The Good Old Days

by Dr. Edwin Leap, MD, FACEP

I’ve been reminiscing about the ‘good old days’ of medicine.  I think about those times because I remember when medicine was focused on the sick and when practice was challenging & exhausting, but at its heart…fun!  So what changed?  Lots of things.  But two things in particular come to mind: EMR and HIPAA.

First, let’s discuss EMR, or Electronic Medical Records.  Where once we used paper charts or simple dictation to record information on patient care, now hospitals and physicians are increasingly forced into purchasing and using expensive and complex computerized record-keeping systems.  This was a growing trend already, but the Affordable Care Act made it all but mandatory, with rewards for implementation and fines for noncompliance.  Many small hospitals and practices, in fact, struggle to pay for the cost of implementation even as EMR companies make vast amounts of money.

I’ll ‘render unto Caesar’ here.  Paper systems are problematic.  The can be illegible.  On paper, written by hand, it is difficult to document complex medical encounters and procedures.  And thus, the next clinician involved may have trouble understanding what happened before.  (As will the attorneys in malpractice suits.)  Finally, hand-written charts lose charges and are often down-coded in billing when insurers can’t find the information they need, or find enough information to generate a proper bill.  Paper charts aren’t perfect. Likewise, dictated charts, while better, have longer turn-around times.  But both are faster and generally make physicians happier than the monstrosities that are modern electronic medical records systems.  

Indeed, to give credit where credit is due, electronic systems capture lots (and lots, and lots) of data.  And they can be helpful in retrieving information from previous visits.  And some use voice recognition dictation programs.  This kind of real-time dictation can be helpful.

And yet…EMR sucks the fun out of medicine.  Because EMR systems leave clinicians slaves to the keyboard.  The sound of modern medicine is the sound of typing.  And the great anxiety for physicians, and nurses, is the terrible tension between doing the thing we love, which is patient care, and doing the thing our employers mandate, which is hour, upon hour, of mind-numbing data-entry, all the while trying to move patients in a way that provides the best satisfaction scores and the lowest wait times.  

EMR are rarely designed with clinicians in mind. So, while the flow of the log-ins, clicks, drop-down menus, signed orders, time stamps, discharges and all the rest make perfect sense to programmers, billing companies and data-collectors, it’s an electronic nightmare for those of us who simply want to get back to our patients.  (The commonly told joke is that physicians are the highest paid data entry clerks in the country!)

In the end we care for the sick and let the charts pile up.  We then end up with ‘in baskets’ or ‘to do lists’ filled with hundreds of clicks and signatures that we have to do on our own time, after shift, to satisfy the appetite for information that administrators and government agencies desire, even when little of it contributes substantively to the care of the sick, injured and dying before us.  And woe-betide those who are delinquent in completing records!  E-mails and threats will abound until they are completed.

Older physicians and nurses, less computer savvy, sometimes simply leave.  They retire, taking their incredible skills and knowledge with them.  Younger physicians and nurses are frustrated, but have no other option except to press on and type away, longing for the bedside and the people they spent years learning to treat and comfort.

What about HIPAA?  The acronym stands for the Health Information Portability and Accountability Act. Passed in 1996, among the goals of this federal legislation is the protection of the confidentiality of patients’ private medical information.  Like so many things the government touches, it had a noble intent.  But now it is less a law and more of a bludgeon.  

Currently, in order to protect privacy, patients are yearly advised of their HIPAA rights and expected to sign forms to that effect.  And physicians are constantly beset by log-ins and passwords.  This may seem like no big deal.  Every computer has a log-in screen!  In fact, plenty of applications exist to store all of our various and sundry passwords for our many programs and devices.  However, the average physician will have a log-in and password for the hospital computer system, then for the electronic medical records (EMR) system and a separate set for the radiology system. And if a physician works in more than one facility, the number of log-ins and passwords just keeps climbing.

Our nurses have a similar burden of logging into EMR computers, but also have to access the medication dispensing cabinets which are password protected.  Taken together, it’s very difficult to move patients quickly, chart effectively or maintain a train of thought because we are constantly accessing computers and trying to remember new passwords.  (Biometrics like fingerprint scans and others might help, but we’re not there yet.)

