Resistant communication

The World Health Organization celebrated Antibiotic Awareness week in November, and many countries, organizations, and others did likewise. Within the veterinary profession, veterinary practitioners, and especially those involved in food-animal production, were among the first to recognize the client communications minefield the subject of antibiotic resistance generated. At the time, veterinary epidemiologist H. Scott Hurd summed up the problem by noting that “If you think you understand antibiotic resistance, it clearly hasn’t been explained properly to you.” Further complicating matters, no one — be they practitioners or clients — wants to give up practices they believe work for them and the animals in their care. However, relative to food-production animals, food safety issues loomed sufficiently large in the public psyche that practitioners could bring up these concerns to make their point to ranchers and farmers. When Dr. Sanger reflected on this period to his younger colleague, Dr. Buchwald, he noted that knowing he had science- and government-backed public health concerns and existing or looming regulations aimed at suppliers and processors to back him up did much to ease food animal client communication.

“Some of the recommendations and regulations were more logical than others,” he admitted. “But they did enable me to get clients who used antibiotics to compensate for sloppy husbandry practices to clean up their acts. The only reason Liam Parker over in Fairview finally fixed the awful ventilation and drainage systems in that barn of his was because I convinced him that keeping his animals on low-level antibiotics to ‘head off’ any medical problems wasn’t an option any more. I’d told him that for years. But he ignored me until he realized that all the public health concerns about antibiotic resistance could impact him directly and cost him more in the long run.”

Although Dr. Buchwald never regretted her decision to purchase the companion animal part of Dr. Sanger’s practice, she could not help envying his ability to play the food safety card with his clients. It did not take her long to discover that the more intimate and emotional the bonds her clients shared with their animals and the greater their faith in antibiotics as the treatment of choice, the more resistant they were to other treatment options.

Part of the problem is generational. Septuagenarian Ms. Schmidt remembers the post-World War II era when physicians prescribed antibiotics for an increasing array of medical conditions, fueled primarily by the belief that they worked. And indeed, at that time most of them did. She still could recall the names of friends and family members who completely recovered from bacterial infections from which those in her parents’ and grandparents’ generations had not. For her, and like many in the medical and general populations during that era and their offspring, antibiotics truly were miracle drugs. And because she always treated her pets like her babies, she wanted those same drugs for them too.

“I always had cats and one or another of them always had some urinary problem. I could always tell because they’d have blood in their urine, or stop using the litter box, or they’d use it too much, or maybe just act funny, kind of clingy,” she told Dr. Buchwald. “I lived in the city then and took them to one of the first pet animal practices in the area. The doctor would put them on antibiotics and they’d clear right up. Those drugs are miracle-workers.”

Not surprisingly, when Ms. Schmidt presents a cat with hematuria and Dr. Buchwald recommends a work-up to determine the cause of the problem, the client resists.

“Why put her through all that? She’s an old cat! That will just make her worse!” protests the client. “Just give her some antibiotics and I’m sure she’ll clear right up!”

Unlike Ms. Schmidt who wants to give her animal unnecessary antibiotics for emotional reasons, different reasons cause others not to use properly dispensed antibiotics as directed. Five different kinds of clients in this group contribute to the communications challenges related to the improper use of antibiotics dispensed by the veterinarian for legitimate reasons.

One group consists of those like Mr. McGee who calls the clinic to find out if he can give the “leftover” antibiotics to his dog that Dr. Buchwald dispensed for the dog’s infection several months previously.

Another group consists of those like Ms. DeFreitas, a millennial who crams so many different activities into her life that she routinely forgets to give any antibiotics to any of her numerous pets as directed.

A third group includes the Lerners who experience impaired memory related to medical problems or the side-effects related to it. Even though they need their dog’s companionship more than ever since a percussive head injury left Mr. Lerner with an impaired memory, dealing with the stress his condition places on Ms. Lerner and their young family periodically causes her to forget to medicate the cat as directed.

Those who want to medicate their animals as directed, but cannot for some reason comprise yet another, sometimes overlooked group. Some days Ms. Collister’s rheumatoid arthritis interferes with her ability to medicate her pet; other days it does not. Mr. Mitchell cannot read the typed instructions on the small pill container’s label and is embarrassed to admit this. If Ms. Muir and her partner’s dog periodically refuses to eat medication buried in a treat, the animal will not receive medication at that time.

And finally, practitioners must cope with that growing population of substance-abusers whose ability to medicate their animals as directed also may fluctuate from day to day. Sometimes this occurs because the client is mentally or physically incapable of medicating the animal as directed. When Mr. Carmichael turns to drugs and alcohol when life overwhelms him, he clings to his pet for comfort but does not medicate his animal that day. When their daughter’s substance abuse results in a prison sentence followed by mandatory residential treatment for substance abuse, the last thing on the Ogilvies’ minds is medicating their dog.

“Well, that’s a depressing line-up!” notes Dr. Buchwald ruefully. “From my perspective, these all seem like no-win situations for me. Either I can dispense or continue dispensing antibiotics for these animals to keep from alienating, and possibly losing the client and deal with all the self-incrimination and guilt I know I’ll feel for contributing to antibiotic resistance. Or I can refuse to dispense antibiotics and mentally prepare myself for the client’s wrath.”

However, the practitioner does have other options. She can focus on those aspects of the problem where change is possible, and learn to accept those where it is not. For example, Dr. Buchwald knows enough about the physiology of the bond, the concept of emotional contagion, and the caregiver placebo effect to know that Ms. Schmidt’s cat truly may improve when the client gives antibiotics to her cat, even if the cat has no bacterial infection. In this situation, the veterinarian’s discussion of the increased science that supports the measurable benefits of these non-pharmacological but nonetheless legitimate contributions to animal health position the client as a valued asset in the healing process and empowers the caregiver.

In the scenarios that result in antibiotics not given as directed, preventive communication requires less time and energy than that which occurs after problems arise. Dr. Buchwald now stresses that the kind and amount of antibiotic dispensed is specific for the animal’s condition. She explains this by saying, “Just as your animal had disease-causing organisms in her body before you noticed any signs of illness, some of these organisms may linger a few days after your pet appears normal to you. Those last days of medication will get rid of those, too.”

Additionally, Dr. Buchwald now routinely asks clients if they prefer medication in child-proof or more easily opened containers, or medication instructions printed in larger type. This benefits clients reluctant to ask for these services. She also recommends a free pet medication reminder system (e.g., https://secure.merck-animal-health.com/reminders.aspx?SiteID=731&st=jfsfyjdjafs) available online in phone app or e-mail reminder forms to help clients remember to medicate their pets in a timely manner. This same information also appears on the client’s receipt for easy reference. By making this information part of her and her staff’s routine client education for all animals receiving medication, she avoids alienating clients who otherwise might think she was targeting them specifically, or those reluctant to ask for this information for some reason.

Once she addresses those areas within her control to her satisfaction, Dr. Buchwald accepts that she has done her best to educate and help her clients. She also accepts that some clients will implement all her recommendations all the time; some will do so part of the time; and others will ignore them completely. Like most practitioners, she would like to ensure 100% client compliance with antibiotic and other drug use as well as all her other recommendations. But knowing she did her best enables her to accept less than this.