I am glad to see that we are taking steps as a profession to try and help the fledglings.....I was one of those that felt initiated by fire and while I don't think any patients suffered for it per say, I can't help but wonder how much better I could have been if there had been more support in place. 

Kudos to you for braving the weather :) and taking the time to address this issue.  Just out of curiousity--should you all come up with great solutions what sort of means are you all going to be sharing this information with the profession??

J.C. November 14th, 2009 07:39:12 PM

I agree that the newbies need mentoring.. Even the newbie M.D's, and D.O.'s after residencies still need mentoring..

Socks started with his vet who was a newbie, and I was hesitant at first. I probably would've insisted on seeing one of the older docs, if Socks was an older dog with health problems..

I was on an Indian reservation in South Dakota when a group of Vet students showed up to  practice  on the animals.. doing exams, spays, and neuters... The students volunteered so they could get whatever experience they could..

I'm excited for you, and your quiting smoking.. I hope you succeed... It isn't easy.. but where there is a will.. there is a way

I can't believe you aren't appreciating the snow.. I spend big bucks to fly out to CO to hang out with my sister from FL, skiing... As far as I'm concerned.. CO has the best snow around, and the mountains are so close to the city..

Barri November 14th, 2009 09:08:32 PM

Out of my realm of knowledge....however...have a GREAT time in Denver!  

agadoresmama November 14th, 2009 11:34:40 PM

People do get hurt by the newbies to every profession and the newbies often don't even know the damage they've done.  Good luck with improving things and hope the BF is there to warm you up and keep you from the stuff behind the counter at the corner store :)

PJB November 15th, 2009 02:38:55 AM

Speaking as a fourth year who is currently working on (er, or maybe procrastinating on working on) my internship application... THANK YOU for being willing to consider the situation facing new grads today. I'm lucky enough that I only have to deal with debt from in-state tuition, but a large number of my classmates are forgoing the opportunity to do an internship because they simply can't afford it. I think our school does the best it can for us in rotations, but I still feel like there's no way I'll be a compentant doctor in less than six months. There's just so much more to learn still...

Megan November 15th, 2009 08:54:41 AM

I'm hoping to begin vet school in September (application submitted and waiting with fingers crossed) and I hope your ideas will be in place by the time I graduate. 

Kristen November 15th, 2009 11:10:26 AM

Hello Dr Khuly!

I'm glad to hear that veterenarians are working towards more support for the younger generation of up-and-coming vets and recent grads. I hope you are staying warm! I'm not too far away from you right now actually, I'm going to school at Colorado State (pre-veterinary) currently just north of Denver. As far as leaving the smoking behind, keep going it at, you are doing something great for yourself!

adrift108 November 15th, 2009 11:16:05 AM

Barri: We are indeed appreciating the snow! It's scary to drive in is all...so we're a little shut in right now. 

JC: As to how we're planning on disseminating the information: A very amenable AVMA bigwig who was in attendance yesterday will hopefully help me publicize and disseminate a comprehensive marketing plan I've put together for new graduate integration. I initially created it for use by my local VMA but I'll be revising it to contain much of what came out of yesterday's issue session. Meanwhile, Colorado will be working on a pilot program for new grad debt management consulting. I'll also be publicizing this issue in an upcoming Veterinary Practice News issue (January's, I think). Any other ideas? I'm game. 

Dr. Patty Khuly November 15th, 2009 12:58:22 PM

I hope the things you came up with do get put into practice. As a current third year vet student, more than a few of us are already wondering how on earth we're going to find a job to pay the bills when our student debt is already high and the tuition's going up (here) by 12.5% a year. 130k for last year's grads, 140k for 2010s, and my class seems to be averaging 150k, before you add in interest. Do the math on that one and with a 10 year repayment plan none of us are going to be having an after-the-bills-take-home any better than full time burger flippers for a few years. Not exactly the glamorous lifestyle some clients think we might lead.

We're looking at contract negotiations with the mindset of knowing we're not going to be making anyone real money for the first year, yet can't afford to accept less than 60K to start with. It's like a bad joke, on both us and potential employers. Then add the desire for a newbie-friendly practice in a desirable (by your own definition) location and more than a few of us are laughing because it feels like a no-win situation with nothing else we can do.

