Veterinary bibliotherapy: All My Patients Are Under the Bed

 

"All My Patients Are Under the Bed" by Dr Louis J. Camuti, Marilyn Frankel and Haskel Frankel.

I’ve been delving into veterinary history for a couple of projects, and stumbled upon the veterinary biography of one Dr Louis J Camuti, written with support from his clients and friends Marilyn and Haskel Frankel. The book, AllMy Patients Are Under the Bed: Memoirs of a Cat Doctor provides a fascinating insight into veterinary practice in the 20^th century.

Dr Camuti was born in 1893, and worked until his death – likely due to a fatal arrythmia when driving – in 1981. He was aged 87 and had been in practice for over 60 years.

The book is intended for a non-veterinary audience, focused mostly on anecdotes about quirky cat owners and their cats. But it contains some fascinating insights into veterinary practice in a different era.

Dr Camuti graduated from New York University in 1920. He lived through the great influenza pandemic in 1918, contracting the virus in 1919 when he was a second lieutenant in the New York Cavalry. When the flu struck his camp, over 100 men died. He made it home – with a fever – and married, but as a precaution didn’t kiss his new wife.

When the horses were struck by shipping fever, Dr Camuti was given the job of destroying all of the sick horses - one that caused significant distress.

"I told myself over and over again that the animal was sick and could not be saved. Wasn't I really sparing it pain? yes, but it was something I had to remind myself of everyday. I knew that bringing the peace of death to an animal was as much a part of being a veterinarian as helping a dog to give birth to its puppies, but still I suffered. I guess I was still a kid, and like all kids who think of becoming
doctors, the first thought is of life. It is only later on that you have to face death as part of the job" (p51).

We now know that killing animals can be a source of moral stress for veterinarians. And moral stress can indicate there are systemic animal welfare issues that need to be addressed. In Carmuti's case there was no alternative to killing the horses, he was a subordinate given the order. But he did endeavour to change the method of killing to ensure it was as humane as possible in the circumstances. Perhaps these traumatic early experiences drove him to focus on companion animals.

He later discussed a request for euthanasia of a seemingly healthy St Bernard. This didn't occur because Dr Camuti, who purchased a bottle of chloroform from the pharmacy on the way to the housecall, accidentally anaesthetised himself when he opened it in a poorly ventilated bathroom. Both the vet and the dog survived.

Early in his career, Dr Camuti established a few practices, but his penchant for feline patients became known and he performed house calls in New York City. In the latter two decades of his life he set up an exclusively house call practice. He would begin his evening rounds from about 4pm, sometimes until well after midnight, often getting to bed at 4am. His wife Alex would book appointments – before people had mobile phones or email. She also rode alongside him and waited in the car, ready to move it if the parking inspectors or police turnedup. He would attend up to 30 housecalls a week.

Many of Dr Camuti’s clients did not have cars or cat carriers. Getting to the vet was impossible. And Dr Camuti felt that his patients were more relaxed in their homes – though he did spend a lot of time trying to find his patients in their homes (that aspect of house calls remains unchanged).

He would ask clients to have his favourite hand-soap ready (Cashmere Bouquet), and boil syringes (they were glass then) on the stove tops of his clients. He practiced when there were no analgesics registered for use in companion animals, when Nembutal (pentobarbital) was used as a sedative, and when blood tests weren’t routinely performed. If a patient needed surgery, a spey for example, he would often perform this in the owner’s home, on the kitchen table or similar. Veterinary practice is very different now.

After he survived a cardiac arrest, Dr Camuti couldn’t climb the stairs to reach patients in apartments above the first floor. So he took to examining many cats in the hallways of huge apartment buildings in which they lived (I would have been terrified of a patient escaping). On the day he died, he was still seeing patients.

The book makes much of the “quirky” relationships people had with pets. It was written before anthrozoology was established as a field of scholarship, well before James Serpell’s book In the Company of Animals put the human-animal bond on the academic map.

When I read about practice, at a time when there was no pain relief for veterinary patients, when there was little awareness about animal welfare, when humane euthanasia could not be guaranteed, it reminds me how far our profession has come.

That is not a criticism of Dr Camuti. He was the first feline-only veterinarian in the USA. Despite limitations in practice, Dr Camuti was deeply concerned about animal welfare, expressing his views about declawing: 

"People who have cats declawed usually do so for one of two reasons: to prevent being scratched by an aggressive cat or to preserve their furniture. Such people are obviously thinking only of themselves, not of the pets they are supposed to love. For their own selfish reasons they put their cats through a surgical procedure which is severe, both physically and emotionally. Very often a cat is declawed without any attempt on the part of the owner to train the animal first to use a scratching post. The cat never had a chance. In fact, I've known of cases where a prospective owner demands a cat to be declawed before he'll adopt it. I certainly would never give a cat to such a person because the request itself is an indication that the household is not suitable to a cat". p91. 

