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Andy Roark DVM MS

About Andy Roark DVM MS

Dr. Andy Roark is a practicing veterinarian in Greenville SC and the founder of the Uncharted Veterinary Conference. He has received the NAVC Practice Management Speaker of the Year Award three times, the WVC Practice Management Educator of the Year Award, the Outstanding Young Alumni Award from the University of Florida’s College of Veterinary Medicine, and the Veterinarian of the Year Award from the South Carolina Association of Veterinarians.

A Heartfelt Thank You

March 17, 2023 by Andy Roark DVM MS

The Cone of Shame Veterinary Podcast Hits 1 Million Plays

The first episode of the Cone of Shame Veterinary Podcast was a Skype call with my friend Dr. Sarah Boston. She had written an article about “Emotional Blackmail” that really spoke to me, and I decided I wanted to talk to her about it. I had some questions and thought the concept she was describing might manifest in ways her article didn’t discuss.

We published the podcast in October of 2019… and then I didn’t publish anything else for two months. In truth, I was trying to get my head around what I could talk about that others would find interesting. I ultimately decided I could ask smart clinicians how they would handle cases I was seeing in practice so even if the podcast bombed I would get grade-A coaching on how to be a better doctor. It seemed like a no-lose situation.

The Cone of Shame originally started as a YouTube show back in 2015. I tricked out my basement into a film studio and started making videos for pet owners. My grand plan was to share these YouTube videos with my rapidly swelling Facebook audience and grow the show into something that would be fun for pet owners and easily referenced by busy vet professionals who wanted to give their clients some educational resources.

Well, things didn’t go as I’d hoped. Right before I launched the YouTube show, Facebook and YouTube got into a huge fight, and Mark Zuckerberg declared that Facebook would be “deprioritizing” links to YouTube in its news feed. When I posted a link on Facebook to the first Cone of Shame episode, it tanked.

I did get some people to watch the show (and a few videos have around a half million views), but it was a battle to get subscribers and took way more time, energy, and money than I anticipated. I also felt fully committed to the show and had hired a videographer/producer, so giving up on it felt like a real failure. It was an invaluable (but painful) learning experience.

My bruises from the YouTube show were a big reason I was so hesitant to commit to trying the podcast, which felt similar in a lot of ways (including, of course, the name). Still, I had greatly enjoyed working with Stephanie Goss on the Uncharted Veterinary Podcast over the previous year and finally built up the courage to give the Cone of Shame Podcast a shot.

I saw the statistics a few days ago, and have just been in awe since then. So many people have told me that they listen to the podcast or that a particular episode spoke to them, but I have never really thought much about how many people are tuning in.

I just want to say THANK YOU to everyone who has checked out the podcast, sent an episode to a friend, or given me a word of encouragement to keep going with it. You all are wonderful and I appreciate your time more than you know.

I like to tell myself that I would make this podcast even if no one listened, just because I love it, but I don’t know if that’s true. At some level, I have always needed to feel like the work I take on makes a difference and that I’m helping my colleagues. Without you all showing up, I suspect I would have set this project aside, and my life would be a little less rich without it.

Thank you. Thank you for your time and encouragement. Thank you for the wonderful and meaningful work you do, and for allowing me to cheer you on and try to support you.

Sincerely,

Andy

Cone of Shame Episodes That Topped The Charts:

EPISODE 122: IS THERE REALLY A BLACK MARKET CURE FOR FIP?

EPISODE 96: THE RISE OF VEG – IS THIS THE FUTURE OF EMERGENCY PRACTICE?

EPISODE 99: ARE VET NURSE PRACTITIONERS COMING TO VET MEDICINE?

EPISODE 104: THE TROOPS ARE TIRED – WHY ARE WE RUNNING THIS MARATHON LIKE IT’S A SPRINT?

EPISODE 118: DO I PULL IT? DO I LEAVE IT? (HDYTT)

Stay up to date with the latest Cone of Shame Podcast episodes here.

Filed Under: Blog Tagged With: Just For Fun, Perspective

The Future of Independent Practice Ownership

March 16, 2023 by Andy Roark DVM MS

The days of veterinarians owning the majority of veterinary practices seem to be permanently behind us. Does this mean that practice ownership by veterinary healthcare providers is coming to an end? Economist Dr. Matthew Salois joins the podcast to discuss the future of ownership and equity in veterinary medicine.

Cone Of Shame Veterinary Podcast · COS – 189 – The Future Of Independent Practice Ownership

You can also listen to this episode on Apple Podcasts, Google Podcasts, Amazon Music, Soundcloud, YouTube or wherever you get your podcasts!

LINKS

Veterinary Study Groups: https://www.veterinarystudygroups.com/

Uncharted Veterinary Conference: https://unchartedvet.com/upcoming-events/

Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/on-demand-staff-training/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Matthew Salois, PhD is currently the President of the Veterinary Study Groups, Inc. (VSG), where he is responsible for enhancing the economic and cultural success of more than 1,800 veterinary member practices.

Most recently, Matt was the chief economist and head of the veterinary economics division at the AVMA between 2018 and 2022, where he applied his skills in economics, business, and communication to support the daily lives of veterinarians.

From 2014 to 2018, he served as director of global scientific affairs and policy at Elanco Animal Health, supervising a team of scientists in veterinary medicine, human medicine, animal welfare, economics and sustainability. His group devised and executed scientific engagement strategy, and built collaborative partnerships with universities, non-profit associations and scientific societies.

Matt is also an adjunct professor of applied economics at the University of Florida, where he previously taught and advised graduate and undergraduate students. He earned his Ph.D. in Applied Economics from the University of Florida and holds an M.A. in Economics and a B.S. in Health Services Administration from the University of Central Florida.


EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am back with my friend the economist, Matt Salois. We are talking about practice ownership. We are talking about equity for veterinarians and vet professionals. What is possible in this modern world of corporatization where there’s private equity groups buying up practices, we have corporate practices, we have a wide variety of opportunities for ownership. What do we need to know? How does this work? How does it look in the future? Is the old style of practice ownership dead and gone? Is private equity going to stick around the way that it has or is that a passing phase? Guys, we unpack all this stuff. Let’s get into this episode.

Kelsey Beth Carpenter:
(singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to The Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:
Welcome to the podcast, Dr. Matt Salois. Thanks for being here again.

Dr. Matthew Salois:
Hey, great to be here. Thank you.

Dr. Andy Roark:
I always appreciate your time. So you’ve been on the podcast a number of times. For those who don’t know, you are a PhD economist, you are the president of the Veterinary Study Groups. You work with the VMG Groups, the Vet Management Groups quite a bit. And you have been a guest on this podcast at least three times now.

Dr. Matthew Salois:
Awesome.

Dr. Andy Roark:
Best you believe it. I don’t know how big an accolade that is.

Dr. Matthew Salois:
No, it’s a big one.

Dr. Andy Roark:
Probably gets pretty low on the CV, but-

Dr. Matthew Salois:
No, really great to be here. Weird conversations.

Dr. Andy Roark:
Oh, I always do. There’s just a number of things I’ve been really interested in recently and you’re sort of in a position to help me look at it outside the box and to see what’s possible. And so, one of the things to you, I’ve always been interested in practice ownership. One of the things that really attracted me to vet medicine was this idea that you could captain your own ship. I think it was really, my father was a physician, but he had his own little surgery center that was just him and two nurses and just small town in North Carolina and that’s what he did. And I think there’s something beautiful about that. And so that type of autonomy I think has always been really interesting and really, I don’t know, I had a romantic view of it I guess.
And then the other part of it is when we talk about, I look a lot at student debt for veterinarians and the whole time that I was coming up, student debt was getting larger. A lot of people were going, “Oh, well there’s an easy way out of this and it’s practice ownership.” And I always thought that was a little bit of mischaracterization of the truth, but I got the concept of it.
And so now I’m looking at increased corporatization in vet medicine. What I wanted to do was talk to you a little bit about how that changes this independent business owner landscape and is practice purchase or practice ownership in going forward, how viable is that going to be? Is it going to be widespread? I’m starting to hear a lot more about different models where there is equity inside of corporate practices, things like that. Those are the conversations I want to have today is I kind of want to understand the landscape for owning equity in a vet practice going forward. And so if you could start off, can you start us at a 10,000-foot level and say, tell me the story of practice ownership, Matt, just get me started on where we’ve been and where we’re going.

Dr. Matthew Salois:
Yeah, really happy to. I’m really excited we get to have this conversation. It’s a deep passion for me, practice ownership in large part why I’m with VMG today. It’s such a tremendous opportunity to, I think, enhance the wellbeing of yourself as a practice owner and more importantly to be put into a position where you can influence so much that happens within the practice. So much of our conversations talks about veterinarian wellbeing and I don’t know if you’ve ever been in this position, Andy, around, oh, I wish the boss would do this. I wish the boss would do that.

Dr. Andy Roark:
Oh yeah.

Dr. Matthew Salois:
You’re in that position. You can make those changes that you so desperately crave.

Dr. Andy Roark:
I will turn it back around, too, and say it’s funny. Later in life I learned that when you’re the boss, you say things like, “Ah, I wish the staff would do this. I wish the doctors would…” It never ends. I always thought when I’m the boss, it’ll be easy. It’s like, no, it’s not easy.

Dr. Matthew Salois:
No, it’s harder, but at least you’ve got autonomy there or more or less, you’re always coupled to somebody.

Dr. Andy Roark:
That’s true.

Dr. Matthew Salois:
In consolidation, corporatization, it’s definitely changing the landscape. And I will say that I think there’s plenty of room for every type of practice, for every size, every aspect of how you define ownership in this profession. The number of veterinary practices continues to grow. Yes, the number of practices that are corporate continue to grow too, but so does the total number of practices that are here parallel with population increases of pets and demand for veterinary care. It’s still such a tremendous runway of opportunity for someone aspiring to be a practice owner.
And I think we need to do a better job as a profession building those aspirations. And I think building transparency and awareness around what it really means to be a practice owner, what it takes, what it involves, as well as the benefits that it imparts. I mean, you said it, your father was the captain of his ship. And I don’t know if this was your father’s story. I don’t know if you had these experiences with him before he owned his own practice and life after he owned his own practice. If you could share if there was a big change in his overall wellbeing and happiness or not. But I see it in veterinarians that become practice owners. It’s amazing.

Dr. Andy Roark:
Okay, so let’s unpack that a little bit because there’s… Okay, so first of all, I still love the idea of being a business owner. One of the greatest things that I aspire to in my life is to create a wonderful workplace for other people. That just means a lot to me. I really want to create a great place for others to work in. And I think it’s a responsibility, but it’s also a passion project and it’s a worthy challenge. And then also, I like the autonomy of making this into the image that I want it to be. Business ownership has been a wonderful challenge that I’ve been very glad that I took on.
At the same time, it is a challenge. I had a guest on a while back and then I had another guest on who argued with the first guest. And the reason was, and I’m trying to remember where the original statistic came from, but basically we were going over some data on burnout and the data that was presented said that the practice owners were less likely to burn out than other professionals. And so, one of my later guests said, “I heard that on the podcast and I thought, that can’t be true.” So he contacted the first guest and what was told was the way that burnout is calculated is your plan is planning to leave the job. So practice owners didn’t burn out, because they didn’t plan to leave the job because the barriers to exit were much higher. And so anyway, I think that that’s an interesting sort of way to talk about does practice ownership make people happier? Are there these psychological benefits? What’s baked into those numbers?