I opted out and am joining the VetCorp for a few years, so the financial strain is eased a little bit, but the trial by fire may be a bit more intense. Luckily enough for me, I like high pressure situations (and have previous clinical experience) so the thought doesn't panic me, but I certainly don't think it's the best option for the patients and their owners. One really nice thing about my school is that we have lots of required 'communication' exercises, so while it's dead irritating sometimes, at least that hurdle to practice is broken down a bit.

lindabcs November 15th, 2009 02:27:36 PM

 I hope Dr Khuly had a nice trip but any marketing plan for integrating new graduates will probably just be added to the plans for reforming veterinary education and training that have been produced over the past 3 decades. The AVMA and veterinary academia have had numerous opportunites to change in the past but lack courage and leadership to convert plans into action. The Pew Report of 1989 was the call to action yet the recommended innovations have never been implemented in academia, state boards or in the way we practice medicine. We are know entering the third decade since this "call to action" was published. Former deans like Peter Eyre of Virginia Tech and Ole Nielsen of Ontario put forth a model that follows engineering education with a core curriculum and then completely separate tracks into small animal, food animal etc. For that to work would require both abandoning the unrealistic concept of omnicompetence for all species which was one of the major Pew recommendations and innovating by tearing down veterinary education and reassembling it so that is relevant and productive. Entrenched academics and the AVMA will not let that happen. The AVMA Council on Education is a major roadblock to change. It threatens the status quo which benefits them well.

The American Association of Vet Medical Colleges will have yet another commission next year led by Mary Beth Leninger on reforming that will have have big meetings with stakeholders and then a big report about it. It probably will reiterate some of the things from Pew Report which were also reiterated in the Foresight Report in 2007. Then likely again no one will do anything about it. The most important report should be a report from the National Academies of Science this winter on workforce needs in veterinary medicine. Although mostly veterinarians are on the panel, there are two economists who actually understand supply and demand on it. One of them, Malcolm Getz, wrote  a book VETERINARY MEDICINE IN ECONOMIC TRANSITION in 1997 which said alot of the same things inthe KPMG Megastudy of 1999 but no one seemed to do anything then about the debt income ratio ten years ago. Do you really think they will do anything substantive now?

The biggest problem in organized veterinary medicine and academia is arrogance. Our "leaders" think because of our education we are smarter and better qualified to handle more than any other profession.  Jim Collins in HOW THE MIGHTY FALL says the first step in decline of all the companies he profiled was "hubris born of success". Sadly, he profiles some companies that go through 5 stages ending up in death. If you think that only works for business, you need only to look at NASA which crashed two shuttles out of hubris and arrogance and with the shuttle retirement will have to depend on the Russians and possibly others to provide manned transport to the space station. There is also doubt whether their current ARIES project will go forward with current funding levels. A very long fall from landing on the moon! I do not see alot of public clamor about the USA no longer having a manned space program.

I apologize for the bleak forecast yet history and the failure of organizations seem to follow pretty repeatable patterns. I think the best thing to happen for veterinary medicine is for people to stop attending veterinary colleges until real reforms like those in the PEW Report are implemented if there are no students then the academics will have to start thinking whether they will have a job since states may decide to cut funds .Maybe then innovation and change might have a chance.

josephknechtdvm November 15th, 2009 06:21:38 PM

New veterinary grads are incompetent - and that's sad after accumulating $130K+ in debt.  It is likely no different in MD land - but they have internships, residencies +/- fellowships before being unleashed upon the public.

After 4 years completing medschool, MDs aren't allowed to treat a human without guidance.  Also, after further training a pediatrician is not expected to treat diabetes.  However, veterinarians are expected to treat many different species, each with inumerable diseases.  This is inane, and is detrimental to advancing quality of care in our profession

You nailed it that the AVMA and current vet school administration are the roadblocks to change.  Now, what do we do about it?

Fedup November 15th, 2009 07:22:34 PM

Hmm, does sound interesting PJB. And I agree with your last sentence.

