Dear Doctor – December 2015


Comparing veterinary practices
Q I was recently at a social outing with friends, many of whom are animal owners. Talk turned to various ailments and stages of their dogs’ lives and where people took their dogs for healthcare. The following comment came up more than once: ‘I would NEVER go there.’ As a surgical nurse reviewer for people who collect outcomes data for a major hospital, that got me thinking. Is there any such database in veterinary medicine that allows people to compare records for how well different practices do with regard to health outcomes? Or do we still need to base our decisions on where to take our dog on the anecdotal comments of friends?
Lynn Felix
Boston, Massachusetts

Dear Ms. Felix,
A That is a really good question with a much less-than-perfect answer. Unfortunately, in veterinary medicine, there is no resource other than word of mouth. That’s no small thing. Glowing referrals from people whose opinions you trust are not without meaning. But it won’t allow you to do a statistical side-by-side from one practice to another.

Here are some things to consider along with the recommendations of friends and family.

Don’t allow the proximity of the vet’s office to your home to carry all the weight in your decision. Granted, you don’t want to be driving an extra hour, especially if your dog has a medical emergency. But an extra 20 minutes to a practice recommended by many people is a better bet than a closer veterinary office for which you haven’t heard rave reviews.

Leave price out of the equation. A lot of people, understandably, factor in the cost of veterinary visits when deciding which practice to go with. But within a given geographic locale, costs stays within a pretty narrow range. And a vet might charge more for one procedure and less for another. It evens out.

Big office, small office? Some people like a small practice with just one or two vets because a better bond will develop, both for your dog and for you. And the doctor may be more intimately acquainted with your dog’s baseline health profile and therefore in a better position to judge changes in health status over time. But some people like a large practice with many vets, both because it may have veterinarians on board who are more experienced with certain types of health problems and because a larger practice may have more state-of-the-art equipment. Neither choice is right or wrong. You just need to decide which tradeoff you’re more willing to make.

Finally, consider inquiring if the practice refers cases to a specialist when it encounters problems it isn’t equipped to treat. Willingness to refer is a good thing — it doesn’t imply that a practice easily gets over its head; it implies that the practice’s goal is to provide owners with access to the best care possible, regardless of who provides it.

You’ll also want to find out the office’s hours (9-to-5 on weekdays only is not good if you have a full-time job), how long it takes to get a non-emergency appointment (more than a few days is probably not the best), and the length of a standard doctor’s visit (a minimum of 20 minutes is optimal — 15 minutes is a bit skimpy).

The dog has started urine marking out of nowhere
Q I have had my Havanese, Pepper, for four years now, since he was about two. He came to me well trained and housebroken. But about six months ago, Pepper started marking everywhere indoors, places we used to go routinely in the past, including friends’ homes. It is getting so bad that I cannot take him anywhere. Yesterday, he marked the inside of our garage. Thankfully he is still okay in our house and can go the usual eight to 10 hours without peeing, so I don’t think it is a bladder/kidney problem. What to do? I miss the fun times we had when I took him with me to visit friends, the bank, appropriate stores, etc. Now he marks in all those places and is no longer welcome.
Ina Henderson
San Francisco, California

Dear Ms. Henderson,
A Poor Pepper. His whole life is closing in because of this, as is yours to some degree. We empathize with your dilemma. How to solve it?

First, although the issue sounds behavioral rather than medical, don’t rule out a medical problem just yet. Some medical conditions, like hypothyroidism, can make a dog more anxious than he would ordinarily be, causing him to urinate in situations in which he would otherwise feel relaxed. So take him to the doctor for a workup to make sure that the cause of his urinating indoors away from home is not physiological. One of our own veterinarians had a dog who was urinating on the floor out of nowhere when she came back from vacation once, and she assumed the dog was simply upset that she had left. But it turned out her pet had a urinary tract infection. The timing of her absence and the onset of the condition was simply a coincidence.

If the doctor does rule out a medical condition after a full workup, it’s appropriate to search for psychological clues to the behavior change. Dogs are territorial creatures, and they urine mark to say “this is mine,” but that doesn’t tend to start indoors at the age of six. What’s more likely is that something is making Pepper feel stressed, as stress can increase the behavior; a dog can want to make things feel more familiar, more comforting, by marking them. But what the something is that’s stressful can be hard to figure out, even if you feel you have a good handle on your dog. He may have been treated harshly by someone indoors somewhere, and the exchange could have escaped your notice. Or some other situation could have alarmed him, making him uncomfortable about going into environments that are not his own. A good animal behaviorist can help you sort through the possibilities. You can find one in your area by going to the website for the American College of Veterinary Behaviorists — — and searching the “Member Directory” tab (under “About ACVB”) by state.

The solution may involve behavioral modification tailored to deal with the source of stress. And sometimes, if a dog is not neutered, neutering will help cut down on the indoor marking significantly.

Medication can help, too. The best treatments we have, outside of identifying the cause of the anxiety and dealing with it directly, are a serotonin reuptake inhibitor like Prozac (fluoxetine) or a tricyclic antidepressant such as Clomicalm (clomipramine). Both are incredibly effective treatments for urine marking (as long as the condition is psychological and not medical).

Good luck. We wish you and Pepper success as you work through this. Let us know how things turn out.


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