Furthermore, HIPAA terrifies every clinical staffer because they are warned, over and over, that violating privacy is a federal issue.  Even innocently handing the wrong instructions to the wrong patient can be a huge problem.  To make it worse, clinical employees of a hospital can be fired for simply looking up their own labs.  (Their own labs!  In other words, protected from their own prying eyes!)  Their privacy ensured, their job terminated.  

And where we formerly handed lab and x-ray reports to patients so they could take them directly to their physicians, now they must go through the medical records office the next day or later to obtain what is, in fact, their own information.  (Again, protected from their own snooping.)  Or they must have their physician’s office request them with the appropriate release of information signed.   

And when we, the physicians who cared for a critically ill patient, transfer them to another hospital, it’s pointless to check on their progress.  ‘Hello, this is Dr. Leap and I transferred Mrs. Howard, the multi-trauma yesterday after intubating her and placing a chest tube.  Can you tell me how she’s doing?’  ‘All we can say is that she is in the hospital.’  Great.  That’s good quality control, to be sure.

HIPAA has indeed protected privacy (except of course for instances of computer hacking or carelessly placed and lost computers…all too common).  But it has also created a vast industry of programs and consultants, and left clinical and clerical staff slower, and more anxious, than ever.

No, things aren’t what they used to be.  Many issues conspire to make modern medicine difficult; an aging population, complex diseases, rampant addiction, resistant infections, high costs, high expectations and many more.  In the end, however, HIPAA and EMR reflect a common core issue, which is the disconnect between the administrative and political forces that govern medicine (and stand to profit mightily from supervising it) and those who day in, day out, must practice it in the presence of living, bleeding, hurting, dying, fearful human beings whose bodies have no password, and who care less about privacy than survival.

And until that chasm is bridged, it’s unlikely that medicine will ever again be as fun as it was before.  But I can imagine, can’t I, a shift without a computer and a chart without a log-on screen?  Ah, ‘to sleep, perchance to dream…’

Logging off….

   

Edwin Leap, MD, FACEP

Dr. Edwin Leap is a happily married father of four children in the process of becoming adults. He practices emergency medicine in the southern Blue Ridge Mountains.  In addition to his career in medicine, Dr. Leap writes monthly columns for the Greenville News, Emergency Medicine News and The South Carolina Baptist Courier.  He also blogs at www.edwinleap.com/blog.  From faith to family and from culture to medicine, he covers every topic with humor, insight and compassion.

How to Implement IDEA: IEP and its Limits

by B. Lana Guggenheim, Staff Writer

All students are individuals and require individual attention, but some students are in need of special aid due to disability, autism, or other non-normative factors that hamper their ability to learn at the same rate or pedagogic style as the majority of their peers. For them, the US Department of Education has IDEA: The Individuals with Disabilities Education Act. This legislation provides resources and tools to help children with one or more of 13 listed disabilities, including learning disabilities. While not every child with learning or attention issues will qualify for aid covered by IDEA, there are many options for those who do. One of those options is the IEP, or Individualized Education Program.

IEP is not the only education aid program; it bears some similarity to the 504 plan, including the government bearing the cost of any programs or services offered to aid the child in attaining educational goals. However, the IEP is much more specialized, as well as more difficult to obtain. A child declined for an IEP might yet be covered by 504 services, which tend to modify a regular education program in the general classroom, rather than arrange for a wide array of services outside of it or alongside it. Because the IEP is more highly specialized and encompassing, the law requires much more stringent documentation and implementation.

An IEP legally requires a written document, and the team involved to include not just the student’s parents, but a school psychologist or other specialist, a general teacher, a special education teacher, and a school district representative. The child’s abilities and progress need to be carefully monitored, and immediate benchmarks and long-term annual education goals need to be specified, thus allowing for progress to be measured and goals to be attained. Also, in order for an IEP to be implemented, the child needs to have both an in-school evaluation, and an official diagnosis by a specialist or medical professional. The law requires that meetings of the IEP team occur at least once a year to keep parents abreast of developments, but they usually occur more frequently, and can be called by parents at any time. Finally, a transition plan must kick in a minimum of one year before the child graduates high school and reaches an age of majority. This is when the child herself often is present at IEP meetings, and includes services and support to help the student transition from school to a successful adulthood and achieve post-education goals.

