This post is a bit outside the usual topics I discuss on this blog, and I have no doubt I will get angry responses and admonitions to “stay in my lane.” But at a time when America is, once again, being forced to confront our long-standing failure to deal effectively with racial inequities built into our society and institutions, I feel an obligation to address the reality that veterinary medicine is very much a part of this problem. 

The facts are relatively straightforward: Over 95% of veterinarians are white in a country where about 80% of the workforce is white. Imagining this is an accident rather than the result of systemic racism is naive or disingenuous. Acknowledging an injustice is critical to rectifying it, and we cannot shy away from clearly and directly describing an unjust reality if we seriously hope to change it. Veterinary medicine is quite possibly the whitest profession in America, and this is like any problem in that we won’t be able to fix it if we don’t acknowledge it.

A common first reaction when a group of mostly white people is asked to consider the issue of racism within their community is defensiveness. There is a misconception that racism is limited to explicitly bigoted and discriminatory behavior by individuals who openly dislike people of color, and since few of us fit that caricature, it is easy to dismiss our own role in perpetuating racial inequities. However, racism is typically more insidious and systemic than this. It is not a problem of a few “bad apples” but a feature of how the barrel is built and maintained. 

As an example, AAVMC data shows that the proportion of white applicants to veterinary colleges in 2016 (78.1%) was roughly the same and the proportion of white students in those colleges (78.3%). This suggests that explicit racial discrimination in admissions is not a major barrier to recruiting underserved groups into the veterinary profession. This is encouraging both because such discrimination would reflect poorly on the profession and because it would be a clear violation of federal law.

However, despite this, the representation of individuals from some underrepresented groups in both the applicant pool and as students in veterinary colleges is still dramatically lower than the proportion of the population identifying as members of these groups. For example, African Americans make up about 17% of the U.S. population but only 4.4% of applicants and 2.5% of veterinary students. The situation is actually worse than it sounds because about 70% of black veterinarians are educated at one school: Tuskegee University College of Veterinary Medicine, a historically black college. The underrepresentation of African Americans in veterinary medicine has persisted despite discussion about it and efforts to remedy it going back to the 1970s, and it is evident that there are strong and pervasive systemic factors behind this.

There have been some successes in addressing discrimination in veterinary medicine. Historically underrepresented groups have increased as a proportion of the student population. 

Women, in particular, have gone from a small minority to a large minority in veterinary schools, and they are now a majority in the profession and beginning to achieve parity in some areas, such as leadership roles at veterinary schools, though there are still disparities in pay and other indicators of equity.

We have actually reached a point where the overrepresentation of women in some areas of veterinary medicine is problematic. Contrary to a common assumption, diversity is not inherently a concept intended to exclude white people or men, and true diversity in the profession requires a better balance than currently exists in the gender representation among veterinarians. 

However, it is important to remember that the historic underrepresentation of women in the field was the result of both individual and systemic discrimination, and the influx of women into the profession can be seen, at least partially, as evidence of effective strategies for combatting this. The underrepresentation of men in veterinary schools today, on the other hand, seems unlikely to represent the same kind of discrimination since it is implausible that a group still in a position of privilege and power in most areas of American society would somehow be excluded by deliberate or systemic discrimination in one small domain like veterinary medicine. 

There are likely complex factors involved in the decline in male applicants to veterinary schools, and many of these may involve the ways in which the profession is portrayed and perceived in the culture as well as economic factors. For example, as veterinary medicine has shifted from a focus on food and working animals to companion animals, it may be seen more as a caring or nurturing profession which cultural stereotypes classify as more appropriate for women (women are also overrepresented in pediatrics and nursing, for example). Veterinary medicine is also among the lowest-paid of the medical professions, and men may be more likely to pursue higher-paying jobs (female-dominated professions in general tend to pay less than male-dominated occupations). The growing scarcity of male role models, at least in companion animal medicine, may also be a contributing factor.

