? Building a good relationship with your vet

[learjetta]

I don't know if there's a discussion anywhere on here about building a good rapport with your vet, but as Boris is newly diagnosed, and was diagnosed while we were RVing in FL, he has seen 3 different vets for this issue. As a result, I've gotten a lot of exposure on different vet methods/knowledge levels regarding feline diabetes.

For example, the emergency vet we worked with (who got Boris's DKA and pancreatitis well in hand, as well as administered fast acting insulin in the ICU) was a traveling vet who was working on contract in FL for the winter. Her knowledge/views seemed much more in line with what I have been reading here. She didn't prescribe a long term insulin, but mentioned to us that glargine would be the best fit for Boris as a first insulin, and recommended a low carb diet.

The emergency vet hospital was only open on weekends and evening, so Monday morning following Boris's initial dx we moved him to a regular animal hospital. They are the ones who prescribed Lantus at 2u BID to start. The glucose curve they performed a week after he came home, IMO, was spoiled a bit by the fact that I misunderstood how much food to send with Boris, and he was overfed the Purina DM dry. When I inquired about how that affects his BG, they told me it wouldn't, despite the fact he ate 2x the prescribed amount for the day in one meal. That's when they upped him to 3u.

Now that we are back in PA we are working with a new vet (loved my vet of many years, but it was too far to travel often with a sick cat, and the practice wasn't the same as the vet is transitioning the practice to his daughter), and they are really pushing only testing once between +4 - 6, and not more often. And yesterday during Boris's bounce, they told me to up his dose from 2u to 3u for his PM dose. I pushed back against this, and I'm glad I did as Boris's numbers fell sharply overnight.

I called the vet this afternoon to report the overnight numbers (also emailed a link to his SS), and the vet tech called me back a little while ago to verify the numbers. She said she was going to speak with the vet about his dosage going forward, but before hanging up admonished me to only test once in the +4-6 window. It really seems like they do NOT want me testing Boris more often. However, after yesterday's bounce, I can only say that will never be the case because I don't believe it gives enough context as to what is happening in his body. I realize we only dose using the nadir, but I now firmly believe more data is better.

UGH. The vet tech just called back, and they told my they feel Boris experienced the somogyi effect, and that we should keep him at 2u for the next 2 weeks, and to stop testing other than the occasional nadir (once or twice a WEEK). She kind of suggested that my changing his dosage from 1u to 2u and now down to 1.75u is causing more instability in his numbers. I had to remind her that they took him from 3u to 1u, then 2u a week later, and that yesterday they wanted me to increase his dosage to 3u again when his numbers went up. I also explained how spot checking would NOT have identified the bounce he was experiencing, and that he might have gone hypoglycemic last night had we not been tracking his sharp downturn and had given him 3u instead of 2u. They're adamant that we should do what they're asking and stop testing so much.

This plus the whole "calibration of my BG meter" issue, and I'm getting nervous that this vet isn't the right choice for us.

I guess I'm looking for input - how did you handle working with your vet once you decided use the FDMB protocols? Did you bring them around to your way of thinking, or did you have to find a new vet? Did you have a lot of push back? I promise I'm not just here to whine... I need some ideas on how to salvage the relationship with this vet to get Boris at least stable before we go away on 6/8.

 

[AmandaE]

You aren't alone! this is a struggle all of us have faced at one time or another. In this case you can tell that your vet is very clearly wrong, especially about how often to test just based on last nights experience alone. Your vet may be very talented at many other areas of health but it is clear that they are unfamiliar with feline diabetes.

They are the ones who prescribed Lantus at 2u BID to start. The glucose curve they performed a week after he came home, IMO, was spoiled a bit by the fact that I misunderstood how much food to send with Boris, and he was overfed the Purina DM dry. When I inquired about how that affects his BG, they told me it wouldn't, despite the fact he ate 2x the prescribed amount for the day in one meal. That's when they upped him to 3u.

There are a few things that would have affected Boris' BG levels at the vet, the food, but also the stress. Vet visits are very stressful for cats - when cats get stressed their BG levels can soar to the moon. Honestly, your vet should have known that at least. I think 2u is a high starting dose for a newly diagnosed cat as well. BG curves that are done at home are in a comfortable non stressful environment so any curve you do will likely be more accurate / representative of Boris' true response to insulin than at the vet.

3u could have had very severe consequences last night. These are the types of experiences which make it easier to follow the dosage protocols found on FDMB over the advice of your vet.

they are really pushing only testing once between +4 - 6, and not more often. And yesterday during Boris's bounce, they told me to up his dose from 2u to 3u for his PM dose. I pushed back against this, and I'm glad I did as Boris's numbers fell sharply overnight.

