Andy Roark DVM MS

Dr. David Dycus provides a practical, in-depth look at managing canine hip dysplasia, from early diagnosis to surgical interventions in this episode of Cone of Shame Veterinary Podcast. Dr. Andy Roark sits down with . Dr. Dycus to discuss the various treatment options, including juvenile pubic symphysiodesis (JPS), pelvic osteotomies, and total hip replacements. He explains the importance of early detection, especially in breeds predisposed to hip dysplasia, and breaks down when and why certain surgical options are recommended. This episode is essential for veterinary professionals looking to better understand orthopedic surgery decisions and help guide pet owners through difficult choices. Gang, let’s get into this episode….

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

LINKS

Dr. David Dycus: https://drdaviddycus.com/

Dr. David Dycus on Instagram: https://www.instagram.com/ortho_vet/

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

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

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

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

ABOUT OUR GUEST

Dr. Dycus attended Mississippi State University’s College of Veterinary Medicine for his veterinary degree, Auburn University for a small animal rotating internship, and Mississippi State for a combined surgical residency and Masters degree.

Dr. Dycus is frequently asked to lecture locally, nationally, and internationally. He has given over 250 continuing education lectures and taught over 150 laboratories. He has published numerous research articles and authored or co-authored several book chapters. He is the co-editor of the textbook: Complications in Canine Cranial Cruciate Ligament Surgery. In 2023 Dr. Dycus received the Veterinary Hero’s Award in surgery by DVM360 and was named by DVM360.com as one of the 10 veterinarians to watch in 2018. Dr. Dycus is a frequent contributor for updates in orthopedics to several veterinary websites and magazines. Dr. Dycus has also been featured on Sirius XMs Doctor Radio’s segment on Pet Health and Orthopedics. His passion for teaching has allowed Dr. Dycus to become a laboratory instructor for the CBLO, TPLO, extra-capsular stabilization, medial patella luxation, angular limb deformity, and fracture repair. He is on faculty for AO (Arbeitsgemeinschaft für Osteosynthesefragen), and he is an orthopedic consultant for VIN (Veterinary Information Network). 

Dr. Dycus became a certified canine rehabilitation practitioner through the University of Tennessee in 2015. He is the founder and surgeon at Fusion Veterinary Orthopedics where he has a focus on total joint replacement, complex and minimally invasive fracture repair as well as angular limb deformity correction, 3D implant printing, and arthroscopy. In addition, he is the founder of Ortho Vet Consulting, an educational consulting and orthopedic coaching service.

EPISODE TRANSCRIPT

Dr. Andy Roark: Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I got a great one for you with my good friend, Dr. David Dycus. Dr. Dycus is an orthopedic veterinary surgeon. And if you haven’t heard him on the podcast before, you’ve been missing out. He is just a fantastic resource on all things orthopedics.

And today we’re talking about hip dysplasia. Guys we see hip dysplasia, we wrestle with hip dysplasia. I wanted a very fast download on the surgical options for hip dysplasia and when they’re appropriate, meaning when in the lifespan of the dog and yeah and what they entail and just just get me up to speed on our surgical options here, Dr.

Dycus. And he did and it was great and it’s not what I was taught in vet school 15 years ago. There has been a number of advancements and of course there has, that’s great. But it is really good. He makes a lot of points and I go, Oh yeah, that totally makes sense. Anyway, this was a fantastic conversation.

This is going to affect how I talk about hip dysplasia in the exam room. I hope it’ll make that impact for you as well. Let’s get into it.

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

Dr. Andy Roark: Welcome back to the podcast, Dr. David Dycus how are you, my friend?

Dr. David Dycus: Oh, I’m fantastic. Thanks for having me back again.

Dr. Andy Roark: Man, it is always my pleasure. I so enjoy having you in the podcast and getting to talk to you and learn from you. You are a very, very smart guy. You’re also a very, very busy guy. You are, for those who don’t know, you are a lecturer. I’ve seen you lecture all over the place. You write a ton.

You are also the founder and owner of OrthoVet Consulting. And, because you don’t have enough going on, your new venture is a surgery specialty hospital outside of Washington, D.C. It is Fusion Veterinary Orthopedics. Which when are you set to open?

Dr. David Dycus: Hopefully, we’re going to be opening in mid October of 2024. So, not far. Things are moving quick.

Dr. Andy Roark: You are right there just staring at the finish line from where we are. I appreciate the heck out of you being here. One of the things that I always like to talk to you about when we get together and we’ve got orthopedics on the table, I always like to keep this thing super practical and I want to keep growing my own skills in the exam room and making sure that I’m giving pet owners the advice that’s going to help them.

And I have had a string recently of hip dysplasia cases. I have got a couple variants. I’ve got the German Shepherd puppy that’s vocalizing when I stretch his hips out, which maybe it’s just behavior. Maybe he’s just tired of being handled. But I’m concerned. And then I’ve got obviously the older dogs that are having a lot of hip dysplasia.

They’re just very minimal muscle mass in the back end and sort of everything in between. And so I’m looking at these patients. I’m thinking about what we can do for them. And today, what I really wanted to do was get a rundown with you of hip dysplasia, surgery options, what are my options for trying to surgically intervene in these hip dysplasia cases?

And then also, when is it appropriate? Because I know that there are some cases that we say earlier in life is I would probably go for this and later in life we’re going to go for that. And so I was wondering if you could help me just as an overview, what are my options for surgery and when would I put these options into play?

Dr. David Dycus: Great questions. And a lot of it is going to depend on the age of the dog, the clinical signs they’re having, the breed. And so what I like to think about is if we’re going to think surgery, we’re going to put them in the category of potentially hip joint improvement in terms of the anatomy.

Versus moving more towards a salvage option which would be doing something more definitive to the actual joint itself. And what I mean by that is we can take the improvement in the hip joints category and there’s usually two surgical procedures that we would put into that category. One is what’s called a JPS.

And we all call it a JPS because it stands for juvenile pubic symphysiodesis, so it’s just easier to say JPS. And then the other would be either a triple or double pelvic osteotomy. And so the reasoning age comes into play and breed is the cutoff points for these two procedures are very, very different.

So with a JPS and the whole theory here is with hip dysplasia, there’s laxity of the hip joint. So when the animal is trying to walk and when the leg is in the air, the femoral head is subluxating from the acetabulum. And then when the foot strikes the ground, it causes the femoral head to crash back into the acetabulum.

And that creates. Abnormal wear and tear on the cartilage, which we all know will lead to arthritic changes. And so, in dogs with hip laxity that are very, very young, we can do things to try to improve the coverage of the femoral head and the acetabulum. And so, a JPS would come into play in dogs at around 16 weeks of age.

One has to have a very high suspicion of a dog with hip dysplasia at four months of age. Because these are usually still bouncing, happy, go puppies. And so, in these situations, we usually look more towards breeds that are tend to be predisposed. So we think German Shepherds, we think Rottweilers, we think Labradors, we think Golden Retrievers, Newfoundlands.

And in these dogs, if they come from a line that has dogs that have previously had hip dysplasia, or perhaps there’s poor breeding practices. Somebody says, Hey, I’ve got this beautiful German shepherd. Somebody in the Walmart parking lot was selling puppies and we, we picked one up.

What do you think, to me, my, my bells are going off. Oh, there’s probably some backyard breeding going on. And, and in that case, a JPS, we make a little incision just above the pubis. And we actually prematurely fuse the cranial part of the pubis. And when we do that, as the animal’s growing, it actually pushes the acetabulum outward and over.

So it actually covers over the femoral head as they’re developing. But if we wait until after, say, 18 weeks of age, then the degree of coverage there isn’t going to be enough to really help us. And the whole goal. Is to try to improve the coverage to minimize changes to the cartilage and thus minimize arthritic changes in life. And if one is astute enough, they could do an exam in a puppy and every puppy squirmy, so you try to extend their hips and every puppy is going to squirm like. It’s bothersome to them, but the reality is many times they’re just not used to being held that way. So what I would recommend an individual do would be to check what’s called an Ortolani, which is a test to check for laxity of the hips.

And that’s done by basically putting a hand sort of on the dorsum of the dog and then taking the other hand at the knee and you sort of push up on the femur And then that will cause the femoral head to subluxate. And then you start to pull the leg away a little bit. And that would cause the catastrophic reduction.

So you’re listening for a thud or a click or a

Dr. Andy Roark: And it pops back in?

Dr. David Dycus: Yep, exactly.

Dr. Andy Roark: How does the dog react to this?

Dr. David Dycus: So in some situations, if the hips are really lax, they usually don’t even react at all. The challenge though is if there’s mild laxity, they could have some muscle strength that could prevent you from being able to get a positive Ortolani when they’re awake.

And so in a otherwise healthy dog that’s there for, say, a routine vaccine visit, I’m going to look at the breed of the dog. I’m going to, And if it’s negative and the breeding of the dog has been very, very good meaning that it comes from a reputable breeder and, and, you know, the, all the due diligence has been done then we might not jump to saying, okay, let’s sedate just to make sure we, we don’t get an Ortolani.

But if I have a dog that we’re just not sure about the breeding principles or I’m not sure if I’m getting an Ortolani or there’s a little bit of discomfort on hip extension, then I might say, okay, it might be worth doing a quick sedation just to check for hip laxity and at the same time get hip x rays.

And we want to get well positioned hip x rays, but we have to remember that when we do that. We put them on their back, we pull their legs down and that actually forces the femoral head into the acetabulum So if there’s mild laxity there, you might miss it and so one of the cool things that people can do and I think the training is free is Become pin hip certified and if you’re pin hip certified What you could do is take the pin hip radiographs and that gives us what’s called a distraction index, which is, tells us the degree of laxity.

And if that distraction index is above say 0. 3 or is on the upper end for that particular breed, then you could do a JPS. You could say, okay, we’ve got a German Shepherd. We believe breeding was good. But when I was manipulating their hips, they were a little more squirmy than I thought they should be on hip extension.

Or I was trying to do an Ortolani and I thought I got it, but the dog was also a little bit reactive, which they, I wouldn’t have expected them to be. So we talked to the owner about sedating. We check Ortolani when they’re sedated, we get our well positioned hip radiographs, and then we do a pin hip. And if the pin hip number is higher than it should be, we can say, okay, we need to do a JPS.

And, for that to take place, we really have to start this thought process of looking into these dogs when they’re very young.

Dr. Andy Roark: Like when they’re a fetus. Like three weeks before they’re born, we should start talking to the client about, do you, okay. I’m

Dr. David Dycus: so what I would say is, think about when they’re coming in for that. I don’t know, was it 12, 13, 14 week vaccine appointment? Make that, and I think that usually correlates to when they’re getting the rabies vaccine, maybe make that visit where you check hip extension, check Ortolani.

Dr. Andy Roark: Okay.

Dr. David Dycus: And you don’t have to do that in a dachshund, or in a greyhound if anybody’s ever actually seen a greyhound puppy.

But, in a German Shepherd, in a Labrador, in a Golden Retriever, absolutely I think it’s worthwhile to check. And then the other one that would be super easy is the dog’s actually having an issue. And so the owner brings them to you, he’s really slow to get up or, he tries to jump on the sofa, but he can’t, or he refuses.

Then that obviously would warrant a more in depth workup, but you can do some slight screening at that visit that really shouldn’t take a lot of time. But if some of your little red flags go off, then it says, okay. We’re not going to do this at today’s visit, but let’s get you in maybe next week and let’s get this kind of figured out just so we can be safe.

Dr. Andy Roark: Do you do a lot of these procedures, David? I mean, in all seriousness, it’s just, I was gonna say, it seems like such a specific case. I, when you said, hey, this pet’s coming in he’s really slow to get up. He’s not, his litter mates are behaving and he’s not, to me, I go, okay, that would be the type of flag where I go, oh, we’ve got someone who’s attuned to what’s going on.

They’ve got a basis for comparison to other dogs. It’s terrifying, I think, to have that conversation with a 12 week old puppy’s owner and say, we’re talking about a permanent alteration of your dog because I’m, I’m worried about what this is going to happen.

And it just, there’s, there seems like there’s so much pressure to say, well, let’s wait and see how it goes. And again I’m really checking myself here. I think your idea of checking Ortolani, I think that’s a real pearl for me to take away and go, I think I can get into that. The reminder at that 12 week visit, I think I can see me really starting to lean into that and to really dig into that orthopedic history there.

I think that makes a lot of sense. I, it, the whole thing, I’ll be honest, my, my hands are sweating because I’m like, oh man, that, that recommendation, unless the owner comes to me and says, I’m concerned because of what I’m seeing that feels like such a hard call to make of, let’s go for it.

That, that’s, I don’t know. I would struggle with that. 

Dr. David Dycus: And I think you just hit the nail on the head. And you hit the nail on the head on the fact that why many of us don’t do many of these procedures is because they get missed. Because it’s not on our radar. And we also don’t want to be Debbie Downer to the clients that have a bouncing puppy. 

Dr. Andy Roark: And the puppies often, they’re squirming. They’re wiggling. I’ll put a puppy’s hips in extension and they go, Ah! And I’ll go, is, are you just, are you doing that because it hurts? Or are you just doing that because you’re tired of this guy giving you this weird petting?

Yeah, and I don’t know. A lot of times, I’m I have to do it a couple of times and try to interpret what’s going on. Yeah.

Dr. David Dycus: yeah and I think once you, palpate enough puppies, you get kind of used to what squirminess versus wait a minute, this is a little bit more, but the way I look at it is, you know, yes, you might have to be the deliverer of bad news, but in theory, if we could do a JPS. There may be the need to do nothing more later in life.

So it’s like, we could have this conversation now, or I ignore it, and then you guys come back in when the dog’s two or three, and now we got to start having a discussion on how we’re gonna manage this for life. Are we now having to be committed to something like a total hip replacement, or you know, and I always think back to myself, well gosh, if we had been more proactive, could we not even be in this boat?

And it’s the same way I approached the whole aspect of osteoarthritis. If we could just be more proactive at recognizing and bringing in the discussion before we get to the point of them having clinical signs, I think we can be a lot better at managing the, the long term aspect of things.

Dr. Andy Roark: Yeah. That, that totally makes sense. I think you’re spot on. I appreciate you speaking to that. But, you know, I remember being taught JPS in vet school and that was always my thought was, am I ever going to have the confidence to say, let’s do it? And I think your point of looking back and saying, could we have prevented this?

Could we have taken action earlier? I, ah, yeah. It’s it’s tough. Talk to me a little bit about the pelvic osteotomy. So if we’re talking about less than 18 weeks here, for the JPS, what kind of window are we looking at there?