The issue of gender representation is relevant to the subject of racism in veterinary medicine both as an example of how historic discrimination can be overcome and also how complex and indirect the factors influencing the recruitment of different groups into the profession can be. The underrepresentation of African Americans in veterinary medicine, for example, is sometimes written off as a lack of interest. This narrative suggests that black people aren’t as interested in animals as white folks and so are less likely to want to be veterinarians. The issue of cultural differences in attitudes towards animals is a real and complex one, but as a facile way of denying racism as a cause for underrepresentation of African Americans in veterinary medicine, it is not convincing.

For one thing, this doesn’t explain the consistent underrepresentation of other minority groups, such as the Latinx community. The idea that multiple historically marginalized groups all just happen to not be interested in veterinary medicine is not plausible. More likely, the paucity of applicants from underrepresented groups is related to a lack of examples and role models from those communities that make the profession seem welcoming and possible for them, the disadvantages such groups face in terms of education quality and opportunity well before veterinary school, the rising cost of a veterinary medical education, and a constellation of other factors. Such factors have certainly been demonstrated to be associated with underrepresentation of African Americans, for example, in other professions, and addressing these barriers has improved diversity in these cases.

Clearly, we have a lot of work to do as a profession if we are committed to real diversity. White people must take an active part in this work, leveraging our power and privilege no support equity and improve opportunities for those who have been, and still are denied then. We must remember that diversity is not a zero-sum game in which one group must “lose” for others to succeed. No one, least of all people of color, is suggesting lowering standards or implementing some sort of active “reverse discrimination” against white people. The goal is to ensure that everyone has a chance to explore and fulfil their potential, and that barriers to this which apply disproportionally to historically marginalized groups are removed. Diversity ultimately benefits the profession and all of us in it.

As a relatively old, white, male veterinarian, I can acknowledge the injustice that has favored those like me without feeling that the effort and struggles I endured to get where I am are being invalidated. I may be good at my job, and I may have earned my place through hard work. But many people who are just as talented, just as hardworking, and who have even greater obstacles before them are as deserving but have been denied the opportunities I have had. There is no question that being white has been an advantage in my journey. It does not diminish me to acknowledge this, but it does engender a responsibility to contribute to a more just future.

Resources-

Navigating Diversity and Inclusion in Veterinary Medicine; 2013, edited by Lisa M. Greenhill, Kauline Cipriani Davis, Patricia M. Lowrie and Sandra F. Amass

Minority Student Perceptions of the Veterinary Profession: Factors Influencing Choices of Health Careers; 2008, by Dr. Evan M. Morse (thesis)

Unity Through Diversity; 2006, Final Report of the AVMA Task Force on Diversity

Cultural Competence in Veterinary Practice. V.Kiefer, K. Grogan, J. Chatfield, J. Glaesemann, W. Hill, B. Hollowell, J. Johnson, D. Kratt, R. Stinson, and K. Urday. JAVMA. 2013 243:3, 326-328 

A Business Case for Diversity and Inclusion: Why it is Important for Veterinarians to Embrace our Changing Communities.  L Kornegay. JAVMA. May, 2011.

Cultural Competence Education; Association of American Medical Colleges.  2005

The Attitudes of Minority Junior High and High School Students toward Veterinary Medicine. A. Asare. J Vet Med Educ.  2007 34(2): 47-50.

Tying Art and Science to Reality for Recruiting Minorities to Veterinary Medicine. PM Lowrie. J Vet Med Educ. 2009 36(4):382-387.

Racial, Cultural, and Ethnic Diversity within US Veterinary Colleges. Greenhill, LM, PD Nelson, and RG Elmore. J Vet Med Educ. 34(2): 74-78.  2007

This an article I wrote for Veterinary Practice News about our hospital experience with the COVID-19 pandemic. Every veterinary clinic and hospital will have their own unique experience of this time, but I suspect much of this will look familiar to others in the profession and to pet owners. One element of the experience that is relevant to my work here on SkeptVet is the importance of a critical, flexible, evidence-based approach, which has helped us tremendously in dealing with the unprecedented challenge.

