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Andy Roark DVM MS

Empowering GPs to Keep (The Right) Cardiology Cases

September 25, 2023 by Andy Roark DVM MS

Dr. Natalie Marks joins the podcast to talk about the opportunity for general veterinary practitioners to do more thorough work-ups on, and treatment of, cardiac cases.

Cone Of Shame Veterinary Podcast · COS – 999 – Empowering GPs To Keep (The Right) Cardiology Cases
CEVA Cardalis logo

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

Cardalis Important Safety Information: Do not administer in conjunction with non-steroidal anti-inflammatory drugs (NSAIDs) in dogs with renal insufficiency. Do not use in dogs with hypoadrenocorticism (Addison’s disease), hyperkalemia or hyponatremia. Do not use in dogs with known hypersensitivity to ACE inhibitors or spironolactone. The safety and effectiveness of concurrent therapy of Cardalis™ with pimobendan has not been evaluated. The safety of Cardalis™ has not been evaluated in pregnant, lactating, breeding, or growing dogs. Cardalis™ administration should begin after pulmonary edema is stabilized. Regular monitoring of renal function and serum potassium levels is recommended. Common side effects from a field study include anorexia, vomiting, lethargy, diarrhea and renal insufficiency.

LINKS

CEVA CONNECT CE Courses

ACVIM consensus guidelines for the diagnosis and treatment of myxomatous mitral valve disease in dogs

Dr. Natalie Marks Consulting

Dr. Marks LinkedIn

ABOUT OUR GUEST

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

She has been a veterinarian at Blum Animal Hospital since 2006, co-owner until 2018 and then associate. Prior to 2006, Dr. Marks worked at Allatoona Animal Hospital just north of Atlanta, GA. 

Upon her return to Chicago, Dr. Marks became very active in the Chicago Veterinary Medical Association, serving on the executive board, the Illinois State Veterinary Medical Association, AVMA and AAHA.

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

Dr. Marks is also very passionate about educating in all aspects of media, both locally and nationally. She has appeared on all major Chicagoland tv and radio news syndicates and many local websites. Dr. Marks was featured nationally on the Today Show and CBS Nightly News during the canine influenza epidemic of 2015 and in multiple issues of JAVMA. She is a guest contributor in multiple media campaigns for Merck, Zoetis (formerly Pfizer), Fear Free, Ceva, Trupanion, Aratana, ScopioVet, and Royal Canin. 

Dr. Marks is a regular columnist in Today’s Veterinary Business, Healthy Pet magazine, the Fountain Report and Pet Vet, and has numerous other publications.

She is a desired national and international lecturer for many of the same companies at VMX, WVC, AVMA, DVM360, VetGirl, and regional conferences, and most recently was a featured speaker at Ceva Sweden’s Derm Day and the Royal Canin Global Symposium.

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

Finally, Dr. Marks is a serial entrepreneur, angel investor and consultant, and on the Executive Committee of VANE, the Veterinary Angel Network.


EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Kone of Shame Veterinary podcast. I’m your host, Dr. Andy Roark. Guys, I’m back today with the amazing Dr. Natalie Marks. If you’ve been listening to the podcast for anytime recently, you might’ve picked up on the fact that I’m on a bit of a kick about thinking about the role of general practitioners in the future. I’m really big on the idea of technicians getting to do more and us leaning on our paraprofessionals, delegating more effectively of giving them some upward mobility. But that means we need to redefine the role of the general practitioner as well. And so I had a guest on not long ago, Dr. Sean Sanders, and we were talking about the general practitioners holding on to cases and being able to work up cases that we’ve gotten maybe in a little bit in the habit of just punting over to the specialists. Anyway, this episode is very much in that vein. We are talking about mitral valve disease. We are talking about cardiology for the general practitioner and keeping the right cases that can be maintained at the general practice level. And so anyway, I think this is a fascinating conversation. I learned a ton here. Dr. Marks is always amazing. Guys, I hope you will get as much out of this as I did. This episode by the way, is brought to you free by our friends at Siva Animal Health. 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. Natalie Marks, thanks for being here.

Dr. Natalie Marks:
It’s good to be back. Nice to see you. It’s

Dr. Andy Roark:
Great to have you. Boy, you’re doing so many things now. You are such, you’re such an interesting person. You are an educator, you’re a consultant. You have been a practice owner in Chicago for years. You’ve been a practicing vet for a couple of decades. You look like you graduated in 2017, but you have been doing this for a while. I talked to you last time you and I did a podcast together. We were talking about invoice bundling and rolling those things together. You just got this. You have this passion that I love for the business side of medicine and entrepreneurship and investing and then rolling that into medicine and where medicine is going. And so you think about medicine in a way I think is really unique. I still see a lot of people there, so I always enjoy catching up with you and getting your insight. So thanks so much for being here.

