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Andy Roark DVM MS

The 4 Gifts of Veterinary Medicine – Rotate Your Dogs

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In this episode, Dr. Andy Roark and Jamie Holms revisit an old article on balancing happiness, stability, and giving in vet medicine. They reflect on changes in perspectives over the years, discussing the evolution of these core principles while exploring the intricate facets of happiness, intentional giving, and the dynamics of optimism and realism in the veterinary field.

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

LINKS

https://drandyroark.com/the-4-gifts-of-veterinary-medicine/

Dr. Andy Roark Resources: https://linktr.ee/DrAndyRoark

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

Dr. Andy Roark Swag: https://drandyroark.com/store/

ABOUT OUR GUEST

Jamie Holms is a chicken mom and the Administrative Manager for Dr. Andy Roark, and the Uncharted Veterinary Conferences. Jamie is passionate about helping the people who are helping pets and is a firm believer that the future of the veterinary profession is bright. Jamie is obsessed with baby goats, axolotls, hedgehogs, tea, plants (especially hoyas), kindle books, food, and sleep – not necessarily in that order.

EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Cone of Shame veterinary podcast. I am your host, Dr. Andy Roark. Guys, I am here with a one and only Jamie Holms. We’ve been digging through some old articles of mine. Boy, she was digging real deep at the bottom of the bag to pull out an article that I wrote back in 2017 called The Four Gifts of Vet Medicine. This is an episode that came up or an article that came up talking to my good friend Dr. Sarah Boston recently. And then Jamie also was around and kind of pulled it out for looking at, and anyway, it is a really, I hope is a good discussion. I thought it was a good discussion. It is all about balancing, giving happiness and stability in our careers and what does that balance really look like. And then Jamie was asking if my thoughts on are those really the three drivers? Have I changed my mind in the last six years? And so we talk about that a lot. So anyway, it’s a really fun conversation. I hope you guys will enjoy it. 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 back to the podcast, Jamie Holms. How are you?

Jamie Holms:
I’m good. How are you Andy?

Dr. Andy Roark:
I am really good. I always loved doing episodes of the podcast with you. I heard really nice things the last time you got together. We did the choosing the rulers that we measure with, and I got a lot of nice notes about that and they were like, you should do more episodes with Jamie. And so I thought, you know what? I think that’s probably true.

Jamie Holms:
Oh, that’s kind. I think that that I like to dig in and get a little deeper into your articles than you have the opportunity to do. Because an article, it’s not a book.

Dr. Andy Roark:
No. Yeah, correct. It’s, it’s funny, I have heard that people struggle to fill like a thousand or 1200 words and I not, I struggle not to write 5,000 words.

Jamie Holms:
Yes. Yeah.

Dr. Andy Roark:
They’re like, what is this? And I’m like, it’s the article. And they’re like, you’re supposed to have the back page, Andy. Not the whole article, the issue.

Jamie Holms:
Not the whole magazine. Yeah, exactly. Well, I was looking back at the way back machine. Are you ready?

Dr. Andy Roark:
The way back machine? Yes!

Jamie Holms:
Yes, the way back machine. We’re going to go all the way back. I think it’s 2015 if I’m not mistaken.

Dr. Andy Roark:
Oh wow. That’s way back!

Jamie Holms:
It’s way back. But this is an article that I know both Sarah Boston and I really love that you did about sled dogs. Do you happen to remember this article?

Dr. Andy Roark:
I only remember it because Sarah Boston, she is a onco surgeon, a veterinary onco surgeon and brilliant. She has a podcast called Co Medicine, which is supposed to be comedy and medicine squ together. And so she had me on and she specifically asked me about it and I was embarrassed. I was like, Sarah, I have very, very limited recollec. I remember an article, I said minute, then I had to go look at it. So I have actually recently looked at it. Oh, fantastic. Only because she caught me. Only she caught me flatfooted.

Jamie Holms:
Yeah. Well, I mean it was, what is that, seven years ago? So I think there’s a little grace to be given there. It reminded me of the story of the Indian elder who was telling a child that who was having some trouble with emotional regulation and they were like, how do I deal with this? And the wise man says, you have two wolves inside of you and you have the anger and you have the goodness, and the one that you feed is the one that survives. And I have always thought with that, and you know me, I have that duality of mind where it’s like it’s right or it’s wrong. Only one dog survives only. We’ve only got one sled dog that’s going to make it to the end of the Iditarod. And you have to choose which one it is.

Dr. Andy Roark:
How many dogs do you have right now, Jamie? I

Jamie Holms:
Have two. And only one’s going to make it.

Dr. Andy Roark:
Only one’s going to make it okay. No. Okay. Alright. Just checking. Yeah. Poor Biscuit. Yeah,

Jamie Holms:
Poor Biscuit. Poor Biscuit. She’s being, I just got a puppy and he’s about 15 weeks old and he very much wants to bite her on her ears and she does not like her ears touched. And so the biting on the ears is not working out real great for her. She does not like it. And he’s like, maybe if I try again in five minutes it’ll be okay. We’re like, no, she doesn’t like it.

Dr. Andy Roark:
Yeah, got to keep checking in persistent. So anyway. Okay, so there’s two wolves. I do like it. It’s the one that you feed.

Jamie Holms:
Yeah. Right. Well yours is about the sled, which is life and the three dogs are giving happiness and stability. And I wanted to go back and first of all ask, do you still think that there are three sled dogs or have you found any others? Because it’s been seven years and we’ve grown and changed in vet Met. So do you think there’s more sled dogs now?

Dr. Andy Roark:
Oh wow, that’s such a good question. It was funny. A lot of times I look back at articles to see where I was in my life and what was going on. And so this was clearly a time and when I was seeing a lot and I was probably feeling a lot of just giving and giving and not you write the article or the book you need to read, which, but I was seeing a lot of burnout. I think the idea is that there, so when I wrote this, there’s three dogs. There’s happiness, which is you taking care of yourself, and then there’s stability, which is kind of financial security. It is you making a living, getting your needs met and then there’s giving, which is you doing for other people? Clearly. I think I was feeling it this time and I was seeing a lot around me of people who they just give and give and give and give.
I said in the article, the most common dog to get starved is personal happiness. A lot of people who they’re like, I have to take care of my family and I have to take care of my team and I have to give to the world and that’s all I have to do. And the big thing is, where are you in this? This has got to work for you. And they’re like, oh no, I’m sacrificing myself, my happiness. And so I think I saw a lot of that. I think I was thinking about the dogs. I think it’s a lot of it is how much I think if I could walk it back, if I wanted to parse this part now in my new for where I’m now, I think I would probably parse happiness into other things. So I do think that there’s giving, and I do think giving is important and intentional giving matters.
And I think I understand a lot of times when we see commentary on social media or out in the world, it’s reactionary commentary is people are like, they’re responding to anger or pain. And so when they say pet owners stop asking us to do these things or stop, I don’t know, stop treating us like jerks, you think, is that really the relationship you have? And it’s like, no, they’re responding to something. It’s not. If you really met them on a calm moment, ask them, they would have a much more robust response. But we’re seeing this emotional reaction. So anyway, I think for a lot of these things when we start talking about giving or start talking about happiness or we’re talking about stability, I think that we’re leaning into this really kind of narrow view of what that is or it’s coming from a place of reaction.
I think if I was going to parse ’em apart, I think happiness is kind of a loaded word and I think that it’s still that balance is key. You know what I mean? Yeah. I think I would probably lean if I was going to do new dogs now, I think interpersonal relationships would be, I think I’d probably parse the happiness into interpersonal relationships and come out how to say it, but basically what I need to recharge and or feel satisfied by. And so I think that those are different things. And so I would say you should still be driven by giving and you should make sure that your needs are being met. And at the same time, I really have become a big believer since 2015 or 2017 or whatever, I’ve definitely become a much bigger believer that our interpersonal relationships really matter. And I think that you kind of put family in there and I think you put colleagues and friends in there and do you know people? Are you taking care of those relationships or are you head down just doing work, paying the bills, things like that. And a lot of us I think are very lonely because we forget about those relationships. And the last part is are you getting what you need out of this? Are your needs being met? So I think if I was going to do it differently, I’d probably split it into four. I don’t know. What do you think? Am I missing something here? It’s hard to rethink it, but I’m glad you asked.

Jamie Holms:
I really like what you said when you said intentional giving because I think that that’s something that we lose or we feel like we’ve lost. And you and I have talked a lot about agency in the past, but I feel like we vet med feel like we don’t really have control over what we give or how we give it because when someone says, Hey, there’s a c-section, can you stay? You often don’t have an actual choice, especially when morality gets involved in and we get stuck in that trap. And so we feel like we don’t have an option. And that’s one thing that I have some friends who work for an organization and one of the things that they say repeatedly is I get to do this. And I love that because it reframes it and it’s an option of I get to do this. And I think back to I was a phlebotomist and I worked at an organization, it was a tiny group called the Lab and they were really small and I got to do things like do blood draws on people in their car when it was inconvenient for them to come in.
And I got to do things to help people be less afraid. And I worked with a lot of elderly and a lot of individuals who had a lot of needle phobia and I basically had free reign to do whatever I needed to do to make those people comfortable. And some of it was white coat syndrome, like don’t come into the building because into the building just is too scary. And the company was bought out by a large organization with a lot of rules and we weren’t allowed to do those things anymore. And it really put me in a mindset of these things that other people were like, what do you mean we do blood draws in the car? And then all of a sudden they were like, we got to do that and now we don’t get to do that. And so I think that that’s an interesting way to look at it. And I think that you can use that intentionality with both stability and happiness. And I agree with you, I am not a big fan of the word happiness.
If I had the choice of being happy for the rest of my life, I would not choose it. I want joy, I want wonder. I want these things that feel deeper and bigger. And I think that we have the capacity through vet med. We see some of the worst things, but we also get to see some of those amazing miracles where an animal pulls through that you never thought was going to pull through or a family. You get to see generations of a family come through with their pets. And I think we’re definitely blessed in that way.

