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Andy Roark DVM MS

Where Are The Jelly Packets In Your Practice?

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Last week I went camping in Canada with my family. It was glorious, and a trip I will always remember. However, I did get one complaint consistently from the kids… and my wife: We ate a lot of bagels and peanut butter.

Bagels and peanut butter are great. They don’t require refrigeration, can withstand being packed and unpacked from a backpack, and together they are a decent mixture of protein, fat, and carbs. Still, I must concede, they can get old after being included in multiple snacks and meals for several consecutive days. It is possible I should have thought a bit more deeply about alternative camping and hiking foods before we set off, but… I didn’t.

The novelty of bagels and peanut butter had long worn off by the time my family caught the ferry from Nova Scotia to Prince Edward Island. We knew we would be off the ferry and on a hike by the time lunch rolled around, and there was yet another peanut butter and bagel experience awaiting us there.

I was passing through the cafeteria area of the ferry when all my food luck changed. Sitting in plastic containers on every one of the tables, I saw something I had never before had strong feelings about: individual jelly packets.

You know the ones. They are usually grape or strawberry, and refrigeration isn’t required because they are consumed entirely when opened. I stood and stared at them. My heart filled with a joy I haven’t experienced since the Christmas days of my childhood.

When I turned my pockets out after leaving the ferry to show my family the treasure I had discovered, my oldest daughter teared up. “Can I…. have strawberry?” she asked in a choking voice. At that moment, we all knew that we had been taking jelly (and a lot of other things) for granted.

Reflecting on the joy I felt peeling open the packet of grape goodness to add it to my sandwich, I realized that we are surrounded by so many wonderful things that we don’t appreciate.

The ability to call an uber to our exact spot, get any sort of swanky coffee drink we can think of, or just drive a car… all incredible when you stop to consider them. I have three different kinds of mustards in my refrigerator. When did we get so much sandwich power? Have you ever stopped to think about how amazing it is that we can buy tomatoes at the grocery store all year long?

Consider the wonders we overlook in our practices. Ultrasonography is absolutely astounding. We put a probe on an abdomen and can see what’s inside real-time. We have vaccines that protect our patients from diseases that would otherwise kill a large percentage of them before their first birthday. We can go to surgery and remove a spleen to save a life. It’s all freakin’ amazing!

Look, I know this may sound over-the-top, but walk with me for a moment. Think about all that’s good around you and what you are taking for granted. Think of the little things that you rarely consider but that make the world a better, nicer, more comfortable place. It’s okay to allow yourself to feel wonder over things that you have access to every day.

We live in an amazing time. Don’t forget it.

#HopePunk

Structuring Associate DVM Pay to Compete

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Dr. Karen Felsted DVM, CPA joins Dr. Andy Roark to talk about how practices can structure veterinarian compensation to better compete for new hires. They discuss salaries, production, split rate production, new graduate compensation and what the future of pay for veterinarians may look like.

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

LINKS

PantheraT Management Consulting: https://www.pantherat.com/

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

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Karen Felsted is a CPA as well as a veterinarian and has spent the last 20 years working as a financial and operational consultant to veterinary practices and the animal health industry. She is active in multiple veterinary organizations, has written an extensive number of articles for a wide range of veterinary publications and speaks regularly at national and international veterinary meetings. In 2011 and 2017, she was awarded the Western Veterinary Conference Practice Management Continuing Educator of the Year and in 2014, the VetPartners Distinguished Life Member Award.

EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am here with a one and only Dr. Karen Felsted. She’s done the podcast before. She’s amazing, she is a veterinarian and a CPA and we are talking about doctor compensation. We’re talking about how to structure associate veterinarian pay. We talk a lot about the competitive landscape of hiring and concerns that people have about, am I paying enough? And how can I structure this so that the doctor wants to work here and also we can afford it? And what are the tips and tricks to make that happen?
And so if you like conversations about money, this is a really good one and a fun one and we kind of weave all over the place. We talk about new graduates coming out of Vet school and the salaries they’re making and how are they going to justify those and no shame to new graduates, but just kind of like what is the landscape and how are these things happening because I get questions all the time about why are doctors getting paid this and are they really getting paid this? And what does that look like and how does that make sense for a business?
Karen talks through all that stuff. This is a really, really great interview. I do have to tell you, Karen has cats and they are very into talking about veterinarian compensation. And so if you hear things clank and pop and crash down, it’s the boys. They’re just going to town. But I was not about to tell Karen to put them out because I was like, “No, this is wonderful.” And so anyway, if you hear any chaos, it’s the boys and they’re having fun. So anyway, 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 to the podcast, Dr. Karen Felsted. How are you?

Dr. Karen Felsted:
I’m good, Andy. How are you doing?

Dr. Andy Roark:
Oh man, I am so great. I love having you here. I’ve had you on the podcast before. I always enjoy our talks. You are a veterinarian as well as a CPA. You are an industry mogul. I see you everywhere. You’re writing for the Fountain Report, which is a neat little business sort of newsletter. If you’re really a business geek about that medicine, you should check out the Fountain Report. You’re running for today’s Veterinary Business Magazine. You’re speaking and just, I don’t know, I always love talking with you. I get so much out of our conversations.
You are just a wealth of information and so I wanted to have you back. I saw a piece that you wrote not long ago about structuring Associate DVM pay. And I was looking at it. It’s always insightful as always. And one of the things that I have been asked repeatedly in the last couple of months, probably the last year, there’s a lot of questions as people are trying to hire and they’re trying to hire specifically doctors about how to set up compensation for veterinarians. But then also sort of how to, let’s just say, so I’m going to give us sort of a scenario here that I’m interested in.
Let’s say that I have a small practice, say a three vet practice, maybe a two veterinarian practice. And I really want to attract that third veterinarian. I’m trying to grow the practice. I know it’s a very competitive landscape. I think I heard recently it’s something like 17 job openings for every veterinarian that’s out there, it’s ridiculous. So I think that there’s a sense of despair, in some cases, where people go, we’re never ever hiring a veterinarian. And my thoughts are, of course, money is important but it’s not the only thing.
And the way that we start to put together a compensation package, I think that matters. And so I wanted to kind of give you that at the very beginning and saying, all right, Karen, I’m going to go with this scenario. Two vet practice. I want to expand to three vets. I want to be competitive. I know that there are some companies out there that are paying big money or practices that are able to make big money. What are my options as far as trying to put together a compensation package that will at least make me feel competitive as I reach out and I try to talk about my culture and try to convince someone that they could make a home in this special little place that I’ve built. So let me open up to you like that.

Dr. Karen Felsted:
So I think I totally agree with you. Money is not everything. Culture, flexibility, hours, schedules, whatever, all part of it. However, if you don’t get the money right, some of the rest of that isn’t going to matter. If you’re paying well, maybe not at the hundredth percentile but at the 60th percentile, you probably don’t have to move to the hundredth if you have a great culture. But if you’re trying to pay the 30 or 40th percentile, culture isn’t going to make up for that at some point.
So, I mean, I had Stacy Purcell, who’s probably one of the best known recruiters out there, said she hasn’t seen a veterinarian get hired in two years that doesn’t have a base salary of $100,000. And that’s production pay on top of that, so they’re ending up making 150 more depending on their production. New grads are getting between 100 and 150. So if you’re still paying 70,000 or 80,000, that may work for a while because the veterinarian you have in place is either getting something else out of the relationship so it fits their child-rearing or their hours or whatever or they just don’t realize it.
But one day they’re going to because this information about doctors salaries is everywhere. So there’s got to be a minimum competitive salary that every practice is offering to get people. And you may have to go above that minimum competitive salary but then you also have to build the schedule. People would rather work four days instead of five. They don’t want to work Saturdays. They want flexibility in their hours. They want a good culture. So you’ve really got to focus on both.

Dr. Andy Roark:
So I know that people immediately have the question of, what is the minimum competitive salary? And, of course, it’s going to be regional. But let me pitch you that question because I’ve seen that recently where people will say, “How do I know what veterinarians in my area are getting or where I should even be?” What are your tricks there?

Dr. Karen Felsted:
Yeah, I think it’s a great question. I do think it’s regional to some extent. I think one way you can look at it is you can look at whatever the doctor’s production is and take it times 21%, 22%, something like that. So if they produce 500,000, then they’re going to make more than 100. But the problem you get with some of that, particularly in smaller practices, is maybe they’re not producing that much but they’re an essential member of the team because they cover some hours, the owner does that.
You can’t say, “Well, you’re only producing 350,000, I’m only going to pay you 70.” Because they’re like, “I can get 100 and they’ll make it possible for me to produce 600,000 at a practice down the street.” So I think the minimum is 100 right now. And that’s a minimum, right? That’s not what people want. They want 130, they want 150, they want more depending on the coast that you’re on.

Dr. Andy Roark:
So I’m really glad that you said that. That whole, like, this person is an essential part of the practice. I’ve seen that a bajillion times and I’ve never really been able to wrap my head around philosophically how to explain it. But I have seen people absolutely blast their own feet right off, because they’ll go and they’ll say, “You’re not producing this number,” which is honestly probably fairly arbitrary. It’s a best practice number but they say, “You’re not doing this, so I’m going to decrease your salary.” And the person goes, “Well, screw you and leaves.” And the fallout is catastrophic. And I’m like, “Well, if she had stayed you would’ve saved 20 grand. So you got that going for you.”