And he goes on. This passage reminds me of important positionstatements on declawing in cats, published more recently by the American Association of Feline Practitioners and the International Society for Feline Medicine.

He was also against ear cropping and tail docking in dogs, and raised concerns about the neglect of long-haired cats, the impact of inbreeding, failure of many people to recognise (and control) their cat's reproductive potential, and the hoarding of animals. He treated a range of exotic pets, back at a time when people could acquire a primate on a whim without any sort of license, permit or clue as to how to meet the animal's welfare needs.

Veterinary biographies like these are such important historic records, often for the minor, seemingly routine details they capture about past veterinarian’s daily routines and habits. This biography is worth a read. Especially if you do appreciate cats. 

On another note, if you are tempted to write your own veterinary (or non-veterinary) biography, the Vet Cookbook is hosting a writing workshop on narrative non-fiction with award winning author Brendan James Murray. Check it out here.  

Veterinary Bibliotherapy: Burnout – A Guide to Identifying Burnout and Pathways to Recovery

“...you might suppose that burnout rates would be highest in those whose work simply because they have to, be less evident in those whose work furnishes them with a career, and lowest of all in those who are passionate about their work. We, however, argue that the inverse applies, as burnout rates appear lowest in those who work simply as a job, higher in those who view their work as a career, and highest in those whose work is at the level of a 'calling'.”

(Gordon Parker, Gabriela Tavella and Kerrie Eyers, Burnout: A guide to identifying burnout and pathways to recovery.

Burnout is a hot topic right now, particularly in the veterinary profession due a proliferation of recent studies documenting high levels of burnout among veterinary team members.

When I first heard the term, I can't pinpoint the date but I'm guessing two decades ago, burnout seemed very much framed around the individual. Maybe people who went too hard and, like a candle, simply burned to the wick. When I began my career, people said “don’t work too hard or you’ll burn out”, as if there were a threshold level of work beyond which burnout became a certainty.

In contrast, people were also saying things like “do what you love and you’ll never work a day in your life”, “immersion is the key to success”, and “you need to get as much experience as you can”. People talked about work-life balance, but they behaved according to the mantra that good veterinary team members worked hard.

Since then, there seems to be much debate about the biggest problems in our profession: is our main scourge compassion fatigue? Empathy fatigue? Moral distress? Secondary trauma? Burnout? Which of these are responsible for career attrition or rates of suicide in our profession?

It is against this background that I read Burnout: A Guide to Identifying Burnout and Pathways to Recovery by Gordon Parker, Gabriela Tavella and Kerrie Eyers (Allen &Unwin). This book manages to discuss, in an engaging way, the evolution of the understanding of burnout, what it is, and what it isn't, and what we need to do about it.

Burnout isn't a medical diagnosis (at least not yet). According to the World Health Organisation InternationalClassification of Diseases (ICD-11, 2018), burnout is a syndrome comprising

• feelings of energy depletion/exhaustion
• increased feelings of detachment from one's work, or feelings of cynicism or negativity
• decreased professional efficiency. 

According to the authors of Burnout, compassion fatigue may be a component of burnout, “being part of a broader 'inability to feel' or lack of joie de vievre”.

The authors explain that there is no single magic bullet, no single brain or endocrine pathology to target, no proven pharmacological cure, and no one-size- fits-all plan to treat burnout. They do stress that any strategy requires addressing both the worker and work conditions. The individual and the system they work within. And by work they also mean the work of carers.

Most scientific papers I've read on burnout to date utilise the Maslach Burnout Inventory (MBI) to measure burnout. The authors of this book developed the Sydney Burnout Measure (SBM), and used it to perform a number of large studies on burnout which they argue revealed different features of burnout. One example is the presence of cognitive impairment, which may manifest as difficulty concentrating or poor memory. They also found an association between perfectionism and burnout. Relatable?

The authors talk about occupations at high risk, including doctors, nurses, lawyers, managers, police and veterinarians.

According to Professor Parker, factors increasing the burnout risk for veterinarians include long hours, high university debt, low remuneration, difficult interactions with clients, animal death and euthanasia. High levels of perfectionism have been reported among veterinary professionals.

“Prevention strategies would require addressing salient drivers and handling perfectionism,” he said.

While burnout isn't a medical diagnosis, the authors warn that employers should take appropriate precautions and limit liability.

The book outlines the key components of addressing burnout:

• addressing work issues
• adopting strategies to manage stress
• address the trait of perfectionism

It contains a number of in-depth case studies, as well as mentions of well-known figures who have been alleged to have burnt out over time. I didn't know, for example, that Florence Nightingale and William Osler likely suffered from severe burnout at times in their illustrious careers.

The book's appendix contains the Sydney Burnout Measure, a checklist of workplace triggers and a perfectionism scale.

Overall this is a very readable book. It is based on science, and written by the scientists who undertook the studies it is based on, yet it is accessible and even – I dare say – enjoyable to read. 

