional with strong communication skills is tremendously important.
We found our way into an environment that sustained our dog for over 3 years. But this was luck, not the result of any real "due diligence" or investigation on our part. Do your homework. Weigh the options. Ask for references and question them. On this last point, be wary of any vet, canine cancer specialist, or hospital oncology department that won’t give you recent client references – especially if they say they don’t want to "bother" current or former clients. In our experience, many clients who have sought treatment for their dogs would be more than willing to share their insights with new clients – especially with owners who’ve just received a diagnosis. We know how hard that time can be.
In our opinion, if you are serious about fighting your dog’s lymphoma, you need to work with a veterinary oncologist. This is a veterinarian who specialized in internal medicine and has completed an internship and residency in oncology. Based on this training, a veterinary oncologist has the knowledge and experience to diagnose and treat lymphoma.
A general veterinary practice
Your dog knows your vet, who may also be the closest source of treatment, and the one where your dog is most comfortable. The more common drug protocols are available for vets, and the basic tests can be performed in a regular veterinary practice. But if your vet will be the sole professional care giver, make sure he or she is conversant with the complex issues involved in treatment of lymphoma, not just the drug therapies but also the drug reactions and side effects. To be successful, you probably need to explore creating a consulting arrangement in which your vet works in concert with a canine cancer specialist or a research and teaching hospital such as VHUP. We can’t imagine having attempted Berry’s treatment with a general practice veterinarian. And our local vet, like many others, would not have taken Berry’s case without consulting with an oncology specialist.
Questions to ask:
· How will the vet perform the more sophisticated diagnostic tests?
If you know you do not want to use your current vet, or your current vet is unwilling to set up the type of consulting arrangement you desire, you may want to contact a major regional veterinary teaching hospital in your part of the country. They can tell you whether there are veterinarians close to you with whom they have consulted in the past. See Appendix I for information on major veterinary teaching hospitals with oncology programs.
A Canine Cancer Specialist
A canine cancer specialist will typically be a board certified veterinary oncologist. This is a veterinarian who has completed specialized training in oncology. The American College of Veterinary Internal Medicine (ACVIM) is the official organization of veterinary specialties for small and large animal internal medicine, cardiology, neurology, and oncology.
How to find a qualified specialist
The ACVIM website (www.acvim.org) can be used to identify canine oncology specialists in your area. The ACVIM database is searchable by location. As of February 2004, a search of the ACVIM site for small animal oncology specialists yielded about 125 matches in the US and Canada. Of this total, roughly one-third were affiliated with university teaching settings; an additional group were affiliated with private facilities with multiple cancer specialists. These universities and private facilities are listed in Appendix I.
About one-half of the ACVIM oncologists are in teaching hospitals such as VHUP, or large veterinary hospitals such as the Animal Medical Center in New York City. The remainder are consulting oncologists who work with local veterinarians on a consulting basis, or specialists who see patients in their own practices. A specialized practice outside a large hospital can give you access to sophisticated care, and perhaps to more individualized attention. We considered this option very early in Berry’s treatment when we were concerned that the institutional setting at VHUP was negatively affecting his care. We thought that if only one oncologist were responsible for Berry’s treatment, there would be greater continuity and knowledge of his individual case. But Bill and Linda reported that the specialist who treated Murphy also had a packed schedule of cases and relied heavily on assistants. And that specialist was over an hour’s drive from us, while VHUP was right in our neighborhood. So we decided to remain where we were.
Questions to ask:
· How many lymphoma cases has the specialist or practice treated, with what drugs, and with what survival rates? Ask specifically about average length of remission and overall survival times, as well as the longest remissions and survival achieved for the type of lymphoma your dog has. (See Chapter 6, "Remission" for more general information)
· Where did the specialist train and was he or she previously affiliated with a veterinary teaching facility (that is how most oncology specialists get their training).