Dr. Matthew Salois:
Well, it can and it can also make your life miserable as can any decision that you embark on in life. But I don’t know, I have to go back to that podcast episode. I can speak to data at the AVMA, because I helped collect and analyze that data years ago when I was with the AVMA around wellbeing metrics for associates versus practice owners. And it was very clear that wellbeing in terms of lower burnout, higher levels of compassion satisfaction, it was clear in practice owners and it wasn’t about whether or not they were wanting to leave the profession. We compiled those metrics based on the professional quality of life, surveyed the pro qual…
And so lots goes into that, a number of different variables and indicators there. And what we always saw, and the AVMA still continues to see over time, is that practice owners have lower burnout and higher overall levels of wellbeing. I kind of chalk it up again to this captain of your ship and in control of your own destiny kind of thing. Now it doesn’t mean that’s always going to be the case, right?

Dr. Andy Roark:
Sure.

Dr. Matthew Salois:
You could be in a very difficult situation as a practice owner and be very miserable and maybe want completely out of it. I think like all things, it depends on the actions that you take, the people that you work with and the culture that you create within your business. I think it revolves around how that looks.

Dr. Andy Roark:
It’s funny. I think that sort of tracks with my experience. Definitely there’s a lot more stress on your shoulders of making payroll and you carry a lot of responsibility. I guess I can definitely buy into the idea that autonomy and the ability to impact your surroundings at a much greater level than other people who work in the practice are. I can definitely see that being something that would keep people in business ownership and that could increase overall satisfaction.
I heard a story not long ago and it was heartbreaking. So one of my friends was going to buy the veterinary practice that she worked in and she’s an associate vet and she saved up for three years to be able to get the down payment that she needed to buy this practice. You can probably see where this is going. So then it was time to do the evaluation on the practice, and they did, and her numbers worked out, but there were corporate buyers who were also interested in the practice and it sort of came at around the same time that she was going to try to make this purchase. And they came through and offered multiples well above what she was able to pay. It was something like, let’s say the practice was valued at $2 million and they came in, they were like, “We’ll give you 3 million.” And the owner said to my friend, “Can you match that?” And my friend was like, “No, I can’t. The bank won’t loan me that much money.”
And so the practice was sold to this other group and there’s not a villain in this story. I really don’t, I don’t think any of us can look at a veterinarian trying to retire and say, “Well, you should have left a million dollars on the table.” I would’ve been heartbroken just like my friend was. And I don’t think that she was wrong, and I don’t blame her if she feels resentful. But I hear these types of stories. So, Matt, can you comment on some of the challenges of purchasing a practice today, of coming into practice ownership in the modern era?

Dr. Matthew Salois:
Yeah. I mean, and you name probably the biggest one there, which are what seem to be absurdly large multipliers that no individual average human being can compete with, especially when you’re looking at private equity groups with deep pockets that have seemingly endless cash flow to pour into veterinary medicine. I think that definitely creates some frictions and difficulties. I think our current environment around inflation and whether or not we are in or will soon be in a recession may soften what we’re seeing there in terms of consolidation and multipliers.
But it pains me to hear stories like that, and yet it shouldn’t be a deterrent either. It didn’t work out in that instance. So try smaller, try buying into a different practice, something that doesn’t have quite the multipliers on it. And you’re right, you mentioned she was saving up for a few years. I mean, it’s definitely a long-run plan. This isn’t something you can think about wanting to do, and then two years later you do it. And this is why I think we need to talk more about it and instill this in the schools, in the program, so that you can be on, at a minimum, a five-year plan post graduation so that you can start preparing the saving, looking at loan options. The opportunities are out there.

Dr. Andy Roark:
Yeah. So I want to step back here for a second. Can you define the term private equity? I know we throw that term around a lot. I don’t know how many people know exactly what that means when we say, “Oh, private equity has deep pockets.” Translate that for me if you don’t mind.

Dr. Matthew Salois:
Loosely, private equity being a collection of investors, pulling their money together and then investing in different areas where they’ll buy up assets, they’ll potentially restructure those assets, invest in those assets, build efficiencies, create more profit from them, and then sell those assets at a gain. I mean, that’s basically what private equity is trying to do. They’re not generally in the long run. They’re here to come in, make an investment, and generate a return within a three to 10-year time horizon and even 10 years might be pushing it. And that’s basically it.

Dr. Andy Roark:
Hey, guys, I just want to hop in really quick and give a quick plug. The Uncharted Veterinary Conference is coming in April. Guys, I founded the Uncharted Veterinary Conference in 2017. It is a one-of-a-kind conference. It is all about business. It is about internal communications working effectively inside your practice. If you’re a leader, that means you can be a medical director. It means you can be an associate vet who really wants to work well with your technicians. It means you can be a head technician, a head CSR, you can be a practice owner, a practice manager, multi-site manager, multi-site medical director. We work with a lot of those people. It’s just all about building systems, setting expectations to work effectively with your people.
Guys, Uncharted is a pure mentorship conference. That means that we come together and there is a lot of discussion. We create a significant percentage of the schedule, the agenda at the event, which means we’re going to talk about the things that you are interested in. It is always, as I said, business communication focused, but lots of freedom inside that to make sure that you get to talk about what you want to talk about. We really prioritize people being able to have one-on-one conversations to pick people’s brains, to get advice from people who have wrestled with the problems that they are currently wrestled with. We make all that stuff happen. If you want to come to a conference where you do not sit and get lectured at, but you work on your own practice, your own challenges, your own growth and development, that’s what Uncharted is. Take a chance, give us a look. Come and check it out. It is in April. I’ll put a link in the show notes for registration. Ask anybody who’s been, it’s something special. All right, let’s get back into this episode.
What do you see as the role in private equity going forward? So we saw private equity coming in and spending a lot of money in the last couple of years. Is that going to continue as you look into your crystal ball? Are we going to continue to see this type of investment? Is this sort of a short-term play? Does this create opportunities for practice ownership among veterinary professionals in interesting ways later on?

Dr. Matthew Salois:
Yeah. I think veterinary medicine will always be, and has been for quite a while, a very attractive place for private investors, equity groups to invest in, particularly because, one, there’s stable growth. We continue to see the number of pets grow and demand for veterinary care grow. It’s also very recession resilient, not recession proof. I don’t think any market or industry really is, but certainly resilient. And so in periods of economic downturn, sluggishness, it’s a good place to invest in because you can maintain steady cash flows or at least mitigate losses that you would’ve in other industries and other areas like travel, tourism, entertainment, those things really take a nose dive during those types of economic environments.
But I think we will see some slowing down here in large part just tied to what’s happening in our economy. The realm of cheap money is done, negative and zero interest rates, those days are over and the money’s more expensive now because of inflation and what we’re seeing happening there. And so it’s becoming more expensive to invest. So I think that’s going to naturally slow things down a bit. I also think eventually, whether it’s next year or a few years from now, we’re going to see some slowing down because the top oil has been mined here. So there’s definitely a sweet spot that a lot of private investors are looking for medium-sized practices that have at least two to three doctors that they can grow into something more and then sell at a profit, at a gain there. That’s been happening for years. And so it’s getting more difficult to find those practices. Still plenty of them out there, but obviously more of them have come under some type of private equity umbrella over the last few years.

Dr. Andy Roark:
Is there opportunities with private equity umbrellas? If the idea is to turn these over for profit, does that create opportunities for independent practice purchase later on, or are those practices… I know the idea is obviously to increase revenue, so they may be very well priced outside of an independent professional’s purchasing price forever, but talk to me a little bit about that.

Dr. Matthew Salois:
Yeah, absolutely. I’ll add here, when we look at what we call corporate practices, which I never really liked that phrase because it’s just very misleading. I mean, really the only true corporate practices out there are the Mars practices. They’re the only company that’s truly incorporated under the eyes of business law. The others are under private equity umbrellas, and they operate very differently than an incorporated business because they’re managed by investors there.
And here, touching on what you just asked, opportunities to hold equity into that company are becoming more and more common. And it’s changing, I think the nature of what we think of as ownership. Yes, it is still and always will be 100% independently-owned business. That’s still very much a part of veterinary medicine. And now we have this new landscape of ownership where you can maintain equity ownership into the practice or more increasingly into the parent company that’s invested in that practice. And that’s important to recognize, because it’s still under the umbrella of ownership and what happens in the future is, yes… So inevitably most of these investors will be looking to sell. So there may be opportunities to buy those practices back. Some of these may incorporate and just become incorporated in true companies there selling to an outside agency that’s interested in that. The landscape’s going to continue to change. That’s clear.

Dr. Andy Roark:
Can you give me some examples of what these types of equity programs would look like? So when we talk about having equity inside of a larger corporation, everything from, you said equity in an individual practice to the larger companies. Give me kind of a menu, if you will, of what these different options look like?

Dr. Matthew Salois:
Yeah, I mean, it’s almost like the sky is the limit here. I’ve seen many different types of structures in terms of how they’re designed, and I think it continues to evolve and that’s going to continue unravel. I mean, I think sort of the meat and potatoes of it, the 101 version of this is the owner sells to a private equity group, and that person maintains anywhere from a five to maybe 15% equity stake into that company, into that organization. And so based on earnings, at the end of every year, they receive equity value based on that.
More and more what I’m seeing is that that’s not just singled out to the owner that sold. I’m seeing equity for professionals all across. And some are offering equity ownership into the whole staff, having a percentage stake in the earnings of the company as well. And I think we’ll probably see that become more common because it’s an important, obviously, income stream for people. It’s definitely an incentive to recruit and retain people that other businesses and practices may not be offering. So it’s going to help you compete for talent there. But it can be designed any number of different ways, but ultimately it’s based on the earnings of the company. And then based on that you receive either a check or shares that can be paid out once you’re vested, so to speak.

Dr. Andy Roark:
It totally makes sense. I’ve seen this a number of times with associate doctors. Because if you buy a practice and all the doctors leave, what have you bought in some ways? I’ve definitely seen that and it definitely makes sense to me for a retention standpoint. So when we’re talking about equity like this, the idea, like you said, is you would have ownership of either this individual practice or this larger entity, and then you would either get a check, like a disbursement of funds, or you would convert to more ownership. And so I guess the ultimate idea is this is your long-term investment and later on at some point you’ll be able to convert this as you sort of cash out your investment, correct?

Dr. Matthew Salois:
That’s right, yes.

Dr. Andy Roark:
Are there other upsides to these types of deals? Are there things that people really like about them?

Dr. Matthew Salois:
Well, I think it keeps them connected. So you think about an owner who’s selling and they’ve spent years building this practice, it could be hard to let go of that. And maybe some just want that, right? Like, “I’m done. I’m out.” Go buy a yacht and sail or whatever, and that’s fine. But for many, they want to stay connected. They’ve built something and they want to continue to see it grow and succeed and not necessarily leave the people that they’ve built this with behind.
So I think the biggest benefit to a structure like this is that it keeps them connected. And the investors gain from this too, because they don’t necessarily want a complete vacuum of institutional knowledge here. They’re not in the business of running practices, they’re in the businesses of helping them grow and then sell them for a profit. They’ll want the right people in place to help drive that mission forward. And oftentimes that involves keeping the people that have built this on the ground so that they can propel it to the next level.