Veterinary bibliotherapy: How Stella Learned to Talk

 

Imagine if your dog could communicate with you using words.

This post is coming to you live from Sydney, where an escalating number of COVID-19 cases have triggered a two-week lockdown. This is a good excuse for some veterinary bibliotherapy. This week I want to introduce a non-fiction page-turner, How Stella Learned to Talk.

As a veterinarian, I often wish I could talk to animals and ask, where does it hurt? What did you eat? (maybe even “why?!”). Even more, I wish I could talk to them and allay their concerns: “it’s just one needle” or “this will make you feel better” or even “just keep still for a moment and I will pull this grass seed out!”.

Enter Stella, a 3-year-old Blue Heeler/Catahoula cross. Her owner, Christina Hunger, is a speech-language pathologist with a special interest in Augmentative and Alternative Communication (AAC). She works primarily with toddlers who have significant delays in language development. She also has the patience of a saint, which helps.

It also helped her model the use of a home-made AAC device for Stella, who can communicate 48 words on her device and can create sentences 5 words long. Her favourite words are OUTSIDE and PLAY.

Christina noticed that, as a puppy, Stella met milestones of communication that toddlers meet, like crying to get attention, turning her head to a voice, maintaining eye contact, anticipating feeding and responding to a request to come here. She observed that dogs don’t simply respond to the tone of our voices – they understand some words (hence people spell out words like W-A-L-K if they don’t want their dog to get excited).

Christina asked herself what would happen if she implemented speech therapy interventions with her puppy? She did NOT ask herself “how do I get Stella to push these buttons to say words.”

Christina’s relationship with Stella is based on presuming competence (“treating from the fundamental understanding that everyone can learn, and everyone has something to say”), listening intently, modelling responses and trying new things.  Christina work’s with Stella’s intrinsic motivation to communicate – it isn’t a reward based system.

This is a fascinating, highly readable book, rich with descriptions of incredible interactions, like this one.

“When daylight saving time arrived in November, we turned our clocks back one hour. Stella showed us, once again, how routine based she is. Between 3:30 and 4:00pm, she repeatedly requested to “eat”. This would have been 4:30 or 5:00 before the time change, which was completely normal for her. But I did not want to feed her dinner so early and throw her off for our workweek ahead. I gave Stella a couple of treats to tide her over but kept saying “No eat now, eat later”.

Fifteen minutes passed.

“Help eat,” Stella said then barked.

“I know, Stella, good waiting. Eat later.”

Stella sighed. She stood still for about ten seconds.

“Love you, no” she said. Stella walked away, into the bedroom.

Imagine if your dog could “speak” to you like that?

Not only does Christina document, in detail and summarising at the end of each chapter, how she taught Stella to use AAC. She also explains how humans  learn to communicate, and how we use words.

For example, I had no idea that around 80 per cent of everything we say consists of a paltry 300-400 words. Core words are verbs, adjectives, pronouns, adverbs. Fringe words are specific words that have more limited use. Thus EAT is a core word, while BREAKFAST, LUNCH or DINNER are fringe words.

One of the things that surprised me was that Stella did not simply produce a list of demands with her words. She used language to make observations, for example saying “water” when she watched Christina water her plants.

I don’t expect that this book is going to produce a generation of talking dogs, although there are other dogs using AAC around the world. Very few people have the patience to model words as much and as consistently as Christina and her partner Jake did for Stella. And Stella’s AAC is not available to her everywhere. Its not like a handheld device she can take with her on walks.

But the example of Stella, and Christina's book, may result in more people presuming competence in animals. 

This is a must-read for anyone who works with or shares their life with animals.

How Stella Learned to Talk is published by Allen & Unwin (RRP $32.99). (I just received an email from my local bookshop stating that the doors are closed during lockdown, but they're taking orders online and over the phone and postage is free, so its a good time to support local businesses if you can). You can follow Stella on instagram @hunger4words 

Veterinary bibliotherapy: awe

 

An awesome creature resting next to a book about awe.

“Something happens when you dive into a world where clocks don’t tick and inboxes don’t ping. As your arms circle, swing and pull along the edge of a vast ocean, your mind wanders, and you open yourself to awe, to the experience of seeing something astonishing, unfathomable or greater than yourself.” Julia Baird, Phosphorescence, p23

It wasn’t until I read Julia Baird’s bestselling biography/meditation on photoluminescence, that I really reflected on awe. What is awesome? What generates awe within us?

According to Jonah Paquette, author of Awestruck: How embracing wonder can make you happier, healthier and more connected, awe is a feeling of perceptual or conceptual vastness, combined with experience that transcends our understanding, and forces us to accommodate new information from a different, perhaps bigger, perspective.

Emerging research on awe shows that it makes us feel less alone, diminishing the ego and giving us a sense of the greater forces that surround us.

