In this fun and informative webinar sponsored by our friends at Purina, Dr. Martha Cline shares how nutrition can play a part in canine heart health!
Effective Enrichment for the Cat That Refuses to Play (HDYTT)
Gertrude is a 16lb obese cat who simply refuses to lose weight. She will not run, play, or exercise in any way. She refuses to eat anything but the food she wants. Her health is on the line and Dr. Andy Roark is out of ideas. Fortunately, Ingrid Johnson is here to talk about how she handles these cases. Let’s get into it!
LINKS
Fundamentally Feline: www.fundamentallyfeline.com/
Put on Your PANTS! Hold Meeting that Matter: unchartedvet.com/product/put-on-y…-pants-meetings/
Uncharted April Conference: unchartedvet.com/uncharted-april-2022/
Uncharted Podcast on iTunes: podcasts.apple.com/us/podcast/the-…st/id1449897688
Charming the Angry Client On-Demand Staff Training: drandyroark.com/on-demand-staff-training/
What’s on my Scrubs?! Card Game: drandyroark.com/training-tools/
Dr. Andy Roark Swag: drandyroark.com/shop
All Links: linktr.ee/DrAndyRoark
ABOUT OUR GUEST
Ingrid Johnson is a Certified Cat Behavior Consultant (CCBC) through The International Association of Animal Behavior Consultants (IAABC).
Ingrid owns and operates Fundamentally Feline, providing in home consults for locals and virtual consultations worldwide for clients experiencing behavior challenges with their cat(s). In addition to behavior consults, Ingrid also offers medicating consultations to help clients overcome, or get ahead of, medicating challenges. Prevention and training, the best medicine! She makes her own line of feline foraging toys, scratching posts, vertical space, and litter boxes. She lectures nationwide on cat behavior at veterinary conferences such as AAFP, VMX, ACVC and the like. She is employed at Paws Whiskers and Claws, a feline only veterinary hospital, as a tech, groomer, and office manager and has been working exclusively with cats since 1999.
In the Fall of 2016 a paper she co-authored, Food puzzles for cats: Feeding for physical and emotional well-being, was published in the JFMS (Journal of Feline Medicine and Surgery) and to compliment it she co-developed FoodPuzzlesforCats.com. To date it is the most popular and widely downloaded paper in the history of the journal! Ingrid’s home, cats, and environmental enrichment expertise has been featured on Animal Planet’s Cats101 show and featured in numerous publications including the website WebMD. She has created a series of educational How-To videos of her own, viewable on Fundamentally Feline’s website and YouTube channel. Ingrid regularly interviews and offers her expertise for various media outlets. She is Co-Director of Paw Project-Georgia, working towards ending the cruel practice of de-clawing cats.
Cat Fancy magazine’s 2008 “Home Issue” showcased her feline friendly accommodations and the aesthetically pleasing ways you can provide for your cats innate basic needs while still having a home the humans can enjoy. Ingrid is a huge advocate for enrichment and is determined to thwart the belief that one’s home will look unsightly in efforts to provide it.
Ingrid shares her home with husband Jake, five rescue cats, and Sebastian, a rescued Great Pyrenees Dog. Follow Fundamentally Feline on Facebook, Twitter, Instagram and You Tube!
EPISODE TRANSCRIPT
This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.
Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary podcast. I am your host Dr. Andy Roark. Guys I am here today with my friend, Ingrid Johnson. Ingrid has been on the podcast a number of times before, because I think she’s amazing. I love how matter of factor and straightforward she is. I love her thoughts on feline behavior, I love her thoughts on play and getting cats to play. And so I bring to her a tough case today. I’ve got Gertrude, she’s a 16 pound obese cat who just is not interested in playing, and she only wants to eat what she wants to eat, and she just basically refuses to lose weight, and you guys know what that case is like. And I put it to Ingrid and say, help me buddy. She’s got great advice. I again, I love the way she thinks, I love the work she’s doing at Fundamentally Feline. I’m glad to have her here. Guys, 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 Ingrid Johnson. Thanks for being here.
Ingrid Johnson:
Hey There. Thanks for having me back.
Dr. Andy Roark:
Always, always, always, because this is exactly what I… This is what I most love to talk to you about and I got a case for you about it. Are you ready? You ready for a challenge?
Ingrid Johnson:
Super. I’m totally ready, always ready.
Dr. Andy Roark:
I’m going to see you improvise, adapt and bend like in the matrix here, I think.
Ingrid Johnson:
That is a tall order.
Dr. Andy Roark:
Oh yeah. You know, here is the thing, one of the things that I love the most about you is I love how you get into the mind of a cat and you are so pro-cat and you want cats to have great lives. And at the same time you very much understand the health outcomes that we’re trying to achieve. And you’re really good at presenting solutions to cat behavior problems in a way that I feel like I can get owners excited about.
Ingrid Johnson:
Cool.
Dr. Andy Roark:
And so that’s why I want to do this with you. So this is just going to be… This is such a classic. It’s not a complicated case at all, but I’ve got a cat that I am working with and the owner is super great, she is super enthusiastic, she loves her cat. I think she’s a very compliant owner, I really do. I think that she’s going to be really great to work with. I just want to make sure that I’m working with her the most effective way that I can. She has got a 16 pound obese female cat.
Ingrid Johnson:
Okay.
Dr. Andy Roark:
Gertrude is her name, which I love. Gertrude. Gertrude doesn’t give a flip about what you want or what mom wants. Gertrude is living the easy life. And so she just eats basically dry kibble. And I’ve talked to mom about weight loss food and things like that, but Gertrude just… She just eats her food, she doesn’t want to play. She doesn’t want to chase the thing. She, you know what I mean? She is just content to lay in the sunshine.
Dr. Andy Roark:
In a way, let’s be honest, Gertrude is my spirit animal, I think, in a lot of ways. I get Gertrude at a deep level, I get her. What am I doing with this cat Ingrid? Just seriously, it’s 100% lack of motivation. It’s like trying to do a weight loss plan with a person who has zero interest in a weight loss plan at all.
Ingrid Johnson:
Exercising or eating healthy.
Dr. Andy Roark:
Exactly, like nope, what else you got Andy? I’m like I don’t have any, don’t have anything else.
Ingrid Johnson:
I’m also guessing that Gertrude hasn’t seen her tush in a few years.
Dr. Andy Roark:
Oh no, no. She’s…
Ingrid Johnson:
May I suggest we start with a sanitary shave.
Dr. Andy Roark:
Yeah, she sways when she walks, if you know what I mean?
Ingrid Johnson:
So at our office with these cats, well we do shave their butts. We shave a lot of butts, not going to lie, it’s practically our specialty. But what we do is, because they’re cats, so we carry all the prescription foods. We carry Hills, Royal Canin and Purina. We have more food at our vet clinic than most clinics that actually do dogs. And we send home what we call our high protein, low-carb sample.
Dr. Andy Roark:
Okay.
Ingrid Johnson:
So the cats go home with one of every single can that could possibly be appropriate for weight loss. And then we send home usually one small bag of dry to sell. And then we often have bags that have been returned for palatability, and so we’ll also give a free sample of some other dries, so they’ve got a couple different ones to choose from. But this is the perfect time to implement food puzzles and foraging.
Ingrid Johnson:
So what this would look like is, once we figure out what the kitties enjoy, then we have them feed two to three canned food meals a day, and we put all the new dry in a food puzzle because cats are not going to work for food that’s been easily available. They do not contrafreeload, if the audience is familiar with contrafreeloading. They are one of the only species on earth that has been studied that will not contrafreeload, which means if food is easily available, cats will not work for it. [inaudible 00:05:17].
Dr. Andy Roark:
Gotcha.
Ingrid Johnson:
I don’t think that it’s they’re lazy, I think that they are very intelligent. And why would you put forth effort when it’s free? So they’re probably looking at us and dogs and chimpanzees, like we’re all just nuts.
Dr. Andy Roark:
Yeah.
Ingrid Johnson:
So we put the novel food in the puzzle, we put the canned food out two or three times a day, and we have to start with some basic guidelines, but I think what we have to remember is that the recommendations on the back of these bags of food and the recommendations even in the formularies from Hills, Royal Canin and Purina are simply guidelines. So we start there because we have to start somewhere. But then as we have the kitty come in for rechecks and sanitary shaves to get weighed.
Dr. Andy Roark:
Yeah.
Ingrid Johnson:
We adjust because everyone’s a unique individual and we might still be overfeeding a high protein, low-carb food because it might not be calorie restrictive enough for that particular cat.
Dr. Andy Roark:
Yeah. Okay, let’s unpack this a little bit because I think that’s really important. I think a lot of us struggle with that because pet owners are like, how much do I give? And you kind of go, about half a can give or take. It seems very… It does seem very unscientific, especially when they’re doing some dry and some can together. I think we as vet professionals are all very good at looking at the recommendations on the bag and coming up with an amount saying, okay, well if you do this much dry food and you do this much wet food and this is what we do. And I think that we can all do that.
Dr. Andy Roark:
Walk me through the process. So I’ve got Gertrude and she is 16 pounds, and I figure out she needs this much sort of canned food, and if you’re going to do this much dry food, I’m going to take that amount of dry food. I’m going to put it into forging puzzles so that she’s going to have to work for and then I would give her the canned food. Okay, from there, walk me through the reduction process. Do you give her what you think is indicated based on what’s on the packaging? From our pet food maker friends?
Dr. Andy Roark:
You give them… Just say, this is what we’re going to start with, what we’ve worked out. Do you go ahead and say, we’re going to shoot under this and then I’ll see you back? And how frequently do you see them back? So yeah, walk me through that process please.
Ingrid Johnson:
So typically if we got a 16 pound cat, we’re probably going to feed for 14 pounds, so that’s going to be your first goal. I mean, you can’t be like, well she should be eight pounds and we’re going to feed her for eight pounds. That’s going to create some starvation frustration behavior, like no get out. You got to bring it down slow. So our first goal is 14 pounds. We’ll go with the recommendations on the formulary to start.
Dr. Andy Roark:
Okay.
Ingrid Johnson:
She might come in and not have lost anything, but maybe at least the win here is that we got her transition to high protein, low-carb prescription food. We’ve got her off of whatever she was eating over the counter that maybe was less than ideal. And we’ve taught the cat to forage. So we’ve now increased enrichment and a little bit of activity. So now is the time, about every two months we have them come in for weight checks, by the way.
Dr. Andy Roark:
That’s what I was going to ask. So two months after we’ve put them on this sort of diet amount, we’re going to get them back. Okay, alright, cool, okay.
Ingrid Johnson:
Yeah every two months for a sanitary shave, you see, I keep circling back to the clean tushy. Every two months for that is about practical too, and a nail trim. So once we have that established that we’re like, okay, well she didn’t lose weight, but she does like this food and we’re feeding this way and she’s actively foraging. Now we’re going to go ahead and scale back on the portions of it. And we might actually leave the can alone, but we’ll scale back on how much dry we’re offering because cats are carnivores and they need meat and they’re going to do better with weight loss with more wet food if we can get them to eat it, so we usually start taking down the dry.
Ingrid Johnson:
And then sometimes what we do is we actually just make the dry even harder to acquire. So we start with those easy food puzzles, clear, rolls easily, multiple holes for the food to dispense from. She learns how to play the game. Once she learns how to play the game, the game gets harder. Those easily rolled puzzles now only have one hole of dispense food, or maybe they’re cubes, maybe we’re filling a small food puzzle and putting it inside a big food puzzle so she has to double work a double stuff toy. That’s going to be more time consuming and probably leave her a little frustrated and walking away from the puzzle going, I’m full, I don’t need to do any more of this.
Dr. Andy Roark:
Hey gang, I just want to jump in with a couple of quick updates. The first one is the newsletter, the Dr. Andy Roark newsletter. Guys I’ve been writing a lot recently and I really enjoy it. I’m just writing stuff that makes me happy and stuff that I think is useful and sort of responding to questions that people ask me. And it’s been a great fun exercise and it’s gotten a lot of really positive feedback. If you guys want to see it, it’s 100% free. Just go over to drandyroark.com, sign up for the newsletter and then you’ll get the writings in your inbox. And I’m trying to write about once a week. It may be once every other week, but it’s just kind of, I don’t like to write more than I have to say. And so my promise to you is when I send you something, it’s something I think is good and at least worth looking at and considering. So anyway, head over there, check that out, it’s 100% free.
Dr. Andy Roark:
I have the April Uncharted Conference coming up. It’s the 21st through the 23rd in person in Greenville, South Carolina. Guys, Uncharted is the conference that I founded five years ago, it’s our five year anniversary. It is unlike any other event out there. It is an active learning discussion based conference. We actually make some of the sessions at the event based on what we do our first night, so we have attendees get together and talk about what’s important to them and what they want to do, and then we actually create sessions based on that, so that you have the conference that you want to have.
Dr. Andy Roark:
It is all about discussion. It is all about active workshops where you take away things you can actually use in your practice. It is about making connections. It is about finding out what’s possible. It is super, super inspiring. And man, if you want to have your spark, your passion for medicine, for running your business, for growing your career, for leading teams, re-lift, if you want to develop young leaders who are coming up in your practice, guys, there’s just nothing better than Uncharted. It really is the conference that never ends because our attendees are members in our online community which is vibrant and active and so useful.
Dr. Andy Roark:
I feel like I’m overselling it, but I don’t think that I am. It really is something special. Check it out. April 21st through the 23rd in Greenville, South Carolina.
Dr. Andy Roark:
The last is my friend, the one and only Jamie Holmes is running her workshop called Put on your Pants, it is how to hold meetings that matter. If you are struggling to get on the same page with your team, this is a fan-freaking-tastic, quick to the point workshop to help you build a structure using the pants structure that will help you communicate effectively and run tight, effective meetings. This is bedrock business knowledge that you should have. If you have a growing business, you should know the basics, how to block and tackle and run great meetings, and that’s what this is. So it is free to Uncharted members, it is $99 to the public. I will put a link in the show notes. Guys, that’s enough from me, let’s get back into this episode.
Dr. Andy Roark:
We have an episode together and I have to look back, I think it’s the first time that you were on the podcast. It’s one of my absolutely favorite ones on losing weight for cats and foraging. Why don’t you give us a quick rundown on forging, because I love the way you present this and your insight on it. So let’s talk a little bit about how you do forging and food puzzles? How you, and when you increase in difficulty? Give me a mile high flyby please.
Ingrid Johnson:
Sure, yeah, so we want to start with puzzles that are really easy, that roll easily, have multiple holes for the food to dispense from, are lightweight and clear, so the cats can hear, see and smell the kibble inside. And then as they get better at the game, the number of holes to dispense the food decreases, the toy might become opaque, the toy might not roll so well, the toy might become a cube. And of course we have stationary food puzzles too, of which a lot of those are quite easy. So we have to look long and hard for some stationary puzzles that really present more challenge and problem solving.
Ingrid Johnson:
And then eventually when the cats get really good at foraging, we start either dummy stuffing by taking crinkled up balls of paper and sticking them inside the toys so that the kibble has to work its way around the crinkled up paper to find its way out of the hole. We might put weights in the toy to make it hard to push. We might double stuff the toy by filling up a small food puzzle, like my little foraging ping pong ball and putting it inside a little foraging cube, and now they have to work that cube to get the food out of two objects at once.
Ingrid Johnson:
So I do want to make the point that there was recently a study published, showing that food puzzles did not help with weight loss. However, I don’t think that they’re implementing all of these other suggestions. You know, you’ve got to do the high protein, low-carb food. You’ve got to make the puzzles much more challenging. If you utilize them the way I utilize them, I think the results sometimes are different.
Dr. Andy Roark:
Yeah.
Ingrid Johnson:
And more successful.
Dr. Andy Roark:
Yeah that definitely makes sense. Okay. Alright. Cool. So I like this. I like combining sort of the food puzzles and the forging with a two month check in cycle and sort of cutting down. Yeah, I like it, totally makes sense. What else we got?
Ingrid Johnson:
Well, we also have to remember this cat needs some exercise, so we have to engage this cat in some interactive play. And a lot of people will tell me, well my cat doesn’t play. Well, if we’re overweight and lethargic, we’re probably a little sedentary, so yeah, it’s going to be a little hard to motivate them, right? But we’ve got to find that toy that gets them going, we’ve got to evoke that prey drive, moving the toy appropriately and evoking chase. But then we also might have to spice up life a little bit, maybe we leash and harness train this cat, maybe we get this cat out in the front yard walking around, sniffing the grass and the…
Ingrid Johnson:
You know, just getting a little activity because now we have this novel environment that is evoking more movement and we can get the toy going out there in the grass, which is even more fun. So it really just depends on the individual, the client’s motivation, the cat’s capability level, all of this factors in, but we can click or train these guys. You know, that’s a great activity. Part of the meal and the portioned amount of food could be a treat that’s given during training. And that clicker training could lead us to walking on a cat wheel, which is feline treadmill, great way to get some exercise.
Dr. Andy Roark:
Yeah, this is the matrix bending I was anticipating, okay right here. That’s a lot. There’s a lot going on there. Okay. Let’s… There’s a lot going on.
Ingrid Johnson:
Possible.
Dr. Andy Roark:
It is. No it is, it definitely is. It is. It is. Okay, so there’s a lot there. If you by magic wand went to my client’s house and you were going to live there and just work with this cat, walk me through how you are going to start implementing these things, because it feels like we’re going from lying comatose on the ground under the sun to full on sprinting Usain Bolt style. And so, talk to me a little bit about what is your thought process? And especially if I’m explaining this to the pet owner.
Ingrid Johnson:
Yeah.
Dr. Andy Roark:
I could just see their eyes getting wider and wider and wider as I talk about leash walking and clicker training and, and, and. So start at the beginning. What’s the first thing you do? How do you tie these things together? What would your thoughts be on what’s the most realistic, reasonable approach to start introducing these ideas to the cat?
Ingrid Johnson:
Well I think first we have to remember that an appeal to the natural predatory sequence that is a cat. So everyone tells me their cat won’t play, but everyone tries to play with their cat in the evening, after they’ve sat down, after dinner to sit and watch TV. That’s nap time.
Ingrid Johnson:
The predatory sequence for a cat is to hunt, stalk, chase and kill. Well, let’s back up. They torture it a little bit, rip off a limb, very suffering death, and then they kill it and then they eat and then they groom and they sleep. So we’re going to play, and then we’re going to give that canned food portion, that first wet food meal.
Dr. Andy Roark:
Gotcha.
Ingrid Johnson:
And then for those… Because cats eat nine to 16 meals a day, many small meals a day. If you want to get a cat to lose weight, you can’t starve them into losing weight, that creates frustration behavior, and honestly I think in most cases slows their metabolism down. So no twice a day meals, none of that. So we’re going to have the food puzzles out throughout the day so they’re not frustrated and they can walk up to a puzzle and bat it around and get kibble whenever they want. So now we’re playing before meals, we’re getting wet food meals as the bulk of our diet. Then the dry food is put in the food dispensing toys to lessen frustration and anxiety because they want to make sure they always have access to their main resources. And then if we want to do a little clicker training, we might incorporate a clicker training session maybe before dinner and we teach the cat to target on a mat or touch a click stick. We have to start somewhere, so we might just teach them to target first. That’s a basic foundation behavior.
Ingrid Johnson:
And part of their meal, say they like chunks and gravy, well, they’re going to get a chunk for every click and treat. We can use their diet food as their reward, or maybe we use a high protein reward, like freeze dried chicken, something that’s not super calorie dense. We’re not going to be using temptations for this cat, we’re never going to get the weight off.
Dr. Andy Roark:
Yeah, right.
