Andy Roark DVM MS

Those You Know, But Don’t Know

November 15, 2023 by Andy Roark DVM MS

When I used to drop my kids off at daycare, my primary focus was ejecting the children from my car so I could get on to my mile long to-do list. Screeching tires, flying gravel and… was that a little girl wearing a halloween costume in March? I passed through the parking lot as quickly as possible.

From an efficiency standpoint, this was great. I was knocking things off the list and making stuff happen! From a relationship-with-daycare-workers-and-other-parents, it was pretty bad.

Relationships are funny and fickle things. You can’t put them on a checklist and mark them off. You can’t show up, say a compliment and walk away. No matter how charming you are or how much corporate communication training you’ve had, building relationships takes time. It requires doing the work to know another person. Putting in the time of simply being together. There are no shortcuts.

I spent years as a veterinarian ducking into and out of exam rooms like a game show contestant navigating an obstacle course. I took great care of pet owners and pushed appointments quickly and efficiently. But at the end of the day, when my technicians would go home, I had no idea where they went. I didn’t know what they did, or who met them when they got home.

I knew the people I worked with, but I didn’t really KNOW them. I knew their competencies and behaviors. I knew their quirks and what made them laugh. I didn’t know, however, what they cared about, how they thought, or what they aspired to become in the future. I didn’t know what they wanted to accomplish before they died, what their most meaningful life experience had been, or what made them proud at the end of the day.

I regret not knowing those things.

I think a lot of us believe we don’t have better relationships with the people around us because we don’t have time to build those relationships. I’m not so sure that’s true. Recently I’ve been pondering the idea that maybe it’s not time that holds us back. Maybe it’s a lack of curiosity. Maybe we forget to wonder about people we see everyday. Or maybe we’re just too shy to ask people about themselves.

In my experience, most people are thrilled to have someone want to know more about them. They smile and open up. They feel special and seen. Asking deeper questions so we can better know others isn’t a weird thing in practice. Instead it’s usually a path to deeper, more trusting relationships.

Who do you know, but don’t really know? What could you ask them today to start to make that journey?

Mastering Weight Management

November 13, 2023 by Andy Roark DVM MS

Dr. Taryn Pestalozzi, DVM, residency-trained in Nutrition, joins the podcast to talk about how she approaches difficult pet weight-loss conversations. Dr. Pestalozzi and Dr. Roark discuss the case of an obese Labrador Retriever named Greta, and how best to handle her care. As a veterinarian who practiced in GP for 7 years before running the Healthy Weight Clinic during her internship at Kansas State University’s Veterinary Health Center, Dr. Pestalozzi has fantastic and practical insight on how to motivate pet owners to make real changes for the sake of their best friends.

Cone Of Shame Veterinary Podcast · COS – 236 – Mastering Weight Management

This episode is brought to you by Hills Pet Nutrition!

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

LINKS

The Hill’s Veterinary Academy is a one site solution for educating the entire veterinary team. On the HVA, you can find FREE RACE CE from leading specialists and experts, patient-centric education beyond nutrition and flexible, on-demand content that fits your schedule.

Hill’s Veterinary Academy: https://na.hillsvna.com/

Hill’s Body Fat Index Tool

World Small Animal Veterinary Association Nutrition Toolkit

Association for Pet Obesity Prevention

Pet Nutrition Alliance Calorie Calculator

Ohio State RER Calculator

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Taryn Pestalozzi received her bachelor’s degree from Smith College in 2008, before graduating with her DVM from Oregon State University in 2013. Dr. Pestalozzi was a general practitioner in the Portland, OR metropolitan area for 7 years before completing a clinical nutrition internship at Kansas State University’s Veterinary Health Center, where she managed the Healthy Weight Clinic. Dr. Pestalozzi recently completed her clinical nutrition residency at UC Davis Veterinary Medical Teaching Hospital.

EPISODE TRANSCRIPT

Dr. Andy Roark (00:07):
Hello and 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 is on mastering weight Management. This is super mega practical, what to say and how to say it. Podcast, I have got Dr. Taryn Pestalozzi here. She is residency trained in nutrition. She’s a joy to talk to. She is super practical and pragmatic, which I really love. She’s got great advice for setting up these weight management conversations in a way that actually get results and help us convince pet owners to make the steps they need to make to take care of their pets. Anyway, you are going to probably get some affirmation for things that you do out of this, you are also going to get some tips and tricks for things that you don’t do or ways to have these conversations that you haven’t had.

(00:55):
I am really big on this. I love it when we get insights on things that we do a lot of because little tweaks in those behaviors make a huge difference because we do ’em all the time. And so anyway, this episode is really good and it’s really useful. I think you guys are going to really, really like it. I have to say thanks to my friends at Hill’s Pet Nutrition for making this episode possible ad free. And I also have to say thanks to ’em for their Hill’s Veterinary Academy. Guys, if you have not checked out the Hill’s Veterinary Academy, it is a fantastic learning platform that Hill’s is putting out and they are steadily growing and expanding and it is packed full of good stuff for training your team. It’s got free RACE CE in there. There’s so much that’s going on and they’re really putting a lot of effort into it. So anyway, if you are not familiar with the Hill’s Veterinary Academy, I’m going to put a link down in the show notes. You can give it a Google if you want to go that way, but check it out. Go see what they’re doing. This is really just a neat little gift through our profession. So anyway guys, that’s enough of that. Let’s get into this episode.

Kelsey Beth Carpenter (01:55):
(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 (02:12):
Welcome to the podcast, Dr. Taryn Pestalozzi. How are you?

Dr. Taryn Pestalozzi (02:16):
Good. Thanks for having me.

Dr. Andy Roark (02:17):
Oh, I am so glad that you’re here. I am looking forward to this. So, what I wanted to talk to you about today, so when you did your internship, you did your internship at Kansas State and you ran the healthy weight clinic there and I see a lot of very heavy pets. I saw a cat that was rapidly gaining weight last week and it bothers and this is a passion of yours. It’s something you have a lot of experience in. I just want to run through a healthy weight campaign with you today and just be like, alright, tighten. Let’s tighten the bolts down here and I want to make sure that I’m running a program and then I can carry this out and I want to get weight off of pets and so are you okay to run through a case with me and just start to finish and get me set for success?

Dr. Taryn Pestalozzi (03:22):
That sounds great. Let’s do it.

Dr. Andy Roark (03:24):
Let’s do it. I have got a 100 pound female spayed chocolate Labrador named Greta. So Greta is eight years old and those hips ain’t what they used to be. Sure not. And I can see it. I can see that the muscle mass in her back legs is not what it used to be. And owners are not reporting mobility issues. She’s not, her gait doesn’t appear to be, you don’t see her walking going, oh boy, but she’s eight and I can see that when I look into my future scope where I look ahead a year or two. And so this dog is probably 20 pounds overweight. I think she should be, honestly, if I’m really serious, she should probably be a 75 pound lab, but she’s a hundred. I could be okay. I think if she’s 80, I have to see it. You know what I mean? And you go,

(04:23):
I think 80 is about right. I have to see it, but I need some help in this. And I think that I can get the owners motivated, they love this dog. I think I can make a solid pitch for the lack of mobility that’s coming down the pipes and I want to really push and so I have not gone into this room yet, but I want you to help me. That’s how the table is set. Taryn, how do you treat this case? Where’s your head at when you’re standing outside this door to the exam room getting ready to go in?

Dr. Taryn Pestalozzi (04:55):
So I think the first thing is maybe keeping in mind maybe these owners haven’t come to see you for this problem. They’ve brought Greta in for her annual exam. Yeah, she’s in needs. So it can sometimes take people off guard when you bring up a topic and you get really fixated on that that they weren’t really coming to talk about. So first thing I think is to not forget your primary reason for the appointment. And if you need to schedule a follow-up to actually spend more time talking about the weight loss, do that. But then also consider asking permission to talk about her weight. Be thoughtful with your language. Don’t use fat humor. There was a consensus statement that came out of the UK between medical professionals and the human medical side and patients from obesity programs that talked about what kind of conversations and language are useful. So some of those tips are coming from that consensus statement sort of extrapolated that to our veterinary friends. So just be mindful that as you go into have this conversation.

Dr. Andy Roark (05:53):
Okay, talk to me a little bit about asking permission, right? Give me some language. I know we’ve had a lot of doctors who, and there’s a lot of technicians that are coming in and taking a history and they know that I’m going to come in and talk about the weight and it would be helpful to me if they could open this conversation up. So give me an example of what that, asking permission, I get the concept, what does that sound like?

Dr. Taryn Pestalozzi (06:12):
Yeah, I would start with an open-ended question probably. So asking the client how do they feel Greta’s doing overall? Do they have an idea of where they think she is in terms of weight? Do they think she’s a healthy weight? Do they have any concerns that she might be over or underweight? And that lets you also assess maybe where they’re at with that topic and then ask them, do you mind if we spend some more time talking about this today? I think I have some concerns.

Dr. Andy Roark (06:40):
I really like that question of do you have any concerns about her being over or underweight? It feels like a standard sort of form question and it’s not a judgment question. It feels like I’m taking a history or I’m filling out my form and it helps me know really quickly do they see it or are they blind to it? And we’ve seen, I mean I literally had a case just like this one chocolate lab a hundred pounds and the owners just could not see it. And I was showing them the body condition out and they didn’t get, that was rare. Definitely happened. I still remember it. They were just like, Nope, she looks like a five of nine to us and I’m just going, we’re not looking at the same things.

Dr. Taryn Pestalozzi (07:19):
Yup.

Dr. Andy Roark (07:19):
Anyway, a great question. Alright, I love it, Taryn. That’s super helpful. Alright, great. So I get get this conversation, get permission to talk to them about it. I like it. Let’s say that they’re like, sure we’re here for our annual exam, wellness, yup, we’ll totally talk about it. Where do you start to go from there?

Dr. Taryn Pestalozzi (07:39):
Yeah. Next would, as part of my exam I do a body condition score assessment on Greta and I think most of us are familiar with the body condition score concept. There’s a couple of different scale systems out there, so there’s a five point scale, there’s a nine point scale in the nutrition world, we tend to go with that nine point scale and if you need a resource in your clinic, the world’s mono, that association has some nice non-branded charts that you can use, but there’s lots of them available and I keep a copy in my exam room laminated and I actually pull it out and I look at it while I do my body condition score because the more you actually read through the definitions of what each of the points on the scale mean, the more consistent you will get. And also if you have your support staff and the other clinicians in your hospital all using that same tool and actually looking at it, you’re going to be more consistent across your whole clinic so that you start building a more reliable history as you’re seeing patients.

Dr. Andy Roark (08:35):
I tend to run into not opposition to this conversation, but just a level of passiveness that they don’t argue with you. They’re not like, no, we’re not going to do a weight loss program. But non-committal I think is how I would

Dr. Taryn Pestalozzi (08:57):
Yeah

Dr. Andy Roark (08:57):
And again, I’m going to lean into the hips in this case and try to make a real quality of life point here, but as I try to motivate for action and try to push through that non-committal place to get them on board with taking action, how can you support me there?

Dr. Taryn Pestalozzi (09:18):
Yeah

Dr. Andy Roark (09:18):
How do you do that?

Dr. Taryn Pestalozzi (09:20):
I think it’s common for a lot of us to maybe focus on those negative outcomes that we are sort of foreseeing in the future. And there’s certainly clients that might need that, right? They maybe need you to really kind of hone in on those negative potential outcomes because they might not budge without it. But going back to that consensus statement in human medicine, it’s actually more effective a lot of times to focus on positive outcomes of weight loss rather than the negative potential consequences of being overweight or obese. So I hear from clients all the time, even with minimal, it’s pretty small amounts of weight loss. They’re acting so much younger, I can see they look thinner. I’m getting compliments on how they look. I’ve had to make their harness smaller. And so really focusing on what the benefits are and what they might see as that progress happens, I think is often more motivating.

Dr. Andy Roark (10:14):
I like that. So what your counsel here would be in the case of a dog that’s overweight and a senior pet is maybe don’t, ooh, she’s getting older, but instead talk about what we could accomplish and she could have the best years of her life. I mean there’s quite possible we could turn back the wheel of time a couple of years and you would see her

Dr. Taryn Pestalozzi (10:35):
Sure, let’s give her the best quality of life where we can as long as possible. And to do that, let’s really focus on getting her down to a lean ideal body condition so that she can be mobile as long as possible and do the things that she loves.

Dr. Andy Roark (10:47):
I’d much rather have the positive conversation than the negative one. No one wants to go tell someone, I’m really worried your dog is going to get worse and have hard time getting up. And that’s not a fun conversation.

Dr. Taryn Pestalozzi (11:00):
No, it’s not at all.

Dr. Andy Roark (11:00):
Appreciate this perspective. I like this so motivating from here to hear to action. I do like that. Any other advice for trying to get buy-in and build momentum?

Dr. Taryn Pestalozzi (11:11):
I think it’s important to try to get all of the humans in the household on the same page. There’s always going to be that person who maybe causes lack of compliance, sneaking treats or they don’t see the importance of the plan. So trying to get everybody involved in that conversation and on the same page is always a good idea if you can, it’s not always possible, but I think that’s going to be helpful for your success.

Dr. Andy Roark (11:40):
What does that look like when you go into the exam room? Because it’s always like my husband does and he’s not there.

Dr. Taryn Pestalozzi (11:50):
They throw each other under the bus. Right?

Dr. Andy Roark (11:52):
Business. That’s totally true. It could a hundred percent not just because they say it’s the person who’s not there. That doesn’t mean that really is.

Dr. Taryn Pestalozzi (12:00):
Sure. I’ve had clients pull me aside, tell me to kind of tell on their spouse or their partner. So I think if you can have ’em both in the same room, maybe you do have schedule a follow-up appointment and ask if they can both be there or I’ll be there. But otherwise, I mean I’ve had clients ask me to write letters to their significant others on letterhead to tell them they need to stop feeding the pet. I haven’t had that as much since I came to nutrition, but I was a GP for seven years before I did nutrition, so I definitely got that apps that several times

Dr. Andy Roark (12:31):
Oh that’s so funny. Alright.