I called the vet this afternoon to report the overnight numbers (also emailed a link to his SS), and the vet tech called me back a little while ago to verify the numbers. She said she was going to speak with the vet about his dosage going forward, but before hanging up admonished me to only test once in the +4-6 window. It really seems like they do NOT want me testing Boris more often. However, after yesterday's bounce, I can only say that will never be the case because I don't believe it gives enough context as to what is happening in his body. I realize we only dose using the nadir, but I now firmly believe more data is better.

On this I say... what difference does it make to your vet how many tests that you get in a day? Seriously... From last night alone you know that one test a day is not enough. At minimum you should be trying to get 3 BG readings a day: AMPS, PMPS, and bedtime. More if possible. The fact that your vet doesn't understand the importance of knowing your cat's BG level before administering a dose of insulin is kind of shocking frankly. There are BG levels that are simply too low to dose.

Also: more data IS better!

UGH. The vet tech just called back, and they told my they feel Boris experienced the somogyi effect, and that we should keep him at 2u for the next 2 weeks, and to stop testing other than the occasional nadir (once or twice a WEEK). She kind of suggested that my changing his dosage from 1u to 2u and now down to 1.75u is causing more instability in his numbers. I had to remind her that they took him from 3u to 1u, then 2u a week later, and that yesterday they wanted me to increase his dosage to 3u again when his numbers went up. I also explained how spot checking would NOT have identified the bounce he was experiencing, and that he might have gone hypoglycemic last night had we not been tracking his sharp downturn and had given him 3u instead of 2u. They're adamant that we should do what they're asking and stop testing so much.

I don't know much about the somogyi effect but there is some reference material around on the forum on it... you should read it in case that's true but it looked like a fairly straight forward bounce yesterday. Boris probably dipped two nights ago causing yesterdays bounce, just like he did last night. This shows that Boris clears bounces quickly, which is nice.

Your vet is very inconsistent with their advice, maybe you could show them some of the source material behind the dosing methods we use here, since you typically like them and it is a pain to switch vets. If they're open minded that shows that maybe your rapport can improve, if not you may want to find a more open minded vet, at least for issues associated with Diabetes.

I don't have the experience to offer you dosage advice but I can tell you what I personally would do in your situation: I would make the tough decision - am I going to follow my vets advice or the dosing protocols found on the board? Based on your vet's inconsistencies I would definitely choose using a protocol from the board and stick with 1.75u for the next week unless a reduction is earned (BG <90) for sure don't go up to 3u. I do want to encourage you to do some research using the source material on the board and some across the internet so that you can be confident that you have made the best decision for Boris and yourself, whatever you choose to do .

Forgive me if I come off a little intense here but I was in a very similar situation to you in March, and I am so happy with my choices. If I hadn't followed information that I'd found here Mowgli would still be on 5u of Caninsulin and I wouldn't be home testing.

Whatever you choose to do: Good luck! I think you will make the best decision for you and Boris

 

[learjetta]

On this I say... what difference does it make to your vet how many tests that you get in a day? Seriously...

All I can come up with is that maybe this vet has had bad outcomes from ill informed owners who took matters into their own hands while home testing? Ill informed, you can end up doing way more harm than good.

Based on your vet's inconsistencies I would definitely choose using a protocol from the board and stick with 1.75u for the next week unless a reduction is earned (BG <90) for sure don't go up to 3u.

Yeah, won't be doing 3u unless his numbers warrant it. And they clearly didn't last night! Last night was very educational, and it taught me that SLGS is the safer method, no matter what.

Your vet is very inconsistent with their advice, maybe you could show them some of the source material behind the dosing methods we use here, since you typically like them and it is a pain to switch vets. If they're open minded that shows that maybe your rapport can improve, if not you may want to find a more open minded vet, at least for issues associated with Diabetes.

Unfortunately, I don't think I have a lot of great choices here - I'm pretty picky about my vets. And if I'm being honest, we have plans to rent out our house, move into our RV and travel a lot more than we've been traveling, so the reality is that we need to be able to triage this on our own, or we could be trying a lot of new vets all over the country! I need to work with an approach I believe in, and I don't trust this vet to manage his diabetes well. Maybe they're open to learning, and I'm willing to try. But my guess, from the push back I've received so far, is that they won't want to do it any other way. Who knows... I may be pleasantly surprised, right?