But to have academia instill the concept that DVMs are equal or better than MD's? I-yi-yi..wow. Oh boy, next to speechless.

I have never expected a newbie or an oldbie to be well versed in every pet-med subject--NEVER! But certainly do expect full knowledge of VET 101, or the basics. And have found that difficult to obtain at least "once" with a group of FOUR vets in TWO clinics(sorry for repetitiveness) And EVEN extra education in internal medicine didn't help. Kind of frightening and makes me wonder if you can somehow pay $$ for initials.

Seriously though, anything beyond basics in a non-emergency can be referenced & delayed decision/treatment.

Something is going to break, I've said it 100 times. People are not going to continue to fork over big dollars and get ZERO accountability/responsibility in return. Sorry, pets aren't cars and the OLD AVMA better start waking up.

Barbara A./NH November 15th, 2009 08:57:41 PM

Blog is eating my comments, so hope over experience here.

In the late 80's / early 90's I participated in an exodus of young academics -- recent doctorates and advanced candidates -- who saw that "the profession" was no longer offering us any kind of sinecure. No one had gone into teaching and research intending to get rich; the deal was, you'd work hard, bow and scrape, demonstrate that you had talent, and there would be a decent career path for you, one that allowed you intellectual freedom and some degree of advancement and eventual security in a job you could love. This was, in fact, an explicit promise issued by our professors as we mulled post-graduate plans while still in college.

The bastards lied.

As I saw colleagues graduate -- young people who were the tops in their fields in their age cohort worldwide -- and get no offers, or be glad to snag a one-semester position as visiting part-time adjutant temporary lecturer in The Thankless Shit Tenured Old Farts Don't Want to Teach, saw them prepare for lives as migrant workers -- I realized that those "retiring" oldsters were never going to go, and when they did, they'd be replaced with temps whose welcome package from personnel included instructions on applying for food stamps.

I was not as smart, as diligent, as disciplined, or as able to choke down my own vomit in the presence of alpha-posturing "superiors" as these shell-shocked colleagues, so I figured it was time to bail, especially since few institutions employed anyone in my subfield in the first place.

It looks to me as if the veterinary profession has gone down a similar path. Decisions are perhaps being made more by individuals and smaller institutions, but there is danger of losing an age cohort of already-trained professionals to despair.

H. Houlahan November 16th, 2009 09:17:19 AM

Out of curiousity, do DVM grads more or less find a job out of the gate, or is it pretty slim pickings?

I finished college during the last recession, got a thankless job that didn't require a degree while working my way through grad school.  I was lucky enough to get a position in my field of study mid-way through the grad program.  As such, I had a little bit of experience when I graduated and was able to leverage that to build something resembling a career.  Many of my friends didn't fare as well because they didn't have any experience.

I think many professions have trouble integrating recent grads, which is why I was asking about job prospects for DVM grads.  What I'm seeing now is that my business degree and experience aren't doing much for me because the job market is flooded with well-qualified applicants who have been let go and are willing to take a step back just to get a job.  I feel bad for those who are just now finishing school without any experience because businesses are less likely to take a chance on them when they can hire someone who requires less training.

Maybe it's just human impatience.  It takes time to train someone, which means that you have to take time away from your daily activities and potentially put in longer hours.  It's easier/ less stressful/ quicker to do the work yourself versus training someone else.  It's very easy to get caught up in the short term pain of giving time to someone else while overlooking the long term benefit of training them properly.

Posey November 16th, 2009 11:39:37 AM

Perhaps you can inspire leaders in your profession to find some solutions by impressing upon them that there are those of us out here who have pretty high expectations of clinical quality. 

And we're usually the clients who you DO want.  (Until and unless, that is, something goes wrong.)  Especially to help pay off debt.

You want us because:

1.  We're not likely to bring you a case of medical neglect

2.  We will beg borrow or steal to pay for the ultrasound or surgery you think our pets need

3.  We believe in treating treatable diseases, not just saying "That's a wrap, nice knowin ya, Fluffy"

4.  In other words, we give you the chance to actually practice medicine by being willing to pay for that.

Provided the word "practice" isn't interpreted literally.