· Does the specialist use standard treatment protocols or have his or her own theories or approaches to treatment of lymphoma? What is the specialist’s perspective about combining alternate therapies with traditional veterinary medicine?
· How much flexibility is there in scheduling appointments?
· Can the specialist provide as references other clients who used his or her services to treat a pet with lymphoma? Ask to speak with people whose pets did not have lengthy survival times as well as those that did.
You may also want to contact the major regional veterinary teaching hospitals in your area to determine whether or not they refer owners to, or work with this specialist.
Major Veterinary Hospitals
The advantages of a major veterinary hospital, particularly a research or teaching hospital such as VHUP, are the sophisticated practice and access to round the clock care and multiple specialists. There is always another doctor who can step in if "your" oncologist is unavailable. And the non-cancer issues in your dog’s health can be addressed by other specialists if you choose. This was the option we selected, because of VHUP’s proximity and quality. Once we were admitted to VHUP’s Oncology Service -- which has a staff of oncologists, not just one specialist -- we were impressed by the level of expertise.
Large hospitals can have an institutional feel, however, particularly in the early phase of treatment before you become familiar with the routines and personnel. And there are sometimes frustrations typical of dealing with bureaucracy. When Berry was admitted to the VHUP Emergency Service early in his treatment, his "file" – already containing hundreds of dollars worth of valuable test data – had been misplaced in transit between the Oncology Service and the records department and could not be located. Finally, in a teaching hospital, as discussed in the next section, you must understand the system and make sure it is working for, and not against, you.
Questions to ask:
· Where did the staff oncologists train?
· Will a senior oncologist be assigned to your dog’s case?
· What roles will other personnel – doctors and nurses – play?
How veterinary teaching hospitals work
Wherever your dog is treated, you need to know every member of the treatment team – his or her professional training in canine oncology, years of experience with oncology patients, and role in your dog’s treatment. But having this information is even more important if your dog is being cared for in a veterinary teaching hospital. The primary purpose of teaching hospitals is to train new veterinary professionals, using the latest research, techniques and equipment. You and your dog are the beneficiaries of this concentration of expertise, but you are also part of the instructional program.
Within a teaching hospital are many students and doctors of veterinary medicine, all with varying levels of training and hands-on experience with veterinary medicine in general and canine oncology in particular. At VHUP, for example, there are nearly 100 vets, most of whom are specialists in one or more areas of animal medicine – oncology, cardiology, dermatology, surgery, etc. In addition, at any one time, there are several dozen senior veterinary students rotating through the various departments of the hospital. Certified animal health technicians also provide care, performing tests, administering treatments, and monitoring patients. In the Oncology Service itself are board certified veterinary oncologists, residents (veterinarians in training for ACVIM oncology certification), oncology nurses, and rotating senior students. Other descriptions of how teaching hospitals work are at http://www.cvm.uiuc.edu/vth/teachapp.html, http://www.vet.purdue.edu/vth/visit_1.htm, http://www.cvm.ncsu.edu/vth/aboutthevisit.htm, and http://www.vmth.ucdavis.edu/vmth/clientinfo/teaching.html
During a single treatment appointment at a teaching hospital such as VHUP, you and your dog may be seen by students "rotating" through the oncology department; junior doctors who are residents specializing in oncology; and senior doctors – the veterinary oncologists. Oncology department nurses – CVTs who may have specialized training in oncology -- will also participate in your dog’s care. In this setting, you must ensure that your dog has consistent attention from a supervisory senior oncology specialist and nurse even though more junior veterinarians or veterinary students participate in his care. And each time you give or receive information about your dog or his care, you need to know the experience level of the person with whom you are communicating. This is because their level of experience may affect the "quality" of that communication. Finally, keep your eyes open and don’t get caught up in titles. An experienced oncology nurse will have more knowledge and hands-on experience than a veterinary student who may have only book learning that he or she has not yet put into practice.
