Big-Picturism

As a relief vet, I see it all. Especially so in Western Oregon, where the country runs from pickup truck red all the way to city folks so blue their hair turns pink. As the buildings get shorter, the standard of care changes. It wouldn't be right to say it diminishes. It just gets different. It's adapting to local environments.

People live in a certain way in a certain place. I can't be charged with the same malpractice suit if I'm a hedgehog plastic surgeon in either Beverly Hills or East Bakersfield. Place matters. "Standard of care" is legally-recognized term that is defined by regional context. Legal punishments can't be the same in every location, so "standard of care" knows where it is at all times, by definition.

My job as a relief vet is to do my best to help the animals in that clinic, on that day. They might be Insta-famous fur babies or just "Clackamas Country Stay Cat 11.5.2023". That might mean minimally invasive surgery or overly-generous use of the term "aseptic technique".

Sometimes I feel overqualified, sometimes overcompensated. Sometimes I feel a lot stupider than everyone else in the building. Sometimes I feel like I'm in a time machine that only goes backwards fifty years. It's a real spectrum out there. There are unethical practices out there, and I don't go back. But there's a difference between having fewer things and doing less. If I clinic is trying it's best and open to my input, I'm flexible. I'll figure it out with what you have. I'd rather have 1970's medicine than 1870's medicine.

Anyway, recently I was in a Zip code we can comfortably assume has a lot of Applebee's, in a small clinic where I do surgery. It was in this fine establishment that I clocked my personal best for number of surgeries in a single day. Any other vets reading this will want to know what that number was, so that they can judge and shame me (or feel judged and shamed themselves if my number is higher), and I won't give them the sick pleasure.

The point is not that I did something remarkable, or noteworthy. I recently talked to a shelter vet who would be embarrassed for me to hear my number. The point is that I didn't even know why I felt good about this number. Why did I even count? Why didn't I just focus on each patient and make sure I got home on time to see my kids? What, stupid little lizard brain part of me was satisfied that I had a bigger number than I'd ever had before?!

In any case, the proximate reason for my high surgical volume that day was that my patients were almost all barn cats, and they got less than the "gold standard" of medical care. Okay, one patient was a fat, beloved golden retriever, so there was a local spectrum of care that day. But otherwise, we were cutting corners. Safety items were scratched out in the financial estimate.

It's a bit odd to me that I will knowingly practice "inferior" medicine because the patient happens to live in an outdoor enclosure for hay. I just go along with it, though! Even more than that, it's kind of fun! I can move faster, treat more patients this way. Slow can be safe, but it's fun to move fast! We used to call this "cowboy" medicine in my internship, and I must admit, I kinda like the snorting and the bucking. I like solving my puzzles with a bit of chaos, I guess!

But on the other hand, I believe it really helped those animals. And their people. In fact, I think the songbirds should be thanking me. Unchecked feral cat populations are an environmental and social catastrophe. Surgerizing them with a couple fewer medical interventions was better than not intervening at all.

In this particular community, it would only have been done under these conditions. The cat owners would only pay a certain amount, and it was not enough to maximally optimize their pet's individual level of care. I must say, though, that we did a fine job mitigating patient risk and providing analgesia in an evidence-based manner on a tight budget. Within our constraints, we did maximize the benefit.

So it's not "less than", it's actually "more than".

I need to remind myself of this. I know what "gold-standard" means. It means the most expensive option. That's the reason it's so much better, and that's what it's named for a precious metal that very few people own in large quantity. Those people deserve access to services, veterinary care included. They deserve veterinary professionals willing to work in their communities, meeting them where they are.

Clinics are hurting for more help. It's hard to fill vacancies, and many vets won't even recommend the profession! I feel like any day I show up and do anything, I'm serving whatever community I happen to be in. Knowing more could be done in the long run but doing my best to improve the short term was helpful. Or so I pretended to justify in front of an imaginary judgmental colleague.

I'm old enough to have now been on the receiving end of professional eye-rolling from younger colleagues. I've had to recognize my own feelings of inferiority and do my best to confront them. I've seen myself in their constant desire to be better. But I also see the big picture consequences of a population of bright individuals all trying to "win": clawing their way up just a little bit higher than the rest, hoping to sneer down as if that validated their efforts.

I don't feel bad about cutting corners that day. I knew the constraints facing me, and I knew the consequences of not making those trade offs. Re-framing the situation as a good thing helps me remember my work as positive, which I still do with the clarity of reflection. I worked hard to be able to do this. But even if the best I can do is eight surgeries in a day, and I'm not saying that's what I did, but if I was, that would be pretty good for a 2013 grad who's kinda slow anyway and hadn't eaten anything that morning. But even if it was only eight, that's eight more than nothing.