I read an article by veterinarian Dr. David Ramey a few days ago that I found very interesting. His bottom line in the article was that sometimes the best thing you can do for your horse is nothing. Obviously Dr. Ramey isn't advocating for ignoring a horse that isn't 100% perfect, he is simply saying that sometimes spending lots of money getting to an exact diagnosis isn't going to change anything (and of course sometimes it will change things which is why you should always work with your veterinarian). We've seen this scenario ourselves a few times with our residents. You can find Dr. Ramey's original article here.
I ran across a thought provoking article in the November, 2014 edition of the human medical journal, Pediatrics.
ASIDE: Yes, I have other things to do.
The article is called, “Overdiagnosis: How our compulsion for diagnosis may be harming our children.” You can read about the whole thing, if you are so-inclined, if you CLICK HERE (it’s free). I think that overdiagnosis is a growing problem with horse medicine, and it’s mentioned more and more frequently in human medicine. Otherwise stated, just because a doctor can make – or try to make – a diagnosis doesn’t mean that a diagnosis is always necessary. Here’s what got me thinking.
The parallels between pediatric medicine and veterinary medicine – in this case, equine medicine, of course – are pretty obvious. For one, you probably already know someone who thinks of his or her horse as if it were his child (WARNING: It could be you). But there really are a lot of parallels. Here are just a few.
Horses rely on us to make important medical decisions for them
Horses don’t necessarily like their doctors
Horses don’t talk – which is actually something of a blessing – so veterinarians have to make diagnoses based on observation and testing
Parents can get very anxious
Kids often have colorful blankets
Anyway, much like the responsibilities that parents have for their children, it’s the responsibility, concern, and caring for a horse by its owner that drives most of the decisions that are made on their behalf.
Now, before we get any farther, I want to go on record that I am all for trying to come up with a diagnosis when a horse has a problem. It’s probably pretty obvious to say this, but it’s a lot easier to treat something when you know what that something is. That said, coming up with an exact diagnosis isn’t always the easiest thing to do, and – here’s where it ties into the article – it’s not always necessary.
Sometimes, no doubt, a precise diagnosis is important. Say your horse has a case of colic (I hope it never happens). An abdominal ultrasound in a horse with colic is usually very accurate at helping to make the decision of whether or not a horse needs surgery. Abdominal ultrasound can, on the one hand, save a horse from surgery, or, on the other, indicate the surgery is immediately needed. Here, a quick, reliable, precise diagnosis is a really good thing.
But sometimes a precise diagnosis isn’t really needed. Say a 20 year old horse has osteoarthritis of the pastern – the common name for that condition is “ringbone,” so-called because of the “ring” of bone that forms around the pastern. In many cases, it’s quite obvious – you can see it from across the barn aisle, if you know what you’re looking for. And it’s a condition that shows up quite obviously on X-rays, too. But in some cases, taking X-rays, while it helps confirm a diagnosis, just adds an unnecessary layer of expense, because the X-rays don’t really change what you’re doing to do anyway.
So, you see, “overdiagnosis” describes a situation when an abnormality is found, but detection of that abnormality doesn’t actually benefit the patient. In equine medicine, veterinarians have added a lot of new technology to help make diagnoses – and a lot of new treatments, too – to try to help resolve various conditions. But, as our ability to make diagnoses increases, it doesn’t always benefit the horse, or the owner. In fact, trying really hard to always come up with a diagnosis can even cause harm.
What harms? Let’s look at three, from the Pediatrics article.
1. Physical Effects. While direct harm from diagnostic testing isn’t a big problem in horses – that is, severe complications aren’t that common – they do occur. So, for example, if you want to get an MRI for your horse, he’ll often have to undergo general anesthesia. That’s a risk to the horse, even though it’s not such a big risk that you would never want to do it. But one does have to weigh the risks and benefits of any procedure. It’s OK for a procedure to carry some risk, but you want the benefit to outweigh the risk. Overdiagnosis exposes horses to additional risk, but doesn’t always result in additional benefit to the horse or the horse owner.
2. Psychological Effects. A diagnosis can change a person’s perceptions of illness. That’s not always a good thing. The horse that has a little limp at the trot, but still happily goes out on the trail can become a “cripple” or a “problem” once he’s diagnosed with osteoarthritis. And once someone has a diagnosis to pursue, he or she can become bound and determined to “fix” it, and even become transfixed by worry.