Dr. Natalie Marks:
Well, I’m excited because cardiology has always been a favorite subject of mine and I think it’s something that touches every generalist out there. Many of us have had our own dogs that have gone through heart disease or have had those moments where we certainly have had emergencies or those favorite patients that have succumbed to heart disease. So I love the fact that we’re able to talk about something new in this field and new research and also how we can practically sort of take cardiology back to our practices and empower ourselves to recharge and learn the medicine, do the medicine that we learned versus sort of this, oh, I’ve got a murmur. I am not going to handle anymore of this and send that out of our hospital. So I’m hoping the next 20 minutes or so I’ll get everybody revved up to start working up those murmurs again. Well,

Dr. Andy Roark:
I love it. We’re recording this right after I did a podcast that came out with Dr. Sean Sanders, who’s a neurologist in Seattle, and we were talking on the podcast and his idea with where medicine is going is general practitioners needs delegate more to technicians and then maybe try to hold onto more of the cases that we’ve gotten into the habit of immediately referring to specialists. And boy, the feedback on that episode was huge and really, really positive. There was a lot of people who really liked that idea. I think that it paints a good picture for general practice vets and I think as we talk about access to care, it makes a lot of sense. And so I was looking at this and looking at working with you and what we’re going to talk about. And I know this is a passion project of yours and you like about, and it fits right with that idea of what does it look like to keep more in general practice, how do we get GPS to get more comfortable with what’s possible and things like that. And so I’m super excited just because that’s really where my head is right now. And so let’s go ahead and start to lay down what we’re talking about. The thing I wanted to bring you on, talk with you about is you, as I said, has this sort of passion project for empowering general practitioners to hold onto specifically cardiology cases. You’re a bit of a cardiology nerd, all the love we have, anesthesia nerds, we have.

Dr. Natalie Marks:
I own it.

Dr. Andy Roark:
Good. Excellent. That’s

Dr. Natalie Marks:
It. I own it.

Dr. Andy Roark:
You’re a bit in that vein and then I always like to hear from you because have such a business mind as well where it has to make sense. And so lemme just start there at a high level, talk to me. Give me the mile high pitch. True or false. General practitioners should consider holding onto the cardiology cases, the heart murmurs, things like that, that they may or may not have just gotten in the habit of kicking to the cardiologist and saying, look, I can’t echo. I’m not comfortable doing an echocardiogram here myself in practice, and so I’m putting this away. Tell me where your head’s at when I say that.

Dr. Natalie Marks:
Well, if I could capitalize and highlight and circle true, I would be doing all of those in that moment. So I guess let me sort of step back and let’s go up to that mile high view just for a minute about can we say everything in that statement is true? Most of it is right. There are going to be cases that we see that an echocardiogram is necessary, that a pacemaker needs to be implanted, that there needs to be some type of atrial window established, or there’s certainly nothing that’s very definitive on radiographs or we need the assistance of cardiologists. And certainly I have a wonderful relationship with my local cardiologist I have for 20 years wouldn’t know what I would do without him. I’ll give a shout out to Dr. Michael Luther, who’s phenomenal. That being said, there are so many other cases that are applicable to what we’re talking about today where we can as generalists without a tremendous investment in money or capital or technology or the time or training or staff that are needed to implement a new program or elevated medical standards, some of the things that we talk about or maybe have a pain point about of why I don’t want to handle a cardiology case or I want to refer those, we can sort of throw out the window because we don’t need a lot of things in general practice to work up a murmur.
So as we’ll kind of talk about, we see heart murmurs every day in dogs, and we’re going to talk specifically about canines today, but we know that 75% of dogs with heart failure have heart failure because of valve disease. So it’s about four and a half million dogs every year. They’re typically smaller and older dogs. We of course think of the poster child, the Cavalier King Charles, but we also see chihuahuas and dachshunds and schnauzers, and I’m sure if you’re listening, you’re thinking, oh, that’s Jimmy and Betty and all these cases that are floating through your head, males more than females, just a little bit. But about 40% of them will slowly progress into congestive heart failure. That is a lot of cases. So if you think about if every one of those got referred to a cardiologist, there’s nowhere near enough cardiologists or appointments or people that have that access to care that could ever be serviced.
So there’s a huge population of patients that are not getting the care that they need necessarily. If the only answer we have to them is, oh, I heard a murmur in your dog not really explaining what that means and saying, here’s the number for the local cardiologist. Make an appointment. So what we’re going to talk about today is how can you as a generalist and your team intervene in that appointment where you’ve heard a murmur? What can you do practically to work up that case? What are the steps and stages of murmurs as according to the 2019 H V M guidelines and how do you use those to sort of guide your approach? And then what we know knew really about spironolactone, that’s really the key here is understanding what’s come out of human research translated to a canine for sure, but this was sort of this refractory kind of hail Mary drug that a lot of people put their dogs on when they were in massive heart failure and nothing was helping and Lasix blew out their kidneys, right? Yeah.

