The Humans of Veterinary Medicine: An Interview With Dr. Eric Fish, DVM, PhD
Up close and personal with the brilliant pathologist & writer
Dear Readers,
I went into veterinary medicine for the animals, but I stayed for the people. The humans of veterinary medicine are some of the best people I know. They’re brilliant, compassionate, honest, quirky, genuine, and vulnerable. They’re the kind of people who will sleep in a cage so a hospitalized animal doesn’t feel lonely, sacrifice time with their families to stay in the lab and confirm their diagnosis for the 10th time, give up their lunch to a picky-eater patient, or drive an hour to pull a calf at 2am in the dead of winter. Veterinarians are some of the greatest people on earth.
One of those people is Dr. Eric Fish. When we first met at Auburn, he was a resident and I was a vet student, and I quickly identified him as the only other non-faculty nerd that consistently showed up to 7am onco-pathology rounds each month. Having earned both a DVM and a PhD, I like to think he’s got a brain so nice, they made him a doctor twice. Beyond the brilliant veterinarian, scientist, and educator that he is, Eric is also a gifted writer and the author of my favorite Substack, All Science Great and Small. He’s been a huge support and inspiration to me as a writer, and I’m so excited to share a bit of him and his story with you in this intimate 7 question interview. I hope you enjoy it!
-Dr. Sami
Dr. Eric Fish, a veterinary pathologist, scientist, and educator with experience ranging from academia to diagnostic laboratories to start-ups. You can read his published research here. His interests span veterinary medicine, molecular biology, and technology (especially AI), along with a passion for travel and learning about the world.
1. After you graduated from veterinary school, you went on to specialize in clinical pathology, but this wasn’t always your plan. Can you tell me about the day you decided that you no longer wished to enter clinical practice? Was there a “line in the sand” moment where you decided enough was enough?
Believe it or not, when I first entered vet school, I intended to be a mixed animal vet practicing in a rural area. My role models were the local general practitioners in Western New York who treated all types of animals at a reasonable cost, sometimes in their homes that doubled as their clinic. During summer breaks in college, I worked on dairy farms on Lake Ontario and at a one-doctor small animal hospital in Niagara Falls.
When I arrived at WesternU in California, I was exposed to so many different sectors of the profession, and everything seemed interesting! Anatomy, physiology, and pathology were endlessly fascinating. I loved the puzzle-solving element of both internal medicine and pathology. Specialization in either offered the challenge of working up the hardest cases, along with potentially higher pay, which was a growing concern as the reality of repaying my six-figure student loans sunk in.
I decided to pursue a rotating internship because it was required for an internal medicine residency and would also make me more competitive for a clinical pathology residency. Overnight emergency shifts were stressful, but in a weird way, kind of fun— there was no shortage of new things to learn, and the variety kept me from getting bored. Internal Medicine was a blast with fun procedures like endoscopy, joint taps, and bone marrow aspirates. The two most frustrating parts of IM were managing the owners of long-term patients who were never cured, and the cases where we hit a diagnostic dead-end and just prescribed guesswork treatment like steroids. On the other hand, clinical pathology offered most of the fun aspects I liked about IM without those “bad” parts.
But to be honest and vulnerable, what really made the decision for me was my time on the Community Practice rotation. Ironically for my initial goals, I was actually a pretty crummy general practice vet. I messed up vaccine schedules. I had trouble with the different preventative care recommendations. And worst of all was surgery: I was responsible for supervising DVM students on spays and neuters and had to lead them through procedures I barely felt comfortable doing myself. In one instance, I told a student something incorrect that could have resulted in a serious complication. While a faculty member above me caught the error and no harm came to the patient, they placed me on probation.
This was a huge blow to my confidence. I doubted whether I should be a practicing vet at all. The deadline for clin path residencies was fast approaching, so I took the plunge and applied. In retrospect, imposter syndrome is very common among new grads, and I probably could have overcome my weaknesses with time and practice. However, on balance I still made the right call and am happy to be a pathologist.
2. For the pet parents out there who maybe aren’t aware of what you do — what is it like to be a veterinary clinical pathologist? What made you choose the route of clinical pathology? What have you enjoyed most about working in this specialty, and what have been some of the unique challenges that you’ve faced?
Pathologists are essentially diagnostic consultants, sometimes referred to as “the doctor’s doctor.” We spend 3+ years after vet school learning everything there is to know about autopsies, blood tests, biopsies, cultures, PCR, and more. Much of my day-to-day work involves looking at fluid and tissue samples under the microscope to tell the referring vet whether their patient has cancer, an infection, or some other disease. Sometimes we are asked to help troubleshoot lab errors or weird results, or to help the clinician select the next appropriate test.
Clinical pathology was a perfect fit because as I mentioned earlier, I love solving these medical puzzles, which is necessary for getting the right treatment to your pets (and farm, wildlife, and zoo animals!) Even though I do not have direct patient care responsibilities anymore, my time as an intern and ER vet highlighted the importance of this work. You can think of pathologists like a kicker on “special teams” in US football: even though they are only brought onto the field occasionally for specific plays, they are critical to winning games, and you hope yours is highly accurate!