We're your biggest fans but not if that inadequately mentored newbie screws up and kills our pets. 

We may not be able to sue.  The Board may not do a darned thing.  But if we have balls and really loved the pet, we will scream to high heavens and make anyone think twice about trusting the practice ever again.  If we can make ourselves heard.

Which, hopefully, scares clients like us away. 

Stefani November 16th, 2009 12:43:51 PM

Barb, re:

"Seriously though, anything beyond basics in a non-emergency can be referenced & delayed decision/treatment."

Have you ever noticed part of the problem is that ER after hours are staffed by the newbies?

I think there are two reasons for this:

1.  Seniority = you get to pick your schedule and make it a more reasonable one; newbies are on the bottom rung and therefore have to do the 1am to whenever shifts

2.  I think most vet hospitals actually MINDFULLY and deliberately use our critically ill pets as teaching tools, ala "trial by fire," "throw you in the deep end of the pool," etc.  This might train up the kids, but at the risk of lives.

I doubt that youngun who gave ketamine to the cat with suspected heart failure who belonged to our mutual friend did so knowing it was contraindicated.  Oooops, dead cat.   Thankfully also, ooops, lost job. (I think)

So, this is one way ER services leverage their knowledge that our pets have no legal value:  when you have the most critical situation, you will invariably get the least experienced vets helping you. And they seem to all be OK with that.

There are exceptions, and this is the reason why when my kitty needed LFB surgery after hours I basically begged the more experienced vet to do it, even tho she looked tired and was at the end of her shift. 

Stefani November 16th, 2009 02:54:24 PM

Stefani: To respond, that is part of the reason why myself and others have a founded fear in ER's and some referral centers.

Two recent cases shared to me, reaffirm this founded distaste. One is the $$$ upfront, credit card & paperwork deposit of up to $1000 without seeing your critically ill pet & wasting possibly precious time and the other is the bombardment of diagnostics w/o even giving a preliminary diagnosis.

How about the example recently: I'll call "zipper dog". Zipper dog is a young dog relinquished to a non-profit rescue and presented with repeated vomiting and some dehydration. Zipper dog is not in critical condition, needs a neuter and a few minor routine diagnostics.

Zip has an x-ray that reveals a "possible shadow" and rescue is urgently advised to okay surgery for foreign body removal (experience of surgeon unknown). Panic and trust causes the ok, Zip is opened up stem to sternum, neutered and declared FB free, $2500 later.

Zip still has an issue though, aha--lyme positive, and is cured with doxycycline. No compromise on the bill, no apology for misdiagnosis, and rescue funds depleted enormously (not to mention that same surgery could have been done in same state for fraction of cost)

I digressed. Yes, indeed, Stef--we are mature and empathetic to be a newbie or experienced Vet's best friend and advocate for the reasons you listed.

Sadly & ironically, we are viewed as the ones to "sucker", because of our willingness to fork up the $$ and diagnostics.

disclaimer: this does NOT apply to ALL veterinarians, there are many GOOD & ethical professionals, regardless of experience

Barbara A./NH November 16th, 2009 04:45:52 PM

Posey: The only new grads who seem to have trouble are those who are somewhat picky. There are plenty of jobs...but not always the kind you want in the city/state you need/prefer to be in.

This year was exceptional in that it became obvious that some new grads were having trouble finding work. The economy, combined with the higher starting salaries new grads demand (given their expensive educations), conspired to leave a significant few out of work.

Normally, though, it's not like that. Vets have historically had no trouble getting work right out of the gate. It remains to be seen whether it'll prove to be a trend. 

Dr. Patty Khuly November 16th, 2009 05:47:10 PM

Stefani: I agree that it's problematic, this hiring of fresh young things to staff the overnights and weekends when they can't possibly be expected to access the kind of mentorship they require. It's a sign of poor hospital-ship when this happens. 

High quality hospitals always staff experienced docs. Some are now run by critical care specialists who demand experience and oversee the cases on a daily/nightly/hourly basis. You'd be surprised at what some well-run places can accomplish. 

But then, there are always those willing to charge you the same exact fees for recent grad attention––which is unfair and wrong, for both the patient and the new grad. 