Ingrid Johnson:
So we have to start with some really basic clicker training foundations. And then of course we can build on that and teach them to hop on a wheel. I mean, I literally have a cat that I can say wheel and he jumps on the wheel and starts running. I realize that’s not every cat, but it is possible, you just have to stick with it.
Dr. Andy Roark:
Yeah. So it sounds like what you’re saying is clicker training is foundational in order to get to these other things. I mean, basically that type of training and interactive work is what is going to let us try things like harness training, leash training, cat wheel, things like that, correct?
Ingrid Johnson:
Absolutely. Yeah, absolutely. I mean, sure you can train your cat to a harness without clicker training, but I think it’s easier for people to have some structure. It helps them teach the cat because we’re very confusing and we’re terrible with our timing. I mean most humans are terrible at training.
Dr. Andy Roark:
I agree. Yeah, no, I completely agree. And I guess that’s sort of part of my concern going into this conversation was sort of like, I’m not even doing the training, I’m coaching another human being to do the training. And so that’s why I wanted to sort of unpack that and try to get down into it. It also seems like if we can get the calorie intake under control and we’ve got… They’re having to do some work for food that will possibly motivate them to engage in training and stuff in a way that right now, when mom’s like, I try to get her to do things and she’s not doing anything.
Ingrid Johnson:
Yeah.
Dr. Andy Roark:
She’s wholly unmotivated. So she’s [crosstalk 00:20:08].
Ingrid Johnson:
She’s [inaudible 00:20:09] from a trough.
Dr. Andy Roark:
Yeah, exactly, right. And so you have no leverage. I guess that’s what I was getting at is you have no leverage and Gertrude has no motivation. If we just start, even by changing our feeding and how we do it, we may be able to create motivation that did not otherwise exist. Talk to me about play a little bit, is it that once we start down this road and we’re doing some training, do you think it’s easier then to start to do some play? Does the cat get more interested in that or is that a whole different ball of wax?
Ingrid Johnson:
I think as the weight starts coming off, they tend to get more interested in the play. So even if we can just get a half a pound off, things start changing. And one of the ways that we can play with them is by tossing kibble on the hardwood floor and they run, they catch that one piece of kibble and they come back for another, and they don’t get another piece of kibble tossed until they walk at least halfway back to you. And that can be a great game. So rather than putting that portion in a food puzzle or just tossing it.
Ingrid Johnson:
And I would like to reiterate or just, I guess, drive that for cats that don’t like wet food, this can totally work for them too. We’re just going to put high protein, low-carb prescription food in puzzles and make sure that we’re controlling to some extent the volume of that they’re eating, but we’re going to appeal to those many, many small meals throughout the day. And I also have a kind of a sneaky trick.
Dr. Andy Roark:
Okay. Tell me.
Ingrid Johnson:
This works really well and seems highly counterintuitive. But a lot of these overweight cats, they’re eating a bowl of Friskies and they’re carbosauruses, and they don’t even want their wet food. And they certainly don’t want to switch to Royal Canine glyco-balance because it’s like one of my favorite foods for these cats. So we will put them on an appetite stimulant to make them hungry enough to accept the therapeutic diet change. And then we slowly wean them off and it works like a dream. And it’s also fantastic for those cats that need prescription urinary food that have struvite crystals and food is their medicine, and if they don’t eat this food we’re going to have a medical emergency. Make them hungry enough to accept the therapeutic diet change and then wean them off.
Dr. Andy Roark:
That’s interesting, I’ve never done that. That makes a ton of sense. That’s awesome. Were you reaching for your version of mirtazapine? Have you got something sexier than that? What do you reach for?
Ingrid Johnson:
Any of the above. Mirtazapine, Cipro, Entyce/Lora? We actually use Entyce more because it’s more concentrated, so you have to give less volume. We don’t understand why the cat version is less concentrated and you have to give more, it seems odd. So we typically work with Entyce, but we put it in a capsule because it tastes horrible. So we [inaudible 00:22:39] the cat with the Entyce in a capsule. And then Mirtazapine, I love that because you’ve got so much flexibility. You’ve got your little 15 milligram tabs, you can cut into eighths. You’ve got dissolvable mini melts from Roadrunner. You’ve got transdermal gel, so many options.
Dr. Andy Roark:
Gotcha. That totally makes sense. This is great. Thank you so much for taking time and doing this with me.
Ingrid Johnson:
Sure.
Dr. Andy Roark:
Tell me a little bit, can people still get foraging toys from Fundamentally Feline?
Ingrid Johnson:
Absolutely they can. I’m making them as fast as my little fingers can be [inaudible 00:23:10]. I hand make all of my foraging toys and they are all available for sale on my website and they’re quite inexpensive really too. So yeah, please feel free.
Dr. Andy Roark:
Awesome. So yeah, I’ll put a link in the show notes. Fundamentally Feline. You are on social media as well under that, and then your websites fundamentallyfeline.com. Ingrid Johnson, thanks for being here.
Ingrid Johnson:
Thanks so much. Appreciate it.
Dr. Andy Roark:
And that is the episode, that’s it. That’s what I got for you guys. I hope you enjoyed it. Hope you got something out of it. As always feel free to leave me an honest review on iTunes or wherever you get your podcast. Just let people know what you think of the podcast and let’s help people find us. Anyway, take care of yourselves. Be well. Talk to you later. Bye.
Editor: Dustin Bays
www.baysbrass.com
@Bays4Bays Twitter/Instagram
How Adobe Animal Hospital is Doing Work-From-Home & Virtual Vet Medicine
Imagine a CSR working from home, checking a client out and booking appointments from his home, or a technician live-chatting with three different pet owners through the clinic webpage from her apartment, or a doctor doing telemedicine appointments from another state? This isn’t fantasy. There are practices actually making these things happen today. Christina Freeman and Summer Burke-Irmiter join Dr. Andy Roark to talk about how their clinic is breaking the mold to give employees (and clients) flexibility like never before. Let’s get into this episode!
LINKS
Uncharted April Conference: unchartedvet.com/uncharted-april-2022/
What’s on my Scrubs?! Card Game: drandyroark.com/training-tools/
Dr. Andy Roark Swag: drandyroark.com/shop
All Links: linktr.ee/DrAndyRoark
PICTURES
ABOUT OUR GUESTS
Christina Freeman joined the Adobe family in 2015 and focused her first few years in the Veterinary Marketplace. She was excited to move to the remote team and work with our online chat services and telemedicine and help these new communication tools grow and evolve. Christina is a native of North Carolina where she currently lives with her family and a large collection of animals great and small. Christina has a retail background and degree in Animal Science from North Carolina State University along with a teaching certification in all things science. She spends her spare time chasing children, gardening, doing pottery and oil painting.
Summer Burke-Irmiter, MBA, has worked in veterinary hospitals for over 25 years. At the Uncharted Conferences, you will find her proudly wearing her Founding Member button and excitedly talking about her two amazing hospitals with over 22 doctors, the Open Hospital design which allows clients to go wherever their pets go and pitching her latest outlandish ideas to anybody who will listen. She’s earned the nickname of “Goddess of Innovation” in some circles (along with other nicknames we won’t mention here) by helping to launch remote teams at Adobe over 9 years ago, pushing for video visits a year before the pandemic, and touting the benefits of online chat to her team. The recent development of Video Client Representatives is one of the many creative solutions Summer has to solve common issues in our industry. Summer runs away to the circus every chance she gets and trains in Cirque du Soleil type arts such as lyra, a spinning hoop 6-12 feet in the air.
EPISODE TRANSCRIPT
This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.
Dr. Andy Roark:
Welcome everybody to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am so excited about this episode. I am talking today with my friends, Summer Burke-Irmiter and Christina Freeman from Adobe Animal Hospital. Guys, imagine your vet clinic for a second. Imagine that the technician is in the exam room with a pet owner and he’s going over the medications to go home. And he asks the pet owner if they have any questions and they say no. And he says, “Great.” And he taps the screen on the wall, and one of your CSRs who’s working from home, perhaps this person, son lives in another city or another state appears on the screen.
Dr. Andy Roark:
There’s a credit card reader mounted on the wall, and this person working from home checks out your client, asks any questions, schedules up follow-up visits, all of those sorts of things. And meanwhile, in between appointments, this person is chatting through your website with multiple pet owners at the same time, as opposed to talking just one person on the phone. Guys, that’s life at Adobe Animal Hospital. These guys are doing amazing things. I’ve got pictures that you need to see. I’m going to put them in the blog. I’ll put a link in the show notes so you guys can drop down and see it.
Dr. Andy Roark:
But at their hospital, at the front desk, there are literally screens turned around to face the pet honors and they have CSRs working virtually at their front desk. Gang, we talk and think a lot about what does the work from home revolution look like in that medicine? Guys, the truth is there’s a lot more things than we have thought of in the past. Get ready for a mind-bending episode about what one practice is actually doing in virtual medicine, in work from home in the vet space. I love this conversation so much. Anyway, gang, buckle up. Get ready for a great one. 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, Christina Freeman and Summer Burke-Irmiter. How are you guys?
Christina Freeman:
Good. How are you?
Dr. Andy Roark:
Doing really good. I am super excited for this conversation. For those who don’t know you… Let me just say why I’m excited for the conversation, and then I’ll introduce you guys through that. You guys work at Adobe Animal Hospital, which is out in the San Francisco Bay Area. You guys are part of Uncharted, which is a community that I love and get to run. And you have been for a number of years and you are one of my fanboy hospitals that I crush over because you do these cool, cool things. You were the first hospital that I was aware of that was an open hospital, meaning that people could go basically wherever their pets go.
Dr. Andy Roark:
My head hurt for a week after I first talked to you and really came to understand what you were doing and what that meant. You guys just, you do these things that get me excited and just remind me about what’s possible, and that medicine can be very different from what it has been in the past. And so I am a huge fan of you guys and the work that you do. Summer, you are the hospital administrator and the owner. Christina, you are the remote manager, which is how we come to be here today. Summer shared with me a couple of weeks ago, a new program that you guys were rolling out with what you called video client representatives.
Dr. Andy Roark:
So I’m not talking about CSRs that are answering phones from home. I’m talking about you guys have screens in your lobby that people can see traditionally, a CSR, a customer service rep. That they can see the customer and they can check out with this video screen. And you have people not just answering phone, but actually dealing with clients in the building while they, the employees are at home. And that’s amazing to me. And so I was like, “I want to talk…” First of all, I want to go through the system with you. I just want to unpack it and understand what you guys are doing.
Dr. Andy Roark:
I’m so impressed with just… And let me just say this too. I know this is a new program, you’re only doing it for a while. I love that you are doing this and putting it out, and I just think that so many people, as we’re looking at the great resignation and people changing jobs and also battling burnout and people being able to work from home. That has been shown to decrease levels of burnout, when people get to spend some time and say, “Hey, I’m changing my environment. I’m going to work in a more relaxed place. Even just a limited amount of time.” I am really looking hard at burnout. I’m looking hard at efficiency. I’m looking hard at making the jobs better and more flexible.
Dr. Andy Roark:
And I feel like you guys are actually out there in the wilderness doing the thing. I didn’t say you were lost in the wilderness. I said you are out in the wilderness, more of a Lewis and Clark, like headed westward sort of feel. That’s, how I feel about it.
Summer Burke-Irmiter:
Definitely.
Dr. Andy Roark:
Definitely. Those are the things I’m geeking out about, and so let’s go through. I just want to go ahead and start to walk through the journey that you’ve made so far with you. Go ahead, why don’t you guys tell me just a little bit about Adobe. I mentioned a very high level. Give me a clear picture of what you’re working with as far as the hospital, what makes it special? Just so people can have a mental picture of Adobe and what we’re talking about.
Summer Burke-Irmiter:
I’ll jump in there. Adobe is a really amazing place. We have two hospitals here in the Bay Area, one, which is a 15-exam rooms, three surgical suites, full cat and dog ICU, full lab and pharmacy. And so we’re big and I love it, 15 exam rooms. Overall between our two hospitals, we have 22 doctors and about 145 team members. Yeah, we’re a big guy. We have a second location about 20 minutes away that’s six exam rooms, ultrasound suite. They can still do major surgeries. They’re open six days a week there.
Summer Burke-Irmiter:
You mentioned the thing that I think makes Adobe special and amazing, which is the open hospital. So clients can go with their pet to ultrasound. They can help us set up an x-ray and then step out. We do vaccines and blood draws in front of owners. And because of that, our have a different level of trust with us. And our doctors all practice the medicine, they feel as best. So as a business, we actually don’t have a lot of hard lines with our medicine and what we recommend. We want the doctors to talk with the patients and the clients decide what the [crosstalk 00:07:15]
Dr. Andy Roark:
Talk with the patients too. You never know what you’re going to get.
Summer Burke-Irmiter:
Where are they going, what their risks are. For vaccines, we don’t say you give every puppy these set of vaccines. You talk with the owner and see what’s going to be best for that puppy and for that owner. Those are the two big things that I think make Adobe in general. Christina, what would you add to that?
Christina Freeman:
Truly the open hospital, I think is one of the big things that makes Adobe different and drew me to Adobe. When I first read that applying, I was like, “Oh, that’s awesome.” I had grown up in a little small town hospital where I got to go wherever I wanted to go, but yeah, I saw other people not be able to do that. So it important to me. It honestly gives a huge hospital that small town feel because you’re part of your pet’s care. I think that was definitely one of the things that drew me to Adobe.
Christina Freeman:
I’m not from the Bay Area, I’m from North Carolina, which is where I currently live. Why? I’m the remote manager, but I think what’s kept me with Adobe is just the constant creativity and growth, and the fact that we’re always changing things up to make things a little bit better for namely the pets. That’s always the first and foremost. That’s how we’ve gotten here, is keeping pets first.
Dr. Andy Roark:
Talk to me a little bit about the idea of remote work. When did Adobe start to really look at this as a concept? You guys were way pre pandemic when you started to kick this around. People are like, “Oh my God, look how far they’ve gotten in the last two years.” And I’m like, “No, you guys were way out ahead starting to work on this.” But help me really understand that, when did this idea of remote employees, when did that come together and why did that come together?
Summer Burke-Irmiter:
It’s been some while so I always have to remind myself. I think it’s eight to nine years ago we started.
Christina Freeman:
Yeah.
Summer Burke-Irmiter:
What happened is, here in the Bay Area, the cost of living is very high. A starter home within an hour of Adobe, you’re going to be at least 600,000 plus. And so a lot of our staff already live farther away, and then if you’re going to buy a home and raise a family, oftentimes our staff would move out of the area. And that’s what happened, is we had a staff member who was going to leave the area and we didn’t want to lose them. We all know how hard it is to get really great staff. And when we were faced with one of our staff members moving, we were like, “No, we need to make this happen.” I was like, “I need to make this happen.”
Summer Burke-Irmiter:
We keep good team members. They’re part of our Adobe family, and so how do we do this? And why are we limited by our building? Why can’t we do more? And so there’s so much work to do. There’s always work to do at Adobe, and so we just started figuring it out, really just one step at a time, lots of trials and errors, but it was to keep our team members. And so that original person did start out, I think like many hospitals now have a remote person, which is helping answer phones, helping call back clients for us. So it did start small and it just kept growing.
Dr. Andy Roark:
You guys also started to do remote communications with pet owners. Tell me a little bit about that. That’s different from having people work from home. That’s having pet owners stay home. How does that come into this?
Summer Burke-Irmiter:
One of the areas that I was really excited to explore was getting into chat. I don’t know about you guys, but pre pandemic, I loved chat. I actually had apparel companies that I would chat with all the time back and forth. I was on Zappos once and buying shoes. And I was chatting with this CSR on there with a question about the shoes and we ended up talking her cute pit bull that she just rescued. And so I saw that you could have a connection and get really great, fast help. And so really started looking at different platforms, what could we use? That’s where we initially settled on live chat, and this is where Christina actually comes in and I’ll let you take it from here because you can give all kinds of information.
Christina Freeman:
Yep. That was Summer’s crazy idea. I came to her and needed to move back for my family to North Carolina and she said, “Well, if you’ll stick with me, I’ve got a crazy idea. What do you think?” And I loved it, and so we really started small. It was truly just, we had a couple people trying some things out, but when we first started chat, it was just me for the first couple weeks. And then we grew to a couple people and added one of our doctors who was remote at the time or starting in the remote world. We were shocked at how fast our clients adopted it. Through the live chat platform, we just popped a widget up on our website.
Christina Freeman:
And so whenever someone would come on the website, the way we started originally was very organic. We would ask the client if we could help them with anything. And they would say yes or no, or some were thrilled. We really found… I think at first we were all like a little bit worried it would feel impersonal, so we really tried to give it a good conversational spin and not using forms and things like that. Just really us talking because I really wanted to create the atmosphere that this was real people, real Adobe people who knew what they were talking about and we were not a robot, and it worked. And our clients adopted it and really quickly and started coming repeat back questions day after day after day, short, little questions.
Christina Freeman:
Little questions about the hospital, little questions about their pet. We love it because we can send videos and pictures back and forth. That really helps us triage, especially like a surgical patient. We can look at that incision site without the client having to drive in and we can get really good images too. So we were thrilled at how interactive we could be with the clients. Another thing that I think surprised Dr. Lau and I, when we were first doing this, we would cover a lot of the evening hours. And we had a lot of our senior pets or our hospice pets that would come day after day after day.
Christina Freeman:
We got really invested in these people and their pets and their journey through what they were going through and just really created a nice, comfortable rapport and atmosphere with the clients that you don’t always have time for in the clinic. And so we really found it not only helped clients, but it sometimes enhanced their experience with us. That was really rewarding and kept us pushing. And as time went on, word got out. And so we became pretty overwhelmed pretty quickly with the load. And so we’ve grown our team from one to 24 in the last two years or three years, I guess and we’ve been really pleased at how the clients and the staff members love it.
Christina Freeman:
We have some staff who still work in hospital that help us with chat, some on a part-time basis, so they’re part-time remote, part-time in hospital. And now we have a lot of people who are fully remote. And it’s helped with people whose life has changed or a medical condition has changed. And so we’ve really been able to keep our good people and keep their skills in this field through this.
Dr. Andy Roark:
I have to point out the elephant in the room here, at least what it is for me can. One, help me understand what chat looks like. I guess what I’m saying is, what are the most common things that people ask? And then two, the reason I’m asking this is, when you guys are talking about chat and you’re very excited about it and you seem to really love it. I’m imagining complete pandemonium in chat of like your own social network and people talking about their grandkids and and like a Friendster network on my webpage. Conviince me of the return on an investment of chat.
Dr. Andy Roark:
You have 24 people doing chat. As a business owner, I’m like, that sounds like a nightmare. Convince me of the value of this. I’m trying to get my head around what this really means for the pet owner and what it means for you guys from an efficiency standpoint. It like more, not less and I want to get my head around that.
Summer Burke-Irmiter:
And actually before-
Dr. Andy Roark:
You’re both laughing real hard as I say that. I think I’m probably having all of the anxiety and the nerves and the worries that you had at the beginning. I’m having this now of… But first of all, my first thought would be, what if this fails? And my second fear would be what if this succeeds? And I can panic in both directions. Talk me down off this ledge.
Summer Burke-Irmiter:
Well, actually I’m going to add to that ledge just a little bit.
Dr. Andy Roark:
Holy crap.
Summer Burke-Irmiter:
It’s not to brag and just really show how big this can get. Christina and her remote team, since we started the live chat in 2018 have helped 60,000 clients. They’ve taken 60,000 chats. And now that’s not the back and forth that you can have. That’s not counting each one of those. That’s a single session with a client. I’m going to add that mind-blowing right there.