Dr. Karen Felsted:
Right. Well, so I think this brings up a couple of things. One, decreasing salary never works, right? Never, never, never. And the second thing is, I think sometimes people say, “Well, the doctor’s on production pay, so this is all in their court. If they want to make more money, they just need to work harder.”
And what we don’t recognize is that half of making a doctor have the ability to be productive is on the practice owner and the practice management team. So it’s the marketing of the practice, it’s the hiring of appropriate staff, it’s the training of the staff, it’s the pricing of the services. So you can’t just shove it all off on the doctor and say, “You’re not producing them much, you’re clearly lazy.” Because half of what makes them productive is what the practice does. So got to look at all aspects of it.

Dr. Andy Roark:
Talk to me a little bit about the vet student starting pay. I’m really curious, just on your perspective. Because I have heard this, too, that the starting veterinarians … And we’re seeing it in the AVMA numbers they put out recently like starting pay for veterinarians is going up. So we’ve got the veterinarians coming out of vet school and I want to be really respectful of those guys, obviously.
You and I are both veterinarians. We’ve been there and you got to come out and you got to cut your teeth and you got to have a first year. But I can tell you I couldn’t generate 150K worth of business and I was in a really busy practice. I went to a place in Washington, DC and it rocked and rolled and had great support and I did very well my first year. But across the board, no way. Like I said, I was in a really massive well set up hospital to generate revenue.
Is that the expectation on new graduates coming out? Is Karen, they’re going to come in and they’re going to be that effective. Is that sort of a write off that a lot of practices are saying, “We don’t expect them to make that and we’re playing the longer game here and we’re going to take this sort of financial hit upfront to retain them. What’s the play there?

Dr. Karen Felsted:
Yeah. No, really great questions. I think the practices that do well are taking the longer game. And I think just taking a new veterinarian and saying, “We’re paying you 150,000, so we expect you to produce 750 in the first year.” One, probably not realistic but also that kind of attitude means the practice is probably not making it possible for that veterinarian to do well. So part of it is you got to mentor these new graduates, you got to integrate them into the practice. You know, you have to make sure they get the help and support they need. Because I don’t know, I don’t about you, but it took me hours to do a spay when I first graduated from vet school. You know? You too, right?

Dr. Andy Roark:
Yeah. Oh, yeah.

Dr. Karen Felsted:
And so it’s the practices that do well are the ones that mentor their people and give them the training and the support they need to produce well and to recognize they may not produce 750 in the first year. They should be at least breaking even. The practice should at least be making some money on them, even if they’re paying more than 20% of their production or 22% of their production. But it’s really focusing less on numbers. You got to focus some on numbers, but on making it possible for them to do well.

Dr. Andy Roark:
Okay. So I really like that point, too, the idea of being, if you’re pushing a new graduate to generate that type of revenue, then they’re not taking their time, they’re not getting mentored because they’re pushing to produce, produce, produce and ultimately that’s negative. I think that that’s insightful. Talk to me a little bit about how we set up compensation for veterinarians. What are the different strategies? I think a lot of times people act like there’s one way to pay a doctor. And so I’m going to talk to you a little bit, lay out for me some of the different strategies you’ve seen. And then I want to kind of talk to you about your personal preferences.

Dr. Karen Felsted:
So right now, and it depends on what data you see, but maybe 60% of practices are paying some kind of production pay. The rest are either paying salary, hourly, daily rates, but let’s say the greater majority is doing production pay. And historically we just did one production percentage, so 20% of all of your production. I do think percentages are going up somewhat. So now maybe it’s 21% or 22% and you’re also seeing some split rate production. So they get less percentage if they do product production and they get more for services.
The biggest thing that I would say here, though, is you can have this most perfectly designed pay system production or any other kind, but if it doesn’t come out to a competitive salary, it doesn’t matter how philosophically perfect it is, you’re not going to be able to keep those people because they can go down the street and make more money.
So yes, I mean, you can design your production system so it encourages veterinarians to do the kinds of things that you want and to be fair to the practice as well, don’t get me wrong. Except unfortunately, right now, it’s a seller’s market, meaning the veterinarians looking for jobs and so they have more ability to influence what happens. It kind of doesn’t matter what a practice owner thinks about it.

Dr. Andy Roark:
That’s hard, hard truth.

Dr. Karen Felsted:
If you want to hire somebody. You can always not hire somebody.

Dr. Andy Roark:
But it’s true. It’s true. It is. But it’s hard truth. And I work with medical directors all the time who … It’s managing people. Managing people when they’re like, “I don’t like what you’re saying. I might go work somewhere else.” Yeah, it’s just like, “Oh, it is so …” And again, props to the veterinarians. Not trying to throw shame, but boy, it really does make it challenging for either side to have that much leverage. Now I remember times when the hospital had all the leverage and so that was not any better. It was just a different-

Dr. Karen Felsted:
That’s not good … No, no.

Dr. Andy Roark:
A different thing, exactly.

Dr. Karen Felsted:
It needs to be a balance.

Dr. Andy Roark:
It needs to be a balance. And whenever it gets out of balance, it becomes challenging. And so I think it’s just interesting that way. But boy, I see a lot of medical directors who wrestle with that. Let me ask you, can you give me because you mentioned split rate pay. I thought this was going to be more common than it is now, Karen. I remember about eight, nine years ago, pay for veterinarians … There’s more and more products that were coming out that were sort of high-end products and they were fairly low margin products, meaning practices would carry these things but they didn’t seem to make a ton of money on them.
But they were very important to have or they really tried to keep the price down on them or they were highly shopped and veterinarians were like, “We’re going to try to price match here. We know people can order these products online.” And so paying the veterinarian their standard 21% or whatever is not going to be feasible. That practice has not grown like I thought it was going to. What did I get wrong or did I get it wrong?

Dr. Karen Felsted:
Well, no, I think that’s an interesting comment. I don’t think split rate production is the be all and end all of everything. Conceptually, I mean, I more or less get it. You can say that the margins on products are not what they used to be, so we’re going to give less of a production pay on that. But most of the practices, in fact, all of the ones that I’ve seen that do lower on product production, do higher on service production.
And I think that comes back to my point is that it has to balance out. If the going rate for a veterinarian in your community is 150, you got to get to 150. I don’t care if you do 20% of the whole doctor production or you do 10% and 22% or whatever, you still got to get to 150. I’m not sure that we know what the best split rate production number is.
I’m not even sure there is a best number out there. And I think if you have a doctor who is slacking off on services and selling more products, which means bringing in less profits for the practice as a whole, I think there’s a conversation to be had there about the quality of medical care. And I’m not sure you deal with that with a compensation model.

Dr. Andy Roark:
Well, it’s funny you say that. There is a tendency in certain types of people in our profession where, I think, there’s a lot of people who don’t want to manage other people. They don’t want to have the heart or the uncomfortable conversation. They’d rather restructure the compensation package.

Dr. Karen Felsted:
And not have to talk to anybody ever.

Dr. Andy Roark:
And not have to say, “Hey, look man, what you’re doing, this is not in the best interest of the pet.”

Dr. Karen Felsted:
That’s right, of the pet.

Kelsey Beth Carpenter:
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And then her and Dr. Andy Roark are going to dive into the components of therapeutic renal food and talk about the benefits that it can offer for patients with chronic kidney disease. They’re also going to talk about current CKD management recommendations. Now’s your chance. Don’t miss out on your opportunity to enhance your knowledge of chronic kidney disease management. Again, head over to the website at drandyroark.com. That’s drandyroark.com/backtoschool. Can’t wait to see you there.

Dr. Karen Felsted:
Well, that’s the whole production pay is like that, right? Because I think owners were like, if I’ll just put them on production pay that I have no responsibility for how well they do. It’s all on them. No, sorry, that’s not how it works.

Dr. Andy Roark:
Yeah. I’ve seen that. I’ve seen that so many times. But yeah, I think that’s why production pay was so popular in that … It’s still very popular, it’s still popular.

Dr. Karen Felsted:
It’s still popular.

Dr. Andy Roark:
But it was like, for a long time, we had less emphasis on management in our training and stuff than we do now. But that is kind of the idea of is if I set this production model up the right way, then I don’t have to manage performance like they’re self to me. I did an externship with this guy and he was in Tampa, Florida and he had a great practice. I really liked him. He is just an interesting guy. And I remember as a vet student, I was there and I said, “Do you pay the doctors on production or only on salary?” And he said, “Well, they’re on production.” He said, “But we’ve done it both ways.” And I said, “Okay.”
And he said, “Here’s the difference. When I pay them on salary at the end of the day and there’s appointments waiting to be seen, I have to go chase them out of the doctor’s office to get them to see the last appointment because all trying to lay low and not get the last …” “They all want to go home. But when I pay them on production, I don’t have to chase them out of the doctor’s office at the end of the day.” And that’s the answer.
And it’s a silly story, but it actually really spoke to me as far as that seems about right. But ultimately you still have to … I really like this point of, you still have to get there. I think you answered my question of what did I get wrong? What I got wrong was, Andy, if you do split pay and you reduce payments on products, you’re going to increase them on services. And I always imagine that, too. And it’s just ultimately, it’s probably just a more complicated way to get to the exact same point and so just do it.

Dr. Karen Felsted:
I’m not opposed to split rate production, but yeah, I’m not sure there’s all these magical benefits and it’s definitely more complicated in how you administer it.