To compare, a 504 plan does not require all these individuals, nor even a written document. Furthermore, while a 504 committee includes parents, the law does not specify the individuals mandated to be on the committee, nor does the law even guarantee parent participation in these meetings, nor is the committee required to keep the parents abreast of developments, nor does it include transition plans as a matter of course. That is not to say that 504 plans are inherently inferior, but they are definitely less thorough, and are probably better suited for students with less severe difficulties or borderline cases.

What happens if things go wrong? The IEP has specific legal processes to resolve disputes. A parent can ask for mediation, and in cases where this does not resolve disagreements, can file a due process complaint. This requires a parent writing an official complaint letter, after which there is a resolution session. If this fails to resolve the issues, a formal due process hearing is held in front of a hearing officer or administrative judge. After this, the parent can file a civil lawsuit. Any agreements reached in any stage of this process are required to be documented in writing. Similar options are available for disagreements arising with the 504 plan, but the steps are not as formalized as they are with the IEP.

The IEP is clearly one of the more intensive options of the few that exist to aid struggling or disabled students. Because it is so comprehensive and requires cooperation between so many people, implementation can easily become difficult. Especially in underprivileged and underserved school districts, teachers are often overwhelmed and don’t receive the support they need to properly execute their general duties, never mind the extra effort it takes to help a struggling student. In addition, both IEP and the 504 plan are aimed at students in public schools. Students in private or charter schools are less able to access these resources to aid children, putting yet more pressure on already strained families, students, and teachers.  But lack of funding and overcrowded schools are well known problems in public schools all over the nation, and as a result students are often underserved and teachers are over-stressed, but those struggling students in need suffer the most.

In fact, disparities in school funding both between school districts and within a district are well recorded. Moreover, in 23 states there are noticeable gaps in funding allocated to rich districts versus poor ones. Children living in poverty arrive in school already disadvantaged, and need more resources just to get on an even footing; instead, they are held further back, and as a result, children in poverty lag behind their wealthier peers across the nation. Studies in New York and Texas show large disparities both within and between specific school districts, which further exacerbate the gap between the rich and the poor. In New York City, the gap could be as high as $400 per student, in favor of the wealthy. And poverty exposes children to many factors that cause developmental delays. A home with lead paint, common in older buildings, might lead to permanent mental disability. Children in low-income homes often lack access to books, adequate healthcare, and their overworked parents lack time with their children, which is a crucial factor for emotional and mental development. This also means that problems will be spotted later, when they are more difficult to address. Already disadvantaged, these children arrive to schools that are more ill-equipped than they ought to be to adequately address their needs.

Programs like IEP are meant to aid these students, but these underserved schools and over-extended teachers all but guarantee that they will not receive the help they need to succeed in comparison to their middle- and upper-class peers. The IDEA legislation and IEP program are crucial steps needed to make sure that students with special needs can flourish to the full extent of their potential, and in the case of students from impoverished backgrounds, break the cycle of poverty and disability. But that can’t happen unless teachers and their schools get the support they need.

Works Cited

Brown, Emma. "In 23 States, Richer School Districts Get More Local Funding than Poorer Districts." Washington Post. The Washington Post, 12 Mar. 2015. Web. 11 May 2016.

"Building The Legacy of IDEA." IDEA - Building The Legacy of IDEA 2004. US Department of Education, 2004. Web. 11 May 2016.

"The Difference Between IEPs and 504 Plans." Understood.org. Understood.org, 27 June 2014. Web. 11 May 2016.

"Guide to the Individualized Education Program." US Department of Education. US Department of Education, 3 Mar. 2007. Web. 11 May 2016.

Guin, Kacey, Bethany Gross, Scott Deburgomaster, and Margeurite Roza. "Do Districts Fund Schools Fairly?" Education Next. Education Next, 17 Aug. 2007. Web. 11 May 2016.

Lee, Andrew M.I. "How IDEA Protects You and Your Child." Understood.org. Understood.org, 11 Apr. 2014. Web. 11 May 2016.

Lovett, Kenneth. "EXCLUSIVE: Rich, Poor School Funding Disparity Hits Record." NY Daily News. NY Daily News, 11 Jan. 2015. Web. 11 May 2016.

Schwartz, Amy Ellen, Ross Rubinstein, and Leanna Stiefel. "Why Do Some Schools Get More and Others Less? An Examination of School-Level Funding in New York City." Diss. Institute for Education and Social Policy Wagner and Steinhardt Schools New York U, 2007. Steinhardt.nyu.edu. Steinhardt NYU, 2007. Web. 11 May 2016.