Dr. Andy Roark:
I feel like you’re helping people in Brazil. That’s what I feel. I feel like there’s people who’ve just found you and they’re like, “These people will talk to me. If you’re lonely and have a pet, they’ll talk to you.” That’s what I feel like. Is that true?
Christina Freeman:
There was a handful. I think the farthest I’ve ever spoken to someone was Singapore when IAMS Pet Food stopped creating their vet diets. It became like this frenzy of finding people with these products. That’s as far as it’s gone. but for the, I would say 97% is our actual clients. We are careful, we don’t, we do. Every time we start a conversation, we get the pet details. We look up their record.
Dr. Andy Roark:
Smart.
Christina Freeman:
If they’re not our clients, we do recommend that they speak to their local hospital, just so that history is with them. We’re not trying to push people off, but we do feel like, don’t talk for me for 30 minutes about diarrhea and then go to your hospital and expect them to know what we talked about. That is one thing that we are pretty careful about. And the great thing about the chat is every single thing we say, every single thing we share, we upload into the medical record, so when that pet does come in a couple days later or later that day, it’s all there, that history’s there. So they don’t have to go back through that again, our medical staff can read through that.
Christina Freeman:
Just a short thing on the ledge, and I know Summer can, can help remove people from the ledge quickly, but what we’ve done with our team is allow the in-hospital team to focus on the pets that are in the building, rather than you’re sitting there helping a pet and you’ve got four people waiting on the phone that have a question for a doctor. We’re able to take that load from them so they can focus. And we can seamlessly help the client. The client has no clue in cases that we’re not actually in the building.
Christina Freeman:
We stay in constant contact with our doctors who are on the floor, they’re feeding us advice. And so we’re able to take that load off of the team in the building who need to focus 100% on the pets.
Dr. Andy Roark:
Okay. No, that makes a ton of sense.
Summer Burke-Irmiter:
And you bring up a good point there, Christina is one of the reasons we started looking at this in 2018 is at that time, if we all can remember past then. I know it’s been eons, seems like a decade, not just three years, we were already experiencing that short staffing with technicians in particular. With the high cost of living in the Bay Area was compounded, and Adobe had always offered medical advice to our clients. We’re probably way more open than most hospitals about that client calls. We will talk to them through, make sure there’s no contraindications. And then if it’s that vomiting lab, we’ll go ahead and give them a bland diet, what to look for and when to call back.
Summer Burke-Irmiter:
And we were looking at losing that. That was something that I felt was really important to Adobe. And by figuring this remote piece out, we were able to keep something that I thought was part of Adobe and part of Adobe soul and just move it out of house. And that worked out really well. And yeah, to talk you off the ledge there, Andy, there are some tips and tricks behind the scenes with these chat systems that really make it helpful. One of which is, and this is good for everybody to know, they can see what you’re typing before you hit enter. Remember that.
Dr. Andy Roark:
Really?
Summer Burke-Irmiter:
So when you’re about to be like [inaudible 00:21:10], and then you erase it, they saw it.
Christina Freeman:
They see all that.
Summer Burke-Irmiter:
You see all that. So when you can already see somebody typing out about the diarrhea, and then what you’re doing is there’s scripts that Adobe did, ourselves, but you can have a diarrhea script. So as soon as that client is done, you press enter on the diarrhea script and it’s got all the questions we always ask. How is their eating? How often? What’s the color? All of that. So then that gives you a minute to either work on another chat. Our chatters who are super experienced can take multiple at a time. You can’t take multiple phone calls at a time per person, but you can with chats.
Summer Burke-Irmiter:
Or it gives you that moment to either take a breath or to do another task, which is a lot of what the remote operators they’re doing. They’re then working on something else while that person fills in their answers with the diarrhea. And you’re already seeing again what they’re doing. So if you’re like, “Ooh, they just said blood.” You’re going to be ready for that and you’re going to get them in the hospital. Or, this is where Christina mentioned Dr. Lau. We have two remote doctors for video visits, which came in 2019. And those doctors also help the remote team with advice, questions of, “Hey, what should I recommend for this?”
Summer Burke-Irmiter:
Or if it’s more specific, “This client is asking a medication question that their dog’s currently on. Can you help us with this?” And so that’s where behind the scenes, they’ll also with that. There’s a lot of tools behind the scenes to help out with those 60,000 chats that they’ve taken.
Dr. Andy Roark:
Okay. I have some questions. Let me start to dig into this. The idea of having some scripts makes total sense, and especially like follow up questions of when they talk about diarrhea, here are the follow-up questions. That makes my innovative efficiency smooth workflow heart so heavy. And so that totally makes sense. Okay. Talk to me a little bit about chats uploading into the medical records. That sounds like it could be a Herculean task. It also sounds like it could be turnkey smooth as silk. Which one is closer.
Christina Freeman:
You’re in the middle. One of the things Summer and I have been talking about recently is there are some pain points in some of this because we’re starting at the very beginning. But the great thing about it is the companies are really listening to us that we’re working with. We are feeding them our problems and they’re helping us solve them. So that has been great. It’s been challenging to be in it, but it also, we are discovering the problems as we go that need fixing. And so the companies are super helpful to help us. We are transitioning with companies major that reason. Right now it is manual, we do copy and paste this into the record, and we’re talking about six key strokes to get it in the record.
Christina Freeman:
But the company that we’re talking with now is going to make that automatic. As soon as we finalize that chat, it’s automatically fed into the record. This has been fun to be on the innovative front of like, “Okay, here’s our problem. Help me solve it.” And so that’s going to speed us up. Summer mentioned, part of the glory of chat is we can do multiple things at the same time and we can help clients at the same time. When you’re speaking medically, and you’re looking for medical records, and you’re having to bring up the pet of, if you’re a seasoned chatter, three is tops because you need to be focused and make sure, like three pets at a time.
Christina Freeman:
But as Summer said, you’re stuck on the phone with one call, where with a chat. And also you don’t get those visuals that we can get via chat. We can say, “Hey, could you go snap a picture of that?” The owner runs away and snaps a picture and comes back while we’re helping another client, or we’re picking up a phone call or we’re answering an email. So there’s a lot of other administrative things that we can do behind the scenes while all this is going on, while we’re also helping pet owners via chat.
Dr. Andy Roark:
Cool. Who are the companies that you’re working with on your chat?
Christina Freeman:
Well, we’ve been using live chat and we’re transitioning to TeleVet. And TeleVet is a more veterinary-centered product that is helping us build the things we need and these automated things.
Dr. Andy Roark:
Hey, everybody, I just want to jump in here with a couple quick updates. If you’re listening to this podcast and you’re like, “Oh my gosh, vet clinics are doing stuff like this. This is amazing.” You should join Uncharted. The Uncharted Veterinary Conference and Community, that’s where I met Summer and Christina, is where we learned about Adobe. This is the type of stuff that we talk about in there. Everything from open hospitals, where pat owners go wherever they want to virtual medicine, to work from home, to the classics about getting the staff to come together as a team.
Dr. Andy Roark:
Building culture, solving problems, growing people as leaders and communicators and visionaries. That’s what we do in Uncharted. If you’re like, “God, I want to live in this world. I want to practice medicine in this other way. I want to be the captain of my own ship.” Check out Uncharted. Guys, our April conference is coming up, April 21st through 23rd. If you’ve not been to an Uncharted conference, I promise you have not been to anything like this. We do choose your own adventure sessions where attendees make sessions on the first night that we then put on during the event, it is all networking focused.
Dr. Andy Roark:
You will make friends. You will talk to people who are doing incredible things. You will get re-inspired, you will get reinvigorated. You will learn techniques and tips and tricks and strategies for running a smoother, more efficient, more rewarding vet practice. That is what this conference is all about. The 21st to the 23rd, is in Greenville, South Carolina. I’ll put a link in the show notes. You can become an Uncharted member. We have a vibrant online community. We talk constantly. It is not a thing where people get in there and it’s a ghost town or where there’s canned content.
Dr. Andy Roark:
We are constantly talking as a community about solving problems, about growing practices, about doing new and different things. About making our lives better and easier, about handling hard problems together as a group. That’s what we do. So anyway, if you’re not familiar, if you haven’t tried out Uncharted and this episode is inspiring you, this is your call to action. This is what you need to do.
Dr. Andy Roark:
Gang, I also have to stop here real quick and just say, thanks again, to Banfield Pet Hospital. Through their help, we’re able to have transcripts for episodes. And this is all about increasing accessibility, inclusivity in vet medicine, and making sure that everyone has access to the materials that we’re putting out. We could not do this without them. They have supported The Cone of Shame and having transcripts and The Uncharted Veterinary Podcast, which is our other podcast. It’s a business management podcast. But thanks to those guys for stepping up and leading the charge to make vet medicine more open and inclusive. They really are doing amazing things. Anyway, guys, that’s all the announcements I got. Let’s get back into this episode.
Dr. Andy Roark:
Talk to me a little bit about how the veterinarians support this. You’ve got veterinarians that do telehealth visits, and I want to put a pin in that and come back to that in a little bit. But let’s just say that you have veterinarian behind the scene that is lending support. How do you back channel that? You’ve got someone and they’re working remotely, I’m assuming, and then they’re doing the chat, and then they’re… How does that person feel supported and not feel like they’re out by themselves? How are you handling that behind the scenes communication?
Christina Freeman:
It’s been interesting. Being remote, we have built some closer relationships than we ever had in the hospital, which we… I’ve been working with Dr. Lau for three solid years all day, every day and I had never actually gotten to hug her until about six months ago. And we actually converged accidentally at the same time on a trip to California. She works and lives in Virginia and I work and live in North Carolina. We’re close, but it just hadn’t happened. But it is remarkable the trust that we’ve all built working together. We are in constant contact via… We use Google Hangouts a lot.
Christina Freeman:
We do a lot of remote training together with each other and with our new team members that we’ve grown so quickly where they are just on video all day with us, and they’re just watching what we’re doing or vice versa. We’re watching what they’re doing. So we are literally, virtually side-by-side all day, every day, which has been really good for team building and bonding and training. We’ve been really surprised at how the efficiency of our training through video. And it’s also grown into like we’re starting to train some in-hospital people through video because it is so efficient and we can be a little bit more open about times and hours and availability.
Dr. Andy Roark:
Let’s let’s follow that thread a little bit. So I said we were going to put a pin in the telemedicine doctor visit stuff. Let’s follow the video path. So we’ve talked a lot about chat and then let’s talk about how do you guys use video… I started off talking about the video client representative but let’s go into the telemedicine part first, just walk me through your approach in video communication.
Christina Freeman:
A lot of our chats do generate into a video visit. So we’re having a conversation with an owner and we’re talking about new puppy owner. They’ve got a lot of puppy questions, but they also have got diarrhea going on at the same time. So pet stable, we’ve answered all the scary questions and everything’s okay. So very natural progression to move into a video visit with one of our doctors. That lets the owner be at home, they don’t have to come in, that lets the pet be at home, be comfortable. And we’ve seamlessly gone from the chat to now a video visit where they meet with the doctor. The doctor’s able to see the pet and evaluate what’s going on. Medication is needed or give a little bit deeper advice on how to get that pet back on track or what that puppy might be experiencing.
Christina Freeman:
Same thing on the senior side where owners contact us and they have a senior pet, got some concerns. We’re able to move that into a video visit pretty seamlessly most of the time, same day. So it’s very convenient for the pet owner, they don’t have to leave the house. Sometimes we can go straight from a chat into a video visit if we have availability. Now that we have two doctors, that’s quite often what we do. So a lot of our more, I don’t want to say simple but more straightforward issues, that’s how are born from chat into a video visit the natural progression.
Dr. Andy Roark:
Good. Talk to me about doctor scheduling for this. So again, I really appreciate you guys just letting me pick through this. So that’s the other thing. People always say, “How do you have doctors…” I think that’s a big hurdle for Telehealth is how do you make the doctor’s schedules work? So do pet owners have the ability to make telehealth visits? And then also we flex chat appointments in to fill that schedule out. Is there a standby vet just support chat? Did that happen at the beginning? Or did you add in some Telehealth visits after you had built the chat up and you were having these conversations and you felt like, “Oh, now we’ve got enough of a caseload that would support this vet.”
Dr. Andy Roark:
Yeah. Share with me your thoughts on that because there’s a lot of people who were like, “Oh man, we’ve been talking about Telehealth visits… I think for me, when I look at Telehealth, it makes sense if you can generate the volume. Because otherwise you’ve got that hanging out, not seeing appointments. And then if they go and start seeing appointments in the physical exam rooms and you say, “Well, how do we get them back out to be on time for these other things?” I think a lot of people are balancing these logistics and you’ve got this really neat outside around the way you have done this. And so yeah. Talk to me a little bit about doctor scheduling for these types of Telehealth appointments.
Summer Burke-Irmiter:
Okay. So yeah, with Dr Lau, who I have to give credit for, for finding our video visit platform. She found TeleVet and we originally thought we would go with a human-based video visit company because they were established, they had worked through the kinks. But it turned out that the human systems were super complicated and really didn’t fit the veterinary world. So with TeleVet, the reason why we originally got excited about them is they had chat on their platform and we’re like, “Okay, if we have chat and they have chat, this might work out well.”
Summer Burke-Irmiter:
And they were super responsive. What we didn’t realize at the time is the reason they were responsive is they were I think a two and a half person company at the time. And it was the big male who was chatting with us. Straight awkward, but. But we loved the response, we loved how engaged they were, the platform fit well, and then as we onboarded and started getting used to it, they would make all these tweaks and changes that really fit us. And again, that’s what called to my heart is we were making this fit for Adobe and that was really fantastic. So I’ll stop there though and let Christina talk a little more about the scheduling and how the juggling that they do over there is amazing.
Christina Freeman:
Well, in the beginning it was just Dr. Lau and I, so we had luxury and the flexibility of being at home and so we worked when the demand was high. And so we were able to monitor the website and know when people came on the website and so when they came on, we made ourselves available and we were there to chat with them and help with them and I’d ping Dr. Lau and be like, “Hey, can you do a video visit?” And she’s like, “Sure.” And scrambling together from whatever else she was doing. So we were very organic in the beginning in the fact that we just saw when our clients were needing us, and so that’s what we did.
Christina Freeman:
As we grew, we needed more structure, we needed a life. We were available 24/7 in the beginning just to get this work in it had figured out. But then we really did discover the peak times that clients wanted and needed us. And so we built a Dr. Lau’s schedule around that. And then as we added Dr. Nakamura as well, he balanced the other parts. So we do have a doctor available to our chatters and for video visits seven days a week between the two. And I guess truly what we did is we looked at the peak request times and managed our time from that. So if you want to get started small, totally able to do that, look at your clientele, look at when they’re asking for things, just very generalizing. It’s going to be early evening hours and sat morning hours when clients first get home from work and they discover there’s a problem.
Christina Freeman:
So you get home from work at 5:30 and you’re like, “Oh, my puppy has diarrhea.” Or you get home from work and you discover your senior has had some changes during the day that you need some advice. And so running some hours in the evening, two or three hours to fit in those requests between getting home and people going to bed. And then those Saturday mornings where you wake up and you’re like, “Oh, I should have called the vet on Friday.” Everyone knows what calling a vet on Fridays is like, so that’s the way we started in the beginning. But now as we’ve grown, we have the luxury of having 24/7 or 7-day a week help during our peak hours.
Dr. Andy Roark:
Gotcha. Okay.
Summer Burke-Irmiter:
And also, especially early on but they still do a ton now. There was a lot of duties that the in-hospital doctors were doing that remote is able to help with and Dr. Lau and Dr. Nakamura are able to help with. So they actually do a few things. They do a lot of the general refill requests, so that now goes on a live spreadsheet online that they can access so they can go through there, especially for doctors who are on vacation, who aren’t going to be in for couple of days. So instead of the technician or the pharmacy tech having to go to that doctor at their desk and be like, “Hi, sorry, but you look at this heart garden prescription.” They actually do that first thing in the morning.
Summer Burke-Irmiter:
And so pharmacy gets in, they’ve got meds to fill or clients to immediately call back and say, “I’m so sorry, the doctor’s really suggesting that we need to do this blood work first. We’ll get you a couple days worth.” So they do a lot of that. They’ve also taken on a lot of doctor flow things in regards to, “You know what? It’s that last day of your work week and you just did blood work on a patient. They need to be called the next day. It’s not one that should wait until next week when you’re back, the remote doctors will help with that.” And they also can help with bridging even if you have two doctors on a case, that’s outpatient, then they can actually help bridge with some of those callbacks as well.
Summer Burke-Irmiter:
And so they’ve helped with a lot of in-hospital things. During COVID, we were doing our shelter in place here in the Bay Area. They also became what we call the COVID doctor would help with all kinds of things just because we did go curbside, which was a huge change for Adobe from open hospital. And so all that extra work, they really helped out a ton with that. So we did initially, they weren’t booked with video visits all the time, they were helping with that. We’ve actually, over the last couple years had to reduce how much that they’re doing of that admin work because they are getting busier and busier there.
Summer Burke-Irmiter:
And actually he’s okay with me being pretty open about this. When COVID hit, Dr. Nakamura’s immune compromised. He had to leave. And if we didn’t have this option, he wouldn’t been in the hospital for a year and a half. So we didn’t lose the doctor, added a doctor. He sees exotics as well, and a lot of the husbandry for exams is really nice to do because you can see the tank, you can see what they’re using, what they’re set up is by using that video camera.
Dr. Andy Roark:
Yeah. So that makes a ton of sense. So we’ve talked about chat, we’ve talked about video consultations. What are some other jobs that you guys are doing now remotely at Adobe?
Summer Burke-Irmiter:
Yeah. I’ve actually got the list in front of me. Christina, do you want me to read it-
Christina Freeman:
Go for it.
Summer Burke-Irmiter:
… off real quick? Okay. So with our entire remote team, they do voicemails. So this is doctor voicemails transcribing them into an online live document. Doctors, go on and say, “I’ll call this one, I’ll just call this one back and do a recheck.” They’ll then go ahead and call that client. They’re doing our advice lines. So we do allow clients to still call in if they be to for medical advice and or triage. And so they’re doing those advice lines, they’re doing live chat, they’re also looking and using TeleVet, especially for prepping clients for their video visits, things like that. They do pharmacy. We actually have a large pharmacy group now of pharmacy technicians who do all the admin work for on the floor pharmacy techs. Surgery, this is actually, I want to say something here. Surgery scheduling. Sorry.
Dr. Andy Roark:
Okay. Yeah. That’s appears [crosstalk 00:41:50] like virtual surgery.
Christina Freeman:
Little robotic arm.
Dr. Andy Roark:
Yeah, exactly. We have a robot and they log in with a PlayStation controller.
Summer Burke-Irmiter:
Well, actually that’s our next, that’s where we’re going to.
Dr. Andy Roark:
That’s where we’re going next. Yeah.
Christina Freeman:
We’re headed there.
Summer Burke-Irmiter:
Is robot doctors. But until then. So surgery scheduling has been an issue in Adobe since I started 14 years ago. We’ve always had our surgery team on the floor who scheduled. And then we had one full-time scheduler in-house. Pre pandemic, it was sometimes embarrassing to admit this. It was up to 14 days before you might get a call back to schedule a surgery. And we were just so busy, the team was busy, our single scheduler was busy. And with all of our different doctors, it’s not easy to schedule. And it’s not because of the team. The team is just busy. And so we have now through a year long process, fully moved this over to remote.