From the trenches: How life has changed since COVID-19 came into our lives: What veterinary medicine is like at Californina’s ground zero

The hospital is quiet as I walk in at the start of my shift. The usual bustle of clients, staff, and animals has been replaced by empty hallways and only a few masked doctors and nurses going about their work quietly, careful to keep their distance from each other. I stop at the screening table and start my day by taking my temperature. It is under 100.4 F, and I have no cough or other respiratory symptoms, which means I can work today.

I set down my belongings at my desk and go to change my clothes. I wear scrubs every day now, and I have a pair of dedicated work shoes that stay at the hospital. I also have a collection of beautiful cloth face masks sewn by one of our employees—I wear a clean one every day.

At the end of my shift, all of my work clothes go into the laundry. When I get home, everything I took to work stays in the garage. I pass quickly through the house and take a shower before I greet my family. I am especially mindful to keep my distance from my elderly mother, who lives with us, and to handle neither her dishes nor her medications. My wife does that now, since she has been working from home and hasn’t mingled with people outside the house for the last month. This is the new routine of our lives, one familiar to countless others since the arrival of COVID-19.

Operating in California’s ground zero
I have worked at the same practice for 16 years. We are an unusual hospital; an independent general practice with 30 veterinarians and more than 150 other staff, open 24 hours a day seven days a week. Because we are located in Silicon Valley, an affluent area in Santa Clara County, Calif., we able to offer services not always found in first-opinion practices, such as orthopedic surgery, in-house ultrasound, cancer therapy, and advanced emergency and intensive care. Our location, however, also means we are in the center of California’s novel coronavirus outbreak. COVID-19 has changed not only my morning routine, but nearly every aspect of the work and lives of our practice, staff, and clients.

Santa Clara identified the first case of COVID-19 in the county (and the ninth in the U.S.) in early February. A sentinel surveillance study in early March confirmed community spread was already occurring, and the county began instituting social distancing measures on March 11. Initially, these involved closure of some public businesses and recommendations for people to avoid large gatherings. By March 16, Santa Clara and surrounding counties had issued shelter-in-place orders, essentially banning people from leaving home except for specified essential activities. On March 30, further restrictions were added and the shelter order was extended into May.

This rapidly expanding public health crisis and frequent changes in restrictions on public activity has presented a tremendous challenge to our hospital. We see hundreds of patients and have dozens of doctors and nurses in the building every day. We also operate on an open hospital model, meaning clients can stay with their pets for nearly every aspect of their care, from being present for outpatient procedures, to watching surgeries, to sitting with hospitalized patients as long as they choose during daytime hours. While this model is unfamiliar and startling to many in the veterinary profession, it has been an intrinsic component to our practice culture for decades. Having clients present throughout the hospital is something we, and our clients, have come to expect.

Doing things differently
The coronavirus outbreak and the public health directives aimed at combating it have forced us to reevaluate our models for patient care, client service, and personnel management; our financial structures and processes; and even our role in the larger public health landscape. Such a comprehensive reevaluation of every aspect of our work, conducted rapidly and in an ever-changing environment, has been challenging, even painful. However, it is also an opportunity to take stock of who we are as health-care providers and as a business, and to grow stronger as a result.

In addition to seeing patients, part of my job in my practice is to drive and support continuing improvement in the quality of care we provide, and to help maintain staff and patient safety. I am the designated evidence-based medicine nag, responsible for translating scientific research into useful tools and actions we can take to better care for our patients. This includes training new veterinarians; developing protocols and guidance documents; conducting clinical audits and evaluating patient outcomes; and many other quality-improvement activities.

One particular project that has proven timely was my effort last August to promote more effective hand hygiene throughout the hospital. I expanded the accessibility of hand sanitizer, put up posters throughout the hospital illustrating proper handwashing technique, and of course nagged everyone to wash their hands. Lately, some staff members have jokingly suggested I may have gone a bit overboard in trying to make my point.

Of course, despite my efforts to support a culture of proactive, science-based medicine, we could not realistically have been fully prepared for what the coronavirus pandemic has required of our practice. However, this culture has proven useful in making the many adjustments necessitated by the virus in the face of limited evidence and great uncertainty. We already had a system for identifying reliable sources of information and translating imperfect science into clinical practices. Our doctors, staff, and management were long accustomed to incorporating scientific data into their daily activities and to adjusting their work routines based on changes in the available evidence. The habits of flexible, pragmatic evidence-based medicine have served us well.