Dr. Andy Roark:
It was the last drug that I used

Dr. Natalie Marks:
Totally. It was

Dr. Andy Roark:
Last drug that I used. Yeah, that’s how I was. I’m not going to blame it on how I was trained. I think it was how I was trained. It might have been me reading between the lines of what was expected.

Dr. Natalie Marks:
I think it’s both, but that’s how I was trained and certainly I would follow suit from what I would see cardiologists doing many years ago, which is, oh, let’s try Spro. How about we try spironolactone? Exactly right. We know now though, that is a very reactive approach and I’m all about practicality and proactivity. So there’s a lot I’m going to share with you about spironolactone and how that can make a huge difference in our heart patients, especially our heart failure patients. So we’re talking stage C and beyond, but also why we don’t just have to wait till the heart failure. What can we do with that murmur patient itself?

Dr. Andy Roark:
Yeah, well, I mean, I love it. Let’s go ahead. You’ve already laid down. You’ve already laid down a number of facts about the heart murmurs that we see. I think that’s where a lot of these dogs that I think we’re starting to talk about. Let’s just start there. Let’s talk about the cavalier, the Chihuahua, the Dotson. Let’s talk about a heart murmur. We’re not talking about the coughing, gasping dog. We’re not talking about wheezing, darken up fluid, stuff like that. Let’s just take the heart murmur dog that we have. And I think a lot of us, we sit there in the exam room, the owner is looking at us and we’re listening and there’s this grade three heart murmur, maybe a grade four heart murmur. We can hear it on both sides and we’re going, okay, this is significant. And the owner has probably been told before that it’s here.
They’re trying to read me in my reaction, they’re looking and going, he’s listening for the heart murmur. Is it bad? Is it worse than it was before? Is he concerned? How is he feeling? And I’m running through my own mind going, how am I feeling? How concerned am about this? What am I going to say as far as their options and management and things like that? Natalie, let’s just start there. So talk to me a little bit about just your classic heart murmur dogs and starting to work these up and what sort of diagnostics in general practice I can be most comfortable going with?

