Bradley Viner discusses reflective veterinary practice

Bradley Viner is a UK based veterinarian and author of one of Success in Veterinary Practice: Maximising Clinical Outcomes and Personal Wellbeing. This is a helpful book for any veterinarian keen to continue to improve their practice. Dr Viner is a big proponent of measuring clinical outcomes and reflecting on all aspects of practice. Reflective practice, as Dr Viner so eloquently and persuasively argues, improves the care we can deliver to animals and clients and makes for a longer, more rewarding and successful (in terms of clinical outcomes) career. So I wanted to find out a bit more about Dr Viner and discuss reflective practice with him - as well as his weakness for Bernese mountain dogs.

Why did you become a veterinarian? Was there anyone (human or non-human) particularly influential in this regard?

Around the time that I stopped wanting to be a train driver at the age of six. I think a seminal event was seeing a dog that had been run over and feeling unable to do anything to help. Everyone told me I would grow out of it - but I never did.

I did have an excellent zoology teacher who was also my sixth form (last two years of high school) teacher. She was truly inspirational. When I met her again many years later I commented on how rewarding her career must have been, and she told me she had always wanted to be a doctor!

Tell us a bit about your career path - how did you get where you are now?

I never had any doubts about the fact that I wanted to go into small animal practice and be my own boss. I set up on my own after a year, and the practices just evolved from there. I made some good decisions, but also missed some excellent opportunities. About 12 years ago I joined a group of other GP vets that were working towards an MSc in Veterinary General Practice, all sharing the ethos that GP skills were undervalued and needed to be developed. That led on to my Doctorate, and I am still in close touch with many of that group. It gave me a somewhat unorthodox mix of practice and research melded together. My interest in veterinary education then led to my involvement with the RCVS, our governing body, to try and help shape its future from a practitioner perspective. 

In Success in Veterinary Practice you devote a chapter to reflective practice. What is reflective practice and why should your average vet take a reflective approach?

It's a simple concept - using Kolb's cycle of reflection upon experience to learn experientially. Most of us think we do that anyway, but the process often gets blocked, and doing it formally in writing can help greatly. Most practicing vets are still hung up on the idea that it is only clinical knowledge and skills that need developing, but reflective practice can help us to become much more effective in our workplace. 

When did you start reflective practice and what kind of impact has it had on the way you work?

Everyone does it to some extent but I was forced to formalise the process when I embarked on a degree founded upon work based learning. It has embedded within the way in which I work the concept of continual improvement which has not only changed the way I practice, but also the way in which I run my own organisation. 

How can reflective practice benefit the health of pets?

By improving our performance all round, including the "soft" skills that are more difficult to develop. In that way we can measurably improve our patient outcomes. 

There's a high burnout rate in this profession - why do you think this is?

I write about this quite extensively in my book. One has to accept that the model of someone graduating into a profession and staying within it for the whole of their lives has become much less common than it used to be in all walks of life. However, in the case of veterinary practice I believe it is often due to a mismatch between expectations and the reality of the routine of daily practice. The greatest skill is to be able to take pleasure in the ordinary. Even a routine vaccination consult can be rewarding if it is approached in a positive manner. 

How do you maintain your passion for this career? Has there ever been a moment when you questioned your career choice and how did you get through it?

I've never questioned my career choice because there is so much that can be done with a veterinary degree. I still enjoy consulting, but I also get a lot of pleasure from leading a successful organisation. We were only the second vet practice in the country to receive the Investors in People Gold Award earlier this year, which is all about developing our workforce. I also enjoy playing an active role in our governing body, the Royal College of Veterinary Surgeons, and some under- and post- graduate veterinary teaching. 

Veterinary students often visibly wince when I use the term "reflect" in classes...what advice would you give budding veterinarians?

Take a page out of the book of medical and nursing training, and get over it! The concept of reflective practice is well recognised as being a valuable tool, yet the veterinary profession still tends to scorn it. I think it may be something to do with the very action-oriented personalities that tend to enter the profession. Call it experiential learning if you like. 

