Dr. Christopher Pachel joins Dr. Andy Roark on the Cone of Shame podcast to discuss the intriguing case of Caliente, a seven-year-old calico cat exhibiting inappropriate urination. Despite the pet owners attributing the behavior to behavioral issues, the duo explores the underlying medical complexities. Tune in as they expertly navigate this conversation by validating the pet owners while shedding light on potential medical conditions driving Caliente’s actions.
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LINKS
Dr. Christopher Pachel: www.DrPachel.com
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. Chris Pachel is a board-certified veterinary behaviorist and is the owner and lead clinician at the Animal Behavior Clinic in Portland, Oregon. Dr. Pachel lectures extensively worldwide, teaches courses at multiple veterinary schools in the United States, and has authored numerous articles and book chapters for veterinarians and pet owners. He is a sought-after expert witness for legal cases and serves on the Editorial Advisory Board for dvm360. He is also a Vice-president of Veterinary Behavior for Instinct Dog Behavior and Training, as well as co-owner of Instinct Portland, which opened in the fall of 2020.
EPISODE TRANSCRIPT
Dr. Andy Roark: Welcome everybody to the Come to Shame veterinary podcast. I am your host Dr. Andrew Roark. Guys, I got a great How do you treat that episode today? I am here with vet behaviorist, Dr. Christopher Pachel. He is a boy. He is fun. He has got, he’s just, he’s got such great energy and I love how he talks about what he says and how he says it.
It’s one of, this is one of those conversations where you hear just, he’s just pearls, he’s just scattering pearls everywhere. And it’s just, you could hear him in the exam room having these conversations. And I was just like, I’m writing that line down. Ooh, I could hear me saying that and I just got so many things that I would actually say to a pet owner.
Such a good conversation. So much fun. We are talking about medical conditions that masquerade as behavior problems. So this is a behavior consult that’s not. it’s anyway, it just, I love his perspective on this. Really good conversation. I think this is good stuff to file away. Anybody who likes behavior is going to love this episode.
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. Christopher Pachel. How are you?
Dr. Chris Pachel: I am doing fantastic, Dr. Roark. How are you today?
Dr. Andy Roark: I Man, I’m so good. I’m so glad that you’re here. You and I have sort of circled around the same circles for a long time. We’ve got a lot of mutual friends. And we only got to meet recently, and you are so fun. I really– Every time I talk to you, I leave with a smile on my face. I caught up with you and we started to sort of talk shop a bit in Orlando early this year and you were laying out a couple of lectures and I was like, Oh man, this is really interesting stuff.
And so I’m so glad you made time to be on the podcast. For those who don’t know you, you are a boarded veterinary behaviorist and lecturer. I have a case that I wanted to run by you if that’s okay. right. He’s making the anticipatory evil genius finger sign.
Alright, here we go. I have got a seven year old female spayed calico cat named Caliente, who goes by Callie for short. And she is urinating inappropriately. And this is not Unusual for her this has kind of been going on and on the owners are not really big on diagnostics they have said no she is spicy It is the spiciness that is causing Caliente to pee outside of the box and they seem pretty adamant about it I am as this problem persists, I am less and less okay with this, but, I’m going to have to wade in and talk to these people.
Their position is, she’s seven years old and has always been spicy and this, she’s just doing this because she’s unhappy. And so I just wanted to kind of run that back to you a little bit and say, When you get these cases that people say, this is a behavioral case or this is anxiety, things like that.
How straight away do you buy that? And what landmines do I need to look out for in these presentations?
Dr. Chris Pachel: That’s such a great question. And that scenario is so incredibly common where an owner comes in with a I almost said a premonition. That’s not exactly right, right? But that’s sort of a a pre existing idea about what’s going on here. And I find that for a lot of clients. So when that happens, even as they’re giving me the answers to my question, I can almost feel them trying to lead the responses into a different direction where everything comes back to, you know, her emotionality.
