Monday, July 26, 2010

VCA VRA History

Steinberg and Cowell



A CONVERGENCE of SORTS

A convergence is most commonly used in astronomical circles, when a series of unrelated events coincide in a unique manner. The seventies were host to a convergence of sorts that was to become Veterinary Referral Associates, Inc., one of the first referral-only veterinary hospitals in the world.

In 1971 Dr. Jacques Jenny died of cancer. Although many well-known veterinarians are associated with the term “pioneer”, the term truly applies to Dr. Jenny. He defined the biology of bone healing using intramedullary pins, Kuentscher nails, in fracture treatment and was the first to bring the compressive ASIF plating system to America and improved upon this system, teaching it to others for many years. He worked alongside human orthopedic surgeons and in the fifties and sixties carved out a place that was equal to his counter-parts in human medicine. He created many unique surgical treatments that he applied with equal skill to horses, dogs and cats. Dr. Jenny chaired the organizing committee for the college of veterinary surgeons and served as its first president.

1971 was also the year that Dr. Peter Ihrke graduated from veterinary school. Peter was destined to become a world famous veterinary dermatologist who has spent most of his career at the University of California in Davis. Upon graduation from Penn, Peter stayed on at Penn as an Associate in Dermatology under the tutelage of Dr. Bob Scwartzman. There were no formal training programs and although there were a few dozen internships, one could become an academic specialist, virtually the only kind of specialist at the time, without one.

1974 was the year that four young energetic veterinarians decided to try something completely new. Dr. Ken Cowell, an Auburn graduate, completed a veterinary internship at South Shore Animal Hospital. This hospital would later become VCA/South Shore in South Whalen, Massachusetts. Dr. Steve Steinberg, a University of Pennsylvania graduate, completed an internship at Henry Bergh Memorial Animal Hospital in New York City. Dr Anne Chiappella, a California native and Davis grad, completed an internship at The University of Pennsylvania. Dr. Clark Dickinson, a seasoned practitioner, was just looking for something new.

1974 was the year Peter Ihrke tried something new. At the request of local practitioners, he started coming to the Washington, DC area once per month to see dermatology cases. The local practitioners loved him and he was an immediate success.

Because of the tremendous legacy of Dr. Jenny, the University of Pennsylvania had established various avenues that would carry his name forward and hold it as a beacon for future generations. In 1974 the Veterinary School through the foresight of Dean Bob Marshak decided to try something new and adventurous, training programs for the teaching of young veterinarians heading into veterinary specialties. They called these programs “residencies” to mimic similar programs that had been the mainstay of training in human medicine. Clark Dickinson became the first Jacque Jenny Honorary Orthopedic Resident. At the same time Ken Cowell became the second orthopedic resident, Steve Steinberg the first neurology resident and Anne Chiapella the first internal medicine resident. Since there wasn’t an established program, these residents were in a kind of free-form adventure where they became best of friends and were supportive of each other. Because there weren’t established programs, these residents also worked alongside contemporaries in training programs who were called instructors, associates, fellows etc. The lines for education in specialties were poorly drawn.

All of the residencies were of two years duration and in 1976 Steinberg stayed on at Penn as an Associate Instructor, Cowell went on to a surgical practice, Chiapella stayed at Penn as an instructor in medicine and Dickinson went on to a private practice in New Jersey.

In 1976 some innovative and congenial veterinary practitioners formed a partnership and opened one of the first emergency hospitals in the country in Rockville, Maryland. Peter Ihrke worked at several of the partner’s practices on a once a month basis. Metropolitan Emergency Animal Clinic (MEAC) still thrives today.

Three of the MEAC vets determined that specialization could be the wave of the future. The emergency hospital was unused during the day and therefore would be a great place to have specialists. It should be understood; the emergency hospital and the idea of private practice specialization were virtually unheard of at that time in 1976.

In February of 1977, Dr. Dick Weitzman, Dr. Sandy Karn, and Dr. Suzanne Jenkins set up a meeting through Peter Ihrke with Steve Steinberg and Ken Cowell. Peter Ihrke had emphatically stated over and over that if Steinberg and Cowell, who had become best of friends, were serious about private specialty practice, the Washington, DC area was the best place for “instant success”.