You are very widely read. Any favourite books or websites on this or related topics?

My book contains recommended reading for each chapter as well as references. If I had to pick one book that has made more difference to my life and practice than any other, it would be The Mind and the Way:BuddhistReflections on Life, by Ajahn Sumedho. I can't claim to be a very good Buddhist, but I believe there is a great deal we can learn from their philosophy. Ajahn Sumedho is an American who became a buddhist monk, and so he is able to explain their concepts in a way that makes sense to a Western mind. For example, his discourse on walking meditation is a very good illustration of the value of rejoicing in the ordinary as I described earlier. 

Can you tell us about any animals you share your life with right now?

Bernese mountain dog (NB this is not Cleopatra, but I felt the need to include
a BMD in the post just to round it out. Objections? I didn't think so).

I own Cleopatra, my fourth Bernese Mountain Dog. They are a bit of a disaster from a strictly veterinary point of view, but they are such gorgeous and characterful dogs that I find it unavoidable to share my life with one. We also own Fluff, seventeen years old and the last survivor of what were five cats. He was always a bit of a loner, very antisocial, chased his brother away, and picked fights with all the others. Now that the others have all died he is in his element, and adores my wife. He is just waiting for me to pass away so that he can have her all to himself. 

Three things I learned: Practical radiography for the general practitioner and environmentally friendly continuing education

The radiography course was focused on companion animals, but I could not help but include this fabulous radiograph of a poor echidna which sustained injuries from a dog attack (he made a full recovery). No, you aren't hallucinating - that pattern in the background is the spines (and the circles are end-on spines).

Last week I attended the Centre for Veterinary Education's one day workshop on "Practical Radiography for the General Practitioner", presented by Perth-based imaging specialist Zoe Lenard.

This was billed as "ecoCPD", i.e. the organisers tried where they could to reduce the carbon footprint of the entire event, keeping paper to a minimum, reducing or eliminating travel and reducing food waste associated with over-catering. Of course this translated into reduced cost too, but I think the fact that the organisers considered the bigger picture should be applauded.

So what did I learn?

1. Positioning is the key and there are no shortcuts. Zoe recommends that we "aim for perfection with positioning" as shortcuts are a false economy - inevitably you need an additional image which means more time for the patient under GA. I am careful with patient positioning, but I was amazed at how elaborate her positioning devices were, ie she utilises custom-made foam "V" troughs (best way to cut foam is with an electric bread knife) covered with vinyl and liberal sand bags. [It sounds easy but remember we can't make our patients wear a paper gown and stand behind a plate and breath in - we have to sedate or anaesthetise and often manipulate animals of vastly different size and shape into different positions!]
2. Vertebral heart score (VHS) is not absolute, but in general 11 indicates mild cardiomegaly, 12 moderate and 13 marked - but she finds this most useful in serial radiographs of the same dog (and she always radiographs right side down first for consistency). In cats an alternative to VHS is a base to apical measurement lined up from sternebrae 2. If the BA measurement is beyond S4, cardiomegaly is likely. (And heart disease is more subtle in cats due to concentric hypertrophy and difficulty in detecting left atrial enlargement).
3. Her system for using radiographic location of lung changes to determine differentials for lung disease is really helpful (for example a focal or multifocal pattern is more likely primary or metastatic neoplasia, an abscess or granumloma while cranioventral changes are likely associated with pneumonia, haemorrhage and atelectasis and caudodorsal changes are likely due to haemorrhage or oedema which may be cardiogenic or non cardiogenic).

I actually learned much, much more and I've come away with some charts and tables that I will use in practice. Its good to see that despite the increase in use of advanced imaging like CT, radiography is still very important and provides useful information rapidly. It was also nice to participate in a course which very much emphasises what can be done in general practice. 