Summer Burke-Irmiter:
We have a surgery scheduling team. They schedule all of our surgeries. We are within actually a couple of days of them. 100% taking it over after training and a prolonged period there, they got to same day callbacks within less than a week. So they now do same day call back for all of our surgery scheduling, take care of the entire process. We do now still have our surgery scheduler in-house when she came back from COVID and maternity leave. So get this, during a time when we’re all short staffed and crazy, we were actually able to add a service. So be because this full-time scheduler is not doing any of the emails or voice messages that we’re getting for surgery, she’s able to go directly into the room. If somebody wants a schedule right now, she’s in the room and she’s scheduling it. So we have an in-house in-room scheduler because we have this team taking care of everything else.
Dr. Andy Roark:
Yeah. That’s amazing. Let’s go ahead and unpack here at the end where we started. Talk to me about the video client representative and how that works and how you rolled it out and what the reaction has been to you having virtual CSRs, actually working with clients who were in the building.
Summer Burke-Irmiter:
Yeah, I think it’s probably the craziest idea my team has let me do.
Dr. Andy Roark:
I saw photos and I was like, “This is bonkers.”
Summer Burke-Irmiter:
Yeah. When I brought it up, I think they all thought it was crazy. You could have beat it, Christina.
Christina Freeman:
Nope, totally on, totally on. It was born out of true necessity. We just didn’t have enough people in the hospital to cover the front desk. And so, someone and I were talking one day and we’re like, “Why don’t we just turn one of those screens at the front desk around and put me on it?” And that’s what we did. And we tried it out. And so it grew into… It started out with we wanted to do in-room checkouts. So each room has a computer, the doctors use to access the medical records. And so we just hijacked that computer and added a camera on. And so that was where we wanted to start, but it grew into the whole process being a virtual. So each exam room, we just added a camera to the screen. So super easy and take a lot of extra tech to do.
Christina Freeman:
And so now when you’re finished with your visit, one of us pop on the screen and we are able to talk about your private address and getting all of your personal information correct in the system, your phone number, your email address, things that people don’t like shouting out in the lobby. So we’re able to go over that. We’re able to talk about the finances, which is not great to talk about in the lobby. You’re able to stay in the room with your pet, you don’t have to juggle the leash. You’re able to pay. We have TeleVet that we work with got really excited when we wanted to do this and so they’ve helped us build this process but we have credit card terminals in the rooms. And so you’re able to pay.
Christina Freeman:
So the checkout process has been a real value add to the client. Clients are thrilled, they enjoy it. They’re like, “Oh, this is so nice.” And we’ve seen adoption. I have not run into someone yet and we’ve been doing it since November, that’s been displeased with that. So that has been nice. Now the front desk video screen is a little bit harder to sell because people are used to having a person up there, but it works. And we are able to do everything via this screen that we would do in person, the only thing Summer and I teased about, but she solved that problem too. I was like, “Well, we can do everything except clean up the pee in the lobby.” And Summer’s like, “Oh, there’s robotic-
Summer Burke-Irmiter:
Roomba.
Christina Freeman:
… Roomba.
Dr. Andy Roark:
Like a Roomba. Yeah. With a wet-
Christina Freeman:
A mop.
Summer Burke-Irmiter:
Right.
Dr. Andy Roark:
A wet mop Roomba.
Christina Freeman:
So if there’s a problem, we keep figuring it out. But so when clients come into the hospital, there is a monitor there on the front desk with signage that says, “Check in here.” And it’s cute. Clients smile and also they recognize us. So a lot of us used to work in the hospital, or all of us right now used to work in the hospital. So they’re seeing familiar faces, they’re hearing familiar voices and they’re like, “Oh, I missed you. How are you?” And so we’re able to keep connecting with our clients.
Christina Freeman:
And so it doesn’t… I think Summer and I both had the worry that the monitor on the front desk would feel a bit impersonal. We’ve actually found this the opposite. We’re chatting of, they’re holding up their little pets, we’re chatting with the dogs as well and so we’ve been pleased with the adoption. And also with COVID, it’s been a safety measure as well, a surprising safety measure. We’re able to speak to them without a mask, they’re able to hear us because we’re remote. And so that’s helped with this process.
Dr. Andy Roark:
Yeah. I imagine it’s like self checkout at the grocery store. If there’s a cashier standing there, I’m going to that person. But as soon as there’s two people in line, totally self checking out.
Christina Freeman:
But imagine that self checkout with a human talking to, because that’s the problem, you get your broccoli and you don’t have your code number and you’re like, “Ah.” But you’ve got a human there to help you with your broccoli. So we are-
Dr. Andy Roark:
Well, I know it. That’s it, they can recommend ice cream flavors. All right guys, where can people learn more about Adobe and your amazing hospital?
Summer Burke-Irmiter:
Yeah. So few different areas. You’re welcome to come our website, adobe-animal.com. And you’ll probably see our chatters on there. If they are busy, they’ll ask you to leave a message that they will respond to. And so that’s the other thing with chat is you don’t have to take them live by That moment if things are busy. And then also I think we sent over some picture.
Dr. Andy Roark:
Yes.
Summer Burke-Irmiter:
You guys, and so you can check out some pictures. Because I know initially when we talk about VCR, it can seem like this big wild concept. Once you see how simple it is. I feel like it’s the post-it note for veterinary hospitals right now. Everybody in a year or two is going to be like, “Oh yeah, VCR, whatever. We’re all doing it.” Because it’s so easy. But right now it can be hard to conceptualize and so check out those videos where you’ll see Christina and her backdrop in her home. Yep. With our lovely vinyl background, that’s the background of our reception areas, and fools a lot of clients. And then you’ll also see though pictures of her on the monitor around the hospital, checking people in.
Dr. Andy Roark:
That’s awesome. So I’ll probably put a link to our blog post about the episode and then I’ll put the photos in there for sure. Also guys, we are posting podcast episodes as YouTube videos. And so we’re going to drop them in there as well if you guys like your podcast as YouTube videos, you got to see photos there. Last question, Christina. I have thought the whole time that you were in some remote location because there’s an Adobe Animal Hospital, big logo on the wall behind you, and that’s your house?
Christina Freeman:
Yes. This is my house [crosstalk 00:50:52] here in North-
Dr. Andy Roark:
What does your family think about the fact that you have a work logo? Your husband was like, “What the heck is this?”
Christina Freeman:
Honestly, they love it. It’s been a very exciting crazy journey which is my life is, but one of the great things is I’m here. I have three children, they know exactly what I do. They see it, they hear it. Sometimes they’re… Actually, my five-year-old got a pencil from the pencil box while we were talking. But so that’s been a great thing for myself and my family. If your kid grow up and don’t know what you do, but they know exactly what I do. And it’s cute because in the background, they’ll be like, “Shh, mommy’s helping a pet with diarrhea.” And they’ve learned so much too. They’re like, “Are you going to tell them about the bland diet?”
Dr. Andy Roark:
Yeah. I could totally see that. I would be getting advice from my kids in no time. And they would be like, “Dad don’t forget.”
Christina Freeman:
Yeah. Oh yeah, they keep me on track too. So live chat has little auditory cues when you have an incoming chat. And so it says in a British accent, “Incoming chat.” Now guys. Nope, nope, Nope. [crosstalk 00:52:05]
Dr. Andy Roark:
Now they’re making appear on camera. Okay. All right. The wheels are coming off here. Yeah. I know how that goes. That’s-
Christina Freeman:
Hi, darlings, now you heard what I said, y’all have to go downstairs.
Dr. Andy Roark:
That’s me. That’s my life all day, every day. I love it. It’s so true.
Christina Freeman:
They heard me. I’m sure they were downstairs like, “What’s she saying?”
Dr. Andy Roark:
[crosstalk 00:52:24] She’s talking about us let’s go.
Christina Freeman:
Like, “It’s her chance roll the ball.” But they made up Carol of the bell at Christmas, incoming chat, incoming chat. So they’ll run behind me and sing that and freak me out. Because I’m like, “Where?” Because once you’ve been chatting forever, you know the words incoming chat, [crosstalk 00:52:47]
Dr. Andy Roark:
Where you’re here and just-
Christina Freeman:
Exactly. Start to salivate, so.
Dr. Andy Roark:
All right.
Christina Freeman:
They love to sneak up behind me and go, “Incoming chat.”
Dr. Andy Roark:
Oh, so cruel. I love it. All right guys, thanks for being here. Guys, thanks for listening to the podcast. I’ll talk to everybody next week.
Dr. Andy Roark:
And that is the episode. That’s what I got for you. Guys, I hope you enjoyed it. I hope you got something out of it. If you did, share the episode with your friends, spread the word. This podcast is growing like crazy. I have been blown away by how many new listeners each month are coming into The Cone of Shame. And it’s a world to me. I’m so thrilled that we’re doing stuff that people find value and are excited about. But yeah. Share the podcast, tell your friends if you feel inspired. Write us an honest review, wherever you get your podcast, it’s how a lot of people find the podcast. So anyway, gang take care of yourself. Be well, I’ll talk to you soon. Bye.
Editor: Dustin Bays
www.baysbrass.com
@Bays4Bays Twitter/Instagram
Battling Back Against Moral Distress
Dr. Indu Mani is on the podcast today discussing moral distress in veterinary medicine. The pain we experience when we know the “right” thing to do but are unable to do it can take an ethical toll. For those of us practicing veterinary medicine, this toll may contribute to burnout, depression and other job stressors. So what do we do about it? How do we battle back against a condition that seems ubiquitous to our profession? Let’s get into this episode!
LINKS
Original Moral Distress Article: www.nydailynews.com/opinion/ny-oped…zvsa-story.html
Ethical conflict and moral distress in veterinary practice: A survey of North American veterinarians – pubmed.ncbi.nlm.nih.gov/30320478/
Uncharted Veterinary Podcast: unchartedvet.com/blog/
Uncharted Veterinary Conference: unchartedvet.com/uncharted-april-2022/
Put on Your PANTS! How to Hold Meetings that Matter: unchartedvet.com/product/put-on-y…-pants-meetings/
What’s on my Scrubs?! Card Game: drandyroark.com/training-tools/
Dr. Andy Roark Swag: drandyroark.com/shop
All Links: linktr.ee/DrAndyRoark
ABOUT OUR GUEST
Indu Mani, DVM, DSc, is the Chief Scientific Officer of Brief Media, editor of Clinician’s Brief journal, and associate veterinarian at VCA Brookline Animal Hospital. She is a Fellow in Bioethics at the Harvard Medical School and a Master of Science in Bioethics student at Albany Medical College. She received her Doctor of Veterinary Medicine degree from Colorado State University and her Doctor of Science degree from the Harvard School of Public Health. She is interested in all aspects of veterinary bioethics, particularly moral distress, and infectious disease bioethics. She was a Distinguished Practitioner/Fellow at the National Academies of Practice and is on the One Health Initiative Website Advisory Board.
EPISODE TRANSCRIPT
This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.
Dr. Andy Roark:
Welcome everybody to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I got a great one today. I am here with my friend Dr. Indu Mani. Indu is the chief scientific officer at Brief Media, the editor of Clinicians Brief Journal and an associate veterinarian. She is also a fellow in bioethics at the Harvard Medical School. She’s amazing. I saw that my friend Indu had written an article on moral distress in veterinary medicine and she laid out what that means.
Dr. Andy Roark:
And, guys, this episode meant a lot to me because I have tried to explain this to people so many times. Veterinary medicine has unique challenges and Indu really puts her finger on what they are and names the moral distress. And I think her wording is so good and I think her understanding of exactly what this means and the ethical implications for veterinarians is so good and so useful in us figuring out how we’re going to go forward and how we’re going to make our profession better. So, guys, that’s what we get into. I love this episode. I hope you’ll love it too. 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. Indu Mani, thanks for being here.
Dr. Indu Mani:
Thank you, Andy.
Dr. Andy Roark:
Oh, man. First of all, I am such a huge fan of yours and I’m so glad that you make time for me. You are the best. For those who don’t know you, what is your official title at Brief Media?
Dr. Indu Mani:
I’m chief scientific officer at Brief Media, that publisher of Clinicians Brief, Plumb’s Veterinary Drugs, the new Plumb’s Pro.
Dr. Andy Roark:
Yeah. The new Plumb’s Pro is exciting. It’s super cool little product you guys are putting out. You and I met, I hate to even say this, it’s probably been like 10 years ago.
Dr. Indu Mani:
Been a really long time.
Dr. Andy Roark:
It’s been a long time. And I was doing some work over at Brief Media, which I loved and there are great people over there and I was super. I still look back.
Dr. Indu Mani:
We love you.
Dr. Andy Roark:
Oh, man. That was the first sort of real consulting job I ever got was with Beth Green at Brief Media and she sort of gave me a chance and I’ve never forgiven her. Never stopped thanking her for taking a chance and let me write some stuff and do some stuff with her. But anyway.
Dr. Indu Mani:
It was all our benefit-
Dr. Andy Roark:
Well, thank you.
Dr. Indu Mani:
… to have you there, Andy.
Dr. Andy Roark:
You wrote an article for the New York Post that-
Dr. Indu Mani:
New York Daily News. Yes.
Dr. Andy Roark:
New York Daily News, which kind of went sort of viral in the vet world. I saw a bajillion different places. And so that’s when I picked it up as I saw it on social media. It came across my feed a couple of times and I was like, what is this? And then I saw, oh, wait, this is Indu wrote this. And you talk a bit about moral distress in veterinary medicine. And so as I sort of unpacked as I read through it, I have strong feelings about what you wrote and I want to get into them with you.
Dr. Andy Roark:
But first can tell me a little bit about how you came to be thinking in this area. I know you’re doing some work in the field of medical ethics and doing advanced training there. Can you sort lay out your background and kind of how you started to get your head into this place?
Dr. Indu Mani:
Yeah. Absolutely. I have atypical background as a veterinarian. Being of Indian origin my parents wanted me to go to medical school, of course. And so I disappointed them greatly by going to veterinary medical school, but they’re happy with it now. I graduated from Colorado State University, I did an internship at the University of Minnesota, after that decided I wanted to work for the CDC, applied to a doctoral degree in virology at Harvard, got in, did finish that, and then decided at that point that I wanted to have children.
Dr. Indu Mani:
And then so went into medical publishing and medical writing and science writing rather than creating science, writing about it. And that seemed to be a better fit. Throughout all this I’ve continued to work in the small animal clinical practice situation, whether I was doing emergency, or urgent care, or primary care. So throughout this entire time I’ve been an active, small animal veterinarian.
Dr. Indu Mani:
I got involved with Clinicians Brief and publishing and I would say about two years ago there are certain things that I think I took for granted as a veterinarian, certain feelings, certain client relations, just dealing with things that were upsetting. And I started to look around a little bit at ways of coping, and let’s just say coping in a very broad amorphous way with the stresses sort of engendered by being a veterinarian, not really understanding what that was.
Dr. Andy Roark:
Yeah. I think most of us in practice have those feelings of that sort of stress and I think we wrestle to put a label on it. So I think the amorphous feelings are pretty calm among us.
Dr. Indu Mani:
And if you’re like me, and I don’t know, Andy, what you guys had, we had one ethics course taught by the late legend Bernie Rawlin at Colorado State, more of an animal ethics course having us consider companion animals, food animals, et cetera, not so much focused heavily on what we feel as practitioners. And we didn’t have any courses in psychology, just some random, I don’t know whether you guys had a little bit more when you were in vet school.
Dr. Andy Roark:
I mean, it was still fairly minimal. I think when I was in vet school the main focus sort of from a wellbeing standpoint was starting to be student debt. And so I think that was starting to unpack and I kind of feel like we went through a student debt wave and still that problem hasn’t gone away. But I feel like it’s been the last probably five to six years that there’s really been a shift over to wellbeing being taught in that schools.
Dr. Indu Mani:
Yeah. And so armed with that kind of dearth of training I started thinking about what makes us different because living in the Boston area, I know a lot of physicians, a lot of nurses, a lot of people who have really stressful jobs, psychologists, but there’s something different about being a veterinarian and I couldn’t really put my finger on it at all. And why we kind of accept living in this soup per se where we have these feelings that we don’t really understand.
Dr. Indu Mani:
In the process of doing that, Lisa Moses, she’s a veterinary internist, she is at Angel Memorial and she’s someone we referred cases to on a regular basis. So we knew her. She’s an incredible doctor, incredible person. She was head of the pain and palliative service. And I noticed that she had been doing some co-associated research on ethics and moral distress. Moral distress was sort of an emerging thing for her at that time. So basically a field of veterinary ethics. And I reached out to her, we talked, she had done a fellowship in bioethics at the Harvard Medical School.
Dr. Indu Mani:
And I talked to her, discussed what she was studying, what she was doing. And she said, I’m the only veterinarian that has done this program, the pioneer veterinarian, you should apply as a practitioner and so I did. And I think transformative is a euphemism for the experience of being in this fellowship. It was incredible. My classmates are about 12 of us. My classmates was an attorney, several psychologists, psychiatrists, neonatologists, anesthesiologists.
Dr. Indu Mani:
And we would get together once a week and talk, we had a bioethics curriculum, we’d have readings and it was so amazing because I always had the 13th perspective. Do you know what I mean? Everybody else had a more common experience with bioethics in the clinical situation except for me who always had a weird experience being a veterinarian.
Dr. Andy Roark:
Yeah. I love to hear that and it fits if it was with kind of what I’m sort of seen in the world. The reason I was so grabbed by sort of what you wrote in the concept of more ethics and moral distress when you put it down and the reason is because I’ve wrestled for years trying to explain, even not really understand for myself. the nuances of the challenges of our profession.
Dr. Andy Roark:
And I’m really been going to this thing recently where I’m pushing back against this narrative sort of is put forward of federating medicine is the worst for mental health. And I understand why we say that. I think a lot of people struggle, right? We have a real burnout problem. We have a real sort of problem with depression and just compassion, fatigue, all those. They’re all real and I’m not discounting them. And I feel like I think most of us struggle to articulate what we’re really feeling with, we just know it feels really bad or that we’ve had these real significant challenges.
Dr. Andy Roark:
And so I think that the shorthand is, oh, that medicine is the worst, we have this mental health nightmare is just so damaging. And I push back against that just because I want to articulate the nuance of our struggle in a truthful way that’s also not leaving people feeling hopeless. And I feel like your piece of moral distress really does that.
Dr. Andy Roark:
I did a podcast a while back with Jen Brandt from the AVMA, it was really great, but I got myself in trouble on social media because we put the podcasts out and I posted a pull quote that basically said, hey, truth matters. Veterinary medicine is not the worst mental health profession and that’s true. That’s never been put forward. No one said that, the CDC didn’t say that.
Dr. Andy Roark:
It’s a thing that sort of came up on social media and people started saying, oh, we are the worst, we have it the worst. And again, I think that comes from people trying to articulate what they’re feeling. I got sort of in trouble because when I say, hey, look, it’s not the worst stop. Think it’s the worst. That feels very dismissive of people and their struggles. And I go, well, that’s not what I wanted to do either. So I missed, that was a mistake on my part, but I believe that we have unique challenges.
Dr. Indu Mani:
We do. I don’t think that was the mistake, Andy. I think this is a very difficult thing to unpack. And there’s a trend, now I’m going to get myself in trouble. There’s a perception people start to examine this that I started to notice. And I think what you’re saying maybe is a little bit in line with what I’m going to try to articulate.
Dr. Indu Mani:
But there’s a perception of individual agency, meaning that we tend to select people, the individuals that encompass this profession have an aptitude towards this type of situation. Or we either select people who are trade perfectionists, or we select people who have trauma. And I’m not sure the data bears that out. And I think we need to look to the institution to see why this is happening and not look to its individual members.