Dr. Andy Roark:
I have definitely, as I’ve gone on in my career and run a growing business, simplicity is underrated.

Dr. Karen Felsted:
Agree, totally.

Dr. Andy Roark:
Simplicity is underrated. So when we get in these conversations and we start talking about compensation, production, things like that, I always think of … One of the ideas we always have to bring back around is we need to talk about compensation holistically. And so we say, “Oh, this is sort of a base and we’ve got production on top of it and it’s this percentage and blah, blah, blah.”
But there’s a suite of other pieces that come along with this. How do you look at things like medical, like the 401k, like vacation time? How does that stuff factor in? Do you have rules of thumb where you say, “I look at this when we start doing time off.” Or do those things … I mean, surely those things factor into the package when you’re putting together. I think a lot of people say, “I don’t know how those things square up.” Help me see the bigger picture of the conversations [inaudible 00:21:05].

Dr. Karen Felsted:
Yeah. So there’s been a rule of thumb out there forever. I’ve honestly, personally, never really used this rule of thumb but I’ll throw it out there because people talk about it. And they’ve said that the total of W-2 compensation plus the cost of benefits should be about 25% of production. And some people throw workers’ comp costs in there, others don’t. It’s not a perfect rule of thumb. I don’t really do that. I think you have to look at the cash W-2 compensation separately and then benefits cost what they cost.
And sometimes employees take advantage of benefits, sometimes they don’t. It’s like sometimes people are on their spouse’s healthcare, so they don’t do the practices, whatever. So I don’t tend to look at that 25%. I look at, okay, what do I have to pay to be competitive in a cash standpoint? And then what are the typical benefits in the market? And that’s going to be health insurance and it’s going to be 401ks. But I think the one you have to focus on the most is, one, it’s the schedule that the veterinarians work.
So I’ve seen more practices being closed on Saturdays so people don’t have to work Saturdays and that’s attractive. And then people are getting more vacation or they’re working three or four days a week, 35 hours is now a full-time job instead of 45 hours a week as a full-time job and that’s very attractive as well. Or they’re getting more days off, whether it’s how do it as PTO or do it as separate vacation or whatever. So I think you have to focus on the scheduling, the day-to-day scheduling of what days a week people are going to work but you also have to look at that that time off as well.

Dr. Andy Roark:
Karen, this has been great. Are there any last thoughts? Like when you look into your crystal ball, do you see changes coming in the future? Do you think that there’s going to be shifts in the way that veterinarians are compensated?

Dr. Karen Felsted:
You know, this is really interesting. So I heard Matt Salois, who used to be the Chief Economist at the AVMA, he gave a webinar maybe a year ago and he said he thought this difficulty in hiring was going to be a 10-year problem. And I’m like, “Oh my God, that’s awful.” 10 years is a really long time, right? And of course, obviously, as long as it’s hard to hire people that’s going to push salaries up. Are we over the hump of it? I don’t know that we’re over the hump. Are we at the height of it? Maybe.
Practice owners are going to have to pay what it takes if they want to have another veterinarian. But what they need to think about is that, one, if you can improve productivity and efficiency in a practice, you may be able to have growth even with the same number of veterinarians and team members that you have. And there are also other ways of improving profitability.
So better marketing to bring in more clients or the productivity and efficiency or controlling your expenses better. And so we also need, bottom line, what we care about is the amount of profits in the practice, not just the total revenue. So the practice needs to be looking at how can I make revenue be as strong as … Or excuse me, make profits be as strong as possible. And some of that, a lot of it, is about doctor productivity but not all of it.

Dr. Andy Roark:
That makes sense. Over the last five years, we’ve had an influx of private equity money into the profession. We’ve had outside investors coming in and a lot of these companies that have taken private equity money have been focused on buying practices and growing and just growth, growth, growth.
And it’s been my perception as I’ve looked at, first of all, we saw multiples that were being paid to buy practices that just seemed unhinged from reality as far as what was being paid in order to have [inaudible 00:24:55].

Dr. Karen Felsted:
Agree.

Dr. Andy Roark:
And I think there was a microcosm of that in doctor pay to some degree. There was always these stories that you hear about doctors being paid exorbitant amounts of money to go … And again, no shame on them.

Dr. Karen Felsted:
Right.

Dr. Andy Roark:
But yeah, hey, if you can get it-

Dr. Karen Felsted:
It depends on your viewpoint.

Dr. Andy Roark:
Yeah, exactly. No criticism. But it’s doctors salaries and, of course, we heard that and we say, “Well, this group was paying,” or these people were paying this amount for paraprofessionals as well as doctor. And owners would say, “I can’t get anywhere close to that. Things like that.” And I’ve always sort of comforted myself when I looked at business and I looked at medicine to say, the numbers got to work. And really in that way, we’re all kind of playing the same game where you’ve got to make the numbers ultimately work.
And different people have different advantages because of where they are, their geography, their corporate structure, the amount of money they have behind them. But ultimately, you’re still playing the same game of we’ve got to set it up so that the numbers have got to work. But Karen, it felt to me in the last couple of years like there have been groups where the numbers didn’t have to work. The idea was we are going to grow, grow, grow and actually putting people into place and paying them a salary that they would ultimately earn back or that we expect them to earn back. That just didn’t seem to actually be the plan. Does that resonate with you at all, when I say that? Have you had thoughts like that?

Dr. Karen Felsted:
Corporate groups that were not expecting as much in production from their doctors? Is that what you’re saying?

Dr. Andy Roark:
I think so. I think basically what I’m sort of trying to say and not the established groups. But my perception was that there were groups that had a significant amount of money behind them and they wanted to grow. And part of growing was, I don’t care what it costs.

Dr. Karen Felsted:
Oh, yeah.

Dr. Andy Roark:
Get practices, get doctors, get support staff. And a lot of other practices would pull their hair out and say, “How are they paying these numbers? How does this come back around and make financial sense in the end?” And it was a very convoluted way that to sort of try to get your head around it. But to me, I felt like this is … It almost felt detached. It was definitely detached from any sort of short-term.

Dr. Karen Felsted:
I totally agree. Long-term reality, absolutely.

Dr. Andy Roark:
Exactly. So I looked at that and then go, it felt strange to me. I feel like I’m seeing less of it now. Do you think that’s a fad, that kind of came and went?

Dr. Karen Felsted:
Yeah, I do. I think it was up there with those multiples that we probably hit a peak on, multiples a year ago. I mean, it’s still a strong market if you want to sell your practice but it’s not the multiples that were there a year ago. But yeah, I think corporate groups are paying less because the multiples before were not realistic, not sustainable. And I do think there’s definitely higher expectations. I think they’re willing to pay high salaries and there’s evidence out there that.
I mean, they’re not just anecdotal evidence, but some numbers the AVMA pulled together that shows on average corporate salaries are higher than individual practice salaries. But I think there’s definitely a higher level of expectations now than for those higher salaries, you’re going to have to produce more. I think all of the corporate groups are focusing or being forced to focus more on operations as well. And part, sorry, my cat is just driving me crazy. They’re recognizing they’ve got to focus on operations more than they did before.

Dr. Andy Roark:
I’m starting to see that as well. That absolutely lines up with what I’m seeing. All right, excellent. Karen, thank you so much for coming on and talking through this stuff with me. I always love our time together.

Dr. Karen Felsted:
I do, too.

Dr. Andy Roark:
Where can people find you? First of all, do you have any resources on this topic that you really like? You’ve mentioned a couple of different things but anything that you’re reading or you’d point someone to who wanted to understand compensation better?

Dr. Karen Felsted:
You know, I’m not sure there’s any one great resource out there. You’ll certainly see webinars, conferences will have sessions on compensation articles in say, Today’s Veterinary Business. You mentioned that and I’ve written some of those. Other people have written some of those. So I think a Google search will unearth some of that. Right now, a lot of it though, is about paying attention to what’s going on in your community because hiring is local. And it kind of doesn’t matter what the average across the United States is.
It matters in Richardson, Texas, where I live, what’s being paid for, whether it’s staff or doctors. And if they want to find me, my company name is PantheraT, which is P-A-N-T-H-E-R-A-T . It’s Pan the Rat, which was an unfortunate … That was a unintended consequence of the name that I picked. PantheraT is actually short for Panthera Tigris, which is the genus and species of tigris. But pantherat.com is the website for my company. And I’m Karen at pantherat.com. So happy to answer any questions on this. Love talking with you, Andy, we could talk about this for another hour, you know?

Dr. Andy Roark:
Oh, I know. Yeah. I always have to rein it in. That’s awesome. I’ll put a link to Karen’s website in the show notes so they can find you. Guys, thanks for being here today. Take care of yourselves, everybody. And that’s it. That’s what we got for you. Guys, I hope you enjoyed it. Thanks to Karen for being here. As always, if you got something out of the episode, please leave me an honest review wherever you get your podcast or share the podcast with your friends. Gang, take care of yourselves. Be well. Talk to you later. Bye.

Heart Murmur and Cough in a Senior Dental Dog (HDYTT)

by

Dr. Andrea Eriksson De Rezende, veterinary cardiologist, joins Dr. Andy Roark to discuss a cardiology case. Dr. Roark has an 11yo FS chihuahua with a grade V/VI systolic heart murmur that needs a dental cleaning. The patient is reportedly starting to cough at home. Dr. Roark wonders if this patient is safe for anesthesia and what sort of diagnostic workup and treatment plan would be appropriate. Dr. Eriksson lends her expertise!