(12:33):
Got it.

Dr. Taryn Pestalozzi (12:34):
I mean you kind of have to play it by ear, but I think trying to get buy-in from everybody is useful.

Dr. Andy Roark (12:39):
Oh, I love it. I just wondered if you had some special tool like I video myself and text it to them. I don’t know. I don’t know. I was just curious if you had any tools for wrangling people in.

Dr. Taryn Pestalozzi (12:48):
Yeah, we do the best we can.

Dr. Andy Roark (12:49):
I love it. This feels so daunting. 25 pounds is a lot. I mean 20 pounds, it’s a lot. 20 pounds per person is a lot and a person weighs more than a hundred pounds. Generally it’s a lot to lose. We’re talking 25%, 20, 25% of this pet’s entire body weight. How do set, it’s not going to be done in a week. This is going to be a process. How do I set expectations so that the clients are not like we’re going to try hard for five days and then I don’t see any changes I’m giving up, help me set us up for success in this and what’s going to be a marathon?

Dr. Taryn Pestalozzi (13:33):
Yeah, I think that’s a really good question, a thing to consider. So there’s a few things. First, the Association for Pet Obesity Prevention puts out annual reports that do surveys of both veterinary clinics and pet owners. And on the most recent data from 2022, they reported on average maybe 30 to 40% of pet owners who had tried a weight loss plan either reported their pet was not successful or they even gained weight. So trying to mitigate that is going to be helpful for long-term compliance. So the first thing is being specific in your recommendations so that you are setting them up for hopefully success right away and not sort of initial lack of weight loss, ribbon weight gain. We can’t always prevent that. So I do warn owners this is a process, it’s going to take us a while. We might backslide occasionally, but we will hopefully be moving forward the majority of the time. I think the second thing is coming up with a timeline. If Greta is a hundred pounds, let’s say that she is, I don’t know, 20% overweight, so she’d be a seven out of nine. For example, if our goal’s a five, so she’s actually 20 to 30% overweight as a seven out of nine. So then we can say, okay, well she’s 20 to 30% overweight and she loses on average 1% per week, which would be the bottom of our target range, then it’s going to take us at least 20 to 30 weeks to get her down to ideal weight. And that’s on an ideal sort of situation. It often takes longer. So giving them a timeline of what to expect I think is helpful.

(15:12):
Then the last thing is just really monitoring so that you can be making adjustments to the plan. I normally see these patients ideally every two to three weeks, or if I’m not seeing ’em in person, I’m at least doing a virtual check-in appointment. I’ll have them weigh them on their own and send me the wait before the appointment and then we can spend maybe five to 10 minutes on the phone or on a video call having that conversation of what’s next, what adjustments do we do or not need to do, what do we need to troubleshoot? And that way we’re keeping progress moving forward hopefully and not running into plateaus that just continue on and on and on.

Dr. Andy Roark (15:48):
Yeah. Okay. I got a couple of questions, so I really like this. So tell me what a specific recommendation sounds like when you say that. How far down the rabbit hole are you going as far as the specificity of what you’re giving to?

Dr. Taryn Pestalozzi (16:03):
Yeah, well, I mean as a GP was totally guilty of this, and I know lots of other practitioners do this too, of they’re overweight to say, oh, just drop their food a quarter of a cup, right? Yeah.

(16:14):
And we go, okay, great. We’ll see you in six months for your net set of vaccines, have a good life, whatever. And instead, what really we should be doing is giving a specific feeding amount. So the first thing is, as much as we can getting an accurate assessment of how much the pet is currently eating, so all the food they’re getting, any treats, any foods they’re going to use to give medications, which often clients forget to include in that history when you ask. And from there, I normally would drop their intake probably 20% initially if, I don’t know if they’re the kind of client who says, oh, well I feed the green bag, it’s really expensive so I know it’s good quality and I just fill the bowl up every two days. Well then I would start for a dog with their resting energy requirement and if they’re a cat, I’d start at 80% of the resting energy requirement.

(17:02):
There’s two methods, so a lot of nutritionists will use an estimated ideal weight to do those calculations and that’s great. That’s how I did it when I ran the Healthy Weight Clinic at K State for that year, and it’s definitely a successful method. That’s also what AHA has in their weight management guidelines. At Davis, we do things a little bit different. We use their current weight, not an estimated ideal weight. We want to use a true number and not an estimate to make all of our calculations. Both methods work really, you’re just picking a starting point and you’re adjusting from that starting point. The other thing we do is we recommend they weigh their food in grams, or if it’s canned food, then at least an easy fraction of a can because we want to be as accurate as we can so that we can make small adjustments as we go.

Dr. Andy Roark (17:46):
Okay. Yeah, that totally makes sense to me. I like the timeline idea as well. I think that’s part of the recommendation. It’s funny when you say 1% per week, I go, okay, well that’s six months, which feels very different. And just saying out loud, this is minimum of six months, just so you know,.

Dr. Taryn Pestalozzi (18:05):
That’s like best case scenario. If there is six out of nine, I can probably get them down to ideal and figure out what it takes to keep them there in about six months. If they’re seven or above, realistically you’re talking more like nine to 12 months or more.

Dr. Andy Roark (18:19):
Yeah.

Dr. Taryn Pestalozzi (18:20):
They’re that 11 out of nine, maybe you’re talking 18 months. So it’s not a short process. It does take a dedicated owner and that’s why you have to be their cheerleader and positive reinforcement of the owner. You’re doing a great job. I’m seeing improvement. Let’s keep going. We give prizes. When they reach their target weight.

Dr. Andy Roark (18:38):
What kind of prizes do you give?

Dr. Taryn Pestalozzi (18:40):
Well, at Kansas we took a photo of them and we were going to make, this was right as I was leaving, we were going to make a wall of fame. So I dunno if that or wall of success kind of oncology departments like to do with their pets finished chemo and then I would give them slow feed bowls or leashes or frisbees, that kind of stuff. If we had plants who are really hesitant to weigh their pet’s, weigh their food, we actually had some gram scales and we would just give them one

Dr. Andy Roark (19:07):
Wow.

Dr. Taryn Pestalozzi (19:07):
Say, can you please just do it? I didn’t do that for everybody, but it was like I was getting a lot of pushback. Yeah.

Dr. Andy Roark (19:13):
Well it shows how serious you are about it, for sure.

Dr. Taryn Pestalozzi (19:16):
Yeah.

Dr. Andy Roark (19:17):
Talk to me a little bit about what these, so I really like sort of the monitoring part. Talk to me a little bit about what these monitoring recheck appointments look like. So you’re like, yeah, we see ’em back two to three weeks. First let’s talk in person. But I think the virtual is, there’s a lot of opportunity there, but just if you have them sort come back into the clinic, what does that recheck look like? I know everybody’s busy, you know what I mean?

Dr. Taryn Pestalozzi (19:37):
Sure, yeah.

Dr. Andy Roark (19:37):
So we’re trying squeeze it in. What does that experience for the clients look like?

Dr. Taryn Pestalozzi (19:42):
So it can be a quick appointment. So my sort of rule of thumb is if I’ve made any changes to their plan, I try to see them back in two to three weeks. If we haven’t made any changes, I push it out like a three to four weeks. So on average every three weeks or so, and it could be probably at the most a 15 minute appointment if you are sort of efficient in how you’re running it, if you’re leveraging your support staff so you could have your support staff go in and body condition that animal if you’ve gotten everybody well trained and on the same book in that regard, get a weight and take a little bit of a diet history. How have things been going? Are you feeding them out? We talked about last time, have you run into challenges? What sort of troubleshooting?

(20:21):
I mean, I think the classic example I give to students is they come in and they haven’t lost any weight and it’s December and you find out that, oh, the in-laws are in town visiting for the holidays and they’ve been feeding the dog a ton of milk bones, so maybe we don’t need to make a change that visit. Maybe we just need to send the in-laws home and get back on track. But if they have kind of lost in that one to two-ish percent percent of body weight per week, then great, we don’t make any changes. We see you again in a few weeks, reassess. If they have not lost as quickly as we’d like or they’ve gained weight, then I’d probably drop them about 10% of their daily caloric intake.

Dr. Andy Roark (21:03):
Okay.

Dr. Taryn Pestalozzi (21:03):
They’re losing too fast, then I’d up ’em 10% and I’d see ’em again in two to three weeks and we’d reassess at that point. And I keep in mind treats. So we plan for treats in our plans. Yeah,

Dr. Andy Roark (21:14):
Gotcha. Talk to me about what losing too fast looks like. So that’s what I was going to start to poke you about a little bit was like when they come back in two to three weeks, what are we looking for? And definitely, I like the idea that we’re going to put ’em on a scale. We’re going to put ’em on the same scale they used last time, so we get some consistency and then if we’re not seeing any weight loss at all, we’re going to start to adjust. And that all tracks to me, when do I have to start worrying like, oh, we’re falling like a stone? Because I suspect that pet owners are probably pretty psyched. They’re like, this is great. We’re making real headway. Greta’s not really thrilled, but the pet owners, I could see them being on board. What am I looking out for there?

Dr. Taryn Pestalozzi (21:56):
Yeah, I mean I’ve had that happen. It’s less common than you might think, but I mean, I’ve had dogs that got boarded when they were sort of starting their plan and they lost like five, 6% in a short period of time, like 10 days. And so our concern there is two things for both species we’re concerned about lack of muscle, muscle losing lean muscle. You mentioned Greta, you were concerned about the muscle in her hind end. So that’s great. I would encourage everybody to actually record a muscle condition score every visit. It doesn’t have to have a number. The world’s Monolo Bed Association actually doesn’t use a numerical scale. It’s just normal or mild, moderate or severe atrophy. And then I’d also be concerned maybe in our cat patients about something like hepatic lipidosis, but that takes a lot. It takes very dramatic sort of extended in tants or hypoxia to get hepatic. So I don’t get too worried about it. But certainly for our cat patients, if I’m starting a new plan, I am really conscious of how I tell owners to transition ’em onto a new food and give them criteria for when they would need to call us. If they’re not eating the new food or they’re not doing well,

Dr. Andy Roark (23:04):
How does the virtual check-in visit work? Because if they’re not there and you don’t have your scale, what is that experience like for the pet owner?

Dr. Taryn Pestalozzi (23:11):
Yeah, I mean it’s a pretty similar, I think outline to how the appointment runs. But what I do is I made a little handout for my owners that shows them some specific photos. I want them to take the photo from the side, a photo from above, and then one of their face if you want to use the body fat index tool from Hill’s and University of Tennessee, I’d also take a picture from behind them staring at their butt. And that lets me just assess roughly their body condition or their body fat index. And then I have the owners weigh them and I just tell ’em, find a consistent way to weigh them, whatever that is. They’re coming to your clinic just for a quick swing by the lobby scale. Or if they have a scale at home, they can get an infant scale or even a floor scale for a big dog relatively inexpensively online. And so they just email me in advance their weight, they send me their photos. I can do the math that I need to do right before the appointment, and then it takes 10 minutes or less to have that conversation about do we need to troubleshoot anything? How fast or how slow were you losing weight? And what adjustments do we need to make?

Dr. Andy Roark (24:14):
Got it. Perfect. That totally makes sense. Good deal. I like this. This seems good. Are there, so we’ve got a plan, we’ve got some good motivators, we’ve got specific recommendations. We’ve got a follow-up plan. I really like the ongoing monitoring. That makes a ton of sense. I a hundred percent see how I can lean on my technicians to help me with this and to run this program. That’s a big deal to me. I really like nutrition for technicians and they can make my job really easy and we can make a real impact together. But anyway, so I like all this. Is there any final pearls pieces that I want to make sure that I’m not forgetting

Dr. Taryn Pestalozzi (24:54):
And I maybe skipped over it? So in our specific recommendations,

Dr. Andy Roark (24:58):
mm-hmm

Dr. Taryn Pestalozzi (24:58):
the majority of these patients should be on a therapeutic, a prescription weight loss diet because if we start restricting their calories, especially if they get below RER or even 1.2 times RER, if we’re talking about dogs, we can cause nutritional deficiencies if we feed a non-therapeutic diet for a long time because those therapeutic diets are fortified with extra protein and vitamins and minerals to account for the lower calorie intake that those pets are having. They also help them with stain full, so satiety, if they’re canned diets, they have a lot of moisture. If they’re kibble, they might be what they call air puffed, so bigger kibbles to take up more volume. And then they also often are high in fiber to help them feel full. So you really should be using a diet like that if you’re going to institute a weight loss plan unless you’re doing small amounts of weight loss and you’re being very conservative with how fast you push them.

Dr. Andy Roark (25:50):
Okay. Define RER for me real quick.

Dr. Taryn Pestalozzi (25:53):
Resting Energy Requirements, and there’s a couple ways you can calculate it. I’m going to give some resources I think at the end that we’ll show you how to do all the calculations and walk you through how to do a plan like this.

Dr. Andy Roark (26:05):
Cool. I love it. And then I want to dig into this a little bit. I think that’s a great point about moving to therapeutic D because one of the pushbacks I always get is, well, I can just, there’s a light version of what they eat. Can I just use the light food? And I want to be supportive of pet owners and kind meet ’em where they are. And at the same time, I do feel like I’m only going to get one good shot. Often it’s one good shot, they’re going to make an attempt and if it doesn’t go anywhere, they’re going to kind of say, well, I guess she’s just a big girl and that’s what she’s going to be. And that’s that. So break that down for me a little bit as far as where your lines are when you’re like, no, it’s time to go to the therapeutic diet. I want to be confident when I make that recommendation to switch to a therapeutic diet and say, yes, this is the play we need to make. Where are your lines? Can you solidify that for me a little bit?