Dr. Patty Khuly November 16th, 2009 05:51:48 PM

JK DVM: Thanks for your obviously well-informed thoughts. Obviously, not all our colleagues have been paying attention to the recommendations. Obviously there are roadblocks born of ignorance or hubris and/or greed.

Truth be told, however, none of us has assumed that the solution to this problem will come through the schools. Nor will it likely come through the AVMA's highest levels (though we will certainly attempt to make it so). Ultimately, most of these solutions will be achieved at the level of the local VMAs where veterinarians help veterinarians on an everyday basis. At the very least I expect a greater awareness of new grad trials.

Eventually, however, I expect an understanding that our profession does itself no favors unless it can train and support each new crop of graduates to the standards animal owners demand of it. 

Dr. Patty Khuly November 16th, 2009 06:15:21 PM

A new grad weighing in, here; I've been lurking for a while.

The veterinary industry is heading for trouble if we don't change something. I have $170 K in school debt, which has shut off whole arenas of practice for me. I'd love to work in wildlife, but what nonprofit wildlife place can afford to pay me enough to pay the bills and put food on the table? I don't know any.

I applied for 27 jobs; I got 2 interviews. Most of the ones I applied to had been filled already, or they were looking for someone more experienced. Of the 2 interviews I received, one was not sure they would even have a place for me - and if they did, it would be for a salary that would have had me living with my parents because I would not be able to afford both rent and student loan payments. The other interview? Was Banfield. It hasn't been as bad a ride with corporate medicine as I was fearing, but it's a far cry from the culture in which I'd prfer to practice. Part of me shies away from starting the process of looking for a new job now, if only because f the huge blow to my confidence when I realized that no one wants to nurture the new grad in a tough economic climate.

I think the industry tends to view new grads as a burden. We need supervision, we need someone to answer our questions, we sometimes need a little hand-holding. A lot of this is the consequence of poor education; I graduated from one of the top schools in the country, and I feel like an idiot because we only get exposed to each piece of information once or maybe twice. In addition to skyrocketing costs, the traditional model is no longer serving us because recent advances have left us with far too much to learn in far too short a time. Schools need to stop trying to train good new grads AND good specialists. I got a bunch of lectures on things that are now firmly lumped into "I can't handle this, refer it," but they barely covered ear infections or a balanced approach to vomiting. Schools also need to lengthen their clinical programs. This might mean making vet school 5 years, or it might mean cutting out some of the basic science at the beginning of the program. I felt very frustrated during large swathes of our first and second years because we were being taught things that should have been covered by our prerequisites. They need to either trust that we will be well-versed in those prereqs or cut some of those, lengthen the vet program, and stop expecting applicants to come to them with an undergraduate degree.

wikith November 16th, 2009 07:00:44 PM

1. Veterinary medicine needs to improve in postgraduate training. Unfortunately, there is no good way to do this. The excellent postgraduate residency system they have developed in human medicine relies on a numbers of things that are not present in veterinary medicine: a centralized hospital system with high caseloads, the need for 24 hour physician coverage of that high caseload, and full funding from medicare for the vast majority of house officers. In human medicine physicians are reliant on hospitals for getting access to the highest quality equipment and services for themselves and their patients, and because for reasons both good and bad the pressure is always to send patients to more advanced (and expensive) levels of care. The academic medical centers dominate the field and are able to drive research, standards of care, and education.

In veterinary medicine the larger hospitals (those with specialists, special equipment, and 24 hour care) are entirely reliant on individual veterinarians for referrals, for reasons both good and bad the pressure is always to bump down to a less advanced (and expensive) level of care, and there is no outside funding for house officers. The academic veterinary centers are peripheral in the minds of most practitioners, generally can't afford the salaries to attract the top specialists, and due to their locations have mostly limited caseloads. The attempts of the universities to open satellite hospitals in better geographic areas which would increase resident training, specialist retention, and research face strong opposition from veterinarians due to the fear of financial competition. All of these factors reduce the hospitals, specialists, and patients available to train new vets.