Dr. Andy Roark:
That makes sense. Are there downfalls, pitfalls, downsides to these types of deals that you see? Is there any small print problems that surface later on?

Dr. Matthew Salois:
Yeah. I think some of the downsides to the investors can be when they find themselves suddenly having to manage a practice and they know nothing about that business. That can be challenging, particularly in a tepid economic climate like we’re in where maybe it’s just the growth and demand wasn’t what you thought it was. So you need to buckle down a little bit. But I think the downsides from the veterinarian who’s in this is decision-making, if that’s impacted. So obviously the investors are the majority here. Is everything top down?
And I think that’s where these practices run a very wide distribution. And why I say the corporate label is so unfair, because I think it creates this thought process of corporate telling the practice everything, medical or nonmedical. And I think that’s grossly unfair because there are so many that support and empower local level decision-making within their practices. They have their HR guidelines and they have their processes and procedures on a number of things, but they empower professionals, the veterinarian to make the medically best decisions to use what they feel is the best medicine. And so if there was a downside there for them, it’s the lack of that empowerment. But I’ll say there are so many out there that support that type of empowerment, which is encouraging.

Dr. Andy Roark:
Matt, if you had a young veterinarian who came to you and he or she expressed interest in practice ownership and they said, “This is something I’ve always look forward to. I like the autonomy. I like the idea of creating a culture and really having my hands in it and I want to work on something that I feel tied to or feel that I’m really able to put myself into.” How would you advise that person if they said, “I don’t know how to get started, I don’t even know what my options are.” Can you lay out a basic advisement strategy you’d give?

Dr. Matthew Salois:
Yeah, and here’s where we’re talking to a financial advisor would be wonderful, I think first and foremost, and having those conversations. And if you haven’t had one on your podcast, that would probably be a awesome next one to do. I’d say great, start now. You can always save for something without knowing exactly what you’re saving for. Just start saving, that’s important. And then be transparent, talk to the owner, let them know that this is what you’re thinking of and try to find out if the owner’s even interested in selling to you or to any veterinarian for that matter. And you can get hopefully the cards out on the table now. Is there a future? I mean, there could always be that situation like you started with the young veterinarian friend that you mentioned where you think you’re going to, but the sale doesn’t work out.
But either way, you can identify with your current owner if they’re interested in that, and then you maybe can work towards a plan to do that in the next several years. And if not, you can start looking for other opportunities to buy into practices. And you don’t necessarily have to buy 100% outright. So look for those opportunities where you could co-buy into a practice with another doctor or a number of other doctors there where you’re co-owning that practice together. Certainly in some ways that’s more complicated, but it softens the blow in terms of what you need in order to buy into that practice.
And then talk to owners, understand their history and their journey, what it’s taken, what they find as the biggest challenges, what they find most worthwhile and rewarding about it, and trying to get into that position of understanding the business more and more of veterinary medicine. I think that’s the important thing and very limited is given in the schools. This is really something that you learn along the way, right or wrong. And so taking those opportunities to the extent that you can with your current owner and others to build that up, build that skillset up over time.

Dr. Andy Roark:
Yeah. Are there any specific resources that you really like for people to look out to, didactically if they said, “What should I read?” Do you have favorite resources?

Dr. Matthew Salois:
Well, I think being a student of leadership never hurts anybody. I think learning more around leading people, and I think that’s the biggest challenge for any and every owner, they will tell you. People are delightfully complicated and getting people to work together in a way that brings together engagement and a positive work, you’ve got to cultivate that. That doesn’t usually happen on its own. And so I think learning leadership is important. You can read books and you can attend webinars and things, but I think there’s no better study for that than working under a great leader. If you look at your leadership and you’re just not happy, well, maybe you need to find another place where you can really learn what good leadership looks like.
And then understanding practical business, how to manage a profit and loss statement, a P&L, I mean that’s definitely a skillset. And understand the nature of strategy is really important around, if you want to grow, what are the steps taken to support that growth, and then how do you execute on that? That’s a learning skill. And you can get a degree and you can get an MBA, but that doesn’t mean you’re going to be good at strategy and execution. And so looking at opportunities to reinforce that will be an important avenue of opportunity.

Dr. Andy Roark:
Yeah, that totally makes sense. Matt, thank you so much for being here. Where can people learn more about Veterinary Study Groups? Where can they find you online?

Dr. Matthew Salois:
Yeah, at our website, veterinarystudygroups.com. Learn more about our mission and vision and how we support practice owners in the profession. And you can find me on LinkedIn where I occasionally post about data and the economy and sometimes I’m funny with a dad joke here and there.

Dr. Andy Roark:
Awesome. I’ll put links into the show notes. Guys, take care of yourselves. Be well everybody. Thanks for tuning in.

Dr. Matthew Salois:
Thanks so much.

Dr. Andy Roark:
And that is our show, guys. That’s what I got for you. I hope you enjoy it. I hope you took something away from it. I hope it was interesting. As always, I’d love it if you’d leave me an honest review on iTunes or wherever you get your podcasts. It lets other people know about the show so they can find it and check us out. Anyway, gang, take care of yourselves. Be well. I’ll talk to you later. Bye.

Filed Under: Podcast Tagged With: Team Culture

What Does It Mean To Be Strong?

March 9, 2023 by Andy Roark DVM MS

Over this past year, I’ve found myself reexamining a number of beliefs I had formed as a child. Some of these reflections come from the fact that I’m getting older. Some come from my wife’s cancer diagnosis last year. And some are simply a recognition that the world is changing and I would like to keep up.

One belief I’ve been thinking a lot about is what it means to be “strong.” Growing up as a boy in the 80s, my definition of strength developed from action movies. Think bulging muscles, boxing matches, and shoot-em-up justice. For a long time, strength to me meant lifting heavy objects and perseverance regardless of the odds.

Today, that definition doesn’t hold up. Of all the strong people I know, not one of them has ever rescued a hostage or even been in a kung fu death tournament (that I know of).

As I look at what strength is today, I don’t think it has anything to do with physical performance. I think it’s about an unwavering commitment to just keep going. 

I’ve always loved the idea that life is not about standing tall. It’s about getting back up when you get knocked down. I don’t think I ever realized, however, that this is the definition of what it means to be strong. It has nothing to do with being “victorious” and everything to do with always putting one foot in front of the other.

I need to say clearly here, that I do not think strength is a refusal to quit. In fact, I think true strength involves seeing situations clearly and sometimes making the difficult decision to change course, to do something new, or to leave the comfort of certainty behind.

Strong people who find themselves in a job that’s unfulfilling don’t exhibit strength by “toughing it out.” They exhibit strength by accepting the situation, deciding what to do about it, and then moving forward down a path of uncertainty where they do not know what will happen. 

Strong people who are burned out and depressed don’t have to show strength by just “hanging in there.” They can show strength by putting one foot in front of the other and accepting help. Strength can be going to therapy, talking to a doctor, making changes in our lives, and doing what we need to do to keep going. For most of my life, I don’t think I understood that some of the greatest acts of strength involve allowing others to help us.

In the end, strength is not about refusing to quit or change. It’s the opposite of that. Strength is about accepting that life will bring us hardship, and we must keep moving forward…often by making changes instead of refusing them.

Filed Under: Blog Tagged With: Perspective

Master’s Degrees, Mid Level Practitioners, and the Future of Veterinary Technicians

March 8, 2023 by Andy Roark DVM MS

Dr. Bonnie Price, Director of Lincoln Memorial University’s Master of Veterinary Clinical Care Program, joins the podcast to discuss LMU’s new master’s program for technicians, its objectives and the pushback against the program. Dr. Price and Dr. Andy Roark also discuss the current state of technician credentialing and what the future looks like for the technician profession.

Cone Of Shame Veterinary Podcast · COS – 188 – Master's Degrees, Mid Level Practitioners, And The Future Of Veterinary Technicians

You can also listen to this episode on Apple Podcasts, Google Podcasts, Amazon Music, Soundcloud, YouTube or wherever you get your podcasts!

LINKS

LMU Master’s of Veterinary Clinical Care: https://www.lmunet.edu/college-of-veterinary-medicine/academics/graduate-studies/master-of-veterinary-clinical-care

Dr. Andy Roark Exam Room Communication Tool Box Team Training Course: https://drandyroark.com/on-demand-staff-training/

Dr. Andy Roark Charming the Angry Client Team Training Course: https://drandyroark.com/charming-the-angry-client/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Bonnie Price has worked in veterinary education eight years and currently serves as the Director of Lincoln Memorial University’s Master of Veterinary Clinical Care Program, the first MS program in the US designed specifically for credentialed veterinary technicians to build on the knowledge and skills learned in AVMA CVTEA accredited programs. Dr. Price is the former chair of the LMU’s Department of Veterinary Health Science and Technology at LMU and led the department through curriculum revisions, new program development, and enrollment growth.

Dr. Price has lectured for undergraduates, graduate, and professional students across multiple disciplines (including veterinary technology, pre-vet, pre-med, nursing, conservation biology, master’s students, medical students, and veterinary students) with the goal of creating interdisciplinary collaborations and developing leadership skills very early in students’ training.

Before training in veterinary public health, they completed their undergraduate work in anthropology and biochemistry and participated in primate fieldwork and conservation studies throughout Central America and West Africa, which fostered a strong commitment to culturally competent and multidisciplinary approaches to improve health and wellness at the interface of animals, humans, and the environment.

Dr. Price serves on the Board of Directors for Pawsibilities VetMed, which aims to actively increase the diversity of the veterinary profession based on gender, race, ethnicity, non-traditional career path, sexual orientation, socioeconomic status, religion, disability status, and veteran status through a novel pipeline approach to recruitment and retention.

Dr. Price is also an active member of PrideVMC’s Mentorship Working Group and DEI Working Group, which exists to promote and uphold PrideVMC’s commitment to diversity, equity, and inclusion among its members, the larger LGBTQ+ community, the field of veterinary medicine, and all communities served by veterinary medicine.

Dr. Price earned a BS in Biochemistry, a BA in Anthropology, and a DVM and MPH from the University of TN.


EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I’m here today with the one and only Dr. Bonnie Price. She is the Director of the Technician Master’s Program as it’s informally known at LMU. Man, this is a lightning rod program. A lot of people have a lot of strong feelings about this, about a technician master’s degree. Why are we doing this? What does it allow technicians to do? Is this the path to the mid-level practitioner? Do we need to stop it before that happens?
I get her in and ask her really hard questions, and we talk about a lot of things. We talk about where the program came from. We talk about what someone would do with a master’s that they get after being a credentialed technician. We talk about the return on investment on a master’s like this, and then we get into the mid-level practitioners and we talk about what that looks like and where we are in that debate as a profession and how a master’s program like this would fit into mid-level practitioners if they were to come around.
So guys, I think for those of you who watch the industry and think about the future, I think there’s a lot of meat for you to stick your teeth into if you’re into meat. Otherwise, a lot of audio tofu if you’re into that, but there’s a lot here. That’s what I’m saying. There’s a lot here that I think you guys will enjoy. So let’s get into this episode.

Kelsey Beth Carpenter:
(singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to The Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:
Welcome to the podcast, Dr. Bonnie Price.

Dr. Bonnie Price:
Thank you so much for having me.