Dr. David Dycus: Usually those are going to be the dogs that we didn’t really pay attention to when they were 12, 13 weeks old. And then the clients start to notice an issue at, seven, eight, nine, 10, 11, 12 months of age. And these are dogs that actually have clinical signs. A JPS is more of a prophylactic type procedure.

Whereas a pelvic osteotomy is you realize that there’s now clinical signs. There’s pain on hip manipulation. There’s radiographic evidence of hip laxity, but there’s no arthritic changes to the hips at this point. Then you would say, okay, sometime around that eight to 12 month time frame, we’re going to actually go in and make two to three different incisions in the pelvis, cut the bone in two to three different places.

And we’re actually going to physically move the pelvis so that the acetabulum rotates over the femoral head. So you’re basically doing what a JPS would have done, but now the animal is at a point where a JPS wouldn’t be effective. So now you have to physically cut the bone and move it and put a bone plate on there.

And, the challenge here, and I remember during my residency in the first few years out in practice, I would do these pelvic osteotomies, but then as I was out longer, I would see these dogs years and years later, and They would still develop pretty horrendous arthritic changes. And now the owner’s like, okay, now what do we do?

You know, you said we were going to do this and it should help. And yeah, it helped for, X number of years, but now they’ve got arthritic changes. So now we’re back to what we’ll talk about in a moment on the salvage aspect of things. And so. a lot of us from a surgeon standpoint that deal with, patients with hip dysplasia, many of us don’t do mini pelvic osteotomies anymore because as we’ll talk about in a moment, we’ve got some other options available to us.

But the key finding of a pelvic osteotomy is that they have to have clinical signs. So she would never do it in a dog that does not have hip pain. So you would never do it as more of a prophylactic thing like you would a JPS. And they also cannot have radiographic evidence of arthritic changes. And the challenge is most of them at that point, if you really start scrutinizing a radiograph have arthritic changes.

They’re just not jumping out at you like when we think about looking at a radiograph and going, oh gosh Those hips look horrible, you know, you may glance at these and be like, oh the hips look fine But if you really start scrutinizing it, you’ll see some changes associated with arthritic changes.

Dr. Andy Roark: Yeah that definitely feels like you’re threading the needle. You need clinical signs, but not radiographic changes, and it feels like you’re really trying to hit a certain window. Okay so talk to me about these alternatives.

Dr. David Dycus: So once we’ve moved out of those categories, we’re left with what we consider our salvage procedures and and the two there would be a femoral head and neck ostectomy or the so called fho and then the other would be a total hip replacement and I feel like where we can bring in those procedures could really be in the young, the middle, and the older parts of life, but there’s going to be different criteria associated with that.

I will say that I always, from an FHO standpoint, put that at the very end of the list, the very last thing I would ever do to a dog. And, I feel like many a times veterinarians dog comes in, say at the age of one and a half or two, and they’ve got hip pain and they take an X ray and they’re like, Oh, they’re, they’ve got hip laxity, they’ve got arthritic changes, let’s do an FHO.

I would reserve an FHO for the absolute last quality of life is absolutely suffering standpoint before I would consider it and a total hip replacement would have to be totally out of the question. 

Dr. Andy Roark: Tell me more about that, right? Like I’m with you. I’ve sort of seen the FHO higher on the list. It’s something, it can be fairly cost effective for pet owners. People go, well, we can make this pain go away right now. Break that down for me a little bit more as to why it’s so far down the list and the total hip has to be off the table.

Dr. David Dycus: Yeah. So the reasoning for that. So number one before the advent of hip replacements and people, they would lop off your femoral head and they’d do an FHO. And it left people permanently crippled for the rest of their lives. They had that 100 percent of people had to walk with a cane afterwards.

And in dogs, yes, there are studies that would say, Hey, dogs seem to do well after an FHO, but their owner perceived versus the reality. But what I will say is after an FHO hip extension, Is restricted in every single case and hip extension is critical to limb function. Maintenance of range of motion is critical to limb function.

So will it relieve the discomfort of the femoral head on the acetabulum? Yes. But what we’re forgetting is that we also typically have a lot of scar tissue around the hip. And in fact, after an FHO, you’re relying on scar tissue around the hip to develop. All of those things are inhibiting range of motion.

And so we don’t take in the soft tissue, the muscular aspect of things following an FHO and the pain associated with those soft tissues. And so the other excuse where people will say, well, it’s cheaper. The actual process of doing an FHO is cheaper. But as I said, Maintenance of range of motion is critical, and so for me, if I were to agree to do an FHO, I require the owners to enroll their pets into a formalized rehabilitation program that starts at about five days out from surgery, because the whole goal there is they’re starting to work on hip extension.

And getting hip extension and I’m sure many of us have done an FHO and the little dog comes in at two weeks for suture removal and the leg is held in a flex position and you try to move the hip and it doesn’t move and at that point we’re so far behind the eight ball we’ll never get normal hip extension back but what I found is if FHO enroll them into a formal rehab program and we do that for up to about 12 weeks We can get the hip extension range close to the normal range not normal But close to the normal range so that we can have the best outcome as possible. But on the cost front if you take in the cost of surgery plus the cost of rehab When we did a price comparison, it actually came out to be 30 more expensive to do that over a total hip replacement. 

Dr. Andy Roark: And you’ve got 12 weeks of work, right? Like the owners have to be committed to this. It doesn’t do itself.

Dr. David Dycus: If we’re wanting to achieve what I would consider to be an appropriate outcome, keeping the pets pain at the forefront and limb function then yeah, absolutely.

And then people will like to say, well, we’re going to rely on the owners to do some stretching at home. The problem is, is that the owners can do that, but they’re not going to be able to push the hip into extension to the amount that’s needed to really improve it. Because they’re worried about hurting their pet whereas the rehab therapist knows how much to push on the tissues and how to get the tissues to respond and react Because the thing that we always forget about is we look at a radiograph and we say, okay the disease ball’s gone And now they’re going to feel better, but we’re not thinking about what does that feel like on the soft tissues when the animal’s walking yes, they’re out there running, but if you look at them run, they’re not really extending their hip It’s just sort of a long for the right so their actual gait and function is not normal and they’re just compensating because they likely are uncomfortable.

Dr. Andy Roark: Yeah, that totally makes sense. All right. This is that you broke that down really nicely. That all makes sense to me. Talk, talk to me about the total hip now. What can we do with total hip replacements that we weren’t able to do 10 years ago?

Dr. David Dycus: Yeah, we can put a total hip in the smallest of small dogs and cats all the way up to the largest of large dogs. And the interesting thing is, is years ago, we used to say, Okay, we have to use a total hip at the very end point. We got to do all these things and then do a total hip replacement. And then we would take the eight year old German Shepherd that’s had trouble for the last four years, we would put a total hip in them, and then all of a sudden this dog is out in the backyard running again, going on hikes with the owner, and the owner’s this is a new dog.

And so then we thought, Why are we making them go through all of this to give them a happy hip? And it was because we thought they’ll outlive their implants. We would have to come back and do it later, but we were basing those decisions on what they do in people, but people live 70, 80, 90 years. So what we’ve discovered is because dogs don’t live 70, 80, 90 years, we could put a hip replacement in a young dog and that hip replacement will be good for the life of the dog.

And so in the way I do this is the way I look at this. Is if I have a six or seven or eight month old dog come into me, that’s an excruciating pain. I’m sure we’ve all seen those. They’re hunched in the back. They’re extended in their hocks. They don’t want to walk. You try to move the hips. They’re screaming.

You try to get x rays. You can’t really get x rays. You put them under heavy anesthesia. You get x rays. And then it just looks like the ball of the femur has never even communicated with the acetabulum. They are in opposite territories. We call those luxoid hips. So in those dogs, what I look at is saying this dog needs a total hip now.

And so the youngest we’ve done is six, seven months of age. Ideally, the time frame would be like 10 to 12 months of age. But if I have a dog that is, say, two or three, And we’ve never seen an issue. The dog has been great and then all of a sudden comes up acutely lame And then we take x rays of the hips and the hips look bad I’m, probably not going to jump to a total hip replacement in that dog because number one, we have to remember that dogs with hip dysplasia and hip OA don’t come up acutely lame So we got to make sure they didn’t tear their cruciate ligament first but if I truly think it’s the hip then I’m going to say, okay, this dog’s had hip arthritis, but now they’re painful.

Why are they painful? likely because they’re in an arthritic flare up. So I’m going to do things to get the flare up under control. And if that’s successful, then we’re going to ride that wave. But if it’s not successful or they, have a repeat flare up kind of over and over and over rather than reinventing the wheel then we’ll say okay We’ll probably move to a hip replacement at this point. So, I sort of you know again on the total hip thing Look at the breed look at the age look at the clinical signs look at what’s been done and that’s why if I had the eight or nine month old dog with really severe hip pain.

I’m not going to do pelvic osteotomy. I’m just going to put a total hip in them because if I do a pelvic osteotomy, they might feel good, but then there’s a chance I might have to put a total hip in them when they’re four, five, six, seven years of age. And it’s why do two surgeries when we can just do one surgery?

And so that’s sort of where my thought process has gone for the surgical aspect of things, but I really think we have to look at the patient in front of us, look at the age, look at the clinical signs, look at the radiographic findings and then we also need to have a discussion with the owners as far as what expectations are, what are their financial means, you know, if an owner is strapped for cash I’m not going to say, well, let’s do an F.

H. O. I’m going to say, let’s take your funds and let’s do all these things from a conservative standpoint to get your pet more comfortable and improve range of motion and then we’ll keep doing these things. As needed, but if we hit a point where that’s not becoming effective, then we might have to say, okay, have we been able to save up over time for total hip?

If we’ve been able to throw some money into a savings account for that, or are we at a point where we need to do an FHO? But rather than doing that FHO on the front end, because I don’t want to cripple that dog, when they’re two rather than doing some other things to improve hip extension.

Because what I will say is the young dog that comes in with the acute lameness, that’s not a cruciate tear, that has hip pain, that’s in an OA flare up, we can usually get that OA flare up under control and get them right back to doing the things that they were doing before they started limping without doing an FHO.

Dr. Andy Roark: Yeah, David. Would you be up for coming back and talking about conservative management for a hip dysplasia?

Dr. David Dycus: Yeah. Any time. Absolutely.

Dr. Andy Roark: Wow, we’re gonna make that happen. David, you’re amazing. Thank you so much for being here and walking me through this. I just, I’ve got so many notes. I came out when the total hip replacement was the, it was the last thing.

You know, it was like, oh, if all else fails, we can replace the hip. And so this is such a perspective shift. I just, it makes tons of sense. I really appreciate it. David, where can people find you online? Where can they learn more about you and what you’re up to?

Dr. David Dycus: Absolutely. So for the those on social media, my Instagram is Ortho_Vet. My Facebook is Dr. David Dycus. You can check out my website at www.drdavidycus.com. And then for the new hospital Instagram and, and Facebook are both Fusion Vet Ortho.

Dr. Andy Roark: David, thanks for being here. Guys, thanks for tuning in. Take care of yourselves, everybody. I’ll talk to you soon.

Dr. David Dycus: Thank you. 

Dr. Andy Roark: And that’s what I got. Thanks to Dr. David Dycus for being here, guys. I hope you learned something. Do not worry. I got David immediately scheduled and we knocked out the episode on managing medically Hip dysplasia. And so that is going to be coming down the pipe. Stay tuned to the Conor Shane Veterinary Podcast.

I’ll probably sped it out a little bit, like I love this stuff. I’m super excited about it. I think there’s people who generally like to kind of mix things up a little bit. In the next couple of weeks I’ll drop that episode. I can go ahead and tell you right now is real good. If you enjoyed this episode, you’re going to enjoy that one and it’s coming soon.

Anyway, thanks to David for being here. Guys, if this episode was good for you, if it was helpful, please leave me an honest review wherever you get your podcasts or comments below. Text it over to your friends. Make sure the other doctors get to see it. You know, we’re always trying to help people. I just, I love making stuff like this.

I started this podcast so that I could continue to learn and boy, have I gotten a lot out of it. So anyway, gang, take care of yourselves. I’ll talk to you later on.

Tyler Grogan, CVT and Creative Marketing Director at Uncharted Veterinary Conference, is on the podcast today to discuss transitioning out of practice and what it means to walk away from what you consider your “life’s work.” In this episode of the Cone of Shame Veterinary Podcast, Dr. Andy Roark and Tyler share personal experiences and reflections on leaving clinical veterinary work, struggling with identity, and redefining success. They also dive into the emotional complexities veterinary professionals face when stepping away from practice. This episode provides valuable insight for those looking to transition into new roles while staying connected to the veterinary profession.

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

LINKS

Tyler Grogan on LinkedIn: https://www.linkedin.com/in/tyler-grogan-63247a192/

Uncharted Veterinary Conference & Community: https://www.unchartedvet.com

Leadership Essentials Certificate: https://unchartedvet.com/certificates/

Charming the Angry Client Course: https://drandyroark.com/charming-the-angry-client/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Tyler Grogan is a Certified Veterinary Technician with experience in specialty, emergency and general practice. She currently serves as the Creative Marketing Director for the Uncharted Veterinary Conference where she focuses on brand building, marketing, storytelling across multiple digital platforms, and exploring new ways to elevate the client experience.

EPISODE TRANSCRIPT

Dr. Andy Roark: Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host. Dr. Andy Roark. Guys, I am here with my friend Tyler Grogan. She is a CVT and she works for me at the Uncharted Veterinary Conference and we are talking about what happens when you are done with your life’s work. And so Tyler’s got a great question here that came from one of our community members in Uncharted.

And it’s, it’s a really good philosophic discussion about phases of our life and what happens when we don’t want to do the thing that we’ve been doing in the past. And the guilt that a lot of people wrestle with when they say, I, I want to leave. I want to change. I want to. to try something different, but I feel like I’m giving up on the legacy I’ve been trying to build, or I feel like I’m quitting on a field that I was called to.

And anyway, we get into all of that. This is a really interesting conversation. I hope you guys will enjoy it. 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 Tyler Grogan, CVT. How are you?

Tyler Grogan: I’m great. How are you Andy?

Dr. Andy Roark: I’m doing really well. It’s always good to see your smiling face, which I get to see quite regularly because we live in the same town and you, you work for me. And so that, that makes us see each other quite regularly. So for those who do not know you, you are the Creative Marketing Director at Uncharted Veterinary Conference.

What does that mean? What does that entail, Tyler? What does that mean?

Tyler Grogan: You know, I do a little bit of everything, Andy. A little bit of promoting our events and telling people what we’re doing over at Uncharted. I help out with our events when we put them on, creating stuff on our social media, all kinds of things like that, writing newsletters. So yeah. A little bit of everything. 