3. You’ve been a part of the profession for over a decade now. What are some of the more surprising ways that veterinary medicine has evolved since you’ve become a vet? What are some of the major issues our profession is dealing with, that you’ve experienced personally?
I would group the biggest changes into three categories: (1) medical advancements, (2) technological shifts, and (3) seismic changes in veterinary education. In terms of #1, it has been incredible to watch diseases that used to be uniformly fatal become manageable in such a short time. Feline Infectious Peritonitis (FIP) is a great example that I recently wrote about: When I was a DVM student a little over a decade ago, nearly every cat with this terrible virus died. Fast forward to the early 2020s, and researchers at UC Davis, Colorado State, and other universities discovered antiviral treatments that cure virtually every patient!
For #2, technology has fundamentally altered the dynamic between clinicians and pet owners. Early in my career, we were already familiar with the problem of “Dr. Google”—clients who did their own research and came in with a list of questions (and sometimes their own suspected diagnosis or treatment demands). Today, this phenomenon has been turbocharged by social media, podcasts, newsletters, and AI systems like ChatGPT. This is a double-edged sword: It does benefit our patients to work with more engaged and informed pet owners. However, that assumes the information they are coming in with is accurate and reliable; when people go down rabbit holes filled with misinformation or conspiracy theories, it can be twice as hard to convince them to accept your medical plan. On a side note, there have been some interesting connections between #1 and #2: it was several social media groups like “FIP Warriors” on Facebook that helped import these drugs from China and pushed for regulatory approval in the US.
Finally, veterinary education is rapidly evolving. There has been a massive proliferation of new vet schools in the last 5 years; there may be as many as 30% more programs opening by the end of the 2020s. The road towards this was paved by perceived shortages during the COVID-19 pandemic, changes to vet school accreditation standards, and frankly, some financial opportunism by schools. On top of this, we’ve seen the recent push for so-called “midlevel practitioners” that can diagnose, prescribe, and do surgery with minimal oversight, culminating with voters approving the Veterinary Professional Associate position in Colorado last November (likely to be followed in other states). How these ultimately impact the profession remains to be seen. If they improve access to pet care that would certainly be a good thing. However, I think there are real questions about whether there is even a shortage of vets, and I worry about how rigorous the VPA training will be compared to the very expansive scope of practice. We’ll just have to wait and see how it shakes out…
4. You talk a lot about the use/role of AI in veterinary medicine. What are some of the things that pet owners should know about the newfound role of AI in veterinary medicine? Is there anything we should be cautious of?
For pet owners who use AI chatbots like ChatGPT, know that they can be great tools, but the way the technology works can produce so-called “hallucinations,” aka making things up. They are also general-purpose tools that were not specifically trained for medical use. So, it is important to verify anything these systems say with an outside source. One (free) tool that is great for this is Perplexity.ai. It works like ChatGPT, and the creators tuned it to reduce the frequency of such hallucinations. What’s more, every statement you get from the system is backed by a citation with a link to a website so you can verify its claims. I have been using Perplexity for over a year and found it is generally very accurate, no major errors yet.
There are so many creative ways you can use AI! You can input text or documents from your vet or pharmacy and ask it to explain them to you in layman’s terms. You can have these systems generate questions to ask your doctor during an upcoming visit. You can even use it to see if there are any interactions between your pet’s multiple drugs or supplements, so nothing falls between the cracks.
One of the things that concerns me most about AI involves computer vision (systems that interpret photos or videos) for diagnostic imaging. This software can help radiologists and pathologists identify subtle findings and speed up their work. However, they are not perfect and can produce misdiagnoses, so it is important that a human is always overseeing such software. Many companies are pushing forward with AI-powered systems that could reduce human involvement in diagnosis, potentially eliminating it altogether. In my opinion, the technology is just not there yet. Pet owners should ask their vets if AI is being used in any of their animal’s diagnostics. If the answer is yes, they should be prepared to explain how it works and why they are confident in the results. Inability to clearly explain those points would be a big red flag.
5. Some of my most valuable experiences as a veterinarian have been those on the opposite side of the exam table—when I was actually the patient, and not the doctor. These experiences open our eyes, fuel our compassion, and teach us so much about medicine, health systems, and the patient experience. What have you learned from your experiences as ‘the patient?’ What were some of your greatest takeaways from your recent hospitalization?
Last summer I spent a week in the hospital with pneumonia. It capped a monthslong upper respiratory infection that kept progressing. I suspect stress and constant traveling for work wore me down and weakened my immune system. While I was fortunate to not need aggressive care like a ventilator, I was on a battery of IV antibiotics, and for the first few days I lay in bed miserable with an unrelenting fever, coughing constantly.