Dr. Andy Roark:
Oh, man. It’s my pleasure. So you and I are just meeting for the first time. I am so glad to get to meet you. My friend Bob Lester, Dr. Lester, who’s been on the podcast a number of times, he speaks so highly of you. I am so interested in technicians, obviously, in technician job tracks and in accessibility of care. Boy, you’re doing something really interesting that I want to talk about.
So for those who don’t know you, you are an Associate Professor of Vet Medicine at LMU, which is Lincoln Memorial University, and you are the Director of their Master’s of Veterinary Clinical Care, which is some people are calling it the Technician Master’s degree, something like that. I want to talk to you about what that is because I have heard things I think are true. I’ve heard things I think are not true. I just want to sort this out with you and understand what’s going on.
So let me start. I want to start really broad and just say to you, I’m looking at our profession and the biggest problem that I’m seeing right now is a labor shortage, specifically in veterinarians. I know I’m vet-centered because I am a practicing veterinarian, but I look around and I say, “Guys, we got too many cases. We got more cases than we can see and we have technicians who want to do more and they would like to earn a living wage, which seems reasonable to me.” So this feels like a problem that has a fairly straightforward answer in my mind when I say, “We’ve got more work we need to do. We’ve got people who want to do more work, and we’ve got people who would like to earn more salary.” That seems reasonable to me and paints a picture of where I think our profession should go. How do you feel when I say that? Does that line up with what you’re looking at? Am I off base? Talk to me about how you see technicians in our profession right now.

Dr. Bonnie Price:
Okay. So yeah, I agree with everything you just said. The one thing I don’t know if I agree with is the straightforward solution. So I think that the problem becomes a lot more complicated when we start looking at all the pieces. So we’ve got this-

Dr. Andy Roark:
Let’s do this. You’re so right, and I’m here for this. Let’s do it.

Dr. Bonnie Price:
Okay. So I think we definitely have a workforce shortage. I’m not sure why, but there is some disagreement among some professionals saying that, but I don’t think there should be. I think maybe overall, maybe we have enough veterinarians to cover the needs of the country, but then when we start looking at the places where we need veterinarians, we don’t necessarily have them, right? We definitely don’t have an enough technicians. We’re in a situation where a lot of practices are using veterinary assistants to do technician work.
So we definitely don’t have enough credentialed technicians. We’ve got credentialed technicians leaving the profession and really high numbers. I’ve read lots of different statistics, but some of them say that the average lifespan of a technician in their profession is seven years. They become credentialed technicians, they leave within seven years.
So I think that when we start to pull apart the threads, what are the problems that we’re seeing? There’s a lot. So we’ve got this issue of what’s the scope of practice of technicians and how is that scope of practice protected state to state. So are technicians the only ones able to do technician work? No, in most states, no. Is the title of technician protected in most states? No. Is there a requirement to be a credentialed technician? In many states, no. So we’ve got this mess of veterinary technology that I think veterinarians are to blame. I think we can say that because we’re both nuts, right, Andy?

Dr. Andy Roark:
“I think it’s your fault, Roark.” That’s what I heard.

Dr. Bonnie Price:
A lot of the power in this profession is in the hands of veterinarians.

Dr. Andy Roark:
Oh, yeah.

Dr. Bonnie Price:
So we really need to understand what’s going on with technicians so that we can start solving this problem and then give the power to them, right? So once we figure out what’s going on, help them, give the power to them to do with their profession what they want to do. That’s how I feel about it.
So I guess I think the best thing to do, and maybe we start with what this master’s program is that we’ve made. So you mentioned you’ve heard a few things. You’ve heard some things that maybe are true, some things that maybe aren’t true. I think you’ve maybe have heard things that were at one point true and now are no longer true.

Dr. Andy Roark:
Yeah. Let me lay this out a little bit. Okay. So now we’ll start to get into it because you already touched on some of the things that I’m talking about. So my understanding is that you guys have rolled out this new master’s program in its, as I’ve heard it called a technician master’s program, but it’s the Master’s of Veterinary Clinical Care. There’s a lot of people who say, “Well, this is a path to a mid-level practitioner,” which is a whole other can of worms, but the idea being this would be something in between credentialed technicians that we have now and veterinarians where this would be the perfect educational path to have technicians that work without supervision from a veterinarian, let’s just say, and all of this is hypothetical, and there’s no legal structure to support this happening or any of those things.
Some people say that this is the path to creating the mid-level practitioners. I think that some people get really bent out of shape when they hear that because they feel like it’s maybe not something that they like and they’re like, “Oh, is this is wedging that door open.” There’s other people who say, “No, this is an advancement of a veterinary technician as a career path.”
Then you hear a lot of the things that you touched on yourself where vet technician credentialing is such a quagmire right now. The whole thing is so messy and bogged down. I think there’s so much frustration. I really think that’s a huge reason why the vet nurse, whether we call technicians nurses or not, it’s a massive ugly debate. I think a lot of it comes down to frustration about licensing and protection of technician abilities and making the certified vet tech position valuable.
So there’s just so much frustration there. The whole thing just devolves into pieces. So that’s the nasty ball that I’m looking at. So yeah, as we start to talk about the master’s program, just start with me at the beginning and just say what’s the goal of a master’s program. Why would we do this? What are we trying to accomplish?

Dr. Bonnie Price:
Okay. Let me start earlier than that. Let me start with before … I came on board as director of this program February 22, 2022. So it was 2/22/22, which is cool start date.

Dr. Andy Roark:
Easy to remember.

Dr. Bonnie Price:
So I’ve been with the program about a year at this point. Our first class started this last fall. So when the program was originally conceived, this was, I mean, really, I think pre-pandemic that people first started talking about this Master’s of Veterinary Clinical Care Program. So that was before I was on board, but I was with LMU. So I did hear a little bit about it, and I was pulled in from time to time because before I took this job, I was the department chair of the undergraduate veterinary programs at LMU, so the pre-vet program and the veterinary technician program.
So the original idea for this program came about at a veterinary innovation council meeting, and some people were talking about workforce shortages, and the idea of a mid-level provider came up. The idea was a mid-level provider could solve a lot of these problems that you brought up right at the start. We’ve got workforce shortage. We need people in to see clients. We need to improve practice efficiency. We need to improve access to care in the profession.
So the mid-level provider was the innovation that came from that meeting. So a number of those people that were involved in that conversation are associated with LMU in different ways, either on the College of Veterinary Medicine Advisory Board, former employees of LMU. So they started saying, “Well, what could LMU do about this?” So they wanted to create a master’s program that was truly more of a mid-level provider when you think of a physician’s assistant kind of thing, right?
So a lot of the early conversations about that program are rooted in that origin. So over time though, it’s evolved. So once I started getting involved, my background is in vet tech education, and so I had some thoughts about where the master’s program should go. I had some concerns. So one of my biggest concerns was that there’s no, as you mentioned, laws to support a scope of practice for a mid-level provider, right? So in every state in the country, the only person that can establish a VCPR is a veterinarian. The only person that can diagnose, prescribe, prognose, perform surgery is a veterinarian. So we can’t create a program for somebody to do those things if they can’t legally do those things.
However, having worked with technicians for about 10 years at an associate’s and bachelor’s level with the undergrad programs, I knew that many of my students were frustrated that they didn’t have more opportunities to advance their education, and having talked with other tech educators, I knew that there was a need for advanced education for technicians.
So veterinary technology is, from an educational perspective, really unusual profession. So veterinary technician programs are accredited by the CVTEA through the AVMA. There’s one set of accreditation standards or skills and knowledge that they need to know, whether it’s associate’s program or a bachelor’s program, there’s one set of skills. Does that make sense?

Dr. Andy Roark:
Yeah.

Dr. Bonnie Price:
So there’s no distinction in the accreditation between an associate and a bachelor’s level. So really, if you look at it from that perspective, veterinary technology is a profession made up of individuals with associate level skills and training. That’s unusual for a healthcare profession to only have somebody at that associate level. So we’re starting to see bachelor’s programs. There’s about 28 in the country right now.
So the guidance that they have from the CVTEA is to build on those associate level skills that are accredited, but there’s not a distinct set of bachelor’s level skills the way there is in … If you look at human nursing, there’s a set of things you learn at the associate level. There’s a set of standards at a bachelor’s level, a set at the master’s, a set at the doctoral level. So this to me is interesting.
So then when we start looking at technicians, technicians, I mean, you love technicians as much as I do it sounds like. Technicians are smart and they want to learn more about what they’re doing and they don’t have an opportunity. I know a lot of technicians, including some DBMs that teach in my program that were technicians who wanted to learn more. They didn’t have anything to do, but go to vet school. So I’ve seen really smart technicians, we lose them to vet school.
Over the years being a tech educator, I’ve thought, “What if there was an opportunity for techs that wasn’t going to vet school if they wanted to get a master’s or a doctoral degree?” So that was where I was coming from when I came into these conversations about this program.
So we’ve got this set of things that these guys wanted to do originally, which is improve practice efficiency, improve access to care, and I thought a really strong technician workforce can do that. If we utilize the technicians that we have now to the top of their license and then if we make opportunities for technicians to learn even more knowledge and skill and veterinary technology, scientific theory, medicine, then we can have a really, really strong technician workforce. So we can have tiers. We can have people up to, I mean eventually, I’d love to see a doctoral degree. We’re technicians, but I think we’re there.
It’s like the VTS, so the vet tech specialist. Having more people with more knowledge in their field is only going to improve our profession if then we as the veterinarians use those people. So the first part, my agenda is to create an educational pathway for these technicians that want to learn more about what they’re doing.
Then the second part is to actually teach veterinarians what a technician is, how they’re educated, what they can do. So the second thing that I’m doing at LMU is I’m actually going to start teaching in the veterinarian curriculum talking about those things, who is a vet tech, how are they educated, what are the skills they know, how do you use those skills efficiently in a practice, how do you delegate work, that kind of thing. So that’s where the program went, right? So now, what the program is is we are a master’s program for credentialed veterinary technicians, and we build on the knowledge and skills learned in those CVTEA accredited programs at a master’s level.

Dr. Andy Roark:
Okay. All right. I want to say this back to you and make sure that I got it, okay? So what we have right now is we have credentialed veterinary technician programs, and those tend to happen at either an associate level or a bachelor level, but they basically turn out the same degree even those investments may be different. Is that right?

Dr. Bonnie Price:
I mean, sort of. I don’t want to say they turn out the same degree, but technically, there isn’t any guarantee of difference. Does that make sense?

Dr. Andy Roark:
Right. Yes, exactly right.

Dr. Bonnie Price:
I know vet tech bachelor’s programs are really good. I know a lot of people at work.

Dr. Andy Roark:
I get that. So I guess what I’m looking at now is we’ve got these credentialed programs. So we have an associate level and a bachelor level, and so they turn this out. There’s also the veterinary technician specialty program, which is like going into specialty and being boarded, but it’s very specific in a certain topic. So what you’re talking about is adding in a master’s level as well to broaden the learning path beyond getting your credentials. I think that that’s very, very true for technicians.
I think one of the reasons that we lose technicians so much is they come up, they get their certified vet tech degree, and then this is your life forever, and they go, “You mean I’m done? I’m 26 years old and I’m done?” They’re like, “Yup. We hope you enjoy this because there’s nowhere else to go,” and they leave the profession. I think it’s a real problem.
I think that is also a problem, just so you know, with general practice veterinarians. I think that that’s something. There is a lot of people who get their DVM and then after a while, they feel stale and it’s like there’s not a clear growth pattern beyond that. I think that that’s a problem in our profession.
So you were talking about adding in this master’s degree. It’s not the same as a technician specialty credentialing. You know what I mean? It is continuing down that developmental pathway. So that makes sense to me I guess as far as what it is.
My question is when we get to this point, what functionally does this look like? So we’ve already talked about the problem with having the bachelor’s and the associate’s and functionally when they come out, there’s no protected difference between those degrees. How is the master’s program going to be different from that? What does this unlocked for them I guess is the question.