Dr. Andy Roark:
Okay. I want to get into this. So let’s start to unpack. I think in order to talk about this let’s talk about moral distress and we have to put that down and then I want to come back to this individual agency because it’s definitely something I want to talk about. Can you define for me moral distress? For people who haven’t seen the article I have links to the article in the show notes, but go ahead and lay it out from me. What is moral distress and how is that different from burnout or just general, I don’t know, depression, being tired?
Dr. Indu Mani:
Yeah. Moral distress is an ethical framework. It was coined by Andrew Jameton philosopher in 1984. So a very long time ago with respect to nurses, which if you think about it, nurses are the population who embodies this. Moral distress is when you have to perform an action you either feel compelled to perform an action or you have to perform an action, or you perform an action which is the opposite of what you feel is right. So it’s a very simple definition, what you feel is morally correct.
Dr. Indu Mani:
So if we were doing an extreme example, convenience euthanasia would be an example where we would feel a tremendous moral distress. You see a, I don’t know, a two year old adorable pit bull who’s in the shelter and you’ve got to euthanize it. That is classic moral distress. That’s extreme, but it is that very hard to define sort of liminal sensation when that happens. What’s also important with that definition is the definition of moral injury, which I think that’s a really potent, maybe something that a war veteran might experience on the battlefield, a potent morally injurious event.
Dr. Indu Mani:
So take that moral distress, concentrate it into a really painful event and that’s a morally injurious event. Then there’s a graphic. And I think it’s a 2009 paper by Epstein. I’ll send it to you, but it’s so biological because it talks about moral distress and then moral residue. So waves of moral distress that keep occurring over time and it leaves a residue. And that just really connected with me for veterinarians what we experience, and then over time biologically the set point of moral residue it just slowly and incrementally increases.
Dr. Andy Roark:
Yeah. I’m imagining almost like a water line where you have a waves that kind of wash up against and the salt on whatever, on the building. The salt line is higher and higher over time.
Dr. Indu Mani:
Exactly. That’s exactly it. I mean, that’s a perfect example. It’s what is tolerable resets? You almost adapt to living in this negative environment, but it’s not a positive adaptation. It’s kind of a negative adaptation.
Dr. Andy Roark:
So let’s get into this personal autonomy part because I’m really interested in that. Are different people affected by moral distress differently? Do they feel it differently? And when I say different people, is it personality types? I guess my question to you is do the perfectionist personalities among us, are they more bothered because they feel more clearly that there is a right way or I’m not living up to the perfect standard and that adds to the moral stress that I feel as opposed to someone who obviously wants to do a good job but that level of perfection doesn’t drive it? Or those totally different things and you say no, whether you’re perfectionist or not, you still feel the same moral discomfort?
Dr. Indu Mani:
Yeah. I’d say that’s probably I think, I mean, I’m in my infancy in my ethics training, but that’s what I’d say, that moral distress will occur no matter your personality type. How you deal with it might be affected by your personality type. I work with someone who’s extraordinarily resilient. He’s a resilient person and he has dealt with really concretely distressing issues over time through his career.
Dr. Indu Mani:
He is someone that I think I don’t know if he can articulate why he’s able to consider, think about it, recognize it, move past it. I think most of us don’t talk about it in this way and that’s the problem. That’s the problem is we have to start talking about it. And for me personally, I’m sure we can all define things that provide distress for us, for me it’s being forced to perform non-beneficial or futile care on some of our patients or not being able to perform care on our patients.
Dr. Indu Mani:
And my own theory that I’m kind of working on is that because animals in many ways are property. How do we work on shared decision making models that empower the veterinarian to be able to articulate what they think is right for their patient?
Dr. Andy Roark:
Yeah. No, I agree with that. I think the first part of all this is is getting our terms down and all talking about the same thing. And that’s why I was so taken with what you wrote and just under understanding moral distress. So I completely agree with you. I think to me when I think about moral distress so much of it boils down to the fact that we know what is the right thing to do, say the morally right thing to do, but we don’t have the agency who necessarily carry those things out.
Dr. Andy Roark:
And what I mean by that is I can’t make the pet owner take their pet to surgery. I can’t make the pet owner go to the emergency clinic for overnight monitoring. I can’t make them do any of those things. And so when I think about moral distress, yes. I mean, I have heard, honestly, when you said moral injury the things that come to my mind is I know veterinarians who were forced to do procedures they didn’t want to do and to me that feels like that next level, like that moral injury and these people carry scars years later that I can see and go, I did not want to this. And I was forced to it or the implication was, I will lose my job and you go, that’s next level.
Dr. Indu Mani:
And nobody talks about it, Andy. That’s the whole thing. We don’t have that built in to recognize this weakness in our profession. Have you read that book The Things They Carried by Tim O’Brien?
Dr. Andy Roark:
No, tell me about that.
Dr. Indu Mani:
Yeah. It’s just a recollection. My daughter is reading it now in school. And I remember when I read it for the first time I was completely overcome, but it talks about morally injurious events among a platoon of Vietnam warriors. And I couldn’t really articulate why it resonated with me so strongly, but I think sometimes I feel like we’re on a battlefield. To expand on what you said because I think what you said is so important, pediatricians, because that’s the easiest comparison, if you think about medical models.
Dr. Andy Roark:
Yeah. No, that makes sense.
Dr. Indu Mani:
Yeah. Pediatricians have the right to advocate for their patients in their patient’s best interest even if it supersedes what the parent wants to do, which is unfortunately happening more and more these days or the harm principle that if you elect a certain procedure will it result in harm to your patient? And it occurred to me that we don’t have any of those protections in our shared decision making models.
Dr. Indu Mani:
And I’m lucky enough to practice outside of Boston in an area where more and more people are getting pet insurance and the pet owner who’s the proxy for the pet and I in this triad of the pet patient, me as the provider and the owner, the pet owner or pet parent, the three of us in that triad can engage in really productive, shared decision making that doesn’t elicit moral distress. That would be the goal.
Dr. Andy Roark:
Tell me a little bit more about what you mean when you say pediatricians have a right to advocate. What exactly does that mean? As a opposed to, I have a right to advocate meaning I can advocate all at one, but I can be ignored. What do you mean? What does that look like in human healthcare? I’m just not familiar enough with that.
Dr. Indu Mani:
They just have legal protections. If they’re struggling with a client most hospitals cannot, not the client, but the patient family, see, it’s so hard to not-
Dr. Andy Roark:
I know.
Dr. Indu Mani:
It’s so hard to not fall into that. But they can call an ethics committee. They’re often ethics committees at hospitals, which will be typically teams of clinicians, nurses, psychologists, psychiatrists, all of whom have significant investment and time and intellectual investment in thinking about these exact issues. So that’s one thing. And there are legal protections. You can involve the law. We can’t.
Dr. Andy Roark:
Yeah. No, that makes sense. Hey, guys. I just want to jump in here with a couple quick updates. This week over on the Uncharted Veterinary Podcast Stephanie Goss and I are talking about modernizing and updating an old school practice. If you have any interest in the advice we give to a manager who’s like, hey, we got new ownership and now it’s time to update and modernize the practice that we’re in, how do we do that with the established team and culture?
Dr. Andy Roark:
That is what Stephanie Goss and I unpack up. Link in the show notes to the podcast, but you can get it wherever you get podcast. That is the Uncharted Veterinary Podcast. Upcoming events, big ones. My dear, dear, dear, dear, dear, dear friend Jamie Holmes is doing a workshop on April 6th. It’s called Put On Your Pants P-A-N-T-S, how to hold meetings that matter. This is all about spending less time in meetings and more time getting effective results.
Dr. Andy Roark:
If you, I don’t know, happen to be kind of busy and trying to get things done and you don’t want to end up having a bunch of meetings to make that happen, you need to be efficient. You need to be effective. You need to know about the parent system. Jamie Holmes is going to teach you that is 6:00 PM Eastern, 3:00 PM Pacific on April the 6th. That is free to Uncharted members and $99 for the public. I’ll put a link in the show notes.
Dr. Andy Roark:
And the other big one is the April Uncharted Conference that is April 21st through the 23rd that is live in person here in my hometown Greenville, South Carolina. It is all about running smoother, more efficient, more rewarding practices. If you are a practice leader and you are looking for something to inspire you to get you to see possibilities, to feel good about the work that you’re doing again, and to feel like, man, we could do interesting and amazing things in the future.
Dr. Andy Roark:
If you need that feeling, come down to Greenville, South Carolina on the 21st to the 23rd for the April conference. Guys, head over the website, I’ll put a link in the show notes, get an Unchartered membership, get in the conference, come and check it out. It’s something magical and it’s almost full too. We are almost sold out. I don’t want you guys to miss the boat on that. Anyway, guys, that’s enough. Let’s get back into this episode. One of the questions I had for you coming in, when I think a lot about wellness and sort of how we take care of ourselves.
Dr. Andy Roark:
Now, I get pretty fired up when I see systems and protocols where individuals on the ground are called upon to make ethical and moral decisions in place of some sort of a stated protocol. And I think the reason that people do that and our practices are set up that way, so I’ll give you an example, when someone comes in and they say my pet is sick and I need to be seen and it’s seven minutes before the clinic closes a lot of practices will say, well, the doctor gets to decide if they see the patient or not.
Dr. Andy Roark:
I have a problem with that because I feel like you’re putting this moral decision on the individual. And if you are wellness plan, if you plan to take care of your people in the long term prevent burnout is people on the ground are going to look a crying pattern in the eyes and set a personal boundary. I think you’re out of your mind. That’s just not going to happen. It’s not who we are.
Dr. Andy Roark:
And so I really am leaning into this idea of sometimes the kindest thing is to set boundaries and protocols at the practice level and say, we’re going to take this moral decision or this on the moment decision. We’re going to take it off the shoulders of our staff, our employees or we’re going to make a decision at the practice level.
Dr. Andy Roark:
And then that’s just, they’re not going to be called on to make this hard decision when half the staff, three quarters of staff they want to go home and the doctor is looking at this person who wants to have their pet taken care of, and now either whatever you choose, you’re going to make someone upset. And I go, that’s unnecessary stress that just shouldn’t be there. There should be a plan of what happens and not just a in the moment decision.
Dr. Andy Roark:
And so let me put that to you and sort of say, do you believe that there are ways to reduce moral distress by having protocols in place? Or are we still in that same place of just because there’s a rule and this person doesn’t get seen doesn’t mean that I don’t feel bad about it and I feel the same moral distress? So help me with that. Is there value to having some sort of a set structure that takes some of these decisions off of the people on the ground?
Dr. Indu Mani:
Absolutely. And I’m glad you’ve said that because, I mean, and I know you are the same way, but I don’t think I could have made it through this pandemic without my CSRs, without my technicians. I mean, and I’m just going to shout out to VCA Brookline Animal Hospital because they are my family. We are a family. And in many ways, my God, they’re the ones who walk out to the car and get the pet from the car.
Dr. Indu Mani:
They have worked so hard. I’m going to start to cry, but I just they’re… And I think we are buoyed by them and a lot of what we’re talking about. And I want to say this to all the technicians, all the non-veterinarians who functions part of our team, this is all equally about you. If not more we’re all together. Nurses were the ones who this concept was first intellectually recognized. So I just want to emphasize the importance of taking care of that staff.
Dr. Andy Roark:
Yeah. I think that’s really important to say because I’m coming at very much. You and I both being veterinarians we come from a veterinarian centric mindset, but the truth is we have much more autonomy and agency in these situations than my technicians or the CSRs who that’s are just told this, go tell them no. And then they’re really put in this type position. And, again, I feel like that’s sometimes a manifestation of that whole, we haven’t set protocols. We don’t have plans. And so then the plan is have the front desk go tell them no because it sounds better coming from them than it does coming from the doctor. And I go, well, that’s-
Dr. Indu Mani:
That’s right.
Dr. Andy Roark:
… that’s awful. That takes a human toll. It takes a human toll on our support staff.
Dr. Indu Mani:
It really does. And, I mean, I’m so glad you said that. I do think, and I’m working on this right now actually so I’ll share more next time we talk because I’m just trying to get something together, but there is a, she just passed away, she’s a philosopher named Renee Fox and she wrote a lot about medical ethics education. And reading her, she told about infusing.
Dr. Indu Mani:
We have such a dichotomy in clinical aspects of a case and nonclinical aspects of a case to our detriment honestly, Andy, to our huge detriment because I think we have to consider each case in each clinical situation holistically. And we are better off for it if we start to recognize the potential ethical situations implicit in each case. Someone comes in, doesn’t have cash, just adopted this dog, doesn’t have financial means, no insurance, mother is ill with a chronic disease in the hospital. I mean, you hear that, we hear that. We smoosh all that information in our heads.
Dr. Indu Mani:
Our technicians are sad because they heard that and then we don’t really do anything with it. We try our best to harness our empathy, our skills we’re kind of [inaudible 00:29:45] in the way that we try to maximize good clinical outcomes for our patients. But then we take it home and then I’m trying to sleep and I’m like, oh my God, I can’t stop thinking about this.
Dr. Indu Mani:
Wouldn’t it be great if we had some ability to take this information and be considering it along with all the clinical considerations? And I’ll say that I’m trying to think of a way that maybe we can do that. And at least articulating that information among our team will help us deal with it going forward.
Dr. Andy Roark:
Are you talking more about having good ways to discuss these types of stressors with your team inside the clinic? Or are you talking more about having this way to discuss sort of across say veterinarians, across multiple practices or some sort of external support structure? Or are you talking more about training in veterinary schools to sort of help people have better vocabulary to explain where they are, what their stressors are so this thing could be addressed? Help me understand what exactly where you’re coming down there.
Dr. Indu Mani:
I mean, you’re so perceptive because that’s exact, it’s all of those things. I read somewhere that when you’re trying to, and I have to find the reference for this, when you’re trying to ameliorate the effects of moral distress it has to be at the clinical situation, so with the patient at hand in the institution, in the organization, in the profession. So it’s multi-leveled.
Dr. Andy Roark:
Yeah. I like that a lot. When people ask me about burnout out and what do we do about the problem with suicide, or depression, or just a high turnover, things like that in our profession, to me it’s got to be a multilevel approach. And so I talk about I think there’s things we do at the professional level, at the practice level is really the boundaries and systems I was talking about before of I take those weight off the individual. And ultimately there really is never going to be a way around this where there’s not agency that has to be taken at the personal level. We are all going to have to figure out how we process-
Dr. Indu Mani:
We are. Absolutely.
Dr. Andy Roark:
… what we deal with. And we also are going to need to set some amount of personal boundaries for ourselves. But God, if the whole program, the whole the wellness program is the individual will process these things and set personal boundaries, that’s baloney. That doesn’t work.
Dr. Indu Mani:
And that’s what’s happening right now. I think this is my informal, anecdotal perception is that we have to, there’s nothing weak in looking at our profession under the microscope. And so what are doing wrong? What are we doing wrong? We have to make the change. Otherwise, quite honestly I worry that what’s going to happen to our workforce. It’s interesting. I have a brilliant, one of my fellowship mates is a psychologist and I presented some of this stuff to my group.
Dr. Indu Mani:
And she’s so articulate, but she said, it feels like you’re a profession in slow degradation in some ways. And I didn’t like hearing that because it made me very, very, very sad but it also made me feel empowered. And I said, if we are a field in slow degradation we’re not doing something right. What can we do? We have to do something else.
Dr. Indu Mani:
So take something which seems ominous and start to say, we need to look at this in a different way and make it because I love this profession, Andy. I still, when I go to work, I’m excited to see. I really love it. I love it. And I would like to help it. I would like us to help it, but it will require us to be self-critical as a profession and not put it on the agency of our members to have these little dots of fixing it. We have to fix it on mass.
Dr. Andy Roark:
No, I completely agree with that. I love that nursing. I love being a veterinarian. I mean, let me push back against you a little bit here and say, Indu, I’m positive about where we’re going. Again, I really am. What most inspired me about what you are talking about is my friend what you write, you are part of the diagnostic process and we know how to figure this out, right? The first thing you do is you run a diagnostics and you say, where is the pain coming from?
Dr. Andy Roark:
As quickly as we can drill into it what are the actual things that are causing this to happen? But once you’ve got the diagnosis usually the treatment part can come along much better. I feel like for the last 10 years we have been in a degradation slide, but I also think our perception of where we are has been, I don’t want to say it’s been counterproductive.
Dr. Andy Roark:
I think the truth, in the modern world when we deal with problems especially in the world of social media and the Internet, Step 1 is awareness of the problem. And I think that we have really lived in awareness and I think that’s a good thing, but talking about-
Dr. Indu Mani:
[crosstalk 00:35:04] too
Dr. Andy Roark:
Exactly. Right.
Dr. Indu Mani:
Articulation bit.
Dr. Andy Roark:
Completely agree. So we started off and people were like, hey, burnout is terrible and we’re having these problems and we’re having high turnover. And the suicide rate for veterinarians and veterinary technicians is high and all those things are true. And we do need to raise awareness to those. And I think that we’ve done that and I think where I am and I think where a lot of people in the industry are is I go, it’s time to transition into some better diagnostics and then into a multimodal treatment approach.
Dr. Andy Roark:
And I feel like when I read your piece and I’m more distressed I go, that’s a diagnostic I didn’t have. That helps me articulate the problem and exactly what’s going on in a way that I think can help our profession to develop ways to approach it. And so I’m not down. I feel like work that people like you do, Jen Brandt, Kerry Journey has been on the podcast recently. And I think that we’re shifting this paradigm from the awareness to the diagnostic part, and then on the treatment part.
Dr. Indu Mani:
Something actionable.
Dr. Andy Roark:
Yeah. I do see this as more of an actionable step or a pathway to actionable steps. And so that’s why I am optimistic, but I do. I mean, I do agree. I still love being a vet and I think these are worthy challenges.
Dr. Indu Mani:
And I think we can love being veterinarians and we can be critical profession.
Dr. Andy Roark:
We should be. I mean, we should be.
Dr. Indu Mani:
Because if we don’t progress and evolve, even in the past two years the profession has really changed the demand on veterinarians right now. I mean, my God in my life, Angel Memorials here in Boston they’ve gone on diversion a few times. Well, they’re referring out, Angel Memorial. If we’re referring away from, and I’m sure you’re seeing that too where you are, Andy, but I agree.
Dr. Indu Mani:
And yes, there’s no reason to dwell in the misery. We have to look for the light and I love how you made this a clinical case diagnostics and therapeutics, but it’s absolutely true. And so that’s where I’m looking right now and focusing on some of my next research is thinking about some solutions that we might be able to implement more quickly.
Dr. Andy Roark:
Yeah. No, I think that’s wonderful. I said, I do see it as a diagnostic. I think for me where I really start to think about moral distress and where it’s super helpful is I would sit and I would wrestle with these things and I would say burnout is a problem and it’s stressful. And that’s stressful when we’ve got these things. But then I would turn around and I would say, first line healthcare responders have a stressful job and social service workers have a stressful job and I’m sure they feel this as well.
Dr. Andy Roark:
And now I have a friend who’s a pediatric palliative care special. I mean, she helps children in pain with cancer, oh my God. And so we don’t have the market cornered on pain. We don’t, but I believe and this is why I like the way you put it so much, I believe that we have a special kind of pain that is different often from what other people feel. And I just think that you unlock that in my mind and that’s why I was like, this is so useful.
Dr. Indu Mani:
Yeah. Andy, we have a special kind of pain and we don’t really have ways professionally to handle that pain or we don’t have those-
Dr. Andy Roark:
What do they look like? I mean, when you gaze into your crystal ball and you say five, 10 years down the road and you say when we continue to work on these things, what does some of those mechanisms look like? Help me understand, to stick with our metaphor, what could a treatment program look like theoretically?