Dr. Natalie Marks:
Yeah, so you bring up a really great starting point, which is our communication to the client once we hear that murmur, and we know in studies and surveys of client reactions as well that a large amount of our client base feels that a murmur that we hear indicates the same type of heart disease that they think of in people, meaning coronary disease or similar disease that lends itself to heart attacks. So we first need to think about how can we best educate our clients that what we’re suspecting, let’s say in that nine-year-old cavalier is not coronary artery disease? Because people often and our clients in our room will hear that and think, oh, oh my God, my dog’s going to have a heart attack. I’m going to wake up, my dog’s going to be dead. What can I do? Or they’ve had a very traumatic experience themselves.
So it all of a sudden puts them back into this very emotional negative place which doesn’t lend itself usually to compliance or it’s a fear related authorization of a workup, which is not what we want. So the first thing we need to do is truly educate what a murmur is, right? It’s an abnormal sound indicating there’s some kind of turbulent blood flow going through the heart itself. A murmur. Sometimes we can say we suspect it’s here based on the location, but we don’t know for sure and we suspect it’s valvular just by commonalities. But we don’t know for sure all it’s telling me, it’s giving me a light bulb and a flashlight and saying, Hey, Dr. Marks, we need to check out this heart and figure out is this a primary heart disease or is this murmur here secondary? Something else is going on in the body?
And so when we can hopefully very succinctly and comfortably and in a warm way, tell our clients, this is what the murmur says to me as a veterinarian, and now this is what we can work together on collaboratively as a team to help figure out what the disease is and what stage. And that again, helps guide us of what we can do. I very much encourage veterinarians to use different either illustrations, animations, I have a fabulous animation that shows the difference between coronary artery disease and what mitral valve disease looks like because a lot of people are visual learners and we know that the average human attention span is eight seconds. So if you start going into a diatribe about what valvular disease is, your human in the room is lost. So break it up with a visual, show them an animation, direct them to something, text ’em something, whatever you need to do to sort of keep them interested.
And then we say, look, the next step is we need to investigate in what we call stage. We need to figure out what this murmur is telling us. And then guided by that what kind of disease we probably have there and what the treatment guidelines are. And thankfully a lot of that work is done for us by the 2019 Cardiology consensus guidelines from A C V I M. So we have a really nice, and I hate to call it a cookbook because it’s not that easy. This is a lot of really brilliant cardiologists put this together, but we have this beautiful guide that helps us fairly quickly once we know the stage, say, Hey, this is what we do. So I think if we’re talking about this, we might as well jump into these stages. I think it’ll help us determine what we say to these clients.
So before we even hear that murmur, remember we can have dogs that are stage A and those are the breeds you just mentioned, right? These dogs that are at high risk of developing moos mitral valve disease, and that is your cavaliers and that’s your chihuahuas and dachshunds and some of those other small breeds, remember male versus a little more than female. So if you have these breeds that are coming in to see you, we don’t want to wait again, not reactive medicine. Proactive medicine is to talk to these owners at two, even one year of age and saying, Hey, a lot of times at an annual exam and these young patients, thankfully there’s not a lot wrong, but that’s the perfect time to say, Hey, right now everything looks great. I just want to bring something up proactively. Your dog is a dog that is at risk for heart disease, a higher risk than most, and I think it would be a good idea for us to be seeing your dog either more frequently or let’s get a baseline thoracic radiograph, or I want to give you some reading on what this is.
So you’re looking for things that are different at home, but at least prepping them for the idea because the more we prep them, if it happens, they’ve heard it, it’s not shock and surprise if it doesn’t happen, they’re thrilled. So it’s a win either way. So remember that’s a stage. These are asymptomatic patients. They don’t have a murmur, they’re just a high risk breed. So we do need to start there. Then there used to be just stage B as one entity, but they’ve been since 2009 to now 2019, they’ve broken that apart into stage B one and B two. So B one are our dogs that have a murmur. This is typically a lower grade murmur, so like a one or a two. They might even have heart enlargement on an x-ray, and I’m talking minimal, right? So we’ll get to the vertebral heart score in a second, but they might have that, but they are asymptomatic.
I think this is really important to remember when we talk about what is asymptomatic, because I think most of us go to, they’re either coughing or they’re not coughing right? With heart patients. There’s a lot more evidence out there though that shows that these dogs can also have an tants. So when we are, there’s a lot of research that’s been done in the area of an tants. We’re thinking mostly like with cancer patients and chronic kidney patients and other things. But when we look at cardiac patients in inappetence is very possible because cardiac disease releases a lot of those inflammatory cytokines too. So when we’re asking our families, especially in a patient that has a murmur, we don’t just want to ask, is your dog coughing or not? We want to ask about changes in behavior. Are they more restless? Are they not sleeping as well as they used to shifting positions?
Do they seem to be more exercise intolerant? Do they have changes in breathing patterns at home? And I’m not talking like they’re breathing three or four times, they’re normal. I’m saying, does something look off? Is their behavior off? They’re normally super clingy and happy to be around you. Now they’re spending more time away, and is there a change in appetite? So it’s not just are they not eating as much, but is there a change in the pattern of eating, which we call dyslexia? So are they a cavalier that normally would snf food down in breakfast and evening and then walk away and now all of a sudden they’re eating like 60% and then they kind of nibble throughout the day and they might be eating all technically the right amount, but the pattern’s totally different. So these are questions we need to ask these families to see is something different symptomatically, again, outside of just the cough.
So those are important questions to ask. The other really critical piece, not symptomatic, but certainly something that has to be part of every history is what is your dog’s diet? The grain-free D c M connection is very proven. Now we know unfortunately, many dogs have lost lives from this. Many dogs have gone through pretty traumatic disease, thankfully caught early enough to be reversible. But we need to know what these dogs are eating and understand if there is a grain-free component to it and obviously discontinue that. So stage A and stage B one, we don’t do anything from a recommendation perspective from meds. The only thing that we’re doing is we’re getting a radiograph either foundational baseline for stage A or if even B one. There might be a small change, but these are dogs that the owners are aware, Hey, my dog has a murmur.
My dog’s either stage A or B one. The only thing that we’re doing is having them come back, not in an annual exam component, but maybe in three to six months, see what’s going on with that murmur and then having those clients again, who are part of our medical team, be the ones that are advocating at home to make sure they’re not seeing any signs of change. That totally makes sense. So now we move into the three that have a little bit more involvement from our end. Those are CJ and B one are education opportunities, and certainly those are pretty quick and easy in regards to how we finish that case. But if that murmur of that, let’s just take the patient that Cavalier that came in and now all of a sudden that murmur is a three or a four and we start to do a workup.
So maybe they came back for a recheck and all of a sudden we’ve done our radiograph and there’s vertebral heart score enlargement. So kind of coming back to what we can do in our hospitals, the starting point of every staging is thoracic radiographs. And I think the nice thing about radiographs in a lot of our hospitals today, and what used to sort of be like radiograph interpretation for a lot of us is that many hospitals today have digital radiography and many of them send off their radiographs, right? So even if you said, I don’t want to relearn vertebral heart scoring, most of the time you don’t have to do it. Most of the digital radiograph programs already have vertebral heart scoring built in as an option, or you’re going to have that evaluated by the radiologist who reviews your radiographs. But vertebral heart scoring is essential.
And if you’re listing and you’re like, oh, gosh, I remembered that, but I haven’t done it in a while, remember it’s pretty easy, right? We’re getting a lateral view. We’re taking a short axis, which we’ll call SS and a long axis, which we’ll call L. Remember the long axis is the tip of the Karina to the apex of the heart. The short axis is just the width of the heart on the lateral radiograph. We take those two measurements and pair them up against the cranial aspect of the fourth vertebrae. So let’s say SS is about three vertebrae long and L is about six vertebrae long. We add Ss n l three and six, and your vertebral heart score for that patient would be nine. The average is about 10 and a half, 10.2 to 10.5. But the nice thing is now there’s been a lot of work to adjust for breed because we know a chihuahua and a great Dane are going to have obviously very different vertebrae sizes and certainly different heart sizes.
So when we have that stage B two, so we’ve done the radiograph, we’ve heard an increased murmur sound, and now we see that vertebral heart score, let’s say in this patient was 12. So we have heart enlargement, we have the murmur that’s created an increased intensity. This is where us as generalists can say, Hey, I don’t even have an echo here, but I know based on the stage B two that over 11.5 without an echo indicates I intervene. And that’s where we start PMO Bendin, everybody listening is probably incredibly familiar with PMO Bendin that MEIN is the brand name for a lot of people that have used this life-changing drug, right? Started with Dobermans, but obviously has a lot of applications with cardiac disease and canine patients. But according to these A C B M guidelines, this is where we intervene at stage B two.
Many people have thought, gosh, I’m going to just wait till I have heart failure. I wait till I have fluid. There’s sort of varying kind of opinions on this, but this is where you start. And so as a generalist, if you are practicing where you don’t have a local cardiologist, it’s a four hour drive or you maybe have a client base that that’s just not going to be an option and you’re not doing echoes in your practice. I don’t want you to feel like your hands are tied. These are all things that you can do in your hospital with a radiograph and a client conversation and POB bendin, and you’re going to make a difference in slowing down that disease because there’s obviously quite a few benefits to Pima bendin.

