3 Things I Wish I Had Known About a Career in Small Animal Internal Medicine on the Day I Graduated
Blog Post | September 1, 2022
By csuvetce
Three things I wish I had known about small animal internal medicine the day that I graduated.
Asked to write about the things I wish I had known on Day 1 of my veterinary career, several key things quickly came to mind. I learned A LOT those first few years from my excellent mentors and I continue to learn from my colleagues, clients … and my mistakes (let’s just get it out there … we all make them…you’re not alone). I’m sure there’s more, but here are 3 things I’ve learned on my career path to date:
- Real clinical learning only begins after graduation and is a career-long process
- Thorough history-taking and physical examination are important keys to clinical decision-making and they will never go out of style
- Communication skills are critical for successful practice and patient care
Real learning begins AFTER graduation
My professional career began with an internship in small animal medicine and surgery. Immediately after I walked off the stage with my DVM diploma in hand, I headed off to the airport to start my internship at the Animal Medical Center in NYC. I thought I was “hot stuff” as I could easily list the clinical signs of a disease, knew the key diagnostic tests to run and the treatments to prescribe. I was confident I could diagnose all the diseases that I learned about in school!
Upon arrival in NYC, the first thing I had to do was find an apartment which was not an easy proposition. I then discovered if I introduced myself to rental agencies as “DoctorTwedt” several apartments surprisingly became available. That DVM degree was very handy and I hadn’t even seen a single patient yet!
The first day of my internship was orientation and meeting my 17 new intern mates. That was followed by a week-long prep for New York State Board Exam (passing the state board exam was required to practice medicine and the New York state board examination was exceptionally difficult). During the prep, we were grilled and quizzed about everything. I then realized that I was with a group of very smart people and I felt pretty darn stupid – shouldn’t I have learned all this in school?
Well, miraculously I passed the NY state board exam and was now ready to see clinical cases on my own! On my very first case, I proudly diagnosed “a pyometra” and quickly transferred her to surgery. Unfortunately, the dog was subsequently correctly diagnosed as having immune mediated hemolytic anemia and I was officially 0-1 in my career – shouldn’t I have learned this in school? I’ll spare you (and me) my numerous mis-steps as I completed a residency in medicine, became board certified in internal medicine, and went on to teach internal medicine at Colorado State University for over 40 years. Over those years, I came to realize that vet school only gives you a basic foundation to begin to learn and that you must build on that foundation after graduation – it takes a lot of hard work. In that internship year, I worked harder than I ever did in vet school, but the learning was purposeful with the goal to become a better veterinarian for my patients. Postgraduate learning starts by reading about your cases, learning from knowledgeable mentors and peers, and most importantly, discovering the best ways to search for an answer when you don’t have someone there to tell you what to do. Vet school has the end point of a DVM degree after 4 years, but in practicing our profession there is no “end point” … rather, there is a life-long learning process and that’s what makes it rewarding and fun.
A former student, that had graduated 10 years earlier, once suggested to me that it would be very helpful if all the vet school notes could be indexed so that information could be easily searched. Though an intriguing idea, much of the information in his vet school notes became obsolete by the time he graduated! A medical school Dean once said to the graduating class, “I’ve got bad news for you … 50% of what we taught you is not true…worse yet, we’re not sure which 50% it was!” Case in point, what we REALLY need to learn is how to find current and correct information.
The successful clinicians I’ve known all have questioning and curious minds that desire to understand medicine … not just how to figure out the latest dose for the latest drug. Today, learning has become much easier and quicker with the internet, as well as a plethora of high-quality, focused continuing education (CE) courses. But one with a questioning mind can learn from anyone; their colleagues, technicians, veterinary students and yes, sometimes, even their client. There is always something new to learn and it is this accumulation of knowledge coupled with a questioning mind that makes a successful clinician.
The Arts of History-Taking and Physical Examination
Over the years following my graduation, I came to recognize the importance of a comprehensive history and physical examination when dealing with my internal medicine cases. As an intern and resident, I had clinic aides that would obtain a basic patient history and, then, I would usually ask a few more questions of the pet owner and quickly begin my examination to come up with a plan for the patient. I often wonder how many things I missed by not taking my own history, asking my own questions? Obtaining a comprehensive patient history is an art that is critical to identify the problems and direct how one works up a case. The history, paired with a careful physical examination, will often reveal key clues to solve the case. This is an art that must be learned and requires considerable practice to be good – why did they not tell me this in vet school? I’m a big fan of the Sherlock Holmes’ short stories and I find that, in working up an internal medicine case, one must become a detective to reach a diagnosis. Sherlock once said to his partner “My dear Watson you must really pay attention to the details. It is a capital mistake to theorize in advance of the facts. Eliminate all other factors and the one which remains must be the truth.” I think those words are so true in internal medicine – don’t ignore the details.