The specific changes we have made in how we handle clients and patients, how we protect staff, and how we have adjusted our business to cope with the legal and economic realities of the pandemic may or may not be useful to other practices in other contexts. However, they illustrate how the methods and habits of evidence-based medicine can help a veterinary practice respond to an unexpected and unfamiliar crisis.

Applying evidence-based medicine
We began our response to the pandemic by developing and collecting policy documents in one central location. With a rapidly changing environment, and frequent adjustments to policies and procedures, it was crucial the most current protocols be readily available to everyone on staff. Protocols were developed by a group representing all the teams within the practice, including doctors, technicians, and management. Input was sought from as many people as practicable, which frequently helped to identify oversights and errors, as well as to generate the widest possible array of ideas and options.

Although veterinary practices are considered essential services in our region, and therefore allowed to operate despite the restrictions of public health orders, we realized early we would need to limit our work to urgent and emergent cases, and to defer most elective and well-pet services to reduce traffic through the hospital and exposure risk to staff and clients. We developed a triage tool to help staff decide which services qualified as essential and which would need to be deferred. This was similar to the tools developed by the British Small Animal Veterinary Association (BSAVA) and other veterinary organizations.

Our initial strategy for reducing exposure risk was to screen both staff and clients for relevant clinical symptoms and for fever. Though this strategy is imperfect, it has been utilized and found helpful for identifying COVID-19 cases in some circumstances. We also set up social distancing guidelines within the hospital.

However, we quickly realized these measures were insufficient, and we made the difficult decision to ban all clients from the hospital, apart from exceptional circumstances such as euthanasia and critical acute emergencies. Clients now wait in their cars, and nurses in appropriate personal protective equipment (PPE) triage pets outside and then bring them into the hospital. All subsequent communication with clients is by telephone until the pet is returned to them outside.

This has been especially difficult for us, and for our clients, as it conflicts with our culture as an open hospital. Being separated from a sick pet is an unfamiliar experience and an added stress for clients who, like all of us, are already dealing with the impact of the pandemic in their personal lives. Most clients have been understanding of our goals in protecting them and our staff, but in the short-term, this has been one of the most uncomfortable consequences of the outbreak. The long-term effects on our culture and relationships with the community are a source of concern for all of us.

Watching out for one another
Having restricted client access to the facility, the greatest risk to our own health became each other. It is often impractical to maintain effective physical distancing when working together treating patients. In response to this risk, we have continued screening staff for symptoms and fever, and we have done what we can to keep people apart in the workplace. The extra hand sanitizer I ordered in September and the handwashing protocols I posted have turned out to be quite useful! We have also had many lively discussions about the use of masks as a tool for reducing the risk of coronavirus transmission within the hospital.

The evidence concerning the value of masks in reducing spread of respiratory viruses is limited and contradictory (e.g. 1, 2, 3). It seems unlikely they protect the wearer from exposure, and they can actually increase risk if improperly used. However, wearing masks may reduce the risk of an infected person from spreading the virus, particularly since asymptomatic shedding apparently occurs commonly. It is also important to remember PPE is in short supply, and the risk and needs faced by human health-care providers are much greater than ours.

Early in the outbreak, our hospital donated a substantial portion of our masks, gowns, and gloves to a local hospital, as well as offered our ventilator for use in human patients through a database set up by the American College of Veterinary Emergency and Critical Care (ACVECC). Our remaining PPE is under lock-and-key, to be used only when strictly necessary.

Ultimately, the mask debate was settled for us by a directive from public health officials recommending the use of cloth masks in addition to physical distancing methods in businesses still operating. We are fortunate to have several employees with handicraft skills who have been making beautiful and functional cloth masks for our staff and their families. These employees have had plenty of time for such projects, as another necessary response to the pandemic has been to reduce staff in the hospital and to decrease payroll expenses.