Dr. Andy Roark:
Well, I mean I love it. The vertebral heart score is something that we can definitely do. We’re all trained to do in vet school. I have to go, I’m going to be honest, when you said most of the digital radiograph software that we have now automatically does it, I was like, I need to go. I’m going to go dig in and see. We’ve got the little cursors and stuff that you can pull. And I’m like, I would not be surprised. I know our software’s updated a number of times over the years, and I’m like, it’s probably time for me to circle back and say what is already automated because I still do it the old fashioned way and I bet that there’s an easier way to do it.

Dr. Natalie Marks:
Well, some are automated, they’re not all automated, and I think some are like yours. But even if you’re using yours, if you’ve got the vertebral heart score icon, this is very easy. You could just put your calibers at S and your calibers at L and it calculates it for you. So that in itself you can get a gauge even if it’s not as exact as maybe you’d like it to be. If your vertebral heart score is nine and your vertebral heart score is 13, right? There’s a big difference in heart size and you can get a sense on where you’re headed. So yeah, so vertebral heart score. So a lot of people at stage B two are like, is that all I have to do just to radiograph and boom, I’m done? Technically speaking, if that’s all your client is comfortable doing at that point, that’s enough to start POB bendin.
But obviously there’s a foundational baseline of lab work we would’ve loved to have, and I certainly encourage everyone to think about having a C B C A chemistry with electrolytes, a urinalysis, just your foundational values if possible. Certainly at minimum, we want to make sure our liver and kidney are working the way they need to be for drug processing and excretion. But also a blood pressure would be incredibly helpful at this point. And then I have people always asking me, what an E k G? So I’m torn. I’ll be very honest on EKGs. If you have them, great, it’s wonderful, right? It’s great information. However, not every client today is going to have blank amount of dollars set aside for you to do every possible cardiology related test. So to me, and from a practical perspective, my radiograph is top of the list. How I stage, certainly those baseline, at least chemistry is second for me. A blood pressure would be nice, and usually it’s within reason from a cost perspective. But E K G for now, especially when we’re talking practical cardiology, I have more as a second or third tier unless I have an arrhythmia, right?