Dr. Indu Mani:
I mean, I wonder if we start to recognize outline situations. Even as pedestrian as it seems maybe we have clinical situations that we teach our students about, we implement in practice. As pedestrian as it seems if somebody came over and said, I want you to declaw my cat. She’s not scratching anything, but I want you to declaw. I want you to declaw. And we can talk about what that I elicits in the veterinarian. Try to explain to the client why that elicits moral distress in the veterinarian to be forced to do something like that, cosmetic procedures, the very existence of brachialis dogs.
Dr. Indu Mani:
And I love all my little Frenchies and all the guys that come in, but I do find sometimes that the clients are somewhat bewildered by the inevitable slew of medical issues that will follow and will sometimes take it out on us, be upset, be angry, and even something like that, education of the client why this elicits moral distress in the veterinarian to have these discussions all of that can potentially help.
Dr. Andy Roark:
Yeah. That makes a lot of sense to me. I do see real value in that. One of the things I really like about sort of your approach and kind of where you’re putting this, I see a lot of people who push and say, well, we need to put this on the clients, or we need to make clients aware of how they come across. And I get it, as a pragmatist I go, hey, I don’t know that we’re going to talk clients into behaving differently than they behave.
Dr. Indu Mani:
No way.
Dr. Andy Roark:
I do feel like it has to be honest and it’s not fair that I have to feel the burden or figure out a coping strategy for a pet owner that’s going to be verbal abusive, or they’re upset because of this thing that they should not be asking me to do or pushing me to. It sucks that I’m the one who has to figure that out. But I do think it’s true and I think if we push back and go, well, you need to tell that client to go stuff it. I don’t. I know I said stuff it today. I called something baloney. I’m aging.
Dr. Indu Mani:
Yeah. You sound from 1950.
Dr. Andy Roark:
I think I’m like a 1950s radio host.
Dr. Indu Mani:
1950s guy. Oh my, no. I mean-
Dr. Andy Roark:
What’s happening to me?
Dr. Indu Mani:
… you’re completely right though. And sometimes I see things on social media, be kind to your vet and that’s a great sentiment, but that can’t be our crutch here. We can’t.
Dr. Andy Roark:
Right. That’s not the go-to strategy.
Dr. Indu Mani:
No, we can’t do that. And, I mean, don’t get me wrong. I’ve had a bad Yelp review a few years ago and apparently I was too pushy with asking for diagnostics and I was very upset. I separated on it. I bugged my poor husband and he was like, why do you care? And I was like, I care, Gary.
Dr. Andy Roark:
Yeah. Well, I mean, I’ll tell you why you care. Because at some point it’s your personal identity and you take this seriously.
Dr. Indu Mani:
Yeah. That’s right.
Dr. Andy Roark:
And I would also say that’s the moral trap. If you feel like this is what should happen and you advocate for it and then someone publicly slams you for doing what you think is right, you really need know when situation, right?
Dr. Indu Mani:
Absolutely.
Dr. Andy Roark:
You either don’t do what you think is important and because you might antagonize this person, or you might upset them, or you might make them a little bit uncomfortable, or you do what you think is right and then you get sort of publicly hammered for it and you go, and I don’t have an answer for that.
Dr. Indu Mani:
The only thing that makes you feel better with that, and this is what I wonder about harnessing, is it helps me when I… With that review I went to two veterinarians I was working with that day and I was like, “Can you believe this? Look at this. What is this?” And they were like, “Oh my God. That’s awful, blah.” But again, that was a mini, it was just a snapshot of what we could do as a profession to buoy one another up in those situations.
Dr. Andy Roark:
No, that’s a great point. The validation and support from our colleagues is super important and we’re not going to get that validation from pet owners. They just don’t understand. They just don’t.
Dr. Indu Mani:
For some you will. I think there’s some, I mean, we both have amazing pet owners who do that, but one thing this is random, but I have to tell you, Andy, that the advent of insurance and more people adopting pet insurance to me has helped my patient population in terms of ameliorating these dilemmas a little bit.
Dr. Andy Roark:
Yeah. I do agree. I think reducing that threshold, that resource-
Dr. Indu Mani:
Financial.
Dr. Andy Roark:
… scarcity threshold that’s a big part of it. Most pet owners are totally happy to follow our recommendations if they have the resources to do so. And I don’t want to leave this as vilifying pet owners in someone because I think we’re all sort of doing our best. It’s a challenge. Anyway, Indu Mani, thank you so much for being here. Thanks for talking with me. This is so great.
Dr. Indu Mani:
Thank you, Andy. I mean, I think about many of our ridiculous conversations that we’ve had, many, many ridiculous conversations and it’s kind of hilarious that we’re having more significant one.
Dr. Andy Roark:
I miss seeing you at conferences because you and I have business suits that look almost identical. Remember that? We both have great businesses.
Dr. Indu Mani:
We were twins. We were twinning.
Dr. Andy Roark:
They looked so similar.
Dr. Indu Mani:
And it had like a cranberry colored shirt or something. Do you remember?
Dr. Andy Roark:
Yeah. We showed up-
Dr. Indu Mani:
And I showed-
Dr. Andy Roark:
We showed up wearing the same thing.
Dr. Indu Mani:
And then I have to tell you. I showed my technicians that and they were like, you know Dr. Andy Roark? It was so awesome.
Dr. Andy Roark:
Oh, man. Well, thank you for being here.
Dr. Indu Mani:
Good to see you.
Dr. Andy Roark:
I’m going to drop the links from our conversation into the show notes for people who want to see them. Indu, I can’t wait to see what you do next. Thanks for all the work you’re doing for veterinaries.
Dr. Indu Mani:
Thank you, Andy, and vice versa.
Dr. Andy Roark:
And that is our episode. Guys, that’s what we got for you. Thanks so much for being here. I had to stop for a second and give a shout out to my friends at Banfield, the pet hospital for supporting our transcripts. We have transcripts of the podcast now. In an effort to increase inclusivity and accessibility Banfield has reached out and they were like, hey, let’s make this thing happen.
Dr. Andy Roark:
Let’s make this thing accessible to everybody. And they have made possible transcripts of both the Uncharted Veterinary Podcast and this here Cone of Shame Veterinary Podcast. So special thanks to them. Guys, you can find it on drandyroak.com and you can find transcripts for all of our podcasting to them there. So guys anyway, wanted to just say thanks and I want to say thanks to you for listening.
Dr. Andy Roark:
If you enjoy the episode, if you got something out of it, please feel free to leave us an honest review wherever you get podcasts. It really is how people find the show and it means the world to me. So guys, that’s it. Take care of yourselves. Be well, talk to you later. Bye.
Editor: Dustin Bays
www.baysbrass.com
@Bays4Bays Twitter/Instagram
Chronic Diarrhea and Anxiety in a GSD (HDYTT)
This episode is made possible ad-free with the support of the Purina Institute!
We have a wonderful (but anxious) German Shepherd with chronic diarrhea that just isn’t going away. Her owners would like to handle this without medications if possible. Veterinary nutritionist Dr. Raj Naik is here to talk about the case, our options, and the importance of considering the microbiome as we treat GI disease.
This podcast was brought to you ad-free by the Purina Institute.
LINKS
Purina Institute Microbiome Forum:
www.purinainstitute.com/microbiome-forum
Purina Institute: www.purinainstitute.com/
Charming the Angry Client On-Demand Staff Training: drandyroark.com/on-demand-staff-training/
What’s on my Scrubs?! Card Game: drandyroark.com/product/card-game/
Dr. Andy Roark Swag: drandyroark.com/shop
All Links: linktr.ee/DrAndyRoark
ABOUT OUR GUEST
Dr. Raj Naik developed a special interest in clinical nutrition while at the Virginia-Maryland College of Veterinary Medicine. After completing a rotating internship at a large specialty hospital in New Jersey, his love of nutrition brought him to the University of Tennessee to pursue specialty training in small animal clinical nutrition. Dr. Naik joined Nestle Purina shortly after completing his residency. As a Veterinary Communications Manager and one of several board-certified veterinary nutritionists at Purina, Dr. Naik serves as a liaison between Purina and the veterinary community. Outside of his day job, Dr. Naik recently served on the Board of Regents for the American College of Veterinary Nutrition. In his free time, you will find Raj attempting to entertain his son along with his wife, dog, and two cats.
EPISODE TRANSCRIPT
Dr. Andy Roark:
This episode of the Cone of Shame Veterinary Podcast is made possible ad free by our friends at Purina Institute.
Dr. Andy Roark:
Welcome, everybody, to the Cone of Shame Veterinary Podcast. Guys, we’ve got a great episode today. It’s me and my friend board veterinary nutritionist, Dr. Raj Naik. And we are talking about a poor German Shepherd with chronic diarrhea and anxiety. I love the GSDs, they tend to be anxious dogs, and anxious dogs tend to have soft stools sometimes. What do we do about it? How do we break this thing down from a nutrition standpoint? 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. Raj Naik. Thanks for being here.
Dr. Raj Naik:
Thanks for having me.
Dr. Andy Roark:
Oh, my pleasure. My pleasure. I’m super excited to talk to you today, I love having you on the podcast. I have a case that I want to break out with you. You up for this?
Dr. Raj Naik:
Absolutely. I love cases.
Dr. Andy Roark:
All right, perfect. I have an interesting one. I have a five year old female, spayed German Shepherd named Aspen, who she’s a chronic diarrhea dog. Well, I see this client a lot, they’re in and out. Aspen is an anxious dog, she’s a clinger, she barks when moms leaves, just a regular high strung German Shepherd that keeps having these bouts of diarrhea.
Dr. Andy Roark:
Mom is a bit of a naturopath. Not, not over the top, she doesn’t hate medications or anything that, but she is having some concerns about continuing just to medicate this dog to deal with diarrhea. She wants something that’s going to be sustainable, that’s going to help get these outbreaks under control. That just doesn’t feel so heavy handed to her. And so I wanted to bring that to you and have you coach me through this. Raj, how do you treat that?
Dr. Raj Naik:
Oh man, so this is such a good case because this is, I think a classic case that you’re going to see in general practice. And of course, we’re going to go through the initial diagnostic workup of what can we do to figure out what is the chronic diarrhea? What is the cause of the chronic diarrhea? What is the main root cause of these anxiety concerns? But, as a nutritionist, I almost immediately go to what’s going on with this dog’s microbiome? How can we modify this dog’s microbiome to help whatever other treatment we’re going through? And so I think about things like probiotics and prebiotics and how we can actually modify that dog’s microbiome to help enhance their recovery.
Dr. Andy Roark:
Okay. All right. Let’s unpack this because you jumped to … It was interesting that your mind went there. That’s not where my mind went so I want to walk with you. So high level real quick, give me a breakdown. Your mind goes straight to microbiome, tell me about that. Define some terms for me, give me an idea of why in the disease process your mind goes here.
Dr. Raj Naik:
Yeah. The microbiome is really interesting, especially in this particular case because we have a behavioral issue as well as a GI issue. And the microbiome is, the definition is the collection of microorganisms and their genes and the microenvironment that they’re in, in a specific area. And for this particular dog, I’m thinking is GI tract. So this dog’s GI tract is the home to a lot of beneficial bacteria, as well as some potentially pathogenic bacteria that is, it’s kept in balance normally. And when that balance shifts, we can potentially run into health issues, like maybe we’re seeing in this dog. So what that shift is called, it’s called a dysbiosis. We can correct that dysbiosis, then maybe we can have an effect on this dog’s particular issues.
Dr. Andy Roark:
Okay. So I think about what I know about microbiome and we talk about the GI tract being the gut shock organ for dogs, is that why the anxiety does that? Is that why that plays into your assessment in this case?
Dr. Raj Naik:
Yeah, absolutely. So, you hear this term like, “Oh, I have a gut feeling about this particular subject that we’re talking about”. There is a true actual gut feeling because there is a vagus nerve running from your GI tract up to your brain. And so there is a strong influence from the microbiota that are in your GI tract on your brain function through various metabolites, through various neurotransmitters. And what’s interesting is we now know that with certain probiotics, you can actually affect brain function by altering GI microbiome. And so for this dog, I’m thinking, oh, I have this back of my mind, all this research on, say for example, a Bifidobacterium longum bacteria, BL999. And if I can use it as a probiotic in this dog, then potentially I can help mitigate some of those anxious behaviors that we’re seeing.
Dr. Andy Roark:
Okay. Are there diagnostic approaches that you take to look into this? Do you start empiric treatment and see if you get results? How do you start to unpack that?
Dr. Raj Naik:
The nice thing about some probiotics is they’re very, very safe and so you can start them right off the bat without necessarily doing indices ahead of time. But that being said, if you’re trying to really work up this dog, there are things like a gut Dysbiosis Index that can be very beneficial before and after you start treatment to say, “Hey, this treatment is actually working to help stabilize that gut microbiome and we’re it to a place where we really want it”.
Dr. Andy Roark:
Okay. Talk to me a bit about probiotics. Walk me through a little bit of the science of probiotics in general and then specifically how we start to introduce them in a case like this. How do we bring that across to the pet owners?
Dr. Raj Naik:
Yeah. So probiotics are a bit mysterious, you hear all this kind of hoopla around them and you don’t really necessarily know how they work. The whole goal of probiotics is to change that micro-environment in wherever you’re administering them. So in this case, we’re going to change the micro-environment of the gut. So those probiotics are going in there, they’re competing for nutrients with those potential pathogens, they’re physically blocking the pathogens from attaching to the GI tract epithelium. They can produce antimicrobial compounds and metabolic products that can actually fight off those pathogens. And when we are trying to figure out what probiotic to use, there’s a few actual considerations that we want to take. There was a study done a few years ago by a gentleman named Scott Weiss, who does a lot of this infectious disease research.
Dr. Raj Naik:
And he looked at a few labels of 25 different probiotics on the market for veterinary species. And he found actually that only two, two of the 25, had a label that was accurate and actually accurately described the contents of that particular probiotic. Which leads to a conversation about regulation by the FDA and things like that. But the point is, we’re looking for something that is safe, it’s viable, it’s going to be alive when you actually administer it to the animal and it’s efficacious. So how much research has gone into that particular strain of probiotic? And is it done by a reputable company because that’s really key, quality and safety, efficacy.
Dr. Andy Roark:
Okay. So, yeah. All right, that makes sense. When we start to administer to our patients and things, how many set expectations for the clients here? So I’m going to talk to them, I’m talking to them about Aspen. I’m like, “Hey, she’s an anxious dog. We can have these things, I want to put her on a probiotic”, in your mind to put this probiotics use, is this a daily thing forever? Is this an as needed? Is it a pulse treatment and then we’re going to withdraw after we’ve reset the microbiome? What walk me through the actual mechanics of me putting this into play in a meaningful way.
Dr. Raj Naik:
Yeah. Good question. So for acute situations, potentially, we only have to do it for a certain period of time. So let’s take Aspen’s diarrhea, if it’s acute, we can do it for just a set number of day. If it’s chronic, a good probiotic is actually, what it’s going to do is it’s going to go in there, it’s going to do its thing, and then it’s going to get pooped out. And that the whole goal is we don’t want it to take up residents in the GI tract. And so because of that, you do have to use a lot of probiotics daily in order to achieve that effect long term. But that’s a good thing, that’s really, really what we want.
Dr. Andy Roark:
Okay. What’s the response time on treatment like this? Are we looking at five days, is this an immediate thing? Again, people don’t get upset about what you give to them, they get upset about the difference between what they got and what they expected to get. So I don’t want to over promise because we’ve all seen that where, I had a client call me just a couple of days ago and he was like, “Oh, you know my dog’s having these soft stools and things”, and then he listed nine different things that he had done and five different diets he’d been on. And I was like, “When did this start?”, and he’s like, “Two weeks ago”. And I’m like, “Oh, buddy, okay. We’re going to start over”. But again, that happened. And people have expectations in their mind, I want to set good expectations.
Dr. Andy Roark:
So help me understand this, when I present this as a therapeutic option, I think a lot of us send home and I’ll just be honest with this. When I comes to GI upset, diarrhea, things like that, I go back and forth with being a good antimicrobial steward and also wanting to give the pet owner something where I’m like, this is a thing that is actually addressing your problem because I want you to see value in coming in the visit. And I’m just being honest about how I have those thoughts, I know I’m not the only vet who has those thoughts. I am increasingly trying to lean on the side of good antimicrobial stewardship. I know it’s important, but I still sometimes worry. I go, what if I send them home and this persists? What if it takes too long? What if they’re impatient? What it’s not robust enough a response? And so, yeah, help me with that as far as what expectations I should set in their mind and what I can expect as the doctor treating it.
Dr. Raj Naik:
I can’t tell you how much I love that you brought up antimicrobial stewardship, because it is one of my soap boxes. I’ll start with how long. Usually if we’re talking about an effective GI probiotic and there is, this goes back to a good company doing great research. You have probiotics out there that we have control studies looking at diarrhea and acute diarrhea in dogs resolves after four and a half days with metronidazole. But if you use Enterococcus faecium, SF68, which is that effective probiotic, that resolves up almost two days earlier. So it can be highly effective very quickly and say a little over two and a half days.
Dr. Raj Naik:
But I think setting those expectations, like you brought up is so important. These aren’t miracle drugs and they’re not drugs at all. And that’s the point. So you have a situation where you may be able to resolve acute diarrhea very quickly. Some dogs have to be on this for say, a couple weeks before you’re going to see effective control of their diarrhea. And then you have another probiotic that we’re talking about with anxiety that you don’t necessarily see full effects until up to six weeks after they’ve started. So if you’re trying to manage something like fireworks anxiety, certainly you’re going to have to start that well ahead of July 4th.
Dr. Andy Roark:
Right.
Dr. Raj Naik:
Yeah.
Dr. Andy Roark:
Okay. So, yeah. So for Aspen, then we’re probably talking about a pretty significant runway, right? If we want to have maximum benefit and we continue to have diarrhea with this dog.
Dr. Raj Naik:
Yeah. And so if I may with the antimicrobial stewardship.
Dr. Andy Roark:
Please.
Dr. Raj Naik:
I think the way you’re approaching it is absolutely fantastic and I see that need between I need something that’s going to work really effectively now. And with some of those antimicrobial drugs, things like metronidazole or Clavamox, if you use a probiotic at the same time as you’re administering those, they may get killed off depending on the probiotic. There are probiotics available, like Enterococcus faecium SF68 that are not killed off by certain antimicrobials like metronidazole. And so doing the research to find out which ones actually stay alive is very important.
Dr. Andy Roark:
Okay. So talk to me a little bit about that with the antibiotics then. So you were saying, if you’re going to do antibiotic therapy and you want to do a probiotic as a supplement to that, so I’ve seen, I know with people, a lot of times we’ll take antibiotics and then start to start a probiotic to repopulate the gut. Do you recommend doing some sort of probiotic therapy through the course of antibiotics? Is this something that we want to add towards the end of the antibiotic therapy? Talk to me a little bit about the integration of antibiotics and probiotics, if we want to use them together.
Dr. Raj Naik:
Absolutely. I would start them at the same time if you can. And again, key is finding out that probiotic that actually will survive that antimicrobial. The earlier that we can institute probiotic therapy, the more like we are to mitigate that, say antibiotic associated diarrhea that we see with Clavamox. In cats, you actually see that if you start, you mentioned FortiFlora at the same time as Clavamox, you reduce the incidence of diarrhea in these cats. And so, as early as possible is my answer.
Dr. Andy Roark:
Okay. That makes sense. And then we talked about treating through the end of clinical signs. Do you usually tell people you’re in this for X amount of days, just plan on it? Do you tell them to continue beyond remission of clinical signs? So we talked about onboarding with this, where is where’s the off ramp?