Dr. Bonnie Price:
Yeah. So for me, the master’s program, I mean, it’s the same way an associate program or a bachelor’s program isn’t a set specific career, but I think it sounds to me what you’re asking is clinically what can they do differently or just-

Dr. Andy Roark:
No, I mean, honestly, if you said to me, “This master’s is a path into industry,” I would say, “Okay,” and I would understand that that’s what it was. If you said, “This is a path to teaching in other veterinary technician programs,” I would say, “Okay.” I get that, but that’s really the question I’m putting back to you is to say, let’s say that my daughter, Jacqueline, who loves vet techs and can see that as a potential job, let’s say that she … She’s 15, she’s always away. Let’s just say that she gets her CVT and she’s looking at this program and she would say, “Dad, I want to go to this program,” and I would say, “Yeah, what are you going to do with that degree, Jacqueline?” Help Jacqueline answer that question.

Dr. Bonnie Price:
So I think there’s a lot of things to do, and I think you said a couple of them, right? So the same way there are jobs for associate level technicians in all of these places, there, I think, are jobs for master’s level technicians in these places. So right now, I know a lot of techs with master’s degrees. The master’s degrees they have are in things other than their field, other than veterinary technology. So business, education, with maybe some random, I think I know one with a history master’s, right?
So here, we’ve got more knowledge about veterinary technology so right away, opportunities in education. So we can get really into the weeds. This is my area as a academic administrator, but we can get super into the weeds about rules about who can and cannot be faculty at different colleges, but it’s difficult, particularly when you get to four-year institutions. It’s difficult to have technicians as instructors and faculty because of institutional accreditation requirements for terminal degrees.
So if we’ve got a technician who wants to teach at a four-year college in a technician program, right now, the terminal degree in veterinary technology is a bachelor’s degree. So they could not teach any … Technically, the only degree that they would be allowed to teach would be at associate’s level. Does that make sense?

Dr. Andy Roark:
Yeah.

Dr. Bonnie Price:
So then we get into these tricky ways to get around that at a lot of four-year colleges, where they get different master’s degrees and maybe some certificates in veterinary tech, right? It just gets complicated. So what ends up happening because it’s easier is veterinarians end up teaching technicians how to be technicians when we know that veterinarians don’t know what technicians can do. It should be up to the technician to do it.
So as we start increasing education levels terminal degrees for technicians, then they’ve got more opportunities in an academic setting to get faculty and instructor positions. With those kinds of positions come things like research opportunities. So then we can have technicians doing research in the field, advancing veterinary technology and veterinary nursing in that way.
So I think there’s a lot of academic and research potential, but that’s not the only potential. I also think that clinically, the same way VTSs can bring a lot to the table clinically, a master’s level technician is going to be able to bring a lot. So our students are going to have that same focus as a VTS, but they’ve got a broader knowledge. So instead of just an anesthesia focus or an emergency critical care focus, we’ve got a broader knowledge in surgery, anesthesia, internal medicine.
So here, within the existing practice acts, I think there’s a lot more that VTSs and master’s level technicians will be able to do without delving into that diagnosis, prognosis, prescribing, surgery. So if we think of, I know clinics that use ECC or internal medicine VTSs to do initial triage, do initial patient assessment, come up with differential diagnoses, I mean, we’re not diagnosing, we’re just preparing a differential list and getting those diagnostics started before a veterinarian sees that patient, and that is all within existing practice. So if we’ve got these really smart master’s level technicians, we can start to improve efficiency and practices that way.
So I’ve got about 30 students in this first class. Most of them are working in small animal practice, and the majority of them are in leadership roles. A lot of them are responsible for training programs within the practice. One of the big conversations that we have is just about the realities of their practices.
Now, ideally, they only want credential technicians doing the work that credential technicians should do, but there are workforce shortages everywhere. Some of my students are the only credentialed technicians in their practice. So they’re kind of practice manager, head technician, and they’ve got to train these veterinary assistants to do things. So understanding veterinary technology and medicine and all these things at a higher level is already helping them make better decisions in their practice in terms of leadership and leading their technician and assistant teams.

Dr. Andy Roark:
Okay. That makes sense to me. I can see that.
Hey, guys, I just want to hop in really quick and give a quick plug. The Uncharted Veterinary Conference is coming in April. Guys, I founded the Uncharted Veterinary Conference in 2017, it is a one-of-a-kind conference. It is all about business. It is about internal communications, working effectively inside your practice. If you’re a leader, that means you can be a medical director, it means you can be an associate of vet who really wants to work well with your technicians, it means you can be a head technician, a head CSR, you can be a practice owner, practice manager, multi-site manager, multi-site medical director. We work with a lot of those people. This is all about building systems, setting expectations to work effectively with your people.
Guys, Uncharted is a pure mentorship conference. That means that we come together and there is a lot of discussion. We create a significant percentage of the schedule, the agenda at the event, which means we are going to talk about the things that you are interested in. It is always, as I said, business communication focused, but a lot of freedom inside that to make sure that you get to talk about what you want to talk about. We really prioritize people being able to have one-on-one conversations to pick people’s brains, to get advice from people who have wrestled with the problems that they are currently wrestled with. We make all that stuff happen.
If you want to come to a conference where you do not sit and get lectured at but you work on your own practice, your own challenges, your own growth and development, that’s what Uncharted is. Take a chance. Give us a look. Come and check it out. It is in April. I’ll put a link in the show notes for registration. Ask anybody who’s been, it’s something special. All right. Let’s get back into this episode.
Talk to me about the pushback against this program because there are definitely people who have strong negative opinions. I’m personally surprised when I see this, but do me a favor and lay down the push against this program for me in a way to understand where people are coming from.

Dr. Bonnie Price:
So I think the biggest pushback I get and, honestly, so honestly, it’s the concerns I had. So I took this job because my dean is going to kill me. I shouldn’t say this, but I’m going to say it, Andy. Okay. So I was asked a couple of times if I was interested in this position and I kept saying no.

Dr. Andy Roark:
“Oh, my God! I don’t need that kind of stress.”

Dr. Bonnie Price:
Yeah. I was like, “No,” because I knew, right? I knew that everyone would be looking at it. I had a great job. I loved my job as department chair with the undergrad programs working with undergrads, but I did see this as a really great opportunity to advance education for technicians, and I had some concerns that I thought if I can get in, I can put the breaks on things a little bit and we can be a little more organized about our approach, if that makes sense.
So the concerns that I had coming into it were we don’t have any laws to support a mid-level provider. I do not like the term mid-level provider because I think everyone’s definition of what that is is different, right? We can all say that word and no one is talking about the same thing. So I don’t like the term mid-level provider, and I wasn’t, honestly, I wasn’t even sure when I took this job, if I liked the idea of a mid-level provider, period, but my opinion on that has changed and I’m happy to talk about that later.
Originally, this program had different requirements for entry. So it wasn’t only for credentialed technicians, and so I thought, “God, it really needs to be right.” So there were lots of issues I had with it. I think the pushback that I’ve gotten since I’ve started the job, and I appreciate the profession’s honesty. I feel like people feel very comfortable telling me.

Dr. Andy Roark:
Oh, yeah, no, they’ll tell you, they’ll tell you what they think.

Dr. Bonnie Price:
Yeah, because I want to incorporate it, right? So I really do value the feedback I’ve gotten from people, but I think the biggest concerns I’ve had is how can you promise somebody that they’re going to be able to practice more sure after graduating, right? That’s not what the program is. I mean, years ago, that’s what the program started as, but that’s not what it is now. So it’s really a master’s program for credentialed veterinary technicians.
I think the other pushback, the other biggest pushback I get is return on investment. So that’s a phrase I hear a lot, ROI, “What’s the ROI of this program?” So that one is really interesting to me, and the answer is I don’t know. We don’t know because this is the first class.

Dr. Andy Roark:
You’re talking to a guy who has a master’s degree in zoology. I have that and I go, “Yeah, it’s kind of …” I think ROI is a great question. Like I said, if my daughter wants to go, I’m going to ask her, “What does it get you?” I have a master’s in zoology and it did not unlock thousands of wealth for me, just so you know. I don’t know that I can justify having it, but I loved it and I did it and it informs the way that I think, and I am a better student of life because I had this experience and I have this knowledge and the process of going through it and just doing something I was passionate about. So I totally understand that.

Dr. Bonnie Price:
So that’s funny because I threw that question. I threw the ROI question out to my students in a discussion board last fall. I was like, “All right. What’s the ROI, guys?” I actually have a student whose bachelor’s degree is in, I think it’s business administration, something business, right? She said, “Listen, the first thing we learn in school about ROI is that financial ROI is not the only kind of ROI. It’s not the only way you measure returns.”
So a lot of my students, the ROI for them is what you just described, “I know more about this thing. I’ve got this education. I can do more at my job with it.” I will say that most of my students have already negotiated for more money once they finish this program or they’ve negotiated for their employer to pay for part of it or all of it. So they’re already doing that. The program itself is a really affordable master’s program. So right now as we’re recording, it’s around $20,000 for the whole master’s program, which isn’t bad.
The other pushback I get … So ROI is the big one. I don’t know how much more on average these students are going to make when they graduate, but I do know that they have definitely come into this understanding that they may or may not make more even though they’ve made that decision. The other thing … Oh, I lost my train of thought. Hang on.

Dr. Andy Roark:
Well, I’ll jump in and say it’s interesting too how people think about education in a lot of ways. A lot of it is a confidence thing for people. A lot of it is feeling like they’re capable of doing other things. There are some people who feel like they could never stand in front of a class and teach if they didn’t feel like they had credentials that clearly empower them to do that. You might say, “Well, you don’t technically need a master’s degree to do that work,” but I do think for some people it’s almost an emotional need to say, “I feel like I need to really have this knowledge if I’m going to present myself in this way.” So I don’t know. It’s just a different type of ROI. It’s definitely the money. You could say, “Well, you could save $20,000 and not do it,” but if you say, “Well, I need $20,000 to believe that I have this opportunity,” you can do that math for yourself.

Dr. Bonnie Price:
Yeah. I’ve got one student who works in veterinary technician education right now, doesn’t hold an instructor or faculty position. Once they complete this, they will, they will be eligible for that, which comes with, I mean, I think within a year or two, the program will have paid for itself. The other thing about master’s programs is … The other pushback I hear is that master’s programs have the worst lifetime ROI in terms of how much you pay for it and-

Dr. Andy Roark:
I get that.

Dr. Bonnie Price:
… the money that you’re going to get.

Dr. Andy Roark:
I get that.

Dr. Bonnie Price:
Let me tell you this. So I’ve been in education a while, and that, if you look at all of them together, that’s true. If you do an average of all master’s programs together, that’s true. I think the most popular master’s program in the country is an MBA and that has a negative return of investment, surprisingly, right?

Dr. Andy Roark:
That’s interesting.