What Steve Steinberg and Ken Cowell didn’t realize at the time was that they were so poor they would have a hard time recognizing failure. In 1976 each had made an annual salary of $7000. Steve Steinberg and Ken Cowell went to the First American Bank of Maryland with a business plan in March of 1977. It was the seventies and both were wearing suits and both were not wearing a single piece of clothing that they had not borrowed (see picture). Steve Steinberg shaved off his “afro” sized hair and removed his earring. They were soon to be businessmen. A loan officer at the bank, Jack Issacson, loved the idea and without collateral allowed the pair to borrow $13,000. They eventually had to borrow a total of $33,000 to get stated.

On October 1, 1977, H. Steven Steve Steinberg, V.M.D. and Kenneth R. Cowell, D.V.M., A Professional Corporation, was formed. The name was a dull mouthful and they were instantly known everywhere as “Steinberg & Cowell”.

On November 1, 1977 they opened their doors at MEAC and were an instant success. The first year they grossed $125,000 and they each received $ 17,000 in compensation. They were wealthy but only by their previous standards. They fortunately had made a pivotal decision, that they would keep all of their equipment separate from that of MEAC’s. Everything they owned went into cardboard boxes at night and was locked up in a closet including unhooking and wheeling the film processor into the closet so the emergency hospital could tank develop their films at night. A film processor in private practice was unheard of in those days. All of these supplies had to be wheeled out each morning. This allowed them to understand and control their own inventory, hard for neophytes, but a very valuable lesson.

Steinberg & Cowell were growing by leaps and bounds and it was hard to get the MEAC partners to realize that unless they could expand they would have to move on. Each of the partners had their own practices to run and didn’t really have the time to understand the specialist’s predicament.

In 1980, Steinberg was driving up what was a small two-lane road, Route 28( today a multi-lane highway). He passed one of the most unique structures in the county, the old Garrett Farmhouse and Barn. Mr. Garrett gave up farming when his wife died and sold a small 6-acre plot with the farmhouse and barn to Dr. Denham, a veterinarian. Dr. Danny Denham had come to the Washington area through the Army eight years previously. He had been stationed at Walter Reed Army Hospital and had turned the Garrett Barn into a veterinary hospital. Denham was leaning on the fence talking to a local large animal practitioner. Steinberg knew Denham through referrals and stopped to talk. When Steve Steinberg complained that Steinberg & Cowell was bursting at the seams Denham said, “Well, I’m moving to Oklahoma, so why don’t you buy my place.”

The move occurred in 1981 to what people refer to throughout the country as “The Barn”. Dr. Anne Chiapella was added as an internal medicine specialist and Dr. David Saylor was added soon after as the soft-tissue surgeon. Dr. Saylor is the current Medical Director and Dr. Chiapella has her own practice nearby in Virginia.

In 1984, Ken Cowell, after eight years, left veterinary medicine, truly at the top of his game, to try his hand at one of his many other interests. He has never returned to veterinary medicine. With the transition in ownership to Steve Steinberg, the hospital changed names to Veterinary Referral Associates, Inc. (VRA).

With the new name came a surge of new specialties many yet to have their own certifying college many yet to have been seen elsewhere. The practice had frequent national notoriety, with articles and stories appearing throughout the country. Many specialists in the US and Europe have spent time studying the hospital and in some cases training there. Dozens of famous figures have come through VRA’s doors and a change in administrations always marks a wave of new and old politicals changing addresses.

In 1995, being one of the largest and most progressive referral hospitals in the country, Steinberg was approached by five separate and unrelated groups to purchase VRA. For the first time Steve Steinberg stood back and wondered if this thing he built was really something that someone would want to buy.

In May of 1995 Dr. Bruce Ilgen and Mr. Bob Antin came to Gaithersburg and met with Steinberg for lunch. Because Steve Steinberg had heard the other pitches first and they were all the same he was unimpressed. One group flew Steinberg to Maine and made their offer in conjunction with laying out his future with their company. When Bob Antin heard of this, he called and said Steinberg had to come to Santa Monica (VCA’s home in those days) and see their operation. VCA owned 64 hospitals at the time, less than a half dozen east of the Mississippi. Steinberg flew to Santa Monica the day after his Maine trip.