For owners, the search for a diagnosis can be a big trap. All of a sudden, the horse that was doing just fine – maybe with a little bit of a pain reliever from time to time – all of a sudden needs supplements, injections, or any number of other treatments. The horse that is not performing to an owner’s expectations becomes a money pit as one test after another gets recommended. The horse that was a reliable companion now becomes a worry, and an expensive one, at that.
3. Financial Strain. Keeping horses costs money, and so does caring for them. I don’t think there’s any reason to spend extra money for services that may not really help your horse much in the long run. So, for example, if you have a horse that has been diagnosed with a tendon strain, ultrasound, while it is likely to be able to tell you exactly how serious the injury is, may not be all that important if you are willing to take a good amount of time, and do a controlled rehabilitation program. Similarly, if your horse has a problem in his foot, and he’s not too lame, you might be able to just wait the problem out. In both examples, you won’t know exactly what the problem is, but spending additional money on tests may not make much difference in how things turn out. It is possible to provide excellent care for your house and still keep something in your bank account. Medical cost containment is a much discussed issue in human medicine, but it’s rarely discussed – much less studied – in veterinary medicine. To be honest, I’m not even sure that it’s even much of a concern.
What are some of the possible reasons for overdiagnosis?
Defensiveness. Defensive medicine took hold in human medicine, primarily because there are legal consequences when doctors miss diagnoses. The thought was, it was better to waste money on needless tests for the many than to possibly miss some obscure diagnosis in the few: a CYA sort of thing. But the fact is that defensive medicine is demonstrably a waste of time and money, and those are two things that most people don’t have enough of.
Industry Influence. It’s just a fact that industry sponsorship influences professional and prescribing activities. This isn’t just “big pharma” – a veterinarian is influenced to do a test by the training and support he or she receives. A diagnostic test is only good if it’s likely to come up with a useful result, not just because its available.
Incentives. As I wrote in a recent article, I don’t think that most people who try to care for horses are in it for the money (CLICK HERE to read it). But the fact is that when you’ve bought an expensive piece of diagnostic equipment, it needs to get paid for. A hospital has a staff and supplies and utilities, etc., etc., and the bills have to get taken care of. Thus, there’s sometimes a financial incentive to overdiagnose. Otherwise stated, the more you do, the more you get paid.
There are incentives on the part of horse owners, too. A diagnosis is a very powerful psychological weapon.
Psyche – Many people are not very tolerant of uncertainty. These folks want to know, or at least they want a reason. And that’s all well and good, but there’s a cost for all that.
ASIDE: I remember reading, “All Creatures Great and Small,” way back before I got into veterinary school. In it, the author, James Herriot (pen name for the late James Alfred Wight – CLICK HERE to read all about him), was told by his employer to give every condition a name. “Call it McCluskey’s disease,” Herriot was told.
Giving something a name empowers the person doing the treatment to a certain degree. A diagnosis can be like a badge of honor. “My horse is insulin resistant,” someone might say about his or her overweight horse, having been told of a horse’s high insulin levels. Now armed with the diagnosis, the search can begin for chromium and cinnamon and low-starch feed and any number of (mostly worthless) supplements. But, in fact, a few simple management changes for an easy keeper can often take care of the problem, at a much lower cost, and without a precise diagnosis. You may not HAVE to know.
Look, I pursue a diagnosis for horse medical conditions just about every day. But I’ve also managed plenty of horses conservatively, assuring owners that the problem doesn’t seem to be too serious, and waiting with them for the successful resolution that usually comes with not-so-serious problems. There’s usually more than one way to go after any problem when it comes to diagnosis and treating horses. Equine medicine is all about – or it should be all about – working together to try to find out what’s best for the horse and the horse’s owner, not necessarily about running every last test.
BOTTOM LINE? You should ask about the benefit to be gained from a test before agreeing to pay for it.
The Pediatrics article challenges a lot of assumptions that veterinarians and horse owners have gotten used to making. For example, while everyone talks about how early detection and diagnosis is always a good idea, that’s not necessarily the case, because many times conditions improve on their own. The drive to find an “exact” diagnosis doesn’t necessarily improve the horse’s health or outcome.
Everyone needs to be humble, and work in the best interest of both the horse and the horse owner. More and more screening and diagnosing may not always be the best thing, for horse or human. And sometimes it’s not just your horse that’s being targeted by overdiagnosis – it’s also your wallet.