Stanberry, Kristin. "Understanding 504 Plans." Understood.org. Understood.org, 03 June 2014. Web. 11 May 2016.

Stanberry, Kristin. "Understanding Individualized Education Programs." Understood.org. Understood.org, 23 Oct. 2014. Web. 11 May 2016.

Valles, Rebecca, and Shawn Fremstad. "Disability Is a Cause and Consequence of Poverty - Talk Poverty." Talk Poverty. TalkPoverty.com, 19 Sept. 2014. Web. 11 May 2016.

Zorgian, Kris, and Jennifer Job. "Poverty and Special Ed." Learn NC. UNC-Chapel Hill School of Education (UNC-CH SOE), 2010. Web. 11 May 2016.

Occupational Therapy: A New Frontier in Healthcare

by B. Lana Guggenheim

Occupational therapy is often confused for other therapies, such as physical therapy. But while occupational therapy does sometimes make use of medical and physical therapies, its practice encompasses a much wider series of activities and healthcare prerogatives.

Physical therapy is a highly specific medical profession and series of practices focusing on a patient’s abilities to move and perform functions. Occupational therapy can and does encompass this, but its focus is on the daily work and life skills of a patient. As such, it covers not just physical capabilities, but mental and cognitive disorders, and other barriers, both physical and environmental, to a patient’s independence. Occupational therapy is inherently interdisciplinary, drawing from psychology, medical science, and social work.

Both physical and occupational therapies have their roots in ancient medical practices like massage and hydrotherapy advocated by physicians including Hippocrates and Galen. But the earliest evidence of using occupations as a therapy method (occupations meaning activities that occupy a person’s time, rather than paid labor) was by the Greek physician Asclepiades in 100 BCE, who advocated humane treatment of patients with mental illness using baths, massages, exercise and music - practices which had been dropped by medieval times, only to be revived in the past two centuries.

Modern physical therapy was established as a discipline towards the end of the 19th century in response to polio and World War I, which increased global demand for such aid. However, occupational therapy began as part of an 18th century hospital reform by French revolutionaries Philippe Pinel and Johann Christian Reil, using work and leisure activities as part of patient therapies. This was part of something called “Moral Treatment,” an Enlightenment-era philosophy that approached mental illness with humane care, derived both from the emerging science of psychology, as well as moral and religious mores. This led to the rise of asylums, which only declined in use in the 20th century. The Arts and Crafts movement of the late 19th and early 20th century also impacted occupational therapy, as it emerged as a form of human occupation and creativity in the face of loss of autonomy and monotony found in increasingly common factory work, as well as staving off boredom for those confined to long hospital stays, whether that was due to mental illness or physical malady. By the early 1900s, occupational therapy was becoming professionalized, challenging the mainstream views of scientific medicine by being inherently interdisciplinary, incorporating social and economic understandings with medical principles.

Reconstruction aides, an umbrella term for both occupational and physical therapists during World War I, most of whom were women, were very successful. Post-war, in order to keep people interested in the profession, emphasis shifted from war-time altruism to the financial and professional satisfaction of being a therapist, and practice and curriculum were standardized, and the profession obtained medical legitimacy in the 1920s. Today, one requires a minimum of a Master’s degree to practice in the field, but increasingly there are doctorate programs and research avenues opening up as well. Occupational therapy is increasingly focused on a patient’s mental health and in treating mental illness.

Ultimately, the two core principles underlying occupation therapy are the centrality of occupations as a basic human need, bringing meaning to life culturally and personally, and thus is therapeutic, and the concept of holism, indicating that a person and their health can only be properly understood in concept of their larger social environment. Occupational therapy grew out of practical applications of psychology and healthcare practice, but there is an increasing emphasis on research, and occupational science, the study of people as occupational beings, was founded in 1989 as a way to provide evidence-based research to support and advance occupational therapy. Occupational science underlines the ability of people to pursue occupations, specific activities that give their lives structure and meaning. While still young, there are increasing numbers of programs offering doctoral degrees in this emerging social science.

Occupational science understands occupations as an antidote to psychological pain, offering structure and means to find meaning in people’s lives. It influences patients’ health, self-respect, and sense of dignity. It is not so much the specific activities undertaken, so much as that the activities chosen are laden with symbolic meaning, thus making occupation a uniquely human enterprise, a point of human experience mostly ignored by other social sciences, and critically important particularly to the development of occupational therapy. Only once the place and potency of a given occupation, defined as culturally and personally meaningful human activity, in a person’s life is understood can therapies be tailored to their needs.