Dr. Andy Roark:
Okay,

Dr. Natalie Marks:
Then it shoots up to the top of the list. But if you have a normal rhythm and you have a radiograph that proves heart enlargement, what is that E K G going to direct you to change your treatment at that point? And the answer is nothing. So for me, when I’m doing a test, the client, I always tell them, this test either has to give me information for the diagnosis I didn’t have, or it’s going to change a treatment plan I already made right? For it to be worth the value. So for me, E K G is one of those more focus tests that I use in those instances,

Dr. Andy Roark:
Not as a general we have our murmur, let’s run an ekg. Yeah, that makes sense to

Dr. Natalie Marks:
Me. So that’s sort of where we are now, a couple things about with sort of the B two to C, which is where we’re getting at, which is the C and D a B one and B two. That is where we consider this patient to have heart disease. And again, we’re talking today about mitral valve disease and a cavalier of course, no brainer, but that’s where we have disease. Once we hit C and D, these are the stages of congestive heart failure. So at b2, I dunno if you’ve ever watched the price is right, I’m probably aging myself, but the yodeler like the cliffhanger where they’re doing, there’s that little yodeling guide and he’s climbing the mountain and you’re trying to guess the price before, and then all of a sudden it just falls off. At b2, we sort of fall off into the pool of heart failure.
And at c and D, this is where we start to see pretty symptomatic patients. So these are the dogs that come in that have lost weight and are exercise intolerant and have a new harsh kind of dry cough and are not eating well and have the sort of that thrifty hair coat and are just not themselves. That’s when we start to see C and D. So as we look at C, C is where we have all of the things at B two, but now we have characteristics of heart failure, which means we have pulmonary edema and we also have an increasing usually vertebral heart score as well as these signs. So at that point we have one or two choices as a generalist, right? Well, actually three, but I’m going to talk about the first two as hopefully our primary for what we would consider a stable heart failure patient.
So these are patients that the client was just like, oh, he’s acting pretty much himself, but he’s got a cough. And those are the patients that are still maintaining their weight. They’re still eating approximately what they would normally, they’re still going for walks. They just were brought in because of the cough. Those are stable heart failure patients that we can manage outpatient at home and have them come back for a recheck in five to seven days. Some of those patients are not going to be stable. Their pulse ox might be low. They aren’t going to tolerate oral meds, they have severe pulmonary edema. They’re starting to get liver enlargement, and we’re starting to worry about decompensation on the right side. So things like that. Those are patients that are going to be hospitalized. Now, depending on that instability, that’s where the third option may come in and you may have no other choice but to refer them to an overnight facility where there is a specialist on staff.
But for our purposes, let’s talk more about that stable heart failure patient where as a generalist, again, we can really come in and make a difference. So what is the big difference here at stage C and D? Well, the big thing to remember is this is not just where POB Bendin is. This is where historically we would do what I learned is the triple threat therapy. This is where we had POB Bendin, we added in an ACE inhibitor and we added in a diuretic like Furosemide or Lasix, and that’s what the standard of care was for a long time. What I am thankful that research has shown us is that that was okay, pretty good, but we now know that quadruple therapy is the way to go, and the beauty of that is quadruple therapy adds in a drug. We were just sort of joking about spironolactone.
What we thought was sort of this very much an afterthought or this refractory, I have nothing else to try, so I’m going to try spironolactone. But we know Spironolactone now has a major place in the quadruple therapy sort of cocktail that we use for stage C and D. I’m going to group C and D together for the purpose of therapy just here. Because really the only difference of D is those are patients that have been on quadruple therapy and are refractory, so they’re relapsing. And unfortunately at stage D as a generalist, we don’t have a lot of other options, and that’s really where we have to have quality of life discussions and certainly intervene with a cardiologist to see if there’s anything else that could be done. Sometimes those are the dogs that need pulmonary hypertension therapy with Viagra or some of the other sort of complications addressed.
But once we hit stage D, unfortunately prognosis is fairly poor, and so let’s focus on stage C because that’s really where the majority of our heart patients will present and where we can make the most difference. For us to understand a little bit more about why spironolactone was added, we have to go back to my nightmare lectures. I think I first was triggered by this in vet school learning about the RAs system. I don’t know if that triggers the cramming for a test memory for you, but it certainly was for me. But now that I think about this a little bit differently, I think it makes a lot more sense. So when we think about the RA system, remember that’s the renin, angiotensin aldosterone system. We often think about it before talking about this as what’s happening in the kidneys and some of the things that can happen when we have hypertension in the kidneys and certainly the activation.
The big things that I want everyone to remember, because I’m going to whittle this down to what we truly need to know and can communicate to clients if they ask with RAs, small, acute, temporary bursts and activations of that system are essential and necessary for the health of our patients and for us they’re very critical. It’s sort of that little spinach for Popeye in the moment that the organs need. What we have learned though is that chronic activation of the RAF system, which happens in heart failure patients, is very negative for the body, not just on the heart, but on the kidneys as well as blood vessels. We see glomerular damage, we see systemic hypertension, we see pro-inflammatory cytokines being released all over the body. We see myocardial fibrosis, so we end up with permanent scarring that we can’t fix and remodel. There’s a lot of changes that happen because aldosterone, which is the key, the real secret here is actually quite high in heart failure.
And we didn’t know this for a long time. This came out of human medicine eight years ago. I dunno, I’m not going to quote that, but I was at a translational conference and they were talking about this finding, but we know that a lot of our cardiologists are understanding this is very much the way the canine body works. So high chronic levels of aldosterone are really bad for dogs. They cause sodium retention. They cause the inability for our heart rate to change. So sinus arrhythmias kind of go away, which is not good. We want the heart to be able to adjust with our breath causes arrhythmias and it causes vascular inflammation. So we get vasculitis all over the body, and so we need to block aldosterone, and that’s what spironolactone does. Sper, it’s it’s really made a huge difference in the ability to not just have better quality of life, but better longevity of life. So when we talk about quad therapy, remember the triple threat was pob, bendin, furosemide and NACE inhibitor. Now that quad is spironolactone. And so when we put those together, when we put an ACE inhibitor in spironolactone together, we actually have complete blockage of the RAs system so that chronic aldosterone goes down and all those negative go away. And that allows us, again, to have a healthier cardiovascular system and a much better quality of life for that heart failure patient.

