When safety, learning conflict in veterinary school

On aggressive patients, school policies differ widely

November 16, 2016 (published)
By Phyllis DeGioia

Part 2 of a 3-part series

Part 1: Aggressive patients

Part 3: Adoption risks

Photo by Nathan Latil / NC State Veterinary Medicine
Veterinary students at North Carolina State University learn to handle fearful dogs, which sometimes are aggressive. This particular dog is muzzled.

The rumor was attention-getting.

"Our vet school now has a policy they won’t see ‘aggressive'pets and will turf them to another nearby referral clinic. The reason given was they don’t want the vet students handling these pets!"

That’s the message Dr. Shannon Donoho got when she referred a dog last spring to the hospital at North Carolina State University College of Veterinary Medicine and relayed the owner’s warning that the dog might bite.

Donoho, an NC State alumna, was so startled by the stated policy that she shared it with colleagues on a message board of the Veterinary Information Network, an online community for the profession. Describing the patient as "an average ‘difficult'dog I see in day to day practice," Donoho wrote: "I completely understand refusing very aggressive dogs/cats, feral pets, dogs and cats that are truly dangerous. However … if a vet student does not learn to handle ‘difficult'patients, then what will they do when they graduate? … I am concerned the policy will not prepare vet students for the real world."

The university hospital did end up accepting the dog because he already was lightly sedated with a catheter in place, and the owner was willing to muzzle him upon arrival. And it turns out that the official hospital policy is not as peremptory as Donoho was led to believe.

According to Dr. Steven Marks, director of NC State’s veterinary medical services, a student, staff member or resident who is presented with an aggressive animal should contact a senior faculty member to assess the case. The senior faculty member decides whether the hospital can provide services without undue risk to students and staff and without compromising patient care.

Told by the VIN News Service about Donoho’s experience, Marks was dismayed. "Our patient care is customized and individualized; our assessment should be the same," he said. "We only use [the policy of turning away a patient] when the animal is actively attacking.

"It’s a very sensitive issue," he added. "It is a bit of a buzz topic now among several veterinary colleges due to risk [to] students."

The VIN News Service asked a sampling of schools about their policies and practices to find out how veterinary educators balance student safety with teaching skills for handling aggressive animals. It found that schools vary widely in their approaches. Some put more emphasis on safety, some on teaching handling savvy. Some come down strongly on neither side. And while a few have written policies, most do not.

Among those with a firm and written policy is the University of Tennessee (UT) College of Veterinary Medicine. The policy, which was established in 1994 and updated twice since, includes clearly identifying animals known to be a danger: " … a known aggressive, unmanageable animal should have a prominent sign that the animal is not to be handled except by the clinician in charge of the case."

Dr. Jamie Bishop, a UT alumna, attested that the policy is followed closely. "As a 2016 grad, I can tell you students were normally not allowed to handle aggressive dogs. We were told to get back and watch while the techs and residents attempted to get a muzzle on the lunging chow," she wrote on a VIN message board.

Exceptions might be made occasionally. Bishop was a veterinary technician for a decade before entering veterinary school to become a doctor. She learned by experience techniques to physically and chemically (with sedatives) restrain aggressive dogs without heightening their fear or risk injuring people in the room. So once, when an aggressive dog came in during her emergency rotation at veterinary school and Bishop was the only person present who felt comfortable enough to handle it, she was allowed.

"If it was another student, I fear that someone might have gotten hurt," she wrote in the VIN discussion.

Bishop also fears that many of her classmates enter the profession remaining uncomfortable and possibly unable to handle such patients because they never learn how. "If you’re not [teaching it], you’re doing a disservice," she said. "Then you have a class of vets who can’t handle a decent subset of the patient population."

Kelley Bollen, an animal-behavior consultant, agrees. She said most people cannot learn how to handle an aggressive animal just by watching. "I could watch somebody play a piano but I still wouldn’t be a pianist," Bollen said. "It’s a mechanical skill like any other. It’s really a shame they’re coming out of school without this."