You’re 

Dr. Andy Roark: doing, you’re doing a bit of speaking these days and you are actually doing really good stuff. Now you’re blushing. You do really good. You do really good lectures. You do really great lectures on the customer experience, I think is sort of your area of expertise. I think it’s, it blends in with the marketing work that you do, but you do very cool stuff on engaging your clients as they come into the building.

You do work on queue theory, which is the science of getting people to enjoy waiting and lots of really interesting stuff. That I just, I love. I don’t think anybody else is talking about it. And so, anyway, you do, you do excellent work in a lot of different areas. And, you’re also writing a bit. And you wrote something that really, I thought was very interesting.

And I have not seen other people talking about it. And so let me pause here and just open sort of the floor to you for a second. Why don’t you sort of talk about the piece about the end of our life’s work.

Tyler Grogan: Sure. one of the things that I do over at Uncharted is our community newsletter. So every month our members get a newsletter from us. And a few months ago I was encouraged to write for it. So I started writing and

Dr. Andy Roark: You were volun-told, I think is the

Tyler Grogan: I, yes,

Dr. Andy Roark: I think is

Tyler Grogan: well, I wasn’t going to call you out on the podcast that you run, but yes, you volun-told me to write more.

So, I started writing these letters from the editor and every month go into the community and look for some things that people are doing and share kind of their wins and their trophies and also just see, you know, what everybody’s doing that’s great in their practices. And there was one post that came out this past month that I recognized someone was struggling with.

This idea of selling their practice or moving on from being a practice veterinarian to pursue other things and there was a kind of a feeling of guilt it seemed like in the post and that really struck me because I remember when I left practice and started working full time with uncharted. I had a really hard time dealing with the idea of not being a vet tech, not being the person on the floor handling the pets.

And what did that mean about my identity and my role in veterinary medicine? And so I could really resonate with perhaps what she was going through. So, it just gave me this thought of what does it mean when you’re done with what you considered was your life’s work? I mean, I’ve never been a business owner or a practice owner, so I can’t directly relate, but I can imagine dedicating your entire world to building this business.

And then considering walking away from that or working in it in a different way could be scary and a really big question to answer. So what do you do when you’re done with what you considered your life’s work?

Dr. Andy Roark: Yeah.

Tyler Grogan: So that’s where it came from.

Dr. Andy Roark: It’s I love that. I think that’s really interesting. And I, it’s funny, I get a lot of private phone calls about this. It’s not, you know, not, people don’t raise their hand at lectures or anything and ask me about it, but I get a lot of questions because I’ve done a lot of different things in my career, I think, and so people say, well, Andy’s, he has done things and then done different things, and, you know, when they’re kind of looking at ending a chapter, I get those phone calls sometimes, and it’s, it’s funny, I’ve thought, I’ve thought a lot about it, I think, I think there’s a couple pieces to this, I think that, I think you put your finger right on it at the beginning, Tyler, I think that, There’s a couple weird things about vet medicine that I don’t think other industries have and I think the identity aspect I don’t think happens so much in other other areas like I don’t know that people see themselves as a barista. 

Tyler Grogan: Like, I’m an insurance provider.

Dr. Andy Roark: exactly right. I mean, it totally, and like, I am actually blown away sometimes when I talk to people who are not remotely defined by their career. And I, I have tried hard to not let veterinarian define me as a person. But it’s a constant battle because it’s, it’s, I always say, it doesn’t define me.

And then I’ll meet new people. I’m like, Hi, I’m Andy. I’m a veterinarian. Because I know that they’re going to like that. It’s going to make them happy. And they’re going to want to know me. And like, I say it and it’s just. It reemphasizes this idea of like, this is who I am as a, as a person. And, and I don’t know the other, the other people have those, have those thoughts.

I think, I think also there’s the calling. And so, you know, I don’t know, I think there’s some, some vet techs that feel this way for sure, but I think it’s, it’s definitely heavy on the doctors. People say vet medicine is a calling. And if you buy into that, it really does feel like leaving is a failure of some great, like, spiritual call that you’ve had.

You know, you’re like, I was called to vet medicine. And I got tired of it and decided I was gonna go into, you know, into pharmaceutical sales. And it just feels awful. I’ve always kind of pushed back against that idea that, that medicine is a calling. And some people really don’t like when I say that because I speak so lovingly of that medicine.

But I could, two things can be true at the same time. You can really like that medicine and also say, I don’t, I don’t feel like it’s a calling. I feel like it’s a job and it’s something I’m happy to do while I’m doing it. But I think a lot of people really struggle with that.

Tyler Grogan: I completely agree with that. And you know, I was definitely one of those people, you know, walking out of practice. I felt like I suddenly wasn’t fulfilling some greater purpose. Like it almost felt like I was abandoning something that was bigger than me. And, I remember sitting with that for awhile and thinking about, okay, who was I before I worked in a veterinary practice?

And like, what are the things about me that define me beyond that, that title? And I’ve also had conversations with people that work in different, in veterinary medicine, but in different countries and their perspective on work in their life is such, it can be so different and their definition, they do really care and are very dedicated to this profession, but they’re also talking more about the things they do outside of that, like their role in their community. The things that they’re active within their community doing, maybe gardening and the local community garden, or, you know, the things that they do with their families or talking about their families.

And I think that there’s just kind of a different perspective and When I thought about this person that I, I know relatively well, thanks to Uncharted being such a tight knit community, I know her for who she is more than I, like, I’ve never worked with her in practice. So I know her as a person and the way that she, she has impacted me in my life,

as a person outside of veterinary practice. And so I think it’s really easy to forget that you have a purpose as a person outside of the context of the walls of a veterinary practice, like how you impact people is so much beyond, like it grows so far beyond that. And then the article that I wrote, I talk about, you know, Was your goal, what was your goal in starting this in this business or starting your practice?

Was it to create a space that you could have medicine be practiced in a way that you felt was good for the animals? Did you want to create an environment for people that also love to practice medicine and that they would want to stay and they would have a lifelong fulfilling career there because as you walk away from that that is still probably true.

You probably created exactly what you were aiming to create. And just because your hands on involvement may change, it doesn’t necessarily mean that it’s not part of who you are anymore. And so there was just so much to, to dig into there. And, and like I said, as a person she’s had a great impact on me in my life.

And so it was just really interesting to think about that. She didn’t see the impact she could have in the same way outside of her practice.

Dr. Andy Roark: Yeah, I think, I think you really put your finger right on it. I, I’m guilty of looking at things like a practice and saying, yes, this is the mark I will make on the world. You know, like, this will be my legacy. And, and you, you look at that and it, it feels like a tangible thing that you need to have.

Like, I need a gold watch from doing 30 years in this, you know, organization or whatever. And, as the world has changed the idea that any of us are going to stay in a job for 30 years is, you know, it’s not as common as it used to be. Now, if you, if you own the place, that can be a little bit different, but for most of us, you know, we’re getting more accustomed to the idea of having multiple jobs and not having one thing.

And so I, I think that that’s, that’s important for the changing state of the world. I think you’re spot on in this idea. A lot of us look at a thing and you say, I’m going to be a house call veterinarian and I’m going to serve this community and that will be my legacy. I am in it and I’m going to do it for the rest of my career.

And then you do it for 15 years and you say, well, I, I’m, I’m, I’m ready for something else. And. If you have tied your legacy to this house call business, walking away from it feels like quitting. It feels like abandoning the legacy that was so important to you. And so I, but I think that that’s a mental trap.

And I think you, you put your finger right on it. The idea that your practice or your time in practice is your legacy. It’s a mental fallacy. I think what’s exactly right, Tyler, is what you said of it is. Why did you start this practice? What did you hope to accomplish? What was your goal in starting it?

Because you can set down that practice and walk away and continue to pursue that goal. And thereby your legacy becomes, I want to have this supportive impact on my community. And I’m not going to do it with my house call practice. I’m going to do it in other ways. I’m going to go and partner up with another group of doctors and do something different, but I am still pursuing the goal and making that legacy true.

And now I’ll say I have served my community for 15 years as a house call veterinarian, and then for 10 more years as a co owner of the emergency hospital, and then blah, blah, blah. And you put together this really great resume, and I don’t know what great resume means in this context, but you put together this resume of continuing to pursue your goal, continuing to make a difference, even though the housecall vet chapter of your life has closed.

But I think, I think, if you don’t break the, what was the point with all of this? Was it really to have a big building and a sign that people recognize? Or was it to do something great? If, if you break that point out, I think that that’s really the key, and I think you can carry that key oftentimes into retirement.

I think a lot of people who are just like, you know, it’s not even about shutting down what I’m doing and doing something else. I think for a lot of people going into retirement, they really do kind of have to figure out what their why is and what pursuit of that why in a different way looks like. And it may just be being the most engaged grandparent that you can be.

That’s, that’s part of your legacy. It’s really, it’s probably, it’s probably one of the most important parts of your legacy.

Tyler Grogan: It’s so true. And I love what you said about, you know, this is a different way to serve your community because. We evolve, and I think this is something I’m, I’m learning more about myself, but we evolve as we age and get older, and our priorities shift, and the things that we care about shift, and then the beauty of veterinary medicine is that the people that come into practices are people that really care about what we do and there are people that by opening the door for them to have a different role in that space may give them the catalyst to do the next amazing thing that they’re going to do.

So, you know, stepping out of that role and allowing someone else to fulfill it or fulfill a different role within that community or that group of people, you know, it, it opens doors for everyone. And it also, you can shift and evolve and do different things. And you’re still growing and you’re still learning and you can still use it to, again, like you said, serve the same people, you know, still help the, if that was your goal from the beginning was to be someone that your community could rely on for the, this information and this care for their pets, it could be different.

It can just be different. Be something new and I think that that’s that’s so fun. I mean, I don’t get me wrong. You work with me you know well enough that I’m not always the most eager about change or uncertainty definitely uncertainty. So I might come off like I’m like change is great. Everything is super easy.

Like this is no problem. It’s definitely not and it’s not for me but it is, you know taking a step back and allowing yourself to have that perspective for a minute and just think okay, this could be really cool. This could be really fun. And the work that we do that we’re excited about is the work that makes the biggest impact.

You know, those are the things that really leave the mark or the things that you did when you were so in it and so in your flow and you were excited about it at the time. So it would almost be a disservice not to pursue what you’re excited about. Rather to stay in something that’s comfortable. So I have to remind myself of these things, like I said, on a regular and daily basis.

I think that it’s a good opportunity to step back and have a different perspective for a minute to let yourself not feel those feelings of, am I walking away from what my life was supposed to be? Because your life is so much more than just one thing.

Dr. Andy Roark: I think there’s also this, this idea. So part of it is, there’s this fear about the unknown. You know, you get quite comfortable in where we are. And that, and there, there’s fear about, about the unknown. Changing and moving in something else.

I think another way to kind of look at it is a lot of us have told ourselves that there is a finish line in our career. So when we say this is my life’s work and I’m going to walk away from this work, probably at some point we decided that this job, this, you know, a position, you know, whatever that was, that was the finish line.

I was like, I will get here and I will do this and my life will be a success. And then what always happens is you get there and you realize that it doesn’t make you a success in your own eyes. You know what I mean? Like you don’t feel any different about yourself now that you’ve been doing this for 20 years than you did when you did it for five years.

And you don’t feel any different about yourself now that you have this, I don’t know, this academic position at the vet school than you did when you were grinding it out in private practice. Like those that we tell ourselves this is going to transform me or this is going to make my life meaningful or this is going to, at least for me, it’s always been like I’m going to do this thing.

I’m going to accomplish this thing. I’m going to build this thing. And then I will have certifiable proof that I have been successful or I’ve made the impact that I wanted to make. And that, that, that transformation has never happened for me, and so I think that, that happens to a lot of us. I, you know, I heard a, a phrase, and I, I say this all the time, and you’ve probably heard me say it a million times, but, you know, Life is what you experience.

It’s not what you accomplish, it’s what you experience. And so, every day that we’re out there, In practice, your life is what you’re focusing on. It is on the actual doing of the work. And so I think it’s easy to say, Oh, no, I’m leaving my life’s work behind. And I say, well, but that’s that’s a thing that you did.

It’s not, one, it’s not who you are, and also, two, it’s not what your life was like as an experience. It was not, it was not the the process of being, if you will. And so I, I think that, that that’s sort of a construct that people kind of get, get sort of tied up in. And so I, I, that was just sort of the, the a big part of it for me is if you can get your head around the idea that your life is not anything that you leave behind, but is instead is the The sum of the experiences that you have along the way and when I say experiences I don’t mean like going on vacation stuff like that.

I mean, the experience I have if you and I are hanging out together and we’re riding a bus And i’m looking at my phone the whole time and scrolling on instagram. That’s my experience right like my life is a bus ride looking instagram And if I don’t have my phone in my hands and i’m talking to you about you know, what, what the end of a career looks like or what career change looks like and we’re having this, this back and forth discussion that’s, that’s, that’s really interesting and engaging and you and I are building our relationship and we’re thinking about things in different ways.

That’s my experience. That’s my life. And those are two wildly different experiences on the same bus ride. But that’s what your life becomes at the end of the day. Did you scroll Instagram all day? Because that’s the life you’re leading or did you engage with other people and talk to them about what’s important to them and feel like you grew the social fabric around you and you made these stronger relationships that, that they’re going to continue to, to be able to take joy in.

I just really think that, that life is the experience. I think that that can help you feel that your life is rolling on, even though you’ve left this big part of you behind. I think the last thing for me. I don’t know if it’s a good story or not, but it’s definitely something that happened in my life and it really affected me.

It’s just so silly when it’s just a simple conversation and the other person doesn’t even remember. But when I was in vet school, and all the way up until vet school, I really enjoyed watching movies. I was a movie fan. I just, I really, I just liked movies. I liked getting lost in the story and just watching movies.

Tyler Grogan: I’ve heard you nerd out about Star Wars a couple of times, so I had an idea.

Dr. Andy Roark: I just watched a bunch of movies. I watched a little art house stuff. I watched all kinds of stuff. I just, I really like movies a lot. And then Alison my wife, was pregnant. And and so we were heading for our first child, and I was at the end of vet school. And my mother in law, was talking to me about something and I said something like, Oh, you know, I don’t know these movies are coming out or there was a movie, you know, the release date was like the next year or something.

And I said something to her. And she said, well, you’re not going to have any time to watch movies after this. And she kind of laughed at me. And I, I remember being, angry, like really angry, like, how dare you, you know what I mean? I think I was probably afraid, like, because you don’t know what’s gonna happen when you have a baby.