Occupation therefore encompasses much more than just paid labour, but hobbies, habits, personal rituals, or cultural activities as well. Many occupations are not productive, but primarily pleasurable, as their purpose is to imbue meaning and carry some sort of symbolism rather than material benefit. And research has indicated that mundane, daily activities affect psychological well-being far greater than major life events, meaning that the ramifications of a person orchestrating and organizing their daily lives and engaging in occupations are significant, particularly because unlike animals, human activity requires self-awareness, memory, planning, and engaging in layers of personal and cultural meanings.

Occupational science however addresses both these, as well as neurobiology and physical health. The USC Department of Occupational Therapy developed a Model of Human Subsystems that Influence Occupation to provide a conceptual framework by which all these factors interact and influence a person’s development. The model depicts a human as an occupational being, seen as an open system in interaction with their environment over the course of their life. The use of the systems model, here consisting of six substrates, explain developmental changes in a person over the course of their life is consistent with developmental psychology, of which in this case, a chosen occupation is the output.

These systems allow occupational scientists to examine how a person makes sense of their life via their chosen activities, within the context in which they function and its significance to the individual in question, which in turn requires a synthesis of knowledge from the biological and social sciences. This model allows it to function as a blueprint to organize the research and findings of faculty, students, and practitioners into a unified corpus of knowledge. The applications of this new science, while born from occupational therapy, will apply far beyond it to other disciplines, though both are empowered by the same values, namely the central role that occupation plays in health and life happiness, and viewing a person as an active agent in their own life.

This is important for keeping occupational therapy practices on track, as some worry that it was becoming over-focused on acute care instead of helping patients, especially the disabled or those with chronic disease, improve life opportunities and ability. Instead, therapists are seen as “treatment machines” and patients as “products” to be displayed on a balance sheet. If one’s identity isn’t taken into account except superficially, any therapies are not going to be as effective as they might, especially because many patients are navigating a transition from their old lives to a life with new parameters and limitations. One’s occupations allow a patient to bridge that gap and provide a framework for adaptation and recovery. Occupational science can help occupational therapists aid patients in internalizing this aspect into their clinical reasoning and therapies, helping nurture the human spirit as well as the human body.

Works Cited

Clark, Florence A., Diane Parham, Michael E. Carson, Gelya Frank, Jeanne Jackson, Doris Pierce, Robert J. Wolfe, and Ruth Zemke. "Occupational Science: Academic Innovation in the Service of Occupational Therapy's Future." The American Journal of Occupational Therapy 45.4 (1991): 300-10. Web. 21 Apr. 2016.

Clark, Florence. "Occupation Embedded in a Real Life: Interweaving Occupational Science and Occupational Therapy." American Journal of Occupational Therapy 47 (1993): 1067-078. Web.

"The History Of Occupational Therapy." The History Of Occupational Therapy. N.p., n.d. Web. 21 Apr. 2016.

Jackson, Linda. "The New Research Climate Surrounding Occupational Therapy." The Guardian. Guardian News and Media, 27 Jan. 2015. Web. 21 Apr. 2016.

Sick & Getting Sicker: the Perils of Nursing

By B. Lana Guggenheim, Staff Writer

The recession might be over officially, but many professions are still feeling the squeeze. Healthcare demands are rising as the Boomer generation ages, but even though they are mostly protected from the worst of the volatile job market by virtue of being unionized, nurses are starting to feel the pain of job insecurity.

First in the 90s and again recently, there have been severe budget cuts impacting the health sector as government attempts to minimize budget deficits. Then and now, the results have been mostly negative across the board.  One of the biggest threats to nurses’ jobs are hospital restructurings - which are results of these budget cuts, and are significant changes that nurses often have no voice in. They also have no way to predict or prepare for the nature of those changes either.

Downsizing can make work intolerable: between budget cuts, hiring freezes, overtime restrictions, and wage freezes, nurses reported they had an increasing desire to quit, citing burnout and decreased life satisfaction in addition to job insecurity. In short, hospital restructures often lead to fewer nurses on staff, thus increasing the workload of those who remain, sometimes dangerously so.