Guest post: Sentient team volunteers veterinarians in Fiji

Dr Adele Lloyd (Sentient Vice President) & Sue (Animals Fiji Vet Nurse) 

attending to a kitten with a fractured leg.

This is our first guest post from Sentient, the Veterinary Institute for Animal Ethics. If you are a veterinarian interested in volunteering, read on.

Our vice president, Dr Adele Lloyd, along with Publicity Officer, Matthew Lloyd, and committee member, Dr Franca Mazzone used their annual leave last year to volunteer at the Animals Fiji clinic in Nadi.

Unfortunately, Animals Fiji does not have a permanent veterinarian so they are always looking for volunteers (veterinary and non-veterinary) to help them help the animals of Fiji.

Animal Fiji’s vet nurses Lynn and Sue are the fabric of this clinic, which could not exist without them. As locals, they have a solid understanding of the welfare issues that Fiji faces and how best to work within the community. They strive hard to educate the local population about welfare issues whilst providing care and a re-homing service for local cats and dogs.

Lynn (Animals Fiji Vet Nurse), Dr Adele Lloyd (Sentient Vice President),
Franca Mazzone (Sentient committee member) & Sue (Animals Fiji Vet Nurse).

In the planning for the Sentient representatives to arrive, Sue and Lynn arranged a spey & neuter clinic for both private clients and welfare cases. They had planned for approximately sixty surgeries,  however the Sentient team worked their way through between 80-90 animals including some urgent emergency cases.

Dr Adele Lloyd (Sentient Vice President) & Franca Mazzone (Sentient committee member) 

during the spey & neuter clinic.

Adele also had to assess ‘Poppy’ who after surviving a horrendous ‘hunting accident’ involving a cane knife or machete which resulted in the loss of a substantial part of her nose and upper jaw, arrived at the clinic starving and close to death. There was no vet at the clinic at this time so Lynn and Sue did their best to care for her medically and emotionally. The vet nurses did an amazing job of this which meant no only did Poppy survive but she was the picture of health (apart from her obvious injury of course) and amazingly loved everyone that gave her the slightest bit of attention. She totally is a ‘popstar’ as we affectionately nicknamed her – the fact that she isn’t frightened of humans after her horrific ‘accident’ is truly amazing and just goes to show the forgiving nature of animals, something we could all learn from.

Poppy's initial injuries. She has since made a wonderful
recovery thanks to surgeons at the Small Animal Specialist Hospital.

Adele liaised with a number of surgery specialists in Australia about possible corrective surgery for Poppy and eventually (to cut a very long story short!), Poppy was flown over to Australia on the back of a lot of fundraisers, and had corrective surgery (which the Small Animal Specialist Hospital in Sydney did for free) and is now in a loving, forever home and will have nothing to fear as she lives out the rest of her days in Australia. The same fundraisers are helping to raise much needed funds to get a permanent vet at the Animals Fiji clinic – there are so many animals in need of help and with only one clinic on the west side of the main island (there are only a total of three in the whole of Fiji, one private and two animal shelters and clinics), there are always a lot of animals to care for.

If anyone is interested in volunteering at Animals Fiji or if there is a vet out there who would love the opportunity of a longer or a permanent posting out there, please contact Dr Adele Lloyd via email (adele.lloyd@sentient.org.au) or via the Animals Fiji facebook page. To see other animal welfare initiatives you could volunteer at, got to www.sentient.org.au and look under the ‘Volunteering’ section.

SAT supports animal welfare initiatives that improve the lives of animals, and welcomes guest posts to this effect (subject to editorial approval). Please contact me for further information.

Busted: the extra rinse cycle

Ever wondered how the dishes you began to stack got cleaner when you left the room to catch something important on the news? Ever wondered how your dog's bottom expanded slightly even when you put him on a diet? Wonder no more. (Although some mysteries in life are better unsolved).

Shelter for cats in Bali

A kitten awaits adoption at Villa Kitty in Bali.