And I was like, is this, is this gonna be the end of my movie watching? Like, it really scared me in that, like, I, I imagined something I love being just taken away from me. And I was like, oh crap. And then we had the baby. And the truth, Tyler, after that is, I just, I didn’t watch movies. But also, it was, I didn’t really want to watch movies. The truth is, I just wanted to go to bed. I was exhausted all the time.

Tyler Grogan: I can imagine.

Dr. Andy Roark: You know what I mean? And like, so it just, I, it just didn’t occur to me. And then we had, we just had other stuff going on. And it wasn’t like I was pining to watch movies and not getting to. It was, I just, that phase of my life of my, my girlfriend slash Fiancee slash new bride and I hanging out watching movies and going on dates like that that that we did that and it was great. But then that sort of phase of our life came to an end and then we had kids and things and it was hard to get out to the movie theater and it just so But I didn’t pine for it, it just kind of, that, that chapter ended.

And that was the first time I, I sort of started to realize and recognize, like, sometimes you have chapters in your life, and those chapters just kind of close. I saw, I saw this post in social media one time, it was this person, and I’m not, I’m still not exactly sure if they were in good faith or bad faith, but basically they were someone in their 20s, and they were asking the question of, hey, people who are 30 and older, what do you live for?

Like, you’re past your prime in every meaningful way. I know! They were like, you’re past your prime in every meaningful way. And again, how ridiculous was this? It was a person in their, probably late teens, early 20s, saying people over the age of 30, not 90, 30. And, again, I wasn’t sure if this person was in good faith or bad faith, but I was just kind of like, I can’t, the idea this person would say to someone in their 30s or 40s or 50s or whatever Why do you keep living?

You, all, the best stuff is behind you. I, I, and here I am with my young family, like, living the most rewarding phase of my life. So far, at that time. You know what I mean? And and the fact that this person who’s 21 who’s like, Psh, now that I can go to the bars, I guess there’s nothing left. And I’m like, you have no idea how you’re going to feel in five years.

You have no idea what you’re going to want in 10 years. You just, you don’t know. And the things that I enjoy doing, I get up early and go to the gym now, and I get teased about it. But, I did not want to get up early and go to the gym in my 20s. But now, I love it. It’s great. And if you told me that when I was 30, I would have said, You’re crazy.

Leave me alone so I can sleep because my child is distracted. It’s amazing. All that to say, it’s through these sort of a couple of experiences that I really came to believe. There are chapters in our life, and you might really, really want things for a certain amount of time in your life. And then that chapter comes to an end by external circumstances.

You just get older, and you tend to feel differently about things when you’re in different phases of your life. Yeah. And the idea that you would feel guilty because what you want in this new chapter of your life is not what you wanted in your previous chapter of your life. I think that’s, I think that’s sad.

And that, that whole chapter of your life thing, it has made me so much more open to change. And so much more I don’t know, just, just flexible when I look ahead and I say, Oh my gosh, the city of Greenville where we live. It’s beautiful. It’s booming, Tyler. Like, there’s people moving here all day, every day.

It’s, it’s gone from a town to being a tiny city, and like, it does not look like it’s slowing down. And I can go, boy, am I gonna wanna be here in ten years? And the truth is, I have no idea. In ten years, my kids will have moved out hopefully. And, you know, they might be, they might be starting families, and like, maybe I wanna be where they are.

Who, who knows? Maybe it won’t be a sad thing. I, I don’t know how I’m gonna feel. When we get to that point, but I talk about this because that, that, that phases of life, those chapters of life, I think that’s so vital to growing and being happy in different phases. And so when someone says to me, how do I put my life’s work behind me?

One, I go back to your point, which is, I think you should tease out the original goal and I think you could probably continue that goal and you will continue your life’s work even as you leave the thing behind. And then number two, I would say. You have chapters and phases in your life. And if a, there’s nothing sadder than someone who has gone on to the next chapter, but is too afraid to turn the page.

And it’s just, it just, it chains them down. And they’re not happy and they don’t enjoy these things they’ve made for themselves. And they feel like because they don’t enjoy them now, they must have been untruthful in the past. And that’s just not true. It’s just We change, and we grow, and we evolve, and these phases, I just think that they’re very, very real.

And so, anyway, for anyone who’s feeling sort of guilty out there about moving into a new phase, I don’t, I don’t, that, the phases of life has helped me a lot, just to say, Yep, I’ve done this, I was in practice full time for this amount of time, and then I did relief work, and I did that, and then I was the parent of two kids.

You know, babies and toddlers. And I, I did that. I’m not, I’m not there anymore. And when I see parents who were in that phase, I look back with nostalgia, but I ain’t confused. My, my teenagers are very, very different, and I do not have toddler problems anymore. I did that, and I empathize. And I, and again, I’m not interested in going back, but it was very rewarding when I was there.

Tyler Grogan: I think that that’s a really good point in comparing it. I mean, I have not been a parent, but I have seen, kind of, people go through the different phases of their child’s lives and how their lives evolve and change, and it’s so true that it’s a good comparison to make. And I’ll just, you know, say that, in terms of a career example, you know, if you had told me that you’d introduced me on a podcast one day, like first, let’s start there.

But second that I’d be, have just got back talking to people about queue theory and queue management. I would have laughed in your face because I would have said, how in the world does that even happen? Like, tell me how that world unfolds because I don’t understand. 

Dr. Andy Roark: You just came back from lecturing in Canada, like you were

in another country. International speaker coming back for a podcast.

Tyler Grogan: I’m working on them, inviting me to be, you know, a dual citizen. So, you know, because the mountains are amazing, but yes, so very fortunate to have had those opportunities, but you know, it’s because of random other parts of my life that those things that even came to be, that was just because of someone I knew that was outside of veterinary medicine, that it came to be, that that would be how I would start to speak.

So, you know, things happen that. You don’t expect they change the chapters of your life open and close. And I think you just have to, you know, walk into those moments and say, this is a good thing. Like, even if it feels scary right now I met, I’ve met so many veterinary professionals and especially technicians, but they’re like, I can’t, I don’t know anything else.

I don’t know how to do anything else. Everything you do in practice is transferable to life or to other careers. And you can do anything that you believe in yourself that you can, that you want to do. And so much of what we do is goes beyond the walls of the veterinary practice. So when you’re faced with that moment where you’re not sure you’re ready to walk away from being in practice or, or whatever it is, whatever part of your career, you’re ready to walk into practice.

If you’re not sure if it feels like the thing that excites you the most then go for it. You can totally you can do it. So I’m, very grateful for our community for being so vulnerable and honest with each other because it really allows us to have these conversations and you know to close i’ll say that this person received so much support and options and you know offers for people to call to talk it out people that have been in similar situations or maybe are also in a similar place. And it was followed by a post somewhat by someone else that’s working on post retirement writing stories about their life in practice.

And it’s been a great memory kind of jogging exercise for them. So I’m really grateful for our community for providing these conversations for us. Cause I mean, it’s, it’s inspiring to watch for sure.

Dr. Andy Roark: No, I agree. Tyler, thanks so much for being here. Where can people, where can they find you? And then where can they learn more about the Uncharted Veterinary Conference and Community?

Tyler Grogan: You could find me on LinkedIn or, you know, in the Uncharted Community. I’m usually most active there. Uncharted. If you’re not familiar, we we are at unchartedvet.com we put on virtual events and we also do lots of other things, and we have a podcast as well. So if you’re interested in that and uncharted @unchartedvet is where we’re at on social, so check us out.

Dr. Andy Roark: Sounds good. Thanks for being here, Tyler. Guys, thanks for listening, everybody. Take care of yourselves. I’ll talk to you later on.

And that’s what I got. Guys, thanks for being here. Thanks to Tyler Grogan for joining us. I hope you got something out of this episode. This is one of those episodes that I really, I’ve very much enjoyed thinking about when I recorded it. I have enjoyed thinking about it since then. I hope, guys find, find some value in it, or at least to stimulate some thought and discussion. So anyway, Take care of yourselves, everybody. I’ll talk to you later on. 

The DermVet, Dr. Ashley Bourgeois returns to help us navigate canine allergies. In this episode of The Cone of Shame Veterinary Podcast, Dr. Andy Roark welcomes board-certified veterinary dermatologist Dr. Ashley Bourgeois to discuss managing difficult canine allergy cases that don’t respond well to Apoquel or Cytopoint. Dr. Bourgeois offers practical advice on identifying hidden infections in claw folds, using consistent treatment regimens, and when to consider alternatives like skin biopsies or recognizing allergy mimickers such as autoimmune diseases or lymphoma. Tune in for insights on allergy testing, immunotherapy, and effective long-term strategies for managing atopic dermatitis. Gang, let’s get into this episode!

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

LINKS

Dr. Ashley Bourgeois: https://thedermvet.com/about

Dr. Ashley Bourgeois on Instagram: https://www.instagram.com/thedermvet/

Dr. Ashley Bourgeois on LinkedIn: https://www.linkedin.com/in/ashley-bourgeois-dvm-dip-acvd-9169208/

Exam Room Communication Toolkit: https://drandyroark.com/exam-room-communication-toolkit/

Charming the Angry Client Course: https://drandyroark.com/charming-the-angry-client/

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

ABOUT OUR GUEST

Dr. Ashley Bourgeois is a board-certified veterinary dermatologist passionate about providing practical knowledge to general practitioners to help itchy pets! She completed her bachelor’s degree at Iowa State University and graduated from the University of Missouri’s College of Veterinary Medicine in 2010. She then completed a one-year small animal internship at Purdue University. Upon finishing her internship, she accepted a residency position with the Animal Dermatology Clinic’s Tustin, California location in 2011. She became a Diplomate of the American College of Veterinary Dermatology in 2014. Dr. Bourgeois moved to Portland, Oregon in 2016 to help expand the company. She is an owner within the company and on the board of directors. She has a strong interest in autoimmune skin diseases, allergies, cytology, and otology. In her leisure, Dr. Bourgeois enjoys outdoor activities, traveling, and watching sports. She and her husband stay busy with their daughter, son, and rescue Lab/Boxer/Pit mix. Dr. Bourgeois is passionate about educating veterinarians in dermatology and work/life integration through her podcast, lecturing, and social media presence (The Derm Vet).

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 good one here. I am with my friend Dr. Ashley Bourgeois she is a veterinary dermatologist, and we are talking about allergies when Apoquel doesn’t work. That’s right, if you’ve been in practice for a while, you’ve seen those cases roll in, and you’re like, Oh, we tried Apoquel, we tried Cytopoint, and we’re still, we’ve still got an itchy dog and I talked with Ashley here. She’s got all kinds of pearls and insights and we walked through what do you do with these cases? is a fantastic episode. I hope you’re gonna get a ton out of it I got a ton out of listening to Ashley break it down, And so anyway, 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. Ashley Bourgeois how are you?

Dr. Ashley Bourgeois: I am doing so good. We are actually going to talk about one of my favorite topics today. So I’m just so excited to go through this journey with you today. 

Dr. Andy Roark: I love when I have brilliant people on the podcast, and I take them problems, and they’re like, this is one of my favorite things to talk about. 

Dr. Ashley Bourgeois: But I’m a dermatologist I like, I could say that about any topic, but this is such a common issue. I can’t wait to shed some light onto it.

Dr. Andy Roark: Oh, yeah, what we want to talk about today, and sort of what I went to you with, is, Ashley, what are your, what are your tips and tricks for treating the canine allergy patient who’s getting Apoquel or Cytopoint and it’s still not cutting it? And so I’m thinking of the case, let’s say we’ve sent home flea and tick preventative and we have, you know, tried to, treat these allergies in the classic way, and they’re getting Apoquel or Cytopoint, things like that.

And we’re still having issues. I think a lot of times people kind of look at their hands and go, Oh boy, you know, what do we need to do here? What do we need to do here? I’ll tell you. I always have a panic moment at, at that, at that, at that point. Not that I don’t have other tools, but it’s almost like, oh, my go-to move isn’t working.

And and I, I need to, I need to walk this back or, or try to approach this differently. So let me just pause there and kind of turn it over to you and say, how often do you see. Allergy cases that make their way to you that are getting sort of what you consider to be quality Sort of top line therapy and you’re still seeing breakthroughs.

Dr. Ashley Bourgeois: Yeah. I think it’s a bit of a double edged sword because let’s say it’s typical for me to get that history where the client comes in and says that, right. But I’d say the two things I see, if that is not true, let’s say like the client comes in with that impression, maybe the veterinarian has that impression.

But I kind of get to the point where I’m not really sure that’s true. I’d say there’s two, two fold one for sure. Flare factors. So like things aren’t infection aren’t controlled. So we see oftentimes where if they do break out with Malassezia or a pyoderma, you know, interdigital spaces, claw folds, claw folds are huge.

When I lecture about cytology, it’s one of the best things you could be doing. Is getting a toothpick, scraping material out of that claw fold. If you have a dog that’s looking and chewing their paws incessantly, but when you look at the paws, they don’t look that bad. Check those claw folds. Malassezia, infection, bacteria really like to hide in there, and they can look pretty darn normal, and then all of a sudden you’ll find a bunch of stuff hiding there.

Dr. Andy Roark: You’re not seeing you’re not seeing kind of pus crusty stuff around the the edges there? You’re not seeing hair loss anything like that?

Dr. Ashley Bourgeois: You can be, you don’t have to. I mean, especially if they have long coats. Like a lot of times I have pictures where they look totally normal. You flip back the claw fold and there is stuff in there or you flip back the claw fold. You don’t see too much, but then when you get a sample, there’s actually quite a bit of infection that’s hiding in that tissue.

So they don’t have to necessarily be lesional, but I always check those areas. I’d say the second kind of, it didn’t work, but actually I think it maybe could, is not consistent. So, Apoquel is a great tool, and I think as a general practitioner, you probably get away a little bit more with, Oh, let’s just do two weeks and you can stop.

But when you keep doing the two weeks and stop, two weeks and stop, two weeks and stop, and the dog keeps breaking out, then they come to us and I’ll say, well, have you just given it consistently? And they’ll say, no, I’m like, well, you might be a dog that just needs it consistently. So I think those are probably the more common things I see.

Now there can be true statements to that. I’ve certainly had cases that don’t respond. You know, I am managing the infections. I have them on the flea control. We’ve done the diet trials. Like they truly are atopic. I don’t have a flare factor present and they’re just not responding. No medication is a hundred percent.

So certainly there are some difficult cases. And that’s when I start thinking of either alternatives or I’d say the flip side is, is it actually allergies? Because sometimes we have allergy mimickers that can present as well. 