She’s got big feelings. She’s really spiteful. So therefore, yeah. That becomes the explanation for a lot of things. And so when I recognize that as a bit of a tip off, my first response is typically to say, you know, it sounds like, you know, your Cali or Caliente, you know, her really, well.
And I’m excited to get to know her right alongside you. I’ve got some additional questions for you to really be able to, make sure that if this is a behavior issue, we really figure out what we’re going to do about it and how we do that. In the meantime, I’m also going to be listening for other things that could actually be there because of an underlying medical issue that might not be all that obvious right at first glance. So if it’s okay with you, let’s dive into some of those questions and let’s see where the conversation takes
Dr. Andy Roark: Oh, I love that from a conversational standpoint just the opening up of you are clearly in tune with her. You are– this is great. I am so glad you are here. I really like that approach and then just introducing the idea there may be other things go off, Chris. That’s really a really nice introduction. I like this opening the conversation.
So great, so you start to put those things forward, what are we talking about here when we see these things coming in? So talk to me a little bit about the medical conditions that manifest as behavior, if you don’t mind.
Dr. Chris Pachel: absolutely. So there’s a number of them that I would say we see with increased frequency compared to others. And certainly in a case like this, where the primary concern is elimination outside of the litter box, you know, certainly, you know, we might tease that out. Are we talking about stool?
Are we talking about urine? And we might go down that systems based approach. They’re really wanting to, I guess, in the ideal world where everything is convenient and nothing costs Money we’d be able to get those diagnostics to rule those things out. But my clients have the same sort of pushback that yours do and that everybody listening to the podcast, you know, it, isn’t necessarily convenient.
Maybe Caliente has different ideas about how she wants to donate a urine sample today, and so we’re flying blind a little bit with our diagnostics. So all of that to say, I’m looking for underlying, you know, issues relative to the urinary tract. So anything that’s creating you know, increase urine volume or urgency and whether that’s a urinary tract infection or stones or even some of the other systems and that’s perhaps some of the endocrine disorders like hyperthyroidism or diabetes that may impact urine volume or the overall patterns for elimination.
And then we broaden it even further to say, is there anything that might be causing discomfort? And especially when we think about a seven year old cat, we say, oh, well, she’s young and healthy. Therefore, it’s probably unlikely that it’s a medical issue. And yet, the more we learn about cats and things like osteoarthritis, the more we start to recognize some of those patterns that even for a cat who is urinating outside of the litter box, that can be discomfort, right?
She has to crouch, she has to posture. She has to walk on, you know, a shifting stand, sort of a surface that can cause discomfort for some cats. We also find in those cats where discomfort is an issue, even sometimes seeing a differential response between urination and defecation, knowing that the physical posture that cat needs to assume for those two elimination events is actually different.
And we can see a lot of specificity of one patter over the other.
So I’m looking for all of those things within my clinical history, within my observation, and certainly within my physical exam.
Dr. Andy Roark: I talked to a dog owner this morning who came in and the present presenting complaint was He’s an old dog. He’s a Westie and 17 year old Westie and he said oh, you know, his biggest problem is that he holds his urine. We have to really convince him to go and my immediate question was around mobility and pain and things like that.
Chris, can you talk a little bit about the interface between pain, discomfort and behavioral presentations? Just, I know that’s sort of a broad topic, but how often do you see this? How often do things make their way to the behaviorist and you’re still, and you’re still thinking about pain or discomfort?
Dr. Chris Pachel: I would say pain and discomfort is probably the most common underlying issue that has not been fully recognized or addressed in our patient population at the behavior clinic. And obviously that can come from a variety of different places, whether it’s a, You know, untreated allergies, and we’re creating itch and pruritus and discomfort in that direction, whether it is low grade chronic, you know, IBD, IBS type signs, and we’re seeing that, that visceral discomfort associated with gastrointestinal disorders, or whether we’re talking musculoskeletal issues, maybe it’s the partially torn cruciate, maybe it’s LS disease, or maybe it’s a type of discomfort.