Dr. Taryn Pestalozzi (27:04):
It’s never wrong to pick a therapeutic diet for weight loss unless they have comorbidities that require other nutritional strategies. And there is not a commercially available combination diet. So there are combination joint support and weight loss diets. They’re a combination hydrolyzed and weight loss diets, et cetera. So it’s not wrong if you can find an option to do that other than it’s more expensive, I think that’s always the safe way to go. If I had a patient that did have other comorbidities, that’s the time to talk to a nutritionist or at least call the vet consult line for one of the therapeutic companies to talk to them about the case because maybe that pet really needs a homecooked diet to be able to accomplish weight loss and safely manage their other disease. But if I was going to go with a light or weight management diet over the counter, I’d be looking at patients that are maybe a six out of nine,

(28:02):
Or they have a calorie intake that’s already quite high. So if they’re eating 1.6, I’m talking about a dog right now, 1.6, 1.8 times their resting energy requirement, then I can probably reduce them at least for a while on their normal food and be safe. If they’re starting below that, which often these obese pets are, they have slow metabolisms, most of them. So if they’re starting at 1.2 or one times their resting energy requirement, then it’s not safe because I’m going to have to be cutting them back over this six to nine to 12 month process. We’re going to be making gradual reductions most likely. So we’re going to reach a point where it’s not safe for them to eat a regular diet over the counter. And I think that’s another takeaway is to talk to owners about the fact that this diet is not as short-term diet. Most of these pets have a low metabolic requirement, even once they’re at ideal body condition, so they really should be on a weight loss diet long term. I own one of these dogs, she’s on a weight loss diet for life unless I have to make a switch for another reason.

Dr. Andy Roark (29:05):
Gotcha. That makes sense. Yeah, that’s wonderful. Any other pearls I should pick up here at the very end?

Dr. Taryn Pestalozzi (29:12):
I mean, I think we’ve talked about a lot of them. It’s really about pick a starting point, monitor,

Dr. Andy Roark (29:17):
Yeah.

Dr. Taryn Pestalozzi (29:18):
Make adjustments, be a cheerleader. Those are the keys that people miss and that are what actually result in success. And I mean, we had roughly a 75 to 80% success rate and healthy weight clinic at Kansas when I was there. And most of the cases that weren’t successful, we had lack of compliance or we lost a follow-up. So I think if you work the plan so to speak, you can help a lot of these pets. And there’s like 60% of both dogs and cats that are overweight or obese currently. So this is the case you see every day.

Dr. Andy Roark (29:49):
Oh, I mean, yeah, the overweight Labrador people were like, oh, that’s really a novel case. Sandy, you haven’t seen that before. Yeah. That’s awesome. You’ve given me a number of resources. I’m going to be linking like crazy in the show notes, which I always love. People love having a list of resources. Any other that you would recommend if somebody’s just like, I love this, I love what you’re talking about. Where do you refer people who are nutrition geeks? They’re just like, yeah,

Dr. Taryn Pestalozzi (30:16):
Anymore. I’ve got a few. So the first one that will really walk you through this step-by-step is that 2014 aha weight management guidelines. There is a later like an updated version, but the 2014 as well. The meat and potatoes of this topic is the world’s model of that association has a nutrition toolkit. So that’s where you can get your body condition, your muscle condition, other resources for your support staff. Pet Nutrition Alliance does have a little online calculator you can use. I think they may have updated the website recently, so I’m not sure how they’ve changed it. And then Hill has the Bed Academy with some cece type videos about weight loss. They also have the quick reco tool that can help you initially make a plan. And then if you want more about the stats from that recent annual survey, the Association for Pet Obesity Prevention website has the results of all of the surveys, but the most recent being 2022 and they’ve got good infographics and stuff.

Dr. Andy Roark (31:12):
That’s amazing. I’ll link up to all that stuff. Dr. Taryn Peal, thank you so much for being here. I so enjoy you.

Dr. Taryn Pestalozzi (31:19):
Great, thanks. It was so nice talking about it. This was a topic that I really like.

Dr. Andy Roark (31:23):
Well, yeah, it’s obvious. That’s why I had to have you. Anyway, guys, thanks for tuning in. Everybody take care of yourselves. And that’s it, guys. That’s what I got for you. I hope you enjoyed it. I hope you got something out of it. Thanks so much to Taryn for being here. I really enjoy her. I really enjoy talking with her about weight management. It’s a thing that we talk about a lot, but man, when you find someone who is really passionate about this subject and who has had a job, just having these conversations, these are important, and just because we have ’em a lot doesn’t mean that we shouldn’t take them seriously and really think about how we get better. In fact, it’s the conversations we have a lot that we should really focus on because that’s where we can make a real difference for the clients and the pets that we see.

(32:09):
I mean, I dunno. I think a lot of times in education there’s this push to find these unique things that rarely happen and to be aware of them, and that’s okay. I really think that finding the things that happen commonly and deciding that we’re going to be amazing at them, I think that’s how we really make an impact on the world through veterinary care. Anyway, that’s just how I feel. Guys, if you have not checked at the Hill’s Veterinary Academy, you should take a look. Go and check it out. It is their learning library, it’s their Learning academy. There’s so many resources there. It is a great, great, great source of knowledge on all things nutrition. I’ll put links down in the show notes, go and check it out. Thanks to Hill’s for making this episode possible, guys. Take care of yourselves. I’ll talk to you later.

Perception: It’s All How You Look At It

November 10, 2023 by Andy Roark DVM MS

Today I am thrilled with my dog. I am so, so happy. Do you want to know why? Because he only destroyed a very nice pair of socks belonging to my oldest daughter.

For those of you who have been reading my letters for a while, you might remember that Skipper Roark is a devout anarchist. He lives life to the fullest and has no interest in joining the brainwashed “good dog tribe” that he hears me talking about every day I visit the clinic. He lives by his own rules… and Skipper hates rules.

Anyway, the socks he ruined were brand new and quite nice. He tore them to shreds while I was running errands with the kids. You might think this would make me angry or upset, but I’m not at all.

The reason I’m thrilled is because my daughter (whose dirty laundry was raided) was absolutely certain that Skipper had eaten at least one pair of underwear while on his rampage. We searched the area and… there was no underwear to be found. She was certain her underwear had been in the hamper… but “there’s none there now.”

I suddenly became absolutely certain that we were headed to surgery. It might involve the emergency clinic that night or our clinic in the morning, but surgery felt imminent. I started questioning whether it was worth trying to find someone who could scope him at 9pm. Guilt (I’m pretty sure I was the last one to close the laundry room door), logistics and medical expenses flooded my mind.

And then… My daughter found the underwear. It was rolled up in other laundry and well-hidden until her final, last ditch effort to set her father’s mind at ease.

Immediately I began praising bad dog Skipper. I hugged him and texted my wife (who is traveling and had no idea any of this was happening): “SKIPPER DIDN’T EAT ANY UNDERWEAR! HE’S A GOOD BOY!”

My wife’s response was nowhere close to as positive as mine. She responded “Well, did he eat something else?!” and was not happy about the socks. To be honest, I think she was even more irritated that I didn’t seem to remotely care about expensive hosiery being trashed.

And that’s the thing about perception. If someone tells you your dog destroyed socks, that would bother you. But if someone tells you your dog is headed to surgery and then says “Oh wait! We’re okay! He just destroyed socks!” you’re probably over the moon.

Hardship in life is often this way. When bad stuff happens, it’s not toxic positivity to try to look at things a different way. It’s just adjusting your perspective to make life a little easier.

Choosing the Rulers We Measure Ourselves By

November 9, 2023 by Andy Roark DVM MS

Jamie Holms RVT interviews Dr. Andy Roark about his recent article in Today’s Veterinary Business titled “Measuring Sticks.” They discuss how we determine our own self worth and the tendency for driven people to choose unhelpful and unhealthy measurements by which to judge themselves.

Cone Of Shame Veterinary Podcast · COS – 235 – Choosing The Rulers We Measure Ourselves By

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

LINKS

ARTICLE: Measuring Sticks

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

Jamie Holms RVT is a new chicken mom and the Administrative Manager for Dr. Andy Roark, 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 got my good friend Jamie Holms on the episode. Jamie Holms is RVT. She’s a dear friend of mine. She’s the first employee I ever hired. We go way back. We go back like popsicles on the porch in summertime. That’s how we go back. All that to say, I’ve known Jamie a long time. And when I write articles that really speak to her, she often says, “Hey, can we do a podcast on that article?” And I have an article called Measuring Sticks about how we measure ourselves, how we determine our own worth. And I think a lot of us really driven people have a bad habit of choosing measurements that are unattainable. We measure ourselves in ways that are not healthy, they’re not productive, they make us feel bad. They don’t really motivate us in any sort of way that is sustainable.
And I think that we all should probably take a step back and just unravel the self-talk that we have around what gives us worth and what gives us value, and how do we measure ourselves and how do we measure success. And so anyway, that’s what we get into. If that sounds of interest, then you’ll like this episode. But anyway, Jamie comes on and we talk about the article and I kind of laid down a lot of thoughts about that. So anyway, guys, I hope you’ll enjoy this episode. Always makes me a little self-conscious to get interviewed on my own stuff, on my own podcast, but I don’t know, I write things that I think are interesting and that really speak to me and this is something I’ve been really thinking a lot about. And so anyway, I was really excited when Jamie said, “Hey, I really like that. Maybe we could talk about it.” So I hope you’ll enjoy the conversation. I think it’s a good one. Let’s get into it and see what you think.

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, Jamie Holms. Thanks for being here.

Jamie Holms:
Oh, I’m so happy to be here. Thanks for having me again.

Dr. Andy Roark:
I always enjoy having you on the podcast. For those who do not know you, you and I have worked together forever. It feels like you were employee number @drandyroark.com.

Jamie Holms:
Before you.

Dr. Andy Roark:
Before me, exactly. You hired me on @drandyroark.com and it worked out really well because that was my name and it went great. You are an RVT. We were just laughing that you are a rivett and not a live it.

Jamie Holms:
So true.

Dr. Andy Roark:
So true. You are the administrative manager for drandywork.com and Uncharted Veterinary Conference. And so that’s who you are. You babysit my tomato plants when I travel in the summer and sometimes my bad golden doodle skipper.

Jamie Holms:
He’s not bad. He’s misunderstood and he loves me so much.

Dr. Andy Roark:
He does love you a lot. According to behaviorist Lisa Radosta, he has low confidence, is his problem.

Jamie Holms:
I love that that’s how we ended up here. That’s so funny because I wanted to talk about this article and I told you I wanted to talk about this article and I was like, I think I’m going to lead in with talking about Skipper and his confidence issue.

Dr. Andy Roark:
His confidence issue. Okay, fine.

Jamie Holms:
So this is perfect.

Dr. Andy Roark:
Okay. So I have a goldendoodle named Skipper who is just as a side, he’s not what you would call a good dog. He lives his truth openly and it’s not one of obedience and the thrill of making his owner happy, but he’s his own person and he does have a trait that drives me nuts as he’ll piddle on the floor when people come over or he gets excited. And so I talked to Dr. Lisa Radosta, she’s coming onto the podcast and I had her on to talk about inner cat aggression or something, and I did that thing where I was like, hey, while you’re here, can I ask you about a case? And I told her about Skipper and she asked me a bunch of questions about what he does with his ears and how he sort of behaves.
And the takeaway I think from her not really getting to see him was she thinks that this is sort of a conflict response and that he has confidence issues and that’s why he meets people in piddles. And so I have been trying to work on my golden doodles confidence and it is the most ridiculous project I have ever gone on. But I don’t know, I’m just going to stop and say I do not know if we are making progress. For three or four, five days I’m like, we’re nailing this and then there’s just a setback. And I’m just like, his confidence is it cannot be saved, I don’t think if he’s not a confident guy.

Jamie Holms:
Well, I love this for a lot of reasons. One is that, I don’t know if you know this, but my nickname is Walnut.

Dr. Andy Roark:
I did not know this.

Jamie Holms:
That is not because I am a tough nut to crack. It is because I have a very tiny bladder and I maybe eat abruptly the size of a walnut. And so I always need to pee. And the moment you-

Dr. Andy Roark:
Do you get excited and pee? Do you pee when you meet new people?

Jamie Holms:
I need to pee when I meet new people. I have better bladder control than Skipper does, but that doesn’t make me a better person.

Dr. Andy Roark:
But you have more confidence, I think.

Jamie Holms:
I have more lived experience than Skipper does, but I definitely, the moment someone is like, your flight is going to board in 15 minutes, I’m like, I got to pee. And then they’re like, the flight is now now boarding, I’m like, I have to pee again.

Dr. Andy Roark:
Yeah, I get that.

Jamie Holms:
It’s just how it is. And so I have a lot of empathy for his situation. But it made me think about confidence and I can think about times when I’m really confident, but that made me go well, when am I really insecure? And so I was thinking about that. And so I wanted to start with the deep question. So Andy Roark, tell me what makes you feel insecure?

Dr. Andy Roark:
Oh boy. What does make me feel insecure? Let’s see. Anytime that I feel like I’m not going to live up to the expectation that people have of me, I get insecure anytime that people are like, I feel like people expect something from me that I’m not going to be able to do, I’m much more worried about letting people down than I am not being able to do the thing, whatever the thing is. And so I am definitely insecure about that and singing. I can’t carry a tune in a bucket, and I am very insecure about singing, but I enjoy it when nobody’s around. But those are my two things. Singing and when people feel like they have expectations of me that I don’t think that I’m going to be able to meet.

Jamie Holms:
So I get a huge gift out of working with you, which is I get to read the articles before anybody else does. And so I was really excited when I read this Measuring Sticks article, which went out in Today’s Veterinary Business, and it’s about how we use all of these, especially in the veterinary profession, all of these things from the outside to judge our self-worth and our confidence. You talk about the SATs and your test scores and how people continue to look for that test to take or that new accreditation to get. And I was thinking about that with this, and I love that you are like, yes, I’m in it. I also get insecure when I think I’m not going to live up to the thing that other people want. And in this article you’re talking about how it’s an internal thing, it’s not the things we get from other people. So I love it that you’re like, yes, I also do this thing.