Dr. Andy Roark: Okay. Tell me tell me more about that. What what are your what are your top allergy mimickers?

Dr. Ashley Bourgeois: So I would say some of the main mimickers we think of are either like autoimmune or neoplastic. I think when we talk about, say, like, pymphagus, right? Because that’s the one people always think of. They think, oh, it has to be the dog coming in where the nose is completely crusted and depigmented and their paw pads are completely crusted.

But if you think about it, pyoderma, what does that look like? It can be colorette, scaly, but it can also be crusty. So when you get some of these pymphagus cases that their mucous membranes aren’t affected, you know, they are just kind of crusty throughout the trunk. And we don’t do cytology. We don’t identify like, oh, there’s not an infection causing that.

They actually can look a lot like allergies. And then I would say one of the other big ones, and it’s going to sound crazy, but it’s so true. And we see this a lot is skin lymphoma. Skin lymphoma can do anything from being detrimental. You know, completely eating away the skin ulcerative. They look awful to a focal area of erythema and scaling.

I mean, it really can be pretty mild in some of these early cases. And a lot of times our till for that is it has started when they’re older and they haven’t really had a history of dermatologic issues in the past.

Dr. Andy Roark: Okay, so old dog with a lesion and that’s, that’s not, not normal for this dog. You would have like cutaneous lymphoma on your, on your list. Are you going to see anything on that with, with cytology, like just regular skin cytology? Are you going to pick anything up or no?

Dr. Ashley Bourgeois: You can. So a lot of times you will pick up these neoplastic cells. And what I try to tell general veterinarians, because some of them will be like, well, I don’t feel comfortable saying that. Yeah. 

Dr. Andy Roark: Oh, I definitely don’t want to say that.

Like, 

I’m like, ooh, we need to send this out and get, get a second, get a second opinion on this.

Dr. Ashley Bourgeois: and you totally could. And what I would tell you as a dermatologist is, I don’t really care if you would say, Oh, I’m Andy Roark. And I feel like this looks like cutaneous lymphoma. Like what I care about is that you can say that’s weird, right? Because if you can even say that’s weird, like that happens to me all the time, you know, I’m a dermatologist, but I’ll look at something.

I’m like, well, that’s weird. Okay. But at least I know my next step should be, well, you know, I can’t, I shouldn’t probably refer, I mean, I could refer to someone else, but it should be me, but you would refer or you’d biopsy. Right? So like you could at least say, okay, well maybe we don’t just throw apoquel at this case.

So to me, there’s a ton of value in that, even if you’re not confident to say. This is an autoimmune disease. You can say, well, there’s not bacteria here. That’s pretty weird. So now what do I think about in this case?

Dr. Andy Roark: Have you got any pearls for me on skin biopsies? I mean, they’re pretty, they’re pretty straightforward. I do love, I love a, I love a punch biopsy. It makes me feel so cultured. I don’t know. It works well. It tends to go well. I know what I’m doing. But I, if, if another doctor turned to me and said, Andy, I hey, you got any concerns about me biopsying this weird spot?

Is there anything that should be on my radar, or should I say, no, go for it?

Dr. Ashley Bourgeois: Yeah, I’d say multiple things. I would collect cytology first because if it’s severely infected, you’re probably better off trying to treat that infection first, because if there’s just a rip roaring bacterial folliculitis, you’re going to get a biopsy that says there’s a bacterial folliculitis. And that’s not going to be that helpful.

You know, other basic stuff is if there’s diffuse lesions, you know, you should be getting multiple sites. You should not just be taking one site if there is diffuse. And it’s not just like a mass you’re taking off. You do not want to sterilely prep them. So I think surgeons probably lose their mind when they walk by a dermatologist biopsying them.

Right. Cause we want the crests. Like sometimes that’s how you get your diagnosis. So we are almost never sterilely prepping unless we’re removing a nodule or mass, but. Or we’re doing a tissue culture, but for just a run of the mill histopathology, we’re actually getting the crust. We’re getting the nasty stuff with it.

And then just making sure that you’re getting bigger punches. So we shouldn’t really be taking two millimeter punches. Like we should be doing more like eight millimeter punches if we’re doing diffuse disease.

Dr. Andy Roark: Not sterilely prepping the area feels like sacrilege. But I mean, I know, I know I’m supposed to do it, but I feel people looking at me like, are you just gonna, you’re just gonna. Do it like that and yeah,

Dr. Ashley Bourgeois: Just come spend a day in derm. Like, I mean, we are just like, you know, crust and nasty and like I said, the surgeons probably lose their mind because we’re just like not sterilely prepping. And I will tell you, I biopsy all the time. I’ve just done derm now for like 13 years. None have ever been like, Oh my God, you cause this patient to be septic

cause he took a skin biopsy. Right. Cause I’ve done cytology. If there’s infection, I’m probably going to treat them anyway. But you’ll, you’ll be 

okay. 

Dr. Andy Roark: That totally makes sense. 

 Hey guys, communication is key to creating amazing experiences in the clinic. From the phones to the front desk, to the exam room. The way our teams interact with pet owners makes a difference. The team training bundle I have drandyroark.com brings together my Charming The Angry Client and Exam Room Communication Toolkit courses to provide flexible on demand communication training for your veterinary practice. Check them out. 

These courses are made to be taken. in groups, they have discussion questions. They are all about taking these trainings and getting them to apply to your practice, your culture. And your clients, whether it’s handling angry clients. Or being effective in the exam room. We’ve got some great training resources that you can grab and drop and use pieces of. 

They’re all broken up into five minute modules to make it super easy for you to use what you want and skip over what you don’t want. Tag them onto the end of staff meetings, or just make a whole staff meeting out of the trainings. Anyway, super flexible. It’s drandyroark.com/team-training Gang, 

let’s get back into this episode. 

Dr. Andy Roark: We’ve laid down a lot a lot of different possibilities here, but we’ve got something. We feel like it’s it should be resolving and it’s not we’re digging in the nail beds Which I think is a beautiful little pearl i’m going to put in my pocket and keep for sure we’ll move towards skin biopsy thing things like that. Are there are there anything that that pet owners should be aware of is there anything that I should

you say to them about where this treatment path might go so that they’re prepped?

Dr. Ashley Bourgeois: Yeah. I mean, usually when I’m giving, so let’s assume it is an allergic case, right? Like it’s not a mimicker. It’s truly an allergic case. That’s like not responding. I certainly talked to owners about, I kind of break it into two options. If I’m managing atopic dermatitis, one is symptom treatment.

And I break that into infection control because we know. We have to control the infection or the itch won’t fully resolve. And then my second kind of symptom control category is the allergic itch itself. And when I do that for dogs, I write Apoquel, cytopoint, cyclosporine and steroids. The reason being, apoquel and cytopoint have been amazing tools for us, you know, you can certainly use them together, you can do all sorts of things, but again, no medication is 100%, so we certainly have cases that do not respond.

They’re allergic, they’re not a mimicker, we’re managing infection, they don’t respond. And you cannot forget about those other possibilities. And I would say I still have cases that respond better to cyclosporine. It’s a more broad spectrum anti inflammatory. It’s certainly something, especially with our crazy pododermis titus cases, things like that, where they can still respond the best.

So just because they don’t respond to apoquel or cytopoint, you know, they’re allergic doesn’t mean you have no option. And then sometimes we do end up with steroids. Like we try not to. You know, but again, if the reality is they didn’t respond to anything else, then we got to still provide comfort. And then I’m also pushing my second category of managing allergies is pushing allergy testing and immunotherapy, especially if they’re a younger, middle aged dog, right?

If they’re not responding to apoquel cytopoint, like what is the next 10 years look like for that dog? We’re going to have a better chance to desensitize them earlier in the disease process if we can.

Dr. Andy Roark: so I got a couple questions here. So when we’re talking about apoquel cytopoint, cyclosporine, steroids What are your feelings about overlapping these? Are you trying to kind of? say we’re not getting the results that we want. Are we adding in something else with the idea that we may keep all the things?

Or are you going to add in something else and maybe wean off of one of our earlier treatments? Are you, so yeah, talk, talk to me about that is, I don’t want to end up, you know, throwing everything in the kitchen sink at this problem, especially if we’re not getting results. But I always wonder, you know, if I take this dog off of Apoquel to try something else, am I gonna, am I gonna make things worse?

How do you sort of assess what to do with that crossroads?

Dr. Ashley Bourgeois: Yeah, it is a very good question. I’m very individual in the case, but I agree with you. So if I started a dog on let’s say we, for that particular case, we started with Apoquel. They recheck with me and let’s say like, they’re like kind of better, but it’s not a hundred percent better, and I want to try Cytopoint.

I usually have them still give a few days of Apoquel initially. After I give the Cytopoint, a lot of the studies show within three days is when you usually get that response, like a bit over half within a day, see a response. The nice thing about Apoquel is you can start, stop it, right? So I usually say, give it a few days.

If you’re starting to notice the pet’s doing really well, try to stop it and let’s see what happens. So I give them the freedom to do that. If we’re starting something like Cyclosporin, if they were on Apoquel, you can very safely bridge the gap. Like, you can keep them on Apoquel because cyclosporine doesn’t act really quickly, right?

It can take a few weeks, a month to work. So you can still safely keep them on Apoquel in that time if you need to. A lot of times I am using like low dose steroid as I’m bridging them to the cyclosporine as a way to provide some comfort. But that’s why the rechecks are important, right? Cause I want to check in and if the dog’s doing awesome, I’m with you.

I want to try to take things away. Like I already have a lot of my patients on a lot of things. I always want to try to take things away, but I also want to see them, evaluate them to make sure they’ve responded the way that I want.

Dr. Andy Roark: How often do you recheck these types of cases, Ashley? Are you getting them every week or is it a sort of a longer, do you have a tapering where you’re like, I’ll see you in a week and then two weeks and then it’s to go from there? Like, how, how is that?

Dr. Ashley Bourgeois: Yeah, I mean, we actually don’t usually see them back within a week, unless it’s like a rip roaring crazy ear or, you know, like, I think you’ve got some terrible autoimmune disease and I’m just treating the infection to know when to biopsy you, but for an allergy case, at least for me, I would say pretty typical is like, I try something, have them come back three weeks, maybe four weeks.

A lot of that’s very dependent on infection. But if it’s just your response to a medication, yeah. Then usually if I’m going to start on Apoquel, you know, I may do the twice daily for 14 days and then drop down. But I always tell people to let me know if things are not improving and we could try to get them in sooner.

But I give them a bit of time and just don’t want to frustrate the owner if I’m trying to jump the gun a bit quickly and see them that soon. So I would say usually like three weeks is fairly typical, maybe four if we’re not dealing with a bunch of infection.

Dr. Andy Roark: I know that you’re a big fan of allergy testing and immunotherapy in cats. How big are you on this, in our canine patients? So, just, just in us talking, you know, we’ve got a pretty good list of medications that we go through, and then you kind of felt like you added on allergy testing immunotherapy as a sort of like, man, if there’s nothing, if that doesn’t work.

Then, then let’s talk about this. Is that, is that really how you kind of feel or should we be thinking about immunotherapy earlier in our canine patients?

Dr. Ashley Bourgeois: Ooh, I’m really glad you’re asking us to differentiate this cause I’m going to not want to give that impression. I am an advocate to allergy tests whenever the owner is willing. So I love a dog that comes in. It doesn’t happen often, but I love a dog that comes in. They’re doing well on their symptomatic treatment, whether it’s cytopoint cyclosporine, whichever one is working for them.

And they are coming because they, they know it’s a young dog. They want to try to minimize drugs long time, and they want to allergy test them. That is actually most of our dreams as a dermatologist. It doesn’t happen very often. Usually it’s, Oh, this worked. And until it did it, and now you should go see them.

But we absolutely, if owners are willing, we are a hundred percent. So happy to allergy test them at a, at a young age, or even when they’re symptomatically doing well, just to see if we can get ahead of it. Remember, this is a progressive disease. So just because they’re doing great on apoquel when they’re three years old, doesn’t mean when they’re eight years old, they’ll necessarily be controlled.

We know that there’s a progression to it, and that’s what I try to explain to owners, too, is if they’re proactive, it gives us the best chance to try to keep that in control.

Dr. Andy Roark: How do you talk about immunotherapy compared to, you know, medical management in a way that sets good expectations? Like, I guess my idea is if I said to the owner as well, I can do this cytopoint injection or we can do allergy testing and then maybe immunotherapy, which is its own set of injections.

What do you want to do? How do you, how do you sort of explain that in the way the owner says, okay, I understand the investment immunotherapy and I would, I’m going to invest my time and energy there now instead of just taking the, the short term medical fix.

Dr. Ashley Bourgeois: Yeah, to me, it’s not necessarily an or, right? It’s almost an and, because the reality is if I allergy test them, Most of the time they’re on some sort of symptom control while we are giving that time to work. So I really try to have them think more of longevity marathon, you know, rather than like the sprint, the comfort now both are really important, but if we are trying to get ahead of the longterm aspect of this disease, none of us have a crystal ball, you know, if you knew that dog would just get cytopoint and be great the rest of its life with no progression of disease, Cool.

But we don’t know that. So ultimately I really tried to break down kind of that longterm aspect. And let me tell you this, not all of my clients allergy test. I have plenty that don’t, I mean, we love it, but we have to meet that owner where they’re at. And I know I can still help them even if that’s not the route they’re going to go.

But to me, what I tell them is these things can make them comfortable. It can still be tools in our toolbox. What I can do is try to identify what they’re allergic to, put it in a bottle, give it to them in small amounts, and basically see if I can teach their immune system to not react the way it’s reacting.

But that takes time and every response is different.

Dr. Andy Roark: No, that, that totally makes sense. Are there any final pearls, any last words of wisdom for people who are looking at some of these more challenging allergy cases?

Dr. Ashley Bourgeois: I would say for sure, like, control the controllable is one thing I like to say. So I know we have talked about this when we’ve discussed cats, but controlling the controllable means don’t forget the other things, right? The flea control, you know, being able to bathe these pets if they’re able to. There’s a reason you always hear dermatologists talk about multimodal therapy.

This is actually a very complex disease. We think of it being simple, right? Allergies, they’re itchy. You know, you know, we, you and I were talking about how we’re getting to be the older ones now. But when we first started practicing, we didn’t have apoquel or cytopoint. You know, that came out at the end of my residency.

So I did my years with not those tools. And so, you know, those things are, have been amazing. And I hope we keep getting lots of tools. But the reality is like we say multimodal because it’s a complex disease. They’re itchy. They’re skin barrier defects, right? Like. There is an abnormal immune system, their microbiome, we’re starting to learn more about.