I do want to encourage you to do some research using the source material on the board and some across the internet so that you can be confident that you have made the best decision for Boris and yourself, whatever you choose to do .

My life for the next few weeks:

 

[Tracey&Jones (GA)]

You pose a very good question.

In my case, I loved my vet but we also did the 2u, 3u and spot checking. Did that from DX till I found this board and started lurking. Then I joined and started to follow the advice. I was fortunate in that my vet and I had a good relationship and she understood that I was willing to go the whole nine yards. In the end, I let her do her do the tests she wanted and I handled all the dose changes. She couldn't argue with the results. Being in Canada I was lucky as well, I didn't need a script to get the insulin for Jones, so I didn't really depend on her for that either.

IMHO - I would never knowingly put my cat at risk, so I believe testing is required. For me, I got 4 tests a day. AMPS, PMPS, and two mid-cycle. During the week my husband was willing to get 1 test in during the day while I was at work and I did the before bed test at night. To me that is the min required to see how they are doing. On days off I would fill in the sheet with other tests. I did a curve rarely after awhile except if Jones was throwing me some weird numbers and I wanted some data. More data is never wrong IMHO.

It has been questioned if the somogyi effect is real in cats or if it really has been scientifically proven. To me, when I read articles on it, it seems to refer to too much insulin causing hypoglycemic numbers which cause the body to release stored glucose to save the body. A bounce is different, in that a "perceived" low by the body will cause the same reaction of released stored glucose even though the BG is nowhere near a hypoglycemic state. In case one, for sure you reduce the dose, in the second you may not depending on the BG's, how low was the low and what all the other tests are telling you.

Now for your question, since this is a new vet and if you want to build a relationship, I would try to bring information for them to explain why you are doing what you are doing. See if you can get some compromise working for. No relationship works if it is all one sided.

Some suggestions you can take or leave:

1. Do your testing but have a vet spreadsheet and your own spreadsheet. Some people here have done that, I just gave my real one. She was actually quite impressed with it. I personally wouldn't want to lie to the vet as FD may impact other health issues.
2. Do your research. Bring the articles you find to your vet to read. There are some references here in the yellow stickies as well that may help in this regard.
3. Ask them why they are insisting on a certain item. Is there a reason for their concern that you can address or research to back up your opinion?
4. Ask them about their prior experience with FD patients, using Lantus etc. What kind of results did they get? Did any of their patience go into remission? Lots of kitties have gone into remission here using the methods used.
5. Ask them what is their aim for Boris? Is it remission, tight control?
6. Tell them that you are a hands on owner! You know Oscar best and feel you need to have input into his care.

If they are not willing to be a partner in Oscar's care, then maybe finding a new vet is required.

BTW - I would of dropped to 1.75u as well and under SGLS was the correct move. I would hold that dose until Oscar proves he needs another reduction or the reduction has failed as per SLGS.

 

[JoyBee&Ravan]

Boris went down to 59 last night. On 2 units. And you're giving him some dry food. I've seen cats here go into remission just by stopping all dry food. It is digested differently than wet food & will raise their BG.

I'd be very careful & continue to test him especially at night. A lot of cats go the lowest then.

You indicated you'll be doing some reading. If you have time please read Dr. Pierson's ( It's on the Main Forum Feline health)
Info Dry Food - PLEASE consider more than just carbohydrate content

You're at the RIGHT place to get expert advice. Ask lots of questions. Everyone here wants to help you to help Boris!

Sad to say but I've been here 14 months & the majority of vets do NOT know as much about diabetes as the women & men here who have been dealing with it for many years every day.

Best of Luck to you & Boris. The more you learn the easier it will be! Is it easy NO! Is it worth it Absolutely!

 

[tiffmaxee]

As someone who wasn’t going to test my timid cat, I became a testaholic when I saw a spot check by my vet at 60 at +5. I would always test at AMOS, PMPS, and +3. Max Gave me clues at +2.5-3. I wasn’t working so I could guide his cycles with food. If I were working I would not have kept him as tightly controlled once I realized he wasn’t going OTJ. My very experienced vet convinced me to test. Once I did I sent him Max’s ss every couple of weeks and got dosing guidance here. My Etta’s fine with that and showedMax’s ss to students that spent a week with him asthey made their way through vet school. My vet stopped suggesting dose changes and handled all his other issues. Max was a complicated boy. So my suggestion is to use a vet you respect to take care of everything but diabetes even if that means as suggested you keep a separate ss just for the vet.