Financial factors are also important. Owners don't want to pay to train new vets (note the owners in these comments who suggest they would not let such a vet see their pet). Specialists and GPs are more and more not wanting to take away from their own income potential to spend time training new grads, although we are fortunate to have so many that forego their financial interests to devote time to teaching/mentoring. The need for a 24-hour doctor coverage is mitigated by the realities of the disconnect between the one making decisions and the patient, as well as the greatly reduced liability in the veterinary profession. If you are in the hospital at 3am and need increased pain control and there is no md on site to provide it you are leaving that hospital after suing it. If the same situation arises with your pet you would probably have no idea, meaning owners and vets are more willing to get away with putting an animal in a cage alone all night. And there is no medicare to pay the way. The result is less general practice mentorship, less internship and residency slots, and very low salaries for veterinary house officers. Yearly salary for a human med house officer is in the $40,000 to $60,000 range. Salary for a veterinary house officer is in the $20,000 to $30,000 range. This means that vets who choose to seek the highest levels of PG training will often end up paying a huge percentage of their income to their loans. In my case the monthly loan payments were between more than my monthly income as an intern for the shortest term to about half for the longest.

I think that we should set as a goal that every veterinarian complete an internship or qualified mentorship their first year in practice. Setting this goal is an important first step and commitment to improving our profession. I just don't see it happening without significant efforts by a lot of people who have no clear personal incentive to change the system. Oh, and all of this discussion is only about small animal med. There are probably even more challenges in PG training for the large/production guys.

2. As to the complaint that only newbies are around on overnights and weekends, timing is everything in life. In human medicine, where they have lots of money to study lots of things, they have found that outcomes are worse in July (when new interns start and everyone moves up a PG year and thus a level of responsibility) and nights and weekends. Get admitted to a hospital at 2am and your admit is likely to be done by an intern or resident there as well. It's not fair that you or your pet may get a lower level of care based on the timing of your illness, which is usually out of your control, but it is a fact of life. Further, following recent comments here and elsewhere it seems that many thing emergency hospitals charge exorbitant amounts for care. If you don't like paying what it costs for care with interns or young grads staffing it after hours, are you going to be willing to pay the significant hike in price to provide 24 hour staffing with a criticalist, internist, or experience emergency vet? Also, we should at least take a moment to reflect that it is nice to be able to complain about having only newbies to see at the emergency hospital that is open 24 hours and fully staffed for appropriate care during this period. Not too long ago there was nothing that could have been considered 24 hour care in most regions of the country.

3. Barbara: Just wanted to make a few comments on Zipper dog's case to give you the perspective from someone who works at an emergency/referral hospital and is not sure that it is fair to have a "founded fear/distaste" for these hospitals based on the details of the case as you described them. First of all, doxycycline did not cure Zipper's vomiting. Vomiting is not a clinical signs associated with lyme disease in dogs from any resource I have every read on the disease. Well, the one caveat would be that glomerulonephritis (GN) and renal failure can cause vomiting and lyme disease may cause GN (this itself is a very controversial statement in both veterinary and human medicine), but they should have noticed this on bloodwork well before they got the 4Dx or C6 back, and it would not have gotten better with doxycycline. Doxycycline is actually notorious as an antibiotic for causing gastroenteritis and vomiting. So it is unlikely that Lyme caused Zipper's vomiting or that doxy cured it. In the meantime, the vet performed what I believe should be standard of care in a vomiting dog. He/she took abdominal films, and noted some abnormality. I don't know what they say or whether they interpreted it correctly or not, only that they thought they saw a radiographic abnormality that in their judgment was consistent with a foreign body and/or obstruction. At this point they had a few possible options: further imaging if available (typically ultrasound in this kind of case), admit for hospitalization and IV fluids and repeat x-rays later for evidence of improvement/worsening, or go to exploratory laparotomy. When you have acute vomiting and a radiographic abnormality you can't just treat for lyme disease that is not known to cause vomiting, and all of these treatment options cost money. Some people tend to be much more aggressive with exploratory surgeries, others more cautious. In my admittedly limited experience, the emergency hospitals tend to be less aggressive than your average GP about exploratory surgery. But once you have vomiting and x-ray evidence of some intestinal disease you need to address that in some way and Lyme disease is entirely incidental.