Dr. Andy Roark:
If you dream of doing team training with your team, getting your people together, getting ’em on the same page, talking about how you guys work together in your practice, I’d love to help you. You can check out drandyroark.com and check out the store. I have two different team training courses. These are courses for teams to do together to get on the same page and to talk about how you do things. I do things, I have my angry clients course and I have my exam room toolkit course and they are both available and there to come out. Alright guys, let’s get back into this episode.
Well, there’s a lot here to unpack. So I like your point about happiness. That word has, I still use it, but I don’t like it very much. I think that we’ve kind of been sold a false bill of goods about happiness and what happiness is supposed to be. I was talking to this veterinarian who’s really deep thinker and very smart and she talked about going to counseling with her partner. And one of the things that she really struggled with is her partner’s position that happiness is not important. And she’s like, what do you mean happiness is not important? And he said, it’s just not important for me. And she says, how can that be? And she said, what makes you feel good? And he says, meeting my obligations makes me feel satisfied and that’s enough for me. If I am meeting my obligations, then I am satisfied.
And she was like, this was a real sort of sticking point for a long time and trying to understand this person who was her partner and she had to really work on it. And I got to tell you, I’ve thought a lot about this and I do. I of get where a partner’s coming from? I do. And then also I can a hundred percent struggle and be like, what do you mean meeting your obligations is enough? But I think that we all know someone who’s like that and they’re like, yep, this is what I do. I meet my obligations and that’s enough. I don’t think I’ve told you this before. I don’t think we’re made to be happy. I really think that we are creatures molded by natural selection and species that are content go extinct. I think we’re made to be a little bit unhappy.
I think our default state is unhappy because that’s what makes us grow and explore and try new things and spread out and take action and hunt for food so we can have a nice little chubby layer when the winter comes. I think if we ate a little berry and we were good for the day, I think we’d starve the death in the wintertime. So we’re made to be unhappy. And so if happiness is the goal, then I think that we are always feeling like we’re failing. I don’t think we’re supposed to be happy. And so I thought a lot about that. I want to jump back to your, I get to do this and say, oh, I frame this up and I get to do this. And it’s funny when you were talking about you did this thing and you went out to the car and you did these things to sort of accommodate these people and then that was taken away.
I can’t help but think about the open hospital concept where the pet owners can go wherever they want. And I know you’ve got experience with that, but I think for a lot of people they’re like, that’s terrifying. But I can also see that if you did it and you got comfortable with it, you would recognize or you probably take pride in the fact that you say, yeah, we have people come back here, they can see everything. I think I could see myself very quickly as part of become my identity of going, yeah, we do everything in front of the pet owners. I think the only thing that scares me is what if I mess up? But I would be fine. I would be fine and it would take some time and I would practice and get comfortable and after a while you get comfortable doing things on display.
And I know that that’s true. Having not done it, I think it’s still scary for me, but I think that I would come to love it and then if I had to stop do it, I would feel it was taken away. I wrote this piece recently. I’m just curious, I’ve not talked with you about this, but I’m curious what you think about it. I’ve been thinking a lot about optimism and happiness and kind of what this really looks like given where I’m in my life. And so I’m in my late forties at this point. I can see 50 from where I am. Same. My wife had breast cancer a year ago and she’s fine. Everything’s gone well. But that was a significant thing in my life and I know you’ve seen and had things like that as well. And the whole just choose happy. I still think that every day you get up, you can decide if you’re going to be happy as a default or if you’re going to be upset or angry or cynical or afraid as a default.
I think you can decide what I’m starting out at happy and I’m to try to hold on to happy and that’s the choice that I’m going to make. I don’t think that’s toxic. I don’t think that’s discounting of anything other than I’m going to try to do this. And so I do think that there is value in optimism. I like looking at the world with an optimistic view that things are going to get better, I suspect. I think wonderful things are going to happen. You said you wonder and joy. I think looking at the world and going, there’s things out there that are amazing and wonderful and I’m going to find them and I can’t wait to see where this day goes. I think that that’s good. And at the same time, the world is a hard place. And when you live through disease or pain for family members or people that you care about, you can’t lie to yourself and be like, I’m just going to choose to be happy about everything.
And I think that that’s a paper shield and I don’t think it really works, and I don’t think it’s honest. So I went looking for insight on happiness a long time ago, and I really do like some of the Buddhist ideas. And a religion is 5,000 years old. They got some things figured out. And the Buddhist say, and it’s funny because I’ll see people and they’re kind of shocked because I have this reputation as Mr. Positive and the guy who loves fat medicine. And then I will stand in front of people and say things like, what life is suffering? Life is suffering and you should own that. Or I’ll, I’ll say, medicine is really just picking your poison over and over and over again. And they’re like, this is the positive guy. This is the funny guy that we came to laugh with. And oh, there was another one that I really like.
There’s a psychologist named Stutz is his name. He’s got a documentary with Jonah Hill, but he said this thing that I have loved and picked up, but he’s like, no one. And I mean, no one can escape uncertainty, pain and constant hard work. And I’m like, that’s awesome because it’s true. And it’s just like, yep. And the number of times I’ve been like, Andy, you’re never going to be comfortable. You are never going to escape discomfort for any significant period of time. You’re always going to be uncertain and you’re always going to have to work your tail off. If you just accept that, then you can go on. And so I think that that clear-eyed, pragmatic look at the world and what it is and what it means to be human, I think that’s also important. And so bringing this all the way back around, I have been thinking a lot about the balance in those two mindsets is can you hold onto clear ride pragmatism? Nothing in this world is guaranteed except hard work, uncertainty and discomfort. And I think tomorrow’s going to be a good day. And I think that there were wonderful things that are happening and there are people that I want to know better and there’s time to be joyful and opportunities for me to explore and do things that I’m excited about in the time that I have. And those things, I think to some people, they feel contradictory. You can’t choose happy and believed life is suffering. And I would say yes you can.
It takes some balance and perspective, but there’s nothing wrong with that. I don’t think they contradict as much as a lot of other things I have to hold in my head to be a veterinarian.

Jamie Holms:
True. Absolutely. I completely agree. I have often been pegged as being pessimistic, which I have wholeheartedly disagreed with most of my life. I’m like, I’m a realist. That’s how I see myself, because I don’t think everything’s going to turn out badly. I couldn’t keep going if I thought that. I believe that things are going when things are hard, I believe that this too shall pass. It’s going to get better. And it’s a season and you don’t have any idea how long your seasons or your droughts or your rains or your amazing harvests, you don’t have any idea how long they are going to be. And so you enjoy the things. And I was looking at, oh, you shared with me some pictures not very long ago. And in there

Dr. Andy Roark:
The nature photographs?

Jamie Holms:
And in there were ones that were pictures of natural disasters. And so one of them was a picture of this field that was just covered in snow and it was so beautiful. And the person who took that photograph was there in the middle of this terrible snowstorm and was like, you know what? That’s gorgeous. That’s gorgeous. And it’s just like, it’s beautiful.

Dr. Andy Roark:
That’s awesome. Yeah, I love that. What comes to my mind is I went with my family and we went to Phoenix as a Christmas trip a couple of years ago before the pandemic, so it’s probably been five, six years now. And so we went there and we were going to go up and go up to Monument Valley and look at all the places and go to the Grand Canyon and everything. And we did, and it snowed on us. It just dumped snow. And I remember at one point being in this lava field and it looked like Mars. You know what I mean? There was nothing really growing in this area. It was just this weird rock and also this beautiful snow on top of it. And I took tons of pictures and they do not do justice to what was there. But I think that’s amazing about incredible nature photography is the ability to actually come close to doing justice to something that’s out in nature.
I cannot do that with my iPhone, you know what I mean? I’m always very excited taking pictures and then later on I’m like, this does not convey what was there. But anyway, but it is that mixture of beauty. I’ll also say that about you too, is you and I have known each other a long time. You are my first employee. You are one of my best friends. You are a realist. I would fight with anybody who says that you’re a pessimist because you are a realist in that. Well, you do. The number of times that I have frantically pitched you an idea, and Jamie, just walk with me, look at what could be possible and we could do this. And you have been like, let’s, you know what? Let’s go for it. There’s so many times that no one can say you’re a pessimist because I have walked you into way too many adventures that you didn’t have to go on.

Jamie Holms:
That is very true.

Dr. Andy Roark:
But you are a realist as well, because Which is good because a lot of times I’ll be like, we get too thiss. And you’re like, I have questions, Andy.

Jamie Holms:
So many questions.

Dr. Andy Roark:
I have so many questions about how this actually goes down. I think we’re good for each other, but I would say you are not a pessimist. You are a realist who wants to be an optimist. That’s what I get from you. Yeah. I think I’m an optimist who wants to be a realist. That’s what I want.

Jamie Holms:
Yeah. That’s where I think that makes sense. Well, I mean that’s the balance, right? So that’s how we find it. Okay, so I have one more question about this article.

Dr. Andy Roark:
Okay, I forgot about the article. Yeah, let’s talk about that.

Jamie Holms:
Have you ever been on a sled sled? Never. Never. Oh my God. I want to do it so bad. So bad.

Dr. Andy Roark:
I have buddies. I have one friend in particular who somehow got involved with the Iditarod when we were in vet school, and he’s just been doing it forever. And I’m like, I might as well go to Mars as to the Iditarod. I’m like, this is just, it’s something like I can kind of get my head around it, but I have no idea what it would actually be. And I see the pictures and I watch videos, and I’m like, I am so out of my depth here. Well, I want

Jamie Holms:
To be real clear. I do not want to do the Iditarod. I want to go for maybe a mile and then have a Starbucks, but I want to do it. I want to do it. I have heard it’s amazing, and I love the feeling of flying, and I imagine that that’s what it’s like. And I love the excitement of the dogs.

Dr. Andy Roark:
I could get into that. I want to create a new sport called Hover Sled, and it’s a sled, it’s like a hoverboard, and then dogs can pull it in Florida in January, or I don’t know, California. We could find an area that’s 70 degrees Fahrenheit, 20 degrees Celsius, beautiful. And then they could pull the sleigh without the blistering cold. That seems to be required right now, like roller sled. We could just have basically, I want to tie dogs to a shopping cart and ride around that. That’s what I’ve decided.

Jamie Holms:
I’m pretty sure that’s already a sport, but I’m not sure if it involves dogs.

Dr. Andy Roark:
I think I’m going to investigate that. That’s what I’m going to

Jamie Holms:
Go do. You go do that and I’ll just hang out with Allison and

Dr. Andy Roark:
We’ll, well, I mean, I’m coming for your two dogs because only have bad dog, skipper Roark, who I do not trust to pull my shopping cart alone. Sure. So I’ll be over soon.

Jamie Holms:
Okay, sounds good. I’ll see you then, Andy. Bye.

Dr. Andy Roark:
See you soon. Thanks. And that’s it. That’s what I got for you. I hope you enjoyed it. I hope you took something out of it. Thanks to Jamie for being here. Thanks to you guys for being here. Take care of yourselves, everybody. I’ll talk to you soon.

Does it ever feel like the world is getting too big?

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One of my favorite ideas from the Hitchhiker’s Guide to the Galaxy is that of the Total Perspective Vortex (TPV). In the book, the TPV was a machine built to show beings a glimpse of the infinity of creation… and it’s used as the ultimate torture device. Human’s brains, it seems, are not meant to process the expanse of the universe. I find the idea that knowing how tiny we are in the universe would be the ultimate torture is darkly funny.

Recently, however, I’ve been feeling a bit like we are all plugged into the TPV and someone is slowly turning up the wattage. We are living in a world where information seems to flow into our eyes and ears faster and faster. More things pop up with breaking news alerts, attention-grabbing chimes or text messages than ever before. More and more screens and streams vie for our limited attention. Short, looping videos that we can swipe through increase the breadth of information we take in by reducing the depth. 

You know what makes this expanded view of the world troubling? For me, it’s the feeling that we are seeing more and more of our world… while the number of things we can control doesn’t budge. We’re not just seeing, hearing and knowing an ever-increasing amount… we’re seeing, hearing and knowing an ever-increasing amount of things that we have absolutely no control over. 

A bigger world with no more control can make us feel less important and empowered. It can make us feel like we are a drop of water tossed around in an increasingly vast ocean, and you know what? That’s a lonely, frustrating way to feel.

I think these feelings of powerlessness may be why people seem to be acting meaner than ever before. Rude behaviors in public, mistreatment of people doing customer service work, aggressive driving… couldn’t it all be a product of people feeling that the world has gotten so big that they desperately need to find a way to show they still have some control? 

Could people be more likely to break rules or hurt others when they feel a need to prove to themselves (and the world) that they are not inconsequential or that they still have some power? Could the epidemic of loneliness be related to feeling smaller and smaller in an expanding world?

To be clear, I think there has never been a more exciting time to be alive. Our ability to learn and connect is incredible and growing by the day. I also think that the potential to feel like we’re in the Total Perspective Vortex, that we are so small in a world that is so large and beyond our control, is more real today than ever.

Going forward, let’s remember that it’s not wrong to be selective about what information we take in. Surviving in a world of limitless noise and knowledge will almost certainly involve making choices about what we spend our emotional energy on, and how much time we spend just gazing at the outlets that would like to have our attention. We have the power to step out of the TPV, or to turn its wattage back down for ourselves.

Sometimes, it’s worth the effort to turn off all the noise and focus exclusively on the things we can control: The work we do with our hands, the relationships we have without screens, and the impact we make on those around us. If you’re feeling overwhelmed, maybe it’s not you. Maybe the world is just too big and it’s time to take back our focus and put it where it matters most. Right in front of us.

HOF: Anesthesia Crash Cart Course

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Dr. Andy Roark dusts off this Hall of Fame episode in which he discusses the essentials of anesthesia crash carts with Veterinary Anesthesia Nerd, Tasha McNerney. Together they talk about what tools should be in your anesthesia crash kit and what kind of common pitfalls they’ve seen in practice.

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

LINKS

Veterinary Anesthesia Nerds: https://www.facebook.com/groups/veterinaryanesthesianerds/

RECOVER Resources: https://recoverinitiative.org/category/resources-and-tools/

Upcoming Webinar (Free RACE CE): https://drandyroark.com/headcases

Dr. Andy Roark Resources 

Dr. Andy Roark Swag

ABOUT OUR GUEST

Tasha McNerney is a Certified Veterinary Technician from Pennsylvania where she works as a educational consultant and relief anesthesia technician. Tasha is the founder of the Veterinary Anesthesia Nerds, while also a Certified Veterinary Pain Practitioner and board member of the International Veterinary Academy of Pain Management (IVAPM) to educate the public about animal pain awareness. In fact, Tasha was the thought leader behind the now celebrated “Animal Pain Awareness Month” within the veterinary industry. Tasha became a veterinary technician specialist in anesthesia in 2015. Tasha loves to lecture on various anesthesia and pain management topics around the globe and was previously named VMX Speaker of the Year.

EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary podcast. I’m your host, Dr. Andy Roark. Guys, I am pulling one out of the vault for you, just blowing the dust off of it. This is a Hall of Fame episode with my good friend, the one and only Tasha McNerney, the original anesthesia nerd. We are doing the anesthesia crash cart crash course. It’s just a box of pearls. That’s what it is. It’s just knowledge, pearls, and I just put ’em all together in this box and here you go. From me to you. Happy holidays. It is a great episode. It is one of our most popular episodes of the last year, and you’re going to see why when you check it out, even if you heard it when it came out, it’s time to brush it up again. There’s so many mind gemstones here that you went through and you put some in your brain the first time, and I promise you there’s a lot more room. You’re ready for other ones. Now you’re ready for the next level of mind stones that go in. I don’t know what this metaphor is, but I think you’re just going to enjoy this episode. Let’s just do 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, Tasha McNerney. How are you?

Tasha McNerney:
I’m good. How are you?

Dr. Andy Roark:
I’m so good. It’s so good to see your face again. You’re one of my favorite people. You and me go way back. I’m like way back, way back. You were here visiting my house when the pandemic hit, and I’ll never forget you and I started the pandemic together.

Tasha McNerney:
Yes, yes. I have great memories of visiting four different stores, looking for canned goods and then finally buying all the beans at a CVS in some random South South Carolina town. Still have those beans.

Dr. Andy Roark:
I still have those beans a hundred percent. I’m like, these are my survival beans.

Tasha McNerney:
Yeah, well you save them.

Dr. Andy Roark:
My wife, she was like, “we’ll never eat these.” And I’m like, look, as long as they’re there, I’ll sleep well at night, but as soon as you throw away my emergency beans, I’m going to be like, what are we going to do if society ends? Yeah.

Tasha McNerney:
Yeah. It was a good time.

Dr. Andy Roark:
I felt, you know what? When the world went sideways, you and I took action. That’s all I’m going to say. And most people, a hundred percent did not, but we did.

Tasha McNerney:
No, people were like, is this happening? And we both looked at each other and be like, oh, we better stock up this pantry. Even though it wasn’t my pantry. I was like, I’ll help you stock up this pantry. You were with me. I had gotten a call from my husband at home saying, everything is off the shelves. It’s kind of pandemonium here. And at that same CVS, I bought two boxes of pasta and took them back in my luggage with me because I was so worried that I wouldn’t be able to find pasta when I went home. So yeah.

Dr. Andy Roark:
Oh man. That’s great to be with an anesthesia specialist because when the world goes haywire, they take action and I felt like that was instinctual for you.

Tasha McNerney:
Oh, 100%. I think I always joke with the anesthesia is that we are very cool, common, collected. When everything is crashing in the ER or in the OR wherever we are, it’s very much, okay, here’s the problem, where do we go next? Alright. And we start this kind of checklist. It’s very much cool, calm and collected in anesthesia. And the joke is that we’re dead on the inside. And sometimes I would agree with that in that we’re not going to be the people freaking out like, oh my God, everything is crashing. Go get this for me. Really that actually with me that things are real bad if I get very calm and monotone. And if I say, okay, what I need you to do next is turn off that vaporizer and can you hand me the epinephrine? Okay. Things are going down. Things are going down.

Dr. Andy Roark:
Yeah. Oh man. Yeah, you are a bit dead on the inside though. That’s just inside baseball from an old friend.

Tasha McNerney:
Yeah. And you know what? Listen, I got a therapist. We’re working on it. We’re good.

Dr. Andy Roark:
I think a lot of people could stand to be more dead on the inside. I think it would probably be, we all know a people who should be a little bit less alive inside. It would help them.

Tasha McNerney:
Yeah. Just calm down.

Dr. Andy Roark:
Totally. Alright, for those who don’t know you, you are a veterinary technician, specialist in Anesthesia. You are the founder of the Veterinary Anesthesia Nerds Group. It’s a Facebook group, it’s a website, it’s a conference. This thing has grown to how many people are involved engaged with the Anesthesia nerds group now?

Tasha McNerney:
Oh, we have about 65,000 members around the world right now. Yeah.

Dr. Andy Roark:
It’s awesome. It’s super awesome. It’s super bonkers. And I could sit here and sing the praises of the anesthesia nerds. I’m all about practical education. I really like to learn stuff that I’m like, I’m actually going to use this. And that is what you guys are all about. So I really love it. I’m super glad that you’re here. I thought of you recently when I had a pet under anesthesia and I can’t remember why. It was an emergency of some sort. And I had this pet under anesthesia and it just kind of dipped there for a second. And so when you pause for a second and you’re like, is this going to be an issue? And then it kind of stabilizes and comes back out and I thought I could use a refresher on the crash cart. That’s exactly what I took away from that specific instance was it was an emergency that came in. I can’t remember what it was. It went under anesthesia to get fixed. And I thought, you know what? Let’s just freshen these skills back up. And so I wanted to get you in and just say, run through the crash cart with me real quick. Let’s do a hundred percent refresher on what’s in my crash cart, what’s it do, what do I need to know about it? And just make me feel like the dust has been blown off my crashing patient knowledge. Is that okay?

Tasha McNerney:
Oh yeah, let’s do it. So, ooh, there’s probably a lot to cover, but we’ll kind maybe put it into categories when you’re looking at your crash cart. And again, just want everybody to know that I’m talking about this in the context of an anesthetic crash cart, not necessarily your ER crash cart, which is probably going to be a little bit different, but when we look at our anesthetic crash cart or what we want to have in that top drawer of our anesthesia machine or on hand during any anesthetic event, that’s what I’m going to talk about here. That’s cool with you. All right. So first of all, any emergency, again, when I say to you, Hey, things are not looking good, can you turn off that vaporizer? And then one of the first things that I want you to do is pull out our real emergency drugs.
And when I say emergency drugs with anesthesia in mind when I’m talking about are our emergency things like atropine and epi and then our anesthetic reversals. So these are really the two big things in our crash cart. We know that we want to have atropine or anticholinergic that we will use in emergencies because it has a very fast onset, shorter duration of action than glycoparalate. But again, in an emergency, we want that fast onset. Now there’s some stuff, and I will let you guys listening at home do some research because I think this is very, very interesting. Looking at the newer research that has come out in the past couple of years asking, especially starting in human medicine, asking is there really any benefit to using atropine during a code or a CPR event? And the human medicine, human literature has actually found that there isn’t, and they actually don’t really use atropine anymore during emergencies.
And if you look at the newest recovery guidelines, they actually state that atropine is not necessarily beneficial, but they don’t know if it’s really going to do any harm either. So if you feel like you still want to keep that in your back pocket, you’re probably not doing any harm. But it’s a little different than we thought 10 years ago that we don’t necessarily know that it’s really doing a lot during our CPR events or our code events. But I still will get it out. And I will say that my anesthesiologist will still have us give it during an emergency. Our next is epinephrine, right? And that’s because we want that basic constriction. We want to make sure that our blood pressure stays tight. We want to make sure that we are delivering oxygen to the tissues to where it needs to go. So again, our emergency drugs, then we need to get rid of whatever anesthetic.
Again, if this is a true anesthetic emergency, we want to make sure that we have reversals in our crash cart to reverse every single drug that can be reversed. Now, most of the time with anesthesia, we are administering opioids. So that means that we need naloxone first and foremost in our crash cart. So if we have an opioid on board, we want to make sure that we reverse that opioid with naloxone. Second most common drug class that’s used are benzodiazepines, things like Midazolam or things like valium, and we have a reversal for those. A lot of clinics don’t even carry the reversal, but I would say if you’re utilizing things like medazolam or Valium in your clinic, you need to carry the reversal just in case things get crazy. And the reversal for those is a drug called flumazenil. It’s a little more expensive than naloxone.
And again, a lot of people don’t keep it regularly on their shelves. But I would say that if you have an emergency, you want to have at least one bottle of flumazenil or at least one in your, or if you have an anesthetic emergency, the next reversal agent that is very important would be antisedan or anapamazol. So this is going to reverse your dexmedetomidine or if you’re in a practice that is still using xylazine, you would want your reversal to be yohimbine, although you could use anapamazol as well working on those receptors. So you want to have antisedan for your dexmedetomidine, right? So if we came into a urgent situation, we want to make sure we have access to atropine and epi and the reversals for all of our drugs. Now, if you’re utilizing ketamine in your protocol, you don’t have a reversal agent for ketamine.
So just realize that if things get crazy and you start reversing everything, that Ketamine is still going to be on board. We don’t necessarily have a reversal for that. Now, this is just for an emergency. I will say that there are a couple other drugs that I do think of as always having in my crash cart, one maybe for some anti-arrhythmogenic effects, and then one for if we start to see maybe some irritation or something like that under anesthesia. And one of these is lidocaine and the other one is diphenhydramine. I like to keep these on board because especially with our patients that are not hemodynamically stable certain breeds, if we see a ventricular tachycardia under anesthesia, so again, this is a ventricular tachycardia, and when I say that, I mean a beat that is greater than 160 beats per minute. So if we see something like this, again, that is going to be not great for forward movement of blood and cardiac output, which delivers oxygen.
So we always want to make sure we have lidocaine available as well. Especially in these more critical patients, you might need to give like a two meg per kg lidocaine bolus if you see that your patient is in vtac. Now again, the reason I mentioned the rate is because sometimes I’ve gone into clinics where they’ll see what they describe as a slow vtac or a ventricular escape beat, or they’ll see it, but maybe the rate is still only around a hundred beats per minute or 110 beats per minute. We don’t treat those with lidocaine. That could actually make it worse. So lidocaine is for those ventricular tachycardic emergencies. And then diaphenhydramine, I usually like to have it on board because sometimes my surgeons will note, Hey, I see that this patient has had a reaction to either maybe they have severe clipper burn or they’ve had a reaction to the chlorhexer iodine that’s been used to scrub their skin and now they have hives.
So if we see something like that, we want to make sure that we can administer some diaphenhydramine to them. Okay, that makes sense. Those are some emergency drugs. And so what I like to have in my anesthesia crash cart, now, these are kind of adjunct drugs that I’ll talk about really quickly, and this is more blood pressure drugs because we know that inhaling anesthesia along with a lot of the drugs that we are going to administer like ace premises, like propofol, like afaxolone, these drugs are going to cause a decrease in cardiac output and vasodilation, which is going to lower our blood pressure. We know that hypotension is going to happen, we want to be ready for it. Now, most of the time you have a normal healthy hemodynamically stable animal. Something like lowering your vaporizer setting or administering a fluid bolus. A five ml/kg is going to get you where you need to go for some animals.
But for other animals, especially if you have a longer procedure in mind, we want to make sure that we’re not just letting that blood pressure and that mean arterial pressure dip consistently below 60 because then we know that oxygen delivery to really important tissues, it’s going to be compromised. And that’s why I always like to have some blood pressure drugs ready and available. Now, I’m not saying that every clinic has to have all of these blood pressure drugs, but the three that I keep on me at all times are going to be dopamine, dobutamine, and ephedrine. And dopamine is a mixed alpha and beta, and that’s why I really like it. If you have a patient that just a cat that’s under anesthesia for, and we know that we’re going to do 12 extractions, it’s going to be a long procedure, but their blood pressure is already not doing so great and they are also a elevated kidney value patient and I want to make sure that they don’t get too hypotensive, then I’m going to start dopamine on this patient again, we’re going to have alpha effects and we’re going to have beta effects, which means the beta is going to help to increase the heart rate and the contractility and the alpha is going to give you a little bit of a squeeze on those vessels similar to another alpha active drug dexmedetomidine.
Now dobutamine, and the reason I like to have dobutamine around is because for some animals like your mitral valve disease patients like your chronic heart failure patients, these little shih tzus that come in and they have heart disease, these guys, if we’re about to do a lung procedure on them and they get hypotensive, they’re going to do better with dobutamine. And that’s because dobutamine primarily acts at disease, can’t handle the vasoconstriction that comes along with alpha activation and dopamine. So we will go with dobutamine for these guys because it’s like it’s having a party at the beta receptor. It’s like all beta all the time. And that’s why I want to have dobutamine for those specific heart cases. And then I also like to have a ephedrine, and ephedrine is one of those because it is very, very versatile. You can give ephedrine as a one-off and it’ll last for about 30 minutes.
So I find a phedrine very helpful. It’s an alpha and beta, very similar to dopamine, but unlike having to set up a concentrate infusion like you do with dopamine, you can give a one-off of ephedrine. Now you have to dilute it out. So make sure if you’re getting a vial of ephedrine, you are diluting this out. So you have maybe a one meg per mil concentration, but then you could give a dose of it. And sometimes if I say to my clinician, well, I’ve already tried the vaporizer, I’ve maybe tried giving, I don’t think the heart rate is an issue, and you’re telling me we still have 30 to 40 minutes left of this dentistry, but I need to do something about the blood pressure. If I don’t have access to dopamine or I don’t want to take the time to set up a CRIsad, I can maybe just do a one-off of ephedrine.
And that’s really effective because again, ephedrine like dopamine effective at the alpha and beta receptors, and we get about 30 minutes of activity. So that’s what I keep in my back pocket if I just need a quick something that I don’t want to set up or I don’t have access to set up a syringe pump and an infusion and et cetera. And then some other things, just like equipment that I like to keep with me at all times is an extra endotracheal tube, an extra laryngoscope. And if you are at a practice that has access to it, certainly paddles for fibrillation. Now again, remember if we are going to use paddles, this has to be a rhythm that’s a shockable rhythm. So we’re not going to shock vtac, but if you see it’s really critical things go south and crazy and your patient is in v fib, then we can shock that rhythm.
But I will also tell you that I’ve worked in plenty of places that don’t have access to paddles and they’ve done okay with that. But this is just equipment. And the reason I’ll go back to the laryngoscope in the tube really quick is on the off chance your patient during movement from induction into the theater gets extubated during the off chance that moving the patient around on the table, they get accidentally extubated. I want to make sure that I can quickly re-intubate that patient. And again, a laryngoscope is going to be the best way to do that because it’s going to give me visualization of where I’m going with the tube. If there are any problems, et cetera, I want to be ready for those problems. And that becomes especially, especially especially important if you’re dealing with brachycephalic patients, you always have an extra tube and laryngoscope ready to go.