The whole experience was very humbling. As a patient, you are so vulnerable, and depend on nurses, doctors, and aides for not only your medical care but also basics of hygiene, nutrition, and comfort. I’m a Type A person and having to page staff for things like help getting to the bathroom was difficult to accept. It certainly increased my compassion for our animal patients who can’t understand what’s happening to them.
Being a patient also made me realize the preciousness of the samples I evaluate in the lab. Every day they had to stick me with needles to collect blood for various tests. By the end of the week, I was covered in bruises. They even put an endoscope down my lungs under anesthesia to collect fluid for culture. It was a good reminder that any time I complain about the quality of a sample or ask for a resubmission, it can be stressful and even painful for the patient down the hall.
Lastly, this episode demonstrated the power of the words in my biopsy reports. Part of why they scoped my lungs in the first place (not a routine procedure for a first-time pneumonia patient) were some scary-sounding sentences in the CT scan report. It turned out that was probably overly cautious and defensive on the radiologist’s part, but it was impacted by the minimal history on the submission form from the ER. It has made me more careful about listing unlikely differential diagnoses or tests just for CYA purposes.
6. Your cat, Phoenix, was your companion through many chapters of your life—both personally and professionally. You write about him often and it’s clear through your writing how much he meant to you. How did you cope when he became ill and passed away? How did you balance being his dad with being his doctor? If you could go back in time, is there anything you would do differently in managing his case?
I think one of the hardest things about being a veterinarian is overcoming the idea that we should always be able to fix every medical problem. Vets tend to feel personally responsible for all their patients, but we can feel especially helpless or even guilty when our own pets don’t respond to treatment the way we hope. Sometimes knowing the natural course of a disease makes it worse.
Phoenix endured so many health challenges in his life, he truly had at least nine lives. One of his most significant was a multi-year struggle with Inflammatory Bowel Disease (IBD) and secondary problems like developing diabetes from the steroid treatment. In 2018, he lost a lot of weight and stopped eating. We feared it might be the end but agreed to try a feeding tube and some last-ditch changes to his medications.
Another difficult thing about being both a pet parent and a veterinarian is you can lose a sense of objectivity; it’s easy to be in denial about the severity of illness when it’s your own family. To combat this, my wife (also a veterinarian) and I set a timetable and objective metrics to determine success or failure. We were fortunate to work with several great outside vets who gave us reality checks as needed. Remarkably, the feeding tube worked and he turned a corner. Phoenix started eating on his own, gained weight, and returned to a good quality life for years.
The end came in early 2022 when he was diagnosed with an aggressive form of cancer in his liver and spleen. We knew the prognosis was poor and opted for palliative care to enjoy whatever time we had left. A few weeks after his diagnosis, I had to go out of town for a two-day work trip. Phoenix seemed stable when I left, but he precipitously declined over the next 24 hours. Over the phone that night, we agreed it was time to euthanize him when I got home.
We never had the chance. Hours before my return flight landed, Phoenix slipped into a coma and died at home surrounded by my wife and our other animals. I was able to say goodbye from the plane over FaceTime, but not being able to hold and comfort him in his final moments was devastating. That remains my greatest regret: If I could do things over again, without question I would have cancelled that trip and stayed home with him.
Grieving Phoenix took months. Just when I was beginning to feel OK again, our other cat Ezra became severely ill and had to be euthanized the day after my birthday. The loss of both cats in such a short time was almost too much to bear. I became depressed. Ultimately, what brought me out of the tailspin was a combination of the love and support of my wife and family, along with a great therapist. In addition, I started writing about the experience and found it cathartic. The saga turned into the essay “When Pathology Becomes Personal,” and inspired me to start writing on Substack full time.
7. As veterinarians, our pets are some of our most valuable teachers. What were some of the biggest lessons that Phoenix bestowed upon you? In what ways is he still with you today?
The biggest lessons I learned from Phoenix were to expect the unexpected and to be persistent. Many people would have thrown in the towel and given up years before he reached a terminal diagnosis. During his 2018 illness, he almost bled to death from a complication of a routine diagnostic procedure (collecting urine from the bladder with a needle). It turned out to be due to vitamin K deficiency from poor gut absorption. This was something that had been documented in one case report in the 90s, but even the specialists at Auburn had never personally seen it. We were able to quickly fix it with Vitamin K injections and getting his IBD under control.
Phoenix lives on in the memories of everyone who knew him. That little black cat was beloved by my friends, family, and veterinary personnel in a half-dozen states. We still tell funny stories about him, like the time he casually walked over a lit candle and singed his tail (never batting an eye), or when he stole a basting brush covered in BBQ sauce and ran around our house with it in his mouth, growling when we tried to take it back.
Finally, I got a tattoo of Phoenix on my calf to memorialize him, so he is literally with me every day. I worked with a wonderful local artist to render him as an illustrated portrait, rather than a photorealistic one. Every time I look down at him, he makes me smile.
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