Steve Steinberg and Bob Antin immediately connected and spent most of two days together, comparing notes, sharing stories, talking family.

February 1, 1996, VRA became VCA/VRA.

Tuesday, July 6, 2010

Veterinary Medicine: It's All in the Journey




I was blessed by a great beginning to my veterinary neurology career. I became hooked on the nuances of a vast, complex system that was an enigma to most, but a rather straight journey through every neuron and pathway that controlled an animal's body, envisioned and shared through the eyes of a great teacher, Dr. Skip Averill.

This journey, though, didn't solidify until I was exposed to a mentor who was truly in awe of what he didn't know and what at the time was unknowable. A mind that was able to avoid the pitfalls of oversimplification but with an efficiency of language on the edge of the sacred, he produced short concise sentences that avoided faithfully an unknown or unproven thought. This, my greatest teacher, mixed language skills and knowledge in a way that made those in his presence self-conscious of their own communications. This ability was lost on most and incomprehensible for many. In a setting, where too many were in awe of what they knew, this was a fresh way of projecting knowledge that was too unique for many to grasp. This was my second teacher Dr. Sheldon Steinberg (no relation to me).


The slide from studying and grasping the intricacies of what was known to the arena of appreciation of what wasn't known, ignited a passion in me to try to recognize the truth when available and feel the power of what wasn't understood on a continual basis. I have yet to put my arms around these topics with clear and efficient language but the groundwork for the thought processes is strongly in place. Every known becomes shrouded in the uncertain. Every diagnoses is challenged. Every truth is held up to the light, looking for that crack that shows its insides to be different than expected.

Many think that we in veterinary medicine are hamstrung by patients that can't convey by language the simplest of facts but this is a total misconception. Our history taking skills are well honed, our powers of observation must be strong, our hands must be determined, our senses on edge but ask any veterinary clinician if they miss verbal communication with their patients and they will invariably state that they hadn't even noticed it was missing.

The "toys of medical science" have brought a new dimension to our quest to discover but have not hardly replaced our most basic of tools. In this state of transition we have made some serious missteps. We often confuse the paperwork with the patient. We often convince ourselves that we have a diagnosis when we may be simply close to one. We often believe the patient recovered because of us, when in fact it was in spite of us.

Mastery of a skill, it has been said, takes about ten years. Those of us who are in the hands-on professions know what dues have to be paid to become skilled, but there are few joys that can compare with holding a beloved pet in ones hands and through skilled manipulation determine the most productive next direction and from that step determine the most productive treatment options and from that step see the most beautiful gaze of thanks from an owner and their animal friend, who now have a diagnosis and hopefully a successful treatment ahead of them.

Monday, June 14, 2010

The Veterinary Rehab Business





You wake up. Your not sure of where you are. The nurse asks if you would like some juice. Expecting the worst, your just-operated-upon knee doesn't feel bad at all. Of course, once the local anesthetic wears off things will be different. What's in the immediate future, one word, Physical Therapy! Woops; that's two words but in veterinary medicine we have to use just one word. The word Rehabilitation or Rehab for short.

Some wonderful Physical Therapists and forward-thinking Veterinarians, have been exploring these reparative techniques for treating our companion animals for quite a few years. While this form of treatment has become routine in human medicine, this aspect of veterinary medicine has really only come into its own over the last decade or so.


I have been fortunate enough to take numerous classes at The Canine Rehabilitation Institute(CRI) of Wellington, Florida.


While rubbing elbows with extremely knowledgeable and dedicated Physical Therapists who have decided to treat companion animals, my eyes were opened to an entirely new way of examining and healing. The basis of any approach to an animal patient is having the correct diagnosis. The diagnostic skills of the veterinary rehab specialist extend the scope of tentative diagnoses well beyond what was available to me in veterinary school. Likewise, the approach to treating even the most common companion animal diseases evolves from a completely different direction and incorporates many techniques, unheard of in the world of traditional veterinary medicine.


