Monday, August 3, 2015

Interview with Dr Sarah Boston: veterinary oncology and being a vet

Associate Professor Sarah Boston, veterinary oncologist and author.

We recently reviewed Dr Sarah Boston’s book Lucky Dog: How Being a Veterinarian Saved My Life (read it here). Sarah is a specialist veterinary oncology surgeon, Associate Professor of Surgical Oncology at the University of Florida and has had her own encounter with cancer which was documented in the book. Incredibly given the subject matter, its also very funny.

Sarah took some time out of her hectic schedule for a skype-chat to share her thoughts on the book, medical vs veterinary approaches to oncology and being a veterinarian in this day and age.

What motivated you to specialise in veterinary oncology?

Initially I wanted to be a GP, I imagined myself as a GP in a little mountain town in Canada. Then I got into vet school very young and I was pretty sure I wanted to be a wildlife veterinarian in Africa, which everyone does. So I was a bit of a cliché for a while. I was lucky because I had a summer job working in a teaching hospital, that and some strong professors in that area turned me onto surgery.
Saskatchewan was a great school, but it was fairly GP oriented so I didn’t know what a residency or internship was til I got into third and fourth year.

Dr Boston is also partial to fun footwear.
I did three years of general practice before doing surgery. I totally believe that being a GP is way harder than being a surgeon, there are a lot more demands on a GP and what people expect of a veterinary GP compared to what they expect of a human GP is so different.

During my surgical residency I had a mentorship with a surgical oncologist. During my residency I got really interested in surgical oncology as a discipline. It’s only in the last 6-10 years that it has been recognised as a true subspecialty. Surgical oncology appealed because it has a creative side to it, it’s challenging, never boring and in general the clients are extremely dedicated.
I went into it because I loved it. I didn’t know at the time that there would be jobs in pure surgical oncology.

Behind every awesome surgical oncologist is an even more awesome dog (this is Rumble).
What kind of cases do you treat as a surgical oncologist?

As far as tumour types, I see a lot of skin and soft tissue tumours, a lot of bone cancer, skull tumours, liver tumours, chest wall masses, lung masses. There is a continuum of cases, from those that a GP can do and those that a general surgeon can do and others that tend to be referred to surgical oncologists. We remove vaccine-associated sarcomas fairly commonly [These are much less common in Australia – ed], and we see cases that require fairly big excisions. We do a lot of oral tumours and perform maxillectomies, mandibulectomies, and remove thymomas and mediastinal tumours and lung masses.

In human surgical oncology it is said that often one team removes the tumour, and a second team close the wound to ensure that the first time are bold in their tumour removal and don’t skimp on margins so they can close a wound. How do you fulfil the role of both the excision and repair teams?

It’s about making a plan. I always have two plans on how to reconstruct a big hole which usually means you prep a lot. The nurses will ask “is this good” and I’ll usually say “no, prep a bigger area”. You do have to separate excision and closure in your mind but you still have to plan ahead for what you can do. If you end up with an open wound with clean margins its better than closing a wound with tumour cells still in it.

The other thing is it’s all about the team. Surgeons tend to get the credit but there’s the anaesthesia team, the ICU team, radiologists – I often say I am very needy, I need that support. We have a great team at the University of Florida. I can do a big resection but I could not do it without knowing that animal is getting 24 hour care and good pain relief.

Your book, Lucky Dog, contrasts your experience with thyroid cancer with that of a canine patient. In a nutshell, how was it different?

One big one was the amount of time a physician spends with a human patient. We [vets] probably spend ten times more time talking to clients, trying to explain the problem and options, trying out best not to use medical jargon. My experience with human doctors was that they had 10-15 min to talk about the fact I had cancer. I understood most of the potential complications because I do that surgery, but most wouldn’t.

I’m not saying that medical doctors aren’t compassionate, but I do feel like vets are more compassionate.

Another thing was information. Thyroid Cancer Canada sent me the most comprehensive little pamphlet that was perfect. But I had to search for it. I went all over the internet and read some crazy stuff. Why couldn’t they have just told me? If you are a head and neck surgeon, you should know about this. Or say “here are three websites I recommend”. Or have the pamphlet in their waiting room.

When I was discharged from hospital after the second surgery I was hypocalcaemic. I was given a little strip of paper on which was typed “call your doctor on Monday.” What if I had had a seizure? I think of the hours veterinarians spend typing discharge statements and discharging patients.

Maybe we go too far. We have a lot of issues in our profession with compassion fatigue and we’re more prone, so maybe we have to pull back a little.
The biggest difference was speed. I just was really in shock about how slow everything was going. I had a fast growing mass in my neck, from time I found the mass, for three and a half months I thought I had cancer when no one else did…our patients would never wait long.

Rumble is ever supportive.
What’s the most important thing from treating cancer in non-human patients?

For me I am very focused on quality of life. That may sound counter- intuitive, but I think that leaving your dog with an osteosarcoma on the leg on is much worse from a humane perspective than getting the leg off and letting them be a three legged dog.

I would rather do a big surgery, knowing I have control of pain management. Most of my patients will live but some surgeries are very risky, and some won’t make out of the perioperative period. I think, “Let’s go for it, let’s give this animal the best chance we can”, it’s a controlled environment. I would rather go in, get the tumour out, get the patient home and get them enjoying good quality of life.

I don’t like middle of the road options where I see animals malingering, maybe not eating well and trying to control pain. I’d rather go in and do something and have an intervention that will potentially help them.

You have to be a little bit into study, but a lot bit into making some fairly bold incisions, to be a veterinary surgical oncologist.
Any advice you’d like to share with veterinarians and future veterinarians?

With oncology, totally follow your principles: find out what a mass is before you do anything active, if a new mass appears put a needle in it and find out what it is. You don’t need to be an oncologist to get good information.

If you’re not sure whether something is treatable or your client wants to have peace of mind, send them to a specialist.

I have clients who come to see me, listen to me and then decide not to do anything. I am happy to spend that time to make sure they have the best information.

As for advice for vets in general, one thing I’ve been thinking about a lot a lot is that vets need to support other vets. Sometimes as a profession we’re a bit hard on ourselves and each other. I love being a veterinarian but it is probably one of the hardest jobs in the world. 

We need to take the time to swap the vet clothes for the civvies and have a break.
The other thing I’ve been thinking about a lot is compassion fatigue and the need to create boundaries. We are a very compassionate profession. We need to make sure clients are cared for but also be able to get away from work. I graduated in 1996 and I feel like I am in the middle between two eras – the “suck it up, this is how it is” which is a pretty harsh attitude, and the millennials who come out thinking they are not working more than 40 hours a week.
I do think we need to protect ourselves so we can have a long career.

Thanks Sarah for your time. She is planning another book about working in the veterinary profession, which we’re looking forward to. If you’ve not yet read Lucky Dog, I thoroughly recommend it. Details here.

You can also follow Sarah via her Blog, Facebook page and on Twitter.