Sometimes the hardest thing to do for your horse is nothing. The hardest diagnosis to make – and sometimes, for owners to take – is “He’ll be fine, you don’t need to do anything else.”
(post written by Jason) Lately every time I turn on my computer it seems I come across another story and embedded discussion about contaminated equine feeds. There have been a couple incidents of monensin/lasalocid contamination in the past few months that seem to have opened up a veritable Pandora's box of worries among horse people, barn owners and others in the equine industry. As someone who spent the better part of twenty years in the feed industry before coming home to board horses and farm full time I hope my experiences in various parts of Canada and the US can bring some perspective to this discussion.
Should I be actively worried about this issue as it relates to my horse, my barn, etc.?
There are a lot of things that horse owners should probably worry about before they get concerned about monensin/lasalocid contamination in their feedstuffs.
Monensin/lasalocid contamination can happen any time anyone buys feed from a plant that handles the product and the great majority of plants DO handle these products or ones similar to it. That said, history and statistics suggest that the chances are extremely slim that any one horse or farm full of horses will ever see any feed contaminated with monensin/lasalocid. If the US horse herd is nine million head strong and if ten horses die every year from consuming monensin/lasalocid contaminated feed.....a big if.....the odds of any one horse dying in any given year from consuming monensin/lasalocid contaminated feed are 1:900,000. On this farm we're concerned about the possibility of monensin/lasalocid contamination but we don't spend much time actively worrying about it.
What do these products do ? Why are we feeding cattle antibiotics ?
Monensin and lasalocid are antibiotics only in the broadest sense. They are not given to cure illness; if your cow is sick these are not going to make it better. They don't work, and were never designed to work, against bacteria that cause disease. Rather these products, often called ionophores, work in the first stomach of a cow....an area called the rumen....and are designed to safely change rumen microflora to significantly improve feed efficiency.
I'm still worried about it. Are there things I can do to further reduce my risk ?
There are definitely things you can do that will make you feel better, though whether or not they statistically reduce your risk is another matter entirely, and too deep for this blog to dive into. There are a few mills out there that only make equine feeds and don't handle any medications not approved for inclusion in horse feeds. That will reduce your risk to almost zero (it is always possible that the wrong inputs could be delivered to any feed mill). In many cases these are small, family run facilities with limited capability of producing anything other than a mash feed.
Larger mills tend to offer more flexibility and also tend to offer a much wider product line, including perhaps toll milling custom formulas for bulk delivery to farms like ours. Here at Paradigm Farms I designed our feed to complement the soils and forage on this farm AND to be safe for consumption at relatively high rates because a lot of our retirees struggle with consuming hay and pasture. Because of how we feed (feedbags) and who I'm feeding (retired horses, often aged) in order to achieve adequate nutrient density we require our feed to be pelleted as a custom formula. Alas, every large pellet mill in our area that toll mills custom formulas carries and uses Rumensin , Bovatec or both in some of their cattle feeds so we mitigate the (very low) risk the best we can.
Our current sourcing partner has never had an issue that I'm aware of in their long milling history. In addition to being HAACP certified they regularly win national awards for quality control AND for the diligence of their truck fleet. Proper, computerized batch sequencing, frequent ingredient testing and rigorous cleaning of every part of the feed mill, bagging line and/or bulk trucks helps reduce the chances of cross contamination. All of this helps set my mind at ease but at the end of the day the only sure way to avoid monensin or lasalocid contamination is by sourcing feed from a facility that doesn't manufacture medicated cattle feed.
Why aren't there more large mills and national companies that manufacture horse feeds in facilities that don't manufacture medicated cattle feeds ?
I surmise it may have something to do with the small size of the equine market relative to cattle and other species in most parts of the country. A quick Google search suggests that there are roughly 5 million tons of horse feed manufactured annually in the US compared to roughly 50 million tons of cattle feed. This is out of a total feed market of between 150 and 200 million tons annually when all species are included. To me that suggests that the equine feed market is pretty small potatoes nationally.
I occasionally find corn kernels in my feed. Is that something to worry about ?
Most mills use a small amount of whole corn to flush ingredients out of augers and hidden corners between batches. The corn itself is not normally contaminated. Thus a few kernels of whole corn in a feed that otherwise looks as it typically does suggests to me that the system is probably working normally and the ingredients which may cause cross contamination are no longer in the system.