Dr. Bonnie Price:
Negative return of investment. The ones that have the highest return of investment are master’s degrees in healthcare professions. So I’m hoping, I mean, obviously, we don’t know that it’s going to be the same for veterinary healthcare, but I’m hoping that that’s going to hold true for veterinary healthcare the same way it does for human healthcare.

Dr. Andy Roark:
Yeah. We are always, always optimistic about the future. I’m super optimistic for technicians in the future in vet medicine. I really think there’s huge upward potential there. I think that’s already tracking that way. So I am optimistic. I hope you’re right there.
Let’s talk a little bit about mid-level practitioners because that always comes up into this and people say, “Is this the path?” I’ve heard people say, “When human medicine started doing mid-level practitioners, they already had training programs before this was licensed to actually happen.” So I’ve heard that put forward in relationship to the program that you’re running.
So talk to me a little bit about mid-level practitioners. Really, I like what you said as far as when we say mid-level practitioners, everyone has a different picture in their head. I have 100% found that to be true. So when you say mid-level practitioner, what are you talking about? Then let’s start to talk about how that intersects with what you’re doing.

Dr. Bonnie Price:
Yeah. So I think in the sense that I think of it, well, I think of it in a few ways. One of the ways that I think about it is just I ask myself the basic question, “Would I be okay with …” and I do, I’m in the camp that if we have this advanced practice provider or mid-level provider in veterinary medicine, I think it should be a technician. So in my head I think, “Would I be comfortable working with a technician who does some level of diagnosis, prescription, even minor surgery?” and the answer is, “Yes, I would.” If I had training that I could feel good about, I have worked with VTSs and I’ve worked with people that aren’t even VTSs that are smarter than me. I know you’re like, “Hey, did you think about this?” and I’m like, “I did not think about that.” So I know. I know that techs could do it, right?
I live in a part of the country where almost all of my healthcare providers are either nurse practitioners or physician’s assistants. They are wonderful. I mean, I know that this isn’t something that only a veterinary can do. I’ve worked, I’ve got an MPH. I’ve worked in parts of the world where non-healthcare providers are trained to do specific skills. So for example, they’ve got … So I’ve worked in parts of Africa where people who have not gone to school to be doctors or nurses are trained how to do one surgical procedure, and they do that surgical procedure better than doctors and nurses from other parts of the world, right?
So this isn’t something that I think only a veterinarian can do, but we’ve got to agree on what we’re comfortable letting technicians do that encroaches into those four things that only a vet can do right now. In the UK, vet nurses are already, veterinary nurses are already performing minor surgical procedures. They’re doing disbudding without a veterinarian present. They’re doing mass removals. You know what I mean? So we’ve already got that in other parts of the world.
So I think the conversation, look, I think let’s start here at this baseline and then maybe set some goals for the next few years, five years, 10 years, but let’s start a conversation about rather than saying, “Do we want a mid-level provider?” let’s say, “When are we comfortable delegating to a highly trained technician, a VTS or a master’s level technician?” I think that we can agree on something. I think that we as a professional, we as veterinarians, we can be absolutely agree that there’s some things that we’re comfortable delegating.
I think for me also, being in a rural setting, it is hard for me. If I need to get healthcare for my animals outside of hours, I don’t have access, right? So then I start talking to technicians about, “Well, gosh, why couldn’t we get creative about how we’re using telehealth to establish VCPRs via telehealth with maybe a highly trained technician present? Let the animal …” Do you know what I mean?
So I think that we can start talking about these things and agreeing on things that are sensible. I think the first step is to figure out what are the real concerns that people have? So the things that I’ve heard about mid-level provider concerns, the one that I hear most commonly, and this one frustrates me the most is, “Well, look what it’s done to human medicine,” and I don’t know what that means because when I look at it, I think it’s improving-

Dr. Andy Roark:
Yeah, no, I get that. That’s a good question.

Dr. Bonnie Price:
I can go see a healthcare provider now because there’s a nurse practitioner in my town that I see. So I think more specifics there would be helpful. I think other concerns are what are these people going to be doing, but we can come up with a list. We can come up with a list of things that they’re going to do. We can come up with educational accreditation standards. We can come up with all these things if we just sit down and figure out what we’re scared of and what we’re okay with.

Dr. Andy Roark:
Yeah, no, that makes sense to me. I thought a lot about this, and I agree about mid-level practitioners looking differently in different people’s minds. I can imagine three or four different ways that something like this might look. It’s everything from the doc in a box model that we have now where in the human medicine you have a nurse practitioner at CVS by themself doing the thing, all the way over to basically the dental hygienist who’s working very independently in the building with the doctors. I could see we’re nowhere close to the dental hygienist model. We’ve talked about it for a freaking as long as I’ve been in the profession, and I don’t know that we’ve really … We’ve migrated in that way some degree, but anyway, I think this thing can manifest a lot of different ways-

Dr. Bonnie Price:
Yeah,. I agree.

Dr. Andy Roark:
… where technicians have autonomy to practice, to really take some of the workload off of veterinarians, to be part of the healthcare team, to have upward mobility in their training, in their education, in their income earning ability. I think all those things are really possible. The devil is in the details.
My worry in all of this is that people react so emotionally strongly that we can’t talk about it, and then veterinarians, I worry that veterinarians are going to take themselves out of the conversation, meaning, “I’m going to get mad. I’m going to dig in my heels. I’m not going to talk about this. I’m going to try to shut it down,” and then powerful external forces, namely pet owners, demanding service and entrepreneurs with money to make it happen coming in. They’re going to just make their own way and I don’t think we’re going to like it, and that, that’s my worry. So anyway-

Dr. Bonnie Price:
I 100% agree with you. So I was just going to say that … So the AVMA recently put out an article saying, “Oh, it’s not the time for a mid-level provider.” NAVTA, similarly, they did a survey among members saying, “Here are all these things. Where do you rank mid-level provider?” and it’s close to the bottom, right? So that’s fine. If you read what the AVMA said about all that, they’re legitimate concerns. We don’t have the laws in place. We don’t have the educational system in place, but those are things we can do, but what you just said is also my worry.
So we’ve got the AVMA doesn’t make the laws, right? NAVTA doesn’t make the laws. State legislatures make the laws about how we practice in our state. If we do start seeing pet owners lobbying together, industry lobbying together, we’ve got powerful organizations lobbying together, they can get in and start changing the laws. I think that we as a veterinary profession, veterinarians and veterinary technicians equal at the table need to have conversations about where we want this to go because I think that the pet owners, shelters, all of these other stakeholders are wanting to see change and they’re fed up, and it’s state legislatures that make the laws.

Dr. Andy Roark:
Right. That’s right. The cautionary tale that bothers me is the taxi drivers. The taxi drivers, I remember as Uber rolled over them, were clutching their medallions that they had paid for from the city that let them operate a licensed taxi and saying, “We paid for these. We have this agreement. The laws say that we’re the only ones who can deliver people around,” and all around them, Uber drivers just picked up their livelihood and drove away with it, and no one came in and protected them.
It was, yeah, the laws were set up for the taxi drivers and, yes, they did have a medallion and, yes, they did pay their dues and they did all the things they thought they were supposed to do, and when people wanted to ride an Uber and Uber showed up with a business model that worked and people who wanted to do the work, our country is set up so that the capitalists win.
I’m not commenting on good and bad and whatever, but it is what it is. I think about the frustration of those taxi drivers and I say I am concerned that those taxi drivers are going to be veterinarians who are pointing out what the state licenses or the state practice acts used to be and saying, “Oh, no, no, no. We are the ones who make that decision,” and I’m afraid that the rules change and we’re on the outside.
So I am not saying that to scare people. I think about it a lot. I think for me, I want to engage what pet owner desires are because I don’t think pet owners are okay waiting three weeks to get in to see us. So I think that I’m worried that by deprioritizing an issue that I think is important to pet owners and that looks like a massive business opportunity for outside forces, I’m worried that we are going to be reacting to what other people do to our profession instead of stepping forward as leaders of our profession, recognizing which way the tide is flowing and positioning ourselves in the most acceptable, most advantageous way possible.
I think 100% that there’s ways that technicians can have more independence and do more for us and veterinarians can benefit from that hugely. I also think there’s ways that the technicians can have more power and that veterinarians are damaged by that. A lot of it is how do you position yourself and how do you look at the situation and do you accept where things are going and read the writing on the wall and make some adjustments or do you dig in your heels until you get squished?
I hope that that’s not true, and I don’t mean to be morbid, but I really do look that way, regardless of whether you like the idea or not. I think you can say, “I like this idea,” or, “I don’t like this idea,” and in both cases, I still see these external pressures. I still see the way that things in our country tend to work, and I need to go ahead and position myself so that I can adjust and still be in a very good place while these changes happen.

Dr. Bonnie Price:
Yeah, and I feel like that’s the kind of pragmatism that we need to adopt, right? So if we close our eyes to this problem now, say we’re not ready as a profession and do nothing, we still won’t be ready in five years, right? All these external forces will maybe have moved on without us. So I think let’s be more organized as a profession and really have the conversations about what are the real legitimate concerns and how can we overcome those.
So one concern I hear a lot is in many states, nurse practitioners, I might be getting this wrong, either PAs or nurse practitioners can work independent of a physician. They can set up their own thing, right? So that I think is a big concern when people say, “Well, look what’s happened in human medicine.” I think that might be one of the things that they’re talking about, but we don’t have to do that. We can set our own rules. So if we’re organized now and we want people practicing under a veterinarian, then let’s start making those rules now. Do you see what I’m saying?

Dr. Andy Roark:
Oh, yeah.

Dr. Bonnie Price:
Get ourselves organized.

Dr. Andy Roark:
I have a podcast episode. It’ll be out when this episode comes live, but it’s not out as you and I are talking. I spoke with a founder of a company called Booster Pet, which is in the state of Washington, and it’s a practitioner. In Washington, technicians can work under indirect supervision from the doctors. Some of the practice stuff there was changed during the pandemic to allow establishment of a veterinary client, patient relationship virtually. So Booster Pet has a central clinical location, and they have wellness satellite locations where that do not have a doctor in the building, they have technicians and they have basically a telemedicine setup.
So the doctor appears on the screen in this building, and the technician does the wellness work, does everything. There has a video otoscope cameras to show the doctor thing, stuff like that, but there’s not a doctor in the building and the technician is working, and this is not an idea. This is happening in the state of Washington now.
I look at that and I process this and go, “The pet owners want it. It’s a lower cost examination.” I believe it’s a lower cost examination, but they can get in there, they can get seen. Sure, some people don’t want it, but there’s other people who say, “Wow, this is convenient, and I’m here for it.”
So anyway, again, I appreciate you referring to my view as pragmatic. That’s how I see myself. I am an optimist, but I am also a pragmatist, and you can balance those things. Anyway, I’m just looking at that a lot. As I said, I think this is an exciting time. I think this is a time of radical change in our profession.
Anyway, I really appreciate you taking time, Dr. Price, to come in and talk with me and just brainstorm. I could keep talking to you for another hour, for sure, but anyway, I’m going to let you go, but thanks for being here. If people want to learn more about the Master’s of Veterinary Clinical Care, where do they go?

Dr. Bonnie Price:
We have a website. So the easiest thing, honestly, to do is just Google Lincoln Memorial University Master’s of Veterinary Clinical Care and it’ll tell you the website because it’s, at the moment, not one of those easy short websites addresses, but it’ll take you to our website and you can check that out. That is the best way to do that, and that’s where all the information is.