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This episode is brought to you by CEVA Animal Health.

LINKS

Explore Free CE from Ceva: https://www.cevaconnect.com/ce/?utm_source=TheConeOfShame&utm_medium=podcast&utm_campaign=Susanne_cardio

Cardalis Info: https://www.cevaconnect.com/cardiology/products/

Skyline Veterinary Specialists: https://skylinevetspecialists.com/

Email: andreaeriksson@skylinevetspecialists.com

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

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Andrea Eriksson De Rezende is a native of Eugene, Oregon and completed her undergraduate studies at Willamette University in Salem, Oregon. She received her veterinary degree from Oregon State University in 2005, which was followed by a one-year rotating small animal and surgical internship at Oregon State University. She then completed a three-year residency in cardiology at North Carolina State University. Dr. Eriksson De Rezende became a Diplomate of the American College of Veterinary Internal Medicine (Cardiology) in 2009. Until mid 2011, Andrea was an assistant professor of cardiology at Virginia-Maryland Regional College of Veterinary Medicine. Andrea then moved to Brooklyn, NY to join the Veterinary Emergency and Referral group. Currently, Andrea is managing partner at Skyline Veterinary Specialists in Matthews, NC. Her research interests include management of congestive heart failure with particular interest in the renin-angiotensin-aldosterone system as well as cardiac imaging. Personal interests include cooking, travel & singing.

EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I got a great one today. I am here with my friend, Dr. Andrea Eriksson. Andrea is a boarded veterinary cardiologist in Charlotte, North Carolina. Man, she’s a wealth of information. I am super happy to have her here to talk to her about a case.
I have a little bitty, itty bitty… Pepita is an 11-year-old chihuahua who’s got a grade 4 heart murmur. And, owner’s report, she’s having a bit of a cough. Well, you’re not going to believe this, this 11-year-old chihuahua has got some dental disease and is really going to need a dental prophy here.
And I’m having some concerns about putting this pet under anesthesia. I’m wondering, “How safe is this? How do I need to work this up? Is it time for some medical management for Pepita beyond what she’s been getting?” Dr. Eriksson walks me through everything. So, guys, this is a quick, action-packed, pearl-packed, little episode that, let’s be honest, you’re going to see this case and you’re going to want to know what to do.
So, anyway, we get into that. We talk about a new drug called Cardalis, which you may or may not be familiar with. But, anyway, it’s great. We’re going to learn a lot. Let’s get into it. Gang, this episode is brought to you ad-free by CEVA Animal Health.

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. Andrea Eriksson. Thanks for being here.

Dr. Andrea Eriksson:
Oh, thank you so much for having me. I’m very excited to be here.

Dr. Andy Roark:
Yeah, it’s my pleasure. For those who don’t know, you are a boarded veterinary cardiologist. You are right up the road from me. You’re in Charlotte. You and your husband own Skyline Vet Specialists, where he’s an internal medicine specialist and you are a cardiologist. And then, you guys also have an emergency practice. Is that separate or is that together?

Dr. Andrea Eriksson:
It’s together with us.

Dr. Andy Roark:
Oh, wow, okay.

Dr. Andrea Eriksson:
Yep, I know, I know.

Dr. Andy Roark:
That’s amazing. All right, wonderful. Well, I am so glad that you’re here. I have a case that I want to work up with you. Is that okay?

Dr. Andrea Eriksson:
I love it.

Dr. Andy Roark:
Good, good, good.

Dr. Andrea Eriksson:
It’s my favorite.

Dr. Andy Roark:
Okay, here we go.

Dr. Andrea Eriksson:
Yeah.

Dr. Andy Roark:
So, I have an 11-year-old female spayed chihuahua named Pepita. I’ve had pepita for a while. She has got a heart murmur. It’s grade 4. I can hear it on both sides of her chest. It’s pretty significant. When I hold her in my hand, I can’t tell if I’m imagining that I can feel it, or it’s really… Is that her natural tremble? Anyway, so it’s about that. It’s not a tiny little murmur. But, she’s always seemed to be spry. Let’s be honest, her feet never touch the ground. Mom doesn’t put her down.

Dr. Andrea Eriksson:
As it should be.

Dr. Andy Roark:
Exactly right, as it should be. She gets carried around. She’s coming due for a dental cleaning. We’re going to need to make that happen. And she’s 11. And mom has mentioned to me that she’s doing a bit of coughing at home. Now, I’m not hearing coughing on the exam, but mom says that she coughs at home sometimes.
And so, what I’m coming to you with is this, is first of all, she’s not being medicated right now in any significant way for her heart condition. How do I look into that? I guess that’s the question. Coming up on a dental, are you terrified of this? Are you saying, “Don’t do this dental, Andy?” Or are you saying, “Why don’t you send this to me and I’ll do this dental?” Help me start to look at her holistically of what does medical management look like? What does risk assessment look like? Is anesthesia even possible? How concerned should I be? So, let me just hand it to you like that and say, Dr. Andrea Eriksson, how do you treat that?

Dr. Andrea Eriksson:
Yeah. So, I would say the most practical approach would be is that we’ve got to, like you said, we’ve got a little chichi that is living her normal life, doing her normal things at home. Probably the owners, at this point, are unaware of the fact that there’s things that we can look for at home, that going forward we can look for, in addition to a progressive cough or a change in cough.
That being said, if Pepita’s going to be anesthetized in her relatively near future, just because that’s what needs to have happen because she’s not eating as well or she’s definitely feeling the effects of having pretty significant periodontal disease, then it’s definitely not a no-go for her to have anesthesia. It’s truly on your physical exam, too, everything that you’re going to look at anyways, is that you’re going to be looking to see does she still have a sinus arrhythmia?
Now, that being said, our chihuahuas can definitely have a heart rate of 160 beats per minute, just because they’re there in the hospital in your hands and not at home. But, one of the things that we do tend to look for is that, as a dog progresses into more significant heart disease, their heart rates tend to actually increase just because it is a natural tendency of the heart to try to compensate to increase cardiac output.
But, the things that you can do, and that would be strongly advised for this particular patient, one, first and foremost in your hospital, would be to do thoracic radiographs. And so, making sure that we’re getting a vertebral heart size that, for that particular patient, seems reasonable. So, that number generally is around 10 for a vertebral heart size. It does vary a little bit between having a barrel-chested dog versus a little skinny thin-chested dog. But, in general, somewhere around 10 is about right.
Then, if we’re seeing something, you’re getting a vertebral heart size that is basically 12 to 13, you actually, at that point, it doesn’t mean you can’t anesthetize them. It just means that patient does need to go onto cardiac medications. And so, we’re thinking, at that point, especially if we interview the owner and the owner is saying, “No, I don’t really see any exercise intolerance or restlessness at night,” if they were savvy and looked up maybe, “What I should be looking for in my pet that maybe has a heart murmur,” if they knew, then they might look up, “sleeping respiratory rate”. It might come across somewhere in their Google search. And so, if they were savvy enough to say, “Hey, no, I’ve done this and it’s consistently below 30 breaths per minute,” then you thankfully have another piece of information. But, many owners don’t know that they need to do that yet until you tell them to do that.
But, say, if that vertebral heart size is 9.7, then that murmur, due to that leaky valve, is not causing any sort of cardiac decompensation at that point. And so, those are patients where you could feel pretty certain that if you use basically your protocol that you would normally use for an 11-year-old dog… So, you’re not going to wallop them with a bunch of medications that are going to change your pressures and their heart rate rapidly.
You’re using things like your midazolam and torodent for your pre-med. And you’re using something like propofol, alfaxalone for your induction. And putting them on a relatively normal rate of isoflurane with your normal five ml per kg per hour type of fluid rate. You’re going to be good.

Dr. Andy Roark:
All right. So, let me say this back to you. So, it’s funny. Yeah, I’m surprised, I think, at how much weight you put on the vertebral heart size. That’s a pretty significant line for you to go to, it sounds like. So, first of all, let me just say, real quick, can you give me a refresher on vertebral heart size just for people who are not familiar, who haven’t been in that position to use it before?

Dr. Andrea Eriksson:
Absolutely. So, it is basically a sum. So, on your right lateral thoracic radiograph, you’re basically going to take a… You can just use a piece of paper, too, where you’re going to take a line, and make a line, and measure this line from the carina down to the apex of the left ventricle. And then, you’re going to do a perpendicular line from the cranial edge of the cardiac silhouette to the caudal edge of the cardiac silhouette just underneath the caudal vena cava. Because you do want to be measuring the ventricles. You don’t really want to get the atria up in there.
So, you’re going to take those lines and you’re going to superimpose them over the thoracic vertebrae. And you’re going to start that line, the very beginning of that line, at the cranial edge of thoracic vertebra number four. And so, you’ll put that line. And then, the second line, which is that perpendicular line, same thing. Start at the edge and start measuring from thoracic vertebra number four, cranial edge. And you’re going to count how many vertebral bodies are in each line, basically, and you add that up. And so, that’s where you’re going to get that.
It’s one of those things that I have plenty of slides showing that. So, if anybody wants to reach out to me, I can shoot them an email super quick and easy. But, there’s plenty of resources out there, too, that show you that way of doing it, but that’s what…
And it’s one of those things that, yes, I get referred these cases all the time for me to echo. And it gives me additional information about that patient for sure. It gives me much more specific information. But, when we’re talking about you having to see 60 patients in a day, and you have 15 minutes to talk to an owner and say, “Hey, I’ve got to figure out if I can take out these teeth because they’re really bad,” that would be the thing that that family veterinarian could do within their hospital to get basically some really good information about that patient.