Dr. Andy Roark:
Yeah, that totally makes sense. This is amazing. I did not have this as clearly broken down for me in vet school as you just did. This would’ve been so helpful 15, 20 years ago. This is amazing.
Hey guys, I just want to jump in here real quick and let you know about an awesome free one hour of RACE ce webinar that I’ve got coming at you real, real soon on December the 13th at 1 p.m Eastern Time. I am working with my buddy, Dr. Simon Platt, who’s a neurologist and a really interesting person. I just had him on the podcast. If you didn’t hear his episode on Spectrum of Care neurology, check it out. It’s a great episode. It’ll give you some idea of what we’re going to be talking about. But man, he is super fun and fascinating, interesting, and I cannot wait to get in and host this webinar for him.
Anyway, it’s called Head Cases, A Spectrum of Care Approach to neurology in general practice. It is made possible generously by Nationwide. There’s no fee to you. It does have RACE CE is going to be a great presentation about neurology in general practice and keeping neurology accessible to people in times when maybe people don’t have as much money as they would like or they don’t have the ability to just throw down and do the most aggressive treatment options possible. So anyway, it’s going to be fantastic. I would love to see you there. I’ll put a link to register in show notes. Let’s get back into this episode.
Alright, wonderful. Talk to me about some dosages. So are there dosage calculators that you really like because there you are and you’re doing the procedure and this is a stressful time and things start to go off the rails. What do you do to keep those things top of mind for you in a useful way where you say, okay, this is what we need. It’s not just epinephrine to effect, but although that works, but how do you track that information? How do you keep that in a very handy format? Or do you just know it, you’re just like, I know you know it, but is that the best way to approach this?

Tasha McNerney:
It’s probably not the best way to approach it because again, unless you’re really dead on the inside and you can block everything out and just go to your rolodex of drug dosages, nevermind the things beeping and people yelling again, I can do it, but I think that’s just because I don’t know, my brain functions a little bit differently, but

Dr. Andy Roark:
I’ve had people say, how much? And I show ’em with my fingers like this much, and they’re like, that’s not science.

Tasha McNerney:
Nope. Yeah, don’t do that you guys at home. But certainly I would say for anybody who’s interested, look at the vex website. They have a lot of really great things. Look at the RECOVER initiative that’s going to give you a really nice dosing chart. And I do know that if you go to RECOVER and look at the RECOVER initiative and their website, they also have posters that a lot of clinics will use that give you the dosages of based on weight. They have a quick wait chart. So a lot of ERs and emergencies will have this just hanging in their practice where they have a really nice weight chart that’s busted down between atropine, epinephrine reversal drugs, things like, again, if you’re in an ER setting and things get really crazy, you want to bust out the vasopressin, things like that. So I really would recommend recover because that’s probably the most up-to-date guidelines as far as what the research is saying, new updated dosages and having it easy and accessible.
Another thing that I do recommend that every practice does is take those dosages and make an excel spreadsheet or an emergency drug calculator, print that out based on the patient’s current weight and have that ready to go. The time to print it out and put it into the excel spreadsheet is not when everybody’s screaming and the dog’s losing a lot of blood. We want to make sure that we do that beforehand. And again, because it’s a really stressful time, it’s nice to have this printed out and checked beforehand because again, when things are really crazy and you’re really stressed out and your clinician says to you, okay, I need you to give a certain mg/kg dose, and then your brain is like, wait, how much does this patient weigh? What’s the concentration? And you’re trying to do this quick math doesn’t usually work out well. Those precious seconds that you’re taking to calculate out this drug can make a huge difference.

Dr. Andy Roark:
Yeah, yeah, that’s fantastic. I’ll put a link to the RECOVER initiative drug doses in show notes, so people could check that out. I don’t think I need a link to Microsoft excel, but um

Tasha McNerney:
I usually say because people can make their own excel, again based on what they have in their clinic, because I don’t think that every clinic maybe has vasopressin ready to go for their patients.

Dr. Andy Roark:
Yeah, no, no, I love that. I think that makes a ton, a ton of sense. What are the most common pitfalls that you see? What are the things that people either putting together a crash cart or using what’s on their crash cart?

Tasha McNerney:
I think that most common pitfalls, at least from an anesthetic perspective that I see, is that there’s not a regular checking of the crash cart and whether or not the drugs are expired or whether or not we have enough volume of the drug ready to go. So for instance, I would give you, yeah, to actually do what we need to do. Yes, I may have a bottle of atropine in there, but if there’s only 0.4 mls, that might not get me where I need to go. So having somebody check that before the procedure, and I’m a huge fan of checklists, and you guys know me. I love checklists. I love anesthesia checklists. If you haven’t read the Checklist Manifesto, please do yourself a favor and read this. It’ll change the way you practice. But certainly having checklists in anesthesia and having somebody to go in before the anesthetic event even happens, check that anesthesia machine, check that cart, make sure the lidocaine is in date. Make sure that you have a bottle of glycopyrrolate ready and available. Make sure that if you’re going to use dopamine, again, you have enough volume to make up your cri because I’ll just give you an example. I was helping out anesthesia on a 62 kg

Dr. Andy Roark:
Wow.

Tasha McNerney:
Great. Dane. Yeah,

Dr. Andy Roark:
That’s 140 pound

Tasha McNerney:
Great Dane in for a CT procedure. And I went to look at the crash cart and our anesthesia machine in Ct and I looking at it, and I was like, yeah, we only have 1 ml of atropine in this bottle. So yeah, I have atropine and it’s in days, but again

Dr. Andy Roark:
That’s not going to make one side of his mouth dry.

Tasha McNerney:
Something goes crazy with this patient. Now I have to run to a whole other side of the hospital to get more atropine because that one ML is not going to be enough for that dane.

Dr. Andy Roark:
Yeah. Yeah, that totally makes sense. Awesome. Tasha McNerney, thank you so much for being here. Where can people find you online? Where can they learn more about anesthesia nerds?

Tasha McNerney:
Yeah, so the Veterinarian Season Nerds is currently a Facebook group, and that’s where we do a lot of our discussion and case-based stuff. But you can also find us on the website. And on the website we have links to the Veterinary Anesthesia Nerds podcast as well as a calendar of events. So you can see where all of us are speaking. And when I say all of us, I don’t just run anesthesia nerds by myself. I am joined by Darcy Palmer, who’s a VTS in anesthesia, and she works out in Alabama. And then I’m also joined by Steven Sital, who is a VTS in, again, not only a VTS in lab animal, but also a surgical research anesthetist and just a wealth of information there. So we have a calendar, so you can see if you wanted to come hear us talk or lecture, we have a calendar on there as well. And then we have a contact form as well. So if you have something that you wanted to ask the anesthesia nerds or you wanted to request some help for something, you can get us there.

Dr. Andy Roark:
That sounds fantastic. Awesome. Thank you so much for being here, guys. Thanks for tuning in. Take care of yourselves. Have a wonderful rest of your week.

Tasha McNerney:
Thanks for having me.

Dr. Andy Roark:
And that’s it. That’s the episode, guys. I hope you enjoyed it. I hope you got something out of it. I said, you can see now why this is the Hall of Fame episode for us, and why so, so many people loved it when it first dropped. Guys, take care of yourselves, everybody. I’ll talk to you later on.

A Spectrum of Care Approach to Neurology

by

Dr. Simon Platt and Dr. Andy Roark dive into neurology’s challenges, emphasizing individualized care and accessible diagnostics. Dr. Platt introduces a forthcoming neurology resource aimed at providing comprehensive information for neurology enthusiasts, all in the pursuit of demystifying neurology and prioritizing accessible patient care.

This episode is brought to you by Nationwide Pet Insurance.

LINKS

Spectrum of Care

Nationwide’s Pet HealthZone

Web-Vet Neurology

Dr. Simon Platt on LinkedIn

Upcoming Webinar with Dr. Simon Platt

Dr. Andy Roark Resources 

Dr. Andy Roark Swag

ABOUT OUR GUEST

Dr. Simon Platt, a distinguished European and American veterinary neurologist with 23 years of academic expertise, embodies a passion for teaching, research, and clinical excellence. His extensive contributions encompass over 240 published scientific papers, including 70 chapters in renowned veterinary publications. Notably, Dr. Platt has co-authored five authoritative textbooks in veterinary neurology, showcasing his commitment to advancing the field’s knowledge base.

A trailblazer in academia, Dr. Platt has secured over $3 million in grant funding, led NIH translational research teams, and held pivotal roles within committees for ECVN and ACVIM. For over two decades, he has mentored neurology residents globally, while his dedication to education extends through the management of educational websites, notably featuring a pioneering 3D virtual-reality dog model for practical neurological examination teaching. Additionally, as the founder of SEVEN, a not-for-profit group, he established an annual southeastern regional clinical neurology conference, fostering collaboration and knowledge exchange within the field.

EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I got a great one for you today I am here with Dr. Simon Platt. He’s a veterinary neurologist. I did not know him before we sat down to record. This is my first time meeting him. His resume is amazing and so I just start off with that. But he has done so much and he is so smart and man is he approachable and easy to talk to and I could listen to him talk for hours and hours. So anyway, I was thrilled to get to talk to him. He has this really interesting way of looking at neurology, this genuine desire to bring it to general practice and to make it not intimidating to GP’s and just to help keep care affordable and accessible for people. And you’re like neurology and affordable don’t tend to go together.

You got to hear what he has to say. It’s just been really good. It is a great conversation. Anyway, I’m actually doing a webinar. I am hosting Dr. Platt for a webinar December 13th. It is made possible by Nationwide. It is totally free for you guys. I’ll put a link in the show notes to register. It’s got RACE CE attached to it. It is a sweet deal. I am really looking forward to it. After our conversation today, I’ve got pages of notes. I’ve got a bunch of questions from our conversation that I’m sitting on until we get together. So anyway, that’s coming up. This is a great episode. I have talked long enough. Guys, this episode is made possible ad-free by Nationwide. Let’s get into it.

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

Dr. Andy Roark:
Welcome to the podcast Dr. Simon Platt. Thank you for being here.

Dr. Simon Platt:
Thank you very much. It’s an honor and thanks for the invitation.