 

[learjetta]

You indicated you'll be doing some reading. If you have time please read Dr. Pierson's ( It's on the Main Forum Feline health)
Info Dry Food - PLEASE consider more than just carbohydrate content

I read that the other night, and I agree, dry food needs to go. We are leaving for a 5 night cruise on 6/8 (and getting married on the cruise), so it’s not something I’m ready to tackle before we leave... I need him to be stable for the pet sitter who will only come in 2x a day. Plus the future husband is convinced they need the dry food for dental health, and I need to find either a replacement or evidence showing otherwise.

I’m definitely ready to get rid of the dry food though!

I’m also adding at least a bedtime test to our AMPS, +4 a 6, and PMPS so I can see how he’s trending towards the night (245 tonight) Of course I’m still learning, but I’m keeping his ss up to date and paying attention!

@Tracey&Jones (GA) , those are some great suggestions! I’ll spend some spare time on that!

@tiffmaxee thats ideally the relationship I want to have with a vet. Hopefully this vet will be open to it!

Thanks all!!!

 

[JoyBee&Ravan]

future husband is convinced they need the dry food for dental health,

Ask him to read this article. https://feline-nutrition.org/answers/answers-what-dry-food-does-to-your-cats-teeth

Congratulations on the future wedding!

 

[Bron and Sheba (GA)]

It is sad to say but there are many vets who know very little about feline diabetes and they have not kept up to date with the latest treatments for FD. It is not like canine diabetes, which vets seem to know more about. They do have many animals and different diseases within these animal group to manage and treat.. I admire vets and their work but with FD I think they need more up to date education.
We have many people who arrive here like you, who have been told not to test at all, or only test infrequently. Only yesterday someone new here had a kitty who dropped very low and if she was not testing and had given the insulin, the kitty would have dropped to dangerously low levels.
I would test before every shot and during the cycle as well. What you do at home is your business, Boris is your cat and you are his advocate. You need a vet who will work WITH you as part of 'team Boris'.
The people here are very knowledgeable and supportive.
The best thing you can do is educate yourself about FD and follow your instincts. Remember you pay the bills and your vet works for you, not the other way around.
It's great you are home testing.

 

[carfurby (GA)]

Unfortunately most vets get very little training on dealing with feline diabetes. A lot of people here take the "nod and smile" approach when dealing with the vet. They listen to what the vet suggests for treating FD (and nod and smile) and then do what they need to in order to take care of their cat. It's sad that some vets won't work with people who are willing to do what is needed and home test and monitor their cat. I hope your vet will be willing to listen and see the importance of home testing and making sure the numbers aren't too low. Another thing that is confusing to some vets is that Lantus is a different type of insulin than what they may have learned about where dosing is based on the nadir. Hopefully you can show your vet some research and Boris's SS and they will work with you.

 

[Justin & Sebastian]

Just my two cents, I don't trust anything my vets tell me anymore. Two vets at the animal hospital gave me bogus information, one saying the ketones weren't a concern, the other saying Vetsulin would be better than Lantus, and both saying DM dry was fine. 3 different vets at my local vet have just generally been clueless on proper treatment for diabetes, one saying any number below 200 was too low, the rest just failing to diagnosis other issues properly based on test results and just generally being more geared towards treating symptoms with fluids and anti-nausea than actually treating the cause.

What I do now is simply use the vets for testing purposes. I mention symptoms on these forums first to get an idea of what tests might be needed, then go to the vet and see what they suggest, then use my judgement between the two on what tests to actually get, usually favoring what I hear here. When the test results come back, the vets occasionally have some treatment ideas and suggestions for additional tests, but I always bring the results here first and additionally do my own independent research.

Case example, Sebastian has been having issues with fatigue and weight loss for months now, bouts of nausea, hairballs, and the past few weeks diarrhea. First trip to the vet for it yielded nothing, no suggestions of cause or suggestions of tests and some token symptom treatment. Second trip they ran a GI panel ($450) which came back that his B-12 was low, so they prescribed that, which was good since I wouldn't have been able to diagnose that on my own. But then they suggested it might be IBD and wanted to do a urine culture to check for UTI. Pointless since he's had no trouble peeing. They further suggest they'd need to do an ultrasound to confirm IBD ($500). I researched IBD and found that not only does the ultrasound not confirm it, the real test is either an endoscopy or biopsy, which are invasive surgical procedures that I'm sure would have cost even more. However, in my research I found the symptoms of IBD and they fit Sebastian to a T, so I'm just assuming that's what it is and proceeding with treatment (raw food diet & probiotics) and not wasting any more money on tests. I might be wrong and then we'll have to go back but it's more likely I'm not and he has IBD and I just saved myself another $1k+.