Dr. Andy Roark:
Yeah, that makes sense. Talk to me a little bit about what you’re looking for with a sleeping respiratory rate. So, I love the idea of getting the pet owner involved in this so they can look at it. Are you looking for trends here or are there certain… You mentioned 30 breaths per minute. Is there some sort of number that starts to give you pause? Walk me through how you use that tool.

Dr. Andrea Eriksson:
Yeah. So, I would say that getting them involved is key. Basically, I talk to my owners about having a triangle of care, which is myself, them being most important with their pet, and then with their family veterinarian. So, that way we can all have a good conversation about what’s going on with Pepita at home. And so, one of the things I’m talking to them about is, “Hey, what we have known about this over the past 10 years is that if we’re able to, whether you do it on an app, so there’s a number of apps, Cardalis has an app, but you basically can track what their sleeping respiratory rate is.” So, I talk to them about, “Hey, if you can get them while they’re completely passed out asleep, just absolutely snoring and sawing logs, then you’re going to watch a rise and fall of their chest, and that’s one breath. They should be, while they’re sleeping a good… nobody having any issues with their heart or anything, they’re going to have a sleeping respiratory rate that’s less than 30 breaths per minute.” Now some dogs, you just can’t catch them while they’re asleep. They know you’re stalking them.

Dr. Andy Roark:
Yeah. They crack one eye open. Yeah.

Dr. Andrea Eriksson:
They’re like, “What are you doing? You’re a creep.”

Dr. Andy Roark:
Yeah. Got you.

Dr. Andrea Eriksson:
So, yeah, they’re like, “You’re a creep.” And so, we allow those guys to get up to 40 breaths per minute because they’re going to change a little bit and fluctuate because they’re creeped out by you. Yeah, yeah. So, that’s what I’m looking for. Trends are amazing. So, if I have an owner that can give me at least data points of three to four per week, that’s like music to my ears. But, it is something I tell my owners that, “When I call you, I’m going to bug you, and I’m going to ask you what this number is, and it’s going to be annoying, so just if you do it will be less annoying.”

Dr. Andy Roark:
I bet they love it. I mean, I bet they love it. It’s something that they can actually-

Dr. Andrea Eriksson:
Yeah, because it’s involved.

Dr. Andy Roark:
… do and feel like they’re involved. Yeah, exactly. I think a lot of times the hardest part with disease, whether it’s you or whether it’s your pet, is a feeling of powerlessness. And so, just the ability to be like, “Yep, I am taking action here,” I think that that’s such a healthy, good thing. So, I love this. I’m on board with the vertebral heart score. I’m with the resting breathing rates. So, I’ve got Pepita here, and let’s say that she’s trending a little bit high, so her vertebral heart size is a little bit greater than 10, maybe up 10, 10 and a half maybe. I’m like, “I don’t know. We’re kind of on the far side of this.” How you do you start to manage that case?

Dr. Andrea Eriksson:
I would say veto. 10 and a half might be a little… We’d be still within a normal range. But, if we bump that up a little bit, say 11.3 or something, and on addition to that you’re starting to see maybe that little hump of a left atrium that’s up next to your mainstem bronchus, and you’re like, “Yeah, that looks a little bit big.” Then, those guys, I typically will say, “Hey, we need to put your pet on Vetmedin, on [inaudible 00:13:49] going to start [inaudible 00:13:50].

Dr. Andy Roark:
Now, we’re going to lay there and make them lay down. Yeah, exactly. Put a box underneath them.

Dr. Andrea Eriksson:
We’re going to have to put you on the box. I wish it worked that way. What we do know about patients that have mitral valve regurgitation due to chronic degenerative valvular disease, and their hearts are getting big, we know that they’re going to live longer and stay within that pretty much asymptomatic period much longer if we get them started on pimobendan.
And so, those patients, I typically will start anywhere from a quarter to a 0.3 mg per kg twice a day Vetmedin dose. It’s well tolerated. There are some patients that may have some GI side effects, so I usually tell them, “Hey, if you see something like that, just try to give it with some food, even though the package insert will say, ‘Give 30 minutes before food.'” It’s like we have to make sure that the patient can tolerate it, and so a lot of them do get it with a little bit of food.
Those are ones where if I have a family vet that’s like, “Oh, Andrea, I need to do that procedure today,” then that’s fine. They can actually have a dose even 30 minutes before they have their procedure because it does work fast. We use it as an emergency drug. So, it does have an effect. If you can wait, maybe having them on it for about a week or so, so that way you actually have that additional support for that cardiac, basically what we’re looking for is increasing the efficiency and decreasing the workload on the heart. So, if we can have it on board before we do the procedure, that’s even better.
And so, some of these guys will get it and they’ll get it about a week before or longer before they go. But, then they stay on it afterwards. So, I usually make that clear. We’re not just using it for the procedure, we’re using it for a long-term. This is going to be something, unless something comes up where the animal doesn’t tolerate it, we’re going to be on this for the rest of Pepita’s life. And hopefully it’s a long life for our little Pepita.

Dr. Andy Roark:
No, I like it. So, great. So, you open up with pimobendan and get them [inaudible 00:15:59]. It’s a miracle drug, in my experience.

Dr. Andrea Eriksson:
Yeah, it is. Yeah. No, it changes things for sure.

Dr. Andy Roark:
Yeah. Well, great.

Dr. Andrea Eriksson:
Yeah.

Dr. Andy Roark:
So, talk to me a little bit about stages and degrees with this case. So, I’ve got Pepita, an 11-year-old chihuahua, I’ve probably got a long way to go. We’re going to start out with management in this regard. She mentioned she’s got a cough at home, things like that. Are you thinking about a diuretic of some sort? Are you not? Are there triggers that are going to send you into action in that regard? Help me walk in that direction, if you don’t mind.

Dr. Andrea Eriksson:
The time where we’ll definitely say, “Okay, we’re going to need to start a diuretic,” is, whether it’s somebody who feels very, very comfortable with thoracic radiographs and say, “Oh, yeah, I actually do see…” Typically, on a radiograph, what we would see is venous distension.
So, on the lateral radiograph, you have an artery, a bronchus, and a vein, and those guys you can see pretty clearly in that cranial thorax. If you do a left lateral, what’s nice is that vein will pop out a lot easier. So, if you do a right lateral… I typically do DV so I don’t have to put them on their back and then I’ll also do a left lateral. The left lateral just shows up that vasculature to that cranial thorax just a little bit better. So, you can compare that vein to that artery.
And so, having a vein that’s plumper, bigger than that artery, that concomitant artery, is an indicator that we’ve got some kind of… that heart’s having a harder time handling its preload, or basically the volume that it feels that’s coming into it. Then, you’re going to be obviously looking for any sort of pulmonary pattern that’s more of a interstitial alveolar pattern. And that pattern, typically in our dogs that have mitral valve regurgitation due to degenerative valvular disease, it usually will start in the right caudal thorax. And so, if you have that DV or VD, and you look in that right caudal thorax, that’s usually where they start to dump the fluid. And so, I typically tell my family that, “Hey, if you can get that view, it’s extremely helpful for us to be able to tell if there’s edema there or not.”
Those patients, if we do see that, and we’re worried about that, and even if they come in and maybe the owners haven’t really… They’ve maybe noticed a cough, but you listen, and you’re watching the dog breathe while you’re talking to the owners, and you’re like, “Well, he’s kind of using his belly to breathe a little bit, too, in addition to those clinical signs,” and owners say, “Oh, yeah, I have kind of noticed that. Anything, from when Pepita tries to run up the stairs, we kind of have to stop and breathe kind of heavy, and I just thought Pepita is getting older. We know that.” And it’s like, “Well, it’s not just getting older. Unfortunately, we need to start some more.”
So, that’s when I will definitely say, “Hey, we’ve got a constellation of clinical signs and radiographic features that do support a diagnosis of congestive heart failure. So, that takes you into, from stage B2, which Pepita would’ve been at before, where she just needed Vetmedin, to stage C, which is basically congestive heart failure. And it may be early stage C. We’ve got a little bit of clinical signs going on. It’s not an animal that’s rushing into the ER, but we’re starting to see those features of edema as well as clinical signs at home.”
So, those patients, we’re going to start them on furosemide typically. So, Lasix. A little chihuahua that is 4.5 kilograms, and is showing us those types of more subtle signs of edema, but we’re convinced this is edema, that little one is going to probably get somewhere around 6.25 milligrams twice a day of Lasix. You might think some, if they’re a little bit more clinical, and you’re listening and the lungs don’t look great, you may start with a little bit higher dose. You might go one full 12.5 milligram tablet twice a day for a little bit and then back down to a half a tablet.
If we’re starting that, then you do need to start something that inhibits the activation of the renin-angiotensin-aldosterone system. What we do know now from recent studies, and this came out a couple years ago, is that dogs will live longer, in addition to having the Furosemide on board and the vetmedin onboard, is also inhibiting the renin-angiotensin-aldosterone system. That’s best done with both an ACE inhibitor and also a mineralocorticoid receptor antagonist too. So, that would be your spironolactone.
So, I usually will say, “Hey, I know it’s a lot of drugs, but your dog’s going to live longer if we get them onto the a lot of drugs.” So, there’s a number of ways of doing that, whether it’s separating them all out where you have Lasix, vetmedin, spironolactone, and an ACE inhibitor. So, that can be your prils. So, whether you like enalapril or benazepril. Personally, this is just… I like Benazepril because it’s once a day. And so, you can get spironolactone and benazepril together and cardalis. And basically you’re going to dose the cardalis based upon the spironolactone dose that you want, which ends up being around two mg per kg. So, for that spironolactone dose. So, that ends up being about two mg per kg for spironolactone and then a quarter mg per kg for the benazepril in that dose.