The limitation of cases to urgent and emergent care has dramatically reduced revenue at our hospital. Veterinary small animal medicine is an unusual hybrid, being both a health-care industry and also, in many cases, a small business enterprise. Large-scale corporate ownership and consolidation of veterinary practices is certainly widespread and growing. However, the average small animal practice in the U.S. employs only two veterinarians and three to five veterinary technicians (2019 AVMA economic report). Though my practice is unusually large, we are still a much smaller business than most human health-care providers.

The drop in revenue, as well as the need to reduce the risk of coronavirus spread between employees, has necessitated dramatic cutbacks in staffing at our hospital. These reductions have involved unpaid leave, furlough, and various mechanisms dictated by the financial and regulatory environment in which we operate. Most doctors, myself included, now work one week and are furloughed for one week. Other staff members are limited in the number of shifts they can work in a month. So far, we have managed to avoid laying off any employees, but the threat to our livelihood adds to the stress imposed by the risk to our health.

Overcoming disruption
As in veterinary practices around the world, our employees are struggling to face not only restrictions on their movement and activities, cancellation of planned events, closure of schools and loss of childcare, and other disruptions in their personal lives, but also a loss of income and of the security and purpose of their jobs, which for many are as much a vocation as an occupation.

Like many in the developed world facing isolation and uncertainty due to the pandemic, the role of virtual communication in our lives and businesses has expanded greatly. We have a dedicated private Facebook community for staff that has provided great support for many of us during the days we cannot work. We are, in some ways, closer than ever since we are learning more about each other’s homes and hobbies, partners and pets through this virtual community.

We are also making use of online communication tools as a hospital. In April 2019, we began offering video visits for clients. These have been a useful way of triaging patients and managing minor health problems that do not necessarily require an office visit. As a result, we had a reliable system and experienced telemedicine staff in place when the pandemic began. Since the outbreak began, the U.S. Food and Drug Administration (FDA) has relaxed requirements for a veterinarian-client-patient relationship to facilitate such use of telemedicine tools. We now have two full-time telemedicine doctors, and this has proven an excellent means of maintaining contact with clients and preserving revenue, while reducing hospital visits and exposure risk to employees and pet owners.

Since the beginning of the pandemic, our clients and staff have had questions about the risk of infection to our patients and the potential for pets to spread the virus to humans. Despite the enormous, unprecedented scientific research effort targeting COVID-19, there is surprisingly little evidence to help answer these questions.

Very few studies have specifically evaluated the susceptibility of companion animals to SARS-CoV-2 or the risk for transmission from dogs and cats to their owners or veterinary personnel. Individual case reports and limited research evidence suggest dogs are very resistant to infection and illness (4, 5, 6). Cats and ferrets appear to be more susceptible, but the risk of transmission to humans is still considered low (6, 7, 8, 9). There is essentially no research evaluating the potential for pets to act as fomites or mechanical vectors for COVID-19 (10).

We have developed guidelines in our hospital for handling pets from known COVID-19-positive households, both those with or without symptoms, and there are a number of such guidelines available from veterinary organizations (11). However, all of these are based on extremely limited evidence, and it will be some time before we fully understand what risk, if any, pets may pose to veterinary professionals or the public. This is an example of the common, but necessary challenge of practicing evidence-based medicine when data is sparse. The key is to be aware of the evidence that exists and its limitations, to take pragmatic and proportional action based on what the research says, and to be flexible and prepared to change our practices as the evidence develops.

There is reason to believe all the effort and sacrifices we have made as a hospital, as well as that of government agencies, businesses, and individuals in our area, have been effective. Though Santa Clara County was one of the first centers of community spread of SARS-CoV-2 in the U.S., cases have not grown as fast here as in some other places, and the health-care system has so far been able to cope well with the number of COVID-19 patients (12, 13). We appear to be “flattening the curve,” a rather dry and abstract phrase that represents a meaningful reduction in human suffering.

As a hospital, we have been fortunate to not yet have any known cases of COVID-19 among our staff. However, the reality is that it is only a matter of time before someone we know is infected, or falls ill, or perhaps even dies as a result of this disease. The mitigation measures we have taken and have been imposed throughout our area and around the world are not sustainable in the long term. With a highly virulent virus spreading through a completely naïve population, no proven effective treatment, and a vaccine well over a year away by some estimates, the disruption this disease has brought to our hospital and our lives will persist and evolve for a long time to come.