Dr. Andy Roark:
All right. I’ll put a link in the show notes for people. I’ll run it down and it’ll be there, but otherwise, people listening can Google it. Thank you so much for being here. Guys, thanks for tuning in. I hope you enjoyed it. I hope you got something out of it. I will talk to you guys soon.
That is our episode. Guys, I hope you enjoyed it. I hope you got something out of it. Thanks again to Dr. Price for being here. Guys, thanks a lot for checking this out. If you enjoyed the podcast, if you got something out of it, do me a favor and leave me an honest review where you get podcasts. If you did not enjoy the podcast, wait and try another podcast and see what you think of that, and then see how you feel before you write a review. I don’t know. That’s just a thought. Anyway, guys, take care of yourselves. Be well. I’ll talk to you later. Bye.

Filed Under: Podcast Tagged With: Care, Vet Tech Life

My Plate Runneth Over: My Top Tip For Keeping ‘Busy’ From Becoming ‘Overwhelmed’

March 2, 2023 by Andy Roark DVM MS

I love picking up new colorful phrases. I especially find joy in short sayings that express a pile of emotions in itty-bitty packages. A recent phrase caught my attention when I asked someone how they have been doing and they replied “Busy. My plate runneth over.”

The combination of “my plate is full” with “my cup runneth over” really captures the experience of feeling overwhelmed by good things in a way I haven’t heard before.

I’m a big believer that staying busy is a positive thing. I find that I’m happier and feel better about myself when I’m steadily hustling from one project to the next. At the end of a busy day, assuming my pace is intentional rather than frantic, I feel accomplished and have enjoyed ticking things off my to-do list.

Crossing the line between ‘busy’ and ‘overwhelmed’

The problem I (and I’m sure others) experience is when busy becomes overwhelmed. Once I fall over that edge, I simply can’t get everything done. And my enjoyment of being productive begins to turn into a feeling of failure. 

Unfortunately, I’ve had this experience a lot over the past 6 months. My job at Uncharted has been wonderful, but endless, and my number of employees has more than doubled. We have so many active projects running that I’m genuinely excited about. My enthusiasm, however, has not saved me from occasionally feeling like I’m drowning in my task list. My plate has truly runneth over.

So what do you do when you get to this point? 

When you are too busy and honestly don’t think you can take projects or commitments off of your plate, how do you make peace with the fact that some days you simply can’t get everything done? Is there a healthier approach than just resigning yourself to trudging onward while trying not to think about how many things are piled on top of you?

How to undo your overwhelm

The solution that has made a huge difference for me is pretty simple: break my overwhelm into pieces and spread it out on the calendar. 

For example, getting a new hire effectively onboarded is an enormous task. It takes a lot of time. Projects like this can make me feel like I’m failing every day that I have not gotten this person fully onboarded. It’s this nagging feeling of not getting all your work done day-after-day for months. And it’s how a lot of people spend their time!

My advice is to imagine what a fully on-boarded person looks like. Then, break out the steps it would take to get your new hire to that point. Put those steps on the calendar spread over a reasonable timeframe. Now, you’re not failing because the new person is not fully onboarded. You’re succeeding because your goal for this week was to cover one specific part of their training and you did that. Also, next week doesn’t seem terrible because you only have to do the next piece of the program you created.

Yes, I know this sounds basic. But it can be life-changing. Think about the big thing that’s hanging over your head and decide what “done” looks like. Then write down the action steps it will take to get you there and put each one on your calendar. Voilà! You’re not struggling anymore. You’re running a manageable program… and you’re right on schedule.

Filed Under: Blog Tagged With: Perspective, Wellness

Congestive Heart Failure Drug Crash Course

March 1, 2023 by Andy Roark DVM MS

Veterinary cardiologist Dr. Anna McManamey joins the podcast to give us a quick and dirty refresher on the Congestive Heart Failure drugs just about every clinic is carrying. This is a great episode that is perfect for anyone who wants to dust off their cardiology drug knowledge and feel comfortable with the congestive heart failure tools on your vet clinic shelf.

Drugs Included in this episode:

  • Furosemide
  • Pimobendan
  • Clopidogrel
  • Atenolol
  • Amlodapine
  • Analypryl
  • Spironolactone
Cone Of Shame Veterinary Podcast · COS – 187 – Congestive Heart Failure Drug Crash Course

You can also listen to this episode on Apple Podcasts, Google Podcasts, Amazon Music, Soundcloud, YouTube or wherever you get your podcasts!

LINKS

Cardiac Education Group: https://cardiaceducationgroup.org/

Practice Managers’ Summit – March 22, 2023: https://unchartedvet.com/upcoming-events/

Uncharted Veterinary Conference – April 20-22, 2023: https://unchartedvet.com/uvc-april-2023/

Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/on-demand-staff-training/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. McManamey (aka Dr. Mac) is a veterinary cardiologist. She received her degree of veterinary medicine from the University of Missouri. She then completed a rotating internship at the Ohio State University followed by an emergency and critical care internship at North Carolina State University. She finished her cardiology residency at North Carolina State University and became an ACVIM diplomate in 2021.

Dr. Mac is currently an assistant clinical professor at Purdue University in Indiana. Cardiology is her favorite subject because it can be made as simple or as complex as needed. Furthermore, every animal has a heart and that means Dr. Mac gets to work with all kinds of species. Her areas of interest within cardiology are echocardiogram, congenital heart disease and interventional procedures, as well as emergency management of cardiac disease. She has a very supportive and patient husband along with three canine fur-children, one of which had a patent ductus arteriosus (of course).


EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:
Welcome, everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am here with the one and only, Dr. Anna McManamey, aka, Dr. Mack. She is a assistant clinical professor at Purdue. She’s amazing. I love talking to her. Guys, I got her in for this episode of just running through my congestive heart failure medications. She’s going to run through the cardiac medications on the shelf in relation to cardiac or to congestive heart failure, and just breaks down real quick. This is what you use this for, this is what I reach this for, this is what you pay attention for with this. Man, it is 15 minutes of just jam-packed education and pearls. So good, so useful, it’s great for veterinarians, it’s great for your technicians as well to listen to. Whether it’s a refresher for you or it’s just new information as you’re learning your cardiac medicines, this is a great episode. I’m so thrilled. Guys, let’s get into it.

Kelsey Beth Carpenter:
(singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:
Welcome to the podcast, Dr. Anna McManamey. How are you?

Dr. Anna McManamey:
I’m good, Andy. How are you?

Dr. Andy Roark:
I’m so good. It’s good to have you back, Dr. Mack. I love having you on the podcast. I’m super excited today, because I think we got one of these really, really, really useful episodes that people love. I wanted to run through the cardiac drugs in my clinic with you, and just a 100% get a refresher crash course of what’s on the average vet clinic shelf. When do you use it? When do you not use it? Just like that. I think it’s great. It’s great review for me. I did this with Tasha McNerney on anesthesia drugs in the anesthesia crash cart recently, and I just loved it. It made me feel so resharpened, and I just want to do that with you. Is that okay?

Dr. Anna McManamey:
I’m so excited. It’s great.

Dr. Andy Roark:
All right. Let’s do it. Where do you start when you look at your average vet clinic cardiac drugs?

Dr. Anna McManamey:
Yeah. I think, for me, there’s two categories that I would want to stock, and so being in the ivory tower, I’m very spoiled, like everything’s at my fingertips. But when it comes down to what I need to have there, and then I would say for the category of congestive heart failure management, I would include drugs, first and foremost furosemide. That’s going to be the go-to diuretic, it still is. Furosemide is also Lasix. It’s given that name, because it lasts six hours in the bloodstream, so it’s why it’s given the name Lasix.

Dr. Andy Roark:
I had no idea.

Dr. Anna McManamey:
… and that goal… Yes.

Dr. Andy Roark:
I had no idea that was true.

Dr. Anna McManamey:
I didn’t learn that till I was a resident. It’s not common knowledge, but that’s why it’s called that. Furosemide, any of the semide drugs, those are going to be your loop diuretics. They’re still the most effective diuretic that we have for treating congestive heart failure. The nice thing with furosemide is that it is oral, and as well as injectable. Having a bottle of injectable on your shelf, I think, is super important. You can give that subcutaneously, and you can give that intramuscularly, or you can give it IV.

Dr. Andy Roark:
Right.

Dr. Anna McManamey:
If I’ve got an animal that is clinical enough where they need oxygen support, I would recommend avoiding the subcutaneous dose. I would only do IV or IM, just because at that state, they’re not really perfusing their subcuta. But it’s nice, because you can give it any way you want and it’ll work. It works quick. It’s just still the best med.

Dr. Andy Roark:
Okay.

Dr. Anna McManamey:
Next one my list would be pimobendan, which I do vitamin P. I’m very obsessed with this drug, but pimobendan, especially in dogs. In the canine world, pimobendan or vetmedin is going to be the go-to next drug, for me. This is one that has proven time and time, and again to be beneficial for these dogs quality and quantity of life, in the state of congestive heart failure. It’s even been shown to help these dogs, before CHF even happens, so a few reasons to keep it on the shelf, but this drug has two main mechanisms. It is classified as an inodilator. It’s a positive inotrope, meaning it improves the contractility of the heart. It does this by basically causing more of a chance for the actin and myosin to meet cross-link, and form a crossbridge.
It’s a calcium sensitizer which is unique, because it doesn’t change the amount of calcium inside of the heart cell, which like digoxin was an old, tried, and true drug that does do that. The downside of increasing the amount of calcium in the cell is it’s pro-arrhythmic. The benefit with pimobendan is that, it’s less likely to develop arrhythmia secondary to the drug.

Dr. Andy Roark:
Gotcha.

Dr. Anna McManamey:
The other benefit is that it is an inodilator, so it’s a vasodilator. It actually does decrease the afterload on the left ventricle, as well as sometimes the right ventricle, based on where it’s going to cause vasodilation. Typically, it’s the veins, so we don’t see systemic hypotension developed with this drug, which is another benefit compared to something like an ACE inhibitor, for example. Two big reasons why I keep pimobendan high on my shelf, or should say low on my shelf, but high on my list, because it’s something that’s good for really any type of acquired canine heart disease, whether it’s degenerative valve disease, or dilated cardiomyopathy.
I will use pimobendan in some cases of cat heart failure as well. If I had cat who has congestive heart failure, doesn’t have a loud murmur, then I feel a little bit more comfortable using that drug. It is definitely considered off-label for that purpose, so you do have to have that conversation with your client. But if I have a cat, especially these older kitties that already have a degree of kidney disease, it’s nice to conserve the amount of Lasix that I need for that patient, so that’s my drug two.

Dr. Andy Roark:
Gotcha.

Dr. Anna McManamey:
And then staying on the cat theme, I would say, having clopidogrel or aspirin, something for blood thinning. Basically, cats that have congestive heart failure, they’re going to have large atria. One of the side effects and risk factors for cats with big atria is aortic thromboembolism, so don’t forget to add that treatment arm in there. We have evidence in the veterinary community that clopidogrel outperforms aspirin, so that’s my choice is clopidogrel. There’s injectable medications you can use as well, but clopidogrel is the easiest, I think, for most clients, and it’s once a day, which is nice, and it’s affordable.
And then the other thing for cats, I would say, I don’t think it’s as of much of an emergency drug, but would be things like atenolol, which is a beta blocker. We used to use this a lot more commonly in cats, until we found out that doing large retrospective studies, and even some smaller prospective studies, atenolol in the asymptomatic stage of heart disease in cats doesn’t seem to correlate to longer survival. This all came from human medicine, but I do think there are still going to be some cats that will benefit from atenolol therapy. Those are usually cats that have loud heart murmurs, or cats that have tacky arrhythmias, so fast heart rates. Atenolol is also an anti-arrhythmic. It can be used for supraventricular arrhythmias as well as ventricular arrhythmias in the cat, and is usually pretty well-tolerated. I also will use atenolol in cases where it’s got a cat that has a thyroid storm, so thyrotoxic heart disease, atenolol can be useful for those cats too.