Dr. Andy Roark:
Well, it is a huge honor to have you here. For those who do not know you, you are a board certified European and American veterinary neurologist. You have published over 240 scientific papers. You have co-authored five veterinary neurology based textbooks. You have gotten a bajillion dollars in different research grants. You have have trained neurology residents for 22 years. This podcast is beneath you, sir. That’s what I think.

Dr. Simon Platt:
No, I’m still the poster child for imposter syndrome and after listening to all of that, I wondered it “Was that me? Where have those years gone?”

Dr. Andy Roark:
It’s a blink of an eye. But anyway, it is an amazing resume. I am happy to have you here for a number of reasons. The first one is I am going to be hosting you in a webinar. You and I are doing a webinar together on spectrum of care neurology cases on December the 13th. It’s made possible by Nationwide, which is very lovely of them. So it’s free for everybody, but I’ll be hosting you. It’s a one hour webinar. It’s got an hour of RACE CE on it. I’ll put a link in the show notes. It’s for people to register for that, but you and I are going to get to talk then. And before we did that, I always like to talk to people in sort of a more conversational format. And so I thought this would be a good opportunity for us to start to talk about something that I’m really interested in and that’s accessibility and it’s spectrum of care.

So what I mean when I say that to lay out some terms, I have concerns about keeping veterinary medicine available and affordable for pet owners. And so one of the things that is really interesting to me is looking at people like yourself who have such deep expertise in specialties and saying, what does this look like at the general practice level to do right by the patients? And it’s always that balance of advocating for patient care and for doing what’s right for the pets and educating the pet owners and also trying to meet pet owners where they are. And neurology is a particularly intimidating specialty to me when I look at it from this standpoint because it feels like very quickly we get to the multi-thousand dollar MRI machine. And I also have felt, I’ve had the feeling as a general practice doctor before looking at neuro cases of like, I can’t cut this, I can’t cut this. My medications feel fairly limited. It can feel like there’s not a lot of options when I’m looking at a neurology case. And so anyway, let me just pause there and open that up to you. What is your general philosophy when you look at neurology in an access to care capacity?

Dr. Simon Platt:
Yeah, I mean you touched on a lot there. I would have to admit neurology is very intimidating. That’s the first problem, not just to us as veterinarians. I mean, I remember starting out and to me I really hated neurology. We got taught by a stand-in neurologist who was our cardiologist. She admitted she hated it. She said, I’m not really sure what I’m doing here. I’ll teach you some neuroanatomy and then we’re away. And it didn’t really make sense. I thought, well, everything I see seems to circle, get steroids and die. This doesn’t really make sense. And so I was a bit scared of it. Now it’s intimidating on every level. The clinical exam is intimidating. Look at some of the other specialties and some of those are intimidating, but the clinical exam part, that’s not dermatology to me, very intimidating. But the clinical exam doesn’t seem that intimidating.

But for neurology, very intimidating check sheet based, you check these things, you don’t really know what does that mean, but I’ll just check it. No one’s watching and it doesn’t really add up. And so we need to get rid of that. That’s the first thing. But then it goes on because as you said, it seems like you can’t do neurology without expensive tests, invasive tests, and it seems that you can’t do neurology without surgery. And so I’ve approached it from the general practice background that I had where I was frightened of it, intimidated of it, trying to work out how on earth I could actually do it without some of those tests where we came from a background where MRI wasn’t actually being used. And so the spectrum of care approach was something that I kind of adopted early but didn’t really know how to articulate it, didn’t really know to say, well, this is spectrum of care.

To me it was all about individualized medicine, individualized for the client and for the pet. So for the client, you are individualizing it based on their personal circumstances, obviously finances, their geographic location, could they get places to do further tests? What’s going on in their life? Are they working 16 hours a day? So we’re making some decisions around that. And then we’re making some individual decisions around the patient as well. Because a patient that’s two years old that has condition A would be treated very differently from a patient who’s 19 years old that has condition A maybe has exactly the same signs. And so we’ve got to take those into consideration and that’s what all of us, I think, in this profession do. And so all of a sudden then it had a name of the spectrum of care. And I felt that’s helped because I feel right at the start we talked about poster children, but poster children.

I think for spectrum of care, one of them is neurology because we have to be able to offer a stepwise approach in diagnostics and a stepwise approach in therapeutics. And the problem that we have many times is that other specialties, other areas of veterinary medicine can do this based on a lot of evidence in terms of what the disease is. And we never get there because without a biopsy of the brain or of the spinal cord, we never have a precise answer. Whereas obviously if you’re dealing with liver disease, you may have a biopsy, you’re going to have other areas of veterinary medicine where it’s a little easier, a little cheaper, a little safer to get a diagnosis. For us, we’re always even spending thousands of dollars MRI type, you’re always guessing. And so I’ve encouraged our students to stand up and have a mantra and say, I’m a veterinarian. I love to guess. And that’s not playing down evidence-based medicine, because you need the evidence to piece together the facts that are given to you. Let me see this dog with this signal and these presenting signs and this neurologic exam piece, those pieces of the evidence together and come up with, well, what could it be and how would they respond to the treatment? So the evidence is out there for those aspects of the case, but not really of what exactly does it have.

Dr. Andy Roark:
So lemme jump in here because a couple of things that struck me. First of all the, for a moment I thought if I ever wrote about a book about neurology, I would call it circle get steroids and die. But now I think I would change that. I think I’m a veterinarian. I love to guess is a better title for the neurology book that I would write.

Dr. Simon Platt:
And the follow-up would be, I am a neurologist, I love steroids. And now some people will be tuning out and going, can’t believe he said that, but I know when the lights get turned out. That’s what the dogs and cats, that’s what we’re using. It’s just about appropriate use. So circling steroids and maybe doesn’t do so well, you need to know the dose of steroids. That’s the evidence in there.

Dr. Andy Roark:
I love it. I always love specialist secrets where they’re, I will tell you I have a hundred percent referred patients to a specialist because, and I knew they were going to give steroids, but I didn’t have the guts to do it. And so I gave it to them and they took the liability and they did it. So it sounds to me like what you’re saying. I just want to clarify that. So first of all, I love the fact that you come from a place in the general practice background and this was intimidating and neurology was scary. I can resonate with that. And I think a lot of other people, it sounds to me like what you’re saying is because getting an actual indisputable diagnosis is so hard, that makes it much more challenging to break neurology down into sort of a clear diagnostic step to a clear diagnostic path that we could walk through because we don’t end up with enough evidence because we don’t often get all the way the diagnosis. And so the fact that we don’t come with that diagnosis makes it harder to teach doctors. This is step one, this is step two, trust your instincts. This is step three. Is that sort of what you’re getting at there?

Dr. Simon Platt:
Yes. But there has to be still somehow a step one, step two step here. And I think therefore with neurology it’s going to be different. What we will use is the evidence behind the presenting signs, for instance. So our presenting signs could be sudden onset or slow. They could be accompanied by pain or not. They could be progressive or static. And so we’ll look at neurology as a series of presenting signs that will help us try to narrow down what the problem is. And so one of those other presenting signs will be, is it asymmetric or not? And so for us, if we’ve got asymmetry, however we see that either just on observation or on taking it further with a hands-on exam, that’s a factor we’ll throw into speed of onset progression of disease, presence of pain or not, because those things will help us narrow down our differential diagnosis list.

I dunno about you, but originally I was taught to think about neurologic diseases using that pneumonic damn knit V and I didn’t know I remember that what that was. So we shuffle the letters around and we’ve come up with vitamin D and I used to teach at Georgia and no one knew what that was. And so I shuffled that around and said vitamin D, and then everyone got it. And what we’re talking about here is the letters, right? Those letters of that acronym there, those letters V for vascular will go down all of those mechanisms of disease and look at, well, what would you present? So if you are vascular that’s in the brain, that would be a stroke. You are sudden onset, you are asymmetric, you are non-progressive. And so now I look at the dog and say, could you be that next thing eye for inflammatory?

You are subacute to chronic, you are progressive, you are often patchy, multifocal, you’re asymmetric. Could you be that? So our step-by-step approaches is let’s answer some questions. Question one is are you really neurologic? Right? That seems like an odd question because many of the times we know straight away they’re dragging their legs or they’ve got a head tilt, but sometimes we’re obviously presented with a case that can’t jump into the car anymore or go up the steps. And so is that orthopedic or neurologic? So step one, are you neurologic? Step two, where’s your disease? And I don’t want then people to become intimidated further by neurology and say, oh no, this is where neuroanatomy comes in because really we’re looking for is your disease in the head or out of the head? That’s where the separation of disease types occur. So our next question then, where’s the disease in the head out of the head?

And then the third question is using this clinical reasoning approach where we try to look at how you are presenting asymmetric, progressive and sudden onset. For instance, we’re going to look at those differentials, V for vascular, I for inflammatory, T for trauma and toxin A for anomalous. We go down the list. And so our step three is what could you be? And at that stage we can communicate with the owner and say, here’s two, maybe three possibilities. And of those we could maybe narrow those down with some further tests and we’ll show you how we’ll do that. So we might not need to advance all the way to the most expensive and invasive tests. And if the owner says “We haven’t got any money for any of those tests,” then we look at those two or three possibilities with an eye for treat for the treatable, and again, stepwise go with the least invasive, maybe the cheapest, maybe the most effective potentially medication. If that doesn’t work, we’ve got a plan for step two and three. So yeah, diagnosis and treatment will still have that stepwise approach without really knowing what they’ve got.

Dr. Andy Roark:
Do you find that walking through this process and you get down to, is it in the head? Is it out of the head? And then sort of going to the owner and saying, all right, here’s a bucket. And I guess that’s kind of how I think of it is I can’t tell you what it is, but I can kind of tell you what bucket it’s in. That allows me to start to have some realistic conversations about what treatment wouldn’t involve or what further diagnostics would involve. We can start talking about prices of things and what options are going to be available to them. I don’t have to know what the answer is, but I have to tell them where I think this path ultimately probably goes or what that journey looks like. And then we can start to talk about where they are, what their resources are, what their intentions are, what their feelings are. Is that kind of how you of look at this and how this sort of shakes out into helping guide people and give them insight when you don’t have a diagnosis?

Dr. Simon Platt:
Yeah, we’ll have those two or three possibilities or buckets where we can say if you have disease, a bucket one, let’s say it’s possible stroke. If we do nothing, this is what happens if we treat, what are we treating with? What’s the advantage and disadvantage of doing tests? For instance, if it’s a stroke, there is no specific treatment. And although with tests such as MRI, you can gain more confidence, there’s nothing definitive and they’ll get better many times in the next two or three days. And so we’ll offer owners, well that path takes you down, do nothing for two or three days. If they get better, you’ve got your answer. And then bucket B, this case will get worse if we do nothing. So again, then we’ve got some help there by just using time on our side as a diagnostic, and this is what you’ll get with bucket B.

Let’s say it’s inflammatory. If we do just blood tests, this is what we’ll get. If we do an MRI, this is what we’ll get If we do C, S, F, this is what it’ll cost, pros and cons of each of those things. And again, we can often help the owners feel comfortable with not going to the extent of doing all of those tests by saying this is the difference it will make if we do the tests. Because ultimately this whole thing about I’m a veterinarian, I’m a neurologist, I’d like to guess MRI sounds like it should give you the answer, but it doesn’t. It’s not often definitive, it just improves your confidence level. And so many times we’re still looking at it and saying, I don’t really know. Is that a tumor? Is that inflammation? And so then we’re still guessing and we’re still then going to treat for the treatable. So I know in a may say, well, what was the advantage of even doing that? And that’s a killer comment because that means we haven’t communicated upfront that you might actually get no benefit of doing these tests.

Dr. Andy Roark:
Do you have or have you had any sort of apprehension about sort of trying empiric therapy when you don’t have those types of diagnostics? When I look at the sort of medications we reach for in our neuro cases, I think I always worry, what if I’m wrong? What if I put this dog on an anti-seizure medication and that’s not the right play? Or what if I reach for steroids and this is not the right play? I don’t tend to have nearly that much apprehension in internal medicine cases or dermatology cases and I don’t necessarily know why, but it’s something scary about, I don’t know, maybe it’s just those, my experiences with those medicines, they still kind of feel like voodoo to me in some ways. Maybe that non-steroidals don’t feel like voodoo to me or antibiotics don’t feel like voodoo. Does that make any sense at all?