I don't mean to say that everything was done right or perfectly in this case. Obviously I have no idea what the true facts are, and did not examine the patient or see the diagnostic results. I merely want to suggest that there are some factors that you don't seem to have considered in your conclusion that the vet in this case misdiagnosed Zipper and wasted the organization's money. And I think most vets would probably also prefer to have someone posting to a blog complaining about how they wasted $2500 on a negative explore versus someone complaining about how they noted a radiographic abnormality consistent with obstruction in a vomiting dog and sent the dog home with doxycycline and the dog later was euthanized because the owners couldn't afford the $8000 minimum for a septic abdomen after the dog perforated due to the obstructive foreign body.

Anonymous Intern November 17th, 2009 04:12:22 AM

Nice post, Anonymous Intern. Thank you for taking the time to reason though and type ups some of the factors surrounding these issues.

lindabcs November 17th, 2009 12:34:22 PM

Anonymous Intern: To your points, in order...

1) I believe the model will change. Veterinary schools will have to open satellite hospitals that serve as secondary care facilities (specialty practices where research is generally considered less important than individual patient care and profits).

This will ensure that students have access to real world situations rather than twiddle their thumbs for four hours during a hip replacement they're required to attend and will never undertake (what a waste of valuable teaching time!). 

Yes on the internship for every new grad. But I don't believe that specialty-track new grads and general practice new grads should be lumped together. One solution is to provide "internships" that are more akin to a heavily mentored first year out than to a traditional university internship. This can be achieved by creating an accreditation system for new grad friendly hospitals.

Reference Australia's model in which new grad support is a fundamental tenet of their system. Hotlines. Debt management assistance. Hospitals can achieve a new grad friendly accreditation proving they have a commitment to mentorship. This latter option would be especially valuable because, frankly, some internships are even worse than my horrible first year out. They're little more than opportunities for slave labor.

2) Read Dr. Atul Gawande's "Complications." He agrees with you and so do I. Patient care will sometimes suffer given the vagaries of clinical practice. That's life. But interns should be off limits in ER environments unless they have access to backup. Residents are another story. But in human medicine, they still have access to their attending.

Dr. Patty Khuly November 17th, 2009 02:13:03 PM

wikith: I wish you'd been present at our meeting (anonymous intern, too). We spent about two hours talking debt and debt management, including how that affects hiring practices that culminate in poor employment opportunities (a week wouldn't have been enough). We spent another two hours talking internships, mentorship details and other new grad support options.

The bulk of the latter discussion related to how our schools are both hog-tied and blindfolded. In other words, they suffer from the need to cram all the vet science known to humanity into four years (including much basic stuff I agree should be prereqs) and still manage to churn out practitioners. It's just not doable. 

Dr. Patty Khuly November 17th, 2009 02:20:14 PM

 I was contacted last week by a 2005 graduate who found my name in a posting I made on VIN about the Army Veterinary Corp in which I served in mid 90s. She has internship and experience in well recognized emergency hospital but cannot afford her $200,000 debt. After talking to the Army who will repay $120,000 of her debt, I told her that really is her best chance for financial survival and for future career opportunities like pathology or lab animal medicine which will give her training that will earn a good six figure income after army retirement.

Next year's class I think will have significant unemployed graduates as Sep 2009 JAVMA reported about 40% of 2009 grads took internship and other educational training for first year out os school which will add to the pool of available DVMs. The fault lies clearly with the AVMA and the Council on Education and the schools of veterinary medicine. The US Dept of Education recognizes the Council on Education as the agency responsible for determining quality in veterinary education since the 1950s. COE and most nongovernmental agencies(like the ADA, AMA and other professional orgs) that certify colleges must be re approved every 4-5 yrs. AVMA Council on Education is up for renewal in 2011. The solution is an anti-trust suit against the AVMA. Western University in 2001 started to sue AVMA after the COE refused to give provisional assurance of approval because of the non veteterinary teaching hospital centered model of education among other things in the Western vet curriculum. A settlement was reached out of court. Entitities other than government can file antitrust lawsuits. Antitrust can be about price fixing, cartels and also any activity that may restrict innovations which benefit the consumer and marketplace. Clearly there has been little innovation in veterinary education. Schools of veterinary medicine bear blame for not seeing the writing on the wall as well as protecting their jobs. While students were being less well prepared, schools wanted more money from state coffers to build better hospitals with high tech equipment to allow veterinary faculty to practice their specialties more than train practitioners. Even before the recession, some school were getting their funds cut. Prestige matters more than people and their performance.