Insufficient staffing raises the stress level of the nurses remaining on staff, but it also leads to dangerous levels of insufficient care for patients. Stressed nurses are driven to the breaking point, and many choose to leave their profession as a result. And high nurse turnover and vacancy rates cause avoidable patient deaths. Similar nursing cuts in Canada have led to nurses speaking out about the dangerously sub-optimal care patients now receive as a result.

The increasing instability of nursing jobs might lead one to think that the job market for nurses is over-saturated, but the opposite is true. An aging Baby Boomer population means there is more demand for nurses than ever before. And the aging nurse population means that there are ever increasing numbers of vacancies to be filled as well. The American nursing shortage is projected to grow to 260,000 RNs by 2025 - a shortage not experienced since the mid-1960s, the worst of which is projected to manifest in the South and West. Yet, nursing schools across the country are struggling to expand the capacity to meet this rising demand. Part of the problem is that these schools simply do not have the faculty necessary to expand their programs. According to the AACN’s enrollment data from 2012-2013, American nursing schools turned away nearly 80,000 qualified applicants from bachelor’s and graduate nursing programs due to the insufficient number of faculty, clinical sites, classrooms, and budget.

There is no magic solution to this problem, no easy quick-fix. But there are strategies that can be employed to ameliorate some of the worst effects of this nurse shortage. Hiring retired nurses, or giving incentives to retirement-age nurses to stay on is one way to slow the shortage. This can be done via financial incentives and job enrichment opportunities, such as leadership positions or taking on special assignments. This can also include mentorship programs, which help train newly hired nurses at the start of their careers under a senior nurse with a lot of experience. And it is cheaper than hiring and training a new nurse to take their place. New technology, along with process improvements, can relieve nurses of onerous and redundant administrative tasks, freeing up more time for them to get back to actual nursing. Finally, allowing for flexible scheduling gives nurses a measure of control over their lives. When allowed to dictate their own hours, nurses reported greater job satisfaction, and turnover rates were significantly lowered.

None of the above strategies will resolve the ultimate cause of this nursing shortage in the first place: budget cuts, both at universities and at hospitals and health care centers. However, addressing budget shortfalls is probably out of the reach of most individual nurses, or even most hospitals. These strategies, once implemented, should help stave off some of the worst effects until we ride this crisis out.

Sources:

https://www.psychologytoday.com/blog/diverse-and-competitive/201603/economic-austerity-and-threat-job-security

http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-shortage

https://www.psychologytoday.com/blog/diverse-and-competitive/201602/managing-and-sustaining-aging-nursing-workforce

http://www.tandfonline.com/doi/abs/10.1080/09585192.2014.921634

http://www.thestar.com/news/queenspark/2015/10/22/nursing-cuts-hurting-hospital-care-in-ontario-union-says.html

Animal Doctors, Human Health

By B. Lana Guggenheim, Staff Writer

The history of humans and their animal companions dates back farther than written history has recorded. People have relied on animals for labor and companionship since time immemorial. Dogs are the oldest domesticated animal, co-evolving with humans approximately 27,000 years ago during the Ice Age, functioning primarily as a herding and hunting companion. Cats were domesticated later, approximately 9,500 years ago, about the time of the Neolithic Revolution, in which mankind transitioned from hunting and gathering to farming and settlement building. They served as house companions and pest control, hunting down rodents and insects that threatened grain storage. It is likely that care for these animals alongside their human owners began at this time, primitive though such care might have been.

History

The earliest written record of veterinary medicine comes from Egypt, 1900 BCE, almost 4000 years ago, and from Vedic literature in India (approximately 250 BCE). The latter contains edicts of the Emperor Ashoka of the Mauryan Empire, where he ordered medicinal herbs planted that were of aid to humans and animals alike. Indeed, after his conversion to Buddhism, Ashoka placed so high a value on animal life that he ended the royal hunt, gave multiple edicts concerning the protection and health of animals, outlawed and fined poaching, and was arguably the first ruler in history to advocate conservation measures for wildlife.

Animal care continued to evolve alongside human society. Horses and cattle often received attention due to their economic significance as beasts of agriculture, as farming aids, means of transportation, and as a source of meat. Farriers in the Middle Ages at around the year 475 would be responsible for both horseshoeing as well as horse-doctoring. By 1356, the Lord Mayor of London, concerned at the poor standard of care given to horses in the city at the time, requested at all farriers within a seven mile radius form a fellowship to regulate and improve their standards of care for the animals, ultimately leading to the establishment of of the Worshipful Company of Farriers, in 1674. The first comprehensive treatise on the anatomy of a non-human species was the Anatomy of a Horse by Carlo Ruini in 1598 in Italy.