You know, an old so as injury or who knows what it is, but you know, we see it over and over again, either as a direct cause of behavior change, you know, perhaps it’s that you know, like the dog you were just describing, maybe it’s a dog who’s now reluctant to go down the stairs when they go out into the backyard because They’re physically unable to do so comfortably.
And so we see that direct sort of cause and effect. I am uncomfortable, therefore I won’t do the stairs, or therefore I won’t go into the litter box and eliminate. So it’s a very direct correlation. And in other cases, it’s much more indirect, where we see, especially with some of the emotional disorders, or some of the emotional patterns, where we may see an animal who’s more irritable, maybe is not sleeping as well as a result of that discomfort.
And so now we’re dealing with more of the chronic effects of sleep deprivation and that effect on cognition and that again, irritability or altering threshold. So we may now have an animal who’s always been, let’s say a little bit sensitive to a particular stimuli or a particular set of circumstances.
And now we get almost a new on chronic presentation for that animal. Because they’re not as physically comfortable, which means they don’t have the same level of tolerance or resilience or threshold as they previously did when all systems were go.
Dr. Andy Roark: you’re, kind of blowing my mind. So orthopedics is something I got my head around a long time ago. Like I just, I’ve seen a lot of inappropriate urination, elimination because of back pain because of hip pains, you know, you see the creaky pets that are having, I get that one, but the untreated allergies presenting as behavior and like IBD as a behavior issue, that’s kind of shocking to me.
I get the sleep disorder as well. It’s kind of funny. I, it’s not one that I originally comes to, or immediately comes to my mind, but talk to me a little bit about that. What, is it like when the case presents for untreated allergies at the behaviorist?
Dr. Chris Pachel: Yeah. So what we’re looking for usually in a case like that is, you know, any little tip off. So if we’re going down the allergy perspective, for example, we may see that pruritus or itchiness, or if the owner is interacting physically with that animal, we may see avoidance or an animal who is, you know, shifting their body in response to manipulation in some ways.
We may see cases where, you know, even while we’re interacting with them, the animal pauses in the middle of a social interaction to itch or scratch or rub on the carpet or something along those lines enough to just sort of prompt the question of, do you see this at home? If so, how often? And, you know, and oftentimes again, owners have had it.
You know, they’ve had the observations, but I’ve never quite made the connection, certainly to that being a primary issue, or it impacting the other issue that they’re presenting the animal for. And that irritability is a huge piece of that.
Dr. Andy Roark: Hey guys, you know, probably the number one plea for help that I get from medical directors, from practice managers, from practice owners, from lead technicians, and especially lead CSRs is, “Hey, Andy, help me, help my staff to deal with angry and complaining clients. They need ways to help these people because angry clients, complaining clients, they need help is what they need. And, our people aren’t empowered or they aren’t trained in how to do that.”
And so why isn’t there more training for this? Why aren’t there more resources that make teams good at dealing with angry and complaining clients?
Well, the number one reason really is, the way that feels natural for your team, the skills that they have that they would bring into the situation, they’re different in every practice. So there’s not a bullet pointed. This is how you do it way. Which is why I end up in this place where people are like, “Andy How do I do this?”
Listen, I made a course it’s called ‘Charming the Angry Client’ and it is my course meant for teams or groups to work together on all about dealing with angry and complaining clients.
I use what’s called the Davidow model of organizational response, which is a super peer reviewed, empirically tested way, of addressing angry and complaining clients. And, I break it up into pieces so that it’s easy to digest. You can scatter it across a number of meetings, it is made to be watched with a couple people together. And then there’s discussion questions about how do we do this in our practice? What does this look like for us? What, when, think about a time that this happened and we saw it. How did we handle it?
Ooh, I also put a bunch of, example videos in there of me being an angry client. So I, I will just give it to ya. As here’s Andy with his pet, and he is upset, and then you can pause it, and then you can talk about right there, “What would we do with this? How would we handle this, guys?” And it is a great, low stakes way of getting your team to talk about what they would actually do.