Dr. Andy Roark:
Cool. This is what the drug cardis is, right? Is your ACE inhibitor and your spironolactone sort of mixed together into one. So just to sort of summarize, when we start to have symptomatic heart failure, we’re looking at PAB bendin, which is a miracle drug and has been for years. So pab, Bendin, our Lasix, our forer rod. Then Cardis is our ACE inhibitor in our spiral tum. Nice little package there. That totally makes sense to me. What kind of follow-up are you looking at in these cases, Natalie? I think a lot of us are great. I like having the tools. I hear this dog coughing. I understand we’re going to maybe adjust our Lasix a little bit up and down and trying to get this dog regulated. What does that look like as far as ongoing communication for you?

Dr. Natalie Marks:
So this is where when we’re in stage C, like I mentioned in stage B one and B two, those foundational other tests like lab work and blood pressure would be really nice to have and certainly helpful. Not every client will be able to do that when we’re at stage C. They’re necessary because we need to see first of all where we’re starting from. And once we know that once we add in an ACE inhibitor and a diuretic, we’re really stressing those kidneys. So we need to make sure that it’s to a point that’s livable and tolerable. So once I’ve diagnosed a patient and we’ve started on our quad therapy, I have them come back in five to seven days, and I explained to the client, this is an essential recheck. This is not, let’s just see how we’re doing this is I need to make sure that if we’ve had hypertension, it’s resolving.
I need to make sure that our kidneys are doing okay with our drug therapy. I need to make sure that your dog is doing okay, right? That clinically they’re looking better. I need to make sure they’re not having side effects that we can’t manage GI side effects predominantly, but we need to make sure that this is a route that our treatment plan that we’ve chosen that is going to be workable for me as your veterinarian for your dog, but also for clients. And that’s really the beauty of Cardis is that it’s a combination drug. So although we’re doing quad therapy for medications that are helping with this cocktail, we know that client compliance is a big deal. There’s a lot of studies that have looked at rates of client compliance. One of the most recent one that came out of AHA press looked at clients in chronic medication that’s been given, and the rate of compliance for chronic meds is only about 76%.
And we know that none of the dogs that were in this survey, if they were on twice a day meds, none of them had a hundred percent compliance. So the more drugs we add to a regimen, the less client compliance we have, the more we ask clients to do twice a day meds, the less client compliance we’ll have. So when we have something like Cardis that combines two essential meds per stage C into one, that’s also a once a day and very palatable option. It’s just helping, again, this medical team, and I know I’ve mentioned that a couple times, but it’s a really important part of my message is that when I graduated, I was taught this very one directional delivery in the exam room like, I am veterinarian, you are client, I’m going to tell you what to do. And you’re just going to say, okay, doctor, and do it.
And it was what we did at that point. I hate saying it like that. It sounds so old, but I’m so thankful that today’s exam room is two directional, that we have a medical team which involves a veterinarian, the veterinary technicians and assistants, the client and the patient. And we’re all in there obviously with the same goal. And so when we work collaboratively and we’re encouraging those clients at home to be part of our medical team, which means I need them to give the meds for my patient to get better, the easier we can make it on them, the better our patient outcome will be and the happier our client will be, right? So they come back at five to seven days. If they’re doing great, I have them every three months come back. And if they’re still doing great, sometimes we spread that out to six.
But I like to see them quarterly unless there’s something that’s changed at home. And then of course I see them earlier. There’s a lot of resources that we can give our clients. You don’t have to recreate the wheel. If you’re interested in Cardis, your CEVA rep has a ton of great options that I’ve looked at. Resting respiratory rate apps that your client can download because it sounds crude, but one of the best things that we can know is what that dog’s resting respiratory rate is at night, and if it’s greater than 40 or there’s a trend, that’s one of the best ways to indicate a refractory relapse in congestive heart failure patients. So resting rest rate apps, client handouts that show a little bit of what I was talking about at the beginning of what mitral valve disease looks like, what that can do and what your dog may look like if suffering from mitral valve disease. Things to watch for and monitoring, as well as some of the other aspects of just heart disease itself and some of the medication support documents. So don’t feel like you have to create this whole cardiovascular portfolio to send out to your clients. Take advantage of the resources that are already there. That can certainly help support your educational delivery in the exam room. And also for follow-ups, sending these as texts or emails when you’re checking in on patients, as well as having on your website to link out.

