One of the more interesting things about third-year is that most of our exam questions test us on subject knowledge as well as problem-solving skills. For example, it’s not enough to recognize that an unthrifty 4-month-old puppy that acts oddly after eating a high-protein meal and has high liver enzymes and high bile acids might have a congenital portosystemic shunt. (This disease occurs when an extra blood vessel allows blood to bypass the liver, resulting in liver atrophy and poor liver function.) The professors encourage us to think beyond the likely diagnosis, by asking questions about which tests to run and which treatment strategies to use.
I was surprised to learn that you can find the shunting vessels outside the liver using ultrasound, as long as you know what the normal anatomy looks like. If you’re unsure or trying to find a shunting vessel inside the liver, you can use a CT scan to get a better look. Our professor showed us a picture of the 3D reconstruction of one particularly long and twisty shunting vessel—it almost made a full circle as it stretched from the portal vein to the caudal vena cava.
Once we have identified the puppy’s problem, we have to figure out the best way to treat it. Although surgery is pretty invasive, it gives the best prognosis—dogs that have their portosystemic shunt surgically closed before 6 months of age will likely have a normal lifespan and regain good liver function. Although surgery is an obvious option, in this case, it’s often really hard to weigh the benefits and disadvantages of different treatments. For example, surgery can be curative for many diseases, but is expensive and has some mortality risk. Medications may not completely control the disease, and some drugs can have serious side effects. Changes to the diet are often a helpful addition to treatment and can be crucial to controlling diseases like copper-induced liver disease or bladder stones.
Being responsible for understanding the disease, tests, and treatment options means that our third-year grades tend to drop a bit…But by this point, we’re all much better at accepting that our grades don’t matter. It’s our ability to think like doctors that counts.