However, we have also learned a great deal about our capabilities as individuals and as an organization. We have been reminded of the value of creating an adaptive, science-based practice culture and of the habits and methods of evidence-based medicine. We have learned from the ways in which we were prepared to cope with this unexpected crisis, and from the ways in which we weren’t. COVID-19 has reminded us of the essential nature of veterinary medicine, not only in companion animal health and food safety, but in human health as well. It would be difficult to find a more dramatic validation of the One Health concept than our current situation.

The months ahead, perhaps even years, will continue to be challenging because of this virus, but we have tools and knowledge not available during the last century that have allowed us to respond more quickly and effectively, and this has made a very real difference in the lives of millions of people. We can and should do better in the future at preventing, predicting, and responding to such public health threats, and with the lessons learned now, I have no doubt we will. My hope is that as a hospital community and as a profession, we will emerge from this crisis stronger, smarter, and better equipped to face such challenges in the future.

John Oliver has often taken on anti-vaccine nonsense and pseudoscience of various kinds. His latest show provides a great takedown of some of the burgeoning myths and misinformation about SARS-CoV2 and COVID-19.

I haver written about pulsed-electromagnetic field devices (PEMF) a couple of times before (1, 2). In my most recent review, I concluded:

Despite the fact that there has been interest in the potential medical applications of electricity for over 150 years, and serious scientific research investigating PEMF has been going on for over 50 years, there is surprisingly little robust evidence showing meaningful clinical benefits…PEMF devices are widely used, and this creates the impression that they have been solidly validated, but the reality is more ambiguous…There are very few clinical trials of PEMF in [veterinary] patients. The studies that have been published have not found consistent and convincing evidence of clinically meaningful benefits…The marketing claims of PEMF manufacturers and the excitement of proponents far exceed the strength of the available scientific evidence.

Unfortunately, the lack of evidence is seldom a barrier to aggressive marketing of therapies in veterinary medicine, and this is certainly true for PEMF. What is perhaps more frustrating, is that companies often support or produce small studies with significant limitations as evidence to promote particular uses. These studies are rarely followed, as they should be, by larger, better trials that could be used to justify actual clinical use. 

This certainly appears to be the case for the most well-known veterinary PEMF device, the Assissi Loop. Rather than following up the tentative studies I reviewed for pain, the company has decided to generate yet more weak evidence to justify marketing their device for yet another indication, this time separation anxiety. Their marketing materials are a classic example of claims that go far beyond anything justified by the actual scientific evidence:

“The solution” is bad enough, but there had better be some pretty solid clinical research to justify “returns the anxious brain to a more balanced emotional state with long-lasting effects” and “proven to work alone without other treatments or training!” I can’t wait to see the large, robust, long-term clinical trial that shows the Assissi Loop is ready to replace all other separation anxiety therapies and vanquish the disease for ever! So where is it? What? There is no such study?

To call what the company offers as evidence for these dramatic claims underwhelming would be a dramatic understatement. An open-label study lasting six weeks in nine dogs. That’s it! No placebo control, no blinding, no peer-reviewed publication (only a conference report), and a lead investigator who also happens to be the Chief Business Officer of the company selling the product. A pilot trial like this is laden with uncontrolled bias and error, and while it might be enough to justify a real controlled study, it is not even close to sufficient evidence to support the wild marketing claims made for the product. 

I would be thrilled to see a treatment with no detectable adverse effects that could improve or even cure separation anxiety in the vast majority of dogs with 15 minutes of treatment twice a day for six weeks. That would be a miracle, and I would be glad to see it. However, the evidence threshold for miracles in medicine is pretty high, and this study isn’t even close to that threshold. It seems to me inappropriate to make such dramatic promises based on such thin evidence, and it would be more useful for companies such as this to put their resources into supporting rigorous, independent testing of existing claims rather than looking for new markets to create with still more small, limited “pilot” trials.