Dr. Andy Roark:
Well, I absolutely do this. So it’s comparison. It’s the flip side to comparing yourself to other people. And so one of my favorite sayings is comparison is a thief of joy. And I see so many people who are so wildly unhappy because they compare themselves to other people. And I think this is the worst thing about social media, and I think there’s a lot of worst things about social media, but this is probably the worst thing about social media is a lot of social media is geared up about getting us to compare ourselves to other people. And we look. And I don’t think people intentionally mean this to happen, but I think we all know it happens at some level, but people sort of post and I can’t help but look and say, man, their vacation looks better than my vacation. Or, boy, they do a lot of things with their kids more than I do. And oh man, I wish I could have gotten free from work to go to the Christmas event at my kid’s school. And wow, look at the fun Saturday they’re having with their dog.
I barely have time to take my dog out and walk a much less spend half the day at the dog park and then go to a cookout. There’s so much of that. But the counterpart to that, which I think is much more common, is the comparison of ourself to some metric that may not be another person. It’s some belief of what we should be doing or what success should be. And so I’ve talked about Skipper before when I talk about what it means to have a bad dog. And the truth is I say that jokingly. The truth is, if you compare Skipper to, I don’t know, Lassie or you say, boy, a good dog comes immediately when they’re called and they’re always right beside you and they don’t pull on the leash and they would never steal food off the table and they don’t piddle on the floor when people come over, then Skipper’s not a good dog.
But if you reset that measuring stick and you say, “I like I want a fun dog, I want a dog that’s always up for adventures and likes to play and squeaks his toys and runs around and is big and goofy and just genuinely funny and happy to be here,” then he is a good dog. But it’s the measuring stick that you set of what does it mean to be a good dog? And so that’s the basic idea with this. But I started writing this thing because I started looking around it and it was a kind of week that came and went. And I just had all these people around me who were just struggling. And one of them was a vet who was struggling. She didn’t think she was a real vet because she only worked one day a week in the clinic and that was really bothering her.
And there was another vet that was really hacked off because friends from high school were messaging her and asking for advice and she felt like she absolutely had to answer them in that moment at dinner and she was just mad. This is dah, dah, dah. And I asked her, I said, “Why do you do this?” And she’s like, “Well, because that’s what I do.” Basically that’s what it means to be a good vet is you drop what you’re doing and you help people who reach out to you. And I’m like, if that’s exactly how you define being good vet, then you are selecting this measuring tool. I don’t believe that dropping what you’re doing in the middle of dinner to ask pet health questions from people in high school is what it means to be a good vet. I don’t buy that.
But that’s a conscious rejection of that ruler for what it means to be a good vet. And so the same thing is people struggling with their confidence because they were not in the top half of their vet school class. And it’s like, I’m sorry, at what time did we all come together and say, “Hey, you know what constitutes being a good vet? The GPA you graduate with?” I wasn’t at that meeting. And if I was, I would not have voted for that because I was not in the top half of my vet school class. And I don’t think that that defines me as a subpar veterinarian in practice. I just don’t believe it.
Hey guys, I just want to jump in real quick and let you know about some great continuing education I have coming your way. Guys, I’ve partnered with Nationwide to put together a series of webinars that are 100%free to you. They have RACE CE, they are good to go, and they are going to be, first of all just genuinely entertaining and fascinating. The first thing I got coming for you is on November the 14th with my good friend Dr. Emily Tincher. She’s been on the podcast a number of times. I love having her here. She’s such a fun, interesting person who’s a deep thinker. And so anyway, she is doing a webinar called Clinical Empathy: The Exam Room Skill that Can Transform Your Team. I’ve had Emily on the podcast before talking about clinical empathy. This is a really good skill building webinar. This is great for your support staff as well as your doctors, but your team leads especially, but your technicians, your assistants, your CSRs, all of this is just, it’s such a great communication content. I think you’re going to really like it.
So anyway, that is on November the 14th. It is at 3:00 PM Eastern noon Pacific. And then the last one in the series is on December 13th. It is with Dr. Simon Platt. It is called Head Cases, a spectrum of care approach to neurology in general practice. So if you’re a neurology buff, if you like seizures, if you like knowing about seizures, if you like a neurophysical exam, tips, tricks and hacks, things like that, this is going to be a great webinar. So again, this is on December 13th. It’s at 1:00 PM Eastern, that’s 10:00 AM Pacific time. Gang, I would love to see you there. Links to all this stuff in the show notes. Go ahead and grab a spot, I’ll see you there. Let’s get back into this episode.

Jamie Holms:
Yeah. I think that that’s very true and I think we continue to use some of those weird metrics and they made sense when we were using them. One of the things, my dad said this to me the other day, my dad is 81 and I love him very much and he was having an old man moment-

Dr. Andy Roark:
I have those.

Jamie Holms:
… which he readily admitted. And he was like, “Did you know that those people can’t write in cursive?” And I was like, “Who cares?” That’s not a metric. That doesn’t make them a bad person. Why would they need to write in cursive? And he’s like, well, we had to write in cursive. And I’m like, “Dad, people used to hit you with a ruler because you were dyslexic.” And he’s like, yeah, okay, okay, old man moment. But it was funny because he pulled this random metric that doesn’t matter today. And I know there are people out there who believe that there’s a big cursive argument of whether we should be teaching it or not. And I understand how it helps your brain, I get that part. But is it going to help you be a better person later in life? Probably not. It’s the same thing as your clients aren’t asking you, “Hey, what was your GPA when you graduated?” They care more about your empathy and whether or not you bond with their pet and whether or not you think that fluffy is actually cute.

Dr. Andy Roark:
Doctor, can you write in cursive?

Jamie Holms:
Yes, exactly.

Dr. Andy Roark:
I’m going to need to see someone else.

Jamie Holms:
Yeah, exactly. I love that. And so I was thinking about how funny it is that we do pick these things and we measure ourselves. And mine used to be I judged myself on the number of CE hours that I had.

Dr. Andy Roark:
Oh, wow.

Jamie Holms:
And I, you’ll be shocked to know, always had hundreds and hundreds and hundreds of hours of CE.

Dr. Andy Roark:
You had hundreds of hours of CE?

Jamie Holms:
Hundreds of hours because-

Dr. Andy Roark:
I do this for a living and I don’t have hundreds of hours of CE.

Jamie Holms:
Yes, I know. But I would go home and I would take every CE thing that was in every magazine. I would do every free CE that came from IDEXX or from the food company, whoever it was. I would take all of that CE because I was just like, the more that I can show that I know, the more people will value my contribution, which was never true because nobody else ever saw that.

Dr. Andy Roark:
No one asked you how much CE you had.

Jamie Holms:
No, no one.

Dr. Andy Roark:
They said, do you have enough? And you said yes. And they were like, okay. And that was that.

Jamie Holms:
Great. Yeah, that was the end of the story. But I held myself to that expectation. And then as I went farther out of practice and started using my skills differently, I started doing less CE. And I didn’t abandon it entirely, I still more than meet my needs, but I looked at it differently. And if I was still holding myself to that same thing, I don’t know that I could do that anymore. My brain is older, I have less energy. I don’t know about you, but I used to be able to stay all night and work all day and my brain doesn’t do that anymore. So I love that we’re talking about how to find different metrics.
And I think self-worth is one of those. And I think that that’s something we’ve talked about before, how imposter syndrome and our colleagues just, they don’t necessarily have the self-worth. And I love that I have people on our team that I can turn to and be like, hey, can you hold this mirror up for a second because I can’t see myself well right now? And they can help me with that. And I was wondering if you had thoughts about how we help our colleagues find a different stick. You had some great ideas about things to use, but how do we shift this for the community?

Dr. Andy Roark:
Well, I think a lot of it is, I think we all struggle to see ourselves. You know what I mean? I think we all struggle to see ourselves. At some level, I think we all kind of wonder if we’re a good doctor or we wonder if we’re a good technician or whatever. Are we a good communicator? Are we a good boss? I did a podcast just recently with Dr. Natalie Marks and she was talking about perfectionism and being a practice owner. It was just fascinating to listen to her talk about this. And she sort of told the story of having this sort of realization that perfectionism is a manifestation of fear and that it was detrimental in what she was trying to accomplish. And towards the end of the episode, I asked her, “How did you come to this realization?” Because we were talking about the truth of the situation and kind of how to manage that if you have perfectionistic tendencies, but I was struck, how’d you come to realize this?
And she told this great story about being a practice owner and really wanting to be a great boss and then doing 360 degree feedback because that was what you were supposed to do. And she just got hit by a brick when someone was like, you are super intimidating. And it was absolutely, it sort of hammered her and made her short stop and step back. And so I think we all wrestle with that. I think one other piece of this that I want to tie into this before I start talking about what we can do about it, but again, it feels like a related thing is man, there’s so many veterinarians or vet techs looking at things that they want to do or whoever that are just waiting for permission. Is this idea that they need someone to tell them that they can have what they want or they can do what they want or they don’t have to care about this thing. It’s amazing.
It almost like it takes someone to say to them, “Hey, I saw the Google review that you got where someone wrote a one star review of you as a doctor because they called you at the clinic and it was your day off. I see that and I want you to know that’s ridiculous and that’s not your fault and you should ignore that.” And it seems absurd that someone have to give you permission to look at this obviously flawed thing and say that’s not representative of who you are. But I think a lot of us really want to hear that from someone else. And so I think one of the things that we can do for each other as colleagues is to point out what really matters to each other and just say, “Hey, I saw the impact you had on that person and that was amazing. And hey, I want you to know you’re a good friend and a good doctor. And hey, I always appreciate your insight and you’re a great mentor and that means a lot.”
And I think that people get so sucked up into other metrics that are communicated to them, they often forget about that stuff, but we can point that out to each other. I think the biggest thing for me in choosing the measuring sticks that matter is just being aware of the measuring sticks. I think my greatest hope with writing the article, and now we’re talking to you about this, is that people will just stop for just a minute and say, what measuring sticks am I measuring success with? And again, I have chosen so badly so many times in my life and just the process of stopping and evaluating like, wait a second, how am I measuring myself here? I mean, I used to beat myself up because of the number of hours that I worked or didn’t work in the practice, and I would beat myself up as a parent for the number of hours I spent with my kids.
And at some point I had to stop and say, well, wait a second, Andy, is hours in close proximity to your children, is that the measurement that we’re going to use here? Because I don’t know that that’s the best actual measurement of what we’re trying to accomplish. And the same thing the clinic is like, is me just physically being here, does that actually mean anything? I mean, we’re not talking about the number of patients I see. That’s just me being at the building and I feel guilty if I’m not at the building. And I go, this doesn’t make any sense. And so I just think so many of us, we don’t even question the measurements or other people put them on us. So you get called in for your performance review and the manager is like, “Hey, this is the number of pets that you saw in the last quarter and this is your average client transaction. And from those two numbers, I’m going to tell you if you’re a good doctor or not.”
And I’m like, no, you’re not. No, you’re not. You can tell me how many patients I saw and you can tell me what my average clinical transaction was, but I’m sorry, that’s not a two metric equation that makes a good doctor. I’m not saying those things are without value or we should ignore them, but I don’t buy the idea that I’m going to be summed up by those two metrics. Or you going to give those two metrics and say, this is really what matters. Because I’m sorry, I have my own beliefs about what measurements it takes to be a good doctor. And they’re around compassion, they’re around empathy. They’re around taking time to listen. It’s understanding other people. It’s being honest and acting with integrity. It’s being patient and kind. It’s all of those sorts of things. It’s continuing to learn. It’s being a better doctor than I was a year ago.
All of those things are measuring sticks that I’m interested in. I’m not saying anyone is worth any more than the others, but you just have to be really careful, especially if we get into this mindset of the only thing that matters is how many hours I spend at the practice, how much money I make in a quarter, things like that. You go, man, you’re summing way too much up into this one ruler. It’s not that good a ruler. It’s just not.

Jamie Holms:
Yeah, I completely agree with that. And I wanted to shout both preach and say it one more time for the people in the back because I hear so many people in the community talking about how they’re not good at this thing. We have a really good friend who’s a very good manager, and they are in a circumstance where there’s a new gig in town and a whole bunch of people left that practice.

Dr. Andy Roark:
Wow, brutal.

Jamie Holms:
Yeah. And she’s like, I am a bad manager. It’s like that isn’t why people are leaving. They are leaving because there are different hours. They’re leaving because of all of these other things, and you can’t judge yourself on that one thing. There are 10 other things that I know about you and I know about the people who work with you and your compassion and your care for the animals and for the people that work for you and what you do for our community as a whole. And again, when you’re in it, it’s real hard to stop and say, what is my measuring stick? What’s my measurement of success? And knowing that people look at it differently.
And there are things that we can change about how we talk to ourselves. And I think that would be my challenge to our community is to say, hey, when you hear people say, I am not good at this, or I don’t measure up in this way, or I’m not good enough, I challenge you to do what I like to do, which is to say, don’t talk about my friend like that. And I learned that because I had a really bad self-talk. I continued to have a bad self-talk. And so I learned to ask myself the question of would I say that to a friend? And if I wouldn’t say it to a friend, then I don’t get to say it to me.