Many times the disease states we are trying to improve with rehab are the result of neurologic dysfunction. Therefore, a merger of skill sets led me to the faculty of CRI. I teach veterinary neurology, incorporating my new found knowledge of animal rehabilitation. After more than 35 years practicing veterinary neurology and lecturing on various topics in veterinary neurology all over the world, this wonderful collaboration was new, exciting and more than anything, rewarding.


We started applying our new found knowledge to my neurology patients that were recovering from surgery. This naturally extended to encompass a much larger group of patients....Those that are older, who have lost neurologic function that aren't good surgical candidates no matter what the diagnosis. We have also focused on those young patients where surgery for one reason or another isn't an option. All of these animals are beloved family members and just need a little help to get through the day in the most pain-free and efficient manner. The goals may be small, getting up stairs unaided, getting in or out of the family car, going for hours without urinary or fecal accidents. Of course, the approach to the athlete or working dog are quite different and require different standards. Once everyone agrees on the goals and they are there in front of us, our dedicated team of Rehabilitation Specialists, under my guidance, directs our efforts to get these patients to these desired endpoints. Weeks of slow progress, so often ends in the most rewarding of success stories.


After building a brand-new veterinary facility with an outdoor work area, a dry rehab area, and a wet rehab space, it was only natural to explore similar areas of recovery in the orthopedic realm. The idea is that by increasing strength, improving range of motion, controlling pain and inflammation with individualized plans for each patient, we can improve their response to traditional treatment by decreasing the recovery time and by improving the recovery outcome. As with the neurologic patients, we are exploring the many options for those patients where surgery might be the best choice but is not a consideration. Our approach is all about balance and quality of life issues.


Can there be a more rewarding sentence, " For the first time in years, my best friend wagged his tail and effortlessly climbed up on the sofa next to me to help me read a book"?


Thursday, June 10, 2010

CCNU and Treating Canine Brain Tumors


On December 23, 1971, President Richard Nixon signed the National Cancer Act. This was soon designated as our national "War on Cancer". This act opened the door and financed a massive review of drugs synthetic and natural that might produce a positive result in the treatment of cancer. In response to this effort a massive amount of review material was generated that was available to the public at the NIH library in Bethesda, Maryland.

As we solidified our meager knowledge about brain tumors in dogs, Dr. Lisa Fulton, our gifted oncologist, and I realized that if we were going to attack these tumors, we would have to better establish the same multi-modal techniques available in human medicine. We had been performing CT scans since 1977 and MRI's since 1984. Being very selective with our cases, we were able to define intracranial masses with a new degree of certainty. We approached tumor removal and biopsy with trepidation but early post-operative surgical results were quite encouraging. Realizing that man and dog were quite different when surgical planning was on the table was quite a fascinating lesson. Radiation therapy was not readily available but was developing in the private veterinary sector quickly. It was available enough for us to call upon it if we thought this was the best choice. What we were missing was that chemotherapeutic agent that penetrated the blood brain barrier with manageable toxic side effects. All of the currently available agents did not penetrate this biological impasse that so carefully guarded the brain's home.

Fortunately President Reagan's act to remove cancer from the face of the earth put a huge amount of readily available knowledge in one place. Whenever I could get away from my growing Specialty Hospital (Veterinary Referral Associates, Inc., in Gaithersburg, Maryland), I went down to the hallowed halls of the NIH library in Bethesda and read article upon article about medicinals of all types, many of which would be explored and abandoned and never be heard of again. During one of these sojourns, I came across a drug called BCNU or Carmustine. Bis-chloronitrosurea is a nitrosurea that is actually related to "Mustard Gas" an agent used by the Germans against the British and French during World War One. Mustard Gas' nephews and nieces would in a peculiar turn of events become key players in the "War on Cancer"? There in Bethesda, I found that some of the original research on BCNU was performed on the dog and there was substantial information that it crossed the blood brain barrier. Not only were these effects exactly what we were looking for but it also had an oral analog, CCNU or Lomustine that could be administered in pill form. To develop treatment protocols from the available research was kind of like trying to guess how much weight a bridge can hold by jumping up and down upon it. The fact is that most of the dogs we wanted to treat were going to die in a few months without treatment and the owners were always made aware of our ignorance. Starting in about 1983, Dr.Fulton and I determined a dosage protocol that was well tolerated and at least by anecdote seemed to extend our patient's lives. The real breakthroughs were to come when we had biopsy material and long-term followup, with autopsies, once our patients died. In the world of veterinary medicine these numbers are always small. Our ability to pull multiple centers together to get real statistically relevant numbers has been stymied by our culture.