A UT representative said the school’s policy does not preclude students learning how to handle aggressiveness in patients.

"[M]ildly aggressive animal[s] have always been allowed, and serve as a good learning tool for students who are developing emerging skills handling such patients," spokeswoman Sandra Harbison said by email.

"Dogs with significant aggression issues pose a significant health risk to all who come in contact with them," she continued. "While students may gain insight from watching experienced handlers manage such cases, they will get better experience handling mild aggression cases while building skills."

Harbison noted, "Often, aggressive dogs are more aggressive and stressed in a large unfamiliar hospital setting. It is a suboptimal environment to try to manage behavior and provide optimal care." However, she also said that since 2008, the school has accepted some aggressive patients, whose handling is aided by a behaviorist.

Marks of NC State said he believes having students wrestle with aggressive patients is neither in the patient’s best interest nor part of an effective learning environment.

Although the school policy allowing the option of turning away a problematic patient is used infrequently, the school gets a lot of pushback over it, Marks said.

"The client is upset, the referring vet can get upset. Some vets that hire our grads who then send a case deemed too aggressive say they think students should learn handling because it’s the real world," he said. "Most clients don’t believe their pets are aggressive. We have a very busy hospital, high stress, and these are not normal patients. These are cases that have already been seen by competent vets, and they can be challenging. You’re trying to provide a nurturing environment for students. Then you throw in a variable like a dog may eat you. I don’t see that as an important [teaching] goal."

Colorado State University (CSU) College of Veterinary Medicine also has a strong, if unwritten, policy protective of student safety. The issue is not hypothetical — students have been hurt in the past.

In one instance, a student was bitten badly in the face by a police dog, according to Dr. Tim Hackett, director of the teaching hospital. This happened even though safeguards had been in place: On the admitting form, questions about the dog’s temperament were answered fully and correctly. The dog’s handler was present, as well.

In other instances, pet owners failed to warn the hospital about temperament issues, and bad injuries resulted, Hackett said.

Consequently, CSU’s first priority is limiting aggressive patient contact with students, Hackett said. "Once an animal displays aggressive behavior, then we pull the student back," he said — regardless of the student’s desire to be involved.

"If the student says ‘I’m really comfortable around crazy animals,'we still say, ‘Let us handle it'because of insurance and liability," Hackett said.

In rare cases, he said, a patient proves so unmanageable that even experienced veterinarians and hospital staff cannot handle it and must turn it away.

Hackett acknowledged that students do need to learn to handle aggressive animals. Learning to handle animals is an important part of students' third and fourth years in the program, he said, although even then, they're not assigned to dangerous animals.

Veterinary student interaction policies

  • Auburn University College of Veterinary Medicine: Decision made by team of faculty, staff, student
  • Colorado State University College of Veterinary Medicine: Students expected to step back
  • Louisiana State University School of Veterinary Medicine: Student choice
  • North Carolina State University Veterinary Hospital: Senior faculty decides
  • University of California at Davis, School of Veterinary Medicine: Senior staff decides
  • University of Tennessee College of Veterinary Medicine: No student contact
  • University of Wisconsin School of Veterinary Medicine: Student choice
  • Virginia-Maryland College of Veterinary Medicine: Section head decides

CSU also deals with wildlife and exotic large mammals. If a lion is brought in, the team standing by includes a police officer who will shoot to kill the animal if necessary. With wolf rescues, staff evaluate the animal in the parking lot to determine if it can be handled. Students never work with wolves or other large mammals at the outset.

"Students are involved, but after it’s safe," Hackett said. "No student is put on the front line. The students are expected to step back."

Allowing student or team decisions

Other schools approach student handling of aggressive patients with greater flexibility. They leave the decision to the student or the clinician in charge, or encourage a team decision.

At Virginia-Maryland College of Veterinary Medicine, for example, the senior clinician decides the level of student interaction with edgy patients, according to Dr. Terry Swecker, director of the teaching hospital.