Awe can be negative – its origins relate to fright or terror, particularly in relation to a divine being – or positive. That negative type of awe can be a powerful driver for change, and even ethical conduct. Awestruck focuses more on positive awe.

Research has shown that awe makes us kinder, more generous, and more curious about the world. Studies have shown that awe has a number of psychological benefits, including increasing satisfaction, making us less materialistic, reducing stress, helping us grow and change and making us more humble.

At a biological level in humans, awe may be associated with reduced levels of inflammatory interleukins – could it have an anti-inflammatory effect?

Could awe be anti-inflammatory?

If all this is true, that seems a good reason to cultivate awe, which is what the second half of Awestruck is devoted to.

First, it is helpful to understand the many forces that can blunt or crush awe: anxiety, multi-tasking, addictive technology, habits, routine, desensitisation…the same forces that nibble away at our wellbeing.

Paquette discusses strategies to minimise the awe-crushers, for example limiting exposure to addictive technology.

But he and Baird also talk about strategies to deliberately seek out awe: for example, disrupting our habitual existence, doing small things differently, and being mindful of the world around us.

According to Baird, “One of the more surprising findings of recent research is how commonly awe can be found: in museums, theatres, parks, ponds, while listening to a busker, or even, surprisingly, in microdoses, while watching a commercial or reading a story.”p31

There are so many potential sources of awe, but a strong theme emerges from both Awestruck and Phosphorescence: one of the most common and powerful sources of awe is the natural world.

The natural world is a consistent source of awe.

And that is probably what resonates with me the most. When I think about awesome experiences, the common factor is animal life. Whether its hearing the exquisite soft snoring of a cat in a deep sleep, or observing a horse grazing in a paddock, animals are a constant source of awe. Neither of these books are written with a veterinary audience in mind, but when I talk to friends and colleagues about what drove us into the profession, and what sustains it, there is often a sense of awe.

These books provide compelling arguments for seeking and cultivating awe, and provide some -practical suggestions about how to do so. Awe-chasing seems like a very valuable use of one’s time.

They also provide compelling reasons for protecting these sources of awe, most of which are threatened by our unsustainable lifestyles.

Veterinary bibliotherapy: "Emotional Female" by Yumiko Kadota

 

Hero also loved Emotional Female, but for slightly different reasons. Image (c) Anne Quain 2021.

In February 2019, the Sydney Morning Herald ran an article by Kate Aubusson entitled “Exhausted Surgeon Dismissed as an Emotional Female”.

I recall reading the heartbreaking story of plastic and reconstructive surgery unaccredited registrar Yumiko Kadota – the punishing hours she worked, the extreme demands she faced in her workplace, including sleep deprivation, and her account of the dismissal of her own illness by medical colleagues.

What struck me was how ironic it was that any kind of healthcare system was designed in such a way that it could have a detrimental impact on the health of its workers. We see healthcare professions as healthy, right? They know the stuff about health and wellbeing that we don't. But knowing and doing are different things.

Dr Kadota’s story resonated in the light of the current discussion about the wellbeing of veterinary professionals. We devote energy to promoting and restoring the welfare of our patients – right down to reflecting on their fear, anxiety and distress in veterinary settings, and doing everything in our power to minimise these. Synthetic pheromones. Places for shy patients to hide. Allowing buddies to be hospitalised together. Offering treats when we give injections.

We talk about the five freedoms of animal welfare – freedom from hunger, thirst, discomfort, pain, and freedom to express normal behaviours. We know all about welfare and the things that compromise it. 

But we seem challenged when it comes to protecting our own freedoms, promoting our own welfare. In some cases, I think it is safe to say that we wouldn’t work dogs or cats like we work ourselves.

And when I say ourselves, I am not suggesting that the blame lies with individuals. Sickness in healthcare settings is a complex interaction between individuals, management and environments – the systems in which we operate.

I contacted Dr Kadota and she gave a brilliant talk at the Mental Wellbeing for Veterinary Teams Symposium in 2019 about the need to put your health first. 

                                Dr Alicia Kennedy, of Cherished Pets, with Dr Kadota.

Earlier this year, Yumiko – describing herself as a “recovering doctor” – released a frank book about her experiences.

Appropriately, the book is entitled “Emotional Female”.

It is a thought-provoking, highly readable autobiography documenting a gruelling career trajectory. Despite clear differences between veterinary and human healthcare, I think many veterinary professionals will be able to relate.

Yumiko talks about beginning her career with konjo – Japanese for approaching everything with guts, “drawing inspiration from the samurai spirit”. She describes the challenges of her medical degree and training, early encounters with trauma and suffering, reflecting on what it means to be “a good doctor”, and the constant drive to be better.

As she climbs the training ladder, she admits that “I did sometimes wonder if I’d ever be satisfied. When there’s always more, you feel like you’re never good enough.”