Guys, there’s nothing more powerful than your team. Talking about what they would actually do and comparing notes, sitting and getting lectured at is nothing close to your team, whether it’s just your CSRs, whether it’s four of your technicians working together, whether it’s a whole staff meeting and a manager or owner or medical director leading the meeting and being the facilitator guys, I put a whole facilitator guide in there too. There is a whole hour long broken up in a module section on how to run an active training program using this course.
And that’s all laid out there and how I do it, how I work with big groups, how it works, small groups, all that information is there. Anyway, it’s called Charming the Angry Client. It is on the Dr. Andy Roark website. I’ll put links directly to it in the show notes. Guys, I hope you will enjoy it.
I think it’s really valuable. It is, honestly the most popular course I have ever put online. Grab yourself a copy. I hope you’ll get a lot out of it.
Let’s get back to this episode.
I, I have felt less than. Sometimes, Chris, when I, you know, when I say to someone let’s, you know what, let’s try an anti inflammatory medication for a little bit and, let’s see what impact this has. I, I don’t know if that makes sense why I say I feel less than, but something, they come in and they have a question and I’m not, you know, I’m kind of feeling something or it’s a cat and I’m trying to do orthopedic exam and it’s not going very well, you know, something like that.
And I feel like I’m maybe faking it in a way of going. Ah, you know, well, maybe can we try this other thing first? How do you so when I sort of say that to you, you know what I mean? And you’ve got IBD you’ve got allergies or things like that one Is that sort of empiric treatment for the things that we’re seeing in the exam room when they present for behavior?
Is that a problem in your mind? And if so, or if not, then how do you usually layer those things together? In my mind, I’ve always thought, I don’t want to start going heavy on behavior stuff while I’m also introducing, An apparent treatment for a potential medical condition because then I’m not gonna really know what’s working or things.
And so I kind of send them away with empty handed from a behavior standpoint. And I’ll be honest. I kind of questioned myself and go, Andy, are you taking the easy way out? Because it’s a whole lot easier for me to treat IBD or you know, or especially orthopedic pain, things like that. That’s a whole lot easier for me to cut a script than it is for me to wade into that behavior conversation.
So I’ve always questioned myself and say, Andy, are you taking the easy, are you kicking this down the, kicking this down the path here? What do you think about those sort of thought, thoughts when I sort of put them out to you?
Dr. Chris Pachel: Yeah, I think what I’m having the conversation with that owner, I may say something along the lines of, you know, this sure looks like a behavior change and what you’re describing is consistent with a behavior change. Absolutely. Without question. You know, Cali better than I do. And sometimes, you know, some of these issues can be hard to detect, even in people who really care about their animals and are paying very close attention.
We know that from some of the studies, and I may go into a lot or a little bit of this depth when I’m talking with the client, but we know that for some of the studies, even when we have an underlying gastrointestinal issue, for example, they may not show any clinical signs until we run the diagnostics.
And so, you know, I’ve got this little inkling in the back of my mind that really wants me to make sure that there’s not something underlying this because, truthfully, if it is a pain related issue, I want your pet to be as comfortable as possible. So are you open to trialing this? As kind of a diagnostic challenge, we can go down this process, and if we do an anti inflammatory, or if we’re talking about GI disease, maybe we do a trial with a hypoallergenic diet for a period of time, and we say, let’s ask the question and answer it if we do this change And the behavior of your pet changes in response to That’s a pretty darn good confirmation that there’s something going on that we probably should take a closer look for And if it doesn’t Well, cool, then we got great information from that as well.
So we’re getting some information either way I really just want to make sure your pet’s as healthy as we think they are Before we go down the pathway of other interventions.
Dr. Andy Roark: I’m sure this really ties tightly to what the other condition is when I ask you this question. How long do you start to go down this alternative pathway? And, look for results before you say, okay, this is not what I thought it was going to be. I don’t know if I’m saying that very well.
I think, what I’m kind of digging for is, so let’s just say it’s allergies. Do you give the expectation to clients that We’re going to do this and in 48 hours this behavior should be gone, you know, or significantly reduced. And my thought too is in some cases there are– I just think about my own life and there have been things that have ailments or injuries that I’ve had and it’s caused me to sort of change my behavior and then the injury gets better and my behavior doesn’t change.