So that’s why you often see dermatologists do all the things bathing and, you know, skin support and things like that. So definitely control the things that we can control because there’s a lot that we can’t control. And then certainly like going back to your point, if you are able to, I know not everyone has a dermatologist by them, try to refer them earlier.

You know, it is just nice to start with these cases before it’s been, Oh, well, now we’re eight and we have a methicillin resistant staph pyoderma, and we have to get through that and spend all the money there. And then we’re like, Oh yeah, we also could do this. And we’ve lost all those years to maybe get ahead of it.

Dr. Andy Roark: And the owners are tired and, you know, and they’re frustrated and they’re like, I just don’t want to deal with this anymore.

Dr. Ashley Bourgeois: Yeah. I mean, we set aside that time, right? Like we are usually setting aside longer appointment times. We don’t have the emergency hit by car trying to rush in the same day. So don’t get me wrong, like we’re busy and I know a lot of us have waiting lists. But ultimately like that is what we’re experts in and we have a better success rate if we kind of start managing them earlier.

I think people think I’ve heard even some of my local vets be like, well, they’re not bad enough. I’m like, I can see things besides train wrecks all day. I’m so happy to see the one year old boxer that wants to allergy tests, like bring them on. So I would definitely say like get to know your local dermatologist if you can, and do not be afraid to refer them earlier in the disease process.

Dr. Andy Roark: Dr. Ashley Bourgeois thank you so much for being here. Where can people find you online?

Dr. Ashley Bourgeois: Yeah. Everything I do is under the Derm vet. So I have a podcast that I put weekly tips on, and then a lot of social media that I put under the Derm vet, including cases and just day to day clinical tips. I really like to keep things real life for you guys, and hopefully you guys find that information helpful.

Dr. Andy Roark: That’s fantastic. Thanks so much for being here. Guys, thanks for listening everybody. Take care of yourselves. I’ll talk to you later on.

Dr. Andy Roark: and that’s what I got for you guys. I hope you enjoyed it I hope you got something out of it. Thanks to Ashley for being here. Thanks to you guys for being here. Take care I’ll talk to you guys later on

Dr. Chris Pachel joins us to discuss the complexities of integrating behavior health into veterinary practice. In this episode of the Cone of Shame Veterinary Podcast, Dr. Andy Roark and Dr. Chris Pachel dive into the challenges veterinarians face when addressing behavioral issues within the constraints of typical appointment times. Dr. Pachel shares insights on effective communication strategies, the importance of proper training for veterinary staff in handling behavioral consultations, and the potential benefits of leveraging telehealth for behavioral management. The conversation highlights the need for practical approaches to behavioral health in veterinary settings, emphasizing efficient client education and the strategic use of support staff.

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

LINKS

Dr. Chris Pachel: www.drpachel.com

Uncharted Team Leads Summit: www.unchartedvet.com/tls2024

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

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Chris Pachel is a board-certified veterinary behaviorist and is the owner and lead clinician at the Animal Behavior Clinic in Portland, Oregon. Dr. Pachel lectures extensively worldwide, teaches courses at multiple veterinary schools in the United States, and has authored numerous articles and book chapters for veterinarians and pet owners. He is a sought-after expert witness for legal cases and serves on the Editorial Advisory Board for dvm360. He is also a Vice-president of Veterinary Behavior for Instinct Dog Behavior and Training, as well as co-owner of Instinct Portland, which opened in the fall of 2020.

EPISODE TRANSCRIPT

Dr. Andy Roark: Welcome everybody to the Cone of Same Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am here with veterinary behaviorist Dr. Chris Pachel, and we are talking about actually getting behavior appointments done in vet practice.

Look, we all know that doing behavior in our appointments is important. Pet owners are interested in behavior, and they have tons of behavior questions and challenges. And, if you’ve done any work in behavior, you know that it takes time. It is not a magic wand.

You can’t give a behavior pill and just script it out and send it home. It is a process of working with people and giving them our time and focus and attention. And guys, a lot of us are shorthanded. A lot of us are really busy. We are trying to juggle a lot of things. So, oftentimes, People bring their pets in for one thing, and then, oh, surprise, here’s a big behavior issue right on top of it.

And I expect you to deal with both of them in this 20 minute appointment that we have. . This is going to be a good one. Let’s get into it.

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

Dr. Andy Roark: Welcome to the podcast, Dr. Christopher Pachel how are you?

Dr. Chris Pachel: I am doing fantastic, Andy. Thanks for having me on.

Dr. Andy Roark: I always enjoy having you on. I really, I’m glad you made it. For those who don’t know you, you are a Veterinary Behaviorist in Portland, Oregon. You are, you’re a busy guy. You have a lot of things going on. A couple of the things I will pull from the pile are you were at the Animal Behavior Clinic. You were also at Instinct Dog Training.

You have done a number of podcasts with me. You were lecturing. You were just, you were very, very busy. And so I appreciate you making time for me.

Dr. Chris Pachel: No, absolutely. The opportunity like this to really have a conversation with someone like yourself, to get into some of these meaty topics that we can cover in these little bite sized snippets. Ah, man, I’ll make time for that in my schedule every day.

Dr. Andy Roark: I always appreciate your perspective. I think you do a really good job. You’re, you’re a thinker. You, you are philosophic in your views and then also you take that philosophy and you translate it into very pragmatic action steps of what people can do or, or what we can say or how conversations can go smoothly.

And so I, I, I love to think about the implications of things and then, okay, what are we going to do about it? And I think you do that really well. And so that’s, that’s what I want to kind of come to you today with. I want to talk to you about behavior, animal behavior, behavior training in veterinary practices.

I love having you on the podcast. You and I have talked through a number of different cases at this point, I will tell you when I am out in the world and I’m sure other people in the vet profession will agree to this. The number one behavior, or the number one thing I get asked about, you know, when people are like, Hey, can I ask you a question?

Behavior is number, is number one. How do I get my pet to stop doing this? How do I get my pet to start, stop jumping up on the countertop, stealing food, barking at the window, yanking me down when we go for walks? It’s the, the percentage of behavior. It’s probably 50 50 behavior and everything else.

Really? And people, they want to talk about their pets. They want to get into behavior. Where the rubber meets the road in practice is, you know, we have 20 minute appointments often. And people, we are shorthanded. There’s a labor shortage. We are trying to go fast and get things done. And so there’s great demand for behavior and behavior services from the pet owners.

We also know that keeping pets out of shelter oftentimes depending, depends on, you know, having having some behavior services and helping them And at the same time, I think a lot of veterinarians and vet professionals wonder, do we have time to have these conversations and how do we do this?

It’s, it’s, it seems like it’s challenging to bill for, you know, clients want to come and have an appointment. And they want to talk to us for an hour and a half, but they don’t want to pay for an hour and a half Of veterinary in time. And so anyway, I just kind of just dumped a lot on you here. Chris, can you just speak at a high level?

Do you see this stress as someone in the veterinary behavior world? Do you see the conflict between vets trying to support people and then also? Let’s be honest some challenging logistics in getting behavior done in the way We were taught in vet school that behavior needs to be done

Dr. Chris Pachel: yeah, it’s absolutely one of the most common questions that I get when I am lecturing at veterinary conferences or I’m doing vet to vet consults with practitioners who are trying to get advice on how to handle a particular case. There’s that sort of that underlying theme of, but how do I actually put this information into common practice?

It’s going to take me forever. I can’t block my schedule. You know, I, you know, I can wait, make way more revenue for myself and my team if I’m doing dentistry procedures or surgeries or other diagnostics. And so how do I, how do I do that? And I think sometimes we, we kind of, if it’s still appropriate to say, throw the baby out with the bath water to some degree, right?

Where we’re, we’re, we’re trying to say, you know, gosh, if I can’t do a two hour behavior consult, then I just can’t do behavior. And, you know, in some ways I think about it almost the same way as saying, you know what, I was in general practice for a number of years. I didn’t do a TPLO myself. I, I didn’t do total hip replacements.

I, I didn’t do intradermal allergy testing of dogs. I, there were a lot of advanced procedures that I didn’t do, but I still had to have a basic understanding of when and if those procedures were appropriate. How to talk to a client about how to choose between their available options. And even from the standpoint of saying, if I, you know, saw that dog let’s say it’s a hind limb lameness, for example, cruciate until proven otherwise sort of an idea.

And I don’t have time to evaluate that dog today. It’s not an acute injury. I can say, cool, we’re going to schedule you to come back on Tuesday. It’s going to take about two hours for the sedation and the radiographs. We do it all the time where we delay the diagnostic or the conversation until we have a window to actually perform the service.

And I think sometimes one of the easiest things to do if we have an interest in really diving into that conversation is say, that’s a great question. It’s gonna take more time than I have available. So let’s see you back on Tuesday. Let’s do it. It’ll take us about an hour to run through the details.

I’ll have some questions. I’ll share my perspective. We can troubleshoot and figure out what’s the best option for going forward. I’ll see you at nine a. m. You know, we can do that in that little snippet that we have at the end of an appointment and still provide that service for the client.

Dr. Andy Roark: I I tell this story sometimes. I went to a physical therapist one time because my my foot was, was bothering me. But also my shoulder was bothering me because I am a master’s athlete. And so, so I, I go in and the person’s like, Great, you’re here for your foot? And I was like, Yeah, my shoulder also hurts.

And she just didn’t miss a beat. And she said, Which one do you want to work on today? And I thought, wow! You could do that? You could just ask which one of these do you want to do? And so, I picked one, but I just, I’ve always remembered that in the vet world I’ve been like, oh well we better go fast then.

And that just did not seem to cross her mind. She was like no. Which, what’s the focus for today? And we can work on the other one next week or make another appointment and I just when you say that it’s so funny I think a lot of us don’t really feel like we have permission to just punt somebody until later in the week.,

Dr. Chris Pachel: Yes, and what I love about that is for that individual who responded in that way to you, they heard your concern and they provided you with a solution and the power of choice and agency to choose your own adventure.

Dr. Andy Roark: It was, it was, it was really well done. It was just, and it was so casual too. It wasn’t like, Hey, look, I’m really sorry about this. It was just great. Which one? So I, I, I think that there’s a, I do think that there’s a lot to that. I, I think that feeling empowered to say, this is gonna take, I really like the wording that you used.

This is gonna take more time than what we have for today, let’s get back in. It’s probably going to take about an hour, but let’s really go through this. I think that you can, I think that you can communicate real value there. I think if the doctor says to you, I, I want to spend enough time with you to really get this problem worked out, and I would not be helping you if I don’t give you that, that amount of time.

I think it makes them feel seen and taken seriously, and, and I, I suspect it conveys value to them. I, I really like that a lot. You know, I, I’m always I’m a big advocate for technician and technician utilization. I, I really, I I think we can use our technicians more than we do. What I see in technicians and support staff really is a desire to learn and develop, you know, not, not everybody, but there is, there’s a hunger for, for knowledge and to be valuable and useful to the pets and the pet owners.

And so I, I look at this and I, and I wonder about technician and support staff. Utilization in these cases. Now, I, I know that there’s, there’s different degrees where we have, you know, some behavioral cases may be pretty complicated. They may have medical components wrapped into them, things like that.

But the vast majority of behavioral questions that we get about, you know, litter boxes, things like that. I feel like that’s things that, that can be delegated whether, whether it’s done by the technician in the appointment or whether we allow technicians to have technician appointments to address things like this.

I know I’m starting to see a move in our profession towards more technician appointments, more technicians working independently. What do you think of when you hear that, Chris? Do you think that things like that are possible? Have you seen technicians taking the lead on behavior cases in practices in a way that makes sense?

Dr. Chris Pachel: Absolutely. And especially in the general practice setting around behavior, the ability to go in and to learn how and to practice taking a good history, where we can ask those questions. Where, you know, let’s say it’s the cat that’s eliminating outside of the litter box. There’s a list of pretty standard questions

that we should know the answers to before we recommend a particular treatment. Simply saying, oh your cat’s peeing outside the box, add a box. Or try a different litter. It’s sort of like saying, oh I’ve got a cat who’s, you know, peeing excessively, here’s some insulin, try that first. We would never do that.

We need the diagnostic information to actually know what the solution to the identified problem is, even at a working diagnosis level and a technician who’s been trained in that area who has a, you know, a foundational knowledge and behavior can do a lot of that heavy lifting and in some of those cases do all of the lifting to really help those clients understand, you know, again, is this something that needs to be approached from a medical side of things?

And, you know, maybe they get that history for that cat who’s peeing outside the box. And in asking some of the routine questions, we also identify the fact that the cat is not jumping up on the furniture the way that it used to. And it’s a nine year old and this is a new onset problem. And awesome.

That dog or that cat likely needs to be evaluated by the veterinary team and there’s probably some diagnostics. Awesome. That didn’t necessarily need the veterinarian to spend 20 minutes gathering the history to be able to determine that that’s the next step. The technician is going to be able to say, okay, I can identify what is quote unquote behavior only and what needs the veterinary lens.

Go for it.

Dr. Andy Roark: Yeah, I, I, I really like that idea of, of the, the history leading into the conversations that we, that we want to have and having my technicians train so that they have the history and then, I don’t want to make it into a, into a, into an algorithm necessarily, but if the answer to this question is yes, then this is kind of the path that we start to go down.

Do you have favorite training resources? So, you know, I think a lot of times. A lot of times we throw our assistants and our technicians kind of into the room and we’re like, here’s the history. Anything that’s weird, just ask them more questions. do you, how do you get your staff up to the point where they can have these conversations?

I’ve seen, I’ll be honest with you, I’ve seen a lot of practices where where everybody’s kind of freestyling, you know what I mean? And you’re getting markedly different behavioral information from the different people that you see in the practice. I don’t want that. How do you, how do I get my people on the same page?

What does that sort of training and support of the team look like?

Dr. Chris Pachel: Yeah, I think one of the easiest places to start is to use a hand, a standardized history form, you know, and those are available through out, you know, and essentially any of the, the textbooks that we have, the, the handbooks that we have for behavior problems of companion animals, they include a history form that you can use to start with in, in the back of that.

And I think the reason I often start with one of those standardized forms is if you’re just on the early side of learning how to do this. You’re going to miss stuff. Of course you are. Unless we have that standardized checklist to follow and whether that’s something that we’re working through with the client in real time or whether it’s something that we’re asking them to fill out before they come in, it’s something that, for example, even when I look at a history form that for my practices, I think it’s five or six pages long by the time it spits all that data, not six pages of text.

But but but looking all that I can review that efficiently, usually in about 6 to 8 minutes. and verbalize my diagnostic plan, the additional questions that I need answered. I can verbalize that over and include, you know, if this, then this, or if we see this, this is going to redirect them to medical, or these are the things that we can recommend from a training standpoint.