At the same time, her social life becomes “bargaining with friends and loved ones all the time – a continuous cycle of cancelling and making up for cancelling.”

She shines a spotlight on sexism, misogyny and the treatment of women who “speak out”.

Her work becomes all-consuming, but it isn’t sustainable. Yumiko, a doctor, eventually becomes a patient, aware that the roles can be seen as mutually exclusive.

“We accept when patients have mental illnesses, but if it’s a colleague there can be a lot of stigma attached. It’s seen as a sign of weakness or a personality flaw. I was realising I had the same prejudices and needed to fight them.”

Emotional Female is a brilliant, sometimes difficult, always compelling read. It will make you think about what it means to be a good health care professional, how health care systems impact the health of healthcare professionals themselves, and what it really means to be a good doctor.

Veterinary bibliotherapy: Letters from a Former Dean

 

My well-thumbed copy of Letters from a Former Dean by Emeritus Professor Trevor Heath.

How are you doing? It seems that everyone I ask has had an extraordinarily challenging time in the past couple of two years.

I’ve come to the realisation that, especially when I am stressed, I seek solace in books. I know, one should be focused on eating, sleeping, saying “no” to additional commitments and getting regular exercise. But if I know I have a book to read on the bus, or in a queue, or if I can steal a moment at home, it gives me comfort. Bibliotherapy.

I recently read by Emeritus Professor Trevor Heath, former Dean of the University of Queensland veterinary school.

I corresponded with Trevor for several years about his research on veterinary careers, issues around retention of vets, and the veterinary profession in Australia. I learned that he was often approached by students and graduates about all kinds of problems, from lack of motivation, to trying to cope with personal tragedy, to struggling with the transition to practice or considering moving out of the veterinary profession.

It must have been at least a decade after we e-met that I finally saw Trevor in person, giving a talk on mental health challenges for veterinarians at an Australian Veterinary Association conference. He spoke not just of challenges that others had approached him with – but his own gremlins, as he called them.

I can see why so many have sought his advice over the years: they trust that he will treat their problems with his compassion, respect and thoughtfulness.

As someone who has existed in the world of tertiary education for over 60 years – as a student, teacher, supervisor, mentor, researcher and Dean – its not surprising that Trevor is in a position to see patterns in the problems people have sought counsel about.

A few years ago he began writing letters of advice to a fictional student, and sharing them with others. These are now compiled in Lettersfrom a Former Dean: Advice for Students on Navigating Their Studies for aSuccessful Career, published by Australian Academic Press.

It is a short, accessible, gentle book covering four major themes: managing university studies, mental health, relationships with others, and career planning. And the final chapter is a distillation of those, in point form.

Unsurprisingly, it contains solid advice, including tips on staying engaged. It made me think about my own undergraduate life. If I felt overwhelmed at uni, I would skip lectures, trying madly to catch up, while simultaneously falling behind, worsening a spiral of overwhelm and crushing motivation. In hindsight, this was a strategy that set me up for failure, but its obviously a common issue.

But it isn’t just about being a good student. Trevor knows a lot about what makes a good teacher, and the potential undermining powers of the “hidden curriculum” (i.e. what we teach through our actions rather than our behaviour).

He offers some beautiful illustrations of the Dunning-Kruger effect (when we believe we know more about something than when we actually do (here is a run down from ZDoggMD), and some ideas on how to avoid it.

And, from his own “long experience with depression”, some very practical advice.

I am sure I could calculate the ratio of tags I stick in books relative to page numbers, but that’s an exercise for a quiet day. However, there are plenty of sticky tags in this book which I feel is the basis for a recommendation. Definitely worth a read. And a re-read.

Book review: The Trainable Cat. Plus that Downward Dog video and dogs day out.

Hero and I will be trying out the key skills in this book.

“[Vet] visits are essential for keeping your cat in tip-top health, but your cat cannot know this, and you cannot afford to simply take the attitude that what happens at the vet’s stays at the vet’s. You may be able to forget the struggle your cat put up while being examined, your vet may be able to dismiss it as one of the expected hazards of the job, but your cat will not forget so easily.” (Bradshaw and Ellis, 2016:225).

Some wise words from my new favourite book. One of the most offensive things I do on a daily basis, in fact multiple times per day – at least from the point of view of my feline patients – is to remove them from the cat carrier to examine them. Some cats will walk out voluntarily, and proceedings are ALWAYS better. 

They have a sense of control. But those that don’t resort to all sorts of behaviours which make this a struggle – adopting the “starfish” position. Digging in. Curling up and becoming heavier than titanium.

If you lived with a cat, plan on living with a cat, know someone who lives with a cat, or don’t live with a cat but you’re interested in animal cognition and learning, you will love The Trainable Cat: How To MakeLife Happier for You and Your Cat by John Bradshaw and Sarah Ellis.

Hero has the crazy ears in this photo because he was about to chew on the book.