Dr. Andy Roark:
Talk to me about cardalis. Just talk to me because there’s a lot of people that haven’t used it yet. They don’t have it on their shelf yet. Just give me a high level overview of cardalis as a medication, and when that plays in, and just the benefits that you see in it.

Dr. Andrea Eriksson:
Yeah. So, the benefits that I see is, honestly, what I tell my owners, backed by studies, which is really nice. There are times where I have to say, “There’s this drug, hopefully it helps.” But, I’m not your cardiologist that really likes to do those things. I love having data behind it. What’s nice about cardalis, is it does have that data. And so, their studies show that if you use the combo of spironolactone and benazepril together, it was better than benazepril alone.
So, a lot of family veterinarians feel like, “Oh, I know Andrea. I know we use the vetmedin. I know we use the Lasix.” And then there’ll probably be 50% of them that say, “Okay, I feel comfortable using the ACE inhibitor.” Now, I’m hoping that people will feel more comfortable with also layering in the spironolactone. What’s nice about the cardalis is it is one pill. And so, Pepita, she would probably get 20 milligram and 2.5 milligrams. So, 20 milligrams of spironolactone, 2.5 of benazepril. And I would probably start her on about half a tablet once a day. And then, they’re done with that drug drug.
So, it’s nice just because you just have it and you don’t have to say, “Here’s two other medications,” remembering which one is which and when. And what’s nice about it, too, is that that’s the actual drug that was studied. So, there’s a lot to be said about saying, “Okay, this is what was actually studied versus other combinations.” And so, when I talk to them about things, I’m like, “If it’s me and my pet, I want the one that was studied.” And then, they did all the safety data to show that there’s… I mean, it’s more than unlikely. It’s really not going to happen where you’re going to worry so much about them becoming hyperkalemic.
So, a lot of people think, “Oh, God, Andrea, if I use both of them together, their potassium’s going to be nine.” It’s not going to happen. And so, if you are worried because you did prelim blood work before you started it, and their potassium’s 5.2, and you’re like, “Oh, God, if I get up to six, it’s going to be terrible,” then start them at a lower dose. And then, just recheck them, because you’re going to recheck them anyway because they’re in heart failure. So, that’s what I typically will… that’s what I recommend in counsel to my owners.
And when they talk to me about the cost, it’s a real thing because it is more expensive than you go into the Publix or Harris Teeter pharmacy and picking out the two. I talk to them like, “Well, this is what was studied though.” So, if it comes down to it that the cost is a really big deal, then okay, but I’m going to tell them what I recommend.

Dr. Andy Roark:
Yeah. No, that totally makes sense.

Dr. Andrea Eriksson:
Yeah.

Dr. Andy Roark:
Talk to me about monitoring of this case. So, you said, “We’re going to recheck it, we’re going to follow up because they’re in heart failure.” What does follow up for you look like in a case like this?

Dr. Andrea Eriksson:
Yeah. So, ideally what I will do, if the patient comes to me, when I see them back, I usually see them back somewhere between seven to 10 days after we’ve started all these medications. Now, the caveat to that is a patient that I’m a little bit worried. So, instead of Pepita maybe being 11 with normal renal values, I feel comfortable going seven to 10 days, even a couple of weeks before I recheck her.
And when I’m rechecking, it’s just I’m rechecking blood work. So, in particular, I want to know what her [inaudible 00:25:56], her creatinine, and her electrolytes are doing. And I check their blood pressure. So, for me, I’m a little bit crazy about checking their blood pressure. But, I check with the Doppler just because I’m making sure that there’s no extra workload on that cardiac muscle. So, yes, I worry about them getting hypotensive. But, I really do worry about them getting hypertensive. And their hypertension is not because they’ve got heart disease, it is because they can develop, just from RAAS activation, them having… them developing hypertension.
Then, you’ve got dogs that are 13, 11 that can also have things like Cushing’s. They have other things. And so, I’m making sure that I’m doing everything I can to unload that heart as much as I can. So, those are the two things I like to get at is their blood pressure and their, whether you call it a renal panel or whatever you use at your clinic.
If I have a patient that I worry that their creatinine’s on a little high end of normal, then I will see them five to six days. I won’t go… It’ll be like I’ll cut out half that time. I need a good five days for the drugs to actually have their desired effect, but also have truly when they get good blood concentration. So, we know that about five days, especially with the ACE inhibitor, is going to be a good landmark for us to be able to say, “Now I can see truly what you’re going to be doing with the ACE inhibitor and the spironolactone at that point.”

Dr. Andy Roark:
Dr. Andrea Eriksson, you are amazing. Thank you so much for being here and helping me with this. I really appreciate it. Where can people find you online? Where can they learn more from you?

Dr. Andrea Eriksson:
Yeah. So, if you just look up Skyline Veterinary Specialists in Charlotte, North Carolina, because we’re a small clinic, you just hit the Contact Us, it basically goes to me. But, you can also andreaeriksson@skylinevetspecialists.com.

Dr. Andy Roark:
Excellent.

Dr. Andrea Eriksson:
Yeah.

Dr. Andy Roark:
Perfect. Thank you so much for being here. Guys, thanks for tuning in. And that’s it. That’s our episode, guys. I hope you enjoyed it. I hope you got something out of it. Thanks again to Dr. Andrea Eriksson for being here and lending her knowledge. Thanks to CEVA Animal Health for sponsoring this and making it possible. Gang, be well. Take it easy. To talk you soon.

Individualism: Does it Really Mean Success?

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Every day we are told that success is doing what we want, when we want, and how we want. Our highest goal, apparently, should be going exactly where we want and doing exactly what we want. Compromise is a sacrifice we should strive to avoid.

Can there be a greater measure of achievement than to take the exact trip you most want to take, watch the movie you most want to see, work at the practice you most want to be in, do the aspect of medicine you most want to do, or eat at the restaurant you most want to visit?

I just got back from a vacation hiking and camping with my family. If I was going alone, or even with only my spouse, I would have camped almost every night. I would have hiked all day long and eaten meals composed mostly of trail mix and peanut butter. It would have been an outdoor deep dive and a near-complete escape from people and the stresses of modern life.

My kids, however, were not excited about hiking or sleeping in a tent every night (my wife was with them on this). They also were not fired up about eating a diet of food that doesn’t require refrigeration. They were instead excited about window shopping, getting ice cream on the regular, checking in with their friends back home, watching netflix shows downloaded on their phones and singing Taylor Swift songs in the rental car. 

You can probably guess what happened. We compromised. We hiked about half as much as I would have liked, and did twice as many non-outdoor things as the kids would have wanted. We camped some nights and stayed in cute B&Bs, hotels or motels on others. We ate some trail mix and granola bars, and we also sat down at some restaurants and ate a good amount of afternoon ice cream. We had days without wifi or a cell signal, and we made some stops specifically to let people download a few episodes of favorite shows.

No one got to have their exact perfect vacation, and you know what? It was the perfect vacation. I wouldn’t have traded my time there for anything. Everyone got enough of what they wanted to be happy, and we were all happy together. 

It turns out that eating at restaurants everyone is “just okay with” can make for the best meals of our lives. Hikes together can create lifelong memories, even if some people participating would prefer to do other things. Listening to music you are, quite frankly, tired of can be a joyful experience if you embrace the happiness of those around you.

I don’t think success is having everything you want. I think success is being a part of an interconnected and interdependent group (i.e. family, community, team, etc) that does its best to balance everyone’s needs and wishes. The idea that getting exactly what we want as individuals should be our greatest goal is flawed thinking. The sacrifices we make to be together are the price of admission to a more meaningful life.

Hall of Fame: Venomous Snake Bite to the Lip! (HDYTT)

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In this Hall of Fame Episode: Join Dr. Roark and the wizard, the legend “Uncle Mickey Schaer” as they talk about that case that terrifies us all – the venomous snake bite!