Paradoxically, Swecker views situations in which an animal appears threatening to be potentially safer than those involving a patient presumed to be docile. "We get caught when we’re not paying attention, and usually with an aggressive animal, everyone is paying attention," he said.

Moreover, he said, when working with animals, there are many sources of potential danger. "There are many more risks than aggressive dogs. For example, my observation of the world is that there are cat people who can handle any cat, and then there’s the rest of us," Swecker said.

Then there are zoonoses and infection. "The average dog we see is neurologic, or it has disk disease," Swecker said. "You are at as much risk of being bitten by an animal in pain as an aggressive one."

Virginia-Maryland teaches animal-handling approaches and techniques, including handling of frightened or wary animals, first through animal-behavior lectures and labs, and later through direct experience when students in their clinical year see real patients.

Auburn University College of Veterinary Medicine takes a similar approach.

"We don’t have a written policy. We have a common-sense policy," said Dr. Dan Givens, dean of academic affairs. "We give the underlying philosophy and methodology in lecture classes. Some students will learn with diagrams and philosophy. For example, cats can be handled better in rooms that only take cats. Students then go to laboratory settings, then to cases in a teaching hospital. We have students at different levels of comfort and ability in being involved."

Givens said each case is unique. For instance, he said, some patients are aggressive only during treatments or particular procedures; such patients are strictly overseen by senior staff. Signs are posted on their cages, and faculty, staff and students jointly decide the level of student involvement.

At Louisiana State University School of Veterinary Medicine, students who are uncomfortable may step away, said Dr. Joseph Taboada, dean of students. But students aren’t necessarily comfortable with that, either.

"If anything, we have students who chose to continue on and should have stopped and sought additional resources," Taboada said. "It probably happens more with horses and cats. We have a student where they aren’t comfortable but are afraid to say it, so we are constantly reminding the students that our goal is to keep them safe. They can learn how without getting hurt."

The general unwritten rule is that students who feel uneasy are to stop what they’re doing and inform the veterinarian with whom they’re working. The veterinarian then assigns someone such as a technician to work with the students.

"We have people in the teaching hospital that are really good at dealing with aggressive animals and at teaching people how to deal with them," Taboada said.

At Ontario Veterinary College at Canada’s University of Guelph, students are formally taught patient handling and aggression through most of the four-year program.

"The first year, we teach them how to recognize fear and aggression in cats and dogs, and get them thinking about how we can recognize those early signals," said Lee Niel, who has a doctorate in animal behavior and welfare. "We give them the tools so they feel more confident. From our perspective, any dog can be potentially aggressive."

Students attend lectures, and even in the first year they practice handling skills on dogs.

In their second year, students take core behavior courses. Guelph is a strong proponent of the low-stress handling movement. Faculty frequently talk about keeping the animal’s perspective in mind, being non-confrontational, going slowly, reading signals and showing students techniques designed to lower an animal’s stress.

Niel doesn’t see students in their third year, but they continue learning handling skills in other courses and while working with clinicians.

During their last year, Guelph students spend three weeks in a small-animal primary health care rotation. There, Niel and teaching clinicians help make sure the students are comfortable with handling, and teach them how to gather helpful information.

"They need to read the chart, talk to the owner, and read the animal even before they touch it," Niel said. "There are lots of animals with fear aggression. If students have an animal that is potentially dangerous and they are uncomfortable, they are to ask for help."

Balancing the competing needs of safety and learning for veterinary students is a complicated issue in today’s litigious society. Dr. Miranda Spindel, a shelter-medicine expert and affiliate faculty member at CSU with off-and-on teaching assignments, says the issue is difficult.

"In any teaching hospital, faculty and staff have a responsibility to continuously model appropriate situation management and safe animal handling," Spindel said. "The teaching adage of ‘see one, do one, teach one'comes to mind, which sounds simple but can be tricky to put into practice. The reality is that students need many opportunities to first observe in the clinical setting before next responding to situations under careful supervision, with a goal of ultimately preparing competent practicing veterinarians once they leave the teaching environment."

Part 3: Aggressive pets adopted out in quest to save animals' lives

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