So from a doctor, I could do six of those in an hour with a skilled training team and technician team who can implement a lot of that. Now, I say that knowing that the general practice cases, at least there are more of the straightforward cases that would apply for something like that. By the time we get to the point where they’re being referred over to a veterinary behaviors, there’s probably more layers that require the clinician to be involved.

But at an intake level of basically saying, is there something that we can do here before we consider referral to a veterinary behaviorist, or as a way of setting them up with the right trainer who’s going to be able to coach them on the implementation of skills knowing that if we’re going down, let’s say, a separation anxiety pathway versus a leash reactive dog pathway, we may have different trainers that we use based on their skill set and the actual problems that they like to work on.

But we can do all of that intake efficiently in the veterinary practice.

Dr. Andy Roark: Talk to me about the potential in telemedicine that you see. Do you think it’s going to be possible that we’re going to be able to have our, our, you know, our, our our behavior specialists in our, in our practice, whoever that, that may be. I mean, are they going to be able to just do a Zoom call with this client instead of having them come in repeatedly?

Is that, is that way more limited than people think? Help me, help me see what you see in your crystal ball.

Dr. Chris Pachel: I. Love. I love telehealth for behavior. I really, really do. And especially when we’re working with a veterinary team that does have hands on to the limit of safety with or without sedation, but we have that team that has the ability to have that established veterinary patient client relationship. I love coming into that conversation as a consulting specialist to say, let me ask a few of the questions that maybe you just didn’t know to ask.

And then let’s give you some some more guidance as to what we can do next and how that works and in real time, then be able to talk through medication options, perhaps even some of the diagnostic testing that we can do to really tease out some of those differentials that might not have been ruled out yet.

I love being able to do that. Truthfully, it’s one of my favorite things on my schedule most days. Not only from the standpoint of being able to reach patients that I otherwise wouldn’t reach, but more importantly for me, if I’m working through that primary care veterinarian, part of my education is to the veterinarian themselves to try to expand their knowledge base.

So the next time around they can perhaps get just a little bit farther with that case before they need to reach for me. So I’m trying to on board a more robust toolbox for them in the process of helping this single patient that’s in front of them so that they don’t have that same level of dependence on me for every single case that comes through.

Dr. Andy Roark: How do you differentiate behavior and training, Chris? I find myself using them largely interchangeably, but I feel like behavior is sort of very much in the veterinary medicine realm, and training may be a bit different. You know, there’s just a huge amount of overlap there. When I think of training, I think of puppy classes at Petco, or people out in a field really working with schutzendogs.

Not to, make it negative, but that feels different than hey, I’m the veterinary and let’s, let’s do a behavior appointment. Those feel very different to me, but do you, do you see them as being different? If so, how, how do you separate them?

Dr. Chris Pachel: So it the lines are blurry. That’s the short answer to that question, because it’s really hard sometimes to know kind of where one begins and one ends. Even we could go as far as to say that almost everything that we see is behavior, right? Movement patterns, ingestive behaviors, where the animal is looking or what they’re responding to.

It’s all behavior. What we do about it and the tools that are in our toolbox to really tease out why behavior is showing up the way that it that it is or how we’re going to modify that, that’s where those roles really start to differentiate themselves. Meaning if I’ve got a naive puppy or a dog that is

newly out of the shelter and doesn’t have its basic cues of sit, come, down, stay you know, things like that. Training is perfect for that. Those dogs don’t necessarily need a behavior assessment or a veterinarian to be involved. However, when we’re doing an assessment where there’s a behavior change, or where there’s any level of suspicion that there might be an underlying medical component.

And whether that’s gastrointestinal sensitivity, whether that’s recurrent itch issues that’s creating a level of irritability, whether it’s airway problems that’s impacting a dog’s ability to sleep restfully overnight, or whether we’re looking at actually prescribing for behavioral interventions, those are all within the purview of the veterinarian and absolutely need that medical lens and that medical knowledge.

The behavior modification piece kind of straddles between there where we’re saying I’ve got a dog who’s doing one thing or a cat who’s behaving in a certain way, assuming that we’ve ruled out or addressed any underlying medical issues, how can I apply the science of behavior change to manage that environment to coach the owner on how to utilize reinforcement based training to modify that and to build a better set of coping skills for that animal who’s doing the best they can, but they might be acting in an unsafe or unproductive way.

And that’s where the behavior consultants and a lot of the behavior professionals come into play. Not in isolation, but in my opinion, in collaboration with the veterinary team. So I don’t have to coach the veterinarian on how to do all the little micromanagement of individual training or behavior modification sessions, but that I also have that veterinary team who understands what underlying medical issues may be showing up with a change in appetite,

or a difference in behavior or a new onset aggression or a disruption in sleep wake cycle. That’s where the differentiation really comes into play for me.

Dr. Andy Roark: No, that, that makes sense. The last question I have for you, when you look into your crystal ball, And you look five years into the future and you’re thinking about artificial intelligence and you’re thinking about, you know, cloud based practice management software and corporate consolidation, all these kinds of things.

What changes do you see coming down the pipeline in the way that we engage with behavior cases?

Dr. Chris Pachel: Yeah, I think there’s a, there’s a couple of intersections here that are really meaningful for me. I personally don’t want to give up any of my client time to AI. I really don’t. I love being able to spend that time to really observe the animal, to ask the questions that I need answered, to be able to do that.

And I like looking at the history data in real time and assimilating my own thoughts about what that, what that might mean. Where I really struggle and where a lot of my colleagues who practice behavior really struggle is getting it all documented efficiently in a way that actually then makes a meaningful list of recommendations to clients.

And that’s truthfully where I use AI in my practice is not necessarily to generate my differential lists. I’m not asking it to assess my history forms. I’m basically saying, Hey, distill this down in my brain. Let me run through the education. But if there’s a little recording playing in the background that can pair that down into an actionable bullet point list.

Oh, man, I’m a happy camper. That is exactly what I’m looking for. So capture my words, put them on paper and assimilated into action items. That’s where I use AI. And that’s where I think, you know, if I could wave my magic wand. getting that dialed in so that I can walk out of an hour long appointment and just check the box and say, yep, captured it.

That’s what I want.

Dr. Andy Roark: It’s done and they’ve got good resources to go home with. I like it. I like where your head’s at. That’s wonderful. Dr. Chris Pachel thank you so much for being here. Where can people find you online? Where can they keep up with all of the adventures you’re having?

Dr. Chris Pachel: Yeah, the easiest place to find me is on my website, which is drpachel.Com, so d r p a c h e l. com. And if you go to that main landing page, there’ll be links there to all of the different projects, the things we’re doing at Animal Behavior Clinic, the things we’re doing at Instinct Dog Behavior and Training.

There’s a link there to my media pages, which will take you to podcast recordings like this one, as well as any other things that I’m involved with. You can keep tabs on me there. It also takes you to my socials on the business side, too. So everything is linked from drpachel.com

Dr. Andy Roark: Outstanding. Thanks for being here, Chris. Thanks for being here, everybody. Take care of yourselves, gang. See you later.

And that’s what I got. Guys, thanks for being here. Thanks to Chris Pachel for being here. Take care of yourselves, everybody. Be well. I’ll talk to you later on.

Dr. Peter Weinstein explores the feasibility of implementing a production-based compensation model for veterinary support staff with Cone of Shame host, Dr. Andy Roark. They touch on the potential benefits and drawbacks of this approach, discussing how it might improve job satisfaction, retention, and appreciation for technicians, assistants, and other support roles. Dr. Weinstein argues that while veterinarians benefit directly from production-based pay, the staff executing the bulk of the work often remain on fixed salaries, creating a disconnect in compensation fairness. The conversation also touches on broader topics such as profit-sharing and the overall drive to enhance workplace morale and productivity. They examine whether tying wages to service delivery could equitably distribute earnings and reflect individual contributions more accurately, potentially revolutionizing compensation structures in veterinary practices.

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

LINKS

Dr. Peter Weinstein on LinkedIn: https://www.linkedin.com/in/pawdr/

Veterinary Ownership Advocates: veterinaryownershipadvocates.com

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

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr Peter Weinstein is a husband, father, pet parent, veterinarian and leader. He has been involved with virtually all aspects of veterinary practice from a 15-year-old kennel kid to a hospital owner.  Organized veterinary medicine has been a passion as well with various roles and leadership and presidencies of Southern California VMA, California VMA, and Vet Partners. He is a published author, most notably of the E-Myth Veterinarian-Why Most Veterinary Practices Don’t Work and What to Do About It. Currently, he is teaching business and finance at the Veterinary College of Western University of Health Sciences. He likes to think of himself as a free-thinking change agent and disruptor who, because he has a daughter who is a recent graduate from  veterinary school, is working for an even better veterinary profession in the future. 

EPISODE TRANSCRIPT

Dr. Andy Roark: Welcome, everybody, to the Cone of Shame veterinary podcast. I am your host, Dr. Andy Roark. I am here with my good friend, Dr. Peter Weinstein. And we are talking about the question of should veterinary support staff be paid on some sort of a production model like a lot of veterinarians are? What are the benefits?

What are the drawbacks? Is that the future for vet medicine? Would that motivate a change in behaviors? Would it show appreciation to our support staff? Would it help us keep technicians, assistants, front desk people, kennel techs, would it help us keep them in the profession longer? Anyway, this is a great idea discussion.

We kind of sprawl all over the place. I really hope you guys will enjoy it. Let’s get into this episode.

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

Dr. Andy Roark: Welcome to the podcast. Dr. Peter Weinstein. Thanks for being here.

Dr. Peter Weinstein: Dr. Roark, always a pleasure to be with you, my son.

Dr. Andy Roark: I’m my son My son. Peter, what advice do you have for me? I, you know, it’s funny. Whenever we, I should start blocking more time on my schedule to do our podcast because we, we talk for hours around the podcast that we actually record. And you and I, you even had a sprawling conversation about the profession so far and what the future looks like.

And I think we sort of naturally in our conversation came to what I want to talk to you about today. But first, let me say, for those who don’t know you, you are a, a failed retiree. You really have not retired very well at all. You are an entrepreneur coach. You’re an educator and advocate for the vet profession.

You have worn many, many hats. You were just running the practice management program at the AVMA convention when I saw you last. You just do many, many things. And. You are one of the main people that I go to when I when I start thinking about the future and looking at my crystal ball and kind of trying to figure out where is this crazy profession going and and you and I have a lot of of philosophies that line up really well and we care about a lot of the same things and so I I came to you recently and I was sort of saying hey look you know Peter we’re looking at We’re looking at changes in profession.

We’ve got corporatization. We’ve got a lot of private equity things coming in. I’m looking at a push to raise the the salaries of our support staff, especially. We know that that’s a big a big factor of stress for our, for our staff members. And I was trying to talk about how do we do this? Like, how do we, how do we make life better for our support staff?

How do, how do we, how do we pay them better? And so, you and I have gone back and forth. We’ve had different conversations about production based pay. We’ve talked about how we pay doctors. And I’m always kind of interested in how those things sort of come together in your mind. And so, the question that I, you and I have sort of kicked around, and you sort of posed this question to me is, Does production based pay in veterinary medicine accurately or adequately recognize and reward the support staff who are doing the work that gets the patient taken care of.

And so I want to go ahead and start to unpack this because you and I have talked before about production based pay for for veterinarians. I’ve had a number of guests on the podcast talking about The benefits and and then the drawbacks and also like is this the culture that we want to foster in our profession?

So I’m fairly neutral on production based pay. But i’m definitely open to change. I am very interested in growing the income of our support staff and keeping them our profession longer and making this a more attractive profession for people to be in. So let me sort of bring that to a close and sort of start, stop talking there.

Yes or no, our current system of production based compensation for most veterinarians totally takes care of support staff in an adequate way. Do you believe it?

Dr. Peter Weinstein: No I think production based pay rewards the doctor for the services that they feel the pet is needed, has needed. However, the individuals who, in many, many, many cases, actually deliver those services are the health care team.

Dr. Andy Roark: Mm hmm.

Dr. Peter Weinstein: So the doctor gets rewarded by salary, and in many cases a percentage of what they put on the health care plan, treatment plan, estimate, whatever you want to call it. They hand it off for somebody else to do the work, who is paid a salary. So no matter how hard they work, per hour, or don’t work, they’re going to get paid the same amount.

Dr. Andy Roark: Right.

Dr. Peter Weinstein: But in many ways, the doctor keeps pushing the work, they keep making more money as the doctor, But the staff isn’t recognized for how much work they’re doing.

And that’s why I think that there’s a disconnect. And if we’re going to look at team based healthcare delivery, where everybody is working together from the person who answers the phone, Oh, and by the way, doctors who are on production, you don’t see clients unless somebody makes those appointments. Oh, by the way, doctors who are on production, you can’t see more people if you’re the one in the treatment area taking radiographs, pulling blood samples, and putting in catheters.

Oh, and by the way, doctor, you’re not the one cleaning the cage for that pet that was in the cage. But you are the one getting paid for all those services that you do. So that’s why I think there’s a disconnect in, and, and I, we have to figure out a way that rewards everybody on the team for all the work that the team does in a collaborative fashion.

Dr. Andy Roark: Is this idea, are you looking at this, if we could magic wand, you know, make it so that the, the revenue of the hospital went to the team based on how much they did or how much, you know, what they, what they generated, that would come back in sort of a, almost like a profit sharing. Are you imagining that as the team should be rewarded?

Or, Are you willing to go a step further? I have long maintained, one of my sort of core values is work ethic. I like, I like working with people who work hard. And I like to work hard. We have set up a lot of pay scales in vet practices, which I think are generally a good thing. But they’re almost entirely, the ones that I’ve seen, built on skill acquisition.

Or knowledge acquisition. The pay scales are not generally, they don’t reflect this person busts her hump and takes back twice as many patients in a day as the average, you know, say technician in our practice does. And I would say, this person might not be the most technically skilled person in your practice, but she has her hands on way more pets than any of your other technicians.

And I think that those, I think those truths are often unrecognized in practice. Do you, do you agree with that?

Dr. Peter Weinstein: Absolutely. But what you’re talking about is a subjective measure and we are an objective profession. In other words, we can measure now, unless we start to measure the number animals that an individual. Team member touches, then we’re making a judgment that says, well, they’re working harder than anybody else.

Maybe they should make more money. And then somebody complains and says, why are they making more money? So what we’re dealing with as well is an environment that’s somewhat competitive at all levels. And how do we create an objective measure of how hard people are working?