Let’s just say that, say for example, say I start sort of leaning on my, I lean on my left leg because my right hip bothers me. And then after a while, I just get used to standing on my left leg. And so if you take away the pain in my right hip, I’m still going to stand on my left leg. And you would say, well, Andy’s still standing on his left leg.
So clearly that wasn’t the answer. Does that make sense? Like, like how strongly do you, and I also know that when I said that, when I sent the pet owner home, they’re going to watch this pet like a hawk. They’re going to be like, is he fixed yet? Is he fixed yet? And so, how do you help? Yeah, exactly. help. What should I expect starting to have some of these therapies where there is behavioral symptoms from underlying conditions?
And what sort of expectations should I set with the pet owner?
Dr. Chris Pachel: Yeah, I think there’s two things that really stand out for me. One is If I’m going down that pathway of, let’s say, let’s go back to that allergy dog that’s with me in the consult room, for example, and I’ve recognized that they look a little itchy. I don’t know if that’s related to the medical issue or excuse me to the behavioral issue or not, but I want to make sure that the client knows what we’re monitoring.
So it’s not just, did we cure the behavior issue and it completely resolved? I’m trying in most cases to identify one or two observations that I can allow the client to look for that would suggest You know if we go down that pathway of an anti itch treatment of some case or something that’s affecting the GI tract Am I looking for changes in the frequency of itching, scratching, or licking on the GI side?
Am I watching for any changes in stool quality or the number of bowel movements per day? Something that is easily identifiable for the owner and that usually stems from something that I’ve heard or observed in either the client’s history or in watching their animal or asking some of these questions.
So I’m trying to find a couple of markers versus just saying, well, let’s try this food and see if he or she gets better and the client goes home and they’re expecting a miracle. They didn’t get a miracle. And so they report back not didn’t work. So part of it is trying to be very specific to the best of my ability in that moment.
What do I think we can monitor for even before we get to the big picture behavior issue? The second side of that is also If there is something where we have an interplay between medical and behavior, let’s say, for example, I’ve got a cat very much like Caliente, the one we were talking about earlier, let’s say the issue was not urination outside the box, but maybe this was a cat has a new onset of reacting aggressively when she’s picked up by the kids or by a visitor in that particular scenario.
I may say, well, you know what? You know, sure, we can try a pain medication trial, and let’s monitor for gait, let’s monitor for movement up and down stairs, let’s monitor for ease of jumping on and off surfaces. I want to watch those things more so than just whether or not she’s more tolerant of being picked up, because If she has had an experience over the last day, week, month, or year where being picked up causes physical discomfort and we now have an emotional response to that, just making her feel better in this moment physically
isn’t automatically going to change that learned behavior or those sensitizing events that she’s experienced in the past. So I want to watch for signs that the intervention is making a difference on that underlying medical issue but I also want to make sure that i’ve set that stage for the owner to say “Hey, And if the behavior issue persists, it could mean that this is not in fact related to that medical issue, or we got two problems going on here.
We have a medical issue that started this whole process, but now she’s learned some stuff. She’s had some experiences, and we need to circle back around and actually address the emotional or learned component as well.”
Dr. Andy Roark: You know, two things I noticed in my conversation with you, and I had this impression when you and I first talked. Well, it’s three things, I would say. You do a phenomenal job of validating the pet owners. I, just, I love how you do that, and you are so on their side as you’re having these conversations.
I just think that’s exceptional. I really love how you set expectations as well. And just as a behaviorist, that has to be, it has to be a tool in your toolbox. You like, you have to, write in behaviors and, also manage many. I’m sorry. you have to reign in expectations and really sort of help them to understand what success looks like and what is reasonable.
And you just do that so well. And then, and the third thing I would just say about you that I love how you share what you say and how you say it because when I hear you say it out loud I just can a hundred percent internalize that and go. Yeah, that sounds good. I could see me saying that or I can see me saying some version of that. So I just wanted to say I just love how you do that.