 

[Sienne and Gabby (GA)]

My reaction to a vet that seems behind the times is to kill them with research -- published research from veterinary journals. If the vet pooh-poohs the articles, ask the vet to find empirically based research supporting his or her point of view. I generally adopt a, "I came across these articles and wanted to know what you thought of them." attitude. With my vet, when I handed her the TR protocol article, she asked to read it and get back to me and then proceeded to convert the entire vet practice to its use. Of course, it depends on the vet. Some how, practitioners seem to forget that many of us have access to veterinary and medical libraries and know how to read.

For example, I've uploaded two articles. One deals with Somogyi. Frankly, there is zero research that supports the existence of chronic Somogyi rebound in cats prescribed a long-acting insulin such as Lantus. Frankly, the original research was done in 1938 on a very small sample of humans and subsequent research could not support its existence. It's what amounts to an urban myth.

The other article deals with home testing.

 

[Sienne and Gabby (GA)]

I want to take issue with the point made by @Justin & Sebastian about using vets for tests only. I have a cat with IBD and went back and forth over a surgical biopsy. The issue with IBD is that the differential diagnosis is IBD vs lymphoma. The treatments differ. Steroids are prescribed to get IBD under control and they may mask lymphoma. Lymphoma requires a chemotherapy drug. Treatment for IBD doesn't just require raw food and probiotics -- it involves novel proteins whether they be a raw diet or processed food.

Vets are not perfect. They have the unenviable task of trying to know everything about every species of animal (unless you go to a cat only vet). It would be the same if you saw a family practice MD who never sent you to a specialist. With human medicine, there is a much greater tendency to go to a specialist but it's always human medicine. Not so with animals -- vets go from treating a cat to a dog to a snake to a gerbil. To me, the issue is one of attitude. Does the vet want to work with you or have you do what you're told without questioning? I don't accept that attitude with my physicians nor do I find it acceptable with my vet.

 

[learjetta]

Ask him to read this article. https://feline-nutrition.org/answers/answers-what-dry-food-does-to-your-cats-teeth

Interesting! I'll share that with him.

Congratulations on the future wedding!

Thanks! It's coming fast now!!!

You need a vet who will work WITH you as part of 'team Boris'.

That's exactly what I'm looking for, somebody who will work with us instead!

Another thing that is confusing to some vets is that Lantus is a different type of insulin than what they may have learned about where dosing is based on the nadir.

I think this vet understands that dosing Lantus is different, but they only want infrequent nadir values... Nothing else.

My reaction to a vet that seems behind the times is to kill them with research -- published research from veterinary journals. If the vet pooh-poohs the articles, ask the vet to find empirically based research supporting his or her point of view. I generally adopt a, "I came across these articles and wanted to know what you thought of them." attitude. With my vet, when I handed her the TR protocol article, she asked to read it and get back to me and then proceeded to convert the entire vet practice to its use. Of course, it depends on the vet. Some how, practitioners seem to forget that many of us have access to veterinary and medical libraries and know how to read.

My problem is that I can see both sides of it. I understand why the vet would want the CG to avoid self diagnosing, because it can lead to bad outcomes. I think it can be incredibly painful for a vet to see an animal who is a patient of theirs suffer needlessly, or die, because a CG thought they knew better than the vet. OTOH, as somebody who works in a technical field, I also understand how important continuing education is, or you become obsolete. I think many vets don't do that and just skate along on what they already know. Sometimes somebody like us comes along who insists they get up to date on the latest treatment, but mostly people accept what the vet says without question.

For example, I've uploaded two articles

I'll read those sometime today. Thanks!!!

Vets are not perfect. They have the unenviable task of trying to know everything about every species of animal (unless you go to a cat only vet).

Agreed! That's why I'm trying not to be too hard on the vet (despite my frustration!). I want to find somebody who is willing to work with me, who is able to say, "I don't know everything about every animal, so please bring me research and help me learn." But they're also human, and it can be hard for them to admit that they're fallible.

To me, the issue is one of attitude. Does the vet want to work with you or have you do what you're told without questioning? I don't accept that attitude with my physicians nor do I find it acceptable with my vet.

Exactly this. Unfortunately, that's the attitude I'm getting from the vet tech. At our initial visit the vet seemed more open to my challenging things like the need for a prescription diet, so maybe it's just the tech. Unfortunately, I've left doctors that I really liked because their nursing/office staff, so if it turns out the vet tech is problematic, it still makes it difficult to use this practice.