This year I was fortunate enough to visit Bali, and wrote this article about a recently opened cat shelter, Villa Kitty.

Any Australian who has holidayed in Bali knows about its famous street dogs. Organisations such as the Bali Animal Welfare Association (BAWA) and the Bali Dog Adoption Rehabilitation Centre (BARC) have been established to improve the welfare of these animals and adopt them to loving homes.

Until recently there was no dedicated facility for Bali’s stray feline population. Yet the island’s cat population has to contend with significant challenges: motorcycles and cars in narrow streets, street dogs who see them as a meal ticket, pythons (also known for targeting well cared for domestic pets), and human neglect.

Vaccination is uncommon, and canine parvovirus is rife, creating the perfect window for infectious diseases such as feline panleucopaenia virus to emerge as a significant threat. Kittens are often orphaned at a young age, leaving them extremely vulnerable to the ravages of intestinal parasites and severe respiratory disease.

Villa Kitty, established in March 2011 by Australian expatriate Elizabeth Henzell, is a dedicated sanctuary for Bali’s vulnerable feline population. While other animal welfare organisations have always tried to assist cats in need, Villa Kitty hopes to fill an enormous gap.

The cats and kittens at Villa Kitty are absolutely beautiful and ready to adopt into awesome homes.

A veterinary clinic, lead by Dr Karnata and associates Isa Ghautama and Magri Nora, is attached to the shelter. Despite housing over 100 cats and kittens, the facilities are cool, clean and far removed from the chaos of the busy streets just metres away.

“We have capacity for 50 healthy cats and kittens in our original building which has the Rainbow room for our fully vaccinated and sterilised cats, our three small West Wing rooms for vaccinated kittens that are still too young to be sterilised and our Maderson Wing maternity runs for our mother cats and their kittens,” Henzell said.

“The Molly Parr Wing is our quarantine building which is made up of 3 rooms divided into two runs each and one large room for the tiny kittens that need to be held in cages until they are in a better state to put them in the runs.”

One of the biggest challenges in running this shelter is the low rate of vaccination in the community, coupled with the high population turnover (in December 2012 the shelter admitted 43 new cats or kittens in less than four weeks).

The hospital is divided into wings for cats suffering from gastrointestinal disease, and another for cats with respiratory signs.

According to Dr Karnata, the most common problems seen are the typical scourges of cat shelters worldwide: flu, diarrhoea and ringworm. Trauma is extremely common, with fractured spines and eye injuries necessitating enucleation particularly frequent.

“We would love to set up a sponsored program to provide sterilisation for cats and kittens of families who cannot otherwise afford this,” Henzell said. “At present we cannot afford this but we are seeking sponsorship to do so.”

A Balinese statue. Nope, it isn't a cat or kitten. But it is from Bali!

Australian’s spending any length of time in Bali can assist by fostering kittens or volunteering as kitty cuddlers. Donations of food and bedding are always welcome.

The Indonesian Government imposes strict regulations which limit international veterinarians from volunteering their veterinary skills. However, while Australian veterinarians cannot perform surgery or provide hands-on treatment to animals, provision of services in a consultancy capacity is still very helpful.

Villa Kitty is backed by an Australian philanthropist but relies heavily on private donations. To make a donation, email Elizabeth at elizabeth@villakittybali.com or check out their Facebook page.

Small Animal Talk: behind the scenes insight

Anne, Phil and Sofi chillax on the couch.

If you wondered how we source the fabulous images used on this site, wonder no more. This pic was taken by our in-house photojournalist Alice, a Sydney-based photographer who uses innovative, animal-friendly techniques like bouncing the flash off the ceiling to diffuse the light and not blind any of her subjects.

The making of...

Alice: portrait of the artist at work.

Alice favours candid shots and would rather approach subjects than rely on zoom. She's also a photographer willing to step into the shoes of her models and demonstrate just exactly how it is done.

Alice holds Phil.