Dr. Simon Platt:
Absolutely. Because I think in the past we’ve been taught to be scared of neurology because if you don’t know all of your neuroanatomy inside out, then you can’t do neurology. Not true. If you don’t have an MRI, you can’t do neurology. Not true. And therefore you feel, well if I don’t really know what the disease is, how can I come up with treatment and the brain and the spinal cord, they shouldn’t be messed with. If I get this wrong, they die. Well, I think that’s the same with multiple diseases. I’d be scared of treating a dog with cystitis. So I mean it depends where you come from. So for me, I have no problem with empiric therapy as long as I’ve had a completely transparent discussion with the owner to say this is what I think’s going on. Two possibilities, three possibilities. This is the best thing for the dog right now.

If we are aiming to see if we can get some improvement, how far will it go? Maybe we don’t know what happens if it doesn’t work. We need a plan B. What’s the worst that could happen if it doesn’t work? And then the owner has a chance to come back and say, well, I don’t like the worst option. What would I do to avoid that? And we can discuss whether tests at that stage are going to help or not. And sometimes they say, well that’s great that you say now an MRI will help but I still don’t have any money. Well, so we’ll address the discomfort that comes from the fact that empiric therapy is an unknown by saying, well if we do nothing, I’ve got more of a known for you. And that is there’s going to be progression potentially or there’s going to be pain. So the empiric will focus on quality of life and so making sure they’re comfortable above all else. But then also looking at, well if you have something that’s treatable, what could it be? If I’m looking at inflammation in the brain versus the tumor in the brain, I’m going to go with treating inflammation because that’s likely to have a more positive effect than anything I can do for the tumor regardless of how much money that you have. And there’ll be some collateral benefit for the tumor if I use anti-inflammatory steroids.

Dr. Andy Roark:
Yeah. Simon, before I let you go, I want to jump back and do the vitamin D with you. And so just to run through it, it’s funny, the acronym is one that I heard back in vet school and it’s been so long and you bring it back up and we start to go through it. So just for our listeners to have it, vitamin D, we’re talking about the origin of a neurologic problem. V is vascular, I is inflammatory, T is trauma or Toxin A is anomalous.

Dr. Simon Platt:
Yeah. So anomalous being, yeah, you’ve been born with something. So in the brain that’s hydrocephalus in the spine. Then if you’re a frenchie, that’s a vertebral malformation. And then we’ve got M for metabolic. So that most of the time is a brain problem rather than a spine problem. Hepatic encephalopathy is a good example. And then we move to I for idiopathic, and that again is on the top 15 list of why people hate neurology because idiopathic, well isn’t that when I find nothing? So isn’t that everything? And so we have to get across that. Yes, you’re right. But idiopathic is for specific conditions. They’re loner conditions where there’s nothing else. So epilepsy, facial paralysis, vestibular, so they’re loner conditions, you’ll find nothing else. And then we’re down to N for neoplasia. And again, we’ll use all of our factors like the average age for brain and spinal neoplasia is eight, so we’re going to throw that in.

If you’ve got a two year old patient, then neoplasia is dropping lower on your list. And then N also is for nutritional, which for a while in my career fell off the map and now is right back on it because people think you should feed raw meat and bones. And so now we’re seeing a lot of nutritional problems hit the brain. And then lastly, D is degenerative in the spine. That is disc disease and myelopathy. And then in the brain really we’re dealing with old age degeneration, a little like Alzheimer’s, a cognitive dysfunction. So we use that list, that sort of acronym there to help us remember what exists in the brain and the spinal cord and we can just cross those off based on how you’ve presented. And so of that list based on your age, based on was it sudden or not based on is it asymmetric based on is if there’s pain, I could cross them off and say, I’ve got one thing left for you, two possibilities.


And maybe one of those isn’t treatable. And now we’ll talk about tests as to whether they will really help or not. And sometimes we won’t perform tests. If I have a seizure inpatient, for instance, 50% of them meridia pathic, and my evidence-based medicine is going to tell me that if you’re idiopathic, you’re pure bred, your age is between six months and six years, you have no neuro deficits. So if I see a two-year-old golden retriever with no neuro deficits having had a seizure, I’m probably not going to be advising MRI tell people, spend your money on the medication. If we need to start treating, if things start coming out of the woodwork in the next few weeks and things change, that may be the time to talk about being more aggressive.

Dr. Andy Roark:
I have about seven follow-up questions and I’m, I’m going to sit on them, I’m going to sit on them until your lecture in December. I could talk to you all day. I really appreciate you being here. Where can people learn more? Do you have favorite resources? And then where can people find you online?

Dr. Simon Platt:
Well, I’m on LinkedIn and so you could find me there. We’ve just actually opened, if that’s what they say, I’m sure it’s not a new website published. Is it? We’ve just released

Dr. Andy Roark:
Launched?

Dr. Simon Platt:
Launched. That’s best.

Dr. Andy Roark:
Unveiled?

Dr. Simon Platt:
What do people say that? launched is good? Yeah, we’ll go website, which is under construction, but you can start to get a feel of it. It’s for neurology for all ages, so to speak. And it’s called web-vetneurology.com. And so we’re going to expand that into hopefully extremely useful resource. We’ve got cases on there, we’ve got some literature on there right now. It’s not as useful as it’s going to be because we’ve got a lot of nuts and bolts, grassroots, grassroots information to add to it.

Dr. Andy Roark:
Perfect. That sounds fantastic. I’ll put links in the show note to all of that. Guys, thanks for tuning in and listening today. Simon, thank you for being here, gang, take care of yourselves, everybody.

And that’s it guys. That’s our episode. I hope you enjoyed it. I hope you got a lot out of it, man. I genuinely, I love this episode. Thanks to Simon for being here. Thanks for talking. I am looking to our, looking forward to our webinar together in December when we’ll be breaking this down in more detail and probably uses the visual aids and some slides and some things like that. So anyway, I would love to see you there. I’ll put a link in the show notes if you want to come to that free webinar, get some RACE CE, hang out with me and Simon. It’ll be a good time anyway, take care of yourselves, everybody. Have a good day. I’ll talk to you later.

The Right Number of Disasters

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I was recently listening to an interview where an economist was criticizing the way modern media reports the news. He said that the mainstream media tends to grab onto a disaster, thrust it into the national spotlight and then ask the question “how do we prevent this from happening again?!”

The economist said this behavior is misguided because some disasters need to happen and trying to eliminate them shouldn’t be an aspiration. The example he gave is this:

Let’s say that you have a house that collapses in an earthquake and some people get hurt or even killed. Some might ask the question, “how do we make it so that no houses ever collapse in earthquakes?” The problem with this question is that we don’t want to have a society where no house ever falls down in an earthquake. The number of building restrictions, the amount of building materials and the enormous cost of making every building earthquake proof would be astronomical. Housing costs would skyrocket.

Obviously, we also don’t want a society where lots of houses fall down whenever there is an earthquake. That would mean that we are under-regulating and monitoring residential building, and that we aren’t valuing the safety of our citizens. 

We should be aspiring, according to the economist, to not have too many or too few houses falling down in earthquakes. A healthy society will have the “right number of disasters.”

Similarly, if we had a society where no crime happened, we would have to be living in the most controlling, invasive police state the world has ever seen. Think about it, to have zero crime, there would have to be complete surveillance, the harshest of punishments, and dogmatic commitment to law and order by at least the vast majority of citizens. It sounds like a nightmare.

Saying that a society with no crime doesn’t make sense does not, of course, mean that we want crime. It also doesn’t mean we think crime is something we should ignore. It’s simply an acceptance of the idea that the tradeoff for letting people have freedom is dealing with the fallouts of personal freedom that we don’t necessarily like.

The basic premise here is that acting like disasters should never happen is a mistake. So is pretending disasters don’t matter. The balance, it seems, should come from asking ourselves: “do we have the right number of disasters?”

We want some houses to fall down in earthquakes because that means we haven’t gotten completely out of control with building costs and regulations, and we want some amount of crime to happen because that means people still have freedom. 

Likewise, in our clinics, if no one ever gets angry about the price of services we probably aren’t charging enough to run a healthy practice. If no one ever fails to follow a set protocol, then I question whether people are actually thinking about the specific case in front of them. If no patient ever dies in surgery, then are we pushing ourselves to save as many lives as possible?

Things SHOULD go wrong in practice. They shouldn’t go wrong in great numbers, and the same thing certainly shouldn’t go wrong over and over. However, there absolutely must be disasters in a healthy practice. Here, just like in the media, asking what we can do to eliminate problems is generally the wrong approach. The right one is about asking ourselves “are we having the right number of disasters?”

Veterinary Diagnostics and Screening Move into the Home

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Aaron Massecar, Executive Director of the Veterinary Innovation Council, joins Dr. Andy Roark to discuss a recent article on technology turning pet owner homes into the first touchpoint for diagnostics and screening of veterinary cases.

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

LINKS

Aaron Massecar on LinkedIn

Article: Home is the Emerging Care Site

Veterinary Innovation Council

My Dog Is A Robot

Healthcare and Information Management Systems Society

Consumer Electronics Show

Dr. Andy Roark Resources 

Dr. Andy Roark Exam Room Communication Tool Box Team Training Course

Dr. Andy Roark Charming the Angry Client Team Training Course

Dr. Andy Roark Swag

ABOUT OUR GUEST

Aaron Massecar, currently serving as the Executive Director of the Veterinary Innovation Council, brings a diverse expertise to this episode. Previously, he held roles as the Vice President of Education at VEG, Assistant Director of Continuing Education at Colorado State University, and served as an Adjunct Instructor at Texas A&M. Aaron played a pivotal role in establishing the Veterinary Innovation Summit and Veterinary Entrepreneurship Academy, leaving a lasting mark in the field.

Outside his professional commitments, Aaron thrives on physical challenges. Recently completing a demanding 127-mile gravel bike race in Iceland, he continues to embrace new feats. Notably, he tackled a 200-mile gravel race from Moab UT to Fruita CO, showcasing his enduring passion for adventure.

EPISODE TRANSCRIPT

Dr. Andy Roark (00:07):
Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I’m here with my buddy Dr. Aaron Massecar. We are talking about innovation in vet space. We start off talking about innovations in veterinary care that is going to move diagnostic and screening into the pet owner’s home. And so if you are interested in how technology is going to make pet owners more savvy and also put diagnostic and screening tools into their hands and how this changes the way that we’re going to work with them in the future, this is a great episode. We start off talking about that. We kind of use that talk about innovation in general. I ask Aaron about what he’s most excited about with innovation in the vet space. He’s really neat. He’s the executive director of the Vet Innovation Council, so he thinks a lot about this.

(00:57):
He sees a ton of startup companies and people having ideas about innovation and where that medicine might go. And so he’s got this really neat perspective on the bleeding edge of technology and innovation in VE medicine and where it might go. So anyway, is a really neat thought provoking episode. Guys. I hope you’ll enjoy it. I really enjoyed making it. As you’ll hear on this, I like Aaron a lot. I like to give him a hard time and just sort of push him and make him try to commit to what he thinks is going to happen. And so anyway, we do that. It’s really fun. Let’s get into it.

Kelsey Beth Carpenter (01:32):
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 (01:49):
Welcome to the podcast, Dr. Aaron Massecar. How are you?

Dr. Aaron Massecar (01:52):
I’m fantastic, Andy. Thanks for having me.

Dr. Andy Roark (01:54):
Man, it’s good to have you here. This has been too long coming. I love when we get to sit down and talk. For those who do not know you, man, you are an interesting person. You’ve had a lot of different titles doing a lot of different things. You are currently the Executive Director of the Veterinary Innovation Council. Why don’t you talk a little bit about what the Veterinary Innovation Council is? It sounds like a group of people like robed, people who meet in a secret location to discuss what will happen in vet medicine in the future.

Dr. Aaron Massecar (02:28):
You’re probably like 66%. So the locations are secret and we do talk about the future of veterinary medicine, but nobody wears robes or tassels or anything like that. So it’s a sponsor driven organization. It’s a 501 C6, and we look at the future of veterinary medicine. We have one conference every year, the Veterinary Innovation Summit. And then when we’re not focusing on that, we’re focusing on some of the trends. So we’ve looked at things like telemedicine, nurse practitioners or mid-level providers. Right now we’re focusing on access to care and we’re looking at a couple of other things like super sexy topic, interoperability. Everyone wants to know about that, AI…

Dr. Andy Roark (03:14):
I don’t know what that is, what is interoperability?