Dr. Andy Roark:
Hey guys, I just want to jump in here with a quick update. Have you seen the Dr. Andy Roark team training courses yet? Guys, over drandyroark.com, I have got resources for people who want to work with their team. I have my angry client course, and I have my exam room toolbox course. These are great little modules that are made to be broken up, and popped into staff meetings, so that you can cover a quick topic about either dealing with angry clients, complaining clients, or to talk about different tools in working with clients in the exam room. Guys, this is fantastic. I’ve got discussion questions to ask your team, so they can talk about what they do, and just is a great way for everybody to see the same thing together, to talk about what works in the practice, and what they think is important, and just to get on the same page. Anyway, I hope you guys will check it out. It’s over at drandyroark.com. I’ll put a link in the show notes. Let’s get back into this episode. Are you using atenolol in dogs at all?

Dr. Anna McManamey:
The only real indication for atenolol in dogs is obstructive heart disease. In dogs, the most common forms of obstructive heart disease are congenital, it’s subaortic stenosis, and pulmonary stenosis. In those animals, the atenolol is purely myocardial protective. Usually, I’m using that in the asymptomatic stages, and then adding in a diuretic once they develop congestive heart failure. But it’s rarely going to be a drug that I am pulling off in case of an emergency, if that makes sense.

Dr. Andy Roark:
Yeah.

Dr. Anna McManamey:
Usually, the cardiologist’s rule is don’t give a beta blocker to a vet patient. A patient that has active pulmonary edema, or pleural effusion, you probably run a greater risk of just worsening their heart contractility, and lowering their heart rate when they need those things in that emergency setting, but still one, I think, is worth having around.

Dr. Andy Roark:
Okay, perfect.

Dr. Anna McManamey:
And then the final one I have really is just in case is, but is amlodipine. This is a blood pressure medication. It is a calcium channel blocker. It really acts preferentially on the cardiovascular system, and just the vascular aspect. We don’t really see changes to the heart itself with amlodipine, but out in the blood vessels, it causes vasodilation. This is another drug I can use in two ways. Both of them have the same goal. The goal is to decrease the afterload on the left ventricle. If you are a cat or a dog, and you have systemic hypertension, well, amlodipine will vasodilate your blood vessels, drop your systemic blood pressure, and that decreases the work on that left ventricle.
Conversely, if I have a dog that has really bad mitral valve disease, really a lot of mitral regurgitation, even if they’re not textbook systemically hypertensive, so I’m talking about a blood pressure that’s less than 160 millimeters of mercury systolic, but greater than one 120 millimeters of mercury systolic. A small window, but a lot of dogs fall in there. I might use a little dose of amlodipine to drop that afterload on the left ventricle, because whatever pressure is in that aorta is the pressure that left ventricle has to generate to get blood to go forward. It’s this fun hemodynamic game I can play with severe mitral valve disease dogs. That can preserve the need for a lot of diuretics, and so I call it a fun hemodynamic game. I think other people are too.

Dr. Andy Roark:
No, I just love if that’s how you see it. I’m like, hi, this is a person who loves their job. I love it.

Dr. Anna McManamey:
Yeah. It’s just finding those balances, what can I manipulate to improve cardiac output? I would say, again, those big five drugs from me would furosemide, so my root diuretic pimobendan, my inodilator clopidogrel for kittycat, so it’s a blood thinner to prevent ATE, and then amlodipine, and atenolol just on standby for those instances where they might come in handy. I think other drugs that I have to talk about, but I don’t think have to be on your shelf for a quick grab are your ACE inhibitors, so the enalapril, vasopril, those pill drugs are very important to the long-term management of heart disease. These have definitely proven their use in congestive heart failure patients, long-term. Same thing goes with spironolactone, which is an aldosterone antagonist. The ACE inhibitor, and the spironolactone together do a really nice job blocking the RAS system.
Trying to prevent the formation of angiotensin II, and aldosterone, because both of those hormones are automatically activated in congestive heart failure. Ironically, they get upregulated when the patient is on a diuretic. We have two reasons the RAS system activates with congestive heart failure, the state of CHF, and the fact that we put them on a diuretic, so we need to suppress that system in order to have the best long-term prognosis. These drugs prevent the angiotensin II, and the aldosterone activity within the body. The reason cardiologists don’t like those hormones is, because those both cause vasoconstriction. That increases afterload on the heart. They cause water retention, and sodium retention, which increases the preload to the heart. They have fibrotic mechanisms, so they actually cause fibrosis within the heart, the blood vessels, and even the kidney, the glomerulus. Chronic activation of these is maladaptive. Those are my [inaudible 00:13:26] drugs.

Dr. Andy Roark:
Gotcha.

Dr. Anna McManamey:
Yeah.

Dr. Andy Roark:
Gotcha. I love it. Can you give me some wisdom, some of your little pearls on dosage and frequency with Lasix? It feels like voodoo to me, where you kind of go, “I don’t know, maybe a little bit more and I don’t, let’s just try six hours instead of eight.” I know that some of it is more art and science, but help me. How do you get your head around that? And then when you’re talking about adding your ACE inhibitor, and your spironolactone, stuff like that, I go, “How do I manage these things together?” Because I feel, it feels like a blunt instrument in my hand sometimes, Lasix specifically. Help me feel a little bit more, I don’t know, a little more nuanced in that usage, please.

Dr. Anna McManamey:
Sure. It’s a great question. I always teach, we always tell students, go look up the dose, and tell us what you want. But if you look up the dose of Furosemide, it’s like one to four mg per kg, once to six times a day. There’s such-

Dr. Andy Roark:
Yeah. It’s huge.

Dr. Anna McManamey:
The nice thing with a diuretic is that it is a high-ceiling diuretic, so you just keep giving more until you get the effect that you want. If you overdo it, you just scale back.

Dr. Andy Roark:
Right.

Dr. Anna McManamey:
Really, it’s very much an art, and a gut feeling. What I would say is a very standard starting place for Lasix therapy, I would say, in a dog, it’s usually two milligrams per kilogram every 12 hours.

Dr. Andy Roark:
Okay.

Dr. Anna McManamey:
In a cat. We’re usually a little bit more conservative. Again, most of them are a little bit older cats. They also might have underlying kidney disease, and their plasma volume volume is just different, so we usually do one mg per kg, every 12 hours. In cats, it’s usually a pretty standard starting dose. I would say that, if I’m going to start a diuretic, that patient is either about to be in CHF, they have enough clinical signs, and enough concern, or they’re already definitely in it.
When I start that medication, I’m not looking to take it away later. I’ve seen those protocols where you start them high, and then you taper them off of the drug. I don’t think that’s going to work for most of these patients. I pick a dose, I start there, and then really it’s about teaching the client to count breathing rates at home, and use clinical signs, and your blood work as well as any imaging you can acquire to help you fine-tune that dose. What I do with my patients when I discharge them from the hospital, I say, “You have the diagnosis, it’s CHF, congestive heart failure. We’re going to start a diuretic.” Again, two mg per kg BID for a dog, one mg per kg BID for a cat. I let them know this does increase urination, so they will be very thirsty, and they have to always provide water.
I also let them know that the medication takes effect about two hours after they get it orally, so they will really have to go potty about two and a halfish hours after it’s given. That can save some of the 2:00 AM trips outside, if you don’t give it at midnight. Those are the little pearls for the clients. And then really it’s, are their breathing rates less than 40 when they’re sleeping? Is the coughing improved? Are they eating? If they’re doing those things, I’m happy with my dose. If the breathing rates are over 40 when they’re sleeping, breaths a minute, if they’re still coughing a lot, I would increase my dose by about 25%, over the course of the day. If that’s still not helping, I’d say, “Probably, I need to get you back in, and see if we made an improvement radiographically of what’s going on, or am I targeting the wrong thing, what have you?”
Typically, my recheck plans are radiographs, physical history, and then looking at renal panels. The view in creatinine and the electrolytes, those things help tell you if you’re overdoing your drug. That helps me know if I need to scale back. I think using those two things together can help you make a more objective decision about what to do. But, in general, I start with that dose, two mg per kg BID for dog, one mg per kg, for cat BID, and then I go from there. If I’m not controlling clinical signs, I escalate my therapy by 25%, and that’s what I do every time. There are some animals where I think, if they’re older, more crunchy kidneys, I usually like to spread out my dosing a little bit more frequently. Instead of doing two doses in a day, see if they can do the same daily dose, but three times a day.

Dr. Andy Roark:
Gotcha.

Dr. Anna McManamey:
Maybe give the kidneys a little bit more of a break, and the body more time to recover that volume loss. And then really from there, we tend to start considering doses over eight mgs per kg per day. That’s when we’re in the, wow. These are really high doses of diuretics.

Dr. Andy Roark:
Gotcha.

Dr. Anna McManamey:
We either need to switch diuretics to a more potent one, or we need to escalate other therapies instead.

Dr. Andy Roark:
Gotcha. That totally makes sense. Man, this is fantastic. I really appreciate this. This was wonderful, wonderful, wonderful. It’s a wonderful refresher. I really appreciate your time. Dr. Mack, you are an assistant clinical professor at Purdue. Where can people find you online? Where can they read more? Are there any resources that you are a huge fan of, in the field of cardiology, that you wish people knew about?

Dr. Anna McManamey:
Yeah. You can Google me, Anna McManamey. I would put Purdue with it, because the other Anna McManamey in the world is a beautiful blonde, bombshell bodybuilder from Australia. She’s not me. I have a lot to live up to with that, yes. But Purdue, Anna McManamey, I’m on their website there. There may be some lingering stuff from the NC State as well. But that’s probably the easiest way. I think in terms of resources, I am a big fan of the Cardiac Education Group, and I think I’ve mentioned that before on a podcast, but it is just cardiaceducationgroup.org. It is sponsored by BI, but it’s really well put together. Many of my mentors help run that site. It’s got great drug formularies for dogs, and cats. It has the doses, what pallet sizes they come in, which is also very helpful, I think, side effects. They’ve got practice cases. I just think it’s a really good starting point. That and the VIN, I think are probably my favorite.

Dr. Andy Roark:
Yeah. Outstanding. I’ll put links in the show notes for that. Thank you so much for being here.

Dr. Anna McManamey:
You’re welcome. Thanks for having me.

Dr. Andy Roark:
That is our episode. Guys, I hope you enjoyed it. I hope you got something out of it. Special thanks to Dr. Mack for being here. Guys, if you enjoyed the podcast, leave me an honest review, wherever you get your podcasts. It really does help people find the show. If you’re like, this is great, share it with your friends. Spread the learning love. Anyway, gang, take care of yourselves. Be well. I’ll talk to you later on. Bye.

Filed Under: Podcast Tagged With: Medicine

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