Dr. Andy Roark:
I like that a lot. I took that from you, and I use that a lot when somebody will be down on themselves and it’s say, “God, I am the worst. I’m such an idiot.” I will say, “Hey, don’t say that about my friend.” And I learned that from you. And so I really do like that as sort of catching some self-talk. One of the other things going back to our person who’s feeling terrible because people are leaving their practice to go work at a new place that’s opening up is, it’s one of those things about picking your rulers again, going back to how are you going to measure yourself? I think we should all be really conscious and cognizant of the idea that we should not be picking ways to measure ourselves that are out of our control. And I see that all the time. You don’t get to control pet owners. Yet I myself would define, I would say, oh, I’m a good vet because I get good Google reviews.
And I’m like, buddy Andy, you are putting your self-worth into the hands of other people and you don’t have the power to make those people happy. There are going to be people who are just not going to like you and there’s nothing you can do about it. And it’s giving them the power to tell you whether or not you’re successful. I think it’s a bad idea. I think if you’re a manager and you set this bar at like, I’m going to have a hundred percent retention rate, no one’s going to leave my practice. I would say, you don’t have the power to keep these people at your practice. You don’t control what other practices can pay. You don’t control what other opportunities come along. You don’t control where other practices open up. Maybe they’re much more convenient to get to. You can’t control if people are just tired and want to change the scenery. You don’t have control over any of those things.
And so using that metric of retaining other people as the definer of whether or not you’re successful, I go, I think that that’s a bad measurement. I think that’s where I’d probably leave this and sum it up is my biggest thing on choosing the measurements that we use for ourselves is one, just to stop and recognize that you’re doing it. Recognizing. Just stop and say, how am I measuring myself here? I feel like I’m failing. What metrics am I using to come to that result? And what are alternative metrics that might be better? And I think it’s 100% on that. And the other part is to stop and say, what metrics are in my control? Am I picking things that I really do not have control over? And if you are, I think you should really rethink those measurements. I think you should go back to the things that you actually have input on.
And so you should decide what it means to be a good parent or a good spouse, not based on what other people think about your relationship, but what you and your partner think on your relationship or you and your kids find meaning in and what you’re going to look back on and be proud of. But it shouldn’t be, Hey, this is what Facebook says parents should do. Forget that that’s noise. But anyway, that’s sort of my thing with the rulers that we choose for ourself. It’s funny. And a lot of us have this ability to cycle through rulers where we measure ourselves this way and we measure ourselves that way and we measure ourselves this way, and none of the ways we choose to measure ourselves are kind. And I just think that that’s sad and that’s silly.
And so it’s something that I definitely picked up in my life is my younger self always chose harsh measurements. And I told myself that was the right thing to do because it was motivating. It was always motivating. But at some point, I don’t need to be motivated like that anymore. You know what I mean? I am, honestly, I’m doing my best. I’m happy with the work that I’m doing and how I’m doing it. I want an honest measurement, not a measurement that’s going to motivate me or terrify me or make me feel guilty so that I work harder or do things that, I don’t know, that I wouldn’t otherwise do.

Jamie Holms:
Yeah, I think that’s a perfect place to end, and I’d like to invite you to come back and talk with me about the art of kindness in an imperfect world.

Dr. Andy Roark:
Oh yeah. Oh, that’s funny. Yeah, The Art of Kindness article is a fun. It dovetails into this-

Jamie Holms:
I think so.

Dr. Andy Roark:
So the thing I want to talk to you about as well, I think I’m writing this piece right now based on what our friend Maria Pirita said to me recently.

Jamie Holms:
Is it, “Who’s Laughing Now?”

Dr. Andy Roark:
No, it was not.

Jamie Holms:
Oh, dang it. That’s a good story.

Dr. Andy Roark:
She does say, who’s laughing now? And that is a great story. I’ll tell a story at some point. But she was basically, we were talking about mindsets, and her mindset is just, it doesn’t seem that hard. That doesn’t seem that hard. And so when you say something to Maria like, oh man, we got to do this surgery. And she’s like, “How hard can it be?” That was the wording. How hard can it be? And I just thought it’s the best mindset you can possibly have is how hard can it be? And I’ve gotten myself into a lot of trouble with how hard can it be? But I’ve also had the best experiences in my life. I’ve also learned more than anything else, I have also just had the most fun, and I’ve also grown as a person when I have thought to myself, how hard can it be? And then I weighed in. So anyway, I think we’ll talk about that in the future.

Jamie Holms:
I can’t wait to read that article. Thanks for having me.

Dr. Andy Roark:
Thanks guys. And that’s it. That’s our episode, guys. I hope you enjoyed it. Thanks to Jamie for coming on. Thanks to Jamie for making the episode happen, because if she hadn’t said, “I really like the article and I’d like to talk to you about it on the podcast,” I don’t think I ever would’ve flipped on the microphone. So anyway, thanks to her for that. Guys, if you enjoy the podcast, it always means the world to me when people leave us an honest review. It’s how people find us. It gives me some feedback on the work that we’re doing, and it means a lot. So anyway, if you have a moment and you enjoy the podcast, please leave me an honest review wherever you get your podcasts, and or share the episodes with your friends. So anyway, guys, that’s all I got. Take care of yourselves, be well. I’ll talk to you later on.

The Daring Release of Perfectionism

November 2, 2023 by Andy Roark DVM MS

Dr. Natalie Marks joins Dr. Andy Roark to discuss her recent article on “The Daring Release of Perfectionism.” They discuss how the selection process for veterinary school and success within veterinary school may favor perfectionistic tendencies, and the drawbacks these tendencies have in practice. Finally, they talk about how to manage perfectionism and make peace with it.

Cone Of Shame Veterinary Podcast · COS – 234 – The Daring Release Of Perfectionism

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

LINKS

ARTICLE: The Daring Release of Perfectionism

Marks DVM Consulting

Dr. Natalie Marks on LinkedIn

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

Clinical Empathy Webinar with Dr. Andy Roark and Dr. Emily Tincher

ABOUT OUR GUEST

Dr. Natalie Marks obtained her bachelor’s degree with High Honors in Animal Science from the University of Illinois in 1998, and then proceeded to obtain a Masters in Veterinary Medicine and Doctorate of Veterinary Medicine degree with High Honors from the University of Illinois College of Veterinary Medicine. She became a Certified Veterinary Journalist in 2018.

She has been a veterinarian at Blum Animal Hospital since 2006, co-owner until 2018 and current associate. Prior to 2006, Dr. Marks worked at Allatoona Animal Hospital just north of Atlanta, GA. Her media experience began in print when she created several monthly veterinary columns in multiple community magazines and was a frequent guest speaker for the German Shepherd and Bernese Mountain Dog clubs of Atlanta.

Upon her return to Chicago, Dr. Marks became very active in the Chicago Veterinary Medical Association, serving on the executive board. She was also a past board member of the Illinois State Veterinary Medical Association and an active volunteer to the American Veterinary Medical Association and American Animal Hospital Association.

Dr. Marks has received many prestigious awards in her career. She was awarded the Dr. Erwin Small First Decade Award, presented to a veterinarian that has contributed the most to organized veterinary medicine in his or her first decade of practice. In 2012, Dr. Marks was awarded Petplan’s nationally-recognized Veterinarian of the Year. In 2015, she was awarded America’s Favorite Veterinarian by the American Veterinary Medical Foundation. And, most recently in 2017, she was awarded Nobivac’s Veterinarian of the Year for her work on canine Influenza.

Dr. Marks is also very passionate about educating in all aspects of media, both locally and nationally. She has appeared on Good Day Chicago, WGN-Pet Central, NBC Morning News, ABC, CBS, NPR, WBBM, Northwestern University media channel and many local websites. Dr. Marks was featured nationally on the Today Show and CBS Nightly News during the canine influenza epidemic of 2015 and in multiple issues of JAVMA. She is a guest contributor in multiple media campaigns for Merck, Zoetis (formerly Pfizer), Boerhinger-Ingelheim, Ceva, Trupanion, Aratana, ScopioVet, and Royal Canin.

Dr. Marks is a regular columnist in Today’s Veterinary Business, Healthy Pet magazine, and Pet Vet, and has been published in Veterinary Medicine magazine, DVM magazine, Dogster, and Vetted. She is on the Advisory Board for Health Magazine and also was the host of numerous veterinary broadcasts for the Viticus Group (formerly WVC).

She is a desired national and international lecturer for many of the same companies at VMX, WVC, AVMA and regional conferences, and most recently was a featured speaker at Ceva Sweden’s Derm Day and the Royal Canin Global Symposium.

Dr. Marks finds the ideal combination of teaching/mentoring and improving the emotional health of pets in the Fear Free movement. She sat on the Fear Free Executive Council and is a national educator helping other private practitioners develop these techniques. She also led her practice to become the 7th nationally and first practice in Illinois to become a Fear Free Certified Hospital. She is an Elite Fear Free Certified Professional.

Finally, Dr. Marks is a serial entrepreneur, angel investor and consultant, and one of the newer members of VANE, the Veterinary Angel Network.

When Dr, Marks is not working, she treasures her time with her family and her three wonderful children: Sophia, Evan and Madeline. Dr. Marks loves traveling, scuba diving, cooking and spending time outdoors, especially anywhere there is a beach!

EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary Podcast. I’m your host, Dr. Andy Roark. Guys, I am here with my friend, Dr. Natalie Marks. She’s amazing. She’s a practicing veterinarian. She’s an entrepreneur, she’s a lecturer, she’s a writer. She does so, so many things. I really love an article that she wrote called The Daring Release of Perfectionism, and she talks a bit in this article about dealing with perfectionistic tendencies as a leader in practice, as a veterinarian, as a colleague.
And then when we get into this episode, we talk a little bit about her own sort of epiphany that perfectionism was undermining what she was trying to do and how she sort of wrestled with that. Man, this is one of my favorite conversations of the year. It really is. I hope you’ll give this episode a chance. If you see yourself as a bit of a perfectionist, if you work with people who are perfectionists and you recognize that it’s a double-edged sword, this is a really good episode. So anyway, I hope you’ll really enjoy this. Dr. Natalie Marks is amazing. Let’s get into this episode.

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

Dr. Andy Roark:
Welcome to the podcast, Dr. Natalie Marks. Thanks for being here.

Dr. Natalie Marks:
Thanks for having me back, Andy. It’s good to be here.

Dr. Andy Roark:
It’s wonderful to have you. You have been here at least three times. I really enjoy you. You are my discovery of 2023, I think. I don’t know that you were on before 2023, and now I can’t have you on enough. I enjoy so much that you’re doing. For those who do not know you, you are an educator, a consultant, a practicing veterinarian in Chicago. You are a leader in the Fear Free movement. You were a member of the original Fear Free Advisory Board. You have won crazy awards that I have to say I’m super jealous of. You were in 2012, you won the pet plan Veterinarian of the Year award, which I was involved with putting on that ceremony and stuff. And so if people don’t remember, it was a big deal. You were voted America’s favorite veterinarian by the American Veterinary Medical Foundation. You just rack it. You rack up big awards and you’re doing so much. It’s amazing to me. You make me tired and I do a lot.

Dr. Natalie Marks:
Oh, my gosh. Well, that’s saying something. I feel like you’re always on the go too.

Dr. Andy Roark:
Oh, man.

Dr. Natalie Marks:
Well, it’s interesting you bring that up because it sort of relates to what we’re going to talk about today, which is just that overachieving drive that a lot of us also coincidentally have with perfectionists. And so I’m curious to see what we can tease out.

Dr. Andy Roark:
Yeah. No, I agree. I think it’s funny. You’re exactly right in that that is the setup for where we’re going. You wrote an article that I saw and I really liked. It was in Today’s Veterinary Business, it was called The Daring Release of Perfectionism. And in it you talk about, you say that our colleagues, clients, and patients are better served when we simply strive for excellence over perfection. And so, one of the things sort of appreciate about you is I see a number of my own tendencies of just have “I have to be the best. We have to accomplish more. We have to make a bigger difference. We have to get more things done.”
And I really personally wrestle with this a lot because you can push yourself for perfection to the point that it becomes counterproductive. And I have often struggled with trying to figure out where that line is of pushing myself hard enough that I continue to make progress and feel good about what I’ve done at the end of the day, but not push myself into the negative place that I’ve been before where I’m like, “Andy, you’ve got to let some of this go.” So let me sort of pause there and let you sort of lay out your thesis on perfectionism.

Dr. Natalie Marks:
Yeah, as you mentioned just when we were chatting, it is a really significant double-edged sword, but I think has sort of overtaken the veterinary industry because so many of us, just to even get into veterinary school, we were told we have to do get almost straight As. Our academics have to be stellar and we have to do all of this sort of extra internships or volunteerism ahead of time. And you should have done a research project and maybe should have also have these recommendations, which means you have to do this extra. And it’s all about truly overachieving, because there were only so many spaces with how many applicants. Although the situation has changed a little bit, certainly with the shortage of veterinarians. But certainly when you and I were in school, that’s how it started.
You get into school and it’s throw, how many, 36 hours of caseload at you every semester. Many of us had jobs, many of us were volunteering, working at clinics. But I think the underlying theme that connects that… As Taylor, we were talking about Taylor Swift. The invisible string that connects so many of us is that we want to be perfect. It starts in a healthy way. And I think many of us maybe were raised that way or encouraged that way or genetically have some of that in us or all of the above. Nature versus nurture, however it was, we ended up at the same place that in order to be the best, we have to be perfect. And what I found as I was sort of thinking about this and reflecting on especially my year as practice owner, I found that it often led more to detriment than to benefit. Not just me, but to my team, to the families and clients I was working with, to my patients, to my family, to my friends.
And the key though, and I think the trick is identifying it in the moment versus having to do this reactive approach that I’m doing right now. It’s hopefully helping obviously in this next chapter of life, but so many of us have our blinders on and are so busy in the muck of practice, and I say muck in the most positive way, but you’re in that daily grind and not realizing that if you just take a few of, hopefully the tips and tricks we’ll talk about today and apply them. These are not major things. These are sort of, if you’ve read about atomic habits, these are little things that can make a huge difference in how you feel, how you present yourself, how you’re received. But I think the goal of all this is how can we make veterinary medicine a lifelong career? I think that is a key of why so many of us have left, why a lot of people have said, “I just can’t do this any more,” because of this.