By 1783, the Odiham Agricultural Society was founded in England to promote agriculture and industry, and played an important role in the foundation of the veterinary profession as it exists today. In fact, one of its founding members, Thomas Burgess, was the one who began to take up the cause of animal welfare for its own sake. The physician James Clark wrote the treatise Prevention of Disease soon after, in which he argued for the professionalization of the veterinary trade, along with attendant veterinary colleges, an idea finally realized in 1790 by the establishment of the Veterinary College in London. The Royal College of Veterinary Surgeons was established via royal charter in 1844, with veterinary science really coming into its own in the 19th Century both in Europe and the United States. Similar schools were established at this time in Boston, New York, and Philadelphia. In 1879, Iowa Agricultural College became the first land grant college to establish a school of veterinary medicine. 

Contribution to Human Medicine

Since then, medicine for both humans and animals has continued to improve with increased medical understanding, evolution of technology, and standards of care. Indeed, there is much overlap in the standards and practice of medicine between humans and animals. The first two-year curricula in both veterinary and human medical schools are very similar in both course names and content, with differences arising in more advanced and clinical courses. While a graduating veterinarian can enter clinical practice immediately after graduation, most medical doctors must complete an average of 3-5 years post-doctoral residency before practicing medicine independently, and often in a narrow or focused specialty. Post-doctoral residency for veterinarians does exist, but it is comparatively rare. However, this means that veterinarians and medical doctors are uniquely positioned to benefit each other's’ fields, and indeed, veterinarians have contributed to many advancements in human medicine and society.

Veterinarians were the first to produce an anticoagulant that has since been used to treat human heart disease, and developed surgical techniques used in surgery for both humans and animals, such as hip-joint replacement, and limb and organ transplants. In 2011, Dr. Ralph Brinster became the only veterinarian to win the National Medal of Science for developing a reliable in-vitro culture system for early mouse embryos, which is the same method used today for human in-vitro fertilizations, mammalian cloning, and embryonic stem cell therapy. The American Academy of Neurology cites more than 12 neurological diseases and disorders that animal research has helped cure, treat, prevent, or furthered understanding. Research veterinarians are also in the forefront of gene therapies, including cures for two forms of blindness, one of which is now in human trials. 

Infectious Diseases and Bioterrorism

With their background in comparative biology,  veterinarians play important roles in public health, particularly in the prevention of zoonoses, or animal-borne diseases that are infectious to humans. Most diseases are easily shared between animals and humans. Approximately 75% of recently emerging infectious diseases are of animal origins, and about 60% of all human pathogens are likewise zoonotic. Some of the world’s most destructive diseases are vector-borne, which means that they are spread by biting insects like mosquitoes, ticks, and fleas. Some examples include the Zika virus, Lyme disease, and the West Nile Virus. It was veterinarians who were in the forefront of the effort to suppress malaria and yellow fever in the United States. Each year, scientists discover an average of two new mosquito-transmitted viruses. Veterinarians are one of the many groups of scientists that are therefore involved in epidemiology, contributing to our understanding and prevention of disease outbreak.

One example of successful disease prevention occurred in Pennsylvania in 2001, when veterinarians developed surveillance technology that provided the ability to stem an avian flu outbreak, which stopped a potentially devastating epidemic at a cost of $400,000; whilst a similar outbreak occurring simultaneously in Virginia cost the state over $100 million. While avian flu is less harmful to humans than other flu strains, because the disease primarily targets domestic fowl such as chicken and turkey, the devastating economic impact on food production speaks for itself. However, with the rapid mutation rate and high adaptability of the virus, public health officials are concerned that strains may adapt to become more easily transmissible between humans, and therefore more dangerous to human health and the cause of a global pandemic - making cooperation between veterinarians and medical doctors all the more crucial.

Veterinarians have aided gains in other parts of medical science as well. Research veterinarians were at the forefront of numerous pharmacological and pathogenic agent discoveries. They were the first to isolate oncoviruses (cancer causing viruses) in chickens and then mice, the first to isolate Salmonella species, Brucella species, the botulism disease-causing agent, and other pathogenic agents. The understanding of cross-species pathogenic transfer, mutation, and disease manifestation also has its uses in preventing and treating agents of bioterrorism in an increasingly politically unstable and hyper-connected world. 