It seems to me that the arts of history-taking and the physical examination have, many times, taken a back seat in the diagnostic work up of our patients. These often are almost unconsciously thought of as being “too time consuming” and “not that important”. True, that being able to take a proper history and perform a comprehensive physical exam takes a lot of practice and only becomes perfected over time, but these skills are what separates the “great ones” from the “everyday” docs. I find that there is a tremendous amount of information that can be gleaned from the pet owner, but often only if I ask the right questions and in the right way. For example, for patients that are referred to me for a vomiting, I always need to be convinced (through careful questioning) that the problem is actually vomiting. Then and, only then, do I direct my questions that seek for any clues as to what might be the cause. I think that, all too often, clinical patients are “glossed over” with only a brief history and cursory exam in the rush to perform blood work, specialized diagnostic tests, radiographs, ultrasound and even a CT scan. Even if these tests yield abnormalities, I frequently find that I struggle to interpret the findings of those tests independent of a meaningful patient history and thorough physical examination. The science & technology of medicine seems to be replacing the ART of medicine and relevant clues, that are important to personalized patient care, may be missed in the process.
I remember a case that was referred for a fever of unknown origin (FUO). The work up included laboratory testing, extensive infectious disease profiles, chest radiographs, abdominal ultrasound and a CT exam. On the CT exam, a foreign body surrounded by an 8cm fluid-filled mass was seen in the right thigh. While, yes, our technology led to the diagnosis, I am saddened that the ART of veterinary medicine failed that day … it was an abscess that was painful and easily palpated upon thorough physical examination. This one cost $1000’s unnecessarily … in other instances, the price can even be higher including loss of life. I’d encourage you to read “Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis” by Lisa Sanders, MD; in it, she talks about these lost medical skills and the dear price that is paid by some patients. I always try to remind myself to put my hands on every square inch of the patient, perform a complete abdominal palpation and auscultation as a minimum and, if the patient is hospitalized, I perform complete examinations each day. I’ve seen instances where hospitalized cases get only “walk by rounds” or perhaps a quick TPR and I can’t help but wonder what valuable clues are being missed. I find that the more I look at my patient, the more subtle findings that I detect on subsequent exams. Internal medicine cases are often dynamic and things frequently change over time … subtle changes can be detected even hour to hour in some instances, but only for the clinician who is looking.
Can You Hear Me Now?
It is accepted by most that client communication is critical in veterinary medicine – easy to say, but hard to do. This is something that I wish I was taught in school. I like to think that we now do a better job of teaching client communication in veterinary school, but it still is an art that must be learned and developed through a lot of practice. Each of us must develop our own communication style, but the bottom line is that we must listen first … and when we do speak, we need to be confident that our client understands what we are telling them. I can’t tell you the number of times I have heard “the vet didn’t tell me what was going on”. Most of us would react “but I DID tell them!” … to which I would point out that it was clearly not in a way that could be understood and retained by the client (much like me listening to my mechanic … he talks and I nod my head, but that doesn’t mean that I understand!).
I tend to be a very visual person and usually draw diagrams or anatomy pictures as I explain complex concepts. For many clients this is helpful, but not for others. I try to find out what best helps my client. Once, after giving discharge instructions for an 8-year-old diabetic dog, the pet owner (who was diabetic herself) told me that only then did she really understand her own diabetes. She indicated that her physician never explained diabetes to her. In reality, her physician likely informed her about the disease, but not in a way that was meaningful, relevant and understandable for her. In contrast, I took the time to logically explain the disease and its management … and I questioned the client along the way to be sure that I was using terms that she could understand (if we’re keeping score, my record as a clinician is now at least 1-1 !). In the instances of a complicated hospital discharge or consulting with a difficult client, I generally schedule an appointment slot so that neither the client nor I feel rushed in our communications.
I was once told by a veterinarian whom I highly respect, that when I am dealing with a sick patient, that appointment is likely the most important thing the client is doing that day… and maybe even that week, month or year. I strive to respect their time and listen to their concerns. (Some studies find that many MDs make a diagnosis in the first 5 minutes of talking to their patient and tend not to hear much of anything after that). You and I need to be good listeners above all. We also need to respect our clients’ time … if I tell my client I will call them at 3 PM, I better darn well call them at 3 PM because they will have changed their entire day’s schedule to be available by phone waiting for my call. If I get busy and forget to call them, l may have lost that client … at that point it may not matter that we are doing a fantastic job in diagnosing and treating their pet. In my communications, I try not to box myself (or others) in to commitments that we may not be able to deliver upon.
I believe one needs to learn to communicate in a way the client will understand, confirm that they understand what the problems are, and always be honest explaining complications, probable outcomes, and financial ramifications. A book that has helped me in understanding communication with my clients, and another that you might want to read is; “How Doctors Think” by Jerome Groopman, MD. In the book, he explores clinical decision-making with a particular emphasis on the poor communication skills and errors that often lead to misdiagnosis and inappropriate treatments in human medicine. I have read the book numerous times and give a copy to each of my residents to read.
Well, we’ve given Oprah and her book club a run for their money, but the value of any book club is in the discussion. How about you? What have you learned along the way? Please feel free to add comments below … after all, we can all learn from another!