Dr. Aaron Massecar (03:17):
So you know how pimm systems, they do not communicate with each other at all.

Dr. Andy Roark (03:22):
Oh yeah.

Dr. Aaron Massecar (03:23):
So it’s basically trying to create the framework so that those systems can communicate with each other.

Dr. Andy Roark (03:29):
And you call that interoperability, that’s not a word at all. You just made that up. That’s not even a thing.

Dr. Aaron Massecar (03:35):
Just a messenger. Just a messenger.

Dr. Andy Roark (03:38):
I don’t think that’s a real word for making PIMS systems talk to each other. That seems ridiculous. All right. Okay. What else do you got besides PIMS systems talking to each other?

Dr. Aaron Massecar (03:51):
Big focus right now is on artificial intelligence, so what’s happening with radiology in particular, but then how’s that spilling over into all sorts of other areas? Everything from endoscopy to decision support to just about everything that’s affecting the clinic. We’re looking at companies who are using AI for inventory management, everything that you can imagine. Companies are starting to use AI for that.

Dr. Andy Roark (04:18):
Everything where a human being looks at information and then makes a decision. I could a hundred percent see that. Yeah, totally. Yep. That’s fascinating. Alright, I reached out to you. You have an article that I saw recently that I really liked. It’s called Home is the Emerging Care Site. It was in the last Today’s Veterinary Business magazine that came out. And I like that because I always thinking about business models for vet medicine and I like thinking about where opportunities are and I’m seeing a real increase in home care providers, so veterinary house called vets, things like that. And there seems to be demand from the public. I see a lot more doctors shifting over to this.

(04:59):
I think that there’s real opportunity for entrepreneurship here. So if you’re a general practice doctor and you want to work for yourself, this is probably the fastest way to get up and get going on your own. And so I’m looking at that and I’m sort of thinking about the way that we’re working and what that looks like and the demand that I see for those home services. And then I see your article on Home is the Emerging Care Site, and I’m sort of looking through it and you’ve had a number of ideas about what sort of home-based treatments look like and home-based medical opportunities look like. And so with an innovation sort of lens, I’d like to look at the practice of medicine in the pattern’s home. And where do you see that now and where do you see that going?

Dr. Aaron Massecar (05:41):
Yeah, so this actually goes back a long time ago to the first veterinary innovation summit that we had where John Ayres was there and he was talking about preventative wellness is a major shift, and this is back in 2017. And you can see that being the case. There’s more and more companies who are starting to focus on that and early screening and that sort of thing. And then at the same time, you see companies like Whistle hitting the market and they were primarily a wearable device for GPS tracking and some activity tracking, and then they start launching some of the algorithms that they have. So this was probably in 2018 maybe, where they were presenting on the algorithms that they were using to look at two things in particular. So one was how often is the animal itching and scratching so they could find the hotspot before the hotspot emerged?

(06:38):
So that was interesting. Another thing that they found was when does activity levels return to normal? So most people were thinking within two weeks your animal’s going to be back to normal. What they found through their algorithms was that it was closer to a month. So this goes back a ways, but then you start looking at all the direct to consumer products that are out there in the market now. So we have a litter robot by whisker. We also have some other things in the house just to kind of help manage the animals, but there’s all these devices that are starting to collect information and yet they don’t have any real access to veterinarians. So I talked with some of these companies and I said, okay, what are you doing with this information? Right, because I’m not a veterinarian, but I’ve talked to a few and they said that it’d be really helpful to know if your cat has increased urination, if the frequency with which your cat is urinating is going up, if your cat’s weight is going down.

(07:37):
These are important things to know for early screening. And yet a lot of the times we’re relying on the animal owner in order to figure out what’s normal and what’s not normal. And the animal owner is just not around enough. So there’s all these devices that are collecting data that can inform future protocols when it comes to taking care of that animal, and yet nobody’s really bridging that gap. So you want to talk about business opportunities. How are you consolidating all this data into a platform and serving that up for veterinarians in a way that it’s easy to access long-term? Is it possible that some veterinarians are basically going to look like air traffic controllers where they’re sitting there with multiple monitors and they’re just monitoring things? Well, that’s already existing on the human side. If somebody’s in ICU, they just see all the data that the human they’re collecting from the human. But all of this exists in the home now, and yet nobody’s really capitalizing on it. So that’s the kind of stuff that I think is really fascinating. It’s hard to tell where it’s going to go in the future, but there’s definitely an opportunity there.

Dr. Andy Roark (08:41):
Alright, cool. So why do you think, I have a theory on this, but why do you think that this is an opportunity that’s not being capitalized on now when you start to look at these products and you look at what’s there, why do you think there’s a hole in the market? I have my qualms with modern capitalism, however, I do think that it’s pretty generally good at looking at where there’s opportunities to generate revenue and going, yeah, let’s do that. And there’s a reason that we don’t see this going. I think. What do you think?

Dr. Aaron Massecar (09:15):
Well, the primary reason why any startup fails is bad product market fit. The second reason is timing What this requires as a veterinarian’s eyeballs to be on this information and every veterinarian that I talked to today is just overwhelmed with the amount of work that they have to do. And so asking for that to come in and say, yeah, can you look at this? Can you pay attention to this? And it’s like, look, I’m dealing with this dog that is currently dying. I don’t have time to look at screening. Which is, I think another reason why AI is going to be hitting the market in a really big way over the next little while is because if they are collecting all of the data and they can standardize that data and provide understanding of normalcy and deviance from the normalcy, then you don’t need a veterinarian to look at it in a lot of ways because you can find out pretty quickly, hey, this is abnormal behavior.

(10:13):
Most companies don’t want to dip into this realm. But if you think about just the amount of labor that’s required, so if you have tons of data that’s being served up to multiple veterinarians in multiple different locations, that’s going to be really challenging. But if you have actionable insights from a veterinarian team who has built the product and built the algorithm, then you can modify a behavior at the home and you don’t actually need to serve that up to the veterinarian anymore, which is not where we want to go. We want to keep a veterinarian in the center of that care cycle. But in a lot of cases, if veterinarians don’t have time for it, and this is an issue we probably shouldn’t wade into, but if there actually is a care shortage, then that kind of stuff is not going to be happening very soon. Veterinarians just don’t have time for it.

Dr. Andy Roark (11:04):
I think that that’s spot on. I do see that as a real opportunity for AI. We’ve had products try to come to market before that are activity monitors and others that do things as far as tracking heart rate and stuff like that. And generally what happens is that people find out their dog sleeps a lot more than they thought they did. You know what I mean? And that boy, he really doesn’t do much when I’m not here. And that’s the big takeaway. And so it’s just been kind of interesting. There’s two parts of it is they’re generating this data, but you’re right, veterinarians are not excited to wade into a pool of data and do data analysis, and there’s really no model for compensation for that. You’ve got a 25 minute appointment and we’re supposed to do significant data analysis in order to do that. And you go, none of this fits into the model of $65 physical exam in a 20 to 30 minute block.

(12:02):
Where does this interface in a way that actually works? And so I think a lot of people struggle with that. I also think that pet owners have struggled a little bit with the return on investment in these sorts of things. It’s a good idea. It’s like buying multivitamins. You get fired up and you buy a bottle of multivitamins and then you go back and you’re like, man, this stuff is expensive. And I didn’t see significant results from the first bottle of multivitamins that I bought, and I don’t know that I want to continue to pay for multivitamins for the rest of my life. And that’s the headspace that young Andy had when I was like, God, these stuff costs a lot. And I don’t know that it’s actually not seeing them any return. And so when you’ve got a healthy pet and you’re monitoring them and what’s, how motivated are people to keep going with that?

(12:50):
It’s funny. I think people, I’ve thought a lot about this, Aaron, with how people are in their pets. Because I see veterinarians all the time going, man, pet spending is soaring. People are spending so much money on their pets. And I’m like, yeah, they’re spending money on costumes and they are their buying football jerseys and sunglasses and strollers, but they’re not like, oh buddy, give me this thing that’s going to actually help my pet lose weight. They’re like, no, I want more fatty stuff that my pet’s going to love. And yeah, he’s going to pack on five more pounds, but he’s going to be happy. And they don’t want to think about mortality in their pets. They just want to suck the joy out of it. And I get it. I really do. And I’m not trying to be critical, but it’s always been interesting to me.

(13:38):
I think for these things to work there has the wellness healthcare part has to be wrapped into a happy package. It’s like your own Apple watch. It’s like, I didn’t get an Apple watch to remind me of my mortality. We’re going to look at this Andy and make sure you’re sleeping well. As you get older, your sleep’s not as good and we’re going to check your heart health. And I’m like, Ooh, this. This doesn’t sound as fun and sexy as I had originally thought about. It’s like, no, we’re going to get you a watch. You can play games on and text photos to your friends and also in the background it’s going to be watching your health. But I do think there’s some of that. And the other part is actually taking this and turning it into something that’s usable. And so I think you make a really interesting point with AI.

(14:25):
And also I think your point about most businesses fail on timing. I think that’s a fun way to kind of think about business failure. But I think that there were probably a crop of products that were five to ten years too early that will probably, we’ll see something similar that will work much more easily going forward. Alright, I am so proud to unveil the biggest project I have ever worked on. This is a partnership with NAVC’s VetFolio and Uncharted, which is the veterinary conference that I started and run for fifteen years. I have worked with people on being effective as communicators and making their practice better places to be. Now I am so thrilled to be launching the Leadership Essentials certificate with Uncharted and VetFolio guys. These are the seven courses that I believe really believe anyone who’s leading other people in vet medicine should have.

(15:19):
This is vision and value setting. This is basic strategic planning. It is understanding different communication styles. And I have my friend Stephanie Goss helping teach that session. It is getting the team to buy in to new ideas and initiatives. It is how to coach and give feedback. It is how to set priorities. It is how to delegate effectively. It is how to do time management. It is the talks and the stories that I am probably most well known for giving. My red.talk is in here and my GPA talk is in here. Everything about the North stars, everything that I lay out where I’m like, this is just so essential to managing people. It’s the trust game. It is everything about building and maintaining trust with your team. I think that this is something that I would recommend for anyone who is a practice owner. It’s anyone definitely who’s becoming a new practice owner.

(16:13):
It’s for anybody who has especially gotten promoted up into management. It is huge for our team leads. We take people who are CSRs, we take people who are technicians and we make them lead techs or lead CSRs, and we give them zero leadership or management training. There’s no excuse for that anymore. This is on demand whenever you want. It’s broken up. It’s eight hours. It’s got RACE ce, it has the Uncharted VetFolio certificate with it. It is there. It is accessible. I really hope that people will take this and put it to work. I went really hard on this. It has been years in the making and refining to get this content down. So it is really for everybody who is leading and managing other people in vet medicine. I hope you’ll check it out. I’m so proud of it. I’m so glad to be partnering with NAVC on it. Anyway, guys, I’ll put links in this show note. I hope you’ll have a look. Let’s get back into this episode. So yeah, how do you think this progresses from here? So when we’re talking about care at home, how do we get to there from where we are? What are the next things that you think are going to happen?

Dr. Aaron Massecar (17:18):
There’s some really interesting technologies that are starting to come in computer vision and being able to analyze the gate of an animal in kind of an ambient device. So there’s some interesting stuff like that. Usually when I talk with veterinarians about it, there’s a certain level of skepticism like, well, I don’t really know if that’s actually real or what that, and it’s like, well, it’s not meant to be a diagnostic device. It’s meant to be a screening device. So I think part of it is finding the positioning that is going to be effective both from a company perspective and from a veterinarian perspective in order to bridge that divide. And that’s where I really do encourage those companies to talk about it as screening and not as diagnostics because the moment we say diagnostics and you’ve got some definitiveness rather than it being an early detection device.

(18:10):
So I think part of it is just developing the appropriate language around it. Another part of it is that there’s a major challenge for a lot of these companies because they want to work with veterinarians, but they don’t really know how to access. So they’re going to Dr. Jones down the street. And Dr. Jones is like, I don’t have time for this. Why would you bother me with it? So the development of something like a community of early adopters, this happens in large corporations all the time where they find these pilot sites. But for community members to self-identify as like, I’m really interested in solving a problem related to cardiology. Show me the companies that are doing something in cardiology. I want to know more about that. So there’s a certain level of matchmaker-ness that has to happen in that area that currently doesn’t really exist. Yeah and I think through those two things, there’s going to be the perception, at least the perception of more value for some of these companies. But for the most part, most of these companies, they’ll try to work with a veterinarian and the veterinarians like, Matt, I don’t have time. And then they’ll be like, all right, direct to consumer, right?