I'm going to end my post with the following thoughts. In today's America horses are mostly kept as pets and most people view killing one, by mistake or otherwise, far worse than killing any species that's primarily viewed as livestock. We board horses for our living and believe me we completely understand this. However, feed companies have been slow to figure this out and as a consequence these incidents are often poorly handled right from the start. Fortunately, most of the time for almost every horse in this country, statistics suggest that the likelihood of monensin/lasalocid contamination is very, very low.
Flyer, Lofty and Donneur
Asterik, Lotus and Silver
B-Rad taking his daily nap with Johnny
Homer, Ritchie and Baby were in a hurry to get somewhere
Silky and MyLight; grooming is hard with blankets on
Hemi licking snow off the gate. It snowed a little bit during the evening on Friday night so I rushed around taking a few "snow" pictures Saturday morning. I had to really hustle since all evidence of snow was gone by 9am.
Chance and Thomas
Ritchie and Homer
Apollo, Elfin and Rip
Grand and Moe
Silky and Norman; as you can see the snow was melting rapidly at this point
After enjoying what can only be described as truly perfect January weather the last few days things are about to change. After several days in a row in the mid to high 60's (20C) we wiped the smiles off the horses' faces today when we put sheets and blankets back on. Tomorrow evening is even bringing with it the possibility of a little bit of snow. This time the snow has at least been mentioned several times and middle Tennesseans are having a more normal response to the possibility of frozen precipitation.
As I was putting on blanket after blanket today I snapped at Jason several times. I will admit that chasing down runners and stuffing them into blankets was starting to make me a bit testy. After taking my frustration out on Jason for at least the nineteenth time I made an announcement. I told him I wasn't going to complain for 30 days and I wasn't going to subject him to my unparalleled snark and sarcasm. Since I had already put my foot in my mouth I decided to make sure I shoved it down my throat and followed this up by saying every time I did I was going to write it down. I've read a few articles about this and I guess they made enough of an impression on me that I made a spontaneous promise that I am now obliged to keep.
What the heck was I thinking
What idiot came up with this concept of not complaining anyway
This really sucks
What on earth made me commit to something that I don't have a snowball's chance of achieving
Needless to say you can see that I'm struggling. A lot. I am looking forward to seeing if I am able to achieve some personal growth over the next 30 days since it is overwhelmingly obvious to me that this is an area where I could use some serious improvement. Since I don't carry around a pen and paper I sat down to start my "complaint" journal once I was in the house this evening. After realizing I was going to be on probably page six of my notebook if I kept everything single spaced, I settled on one entry in my no complaining/snarking/sarcasm journal for the day: I desperately need to learn how to keep my mouth shut.
Given that it is supposed to be 40 degrees and raining all day tomorrow, I have about 27 loads of laundry to do and I'm also in the middle of 30 days of not eating any sugar or artificial sweeteners at all . . let's just say I'm expecting to have some lengthy entries into the no complaining/snarking/sarcasm journal tomorrow. Wish me luck.
Flyer waiting for breakfast
Johnny and Lighty were having some fun while waiting for breakfast
I can hardly believe I made it to 1,000 posts for any number of reasons, but when I published my last post I noticed that I had published 999 posts so far. And now with this post I have made it to 1,000. Who would've thunk it? I realize 1,000 posts is nothing for some people, but given that I make time for this around my "real" and very much more than full time job I'm pleasantly surprised I made it to 1,000.
I think the thing that surprises me the most with this blog is that a few people actually read it! At times Jason and I have some interesting things going on around the farm, other times not so much. I will admit I am also surprised that I have managed to maintain a blog for almost seven years. Has this blog really been around for almost seven years? How on earth did that happen and where did the time go?!
Without question the best part about this blog is some of the really neat people I have met because of it. The internet really does make the world a smaller place, and it also gives you lots of people to visit when you are traveling! Others I have not met in "real life" yet I have interacted with them so much it seems as if I have.
Jason asked me if I had another 1,000 posts in me. I didn't have an answer for him. I'm going to give it my best shot and we'll see where the blogging journey takes us. Thank you for reading, for helping me manage to post 1,000 blog posts, and most of all for being part of our little corner of the world!
Hesse, Walden and Remmy
Rubrico and Oskar
Kennedy, River, Largo and Rocky hanging out in the sunshine
Lofty, Donneur and Romeo
Murphy, Taco and Johnny
Traveller, Cuffie and Maisie
World's Cutest Fainting goats basking in the sun
Gibson and Cocomo
Homer and Moe
Asterik and George doing some early morning grazing