All Complications Great and Small

It was a good book, but I think it fell short of my expectations after seeing on the cover that it was a National Book of the Year Finalist. The beginning was great, the end really had me turning the pages to see if the case was a zebra or a horse, but the middle seemed to simply contain filler material: Friday the 13th?, rare and idiopathic cases? I guess to me they didn't really fit the title of the book.

The topics you have brought up for discussion have been interesting to consider from the viewpoint of a veterinarian, especially the idea of death panels and "doctorly manipulation".
The first several months that I was in practice I kept a tally of all of the animals that I euthanized, kind of like a fighter pilot might keep a running tally of the enemy planes he shot down. I know that might sound bizarre or morbid, but I guess that was my crazy way of dealing with a very emotionally difficult part of the profession. I have a friend who wanted to be a veterinarian, but she couldn't handle the idea of "putting an animal to sleep." She is now a human anesthesiologist. Ah, the irony.
Related to dealing with euthanasia is the art of "doctorly manipulation." It is amazing how attached people can become to their pets, and yet how removed they can be of the reality of animal suffering. I believe it is often a case of denial. Deep down they know that their cat that is in terminal renal failure is wasting away and is suffering because of it, but they dread letting go of what is more a companion than a pet. And so it is the veterinarian's responsibility to open the eyes of the client. It is a very difficult dance of tactful discussion. Just as difficult are the conversations where there is a treatment available for a patient, but the client is not able to afford the treatment.

On the topic of misdiagnosis and inexperienced physician, I feel that has my name written all over it. There are internships and residencies available to veterinarians, and it is becoming more common for graduating a graduating veterinarian to pursue some area of specialization, but there are still many who go right out on their own after getting their diploma. Such was my route. I remember my first day on the job, I had passed my board exams, but my license had not yet arrived in the mail. I showed up to work a little early in order to make a good impression and make a few preparations for the day. None of the other veterinarians were there yet, so when one of the employees brought in her cat that had been attacked by a dog just before leaving for work, it was to me that she handed the animal. It is hard to put into words the feeling of inadequacy as she looked to me as THE veterinarian that would save her cat. Fortunately it wasn't too bad. I placed an IV catheter help stabilize the animal, and we cleaned up some of its wounds as we waited for the other doctors to show up for the day.
There were other moments where I didn't feel completely up to the task, but I did my best. With difficult cases, referral to a specialist in a neighboring city, wasn't much of an option because of financial restrictions or because of the distance to the specialist. I would sometimes purposefully leave my pen at my desk, so that when I was in the exam room and had little clue as to what I was dealing with, I would go to make a note in the patient's record and then tell the client, "Just a moment, I need to go get my pen," allowing me a couple of minutes to quickly look through one of the medical texts in the office. Another "trick" that I picked up in vet school: one of my professors was faced with a sick cow that required an operation that he had been taught, but had never performed. Just before he began the client asked, "Have you done this kinda thing before?" To which the vet replied, "Oh, I've done a number of them." After relating that story to us during a lecture, the professor grinned and said, "Zero is a number."
I surprised me how forgiving clients could be about my lack of experience. I believe that they understood the challenge in diagnosing a case where the patient can't talk and the resources are limited. I don't feel too much shame in admitting, "I don't know," because most clients don't expect the vet to know everything about every species of animal. Sometimes we have to figure it out as we go. There's a reason we call it "practicing medicine."

Wow, I can't believe how much I have rambled on here. Just one quote from the book before I end this post.
"Conscious learning becomes unconscious knowledge, and you cannot say precisely how." pg 21