Dr. Raj Naik:
Yeah. Acutely, I would say within, you could probably stop after resolution of clinical signs within three days or so. A lot of these dogs, especially this German Shepherd that we’re talking about, chances are he’s going to have to stay on it long term because he’s got some sort of German Shepherd chronic enteropathy that we would love to actually diagnose. Maybe the owner’s not going to let us this particular time. So they may need to stay on it for life.
Dr. Andy Roark:
I like this interaction between probiotics and other therapy modalities. Talk to me a little bit about how nutrition integrates into this. So you’ve got these diarrhea dogs or repeated diarrhea dogs. Are we changing that dog’s diet to something that supports GI health in the short term? Are we leaving them on their regular food to avoid transitioning back and forth? What are your thoughts on changing diet while using a probiotic, trying to get through these bouts of repeated diarrhea?
Dr. Raj Naik:
Yeah. I think that’s such an excellent point. Having the right diet there available for that dog is critical because we need to supply that probiotic with the food that it needs to do its job. And often that food comes in the form of what we call a prebiotic. Prebiotic is just a fancy term for a, usually is some sort of fiber source, a non-digestible carbohydrate that the probiotic can munch on and then create short chain fatty acids, which are beneficial to the host and sustain itself that way. And so if we’re providing the right food for not only the probiotic, but for the pet him or herself, that could go a long way in resolving some of the issues that we’re seeing. What’s interesting about microbiome research and diet is that when you shift, when you change a dog’s diet to something completely different, their microbiome shifts with that diet.
Dr. Raj Naik:
And so in the short term, if you were to change to a highly digestible diet, which is often what we’ll use for this chronic diarrhea patient, then you are potentially shifting that microbiome back to, closer or to the baseline for that dog. Oftentimes these dogs need to stay on that diet long term in order to maintain that good microbiome level for them. But you may be able to change it back once they’re actually a little bit better. Or, what diet am I going to choose for this dog? I think is probably where you’re hoping to go [inaudible 00:18:03]. Yeah.
Dr. Andy Roark:
Yeah. That’s why we’re starting to drill into this. I’m seeing some, you’re advocating it seems a more high fiber diet, as opposed to some of the, I don’t know, more easily digestible, fully digestible diets. So, yeah.
Dr. Raj Naik:
Yeah.
Dr. Andy Roark:
Talk to me about that.
Dr. Raj Naik:
I think that, so starting out a highly digestible diet doesn’t necessarily mean that it doesn’t have any fiber in it. So, that-
Dr. Andy Roark:
Right. I didn’t mean to, I know, I heard that coming out of my own mouth. I’m like, that’s not exactly what I’m getting at. But, yeah.
Dr. Raj Naik:
No, it’s confusing. It’s confusing. You hear this term highly digestible and you think, oh, well, it’s just chicken and rice, right?
Dr. Andy Roark:
Yeah. I’ll be like, that is the metaphor in my mind. When you say, explain this to the pet owner in a simple metaphor that they’re going to get. I taught to them about chicken and rice, just in a metaphorical sense, not in an actual sense. But I’ll be honest and say that’s what’s in my mind.
Dr. Raj Naik:
Yeah, absolutely. And I think that’s a good metaphor. What we remember with these therapeutic, highly digestible diets is they’re complete in balance. So you can feed these diets long term to these pets and they’ll be usually totally just fine as long as they’re formulated for adult maintenance. But if we have a dog that isn’t necessarily responding to that highly digestible, complete and imbalanced diet, the next place I would go is that high fiber diet that you were talking about. If this dog has a large bowel diarrhea, that’s where I’m going. And I think that’s an overlooked therapeutic modality for a lot of these dogs, especially this German Shepherd. He’s most likely got, just based on his signal, he’s most likely got a large bowel diarrhea.
Dr. Andy Roark:
Right. Is that a breed specific? Because when I see the German Shepherds, it immediately goes to it. The big thing is, it’s a luxury dog, for whatever reason, I’m immediately going to large bowel. And then the other thing is when I see, and again, correct me if I’m wrong here, but when I see those 10, 11 month old puppies that are just having ongoing diarrhea fiber responsive colitis, things like that into my mind, just based on the age of the pet. First of all, is that accurate? And then second of all, are there other signals that really make you think large bowel?
Dr. Raj Naik:
Yeah. I think that’s a really good example and a good watch out because if you have a 10 month old puppy that is having large bowel diarrhea and chances are, if it’s this breed, yes, you’re right. That is what we’re seeing. We have to be careful with those higher fiber diets that I was talking about because some of them are not formulated for puppies. We have a high protein requirement in these dogs, we have other macronutrients, micronutrients that we have to have at certain levels. And the fiber sometimes gets in the way of absorbing some of those nutrients. So what I always do is look at the patient in front of me. What what can I do for this particular patient? What have I tried already? And do I maybe need to consult with a nutritionist to come up with a plan to make sure that this dog is getting what they need?
Dr. Andy Roark:
So when you see those cases again, so especially, let’s talk about the young dogs. And we say, hey, we’ve got these young dogs, there’s an ongoing problem, we’re trying to increase fiber, we’re still want to make sure that growth needs are being, things like that. We need to talk to the nutritionist. How do you bring that to the client? How do you say to them, hey, I know you think this is just some soft stool that’s going on and on, but we need to bring this other person in and really start to get serious. How do you broach that conversation? How do you get them on board with the changes that we’re making? Because now we’re no longer talking about grocery store dog food, we are a hundred percent into the realm of like, okay, this is nutrition and we’re doing this and your dog is special. At least in the short term, give me some communication approaches to help people explain it and to get pet owners on board with going on this journey with me.
Dr. Raj Naik:
Absolutely. It’s such a good question because I think a lot of people struggle with this in practice, is talking about nutrition as a therapeutic modality. One, talking about it as a therapeutic modality and two, talking about it as a diagnostic tool potentially. So, the third option that we haven’t talked about yet is a hydrolyzed or elemental type diet, where we are trying to figure out if this dog has a IBD or a food allergy or something like that. And so I always talk to owners about this being something that they’re doing every day already. Number one, you have to feed your dog and two, something that we can use as a tool in the toolbox. We’re going to look at the animal as a whole and tackle things from all different angles. And I think most owners are happy once you explain to them that you’re using it as a therapeutic tool and a diagnostic tool. Are happy to go down that road with you at least for a little while. And you say, let’s reevaluate this in a month and see what’s happening.
Dr. Andy Roark:
No, that makes sense. I do appreciate that. Okay, good. All right, cool. I’m feeling pretty good about where we are with Aspen. I think I can work with mom and explain to her what the plan is and why the plan is, I think I can meet her needs. Are there any last words of advice? Are there any pitfalls I need to look out for? How do you see GP’s get this wrong? What can she talk me into that’s ultimately a bad idea or where do I go off the rails here and get myself in trouble?
Dr. Raj Naik:
Yeah, and it’s not necessarily that you… It’s not your fault, it’s nobody’s fault. It’s just that we’re busy. The follow-up, the follow-up is really what’s critical. So I can send a bag of dog food home with this client, or a probiotic home with this client and say, good luck. Or I can have a technician call them back in, say a week or two weeks and work through any issues that they might be going through. I’ll use a completely separate disease process as an example, but obesity is the number one disease that I see a problem with this for. So we send home a bag of dog food, we say, good luck, we’re going to get some weight off your dog. Then the owner gives up a weekend because they can’t deal with the begging, they can’t deal with not giving treats to their dog or giving fewer treats. And then you check back three months later and they haven’t done anything with the actual plan. And same goes with any other disease process that we’re going through. So the follow-up is key.
Dr. Andy Roark:
No, that totally makes sense. Awesome, Raj. Thanks for being here. Where can people learn more if they’re getting a lot out of this and they want to dig deeper, you and I just touched on the microbiome concepts and the science that’s there. I know that there is a lot of information education coming out in this realm. Help people get started unpacking this and exploring more.
Dr. Raj Naik:
Yeah, there are fantastic resources on the purinainstitute.com. So purinainstitute.com, and then if you’re interested in the microbiome, there’s a microbiome forum tab that you can click on and deep dive into all of this. If you’re interested in learning more about those conversations that you brought up, Purina Institute has a lot of resources to help you have those conversations about nutrition with owners. And I really, I point this website out to students to general practitioners, to specialists often to say, here’s how to talk about nutrition. So I’m a huge advocate for that platform and it’s called Center Square. That can be found on Purina Institute.
Dr. Andy Roark:
All right, thank you very much. I’ll put links to all this down in the show notes. Thanks for being here and thanks for your help.
Dr. Raj Naik:
Thanks for having me. I really appreciate it.
Dr. Andy Roark:
And that is our episode. Guys, I hope you enjoyed it, I hope you got something out of. I did, I like this episode. I was jotting notes down, this is stuff that I’m going to use in the exam room. Guys, thanks again to my friends at Purina Pro Plan Veterinary supplements for making it possible for us to bring this to you. Gang, take care of yourselves. Be well. I’ll talk to you soon. Bye.
Editor: Dustin Bays
www.baysbrass.com
@Bays4Bays Twitter/Instagram
Old Murmur & New Cough in a Small Dog (HDYTT)
Veterinary Cardiologist Dr. Anna McManamey (AKA Dr. Mac) is on the podcast today talking with Dr. Andy Roark about a 12 year-old Maltese named Higgins who has had a heart murmur for a long time, but just recently developed a cough. How concerned should we be? What do we want to make sure we investigate, and what pitfalls do we need to avoid? Dr. Mac takes us through it!
LINKS
Uncharted Veterinary Podcast: unchartedvet.com/blog/
Ninja Nerd: www.youtube.com/c/NinjaNerdScience
Client Curation w/ Dr. Saye Clement: unchartedvet.com/product/client-c…ind-your-people/
What’s on my Scrubs?! Card Game: drandyroark.com/training-tools/
Dr. Andy Roark Swag: drandyroark.com/shop
All Links: linktr.ee/DrAndyRoark
ABOUT OUR GUEST
Dr. McManamey (aka Dr. Mac) is a veterinary cardiologist. She received her degree of veterinary medicine from the University of Missouri. She then completed a rotating internship at the Ohio State University followed by an emergency and critical care internship at North Carolina State University. She finished her cardiology residency at North Carolina State University and became an ACVIM diplomate in 2021. Dr. Mac is currently an assistant clinical professor at Purdue University in Indiana. Cardiology is her favorite subject because it can be made as simple or as complex as needed. Furthermore, every animal has a heart and that means Dr. Mac gets to work with all kinds of species. Her areas of interest within cardiology are echocardiogram, congenital heart disease and interventional procedures, as well as emergency management of cardiac disease. She has a very supportive and patient husband along with three canine fur-children, one of which had a patent ductus arteriosus (of course).
EPISODE TRANSCRIPT
This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.
Dr. Andy Roark:
Welcome everybody to The Cone of Shame Veterinary Podcast. I am your host Dr. Andy Roark. Guys, I got a great one today, we’re doing some cardiology work with the one and only Dr. Anna McManamey or Dr. Mac as she goes by. Gosh, she’s a joy, she’s a treasure, she’s a treat. You are going to get so much information stuffed into your brain. So many beautiful little pearls that you’re going to use in your clinical life. This is such a good episode. Guys that’s it, I’m not going to oversell it. Let’s get into this.
Kelsey Beth Carpenter:
(singing) This is your show, we’re glad you’re here, we want to help you in your veterinary career, welcome to the Cone of Shame with Dr. Andy Roark.
Dr. Andy Roark:
Welcome to the podcast, Dr. Anna McManamey. How are you?
Dr. Anna McManamey:
Good, how are you, Andy?
Dr. Andy Roark:
I am really good, I am super glad that you are here. You have been my favorite discovery of the year so far in 2022.
Dr. Anna McManamey:
I’m flattered.
Dr. Andy Roark:
I sat next to you just in Orlando at the VMX Conference and you are just delightful. I enjoyed talking with you so much.
Dr. Anna McManamey:
Thank you.
Dr. Andy Roark:
I said would you come on and talk to me about some cases? You like a sucker, you were like okay and here you are.
Dr. Anna McManamey:
Like I said, I’ll talk about the heart as long as someone will listen.
Dr. Andy Roark:
It is awesome. Well, thank you for being here. You are a board certified veterinary cardiologist. You are a clinical professor at Purdue’s College of Veterinary Medicine. You are a lecturer. Like I said, I met you at VMX and I asked you what you were talking about and you told me some stuff. I was like that’s really cool. So thank you for making time to be here, I really do appreciate it.
Dr. Anna McManamey:
My pleasure.
Dr. Andy Roark:
All right. I have a case for you, are you ready?
Dr. Anna McManamey:
I’m ready.
Dr. Andy Roark:
All right. I have a 12-year-old male neutered Maltese named Higgins. Higgins’ parents love him. They love him a lot. Higgins has had a heart murmur for a long time. As long as I can remember going back to young age, he’s had a heart murmur. He is in now for coughing and that bothers me a lot because he’s had this heart murmur and now he’s coughing. What I’m tripping up on a bit is the fact that I’m listening to his chest, I’m not hearing any crackles, any wheezes. There’s maybe some upper airway kind of referred sounds. He pants all the time and so he’s panting, which I go… But then I listen and I’m like I don’t hear anything in his lungs.
Dr. Andy Roark:
I take chest RADS and he’s got this mild bronchial interstitial pattern. It kind of look just like old dog lungs to me. What I’m not seeing is a bunch of fluid around his heart. He doesn’t have distortional displacement of the trachea, anything like that. His heart doesn’t seem to be abnormally shaped. Let me just pause here and ask you and say given Higgins and kind of what I’m laying down, I am I right to be concerned about this cough? I don’t feel like he’s a congestive heart failure guy and I’m worried about putting on medicines forever. Can you give me some guidance? How do you treat this, Anna?
Dr. Anna McManamey:
Yeah, absolutely. I think there’s a lot that we can break down. I think the most important thing that you did is honestly, taking the chest X-rays. So I would say that this is something that I can’t emphasize the importance of it enough. I think with cardiologists, everyone assumes that our most important tool is echo. But really, the chest X-rays is the most important test that we have, especially anytime we’re worried about congestive heart failure. Which I think is a very appropriate differential for any coughing dog with a murmur, regardless of its chronicity. So I’d say kudos for that first of all because that’s really important and really helpful.
Dr. Anna McManamey:
The other thing I want to comment on is the chronicity of the heart murmur. I get a lot of these dogs that have a heart murmur “forever” since they were young. So sometimes I want to make sure is it really forever, forever? Is it a congenital heart murmur or are we talking like for just years now? That can change my differentials.
Dr. Andy Roark:
Yeah, I think I probably oversight it, I think it’s probably for years now. I don’t know that he was born this way.
Dr. Anna McManamey:
Yeah, and we get that all the time and it’s from our clients, who would say, “Well he’s always had a heart murmur.” But when we say always, it’s like for the past five years but we’re just keeping an eye on it. That’s usually what comes in. So with these, knowing the location of the murmur’s really helpful. So with the small breed dog, an older dog that’s had a chronic murmur, I’d say mitral valve disease is the most likely. So that’s going to be a left-sided systolic murmur, we call them apical. Just because they’re lower towards the mitral valve instead of towards the stern or excuse me, towards the spine, as a dorsal basilar murmur. So that’s a very classic presentation.
Dr. Anna McManamey:
Things that can really help me further evaluate if it’s congestive heart failure. So history in addition to the X-rays. Physical exam also helps. I think you’ve explained the most common problem, is the auscultation to the lungs. Doesn’t always give you the answer. They’re panting, they’re hard to listen to. The absence of crackles and wheezes doesn’t rule out congestive heart failure but hearing crackles and wheezes doesn’t rule it in either. So I think the X-rays you have to come back to the X-rays and part of the history. So with X-rays, the classic findings of left-sided congestive heart failure. The three things that I always look for as my checklist is the left atrium enlarged? So there are objective ways of looking at that. We call it the vertebral left atrial score and there’s some really cool resources out online, like on VIN, some [Lance Vista 00:05:51] papers that have come out.
Dr. Anna McManamey:
But this is a newer thing. It’s a vertebral left atrial score. It’s a way to measure the left atrium and compare it to the spinous processes. You can look at it subjectively. So is that carina, is that where the tracheal bifurcation exists? Is that push dorsaly towards the spine? Yes or no? If they don’t have that, then the left atrium isn’t big. The second thing I look for is are the pulmonary veins dilated? So you have your pulmonary arteries, then your bronchus, and then your vein. Your veins are central and ventral. That’s the rule when you’re looking at X-rays. If those pulmonary veins are bigger than the pulmonary arteries, then that’s dilated, that’s distended. That tells me I have high left atrial pressure. The last thing I look for is inappropriate interstitial to alveolar pattern in the caudodorsal, the perihilar lung space. That one I think is the most tricky because that’s the location in the radiographs. Where it’s the thickest part of the chest that we’re shooting through in the dog.
Dr. Anna McManamey:
So on a lateral X-ray, it always looks what we call “busy.” Especially if the animal’s panting or if they’re expiratory, those are the lung fields that collapse. So we see like this busier pattern in that caudodorsal lung field. So it’s very easy to psych yourself out and think that there’s truly edema there. So again, checking yourself is the left atrium big, are the pulmonary veins distended? Then on the dorsal ventral or the ventral dorsal view. So the importance of the orthogonal view is again, looking at those lung fields, looking for that classic circle of the left atrium at the six o’clock position of the heart. That’s my checklist every time.
Dr. Andy Roark:
Okay, I got that. Can you give me some best practices on getting radiographs on these little panting dogs? Are there things that I either want to do or say to my technicians hey, really try to catch this on inspiration? Anything, give me any pointers to get the most useful RADS that I can get?
Dr. Anna McManamey:
Yeah, I think the positioning and technique is huge. I think anytime, I think everyone’s kind of understaffed, which is a huge problem. But having enough hands to take them, I think is really important. Especially if you do think this animal has congestive heart failure, it might be a little it more delicate. So having enough hands to restrain the patient safely. I think a little bit of Butorphanol in anybody is never wrong. It’s very safe for the heart, it is a cough suppressant. So if the animal’s actively coughing while you’re trying to position it on its side, Butorphanol, whether that’s IV or intramuscular works really well. If you give it IM though, you got to wait about 15 minutes for it to take effect.
Dr. Andy Roark:
Yeah. No, that’s super useful. That was exactly my question. We’re talking about a little dog that squirms and doesn’t like to be on his side. I’m going I don’t want to sedate this guy. That’s gold, thank you for that.
Dr. Anna McManamey:
Yeah. Then the other thing I’d say is cardiologists, we actually prefer the dorsal ventral projection instead of a ventral dorsal. Sometimes it’s easier to get and it’s less stressful for the animals. So don’t ever feel defeated if you can’t get the VD but you can get the DV.
Dr. Andy Roark:
Okay. All right, perfect. So if I’m looking at this little beast and let’s kind of walk it through both ways. To let’s say that I don’t feel like there’s enlargement of left atrium. I’m not seeing these classic signs. How seriously do you take this when he is coughing, things like that? Where does that lead you? We’re going to go back and say if I see enlargement left atrium, I’m starting to see this elevated carina, things like that. I’m assuming that’s a pretty significant bifurcation in our diagnostic path.