(19:25):
I’m going to bypass it.

Dr. Andy Roark (19:26):
Sure. Well, the veterans don’t know about bringing technology products to market. It’s not their thing. And yeah, I could definitely see that sort of failure to failure to launch. I like your idea, and I think you’re probably right about a lot of this getting rolled up into the term screening over being something that is marketed to veterinarians as diagnostic. Because I just started thinking about it. I’m like, okay, we’ll be the driver for this because usually there needs to be a driver. I can a hundred percent imagine Amazon pets coming up with an app where you record your pet walking and running and it gets crunched by AI and it comes back and says, Hey, I’m worried about your pet’s hips. I think you should go to the veterinarian and get checked out. The hope being that the veterinarian will say, yes, you’ve got some arthritis in these hips, some osteoarthritis, maybe some early hip dysplasia, and we need to get you onto a joint supplement or osteoarthritis medications or something that you would want to get on autoship that the company that had the app could help you do.

(20:40):
If you’ve already got our app, you’re probably buying from us. And so I can a hundred percent see drivers like that pushing those screening tools, and again, going to the pet editor and saying, do this, do this video. We’ll raise some flags and then you can go and ask your vet specific questions and it’s good for your pet, it’s good for you to know what’s going on. And also it’s probably going to be good for me because you’re going to come back and buy products from me based on the information you get. And so all of that stuff kind of makes sense. I got to note, so as are the head of the Veterinary Innovation Council, do people ever come to you with ideas and you’re just like, that’s a terrible idea. You don’t have to tell me who don’t want no examples. But again, I’m a little bit cynical about innovation in general. We also say innovation, and then people are like, look, I’ve got a water bottle that screams when it’s empty. And I’m like, that’s a terrible, who wants that? There’s people who love babies. I don’t know.

Dr. Aaron Massecar (21:42):
There’s water bottles… just peeking into your brain a little bit…Just going to close that door back down.

Dr. Andy Roark (21:52):
Exactly. Yeah, I’ve got million dollar ideas. I’ll tell you what, I’ve got a lot of ideas.

Dr. Aaron Massecar (21:59):
It happens all the time. And some of them are interesting and some of ’em are like, there might be some sort of medical application for what you’re talking about, but I cannot provide you with any guidance. Right? And then some of ’em are just like, it’s just not innovation, right? So I try to help people understand that there’s a difference between true innovation, which is disruptive innovation, which people use that term all the time, and what that actually means in a genuine sense. And then there’s stuff that’s solving a problem, but maybe it’s not super innovative, but it actually does solve a problem and nobody else is solving that problem. And that’s okay, but don’t pitch a product that you think just a bunch of examples that are rolling around in the back of my head, but that you think is really innovative and you want to call it innovation when it just, it’s solves a problem, contextualize it appropriately.

(22:58):
So yeah, people come forward all the time. For the most part, I’m able to help them because we’re a nonprofit, we’re not investing in any of these companies or anything like that. My currency is information more than it is dollars. And so just trying to figure out who’s doing what and where and how can I help them? Because yeah, some put together a pitch for the innovation summit and they want to exhibit there and they’re like, this is really innovative. I’m like, this isn’t really the place for you going to a VMX startup circles, that’s the place for you because you’re solving a real problem for real veterinarians and sell the product that way, but don’t talk about it as though it’s revolutionary.

Dr. Andy Roark (23:39):
Yeah. So in your mind, when you talk about innovation, is there always a significant technology component to it? Is that kind of the line is for you? I hear it totally what you’re saying, and there’s a lot of things that I really like and impressed with that they’re super simple, and I’m trying to think of an example off the cuff, but basically are ways to solve problems that don’t involve radical new technology. They’re just, oh, this person has thought about this in a different way and blah, blah, blah. I mean, I’ll give you an example. So the company that I run is called Uncharted. And so we do boutique conferences and they’re very much workshop based in a way that when we launched six years ago was you did not see that other places. And again, you’re not going to hurt my feelings. In your mind, is that innovation or would you say No, that’s a very real, it is a great solution to a problem that people had about different ways that we learn and things like that. So yeah, would you classify that as innovation? And if not, where does it differ what is required to be innovation?

Dr. Aaron Massecar (24:43):
Yeah, I don’t necessarily think of it as kind of an on off switch, but in that case, I would say you’re offering an innovative take on a preexisting model. And so is it true innovation in the sense that you are matrix plugging into people’s brains and offering them new skills? But that would be an unrealistic expectation for anything but saying it’s an innovative take on something that pre-exists. Yeah. Is it true innovation? Is it true disruption? It’s not disruption, right? Disruption would be a fundamental change in the way in which people experience these things, but it’s innovative, right? Yeah,

Dr. Andy Roark (25:26):
No, that makes sense. Okay. And that totally fits. I was just trying to figure out where the line is in innovative ideas versus an innovation, and that does make sense. Alright, I like all of that. When we start to look around and we are looking, we’ve talked a lot about products that would come to market and what that looks like and where consumers interface with that. Is there anything that you are super excited about when you think about innovation? You’re like, oh man, this is the thing that I hope happens or this is the thing when I get out of bed in the morning, I’m like, oh man, maybe today somebody will come with this idea. This is going to be huge. Is there anything that gets you fired up?

Dr. Aaron Massecar (26:09):
So there’s two things. So one exists, and then the other one I want to exist, and I’m not really sure if it’s going to exist, but the one that exists already, there’s a lot of people who are providing innovative PIMS. And so there’s companies out there who have ambient listening devices where they will just listen to the conversation that you have with the client and turn that into the medical record and use decision support in order to provide you with a possible treatment plan. And so you just go in and you’re like, yep, yep, yep, nope, nope. Done. And your record is done. So there’s that kind of stuff that I think is absolutely needed when I would watch it. So my wife is a vet and when I would watch her come home from work and just sit down and be like, yeah, I’ll be with you in an hour.

(26:56):
I’ve got to finish my notes. And I’m like, and she would pull up her little post-it notes and then turn those into the record. And I’m like, that’s insane. So changing that model, anything that provides veterinarians with more time and is less of like a, well, if you just did this, then you could have this other service, right? No more boltons, save veterinarians time in the clinic. Anything that does that I’m really excited about. But the thing that I would really love to see is a fundamental new model of education. The way in which we educate people is based on a 15th century model of scarcity of information and not at all in line with contemporary research on learning. We don’t even teach people how to learn. We teach learning incidental to the process itself. And so some of the AI models that are coming out utilizing veterinary education as kind of the background are super interesting and they’re way more engaging than lecture format.

(27:58):
Lecture is not the fact that you were using workshops already points to you recognize that there is a need in the market for engagement with people that wasn’t just like, listen to me lecture at you for an hour at a time. And that’s called the Generation Effect. So you’re listening the generation effect in the individuals. And so the retention of that is much longer, and yet we don’t focus on these things. So there’s like 10 to 12 facts that we have about learning that are not being deployed currently. And that needs to change because I genuinely believe that that is actually the root of the majority of the issues that we have in Vet Med. Everything from wellness and burnout and all of that. If we taught people appropriately and taught people how to teach people appropriately, I think a lot of those issues would just be gone.

Dr. Andy Roark (28:49):
I heard recently one of the brand new vet schools that open up, it may be Arizona, they don’t quote me on that. Their students will not have any lectures. They don’t have lecture, and that’s not how they’re trained at all in vet school. Everything is case-based and sort of workshop-based. And I had to sit down and think about that for a minute because again, I have my own beliefs about the lecture is as someone who does a lot of lectures and I enjoy lectures and I can tell a good story and I have a lot of fun, but I did start Uncharted because I do think that when we get into types of learning people, they want to work on their own stuff and they want to talk about their own things and they need to process it, they need to talk it through, they need to reflect back on lessons learned and things they’ve tried.

(29:42):
And there’s all of those sorts of things that don’t tend to happen when we just sort of sit in a lesson lecture and maybe jot some notes down. But for the most part, we’re just kind of taking this information. We know that people retain about 10% of what you tell ’em, but if you give ’em a project, I make ’em work on it. They retain a lot more. And so I’m totally with you on that. I think that that’s exciting. That’s what we’ve bought into in Uncharted. I think the idea of using artificial intelligence stuff to come up with new ways to learn. I think that’s super fascinating. Aaron, I could talk to you all day, man. I really appreciate your time. I appreciate you being here. If somebody is like, man, this whole veterinary innovation thing space is just new to me and I would like to know more about, I geek out on technology and medicine and how do I even learn about what’s going on? How do I know more about this area? Where would you point ’em?

Dr. Aaron Massecar (30:36):
Number one place, not to compete with your conference, but the Veterinary Innovation Summit, that’s where a lot of that stuff gets shared. I’m going to be publishing more of this on LinkedIn, so recommend that you follow me on LinkedIn. The Veterinary Innovation Council, our website, we just did a refresh, and so we’re starting to develop more content that we’re going to be putting on there. But there’s fun places. Like mydogisarobot.com. Oh really? Okay. Check on it. Yeah. So my dog is a robot.com and the guy puts up all sorts of directing consumer products. So it’s interesting to see what he’s got in there. Yeah, those are some of the main spaces that I would look at. There’s so much out there. If you are a conference junkie, the two of us definitely go to the Consumer Electronic Show, CES. It’s unbelievable the amount of stuff that exists at that conference that has applications to that med, but most people don’t know. And then the Healthcare Information Management System Society.

Dr. Andy Roark (31:46):
That sounds like a party.

Dr. Aaron Massecar (31:48):
Oh yeah.

Dr. Andy Roark (31:49):
The Healthcare Management Information Systems Summit

Dr. Aaron Massecar (31:52):
Healthcare Information Management Systems Society. They really have to do some rebranding,

Dr. Andy Roark (32:00):
Some Healthcare Information Management Systems Society.

Dr. Aaron Massecar (32:04):
That’s it.

Dr. Andy Roark (32:05):
No? Okay. Is it really? Okay, alright.

Dr. Aaron Massecar (32:09):
Everything digital health on the human side is there. And so when you go to a conference like that and you start talking to companies like GE or Zimmer Biomet, like Zimmer Biome has this implantable knee that has wifi capability that will measure stride length and all of these other parameters. And you’re like, have you ever thought about VetNet? And they’re like, no, no I haven’t. So if you’re a budding entrepreneur, you just go these conferences, talk to people and say, look, I could launch your vet med division. Or a lot of companies will say, we’ve wanted to get into it. We know that it would be a really good proving ground and all of this stuff. We just don’t have the resources to do it. Going to these places and saying, I’m interested in talking with you about it, it’s unbelievable how quickly you get some traction.

Dr. Andy Roark (32:59):
Yeah, I’m still, I’m sorry, I didn’t hear what you just said. I was thinking about my dog’s knee attaching to the wifi and I was like, I don’t even know what that means. My knee attaches to the wifi. How does that even

Dr. Aaron Massecar (33:14):
Magic!

Dr. Andy Roark (33:15):
I’ll be like, “Look, kids, you’re bogging down the network. Unplug the dog’s knee.” Okay. Alright. That’s enough of that. Aaron, thank you so much for being here, buddy. I really, I thoroughly enjoy you. Thanks for doing Let’s do this again. For sure. I’ll put links, I’ll put links to all the events that you mentioned and the Vet Innovation Council and my dog is a robot and you on LinkedIn so people can see what you’re writing about.

Dr. Aaron Massecar (33:40):
That’s awesome. Thanks for the opportunity, Andy.

Dr. Andy Roark (33:42):
Oh man, I love it guys, thanks for being here and listening to everybody take care of yourselves. And that’s our show. That’s what I got for you guys. I hope you enjoy it. I hope you got some the out of it. Thanks to Aaron for being here. Check out the Veterinary Innovation Council. Consider going to the Vet Innovation Summit. If you haven’t been to it, it is a neat little gathering. I have not been, I want to go, it always lands on a concept for me. One day I’m going to go and I’m going to check it out. So anyway, but I continue to hear great things about it. So alright team, I will see you guys later on. Take yourselves.