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

LINKS

Uncharted Practice Leader Summit: https://unchartedvet.com/practice-leaders-summit-2023/

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

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Michael Schaer received his D.V.M. degree from the University of Illinois in 1970. He then went to the Animal Medical Center (AMC) in New York City where he served as an intern and then as a medicine resident between1970-73. After the residency, he remained at the AMC as a staff member in the Department of Medicine until 1977. He then joined a private small animal practice in New Jersey until late 1978 at which time he joined the faculty at the University of Florida, College of Veterinary Medicine where he has remained until the present time. He has published several papers and book chapters and he has lectured nationally and internationally. Dr Schaer is also the author of five textbooks: Clinical Medicine of the Dog and Cat – 1st, 2nd, and 3rd editions and Clinical Signs in Small Animal Medicine, 1st and 2nd editions. At the U of F, Dr. Schaer functions mainly as a clinician and a teacher. His previous UF professional duties included: Professor and Associate Chairman-Department of Small Animal Clinical Sciences, Associate Chief of Staff-Small Animal Hospital, and Service Chief-Small Animal Medicine. Dr. Schaer served as Interim Chair, Department of Comparative, Diagnostic, and Population Medicine from February 2017-September 2018. He is currently Professor Emeritus and Adjunct Professor in Emergency and Critical Care Medicine, while still doing active teaching in the classroom and in the critical care unit. Dr. Schaer is board certified in internal medicine (ACVIM) and emergency and critical care (ACVECC).

EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. I am back for you. It’s summertime, and that means the snakes are moving around. That’s right. This is the time of year where if you go out in the evening, you’ll see them on the road there. There’s a lot of snakey activity right now, and I recently came upon a copperhead walking my dog and it scared me and it scared the copperhead and my dog was super into it, but that was not helpful. And so anyway, these things happened.
Guys, I did an episode a couple years ago with someone that I just think the world of. He was that guy when I was in vet school, he was the mentor. I think every vet school has got this clinician that is just the clinician that everyone kind of looks up to. And at the University of Florida for a couple of decades, Dr. Mikey Scher was that guy. And so Uncle Mikey, as he’s known to us, Florida grads, came onto the podcast and talked about dealing with venomous snake bites and canine patients. And guys, it’s a great episode, super timely. 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 Dr. Michael Scher. Thank you for being here, sir. Really appreciate it.

Dr. Michael Schaer:
Oh, you’re welcome, Andy. It’s a pleasure to be here.

Dr. Andy Roark:
I have a case for you from my … Some of our cases that we like to make are theoretical. This is not. One that I had recently and I want to go with it with you if you don’t mind. I sure have. And I know this is something that you do a lot of in Florida. I had a two-year old Boykin Spaniel, which I never saw in Florida. I never saw it in Gainesville. It’s the state dog of South Carolina, and now I see them all the time.

Dr. Michael Schaer:
Really?

Dr. Andy Roark:
But yeah, very similar to Cocker Spaniel for people who are listening who don’t see a lot of those, but the Boykin Spaniel I see a lot of, and this is a young Boykin Spaniel stuck his nose underneath the deck at the house, barking, head down, tail wagging. Mom brings me the dog and says he got bitten by a snake. And of course, I wait until presentation to decide how excited I’m going to get about this. Mom said on the phone she says a copperhead bit him in the face. It was a small copperhead. And the dog shows up and sure enough, this is, it’s probably been about 30, 45 minutes by the time I see the dog from the time of the bite and the left side of his lip, I can see those two small little draining tracks. I see the punctures and his lip is swollen. Not whole face, but you know what I mean? It’s probably the size of a large grape is the swelling. And I’m getting some ooze out of there.
And so I’m looking at this dog and this copperhead bite and a million things are going through my mind and I’m hearing don’t give him NSAIDs. And then other voices are like, “We’ve got to do something for pain control.” And what is my risk of tissue necrosis here? And then it’s on the lip. And so I’m worried about tissue death there, because it’s a fairly small area. And so I just want to put this to you and say, Dr. “Scher, where do I go from here?” Like I’m looking at this dog, it just happened. I’m thoroughly convinced it was a copperhead based on, I didn’t see the snake, didn’t bring it in. Dad killed it, but it didn’t come along. Well, let me ask this, how do you treat that? Where should I go from here?

Dr. Michael Schaer:
The fact that this is occurring in South Carolina, copperhead is certainly one to consider, but the water moccasin can sometimes extend that far up as well. And even the eastern diamondback in some areas as well. But as far as the frequency of encounter, I would say copperhead is probably the majority up there. The one thing that I try to teach all the time about snake bites, Andy, is that no two cases are the same, okay Because the victim is different and the snake might be different than another copperhead a mile away. Their venom composition might vary, okay? And depending on the pressures of the ecosystem as these animals evolve in nature, but the copperhead in general, it is a pit viper and it contains a venom that is necrogenic. It might not necessarily be toxic, it’s not neurotoxic. So with the copperhead, we worry more about local damage.
Now whether this is going to turn into something that’s just simple edema or some focal hemorrhage with edema, it might stop there. If necrogenesis is going to occur, what I have found here in Gainesville with the other types of pit vipers that I deal with, the signs of necrosis usually don’t occur ’til the end of day until around day three. So as long as that lip is spongy and it looks well vascularized, there’s not any change to brownish or blackish or black, there is a chance that the swelling’s going to go away. And as far as the timing of the disappearance of that, it usually starts by day three as well. Where it starts resorting. It might drop a little bit more dependently and then it will disappear. Now, the thing about tissue necrosis, especially with a snake like the copperhead, the tissue necrosis occurs very soon after the bite.
So during that 40 minute car ride, the collagenases and the hyaluronidase contained in that venom allowed that venom to spread, and get a fairly good seating as to whether or not, as far as into the surrounding soft tissues. So what you don’t know when you’re looking at that dog is will this go on to necros? The answer is you don’t know.

Dr. Andy Roark:
Okay.

Dr. Michael Schaer:
I don’t know. And you say that to the owner. So the next thing is, well what about treatment? So when you look at the spectrum of severity for the copperhead, at least in people in that part of the country, they’re usually more local wounds. They get their swelling and they’re out of the ER in maybe three hours. But there are some people who can actually go on to become coagulopathic and they’re the ones who are in harm’s way, and that’s when they start having to take in a whole bunch of anti-venom. Now, it is going to be up to you to decide whether or not you want to give anti-venom, and a lot of that is going to be dependent on the cost, whether or not the owner can afford it. My philosophy is that if there’s the possibility that this invemination can go beyond a minimal localized invemination, I’d rather be proactive and head it off.

Dr. Andy Roark:
Okay. I see.

Dr. Michael Schaer:
And I would suggest one vial of anti-venom.

Dr. Andy Roark:
All right.

Dr. Michael Schaer:
Now something like VenomVet’ll be fine. Or even the Boehringer Ingelheim, the one we used to call Fort Dodge.

Dr. Andy Roark:
Yeah.

Dr. Michael Schaer:
Okay, that’ll work as well.

Dr. Andy Roark:
Okay.

Dr. Michael Schaer:
And the chances at one vial causing anaphylaxis, I would say would be less than 10%. But the chances of that invemination getting worse is probably more than 10%.

Dr. Andy Roark:
Okay. Hey guys, I just want to step in real quick and let you know that on August 19th, my good friend Jen Galvin, who is a practice manager in Arizona and just an amazing, super fun, super funny person, is hosting a virtual workshop at the Uncharted Veterinary Conference. She’s doing her workshop called How to Have Fun and Engaging Meetings. Let me tell you Jen Galvin, I have seen Jen Galvin have Nerf gun fights at her practice. She has game shows for staff meetings. She does education in the most fun ways possible. She is so fun. And this is a workshop, which means you’re going to actually get ideas and you’re going to get to work on your own practice and come away with some tangible things that you can take back and do with your team to have fun and engaging meetings.
Guys, this is a great workshop. It is on August the 19th, so that’s coming up next week, from noon to 2:00 PM Eastern Time. That’s 9:00 AM to 11:00 AM Pacific time. So anyway, noon to two eastern time workshop. I’ll put links in the show note for you to register, check it out. It’s also a great way to see what the Uncharted virtual events are like, Uncharted Vet Conference is the conference that I started, I love it. I think that there’s … I don’t know that there’s a better, more fun engaging way to learn than things like this. So anyway, guys, I hope you’ll try it out. I hope you’ll take something back for your practice. That’s it. Let’s get back into this episode.
Can you unpack a little bit about anti-venom for me as far as, is it species dependent, snake species dependent? Because I had sort of thought that obviously I’m in the south, the eastern diamondback rattlesnake is what we really worry about the neurotoxin, as opposed to your more locally destructive bites of your water moccasins and your copperhead, things like that. Does the species of snake play into your choice to use anti-venom or not? And then also you say, go with a single vial. Is that size dependent on the patient at all? So if you could unpack a high level of anti-venom thought right now, I think that would be so helpful.

Dr. Michael Schaer:
Okay. There are a few types of anti-venoms available to us in the United States. We have VenomVet that’s made in Argentina that’s made from the South American, and I think the Central American pit vipers. VenomVet two is coming out, and when it gets cleared, it’ll be made from the venom of local snakes and then in North America. But the VenomVet that we use now comes from pit vipers from south of the border. The reason that it works for our snakes is because the pit viper venoms in this part of the world, in the Western hemisphere, share antigens. So using an anti-venom that’s against [inaudible 00:11:26] or one of the other pit vipers, that might very well still be effective against the eastern diamondback and the water moccasin and the copperhead.
So that’s good. Now the VenomVet is, and it’s called an Fab2, where the most primitive anti-venom that they used to use in people from [inaudible 00:11:49] has an FAB, an FAB, and an FC component. Remember the stuff is made in horses. So you’ve got the specific ground to air missile, the FAB, but they’re linked together with this FC, which is extra protein from the horse serum.

Dr. Andy Roark:
Okay.