Dr. Andy Roark:
Well, there’s so much to unpack there. So I completely agree. I think we select for perfectionists going into vet school. And so those are the people who go through the hoops and set themselves in a place where they get selected. And then when we get trained, I think we train people to be perfectionists. And again, I know things in vet schools are changing and their curriculum is evolving and I think it’s wonderful, but generally we don’t work collaboratively in vet school. We work as individuals and we are graded on our perfection, on our completeness. And so I think that we select for people who have that fixation and we further train to that. And then we put them out into a scenario where honestly being a perfectionist, just from a pragmatic business standpoint, is really limiting. The vets that really thrive are ones who are okay with something not being exactly perfect as long as it’s good enough and they didn’t have to do it.
And it’s like that’s how you leverage staff. That’s how you’re able to get work done. But if the only way that something is good enough is if you yourself do it. There’s no way out of that. It’s absolutely limiting. Can you flesh out some of your comments, because I think this is important to get our heads around? So you say perfectionism is not ideal for our team, it’s not ideal for our patients, it’s not ideal for our clients. Can you sort of flesh out what that looks like? I think some people would say, why is perfectionism not ideal for our patients? How is that true?

Dr. Natalie Marks:
Right. Well, so let’s start specifically just right with medicine. And what I think both of us… And I don’t mean to speak for you, but I would assume you would feel this way. We aren’t saying, I’m certainly not saying, just strive to be sort of average. If you’re doing surgery in an average way, that’s fine. Not at all where we’re getting at. But I think a perfect example, and I’m glad that I went right to surgery because I think this is a key. When we as perfectionists, we often will think to ourselves one of two scenarios. Let’s say you are brand new associate and you’re like, I have a client that comes in and they want to have a gastropexy and you’ve never done a gastropexy. Many perfectionists will actually do one of two scenarios. They will either say to themselves, I’ve never done this before. I don’t want to fail, so I’m not even going to learn.
I’m not going to take the steps. I’m going to decline this. I’m going to shy away from this because if I can’t be perfect, I shouldn’t even try. But there’s another camp of perfectionist that will say, I’m going to admit to myself I don’t really know what I’m doing, but I would never let anybody see that fear. I would never ask for help because God forbid they see me having a vulnerability. So I’m going to try this surgery even though inside I’m terrified and I might make mistakes, and you probably will make mistakes, and the patient’s going to be under anesthesia longer. You’re not going to understand the shortcuts. And perhaps there’s going to be even complications, God forbid, but they might be. So both of those scenarios perfectionists can lean to. But if you notice, those are extremes.

Dr. Andy Roark:
Yeah.

Dr. Natalie Marks:
What we want to think about is how can I take fear, which fear is such a innate and sort of natural survival instinct we all have, but we don’t want to be guided by it. I work with a life coach, and she gave me this amazing sort of imagery of how to keep my fear in check. And in my head I have a boardroom, and I’m sitting at the head of the table and I have all my emotions sitting in their chairs. And every emotion that I have when I’m thinking about a decision has a voice including fear. But fear can have that voice and then I can say, “Okay, fear, I’ve heard you, but I’m going to take the consensus and figure out what my view is.”
And so when you have a situation like that, instead we’d love to encourage and hopefully teach and mentor the hybrid model, which is, “Okay, I hear you fear. Never done this before. I get that. That’s noted. That’s needed.” We have to have some of that healthy sort of wary optimism.
But I also heard that in that bravery of saying, “I’m going to try it,” you probably need a little bit of help. So let’s take the cautious nature, but let’s take the bravery and let’s meet in the middle. Let’s ask someone for help. Let’s go in for guidance. Let’s take a little bit of extra study. Let’s take a course, but let’s find that healthy goal of helping that patient but also having that self achievement without the worry you’re going to fail or without even trying. And so that’s what I mean by around our patients. We can either not help them at all or we can be too bold because we don’t want to show vulnerability. And I think that’s one of the keys of perfectionist is they’re so scared… again, I’m speaking as a recovering one… so scared to let somebody see you fail most of all yourself. Even though that often doesn’t happen.

Dr. Andy Roark:
I like this a lot. I was talking just a couple of days ago with Dr. Ivan Zack, and so he’s the CEO at Galaxy Vet, and just a genuinely neat, interesting guy. And he said, I’ve never heard it bluntly, but he said, “Perfectionism is fear.” And he said, “That’s what it is.” And now that you’re talking about fear… And I sat with that a little bit and said, “Is that really true? I hear what he’s saying, but is that true?” And then as you’re saying, “Well, there’s really two different paths, but they’re both fear driven.” I go, “Oh, that’s sort of starting to square up.” Do you generally agree with that assessment?

Dr. Natalie Marks:
I do. If you think about if this is relating to you, if you’re sitting there going, this is me, this is me, if you think about how perfectionism guides you… And let’s take another aspect, let’s say with your team. So say you are a leader in your practice in some regard, whether management or a peer leader or a champion for some aspect, and you’re tasked with a project that you have never done or is quite large or means stepping into a whole nother realm that maybe you failed at before even. Perfectionists, again, tend to go to extremes.
They tend to, and I think I wrote in my article about silent expectations. They often feel like if I have this expectation that this project has to be perfect, then I’m going to not really tell people around me what I need them to do and help me with because I don’t want to be bossy. I don’t want to come across as taking over because I have that fear of being looked at that way. But also then I’m never clear. I don’t give expectations of what our goals are. And then when someone presents me with something they’ve done for this project, then there’s inherent disappointment which often in body language is communicated to the team member, which then of course creates this conflict.
So to your point, led by fear in both scenarios instead of finding that middle ground of saying, “I understand I’m me and I understand you’re you. And for this project, our expectations are such. And so I want to discuss with you, same way we do shared decision making in the exam room, I want to discuss with you, this is what I want out of this project, but what do you want out of this project and how do we find that shared goal together so that expectations are out, they’re on the table, we know exactly what they are, we hold ourselves accountable for our roles and then we regroup.”
I didn’t do that as a young owner. I didn’t want to be that person because especially I think a lot of them are the associates, which I was, that then become owners and you’re working with the same people but in a different role, and you do not want to be looked at as, if I can just say it, a bitch the that just bought the practice. So you come out there and you are just like, “Well, whatever you think you can do,” but that never ends well. But that stems from this perfectionistic tendency of I expect here, and I assume everybody else thinks they should be up here, but that’s not the case and nor is this case healthy. So we have to sort of bring down, yeah,

Dr. Andy Roark:
Is it perfectionism kind of getting trapped in two spaces? Do you think it’s perfectionism of the job has to be done perfectly and I don’t want to make other people feel micromanaged and I want to be the cool boss and I don’t want to be the boss that people don’t want to work for. And so then you’re completely stuck at that point because you’re like, “It has to be perfect, but I don’t want to really communicate my expectations because then I will not be this other part of perfection.” It doesn’t seem like there’s any way out of that if you set yourself up that way.

Dr. Natalie Marks:
Yes, and that’s the key is that… I wrote this article because as I was reflecting on my first several months of ownership, I was thinking if I was mentoring people, which I do, what advice would I give them now as these young owners, whether they’re in sort of a corporate partnership or they’re independent, but whatever that is, if they are in this role, what is a better way to start? And again, I don’t like to look back on regret. I like to look at everything in life as a learning opportunity. And so I think this is just a way for us to think about how can we set ourselves up, especially to improve work culture, because that’s really where this is stemming from. Every person, especially perfectionists, they feel very, very nervous about someone else seeing a flaw, because to them a flaw creates extreme anxiety.
And I think we all know that. Even though many of us have failed, if we look back in life, we failed. Sometimes we ignore the failure. Sometimes we are embarrassed about the failure. We do come back, but many of us don’t go back in the same way or don’t even go back to that same experience because it’s so traumatic for a perfectionist. However, if we reframe that and say, how much could someone learn from you being vulnerable enough and brave enough? Those two can go together. That’s the thing. We don’t often think that bravery and vulnerability are together. We often think vulnerability is a weakness. It is a strength. So if you are brave and vulnerable in the same time as a practice leader and demonstrate, not be embarrassed, but just demonstrate the humility of a flaw or we’ll say a perceived failure, because often it isn’t. Often what we perceive as a failure is a minor blip in the road, but to a perfectionist, it’s a catastrophe.
But then show how we learn together. You misquoted a client, how do we learn from that experience? What process can we create so it’s better next time? Something happened in a surgery, no one’s perfect. How do we learn from that experience? How do we teach someone not to do the same thing and then get that personal reward out of mentorship? So I think it’s all about reframing it and understanding that, again, a brave vulnerability is I think how I choose to lead as I move forward, is to say it takes a lot to show somebody that I messed up. It takes a lot to admit a mistake, especially as a perfectionist, but the reward that you get from that vulnerability is actually so much more bucket filling than we realize.

Dr. Andy Roark:
Yeah, I love that you say that. And having that behavior modeled, that is something I feel like I’ve seen a lot more in the last say 10 years than in 10 years before that. And I had a couple of mentors. So I’m a Florida grad, and Uncle Mikey as we call him, Dr. Michael Scher was at Florida. That guy was absolutely brilliant, absolutely brilliant. But he would talk in rounds about his pile of bones, he’d be like, “Yeah, I remember him. I missed that one on my pile of bones.” And I remember just, I liked him so much in the time, but for someone who’s a bonafide… And maybe you would say, “He’s such a bonafide genius, no one’s questioning his competence.” But I thought that was such wonderful behavior and philosophy to say, “Well, I’ll tell you about how I messed this one up.” And it made an impression on me to have this person who I just respected so much being willing to say, “Well, I’ve made these mistakes.”
Hey guys, I just want to jump in real quick and let you know about some great continuing education I have coming your way. Guys, I’ve partnered with Nationwide to put together a series of webinars that are a hundred percent free to you. They have Ray-CE, they are good to go, and they are going to be, first of all, just genuinely entertaining and fascinating. The first thing I got coming for you is on November the 14th with my good friend Dr. Emily Tincher. She’s been on the podcast a number of times. I love having her here. She’s such a fun, interesting person who’s a deep thinker. And so anyway, she is doing a webinar called Clinical Empathy, the Exam Room Skill that Can Transform Your Team. And I’ve had Emily on the podcast before talking about clinical empathy.
This is a really good skill building webinar. This is great for your support staff as well as your doctors, but your team leads especially, but your technicians, your assistants, your CSRs. All of this, it’s such a great communication content. I think you’re going to really like it. So anyway, that is on November the 14th. It is at 3:00 PM eastern, noon Pacific.
And then the last one in the series is on December 13th. It is with Dr. Simon Platt. It is called Head Cases, a Spectrum of Care approach to neurology in general practice. So if you’re a neurology buff, if you like seizures, not like seizures, if you like knowing about seizures, if you like a neurophysical exam tips, tricks and hacks, things like that, this is going to be a great webinar. So again, this is on December 13th. It’s at 1:00 PM Eastern. That’s 10:00 AM Pacific Time. Gang, I would love to see you there. Links to all this stuff in the show notes. Go ahead and grab a spot. I’ll see you there. Let’s get back into this episode.
I was having a conversation with my team, and this comes from a practice manager named Maria Pirita, who I work with who’s amazing, but she’s one of the most optimistic, positive people, can do people I meet. And her life philosophy as she told it to me was, “How hard can it be?” And I’m like, that’s such a wonderful… So that surgery, she would look at the surgery and go, “How hard can it be?” I just think, how refreshing is that? How wonderful would it be to have that be at least one of the driving voices in your mind of, other vets do it. I’ve done a lot of surgery. How hard can it be? And I love how you put it. I love your sort of board of directors where I’m just like, I’m not saying this is the defining voice, but it’s one of the voices. And I think a lot of us have lost touch with that how hard can it be voice?

Dr. Natalie Marks:
I love that too. And I think that speaks to, and again, we’re sort of this underlying tenet of fear is that a lot of us go into… And let’s just even take practice ownership. We’ve been talking about it as an example. A lot of people look at practice ownership. And maybe if they allowed themselves, again, I call that daring release because it’s not easy. It’s not easy to release that sort of… It’s almost like a body suit. It’s this control and sort of this safety in a way of sitting in this space of perfectionism. But when you let that go, and it can be slowly at points and starting with baby steps, but you let that go and you actually look at yourself and say, “What do I want? What do I want right now out of life?” And if that’s to you, it’s like, I want to be a practice owner. And then that ugly fear that’s sitting on your shoulder goes, “You can’t do that. Are you crazy? That’s insane, blah, blah, blah.”
You have to listen to it, but you don’t have to follow it. And that’s important I think, because we don’t want to get rid of all of our fear. Fear is needed in small… Otherwise, fear would say, “I’ve got a cliff. I could just walk off. I can fly.” Fear is needed, but fear also is, if we think about where that started, it was because when we were living in caves and there’s a saber-tooth tiger around the corner, fear kept us in the cave and away from threats. And it’s still there, but we have a much better way of controlling it. And how hard can it be? And so the other thing I think that has been really helpful as I’ve been working on this journey of releasing perfectionism is exactly what you mentioned, which is surrounding yourself with people who think about the world differently. Perfectionists tend to want to stay around perfectionists because it’s like safety in numbers. It also feels better for someone to say, “Oh yeah, totally. I agree with you a hundred percent.”

Dr. Andy Roark:
Yeah. It validates what you’re doing and how you see it. And it validates your fear as well. They’re like, “Oh yeah, I would never let someone else do that.” And you go, “Okay, good. I feel good about this.”

Dr. Natalie Marks:
And then you’re like, “Of course I knew it. I was perfect,” and it’s just sort of this vicious cycle that you again trapped and you can’t get out of. But when you allow yourself to be surrounded by people who have different ways of looking at the world, have not necessarily struggled with the challenge of perfectionism, but strive for excellence, that healthy hybrid form, it challenges you to think about what if I did look at it that way? Or what if I did take a step back? What I just saw is a massive mistake. Maria might’ve been like, “That’s nothing. What’s going on? Why are you thinking that way?”
And the more that you allow yourself to internalize those other comments, the more you can validate that you know what, that was a little minor mistake and everybody makes them, and I’m going to move on, instead of internalizing that and having it stay with you for days and weeks and affecting other parts of your life. And I know that I definitely did that as a younger associate, and I would let a case just linger and fester for a long, long time instead of surrounding myself with people who could allow me to think differently, but also being brave enough to say, “Yeah, I made that mistake. I can’t believe I did that, but I did do it. Help me get through it.”
Because we get embarrassed and we just sort of wallow in this alone. And being alone in perfectionism is awful, absolutely awful because not only do you feel alone, but there is nobody there… Again, I’m going to just keep using Maria… I hope I get to meet her someday… being that beacon of light that says, how hard can it be? It was one mistake. You quoted the client $450 instead of $500. Yes, the client’s response was as such, but it’s not that you’re the worst person. Let’s just think about a different way to diffuse a client next time you’re on a call.