In 1990, Lisa and I published the first paper on the use of CCNU in the dog. It continues to be one of numerous primary chemotherapuetics used in dog cancer treatment today. It has a significant place in the treatment of canine brain tumors.

We have yet to erase the frustration of treating canine brain tumors but we certainly have one more bullet in our arsenal.

Tuesday, June 8, 2010

Securos Veterinary Tools



In 1976 I was trained to perform spinal surgery in dogs and cats by the flamboyant and very skilled Dr. Eric Trotter of the veterinary teaching hospital at Cornell University in Ithaca, NY. I was ending my neurology residency at the University of Pennsylvania and Cornell was one of the premier institutions for veterinary neurosurgery. Little did I realize that in just another year I would be opening one of the first private practice veterinary specialty hospitals in the country and the lessons I learned in Ithaca would be indispensable.

One of the procedures I learned was how to perform a cervical ventral decompression. In this procedure, once the trachea and esophagus are moved out of the way, one is looking right at the bottom or ventral aspect of the cervical spine. Once the muscles are removed a high speed drill is used to carve a slot through the intervertebral disc and adjoining vertebrae and then comes the fun part. An opening is made into the spinal canal and through this tiny opening the protruded disc material is removed. The surgical approach can be quite deep, as much as seven inches sometimes. The hole carved into the bone gives one a 1/2 inch to a 3/4 inch slot to maneuver this offensive, abnormal disc material, out of the hole so it will cease to irritate the spinal cord and the associated nerve roots. This abnormally positioned material which originally was part of a once healthy intervertebral disc, produces one of the most painful conditions in the world of the dog.

I can't remember what instrument Dr. Trotter used for this procedure, but after I performed several hundred of these surgeries I found a dental instrument that was just perfect for teasing the abnormal disc material safely out of these tight, deep quarters. Having hundreds of these procedures in my future (by now I have performed several thousand cervical decompressions) I purchased about a half dozen of these perfect dental pics.

The pics had two ends and over the years the instruments were either misplaced or an end broke off because they weren't of the finest steel. Twenty some years later, I found myself with just one single pic with only one working end and the manufacturers of this instrument out of business. In earnest, I bought instruments that looked similar from catalogs and off the exhibit tables of our national shows. Only trying these supposed replacement instruments, did I realize that the predicament I was in was more serious than originally thought.

Along comes a gregarious and passionate tool maker/artist Harry Wooton. Harry and I met at a surgery conference and ended up at dinner together arranged by a mutual friend. Harry was the President of a veterinary company, Securos, http://www.securos.com/, that designs instruments for the veterinary orthopedic market. Harry shared his passion for design at dinner and when I described the instrument that I could not find, he assured me he could make it to my exact standards. With giddiness, I started imagining slight changes I might make to the "perfect instrument" that just moments before was irreplaceable.

When I expressed my concern about allowing this one-of-a-kind instrument out of my sight, Harry assured me if I overnighted it to him he would copy it and I'd have it back in just two days. This became the only hitch in our relationship. The instrument wasn't back in three days and now I was worried. When I called Harry with trepidation, he told me he didn't think he could do the instrument justice copying it in the office so he had sent it to Germany for a better reproduction, my heart sank. I envisioned every nightmare that ended with the irreplaceable becoming the irretrievable.

Not all nightmares come true. Harry's team of engineers went into high gear and reproduced this instrument with my exact recommendations, making this beloved instrument even more perfect. A few prototypes later, I now have six of the most perfect instruments for this delicate procedure. They fit my hand and my need perfectly. Harry's the best.