Hunger

Because of their work with animals, veterinarians are also deeply involved in food safety and food production and combating the world’s number one public health threat: hunger. Hunger kills more people worldwide than AIDS, tuberculosis, and malaria combined, according to James T. Morris, Executive Director of the UN World Food Program.  In addition to tackling animal diseases, such as avian and swine flu, veterinarians also develop food safety systems. One such system, which debuted in 2011, enabled eggs to be tested for Salmonella at a swift rate - about 10 times faster than previous methods. This not only saved millions of dollars and ensured public safety, it also increased the distribution of food available to the public. Veterinarians working with dairy farms advise farmers on feed formulations and additives, as well as milking schedules. Not only does this aid the animals, it aids the farmers, as it often results in increased milk production. In the USA, milk production has grown even as the number of dairy cows has decreased.

Beyond enabling and encouraging consumers to eat local foods (a benefit to farmers and the environment at large), this has global implications as both First World and developing countries demand higher quality food and more of it, particularly animal proteins such as meat, milk, and eggs. In the developing world, milk production has not grown despite the increase in number of dairy cows - a trend that veterinary science can help reverse - to the benefit of hungry populations worldwide.

From this brief overview, we can see that veterinary science has huge social effect well beyond care given to companion animals. From aiding advances in medical science, to prevention of infectious diseases, to addressing world hunger, veterinary medicine is responsible for the health and well-being of the entire globe, both for humans and the animals we live with.

Bibliography

http://www.mcall.com/news/breaking/mc-pa-bird-flu-outbreak-20150529-story.html

http://www.upenn.edu/pennnews/current/node/3691

http://www.foodproductiondaily.com/Safety-Regulation/Swifter-salmonella-test-a-milestone-for-egg-industry-researcher

http://www.huffingtonpost.com/joan-c-hendricks-vmd-phd/what-the-world-particular_b_2806181.html

http://www.nap.edu/read/11366/chapter/1

http://www.cdc.gov/mmwr/preview/mmwrhtml/su5502a4.htm

https://www.avma.org/KB/Policies/Pages/Research-Priorities.aspx

http://www.ncbi.nlm.nih.gov/books/NBK22905/


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Veterinarians: The Animal Welfare Experts

Americans truly love their pets, with an estimated 37 - 47% of all households having a dog and 30 - 37% of households having a cat. Taking care of these companion animals and keeping them in good health is a task that takes a significant degree of skill, as dogs and cats are not the only animals Americans keep as pets. Veterinarians are the doctors who focus exclusively on caring for animals of all types, but most in the United States specialize in companion animals, about 75%. Veterinarians are needed in more than just pet healthcare situations, though, as many vets are employed in the food animal safety industry and others are involved in research.

Veterinarians care for the health of animals and work to improve public health. They diagnose, treat, and research medical conditions and diseases of pets, livestock, and other animals. Veterinarians use a wide variety of medical equipment to treat the injuries & illnesses of animals, including surgical tools and x-ray and ultrasound machines. Most veterinarians work in private clinics or hospitals, but some work for government, in labs or classrooms, or on the farm. Vets who treat horses or food animals travel between their offices and farms and ranches. They work outdoors in all types of weather and may have to perform surgery in remote locations.

Becoming a veterinarian is an involved process, and requires a lot of post-secondary education. Veterinarians must complete a Doctor of Veterinary Medicine (D.V.M. or V.M.D.) degree at an accredited college of veterinary medicine, of which there are currently 30 in the United States. A veterinary medicine program usually takes 4 years, most of which are spent in the classroom and laboratory settings. The final year of the program typically involves a clinical rotation in a veterinary clinic or hospital. Admissions to veterinary medicine programs are quite competitive, and less than half of all applicants were accepted in 2014. In order to practice as a veterinarian anywhere in the United States, you must be licensed. The licensure process generally involves completing an accredited veterinary medicine program and passing the North American Veterinary Licensing Exam, but requirements vary by state.

If you are interested in learning more about veterinarians, check out our infographic below. Our Facebook, Twitter, and Instagram pages will be full of veterinary medicine content all week long, so be sure to head there for the latest content!

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