This book is not a book about training your cat to do stunts or tricks. Rather it recognises that we expect cats to adapt to our world, even when it goes against their natures. They do a pretty good job, but sometimes it overwhelms them.

It may shock readers to learn that, “lacking the necessary brain structures, cats must logically perceive their relationships with their owners (and with each other) in a far simpler way that we conceive of our relationships with them” (p14). That does not mean they’re not intelligent – it means we have to learn how cats learn. (And yes, it’s also unlikely that cats can be devious, spiteful or scheming – a myth that unfortunately is associated with very unhelpful punishment of cats – the authors explain why this inevitably fails to change their behaviour).

The book opens with a discussion of feline evolution and ethology. How do they live in the wild and what are their natural behaviours?

It provides a core set of key stills, all outlined in one chapter, that can be used to help cats cope with a range of challenging yet common situations (outlined in the other chapters): adapting to an indoor lifestyle, dealing with being touched, going to the vet. And the carrier. As far as I am concerned these authors have nailed it: there is an entire chapter on how to get your cat in (and out) of the cat carrier. There is even a beautiful flow chart.

If every cat owner read this book and applied these principles, the welfare of their cats would be excellent – and the bond between cats and owners would be stronger – to the benefit of both parties. This weekend, I'm making Hero a toolbox, and investing in a more suitable carrier.

Meantime, on an anthropomorphic note, check out this video, “Downward Dog”. As one of my colleagues said, they weren’t 100 per cent sure about it – but it says a lot about human behaviour. Its 11 minutes so you’ll need a cup of tea. We’d love to hear your thoughts.

Finally, if you’re in Sydney this weekend with a canine friend or two, the Pawfect Day Out will be held at the Vic on the Park on Sunday from 2-5pm. More info here. 

Cats as therapy: When Fraser Met Billy

Hero helped me read When Fraser Met Billy. Complete with his plush Corgi (this is quite appropriate as Fraser and Billy grew up on the Queen's Balmoral estate).

Companion animals are important to people in so many, many ways. Take Billy Booth, a kitten who was rescued from a deceased estate just in the nick of time (the house was to be boarded up but someone went in to check). Thanks to Cats Protection in the UK, the grey-and-white moggy was rehomed to the family of a three-year-old boy diagnosed with autism. Fraser, born with a range of conditions, barely communicated with a soul, but he took to Billy the moment he saw his photograph. And when the pair met in the flesh, the connection was undeniable.

In When Fraser MetBilly, Fraser’s mum Louise Booth documented the incredible bond formed between Billy and Fraser. And this is not a cutesy-lovey-dovey fairy-tale book about how warm and friendly animals are. You can hear Louise talk about Fraser and Billy here.

In part, it’s a frank, honest and very brave discussion about the impact of Fraser’s condition. Louise describes Fraser’s birth, her experience of post-natal depression and learning to meet Fraser’s very different needs by “trial and horror”.

“Now I was on my own with a baby that bellowed and vomited for twenty four-hours a day, seven days a week. Slowly but surely, my sense of isolation began to deepen.”

Fraser’s autism meant that he was hypersensitive to noises, and prone to meltdowns at triggers that other children might not have noticed. His hypotonia meant that he struggled with mobility and needed splints to walk.

When we think of pets as therapy, we tend to think of dogs. After all, cats tend to be more independent creatures, less sensitive to those around them, limited in their ability to provide any physical form of aid and keen to do their own thing. Certainly as a vet most of my experience of animals in therapeutic roles relates to dogs – though I wonder having read When Fraser Met Billy whether some people are self-conscious about sharing their own experiences with feline friends.

Louise’s account of Billy brings into question all of the above assumptions. At first she was a bit awkward raving about the impact of Billy on Fraser’s world, but Cats Protection had no doubt this was not a one-off. They alerted the Daily Mail, resulting in this article (worth clicking this link for the photos alone).

While n undoubtedly equals one in this case, it’s impossible to doubt the positive impact Billy has had on Fraser – despite one falling out between the pair when it appeared Billy was favouring the kids next door. He sat through some of Fraser’s major meltdowns. He was a calming presence during major life transitions. He allowed himself (literally) to be leaned on by a toddler. Billy even encouraged Fraser to walk up the stairs when no one else could convince him to.

The not-so-explicit storyline is the importance of Billy to Fraser’s family – his parents Louise and Chris, and sister Pippa. One gets a sense that the mere presence of Billy was a much-needed balm.

The photo on the cover of the book, by Daily Mail photographer Bruce Adams, makes for one of my favourite book covers ever, and the story behind it is beautiful. (Louise tells the story of the article, and the process of organising the photographer, in the book. As with everything involving Fraser, it wasn’t simply a matter of inviting a stranger over to take some happy snaps. The idea had to be introduced slowly, repeated, and executed sensitively so as not to trigger any sort of anxiety or meltdown).