The Royal College of Veterinary Surgeons in UK in 2001 produced a paper detailing a veterinary training framework that provided for mandatory internships in approved practices for the first year for all graduates with provisional licensing (just like a learner's permit). After completing a list of required objectives and tasks, then full licensure in a specific area of practice is granted. The internships are in small animal, equine, food animal etc. Additionally the program will offer further educational modules where vets can get a certificate to be recognised specialist in their fields. UK graduates are already taking advantage of this program today. Additionally, the RCVS is also sponsoring a program that will certify practices as to their level and type of service from basic outpatient to emergency etc.

Unfortunately, 95% of the profession is in analysis paralysis; let's study it one more time. The Marine Corps solution is the 70% solution. Once you have 70% of the information, 70% of the analysis and 70% confident, then move. Less than ideal solution well executed stands a better chance of success than no action which stands no chance.

AVMA, COE and licensing boards need to lead, follow or get the hell out of the way as the Army Rangers say. Two decades of waffling is enough and wasting valuable human capital. That is irresponsible leadership. Leadership is responsibility saith Peter Drucker

josephknechtdvm November 17th, 2009 03:53:42 PM

Analysis paralysis is right. 

Given this perspective I can understand your pessimism. But while I largely share your cynical take, I seem to have an irrational amount of optimism for this profession.

But then, I know what a small organization like my local VMA can achieve. And I'm willing to bet that even if our schools and our professional organizations can't move, our smaller, grassroots organizations can suss out the need and make things happen.

For my part, I'll just keep pushing the buttons and see what the profession comes up with. 

Dr. Patty Khuly November 18th, 2009 07:43:06 AM

Anonymous intern: Thank you for offering a few alternative suggestions about Zip.

Zip was not observed very long before exploratory surgery was 'urgently' performed. Zip did NOT have a snap3 test prior (that should have been #1 , IMO) . I do not know if he had ANY pre-anesthesia bloodwork. The price for Zip in comparable area was "outrageous--3-4X) and I believe a 2nd  'outside' Vet has offered an opinion.

But I really must tell you, I live in an endemic area for Lyme. I have had 3/6 dogs positive with follow up titers. And the symptoms range from decreased appetite, nausea, and yes--sometimes vomiting bile or food. The symptomjs in some dogs are NOT always obvious lameness either.

Oh, and as far as the course of Doxy., please do not assume that the minumum doasge typically suggested will take care of it. (that goes for humans too)

But then again Scottish Terriers are called "diehards" for a reason, I guess which can make overt signs that are typical in other dogs---go un-noticed

BTW, a friend in PA young (5 yrs) Scottie went untested for Lyme & prescribed Rimadyl for limp and was dead within a week. If I can impart any experience, please do not assume the textbook is right in every case.

I sure am glad you are following this blog though, it will help reading pet-owners experiences!

Barb A./NH November 19th, 2009 06:38:06 PM

I'm glad the profession is addressing the debt/salary/quality of life issue.  I could see the problem by the time I graduated ten years ago and it's become much worse far more quickly than I could have feared at the time.  I routinely tell veterinary school hopefuls to pursue another profession unless their families can pay for tuition out-of-pocket.  My debt is average ($80K) for my time of graduation and, as I tell students, translates into $500/month for 30 years.  Had I taken out any private loans that could not have been consolidated at 4% it would have been much, much worse.

At the moment, I'm in the process of folding my practice and leaving to work in industry.  I'd like to pay off the debt and save for retirement while enjoying some quality of life during my work years (I am an equine veterinarian and have had it with on call 100%, 24/7 - it's ridiculous).  I see too many veterinarians forced to continue practice because they simply can't afford to retire.  It's frightening, and I think it's going to get worse.

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