Dr. Andy Roark: Yeah. I mean, yeah, I agree with that. And I think that it gets tricky when you say, well, we’ve got one technician in the lab, and we have one technicians at the treatment room tech, and their names don’t really get put on the cases. I definitely get that. I have always thought that there was great value in recognizing, say, the technicians who are doing more senior blood work

than the other technicians. And maybe that’s because the doctor they’re working with is better at recommending senior blood work. But I’m finding more and more that’s not really true, you know. When we have well leveraged technicians and they know what the plan is and they know what our wellness protocols are, they’re in there talking about heartworm testing, you know, senior blood work.

They’re talking about, in some cases, they’re talking about dentistry. They’re talking about a lot of services that can be objectively measured. I think it’s, it’s a little bit challenging to tie those services to the individual technician or support staff, but that’s kind of my holy grail. I think Peter is, I really would, the way we track services for doctors, I would love to try to figure out some way, and it’s going to be sloppy because it’s because of how, how the team works together.

I really think that there’s great value in that. I think that there are some support staff members who just absolutely crush it. And I think that they could. share best practices with the rest of the team. And, and also I think they should be compensated for their skills and their effort in a way that, that, I don’t think we’ve done that very well so far.

Dr. Peter Weinstein: Well, let’s put it this way. When you, as a Dr. Roark schedule my pet, Bruce, for a dentistry, the invoice gets processed

Dr. Andy Roark: Mm hmm.

Dr. Peter Weinstein: the end of the day and everything on the line items associated with that dentistry goes to Dr. Roark 

Dr. Andy Roark: Mm hmm. 

Dr. Peter Weinstein: in most cases, but Dr. Roark never touched the teeth. except to check and make sure that they were clean.

Dr. Andy Roark: Yeah, I looked at them. I looked at them.

Dr. Peter Weinstein: Yes, but you didn’t touch them. So what if that invoice said your dental hygienist today was Susie, her assistant today was Judy, and the animal caretaker who took care of your pet’s cage was Jane. We are not giving, oh and by the way your receptionist today was Crystal. We’re not using our invoices to identify and recognize the team

for the work that they’re doing. And I would suggest that every dentistry should be linked to probably a credential technician and an assistant. Every surgery should be linked to a credential technician, an assistant, and a doctor. Because I think it’s time to start recognizing them in the same way that we don’t, we have started to do more and more, quote unquote, tech exams.

But does it give credit to the technician by name who did the tech exam? So now we’re going to make it even more complex and we have a hard enough time getting invoices right in veterinary medicine And especially if you’re on production based pay where every line item could determine what your paycheck is think about now we have to give credit to the technicians now I’m not taking away from the doctor But I am wanting to give credit to the technician who was tasked to do the work And we have to leverage it.

I think, you know, you’re talking about giving more credit to the techs. I think we need to give more credit to the CSRs because they’re the ones who are making the appointments. And they’re the ones who check, in many cases, checking clients out. And they’re the ones, in many cases, who are dealing with the really difficult clients from an emotional standpoint.

Dr. Andy Roark: Well, it’s,

Dr. Peter Weinstein: It’s a team based effort. We can’t get the rowboat down the lake unless everybody is stroking at the same cadence.

Dr. Andy Roark: I, I, I do, I completely agree with that. 

 Hey guys, national veterinary technician week is coming at ya. And if you’re someone who wants to do something nice for your technicians and you haven’t thought about what yet. Don’t worry. I got ya, but you need to add now my new card game, Dr. Know-It-All is out. This is a veterinary specific card game. 

It is vet trivia. It is fun for the whole team. You can play with the whole team. It is fast. It is funny. You will have a really great time. Anyway. it is geared up here. Ready? I’ve got it at my house. I will send it. Directly to you or to your practice. All you gotta do is buy a copy. 

I’ll put a link in the show notes, head over to drandyroark.com. Grab a copy grab a copy for everybody. This is something that the techs are gonna really love. The trivia questions are meant to be at the level of the veterinary technician licensing exam. And so they are a little bit spicy in their questioning. 

We have a hard mode that you can use with the doctors. We can make this much more challenging. We can also make it much more easy for onboarding new people in there. You know, they’re new to the vet medicine. They just want to learn. So anyway, got you covered from an education standpoint. Gotcha 

covered from a fund standpoint. Gotcha covered from a gift standpoint. I really, I think I got you covered all the ways. All you gotta do is get yourself a copy of Dr. Know-It-All and get it wrapped up for the technician that you want to say thank you to anyway, that’s what I got. Link in the show notes. 

Let’s get back into this episode. 

Dr. Andy Roark: I have been a big proponent for a long time. I think the front desk is the most underrated position in the practice and they have for a long time. That’s not taking anything away from anybody, but because they’re up front, most of us don’t see them and think about them and what they deal with.

And so I, I don’t think that they get necessarily the recognition they should. I had this thought. I’m just curious if you’re going to bite on this. I yeah. So, we was at the AVMA convention and we were in Austin, Texas, and I went up to a restaurant and I ordered myself, like on the screen, I punched in my, well I put in my phone number, I punched in my order, and then after I had ordered self checkout on the screen.

It then asked me for a tip. It asked me if I would like to tip. And, I mean, I swiped my own credit card. I did the whole thing. And I just kind of looked at it like, I guess this is where we are in that I am not tipping. And first of all, it asked me for a tip before I got my food. It wasn’t even like, didn’t you like your food?

Would you like to tip? And I just thought, this strange idea of tipping has become so ubiquitous. I mentioned it. I wrote an article and said, Are We Ready for Tipping? And I got a lot of flack for even I don’t know, asking the question of whether or not Vet Medicine was ready for this. Would you be open to tipping the staff at a vet clinic or do you think that’s totally gauche?

Dr. Peter Weinstein: would not be adverse to tipping the staff at a vet clinic if it is done by the leadership, management, and ownership of the clinic, which of course doesn’t make it a tip.

Dr. Andy Roark: That’s not a tip, that’s a bonus!

Dr. Peter Weinstein: Yes. I would have a problem somebody individually giving a tip to the technician who did the profi, for example. And I, and I think we’ve seen tipping quote, unquote, occur

when house calls are made or other things, and probably not even being reported. In those situations where everything is pretty much automated and you get that request for a tip, the reason I might give a low end tip, maybe not the 20 percent I normally give, but 12 to 15%, is because there is still somebody putting the coffee in the cup, putting the lid on the coffee cup, making the latte, and doing the work there.

Now whether that gets bundled into the cost of the coffee, I don’t know. In in many restaurants the tips are all brought together so that the busboys, who do the heavy lifting. The busboys in a restaurant are the equivalent to the technicians in many cases. Maybe they’re the assistants, because the waiters and waitresses would probably be the technicians.

But then who’s the doctor? Anyhow, the chef, the chef would be the doctor.

Dr. Andy Roark:  Okay, okay, 

Dr. Peter Weinstein: And then you have a sous, you have sous chefs who doing a lot of the line work that you never get credit for. I mean the, Chef Ramsay gets all the attention, but who’s actually doing all the work?

Dr. Andy Roark: No, I, I like it. I think, I think that may, I, I’m not even, I’m not even advocating. I like to bring it up. I’m just when I see tipping like that, it just, in my mind, it’s interesting. Clearly, this is a, this is a strategy that other businesses and other industries have employed to try to increase the income of people who are working there without raising the actual prices.

And so, I think that’s why it pops into my mind. I’m not, I don’t know that I feel good about it. I think. I think there’s probably lots of ways it can go badly, but I just, as we start to talk about recognizing the team, things like that, it just, it occurs to me that, that that is something we see in other, in other industries.

And I like your analogy too, of the way, my understanding is the way those tips work is, they go into a pool, and it gets split amongst every, the people who are there. And I think that that’s a fair way. Of kind of compensating across the board again. I don’t know that we’re ready for tips or that we want that, but it’s just that you should always be looking at other industries and sort of seeing seeing what they what they do.

Dr. Peter Weinstein: I’m sitting here and you know, you know I’m in Los Angeles and I’m sitting here and I’m thinking of all the plastic surgeons in LA, you know, do you think that they get a tip for doing a perfect nose job? Do you think they get a tip for, you know, we don’t tip in human healthcare in most cases, even if it’s the elective procedures? We don’t tip our dentists.

And I mean, as much as, and, and I’ve said this before and I’ll say it again, as much as veterinary medicine is a service industry that provides healthcare, we don’t tip on the healthcare side of things. It just seems to be a it, it’s, it’s, it just doesn’t fit in being a healthcare professional from that standpoint.

On the other hand, you all read All Creatures Great and Small, and let’s just say that James Herriot got tipped with bacon and eggs and sides of beef but that was a different era. And so, it’s really, I mean, if you want to look at tipping, it goes back to something you, you superficially talked about earlier, which is profit sharing.

Dr. Andy Roark: Yeah,

Dr. Peter Weinstein: And, and I, I really do think, that that’s in the sense, essentially, that’s what production based pay is, but let’s look at profit sharing for the entire team and not just for the doctors, although the doctors do deserve to be rewarded for the work that they do. We can’t do this if we don’t have a team to support us.

We cannot make as much money for the practice without a team to support us. And Unless the doctors start to take some of their production based pay and give it to their team. Hey, Andy, you want to give some of your production base to your team? 

Dr. Andy Roark: I mean, 

Dr. Peter Weinstein: I put you in a corner there.

Dr. Andy Roark: yeah, ooh yeah, no, that’s I think that that’s the, that’s the question that comes into everybody’s mind, right? Is, is we say, well, should we play the team on production? And then the doctors kind of go, well, I’m, you know, I’m, I’m, I’m not interested in giving up what, what I’m earning and this is how I’m getting paid and again, I, I think that that’s very, I don’t think anyone expects that level of altruism from the average veterinarian across the board of let me, let me reduce my salary and hand it over to the support staff.

I think that that would, I think that’d be a lovely thing, but we also know from the Merck 2023 well being study that student debt is one of the main stressors, especially for young vets, and like, so people have got, they, they’ve got their own sort of burdens that they’re, that they’re carrying.

Dr. Peter Weinstein: Well, and again, ladies and gentlemen, veterinary medicine, although you may think it’s a not for profit business, is a for profit business. 

Dr. Andy Roark: Yeah. 

Dr. Peter Weinstein: 50 percent of the hospitals out there probably aren’t making a profit when it comes down to it, but we’re a for profit business. Which means, theoretically, we should have a budget.

Theoretically, we should be looking at the numbers that, from which that budget feeds. Whether it’s income or whether it’s expense. And, when it’s all is said and done, as the practice does better, the team that helps the practice do better, if you are an, an above board owner, we’ll turn around and say, Thank you for helping us get us to where we are.

Dr. Andy Roark: Mm hmm.

Dr. Peter Weinstein: Because that profit, let’s just say we’re at a, a really nice number of 20% profit. What if we took 2% of that profit? So as the owner, I only got 18%. And let’s say that’s $2 million. Now Andy, get your abacus out and tell me what 2% of $2 million is

Dr. Andy Roark: Fast math!

Dr. Peter Weinstein: So $40 million, $40,000. What if we took that amongst our team of 20? And spread it out in some fashion that represents both subjective and objective work and maybe longevity. And if one member of that team got a thousand bucks, maybe even a quarter or at the end of the year, maybe they got 250 a quarter.

How big would that be for somebody who’s only making 18 an hour?

Dr. Andy Roark: Yeah.

Dr. Peter Weinstein: I mean, that’s, you think about the motivation there that doesn’t necessarily impact the doctors. Because they’re still doing production based upon their budget and everything else. It’s really looking at an owner and saying, I want to keep my team.

I want to recognize my team, those who work hard, and I want to reward them for the work that they’re doing.

Dr. Andy Roark: You know, I’ve heard, I’ve heard of practices talk about this a number of times. I’ve talked to practitioners about profit sharing and things in the past. And I think that you’re probably understanding. I like the way you’re looking at it as a, as a way of rewarding and showing appreciation. I think that a lot of people in vet medicine have tried this as a motivational tool.

And, and generally it doesn’t work that well to motivate. You know, they say, Oh, we’re going to do a profit share. I think people very much appreciate it, but I don’t think a lot of our support staff is not, they’re not super money motivated driven or the frequency that we’re making sort of payouts and things like that doesn’t, doesn’t, it doesn’t click the, you know, the box for them the way that people sometimes think that it will.

And so I, yeah, I, I, I like this as a, as a way of rewarding and, and and showing appreciation. I think that makes a lot of sense.

Dr. Peter Weinstein: Here’s, here it is in a nutshell, for lack of a cliche. If we run our businesses so that passion drives profit, we will have a successful business. But if we run our businesses where profit tries to motivate passion, you’ll fall on your face.

Dr. Andy Roark: Yeah, that’s I think that’s I think you’re spot on. I think that’s a really good way to summarize what I have seen with profit sharing that that totally makes sense. 

Dr. Peter Weinstein: Keep the passion, because passion is really, and, and maybe it’s overused, maybe it’s trite, but we’re not in this field, you know, you do, Andy, do a, do a survey sometime of your, of your followers and see how many people entered veterinary medicine to get rich.

Dr. Andy Roark: Right.

Dr. Peter Weinstein: You know, we’re in it because we have a focus, we have a direction, we have a desire to make a difference.

That’s passion. And reward passion. And I think we’ll all be in a much better position.

Dr. Andy Roark: No, I agree. Dr. Peter Weinstein. Thanks so much for being here. Where can people find you online? Tell us tell us a little bit about your entrepreneurship program that you’re doing right now.

Dr. Peter Weinstein: Thank you, Andy. We just released a a program that’s focused on helping create the next generation of veterinary entrepreneurs. You can find that at www.veterinaryownershipadvocates.com. And it’s an online course. We have 24 hours of race approved CE with a monthly, what we call a mastermind call to talk about how you can be successful, the problems that you’re having in running your practice.

And so we’re really hoping to build a community of entrepreneurs to keep veterinary medicine independent And to build this next generation of hospital owners So that’s one of my passions and the best place to find me is probably on linkedin and you’ll find some of my thoughts and opinions and sharings there and you know It’s hard not to find me at most of these meetings, too.

I’m the one walking behind andy in great awe

Dr. Andy Roark: Right. Thank you so much for being here, guys. Thanks for tuning in, everybody. Take care of yourselves.

 And that’s what I got for you guys. I hope you enjoyed it. I hope you got something out of it. Thanks to Peter for being with me. I always enjoy kicking ideas around with him. It always affects my thinking. I’m gonna definitely have to meditate on this episode a little bit for a while. I think there’s a lot here.

So anyway, guys take care of yourselves. Be well. I’ll talk to you soon. Bye.