Dr. Chris Pachel: Thank you.
Dr. Andy Roark: When you look at these cases of medical conditions that are sort of masquerading as behavior, kind of what we’ve been talking about, are there significant pitfalls that you see general practitioners falling into that can either be rare mistakes that are catastrophic? You make them or common mistakes where they show up in your clinic and you say, Ooh, I wish.
I wish this last doctor had asked this question. Are there consistent little blind spots or problem areas that we need to be aware of in these types of cases?
Dr. Chris Pachel: You know, I think this is actually something I was chatting with some folks about in Columbus this last weekend when I was lecturing at Midwest conference event conference as well. And we’re having some examples there where we make assumptions too soon, like when we’re busy in the clinic, right?
That client comes in, that animal comes in, we do a quick physical exam. We either find something or we don’t, we ask three or four questions and we get sort of that clinical picture. And You know, for example, it may be that dog who comes in. It’s a four year old Labrador. It’s gained some weight. It’s a little lethargic and, you know, and our brain is like, okay, well, it’s hypothyroid.
I’m just going to test the thyroid and let’s just see what happens, right? So we sort of make the assumption based on what’s most likely. And that is a part of our differential diagnosis, right? We are ranking the probability of those things. With that being said, I find there’s so many cases where we test the thyroid and it’s not a hypothyroid dog, then what?
And I think in many cases we sort of either lose the, skill set over time, or maybe don’t leverage that skill set of really running through that scheme of what are the developmental issues, what are the anomaly issues, what are the metabolic issues, and really running that comprehensive differential is to say, what else could this be?
So that I can run that process down because a lot of these cases, you know, whether I’m talking about dogs or cats or any other species, once we get a couple of questions and we tease out exactly what are we working with in terms of a data set or a breed or a signalman, when we identify what that medical issue is, oftentimes we, you know, we kind of go, well, yeah, that actually makes a lot of sense.
Now that I know all the pieces, Okay. But if we’re not looking at that sort of broad lens of what are all the things that could be, we’re going to miss some stuff. And I get it. I totally understand when we’re super busy, we’re in, clinic, we have to be efficient. So we have to think about that. But I think that the biggest mistake, if there is one here, is If it’s not what you thought it was at first, what else do you think it could be?
Before we go to the next assumption, really, what does it look like to really tease that out? How would we get that client on board for running some diagnostics? How do we rank or triage those recommendations in? You know, I almost said in the worst case scenario, but maybe it’s the best case scenario. If you’re not sure, reach out to a specialist.
So many of the folks like the veterinary behaviorist, like, like in my college, You know, we’re happy to hop on the phone call to be able to say, tell me about the case you’re navigating. Let me see if anything lands differently for my ear or my eye than what you considered, and let’s see if we can work it up together.
Dr. Andy Roark: Outstanding. Dr. Christopher Pachel thank you so much for being here. Where can people find you? Where, I know you’re, traveling, you’re lecturing if people are like, I wanna learn more from him. Where can they find you?
Dr. Chris Pachel: That’s a great question. So, the easiest place to track me down is on the website drpachel.com. So, D R P A C H E L dot com. And from there, you can link into any one of the different avenues, whether you’re trying to find me at the animal behavior clinic or at instinct, dog behavior and training, or if you want to link to any of the podcasts like this one that will end up being linked on that site, all of that is there in addition to webinars and travel schedules and all of that.
So that is the one stop shop that will get you to all the things that I do.
Dr. Andy Roark: That’s phenomenal. Thanks so much for being here. Guys, thanks for tuning in and listening. Take care of yourselves, everybody.
And that’s it. That’s what I got for you guys. I hope you enjoyed it. I hope you got something out of it. Thanks to Christopher for being here what he’s super fun. I just I really enjoy him. Gang take a look at his website check out what he’s doing. Anyway, take care of yourselves everybody. Have a great rest of your week. I’ll see you later on.