This is a beautiful book for anyone with an interest in animals, pets-as-therapy, kids, any parent that has ever had a toddler that has had a meltdown, and anyone working with animals who seeks to better understand the relationships we form with them.

You can see more photos of Billy and Fraser on their facebook page. 

Book review: Forgive and Remember - Managing Medical Failure

Hero also likes to use Forgive and Remember: Managing Medical Failure as a pillow.

“…residency training is designed as a moral education, the purpose of which is to teach young doctors the standards of practice.” Charles Bosk, 1979

We take for granted the fact that ethics is taught in medical schools, but it certainly isn’t taught in all veterinary schools – although there is movement afoot to improve, standardise and introduce the teaching of veterinary ethics.

So it was interesting to read Charles Bosk’s landmark account of (human) surgical resident training, in which he argues that technical training is largely secondary to moral training.

Forgive and Remember: Managing Medical Failure takes its title from a mantra of surgical teachers. Errors are not in vain if we learn from them.

“Benefits of the error are believed to outweigh the costs. One individual suffers, but legions of patients yet unseen have the lesson gleaned from this error passed onto them”.

That may be so, but as Bosk points out, “…the costs of technical failure never shrink to zero, and it is the patient who always pays”.

Bosk, a sociologist, spent 18 months embedded in the surgery team at a large teaching hospital in the US. In the 1970s. Before ethics committees were common (he didn’t even obtain ethics approval for his study) and before ethics was formally taught in most med schools.

The book was a revelation at the time, highlighting the challenges of training young surgeons. The following passage is one that any vet who has taught students surgery can relate to:

“The superordinate’s task is a delicate one. He must control mistakes. Yet at the same time, if he wishes to train competent, independent and (eventually) autonomous professionals, he must allow his subordinates enough room to make the honest errors of the inexperienced. To allow this requires a certain level of cold-blooded calculation on the part of the superordinate. On the one hand, he needs to restrain himself from taking charge of situations too quickly lest he damage a subordinate’s confidence. On the other hand, he needs to know when to rescue a subordinate – and patient – lest a surgical accident shake the novice’s belief in his abilities.”

Forgive and Remember gave people insights into the challenges of being a doctor and the limits of clinical decision making.

“Medical decision making is a probabilistic enterprise. Presented with a patient with a set of symptoms, the physician makes a diagnosis and then decides on an intervention. Only rarely is it the case in which the physician can say “this patient has x and we must do y”. Even when it is certain that a patient has x, this does not dictate what should be done since the treatment of choice will vary according to the severity of x, the patient’s age, the physician’s skill, and the technology available at any given hospital. Moreover, there are some disorders for which there is significant disagreement among equally learned colleagues over what the treatment of choice should be. Finally it is not always clear that a patient has x since there are any number of disorders with similar symptoms. Whatever may be the nature and depth of his uncertainty, the physician is usually forced by the patient’s condition to act before the uncertainty is resolved. In this situation, the phyician’s action is dictated by what he knows at the time.”

“Clinical results, not scientific reasoning, determine how correct judgement is.”

It was one of the first books to lift the cone of silence around morbidity and mortality meetings.

And it offered an argument about why the character of surgeons, and other professionals, is often attacked in the event of an error.

“The physician does not promise to cure. The lawyer does not promise to win the case. The most that either can promise is to help as best he can and in a fashion consistent with the highest standards of the community. Now, in most professional-client relationships, the client has a great deal at stake. In fact, so much hangs in the balance that suspicion of the professional’s motives and the appropriateness of his conduct is always a possibility.”

It describes a world in which technical errors are more acceptable, and more likely to be forgiven, than normative errors (failing to discharge one’s obligations conscientiously), and quasi-normative errors (failing to meet the particular standards of an individual clinician, with their own protocols and values that they and they alone subscribe to).

When I wasn't reading it, Hero was sleeping on it.

Although the world Forgive and Remember describes is dated – it would be a rare hospital where surgeons where allowed to make life and death decisions without consultation, or get away with treating subordinates in a blatantly sexist or racist manner (Dr Cox and Kelso from Scrubs would fit right in), it’s an amazing account of the way surgeons are taught how to BE a surgeon. Not so much the technical skills, but moral standards.

This is a book with two key narratives. The focus of the first is on the surgeons. But in the second, the author shifts his analysis to his own role – revealing his own bias and the impact of his own observing on the team. Not insignificant. He wasn’t just a fly on the wall. At times he was scrubbed in, retracting, joking in the locker room.

He details major limitations to objective analysis (some would argue that that isn’t even possible), including his own sense of obligation for being included, and the ethical issue of whether to intervene where his input might have changed an outcome.

Just as a misjudgement about where to place a scalpel can alter surgical outcomes, so too can judgements about what to include and how to identify participants in an ethnographic account. In an amended appendix, written decades after the first edition, he reveals (confesses?) to changing a detail in order to protect someone’s identity – a supposedly simple change that has huge implications for how the text is read and the influence it has (I don’t want to spoil it for anyone who will read the book).