Dr. Andy Roark:
Yeah, I love it. Natalie, was there a turning point for you? Was there something that made you stop and sort of assess? Because you clearly thought a lot about this. And you say sometimes you have a before version of yourself and an after version of yourself. What was it that sort of made you stop and take stock?

Dr. Natalie Marks:
Yeah, it was probably one of the hardest days of my veterinary career, and it was actually, we had been doing, I was a practice owner, we were doing reviews. And we had of course our team review us, myself and two partners. And I had set myself up in the safe space of perfectionism of saying, “Oh, well, look at all this great stuff that’s coming back. You’re a wonderful mentor. You teach us, you do rounds with us,” and all this stuff. And then all of a sudden, I had three comments from newer team members who said, “You’re really intimidating and unapproachable.” And I’d never really had that direct feedback before, especially from a position of leadership.
And if I thought about it in the moment, certainly now as I reflect, of course I have many different feelings on it, but in the moment, I remember hearing that from my senior partner, delivered in a way that I think if I had delivered that now would be different, but sort of just this very direct, almost like a brick hit me. You’re pretty intimidating and really unapproachable, and they don’t really feel like they can come to you. In that moment, I know I went home, I didn’t eat for two days. I had stress colitis. I’m thinking, how do I even go on? You start to ruminate and go into this spiral of, I must be the worst practice owner anyone’s ever had. Oh my gosh, if people think of this here, do my friends think I’m that way and they just don’t tell me? Do my kids think I’m that way? And you go into this really dark place.

Dr. Andy Roark:
Yeah.

Dr. Natalie Marks:
And my best friend at that moment said to me, “You’ve got two choices. That’s what you got here. You can sit here and continue to wallow,” because it had been days of me really being in this dark place, “continue to wallow, and you are going to lose everything you worked for.” Because practice ownership at that point had been my veterinary goal and I’d finally achieved it, “And you could lose everything. Or you can take this and you can say you don’t want to be looked at that way because the way you’re acting, it sounds like you don’t. And you can be super brave and sit down with those three people and get feedback on what they are seeing because you obviously aren’t seeing it. And it’s going to take strength and it may even go down a little bit more before you go up, but you’re going to go back up.”
And I thought it took a lot of guts for me to sit down with those people because they did give me a lot of feedback that I wasn’t necessarily expecting or even in the moment wanting. But I wrote it all down and I sat with it. And I said, “You know what? This is probably the bravest thing that I’ve ever done for myself, but it’s also the bravest thing you’ve ever done because they definitely didn’t need to give me that feedback.” But I realized that’s not the leader I want to be. And so it took a while though to tease out why was I looked at that way. And that’s where I came kind of to those silent expectations. That was a big part of it for me is working on projects with team members and not giving them transparency and not showing my weaknesses, realizing that instead of them looking at them as weaknesses, they would realize that I’m human too. It humanizes leaders to be that way, and perfectionists just don’t see that in the moment.

Dr. Andy Roark:
No, I love that. Thank you for telling that story. And again, I resonate with that so hard. I know exactly how you feel because you want to be the best boss and you want to be the best manager and the best doctor. And then when you get hit with feedback like that, sometimes it’s really hard to let it go, if that’s what you really care about.
The way I came into thinking about perfectionism just for myself is very much… I ended up in sort of the same place as you. At some point you just get tired of getting trapped again and again. And ultimately, you have to pick your poison. And I think your friend was so spot on. You can just continue to do this or you can decide that you’re going to try to make some changes. But those are your only two options. Keep doing what you’re doing or do something different. Anyway, I love that you shared that. I love this conversation so much. Dr. Natalie Marks, you are absolutely amazing. Thank you for being here. Where can people find you online? You are doing so much. I love your column in Today’s Veterinary Business. Where else can people find you and follow you?

Dr. Natalie Marks:
Yeah, I do a lot on LinkedIn. I’m certainly doing a lot educating. My website is marksdvmconsulting.com if people want to check out a lot of the articles and blogs and where I’ll be next. But I’m certainly around and I really am on Facebook and Instagram too. But I love, just like you, I love connecting with colleagues, and I think this issue is one that has sort of remained behind the screen and behind that big curtain for a long time. But I think the more that people talk about this and realize there’s a huge community of recovering perfectionists out there that have been where you are. And if you’re feeling this way, don’t feel like this is the end, that I’m a perfectionist, it’s ingrained in me, and I will never be able to change. Small steps make a big difference.
And also, one last thing I would say is you need to recognize the joy along the journey. We’re so committed to, it’s got to be if we don’t hit the ultimate goal, the only way we can really find joy is the end result. Only for a second, because then we got to move on. It sounds so trite, but stop and smell the roses and the little, little pieces along the way because that’s where we find purpose and meaning. And often that’s even more rewarding than the end of the journey.

Dr. Andy Roark:
Oh man, you’re speaking to my soul. Anyway, we could have a whole other conversation about that.

Dr. Natalie Marks:
We certainly could.

Dr. Andy Roark:
We’re going to stop here, but I have lived that reality so much. And I’ve come to the same place as you. You’ve just got to let some of it go. You got to stop and smell the roses. Thank you so much for being here. Guys, thanks for tuning in, and everybody take care of yourselves. All right? And that’s it. That’s what I got for you guys. I hope you enjoyed it. I hope you took something out of it. Dr. Natalie Marks, thank you so much for being here. She’s absolutely fantastic. Gang, take care of yourselves. Be well. I’ll talk to you later on.

Halloween Horror: Pancreatitis Panic!

October 30, 2023 by Andy Roark DVM MS

Dr. Harry Cridge, veterinary internal medicine specialist, joins Dr. Andy Roark to talk about why we shouldn’t be SO afraid of pancreatitis. They discuss common pitfalls in the treatment of this condition, how to effectively work these cases up, and finally how the new drug PANOQUELL-CA1 works in these cases.

Cone Of Shame Veterinary Podcast · COS – 233 – Halloween Horror: Pancreatitis Panic!

This episode is brought to you ad-free by Ceva Animal Health!

PANOQUELL-CA1 IMPORTANT SAFETY INFORMATION: The safe use of PANOQUELL®-CA1 has not been evaluated in dogs with cardiac disease, hepatic failure, renal impairment, dogs that are pregnant, lactating, intended for breeding or puppies under 6 months of age. PANOQUELL®-CA1 should not be used in dogs with a known hypersensitivity to fuzapladib sodium. PANOQUELL®-CA1 is a highly protein bound drug and its use with other highly protein bound medications have not been studied. The most common side effects in the pilot field study were anorexia, digestive tract disorders, respiratory tract disorders and jaundice. PANOQUELL®-CA1 is not for use in humans. Limited data is available on the potential teratogenic effects of fuzapladib sodium. Therefore, anyone who is pregnant, breast feeding, or planning to become pregnant should avoid direct contact with PANOQUELL®-CA1.
Conditionally approved by FDA pending a full demonstration of effectiveness under application number 141-567.
It is a violation of Federal law to use this product other than as directed in the labeling.

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

LINKS

CEVA Connect

CEVA Dehydration Wheel

REVIEW: Advances in the diagnosis of acute pancreatitis in dogs

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

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Harry Cridge, MVB, MS, PG Cert Vet Ed, DACVIM (SAIM), DECVIM-CA, FHEA, MRCVS
American & European Specialist in Small Animal Internal Medicine
RCVS Specialist in Small Animal Medicine (Gastroenterology)

Harry qualified from the University College Dublin, Ireland in 2016 and went on to perform a Small Animal Internship at Mississippi State University, USA followed by a Small Animal Internal Medicine Residency and a master’s in veterinary sciences at the same institution. He became a Diplomate of the American and European College of Veterinary Internal Medicine in 2021. Following his residency, he moved to Michigan State University where he currently serves as an Assistant Professor of Small Animal Internal Medicine, in addition to an administrative role with oversight of the internship and residency programs within the college. Harry has published several research articles in peer-reviewed veterinary journals and lectures regularly at national and international courses/conferences.

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 Halloween episode for you. Dr. Harry Cridge is here. He is a veterinary internal medicine specialist and he’s joining me today to talk about maybe why we shouldn’t be so afraid of pancreatitis. We’re talking about pancreatitis panics today. We’re talking about the horror stories of how pancreatitis cases go wrong and what’s real and what’s not. We are talking about common pitfalls and the treatment of the condition, how to effectively work these cases up. And finally how the new drug PANOQUELL CA-1 works in these cases. Guys, quick to the point, super useful and one less thing to be terrified of. Guys, let’s get into this episode, but before we do, I just got to stop real quick and say thank you. Thank you to Ceva Animal Health for making this episode possible ad free. Guys, let’s get into it.

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

Dr. Andy Roark:
Welcome to the podcast, Dr. Henry Cridge. Thanks for being here.

Dr. Harry Cridge:
Yeah, thank you for having me.

Dr. Andy Roark:
Oh, it is my pleasure. So for those who do not know you, you are on the faculty at the College of Veterinary Medicine at Michigan State. You are a boarded veterinary internist and you are a researcher and your research focus is in disorders of the pancreas. And so I wanted to have you on today to talk with me a little bit about the scariest part of the abdomen in my mind, which is the pancreas, which is where when you make it mad, bad things happen. And I want to ask you, here’s what I’m looking for for you. I want a little bit of comfort in my treatment of pancreatic disease and illness, and it’s in my mind the pancreas is kind of this glowing red button that I really don’t want to press. And so I want to talk to you in realistic terms. I just want to start a high view about pancreatic disease and illness, and I wanted to ask you about what are the most common pitfalls that we make in treating pancreatic disease? And let’s just start there. So again, it is a sort of a scary thing for me. And so let’s just start at how much is a risk and what are the most common risks?

Dr. Harry Cridge:
Yeah, so I think in order to effectively talk about treatment of pancreatitis, we really have to think about how we diagnose the disorder and what our goals are. And that may vary dependent on the clinical situation you’re in. Historically, people used to use pancreatic biopsies, but we all know that they have significant limitations. They’re invasive, they’re costly, they’re

Dr. Andy Roark:
Terrifying. They’re terrifying.

Dr. Harry Cridge:
Yes, they’re not good anesthetic candidates. So we’ve fortunately largely moved away from that for that very terrifying reason. But it does put us in a position where we’re now reliant on an overall assessment of the clinical data that we have. That may be the patient history, may be the signal, and it may be the results of imaging and pancreatic lipase assays. We ourselves then become the gold standard. And while that’s fantastic for us and fantastic for job security, we do need to be very aware of some of the limitations of some of these diagnostics so that we can accurately interpret them and do the best by the patient.

Dr. Andy Roark:
Okay. Let’s drill into this a little bit. So I am intrigued here. So I like your idea. The pancreatic biopsy is generally I’m not doing those and so it makes me feel good that that’s not accepted standard and we’ve got to move past that. Talk to me about the limitations in the standard tools. So my impression with pancreatitis is I kind do some voodoo. I think most veterinarians sort of do. I look at the patient, I’m feeling the abdomen, I’m looking for clinical signs. I’m looking for obvious pain or discomfort. I’m looking for the general dumpiness. I think that that’s a clinical turn is dumpiness looking at the general dumpiness that I’m looking at the blood work and I’m kind of squinting at the lipase. And that’s probably, I don’t know how much that means exactly. Again, I kind of take it with a grain of salt, but I’m definitely looking at amylase, lipase, things like that. I’m going and then my pancreatic lipase, snap tests, things like that. But even then I still know that there’s a big range of what is clinical and maybe what is diagnostic. And so anyway, can you sort of flesh out in more specific terms what you mean when you say “We have to be careful in making diagnostic here and there are shortcomings in how we do this?”

Dr. Harry Cridge:
So I think as veterinarians we have to think ultimately what is the purpose of the test that we perform. And in a case where we have a patient that’s clinically unwell, has cranial abdominal pain and we’re suspicious for pancreatitis, then the question becomes what do we have to rule out in order to not change how we treat this patient?

Dr. Andy Roark:
Okay, I like this.

Dr. Harry Cridge:
We may get away with limited blood work, some level of pancreatic lipase assessment and a radiograph to rule out the foreign body that we don’t want to miss. So practically that may be what we need in a first time offender with no other complications, but that patient that’s not getting better or that patient that keeps coming back, that’s probably a case we need to be a little bit more solid in our diagnosis to make sure we’re treating the right thing. And I suppose that’s where we have to look a little bit more closely at the limitations of each of the diagnostic tests we have.

And you mentioned a few of those diagnostics predominantly blood work, biomarkers, lipase, amylase, and pancreatic lipase. And what I like to encourage people to think about with those particular assays is lipase and amylase. They can come from multiple different tissues. And why that matters to us as clinicians is if they’re elevated, we can’t say for sure that it’s coming from the pancreas. It could be coming from another organ system or it could be not getting excreted properly, the problem with the kidneys or something else. So we try to find an assay that is the most specific to lipase from the pancreas. And the hope there is if that’s elevated, the pancreas is inflamed, the pancreas is annoyed. So we try and pick a more specific test out of those tests. The pancreatic specific lipase or the quantitative test that often gets sent out to the lab is going to be the most specific one, the one that we can put most strength in our diagnosis behind.

But we do also have to be aware that there are other diseases outside of the pancreas that can also irritate the pancreas. We know for a fact that if the abdomen is angry, the pancreas is also angry. So just having the elevated lipase on its own is not going to be enough. We need to still do imaging and look at all that data together. And that’s why we went into some challenges is we can’t rely on a single test. So it can be challenging to get all those diagnostics and convince our owners to do those, but the cases that probably need that the most are those cases that keep coming back or those cases that aren’t responding to standard of care therapy.