We’ll illustrate these points by describing the VHUP system. Upon arrival for a typical appointment, Berry and I were greeted in VHUP’s general waiting room by a fourth year veterinary student. This student, who was rotating through the Oncology Service for several weeks, was responsible for intake -- for asking us basic questions about Berry’s disease, changes in his health since his last visit, and the purpose of that day’s appointment. The student then delivered Berry, and whatever information we had provided, to the Oncology Service upstairs. There, the Oncology doctors and nurses gave Berry a physical exam, and the nurses drew blood and performed other tests (see Examinations and Tests, in Chapter 6), sending some of the samples off to the lab and pathology for analysis. Meanwhile, Berry selected a stuffed toy to dismantle while they waited for the test results.
After Berry's test results were in, the doctors reviewed them to decide whether it was safe to administer chemotherapy, and, if so, what drug and how much. They placed an order with the pharmacy for any medications to be given by us at home prior to our next office visit. Then the doctors or nurses gave the chemotherapy drugs by injection or IV and monitored Berry’s post-treatment response. At the end of the appointment, one of the doctors – either one of the oncologists, or an oncology resident who might not have seen Berry before -- returned Berry to us. At that time, we discussed the test results, that day’s treatment, any drugs to be given at home, and any other issues we had raised. Sometimes the doctor spoke with us mid-way through the appointment, in which case Berry was returned to us, together with his papers and drugs, by the fourth year student or the oncology nurse. As you can see, a dog in treatment at a teaching hospital can pass through a lot of hands in a short period of time.
What can go awry?
The benefits of the teaching hospital are many, but there can also be rough spots when viewed from the consumer’s perspective. Here, from our many years of experience at VHUP, is our advice about what can happen. These things may not happen to you, and if you take some of the steps suggested in the book, you may avoid them altogether.
The role of junior personnel. Veterinary students are very smart, but skills, knowledge and experience develop over time. The method by which students gain experience is to "practice" on your dog. As the various teaching hospital websites point out, any work involving medical procedures is performed under the supervision of veterinarians. As a result, you should not need to worry about a student administering the actual chemotherapy or prescribing the wrong pills. That said, there are still areas where the teaching hospital system can complicate your dog’s care, and you need to have a very clear understanding of when and how veterinary students are participating in your dog’s care, and how that may affect your dog’s care.
At VHUP, for example, your dog is typically handed off to a fourth year veterinary student in the waiting room. This means that the student, a person with limited knowledge of oncology and no knowledge of your dog, is interacting with you, a non-professional. Especially in the early weeks of your dog’s treatment, you are scared and uninformed. The student is receiving from you critical information about your dog’s condition. The student is not necessarily going to remember all that information by the time he or she reaches the Oncology Department with your dog and is expected to repeat it to the doctors and nurses there. And, especially in the critical early weeks of treatment, you are learning, too. You may not be clearly reporting information to the student or precise in what you say or the questions you ask. As a result, communication may be imperfect or incomplete at the very time when it matters most to your dog.
Multiple oncologists. Another problem is the wealth of oncology resources in a veterinary teaching hospital. How could this possibly be a problem? Because there is a department – and because the oncologists may rotate between seeing patients and teaching – your dog may not be seen by the same doctor each week. Especially in the initial months before the core oncology staff gets to know your dog, it is essential to determine who is going to provide continuity in the care of your dog and maintain a dialogue with that person.
Early in treatment, you must avoid the "revolving door" where your dog is seen by a different doctor each week. If this occurs, it will be difficult for the doctors to develop comparative information from the physical exams and for you to develop a rapport with the doctors. In the first months of Berry’s case, his lymph nodes and spleen were palpitated (evaluated by physical examination) each week by Dr. Bissett, who initially diagnosed Berry, to ensure accurate comparisons could be made during the period when Berry was being transitioned to Dr. Barber’s care. Dr. Bissett’s assessment that the nodes and spleen were decreasing in size was just as important to us as the "hard data" from the blood tests that showed the percentage of cancer cells was decreasing.
