What is veterinary internal medicine?
A closer look at what this specialty encompasses, including a very special case named Syd
This week we will be taking a closer look at what it means to be a board certified veterinary internal medicine specialist, and what kinds of diseases are treated and managed within this specialty.
So the basics: veterinary school is 4 year graduate program. After you graduate from a veterinary school, and pass a national board examination, you can go into practice as a veterinarian in general practice. These are the veterinarians most people are familiar with, the ones you see on a regular basis for puppy and kitten visits, spay and neuter procedures, vaccines, and flea/tick prevention, as well as minor illnesses and injuries.
Just as in human medicine, veterinarians have the ability to specialize further in different fields, such as oncology, surgery, ophthalmology, dermatology, or internal medicine (amongst others). This requires additional training.
The first step in this training is a year long rotating internship. It is called “rotating” because you rotate through different specialties as opposed to just working in one field (like a specialty internship in neurology just focuses on neurology). Interns typically have just graduated from a 4 year veterinary school, although there are non-traditional interns that have worked as general practitioners and then decide to do an internship. If anyone remembers Noah Wyle’s character on ER, he was an intern in the first season. Basically, the interns are young and inexperienced doctors that work long hours for low pay in exchange for learning from amazing clinicians and improving their clinical skills and knowledge. Also, the prerequisite for specialty residency programs includes the successful completion of a one year internship.
After internship, then comes residency. They actually call it that because residents originally did live at the hospital, literally in hospital housing. I didn’t live at the hospital but was there basically every day. Compared to internship, you are slightly better paid, with still very long hours. Residency programs are 3 years long, and as opposed to “rotating” you are mainly focused on your area of interest. During my residency, I learned about internal medicine in dogs and cats, which includes managing any diseases that aren’t neurological, cardiac, or surgical. We didn’t manage cancer either, but we diagnosed a lot of cancer during our investigations to figure out why a pet is so sick.
The scope of veterinary internal medicine is huge compared to human medicine. Physicians sub-specialize to a level not possible in veterinary medicine. So veterinary internal medicine doctors treat all diseases encompassed by autoimmune disease, infectious diseases, kidney and urinary disease, liver disease, endocrine disease, and respiratory disease. In human medicine, this would be sub-specialized into the different fields of rheumatology, infectious disease, nephrology, urology, hepatology, endocrinology, pulmonology, etc.
Basically, veterinary internal medicine specialists see patients that are too sick for primary care veterinarians to figure out and treat. It is like being a detective and following the clues of clinical signs and lab work to solve the mystery (get a diagnosis) and start treatment.
In order to achieve board certification in a specialty, you not only have to successfully complete your 3 year residency program, you also have to publish a research paper, and pass a qualifier and certifier exam (the certifier exam is what means you are board-certified).
What I love about internal medicine is that every day is different. Because we treat and manage such a wide variety of diseases, and investigate a lot of causes of mystery illness, it is impossible to get bored, and I’m always learning.
I wanted to give an example of a typical pet that would come to see an internal medicine doctor, and the best one I thought of was a husky named Syd. Syd didn’t see me as an appointment, however, because he was my dog. I adopted Syd as an adult when his previous owner (my former co-worker and neighbor) passed away. Syd was an amazing active and sweet husky. Even though he was 12 years old, he was still spry enough to want to go running with me. So I knew something was wrong one weekend where he was very weak, and reluctant to eat.
I brought him to work for some fluid therapy to get him more hydrated, as well as anti-nausea medications. We did a small blood panel on him and found that he was mildly anemic (had low red blood cell count). Before I adopted him, Syd had been hospitalized for a disease called immune mediated hemolytic anemia (IMHA for short), where the body destroys its own red blood cells because of a dysfunctional immune system. Because this is an immune system disease, it cannot be cured, but Syd’s disease had been in remission for years. Could he be sick again because this disease was recurring?
I didn’t think so. His anemia was mild and most dogs with IMHA have a moderate to severe anemia. Looking at a slide of his blood under a microscope, I could see the red blood cells were decreased but structurally normal. Typically with IMHA the cells change shape and appear like a sphere, which is called a spherocyte. I didn’t see spherocytes on the slide.
We did more bloodwork which showed normal kidney values and electrolytes. However, his liver enzyme values were too high for the machine to read. This indicates severe elevations.
I remember looking at that bloodwork, and having to turn my worried pet owner mind off and turn on my clinician mind. I thought, “If I were looking at these values of mild anemia and liver enzyme elevations for another dog, not Syd, what would I be worried about?” The immediate answer was a tumor in the liver that was bleeding, which would mean liver cancer.
So the next step would be an abdominal ultrasound, to evaluate the organs in the abdomen for structural abnormalities. I watched as our radiologist revealed multiple masses in the liver, which meant there was no surgical option for this. I started to cry, and my caring co-workers told me how sorry they were. I was sad, but at the same time, I was glad that my diagnostic skills and knowledge had let me figure out what was wrong with Syd quickly, with a minimum of diagnostics for him to go through.
Since Syd was stable and feeling better (the previous episode of a liver mass bleeding appeared resolved on the ultrasound), I took him home and we spent the next few days doing all of Syd’s favorite things. This included walks to his favorite sniff spots and a pork chop for dinner (which I don’t even cook for myself). I had a vet from an in-home euthanasia service come to my house, and had Syd put to sleep. It was peaceful, and the other dogs were present so they were aware of what was going on.
So in short, there are many specialties within veterinary medicine, with internal medicine dealing with a multitude of disease processes. It involves critical thinking and problem solving skills, which I have even used to figure out the cause of symptoms in thousands of dogs and cats, including my own. Next week, we will discuss how I personally decided to become a veterinarian that specialized in internal medicine (also known as why would anyone want to do this?).
Thanks for reading, and until next time.
-SG