Dr. Andy Roark:
Talk to me a little bit about your perspective on ultrasound as a diagnostic tool in pancreatitis. How much value is that over radiography just to rule out foreign bodies? Just wade in a little bit on that because you haven’t mentioned it as a diagnostic tool.

Dr. Harry Cridge:
So I think those lipase assays have to be combined with some level of imaging. Ultrasound is the one that’s most classically used, and ultrasound is very valuable in the fact that we can really see if there are any changes to pancreas consistent with pancreatitis, but also we can help rule out other abdominal disorders that could cause similar clinical signs. One of the times that we run into some challenges with ultrasound is there’s been a few studies recently that have looked at those cases that you may have seen in practice where you finally convinced the owner to do the lipase test, the ultrasound, and you think you’re doing a great job and then all of a sudden all your test results disagree with each other and you’re like, well, what do I do now? And that patient population certainly does exist. We’re getting more data out now to try and explain why those discrepancies are occurring.
And I think one of the things we have to think about is these are biomarkers of disease and each biomarker of disease or each imaging finding takes a certain amount of time to develop and a certain amount of time to disappear. And the preliminary data that we have is that any of the biomarkers of inflammation, so pancreatic lipase or C-reactive protein, any of those inflammatory type of biomarkers have relatively short half lives. So they’re going to go up relatively quickly after an injury to the pancreas, but they’re also going to fall off relatively quickly with most data out now saying that within two days of diagnosis of pancreatitis that pancreatic lipase is going to return to within the reference interval, whereas ultrasound changes may persist for longer. So when we’re taking a single time point in these cases, we don’t know where exactly on the upswing or the downswing of those lipase markers or the ultrasound we’re going to be, and that’s when discrepancies can occur.

So the way that we are trying to work on that in practice is thinking about these tests is more dynamic than we originally did. I think we used to say, okay, we’ve got my diagnosis, we’re good to go. But those cases where there are discrepancies, they’re probably cases where we need to do either repeat imaging or repeat lipase or repeat snap test to see how things are changing over time. And that can help further solidify that diagnosis. So thinking about the half-life of some of these tests and thinking about, okay, if they disagree, let’s get another time point and see which direction are we moving and are we moving towards agreement and that it was a relatively recent injury or are we getting further apart and it was probably a past pancreatic injury.

Dr. Andy Roark:
When you think about gastroenteritis, pancreatitis, do you see levels of disease? Is there a mild pancreatitis in your mind or are they always to be worked up the same way? Talk to me about severity in the disease as you see it.

Dr. Harry Cridge:
Yeah, so there’s certainly fairly substantial variations in the degree that an animal is, whether they’re clinically affected by pancreatitis or not at the referral level, we get a lot of the severe pancreatitis cases, the one that causes the most stress but also the most fun. But there were a lot of cases in practice where you can make the diagnosis and sometimes treat them on an outpatient basis. And we’ll touch on that a little bit later when we talk about treatment options. But yeah, there’s certainly a big, big spread and I think there’s probably the fact that some animals have chronic disease that we under recognize and they have acute on chronic flare and typically are a little bit more mild, at least in my opinion, versus the first time really severe acute disease.

Dr. Andy Roark:
What do those acute on chronic cases look like to you? I mean, how do I not look at this and go, well, this is acute pancreatitis, what should I be looking for if I’m trying to catch on to that? Is it just that I’ve seen this patient before or Yeah.

Dr. Harry Cridge:
I think it’s twofold. One is if that patient keeps coming back and keeps getting diagnosed with pancreatitis, I think the likelihood of these being independent events specifically if they’re in short succession is probably lower. And it’s probably had some level of chronic perhaps subclinical inflammation going in the pancreas between flare-ups. And then the other thing is ultimately a lot of these patients come in on an emergent basis, so we’re all focused on stabilizing these patients and getting them to where they need to be. But when we take a step back and think about asking more detailed questions, often these animals will have more substantial GI histories than they were initially reported. And we actually found that in a study we did relatively recently. I think last year we took several hundred dogs that had elevated pancreatic lipase concentrations and we surveyed and looked at clinical presentation of these dogs, what risk factors for disease they had, and also how many of them had past episodes of GI disease, and it was a significant number of them that had these chronic GI histories that perhaps go under recognized on first glance.

Dr. Andy Roark:
Yeah, that makes sense. It’s funny, I love that you called out sort of emergency cases where they show up and you’re the emergency doctor and you have no idea what the rest of their file looks like. And I think about cases I’ve seen when you look at this patient, especially if it’s a 10, 12 year old dog that’s had GI upset diarrhea, things like that throughout its year, it’s easy to just gloss over that and not really say, Hey, is this something that’s related to what we’re dealing with today? And so anyway, that’s a arrow I’m going to put in my quiver. I need to start looking for the chronicity of that. So anyway, I love that you say that. How do, let me just ask you this again. I said this is sort of a fear episode for me. What mistakes do you see as people start to address these and decide how they’re going to treat these cases? Do you see, I don’t know, do people tend to be less aggressive than they need to be or are there tricks that you say, oh man, I don’t know why doctors consistently don’t do this, or Talk to me a little bit about how people struggle to treat these cases.

Dr. Harry Cridge:
And I think this sort of touches on both diagnosis and treatment in terms of diagnosis, there was some common pitfalls, and again, I don’t always think that these are the fault of the veterinarian. It’s often the situation you’re in and the finances that you have available to you. But there are a lot of cases where clinical signs and abnormal SNAP test, it’s not a guarantee of a diagnosis of pancreatitis. There’s a lot of all the diseases where it’s either a false positive test, which is proposed in the literature, or this animal has some level of pancreatitis, but it’s secondary to whatever else is going on. So relying on just the SNAP test is probably not great, particularly in cases that are recurrent. Other things that we sometimes see is those patients that keep coming back, we’re all really, really good at managing those acute pancreatitis cases.
We get ’em on fluids when we can. We treat them for pain medications as we can and we get them better. But I think one of the things we sometimes don’t put as much time into is thinking about are there any identifiable risk factors to prevent this animal to keep coming back? So in those patients measuring a triglyceride concentration, looking to see if they’ve been on drugs that have been associated with pancreatitis in the past and whether they need to be on those drugs. Some of those common ones is anti-seizure medications, and some of those you of course can’t come off, but it’s worth looking at and thinking about, and especially screening for lipid disorders or endocrine diseases. They’re the cases that when we identify those and treat those, my opinion is they’ve got a reduced chance of recurrence and reduced chance of coming back in with a severe disease again.

Dr. Andy Roark:
I like it. That makes sense. One of the new things this year that I’ve really seen a lot of discussion of is the PANOQUELL -CA1 medication that just sort of just came out is conditionally improved by the FDA. Can you talk a little bit about the role that you see PANOQUELL- CA1 playing in treatment of these patients?

Dr. Harry Cridge:
Yeah, so as you mentioned, PANOQUELL- CA1 is a new drug on the block and there’s a lot of excitement about it. I think there’s a lot of excitement because for many, many years we’ve been restricted to just supportive and symptomatic care in these patients. And we all know from our own experiences or from the literature that as hard as we try, there’s often a significant morbidity and mortality, especially with the severe cases. So having a new option is really exciting. I think it has got conditional approval over time they’ll need to work full approval, but it’s really exciting to have a novel treatment on the block for these tough cases. The way that the drug works is it’s a drug that acts on neutrophilic inflammation. So the way that inflammation is obviously strongly associated with pancreatitis. So the theory behind this drug is if we reduce the amount of neutrophils that come out of the blood vessels into the tissues, we’re going to reduce the amount of inflammation and therefore help this patient.

The way that it does that is it focuses on how neutrophils come out of the vessels. So we think all the way back to vetco, we think about the rolling, the activation, the adhesion and migration of neutrophils from the vessels into the tissues, and that PANOQUELL- CA1, the fuzapladib acts on one of the key players in that. So the key player acts on is something called leukocyte function associated antigen one or LFA1, and that is a specific molecule that allows that neutrophil to subsequently extravasate. So that fuzapladib blocks the activation of LFA1, which then prevents it from being able to go into the tissues so it stops that neutrophil extravasation.

Dr. Andy Roark:
What’s the impact if I catch this late, so I understand the slowing down, reducing neutrophils coming out of the vessel, that makes sense to me, but it feels like if I inherit a pancreatitis case and everything has already flared up, am I still getting benefit from this medication?

Dr. Harry Cridge:
So I think certainly what we know so far based on the studies that are out there is that it has been shown to improve the clinical signs associated with the acute onset of pancreatitis. And that was a fairly broad patient population that was used in those studies. We do over time, I think we’re going to work out when is going to be best to use this medication, but when we really think about it, there’s a lot of these cases where the degree of inflammation is what’s causing the challenge. If you get in nice and early and prevent that severe neutrophilic inflammation, in theory, that would strongly benefit the case. And there’s a lot of utility in using this early in the course of disease later in the course of disease. Of course, helping with any level of inflammation is going to be of benefit is just working out how beneficial it may be in those particular cases.

Dr. Andy Roark:
Yeah, that makes sense. Getting back to our horror theme, what are the side effects? Are there contraindications that we’re looking at, things like that?

Dr. Harry Cridge:
The only labeled contraindication is don’t give this drug to a dog that is allergic to the drug, which it’s a classic and one that’s always on the label. So that’s the only label contraindication. As with any new drug that comes out, there’s certain ways that we can look for adverse effects. One of those is to look at the safety studies, and one of that is to look at any adverse event that was reported in the efficacy studies. So when we look at the data, and that is available to anybody on the FDA website, the freedom of information summary for the particular drug, you can look and see what adverse events occurred in the patients that received the drug and what adverse events occurred in those that didn’t receive the drug or those that received the placebo. A lot of the adverse events that were reported are GI upset, some elevations in liver enzymes and various other adverse effects, and any of those could be either from the underlying disease or from the drug administration. So that’s why we try and look at what happened in those that got the drug and what happened in those that didn’t get the drug. And the other place we look is the target species safety data, again, which is publicly available to any veterinarian out there that wants to look at this data firsthand. And in those type of studies, what they do is they give the new drug and they give it at higher doses and for longer periods of time than is on the label, and they look to see what happens.

So fuzapladib, PANOQUELL – CA1, it’s like a five times overdose, and they get it for nine days instead of three days, and they look to see what happened in those populations. A higher blood pressure was noted in those dogs on significantly high doses of the medication, and there was some injection sites swelling it in one dog, I believe, among some other adverse effects. So right now it’s hard to be 100 percent sure what’s the drug and what’s not, because a lot of the clinical signs that were reported are things that we see in pancreatitis. The dog that’s vomiting, that has nausea. So we can’t definitively associate those with the drug. But as more and more people use the drug and more and more data comes out, I think we’re going to have a much stronger idea of the specific nature of that drug.

Dr. Andy Roark:
Tell me about the route of administration and the time to affect. I mean, how do we get this on board? How long does it take before we start to see benefits?

Dr. Harry Cridge:
Yeah, so that’s a great question. So the drug is given once daily for three days, and it’s given intravenously in terms of what data has been used for the drug approval was the clinical improvement, the clinical score system by day three, the end of the drug administration. But the next of question is it’s an injection. So how do I store that and what can I use it for? So it’s a medication that comes as a powder LIA drug, and it’s mixed with a sterile diluent, and it’s then stored in the fridge for up to 28 days. So once you have this drug in practice, you can store it for up to 28 days, and it’s a multi-dose vial, so it’s really, really useful for multiple patients.

Dr. Andy Roark:
Is there anything that says I have to give this intravenous injection to a hospitalized patient? I mean, sometimes I’m trying to help patients. They may have money constraints. Sometimes we treat complicated cases on an outpatient basis. Anything that says I have to have the patient in hospital, does it need 24 hour monitoring? Anything like that?

Dr. Harry Cridge:
No, absolutely not. So the medication is, it’s a once a day medication and it’s intravenously, but there’s nothing specific about the drug that would mean that they would’ve to be hospitalized between those injections. I know there’s a lot of cases in practice where we treating these outpatient, whether it’s a milder case or financial limitations or frankly, the staffing available in the hospital to manage these as an inpatient. So I think it certainly has utility in outpatient management as well as inpatient management.

Dr. Andy Roark:
Awesome, Dr. Henry Cridge, thank you so much for being here. Thanks for making me feel safe about pancreatitis. I appreciate that. Are there any resources that you really like anywhere that you would point people if they want to learn more?

Dr. Harry Cridge:
Yeah, so the Ceva Connect website is really, really useful. They’re putting a lot of really clinically relevant information about the drug on that website. They also have a dehydration wheel, which is designed for those veterinarians in practice where you may not always have the amount of time to fully calculate fluids or you perhaps just want somebody to double check you. You can enter the patient’s weight, the level of dehydration. It’ll tell you what fluid rates might be appropriate for that particular patient. It’s a lot of really useful things just for the general management of pancreatitis on there. We at Michigan State have put out a review article on pancreatitis in both the general veterinary internal medicine and JAVMA and the Clinicians Briefs. There’s a lot of publicly accessible data on how we treat these patients, and at the end of the day, we’d love to hear how other people treat these patients. The more we talk about pancreatitis and the more we learn from each other, the better chance we have of improving the outcome in these patients that don’t always have the same outcome that we would hope for.

Dr. Andy Roark:
No, that’s amazing. I’ll put links to all these resources down in the show notes. Everybody can check ’em out. Guys, I hope you’ll take a look. Gang, thanks for being here and listening to everybody take care of yourselves.

Dr. Harry Cridge:
Listen, thank you.

Dr. Andy Roark:
And that’s it. That’s what I got for you guys. I hope you’d enjoyed it. Thanks so much to Dr. Cridge for being here. Thanks to Ceva Animal Health for making this episode possible. I hope you learned something. I hope you’re going to be able to put this to work so that maybe it makes your pancreatitis cases a little bit less scary. I know it will for me anyway. Take care everybody. Talk to you soon.

Andy Roark DVM MS

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