The customer knows best, right?

This gem popped up on my YouTube homepage today https://youtu.be/urZLTobAfJc.

In the clip, Dr House from the eponymous US TV series is seen in a consultation with a worried mother and her young baby who is mildly unwell. The mother becomes disgruntled when asked whether the reason she has missed her child’s vaccination dates is that she thinks vaccines don’t work. ‘I think some multinational pharmaceutical company wants me to think they work. Pad their bottom line’. In classic blunt House fashion, he confronts the mother with the fact that even a business selling coffins for small children is a money making enterprise, and perhaps she might want to spend her money on something that has the potential to save her child’s life.

Though my patients are furry, as someone in the medical realm who deals with the general public all day every day, I could empathise with House’s sentiment watching the clip. I’ve felt the same sense of frustration welling up inside of me at times. I’m pretty sure most vets would agree with me saying that it seems increasingly commonplace for pet owners to rebut evidence-based veterinary advice, or at least question it, in favour of something they have either read on the internet, or advice from Jan from pilates. The fervent anti-vaxxers do not only exist the the realm of human medicine. At times I find myself having to make a conscious effort to force my eyeballs not to roll.

It’s very easy in these situations to be driven down a path towards misanthropy.

I can empathise with the reasons why pet owners might want to do their own research: they just want to do the best for their pet and be reassured that what the vet has told them is indeed correct. Seemingly infinite information is available everywhere at any time via the internet in our pocket. Anybody who wants to can tap away and do their own studies on any topic they please. Veterinary medicine is no different, but unlike doing research on what car insurance to get, the best way to rid your garden of snails or finding DIY instructional videos, pet owners are seeking information about the best way to look after a living being who they usually love dearly. So things can understandably get a whole lot more emotional, particularly when a pet is very sick.

As veterinarians, we are trained to practice evidence based medicine – to base our advice where possible on research and information which is gained empirically, and this approach is the cornerstone of modern medical practice. As students, as well as laying down the bedrock of knowledge in veterinary medicine, all vets are taught how to critically evaluate information in a scientific manner. I certainly don’t always know everything, but like all vets have been given the tools to keep developing and expanding my knowledge.

The internet can be a real minefield. The internet affords us all with freedom of expression. But whilst this is considered indispensable in Western democratic society, when it comes to incorrect medical advice it can be really harmful. Accountability is practically non-existent online. The issue is that on the internet, absolutely anybody with any level of expertise can erect their own soapbox and present themselves as an expert in an area that they have absolutely no formal training in. The internet is also a place where emotional individual stories capture attention and go viral in a way that more reliable sources of facts and figures just can’t compete with, even if presented in an interesting way.

The ‘Lepto 4 vaccine’ debate is a classic example of this. It is a vaccination that is widely used to protect dogs against 4 different serovars or types of leptospirosis, a bacterial infection which is transmitted primarily via the urine of rodents. It is an infection that in dogs is challenging to diagnose, difficult to treat and has an extremely high mortality rate in dogs that become ill with it (shown to be 40-60% in various studies).

As a general rule when talking about both humans and animals, vaccinations are given most widely for infections that are either very common in a population, even if infection causes mild, but still significant disease, or if the disease caused by the infection has a high mortality rate. This infection falls into the high mortality rate category. Additional to this, the infection is zoonotic meaning it is one that human owners can pick up from their dogs, making it even more important to vaccinate against.

Here is some useful and reliable information of leptospirosis and vaccination against it in dogs:

https://onlinelibrary.wiley.com/doi/full/10.1111/jsap.12328

My dog’s had the L2 but not the L4 – should I upgrade?

The first is a review paper with a lot of technical jargon. The second is a well referenced information page directed at pet owners so is more accessible.

Whenever a vaccination is given, there is always a small risk of a ‘vaccine reaction’. For the Lepto 4 vaccine, the incidence of suspected adverse reactions is 7 in 10,000, or 1 in 1429. As this is ‘suspected’ cases this will include some cases that are reported but not proven to be linked to the vaccination, and will include many minor reactions that are easily treated, such as swelling at the site of injection. Speaking from my own personal experience, in 5 years of being a vet and using the Lepto 4 vaccine for the majority of that period many times every single day, I have never seen an animal become seriously unwell following vaccination. That’s not to say it doesn’t happen, and that it isn’t awfully sad when it does. However, it is extremely rare and the benefits brought around by vaccination outweigh this risk.

Despite this, in a movement initially gaslit by several inaccurate and sensationalist stories in the press, a really high proportion of new puppy owners come to me for their new family member’s first health check and immediately tell me that they do not want their dog to be given the Lepto 4 vaccination, because it is dangerous. They have often been told by their breeder or have read online that it kills dogs. There are angry communities of outraged people that have sprung up on social media, echo chambers where pet owners go to be share their experiences of the awful Lepto 4 vaccination and declare war on the corrupt companies that manufacture them and the disgusting money-grabbing vets that administer them.

We live in an era where the line between fact and fake news is increasingly greyed and even everything that Donald Trump, the ‘leader of the free world’ says, has to be fact checked. The relationship between the vet and pet owner sadly nowadays can often begin on a delicate footing where trust is not assumed.

A growing contempt for and distrust of modern medicine by some is not the only factor. When it comes to the relationship between the vet and the pet owner, money is a definite influence when it comes to trust issues.

While I know from speaking to friends who are NHS doctors that it is commonplace for people to question medical advice, cost doesn’t really play a role because it is largely taken out of the equation in human healthcare in the UK (thankfully). As a vet, every treatment or piece of advice I give generally has an associated cost, and this can frequently act as a barrier to the best treatment. It costs £40 to take my advice and give the Lepto 4 vaccine – the hurdle that I have to jump is proving I don’t have a vested interest. That I am giving the vaccine because I believe it is the right thing to do for the dog, and backed up by the science. I wonder how if pet owner attitudes would change if the same treatment was free?

It can be exhausting to fight against this lack of trust all the time. On occasions it is frankly quite upsetting. Like most other vets, I’ve had to make a lot of sacrifices in my life to get to this point in my career. And the main reason why I continue to do my job is a love for animals; the same little fire that burned inside me as a child and set me on the arduous path to become a vet.

So while adopting House’s rude manner is likely to be counterproductive, vets like me should be unapologetic about taking a firm stance against pseudo-science, misinformation and quackery. Because it is so important for our animal patients that we remain champions of rational evidence-based medicine and firm advocates that we should be the primary port of call for health advice for pets, not Dr Google.

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