It isn’t exactly a light read but a fantastic read for anyone interested in surgery, sociology, observational studies, clinical decision making, ethics, errors and medical history. 

Reference:

Bosk CL (2003) Forgive and Remember: Managing Medical Failure. Second edition. Chicago: University of Chicago Press.

Atul Gawande on Being Mortal

Medical writer and surgeon Atul Gawande, author of Complications, Better and The Checklist Manifesto (yep, a book about checklists – which is an unexpectedly BRILLIANT read) just released Being Mortal.

This is not a book about veterinary science or veterinary practice but it is of interest to such an audience in the main because it deals with systematic problems with medicine – problems that will affect us all (if they don't/haven't already).

In this book he reflects on end-of-life care of human patients, including his own dad. 

BeingMortal takes aim at our fetish for medical intervention, right up to someone’s dying moments. It’s something as a vet I’ve come to appreciate. It is common, when I euthanase an animal, for the owner to tell me that they wish that a family member who recently died in hospital could have died at home, without all of the treatment that has become the norm for preserving human life – ventilators, antibiotics in the face of insurmountable infection, feeding tubes and so forth. Of course these technologies have a place, and have saved lives – but sometimes they simply prolong a life, which may not be a life the patient considers one worth living.

He is, as usual, very critical of his profession – in a constructive way. It takes guts to be critical of one’s profession, and I don’t imagine one publishes a book like this without copping inevitable flak. Gawande is also a physician with the maturity to admit and reflect on his mistakes. He recognises his own role in perpetuating the problem. Which makes for compelling reading.

Gawande astutely observes our fetish for intervention, and suggests that medical students may be set up for this early in their careers.

“You become a doctor for what you imagine to be the satisfaction of the work, and that turns out to be the satisfaction of competence. It is a deep satisfaction very much like the one that the carpenter experiences in restoring a fragile antique chest or that a science teacher experiences in bringing a fifth grader to that sudden, mind-shifting recognition of what atoms are. It comes partly from being helpful to others. But it also comes from being technically skilled and able to solve difficult, intricate problems. Your competence gives you a secure sense of identity. For a clinician, therefore, nothing is more threatening to who you think you are than a patient with a problem you cannot solve”.

Agreed. The problem of course is when attempts to do something – because we fear doing nothing- impact on the quality of life of patients.

Much of the discussion is around the care of the elderly, which – though improving in some areas – can be barbaric. Part of the issue is the obsession with safety which is prioritised over and above patient autonomy.

“Nursing homes have come a long way from the firetrap warehouses of neglect they used to be. But it seems we’ve succumbed to a belief that, once you lose your physical independence, a life of worth and freedom is simply not possible.”

He well and truly argues against that conclusion, discussing palliative care and hospice in a way that I’ve not been exposed to prior. And it’s a conversation that all health care professionals – and those who will use their services - should be involved in.

“The problem with medicine and the institutions it has spawned for the care of the sick and the old is not that they have had an incorrect view of what makes life significant. The problem is that they have had almost no view at all. Medicine’s focus is narrow. Medical professionals concentrate on repair of health, not sustenance of the soul. Yet- and this is the painful paradox – we have decided that they should be the ones who largely define how we live in our waning days. For more than half a century now, we have treated the trials of sickness, aging and mortality as medical concerns”.

The problem is that our population is aging. Now, more than ever, all of us need to consider the important question: when should we try to fix and when should we not? (One of the big revelations for me was the evidence in Gawande’s book that in opting to “not fix” there is still much we can do to improve quality of life).

Gawande argues that there is more to being old than simply being safe and living a bit longer, that the meaning in people’s lives is their ability to shape their own story, that we can ALL work to reshape our aged-care institutions – and even our culture – to improve the quality of everyone’s lives. I was in tears when I finished the book, but they were tears of hope. Gawande’s is a really positive message. This sort of reflection is what should lie at the heart of medicine.

“The battle of being mortal is the battle to maintain the integrity of one’s life – to avoid becoming so diminished or dissipated or subjugated that who you are becomes disconnected from who you were or who you want to be. Sickness and old age make the struggle hard enough. The professionals and institutions we turn to should not make it worse. But we have at last entered an era in which an increasing number of them believe that their job is not to confine people’s choices, in the name of safety, but to expand them, in the name of living a worthwhile life.”

Animals aren’t a big feature of the book – although the ability to keep an animal in a home, hospice or aged care facility definitely improved the quality of life of many – but the content is relevant to anyone, vets, vet students or otherwise. In fact, it’s a book I’d recommend to any mortal. And it’s one I hope my doctor reads!

Reference

Gawande, A (2014) Being Mortal: Medicine and What Matters in the End. Metropolitan Books.