Dr. Michael Schaer:
And that’s what contributes to its anaphylactic genicity.

Dr. Andy Roark:
Gotcha.

Dr. Michael Schaer:
Okay. Now BI or the Fort Dodge product has the FC component RTLR, the new anti-venom that comes in those plasma bags, that’s a large molecule as well. They have a tendency to load more extra antigen and to make the animal perhaps more hypersensitive to it. CroFab we don’t use because of the expense. So what veterinarians are going to use is RTLR, the Ford Dodge product, and the [inaudible 00:12:43]. As far as I’m concerned, they all work. The RTLR might have some extra antigen to it and some people might not want to get involved with that, but it’s still effective against venom.
As far as duration of the anti-venom in the blood, this is where you want your grout to air missile to get into the bloodstream, nuke out the venom protein and hang around for a while. The problem with CroFab, it’s out of there in six hours. The VenomVet hangs around for around 24 to 36 hours. The Fort Dodge product can hang around for as long as 48 hours. So that comes to an advantage to you because when the dog gets bitten by the snake, some of the venom will go into the system fairly acutely while the other amount of venom is deposited at the bite site and then it slowly infuses over the next several hours. Well, if you use a fast acting anti-venom like CroFab, those ground to air missiles will already be out of the sky. But if you use the longer-acting anti-venoms, they’re still there to intercept.
So that’s where VenomVet and the Fort Dodge products will work to your advantage. Now, as far as the dosage of anti-venom is concerned, it’s impossible to specify, for the reason being that we don’t know how much venom is inoculated. So I go by clinical science. The other question that goes along with the choice of the anti-venom is what snakes contribute to the manufacturer of that particular product. The Fort Dodge product is going to use several North American snakes. The VenomVet one, which is what’s available now, uses the South American snakes, but it’s still effective against the North American snakes. So I take advantage of the cross antigenicity.
The RTLR is made from North American snakes. Now the question you asked me, when there are several snakes in one geographic locale, how do you know which snake bit the dog? We can squeeze out of that predicament by using the polyvalent anti-venom. Now in Australia they might use monovalent, in other words, an anti-venom against the brown snake or the tiger snake or the Taipan snake. But they’re getting smarter now in Australia because some of their antigen detection kits might be inaccurate and they’re switching over to polyvalent and just covering the victim with all of them in that area. So here in the US we have traditionally always used the polyvalent vaccine. So like I said before, they all work, they differ in their molecular size, and the choice is going to be up to you as to which product you want to use.

Dr. Andy Roark:
Gotcha. Yeah, let’s go on from there. So anti-venom, your recommendation is much stronger than, I guess what I sort of gave [inaudible 00:15:45]. So I really love that we laid this out. So at least a single vial of anti-venom, I think that makes sense. What other sort of supportive care are we talking about? If it’s three days until I’m going to see signs of necrosis, do I need to have this dog on fluids for 72 hours? I mean, help me with that part.

Dr. Michael Schaer:
As far as the dosage of the anti-venom, that’s going to depend on a scale that we call the snake bite severity score. And that goes from one to 20 and it encompasses various pathophysiological things that we see clinically, whether there’s coagulopathy, neurotoxicity, cardiac arrhythmias, hemolysis. If we see all of those in that one victim, I’m going to start off with several vials.
And I’m going to make it simple. If the animal comes in walking wagging its tail, I might give one vial. If it comes in walking very slowly and it doesn’t look right and it looks like it’s going to get sick, I might start off with two or three vials. Now behind those guesstimates is the snake bite severity score going on in my head. If an animal comes in recumbent and trying to die on me, he’s hypotensive, he’s bleeding, he’s hemolyzing. That dog will probably start off with four to six vials, and then if they’re really severe, we will run an ACT, where normally the ACT is less than 120. If the ACT doesn’t normalize, I might repeat a couple more vials of anti-venom at hour six.

Dr. Andy Roark:
Okay.

Dr. Michael Schaer:
You see what I mean?

Dr. Andy Roark:
Yep.

Dr. Michael Schaer:
Okay. And it just goes on to assess and reassess, assess and reassess until the patient is stabilized. Now with the copperhead, I know a lot of times the animals get better without the anti-venom. You might just give them some fluids and they might get off real cheap and go home and everything’s going to be okay. A lot of practitioners will also use antihistamines and steroids. There’s no evidence-based medicine to show the efficacy of steroids and antihistamines. The only time I use them is when there’s a hypersensitivity reaction to the anti-venom. But if the blood pressure is kind of borderline when it comes in, I’ll give them [inaudible 00:18:08]. We don’t use anti-venom in every case here in Florida either. If I have a pygmy rattler and an animal comes in walking wagging its tail, but it hurts because it got bitten on the paw, we’ll watch it for 24 hours. That’s important.
We keep them in the hospital. If the people have absolutely no ability to pay the bill or anything like that, that’s the only time they will walk out on the same day. But they’re told to come back of course, if there is further decompensation. But I know that close to eight out of 10 practitioners want to use the antihistamine and the steroid. And I’ll give you some clarification on that. It depends on where you are in the world and whose country anti-venom using. If you’re in Pakistan or if you’re in India and you’re dealing with the snake bites out there, a lot of times they’re vipers or cobras. Their products might not be as pure as those products that we use here. And the incidence of allergic reactions are very high.
In those situations, they’ll give the patient antihistamines and steroids initially and then give the anti-venom, but in the western hemisphere, it’s not recommended in human medicine and I’ve convinced everybody here at the school on now hundreds of cases that you don’t have to use steroids and antihistamines, that my cases will get better just as fast as yours if those two drugs are being used. So I leave it, of course, to the individual colleague. If they’re using something that works for them, I don’t want to upset their apple cart. But if they were to ask me for, is there anything to document the efficacious of this, I would answer it in the way I just told you. Okay?

Dr. Andy Roark:
Perfect.

Dr. Michael Schaer:
Okay. Now as far as waiting for necrosis, there are times when dogs will be discharged from here at the end of the second day and it hasn’t actually been long enough for necrosis to make itself known. So we tell the people, look for any signs of discoloration and change in texture of the skin. If the skin changes from pliable to feeling like leather, there is a likelihood that that’s going to necrose. So they could tell, or they could send you a picture on their cell phone or a video and you could make a decision whether or not they should bring it back for debridement.

Dr. Andy Roark:
That makes sense. What is your pain control plan with these patients?

Dr. Michael Schaer:
All right, pain control initially on a severe case is minimal.

Dr. Andy Roark:
All right.

Dr. Michael Schaer:
Because I don’t want to knock them out with drugs when their level of consciousness is helping me decide on whether they’re trying to die or not. And we will use methadone and extend that for maybe the first two days on those who aren’t severe. Or we might, if the severe case comes in, we’ll hold off on the pain control until we get the patient stabilized and then we can monitor them better. But if you have a copperhead doggie that comes in after barking at something under the porch and the paw is swollen and then it’s obviously not weight-bearing and it hurts like crazy, then gabapentin works, methadone works as an injectable. Or you might start off with methadone and send them home on a few days of gabapentin, something like that.

Dr. Andy Roark:
That’s wonderful. Thank you. Thank you for doing this. I really appreciate. This has been so enlightening. Do you have any parting pearls, any last words of wisdom from me as I head off to take care of my snake bitten dog? Anything I should look out for? Anything like that?

Dr. Michael Schaer:
I know this is go going to sound silly, but I say to the residents, look at the patients and only the patients, so help you God. In other words, don’t walk in there. Oh, I know all about this. I’m going to do this, this, this, and this. It’s like driving your car on the road. You’re going to drive according to the speed limit and the safety conditions, and I’m going to assess that patient according to what that patient is telling me. And don’t be presumptuous. Interpret everything that you see with as open mind as you can, and I think that’ll get you out of trouble. And always remember Uncle Mikey’s maxims because they’re always out there to save you.

Dr. Andy Roark:
Thank you, sir. Awesome. Thanks a lot for being here. I really appreciate your time.

Dr. Michael Schaer:
It’s a pleasure indeed. You take care.

Dr. Andy Roark:
And that’s it. That’s the episode. That’s what I got for you guys. I hope you enjoyed it. I hope you got something out of it. Special thanks to Uncle Mikey for coming and sharing his wisdom. Guys, take care of yourselves. Enjoy the rest of your summer. Be well. Bye.

Leaders, Take On The Problem Without The Feelings

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As a leader, you will undoubtedly be given problems. People will let you know what is not working and ask you for your help. In these situations, it’s your responsibility to assist them. That doesn’t mean you have to fix the problem for them (often it’s better to coach people in how to solve problems themselves), but it does mean you need to engage with the challenge that has been presented.

When people bring you problems, it’s important to recognize that they generally bring their feelings about those problems along as well. It’s rare to be presented with information about a challenge without some level of commentary about how big an impact the challenge is having on patients, clients, or the future of the practice. 

Remember that, while you may have to take on the problem, you don’t have to take on the feelings that come with it. 

While you may feel as if the problem you’re being asked to help with is the event that will cause every employee in the building to resign within the next 7 days, you don’t need to accept that belief or react as if it is true. 

You can listen to the problem, validate how the person telling you about it is feeling, and then decide what emotions you choose to attach to the moment. 

Always remember that you can’t choose what problems come to you in life. You can choose how you react to them, and you do not have to follow suit from the person who came before you.