The "revolving door" can occur for one of several reasons. It can occur because that is the system of the particular hospital -- it operates like an HMO. It can occur because your dog is new to the oncology department and is being worked into the doctors’ schedules. It also can occur because of the teaching hospital system. It took us two years to understand how the teaching rotations worked. VHUP probably explained the teaching rotations to us and we didn’t understand because of all the other information crowding in at us. But I do remember that we felt frustrated that after four consecutive appointments with "our doctor", Dr. Barber, Berry would be seen by other, different doctors for several weeks. Then, just when we grew agitated about these new doctors, Dr. Barber would miraculously reappear. As I reviewed Berry’s discharges to write this book, I could clearly identify the months when Dr. Barber was teaching and not seeing patients in the Oncology Service, but it wasn’t apparent to me at that time.
Compartmentalization. A teaching hospital is a collection of specialists. As a result, it can be difficult to find someone to keep an eye on the "whole dog" as opposed to the pieces. We experienced this situation with Berry’s coat problems and other non-lymphoma conditions (See Chapter 8). Expect the oncologists to limit their work to the specialty.
Making the Hospital System Work for You (and Easier for Everyone Involved)
Educating the Students and the Oncologists. In our first weeks at VHUP, while trying to sort out Berry’s debilitating vincristine side effects, we found a way to make the teaching hospital process work for us and for VHUP. We would recommend this technique for any treatment setting; it may be especially useful in those where you do not physically accompany your dog through the entire appointment. We created a simple form in our home computer. Prior to each visit, we filled it in with Berry’s recent health, the anticipated treatment for that day, any questions we had, and any medications we needed to have refilled. We also included notations about Berry’s other, existing conditions (such as a benign lump on his side) to ensure that they weren’t repeatedly re-evaluated by new veterinary students who worked with him. Off we went to VHUP.
In the VHUP waiting room, we handed one copy of our form to the fourth year student and kept one for ourselves. We reviewed the form with the student to be sure he or she understood its contents. Then we settled in the waiting room (or went home to await VHUP’s call), confident that everyone who saw Berry upstairs in Oncology would have access to the same data. When we had our exit meeting, we could review the form to be sure that all our questions had been answered and all Berry’s medications were in hand. Appendix IV includes several actual examples of these forms. We kept these records, along with Berry’s discharges and bills, in a notebook that we took with us to each appointment.
Securing continuity of care. It is critically important to have a strong practitioner assigned to your dog’s care. Several owners’ web sites discuss the struggle at other large facilities to find continuity of care, either because of the "revolving door" or because key personnel moved to another facility in a different part of the country, leaving a void. In each case, what those owners say is that they had to take affirmative action to get what their dogs needed.
In addition to the senior oncology specialist, the people who will provide continuity of care are the oncology nurses. They are critical to the functioning of the department. If they are specially trained and experienced in oncology, they have as much practical knowledge of what goes on in Oncology on a day to day basis as anyone else. And this is their full time job. They aren’t rotating through the department or dividing their time between teaching and seeing patients. They see your dog each and every time he visits. On our first consultation with Dr. Barber, I wrote Roxanne Bachman’s name across the top of my notepad when we were told that she would pay a major role in Berry’s care. She is first in our acknowledgements because of her watchful eye, her technique (including those small non-medical touches like doing the bone marrow aspiration without creating a visible shaved patch!) and her love of Berry. Find out if there are specialized oncology nurses who will be a key part of the treatment team, and if so, make sure you know them and they know you.
Overcoming compartmentalization. Veterinary oncologists or hospital oncology departments focus their in-depth knowledge of cancer in small animals on treating your dog’s lymphoma. You need to recognize that this may mean that they will overlook other non-cancer issues. Just because your dog had an appointment doesn’t mean that all aspects of his health were evaluated.
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