Dr. Anna McManamey:
Yeah, I would agree with that. So let’s say for the first path, we don’t have evidence of congestive heart failure. So what do we do with that? Then I have a little bit more time. So I know okay, whatever’s causing this patient’s cough it’s not probably life threatening in the immediate sense. So I’m going to take a break. I’m going to go back and just question that owner a little bit more. About the frequency of the cough, the nature of the cough. How, if anything they’ve done seems to initiate that cough? Knowing the time of day it happens, knowing if it’s a self-limiting cough. If it’s progressed over years slowly or if this is an acute onset, those things are really, really helpful. I think it’s a little bit harder just from my own clinical practice of trying to get owners to say it’s a dry cough versus a wet cough. I think that’s hard for them to kind of suss out. So I don’t put too much stock in that comment of it’s dry or it’s wet. But is it hacking cough? Is it in the morning when they wake up? Is it when they’re excited? Is it after they’re drinking or is it when they’re trying to settle down and go to sleep and it’s all during the night? So those things kind of split my differentials a bit.
Dr. Andy Roark:
Okay. So when you’re seeing coughing first thing in the morning, is that pushing you more towards maybe early congestive heart failure, things like that? Yeah, so what walk me through that a little bit. If they say yeah, I hear it early. My training had always been coughing first thing in the morning is generally a sign of heart disease, things like that. Coughing when drinking water, what does that tell you? Does that lead you more towards trachea, respiratory?
Dr. Anna McManamey:
Yeah.
Dr. Andy Roark:
Okay, walk me through those.
Dr. Anna McManamey:
So classically, congestive heart failure and heart disease coughs classically, they happen at night. So we kind of call it a nocturnal dyspnea or a nocturnal cough. It’s usually when the heart rate’s slower, it’s usually when they’re trying to rest down. That pressure they put on their chest when they lay down in a sternal position, it elevates the heart in the chest. They get this mainstem bronchial compression. So we can actually see coughing when they’re trying to settle down to rest. When they are coughing when they’re excited or when they first get up in the morning, I do still think about the heart as a possible differential but not failure. I think about the sheer size of the heart. Again, the left atrium, it sits right in the middle of the mainstem bronchi, where those two bronchi come off of the carina. It sits right in the middle. So when we get severe left atrium enlargement, even if there’s not heart failure yet, we see this compression of those bronchi. So any type of excitement, any type of position change when the owner picks them up under the chest because they’re a little dog. It’ll initiate a cough cycle. But otherwise, after the drinking, tracheitis excitement causing the cough. I’m thinking collapsing, trachea mainstem airway disease. That’s where my brain’s going.
Dr. Andy Roark:
Right. No, that totally makes sense to me. Hey, guys, I just want to jump in real quick with a couple of updates. Number one if you have not seen our transcripts yet, you got to check them out. Banfield, the pet hospital has stepped up in the name of inclusion, equity, and diversity. To help make our content on the Cone of Shame Veterinary podcast and the Unchartered Veterinary podcast open and free and available to everyone in different formats. I could not do this without them. I wanted to make this happen in the past, they answered the bell, and they have made this thing real. I’m so deeply grateful to them. So anyway, if you want to see the transcripts of the podcast, they are there. Check them out, the Cone of Shame podcast transcripts are at drandrewroark.com. The Uncharted Veterinary podcast transcripts are at unchartedvet.com.
Dr. Andy Roark:
Speaking of unchartedvet.com this week on the Uncharted Veterinary podcast, my friend, Stephanie Goss and I, we have a love letter to all of you practice managers, you medical directors, you practice owners, you head technicians, you head CSR office managers. Who have leadership things that you need to do but you don’t get to do them because you’re always being pulled on the floor. How do you say to your people I want to help you but I really do need to do these other things, so that our practice runs? Without them feeling like you’re abandoning them or you’re turning your back on them. How do you feel okay about that?
Dr. Andy Roark:
Guys, that’s what we get into. If this resonates at all with you, you got to check this out. I don’t have anything else to talk about it. Stephanie and I are talking about a lot because man, with practice being shorthanded and everybody being busy, it is hard to take time to actually do the leadership management things that have to get done. You can hurt people’s feelings when they’re like hey, can you hold this cat? Can you put on the lead apron? You’re like no, I can’t. That’s hard. Anyway, that’s what we’re talking about. If that resonates, go over there, check it out. It’s a great podcast if I do say so myself. I really do love it.
Dr. Andy Roark:
The only other thing I want to tell you about is on March the 13th we have a virtual workshop with the one and only [Dr. Sire Clement 00:14:05]. This is on clientele curation. Guys, there are clients that get you and get your practice. They see you, they see your values, they see what you care about. They see what your worth and your value are and they trust you. You understand and see them and those are your great clients. They just match up with you in a deep way. Guys, they tend to be compliant. They tend to communicate well with you and you communicate well with them. You guys hear each other. Man, those are your clients and everybody’s got different clients but you have your clients. If you think about them for a second and the clients you really love to work with, you know who I’m talking about. How do you find more of those clients? How do you attract those clients who get you, who get your culture, who get your values, who get your worth, who get the way that you communicate? You enjoy working with them and they enjoy working with you. Does that not sound like heaven?
Dr. Andy Roark:
I always used to say the goal of being a veterinarian is not to be book solid. It’s to be book solid with people who trust you and who see value in you. Who you get and who you understand. Guys, that’s what this workshop’s all about. It’s clientele curation. How do you find your people and convince them that you are the vet for them? I’ll put links in the show note, it’s a two-hour workshop and check it out. Don’t miss this one, it’s going to be great. That’s enough for me, let’s get back into this episode.
Dr. Andy Roark:
Okay, let’s walk it back and go back to left-sided heart enlargement that we see on the radiographs. Let’s say that I’m starting to see changes in the heart. Where do you go from there? In Higgins case, mom and dad love Higgins. They have some resources and they’re willing to invest them in Higgins. Yeah. Where would you take this case?
Dr. Anna McManamey:
Yeah. So if we see cardiomegaly, so we do think that the heart is enlarged. Then we kind of have two separate things. Is the heart and large but there’s no pulmonary venous distention and there’s no pulmonary edema? So we just have enlarged heart but no congestive heart failure. Well, if he’s a typical older Maltese with a chronic murmur, it’s left apical systolic. It’s probably mitral valve regurgitation. In those dogs, we do know that even before congestive heart failure happens. If their heart is a significantly enlarged size, we consider them this B2 category of the mitral valve disease. So what that means for us general folk is that starting Pimobendan may actually improve some of their clinical signs. So they don’t have to be an active congestive heart failure to see benefit from that drug. It may be that their heart size is just so big, it’s actually pushing on their atria.
Dr. Anna McManamey:
We can see dogs that have syncope or passing out before congestive heart failure. Again, they just have pretty bad disease but they haven’t decompensated yet. So Pimobendan is a trial drug that I’ll use for those patients. If they improve on it, then they stay on that lifelong. If they have a big heart, chronic murmur, they’re older. The other important diagnostic step that I recommend for general practitioners is a blood pressure. So we’re trying to screen for systemic hypertension. I’m actually more worried about hypertensive patients or even pre-hypertensive patients with mitral valve disease than I am for them ever being hypotensive. They come in your office and there’s tails wagging at you, they’re probably not hypotensive. But screening for that even pre-hypertensive state, having a blood pressure over 150 millimeters of mercury is pre-hypertensive.
Dr. Anna McManamey:
Over about 160 millimeters of mercury, we call them systemically hypertensive. Then over about 180 millimeters of mercury, that’s pretty significant hypertension. That we’re going to chalk up to more than just them being stressed in the hospital. The reason that number’s so important for us is because it really lets us know what the after load on that left ventricle is. So if you have a leaky mitral valve and you have high blood pressure, you’re actually going to have worsened mitral valve disease because of how much more work that left ventricle’s doing. So that’s another target for me. If a patient is coughing, has a big heart, big left atrium, no congestive heart failure but their blood pressure’s really high. I might actually start anti-hypertensive in that patient and then further work up the cause for the hypertension. So that’s a really important diagnostic for a cardiologist, is a blood pressure in mitral valve dogs.
Dr. Andy Roark:
That makes a lot of sense. I’m going to be really honest and vulnerable here and say that blood pressures checks are a weakness in my game. I don’t check them as often and regularly as I should. Can you give me tips for success with K9 blood pressure checks? Just things that I should have in mind as far as getting good reading, get the best results, getting reliable information.
Dr. Anna McManamey:
Yeah, of course. So there’s two main options that we have in veterinary medicine. We have oscillometric blood pressures. So those are the ones like the little SunTechs. That are just little machines that you put the cuff on the limb, you push the button, and then it does everything for you. Oscillometrics will give you a systolic, a diastolic, and a mean blood pressure. The most important thing with the oscillometric is to just make sure the heart rate it’s calculating matches the heart rate of the patient. If those don’t match, then it’s not a real number, and you can get crazy differences. So we always repeat that blood pressure measurement, at least three times, sometimes up to five times. The oscillometric’s nice because you can leave the patient in the client’s lap and just put the cuff on the limb, on the tail. Is actually my favorite spot, is on the tail. Push the button, say we’ll be right back. Then you can even tell the client to push the button if you want but you can get those readings and then take the average.
Dr. Anna McManamey:
There’s the other method, the doppler and the doppler is the older method. It’s really just systolic pressure. It does require a little bit more training, a little bit more skill to use it. But the nice with the doppler is you’re hearing the heartbeat, so you know that it’s pretty accurate if you have the right size cuff and the technician or a doctor who’s comfortable using that technique. But the biggest things are having adequate restrain, making sure the environment’s as calm as it can be and the animal’s as calm as they can be. Then just making sure you’re checking that heart rate, checking that patient, making sure the numbers make sense to you.
Dr. Andy Roark:
Cool, okay. That totally works for me.
Dr. Anna McManamey:
I think the other kind of big tear off. So let’s say again, that was kind of like big heart but no congestive heart failure. Then it’s going to become big heart but we do think there’s congestive heart failure. So if there’s active congestive heart failure, the “emergency therapies” are going to be Furosemides. So that’s tried and true, pure diuretic. Lasix, of course, is its other name. Then Pimobendan. I really think that Pimobendan is underutilized in the emergency setting. So Pimobendan or Vetmedin, it has two jobs. One thing that it does is it increases heart contractility. The other thing that it does is it reduces the afterload on the heart. So it equates to a lot more blood forwards, less blood backwards, and patients tolerate this very well. They really don’t get hypotensive on this drug.
Dr. Anna McManamey:
The only trouble is it’s oral, so you have to be able to get it physically in the animal. So sometimes the stress is more than it’s worth. So at the end, you can always fall back to a Furosemide Lasix. It’s available by mouth, you can give it injectable IV, IM or even subcutaneously if you need to. But my typical dog dose of Lasix is two milligrams per kilogram, IV, IM Sub-Q, PO, whatever route you want to give it. Then oxygen, my mentor always told me there’s no contraindication to oxygen unless the patient’s on fire. So oxygen is never wrong. Oxygen sedation, Lasix, never, never wrong. Then usually, we’re trying to get a dose of Pimobendan in the short term.
Dr. Andy Roark:
Okay, that makes sense. Talk to me a little bit about ACE inhibitors. Is that something that you reach for fairly early or at all anymore? So in the emergency case, I’m looking at this dog. The classic therapy I was taught, obviously, when Pimobendan was brand new when I was coming out of vet school. So it was Lasix and ACE inhibitor. Has that thought changed? Yeah.
Dr. Anna McManamey:
Yeah, it’s a great question. So there’s kind of like two camps I would say. People that are very, very motivated to use ACE inhibition whenever they can. It makes sense, I think theoretically. The frustration that I have as a cardiologist is try as we might, we don’t have that hefty piece of literature that shows that it makes a difference in the emergency setting or even in the preclinical setting. So unlike the epic and the protect studies that looked at Pimobendan and the preclinical heart disease cases don’t have that same evidence in an Enalapril, Benazepril or Spironolactone. Especially with mitral valve disease, I’d say it’s a little bit different when we get to DCM.
Dr. Anna McManamey:
So in the asymptomatic heart disease, I don’t routinely use ACE inhibitors. I use them if I have a pre-hypertensive patient because maybe I’ll get a little bit of after load reduction, a little bit of drop in blood pressure. So that’ll help. In the congestive heart failure patient, we do know that makes a difference and their long-term survival. So it’s not a drug that I consider emergent. Giving that dose of Enalapril there in the emergency room is not going to make the difference for that patient. But long-term, absolutely. I try to get them all on it. There’s in Enalapril, Benazepril. A common question I get is one better than the other? No, one’s not better than the other. It’s purely preference. Benazepril may last a little longer in the bloodstream. So maybe you can get away with once a day dosing instead of twice a day dosing. But both have similar risks of azotemia developing in these patients. It’s very, very low risk but it’s still enough that we always recommend checking renal values before starting.
Dr. Anna McManamey:
ACE inhibitors also, I don’t like giving them to patients that aren’t eating or feeling very well. Just because it can kind of further worsen that nausea, inappetence. But Enalapril or Benazepril is great. Spironolactone, that’s an aldosterone antagonist. We all learn as a potassium-sparing and diuretic. It does do those things but it’s now aldosterone antagonist, also has great benefits.
Dr. Anna McManamey:
So emergency drugs for me, Lasix and Pimo. Long-term management, some type of ACE inhibition and some type of aldosterone antagonist, which is usually Spironolactone.
Dr. Andy Roark:
Can you talk to me a little bit? So we are going down this sort of emergency rabbit hole but I really love it. So I want to go a little bit deeper.
Dr. Anna McManamey:
It’s okay.
Dr. Andy Roark:
So yeah, can you talk to me a little bit about sort of follow-up care? So we’re doing two mix per gig of Furosemide, we’re trying to get the coughing sort of under control. Is it dose to effect, are you watching for coughing, and you were going to read? I know the dosing range on Furosemide or Lasix is pretty large. I always look at that, it’s something like two to 12 milligrams per kilogram.
Dr. Anna McManamey:
Yeah, it’s a little unhelpful.
Dr. Andy Roark:
Yeah, exactly. So I’m kind of like we’re going to do a little bit and then we’re watch and see. Can you give me some guidance there? Maybe help me make that less gut instinct and give me some things I can put my feet on.
Dr. Anna McManamey:
Yeah, absolutely. So again, I think for dogs, two milligrams per kilogram is a very appropriate starting dose. If you have an animal that is coughing and a little bit to kipnuck, you can probably wait another few hours before re-dosing them. But you’re going to have to treat every animal a little different as it comes in. So you’ll kind of use your clinical judgment for that. The nice thing about Lasix is that it works pretty quick. So if you give an injectable dose of the drug, I would expect the urine production to peak within an hour of giving that drug. So if that animal makes urine, urinates, has a big bladder after about an hour, then you know your dose did its job. Now, usually you got to go let them pee because then they’re uncomfortable holding their bladder. But once you’ve done that, you’re in the right direction. Then, usually, you can consider re-dosing them.
Dr. Anna McManamey:
So if their coughing hasn’t gotten any better, honestly, the most important monitoring for these dogs is their respiratory rate. So their respiratory rate is what I use in the clinic and it is what I use for clients at home. A normal resting respiratory rate in a dog or a cat really should be below 30 breaths in a minute. We give them a little bit of leeway and say less than 40 breaths per minute is a normal resting respiratory rate in the hospital. So I’m targeting that number. So if I give my dose of Lasix, wait the hour, the urine is made, the dog pees, and we’re still having a respiratory rate higher than 40. Doesn’t include panting but true resting respiratory rate, I’m going to re-dose. We’re going to keep going until we get to that lower rate. I would say most dogs that come in with respiratory signs that are very mild and it’s just kind of coughing, probably need about four to six Mgs per Kg their first day of congestive heart failure. The ones that come in four to kipnuck, that’s the sign of the owners know, they’re going to need more like eight, 10-ish Mg per Kg their first day.
Dr. Anna McManamey:
But then once you get that edema gone and they’re breathing comfortably, their respiratory rates are less than 40 again, that’s when we transition to an oral maintenance dose. Which is usually going to be about two Mgs per Kg. BID is a very common, very appropriate starting dose for dogs.
Dr. Andy Roark:
Okay, that’s awesome. That is super helpful. I want to jump back real quick back to Higgins undiagnosed heart disease at this time. Any final pearls of advice for me? Any words of wisdom? Anything I want to make sure I don’t mess up? Any pitfalls I should look out for as I go and kind of reengage with this case and start to take it forward?
Dr. Anna McManamey:
Yeah, I think the most important diagnostic you’ve already done, which is the chest X-rays in your physical exam. Blood pressure would be the other diagnostic to consider and then you can always offer blood work. But if you’ve ruled out the life-threatening causes of the cough, that’s the first important step. I would say in terms of client education and potential trial therapies to do because they want the cough to stop. Is have them start counting respiratory rates at home, make sure that number stays below 40. I would say in terms of trial therapies, things that we’d say if we don’t know, we’re just assuming it’s mitral valve disease. But we’ve done the RADS, we know that it’s not congestive heart failure. Trial therapies for cough, usually trial of Doxycycline. Just treating anti-inflammatory, treating potential mycoplasma infections, those kinds of things. Then my next step is considering a tapering dose of steroids. So low dose but tapering dose of steroids, whether that’s Temaril P or truly Prednisone and then cough suppression. It’s kind of sometimes the little thing will last with left. So always considering that as kind of our final thing. But if you’ve done the important part of ruling out congestive heart failure and the animal’s otherwise, stable, then you have some time to think and to work.
Dr. Andy Roark:
What’s your favorite cough suppressant?
Dr. Anna McManamey:
My go-to is Hydrocodone, I do hit them pretty hard. We’re having shortages again, so Lomotil is another one. It still is controlled though, Lomotil is still a controlled drug. Getting some shortages of that as we see everyone going to Lomotil now that Hydrocodone is on a little bit of a shortage. But those two drugs are the ones that have the most success with truly suppressing a cough.
Dr. Andy Roark:
Dr. Mac, you are amazing. Do you have any recommendations for people who are just like man, that cardiology is amazing, and I would love to learn more? What’s your favorite resource for people to go and just brush up their game?
Dr. Anna McManamey:
Yeah, that’s a great question. I think that we need to do better and make more. I’m spoiled and I’ve just been surrounded by very intelligent people that have it all figured out. So I just go down the hall and have a chat. But I would say if you just want some more questions about like the physiology hemodynamics. Honestly, I laugh when I say this. But there’s a gentleman called Ninja Nerd, I don’t know if you’re familiar with him.
Dr. Andy Roark:
I’m not.
Dr. Anna McManamey:
He’s a human physician assistant and he has these amazing YouTube videos. That he just draws on whiteboards and just talk about anything. This is how I studied for Boards, was Ninja Nerd.
Dr. Andy Roark:
You listened to Ninja Nerd to study for your Cardiology Boards, okay.
Dr. Anna McManamey:
I did but even for other stuff. But if you just want to hear it in a different way from a different person, a lot of cardiology between species is the same. So you can go to human resources, it doesn’t have to be veterinarian. I think there’s a lot of good posts on VIN, honestly, and message boards there. But my goal is to make similar resources because I think that it’s a topic that’s intimidating for a lot of people but it’s one I love. So whatever I can do.
Dr. Andy Roark:
You let me know when you get that up and going and I am happy to support you as I can. As I said, you are amazing. I’m going to put links. I’m going to check out some Ninja Nerd videos and I’ll put some links to the show notes for people who want to check it out. Thank you so much for being here, you were really amazing.
Dr. Anna McManamey:
It’s my pleasure, thank you for having me.
Dr. Andy Roark:
That is our episode, guys. I hope you enjoyed it, I hope you got something out of it. If you did, as always, the kindest thing you can do is leave us an honest review wherever you get your podcast. It really means the world to me, it’s how people find the podcast. It’s nice feedback for me and my team and all the hard work that we do. So, guys, that’s it. Take care of yourselves, be well, I’ll talk to you soon. Bye.
Editor: Dustin Bays
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