Dr. Andy Roark:
Dr. Natalie Marks. Thank you so, so much for being here and talking through this with me. I really enjoy this. Guys. Thanks for tuning in. I hope you guys got as much out of it as I did take care of yourselves, everybody. Thank

Dr. Natalie Marks:
You.

Dr. Andy Roark:
And that’s it, guys. That’s what I got for you. I hope you enjoyed it. I hope you got something out of it. I always love a crash course like that. It was just such a fun episode. I have three pages of notes coming out of this podcast. That’s one of my favorite things about doing these episodes is I get to sharpen my own skills and I always learn a ton. So anyway, gang, take care of yourselves. Be well. I’ll talk to you soon. Bye.

Filed Under: Podcast Tagged With: Medicine

‘Comfortable’ Does Not Equal Good ‘Work-Life Balance’

September 22, 2023 by Andy Roark DVM MS

Being comfortable and having a good work-life balance are not the same thing. 

Work-life balance is about looking at our lives over a significant period of time (say, a year) and making sure we are doing the things we believe are important. Everyone will have a different balance in how they want their lives to be, and there’s not a right-or-wrong way to spend our days. There’s just what we want our lives to be and how good a job we are doing when it comes to actually making the things that matter happen.

In my experience, having a good work-life balance is rarely comfortable. It involves working really hard sometimes, saying “no” to people we would like to help, setting and keeping some personal boundaries, and putting important events (including time off) on our calendars far in advance. It means being intentional about how we use our time, and missing some things at home so that we can later miss some things at work (and vice versa). Pushing for this balance is never easy, it never ends, and it certainly doesn’t make us feel comfortable.

The assumption that having a good work-life balance means we will feel comfortable in day-to-day life sets a lot of people up to feel that they are failing in a way. Those who assume having a life that is “in balance” will make them feel comfortable consequently believe that feelings of exhaustion, stress, or busyness must mean they are doing something terribly wrong. 

This is simply not true. 

I just want to say that having a good work-life balance IS HARD. Those who pursue it can expect to be stressed, exhausted and busy. These unpleasantries are unfortunately required to have the lives that we want. That doesn’t mean we should live in these emotions, and if we find ourselves constantly overwhelmed and stressed then we are going to need to make adjustments. That said, too often people decide that because they are working hard and finding themselves in uncomfortable situations, they must be failing at creating a life of meaning and purpose. The opposite is more often true.

Often, the default path is the one where we do what is most pleasant in the short term but most frustrating in the long term. It’s much more comfortable to just say “yes,” to sit back and relax, or to resist the urge to “rock the boat,” but this is obviously not how we get the lives we want. In the short term, being comfortable seems great. In the long term, it’s generally a direct path to an unhappy and unbalanced life.

So don’t beat yourself up if you are fighting to have a full life and finding it challenging. Being uncomfortable does not mean you’re doing it wrong. Making the life you want to have takes intentionality, discipline and resolve. Please do not judge yourself on how comfortable you are but instead on how much of a hard-working, boundary setting, sacrifice making, forward planning badass you have become. 

And finally, don’t forget…  Being comfortable and having a good work-life balance are not the same thing.

Filed Under: Blog

Inter-Cat Aggression (HDYTT)

September 21, 2023 by Andy Roark DVM MS

Dr. Lisa Radosta, veterinary behavior specialist, joins the podcast to scatter a PILE of knowledge pearls upon us! This is a wonderful discussion of inter-cat aggression and what vet professionals and clients can do to maximize their chances of success.

Cone Of Shame Veterinary Podcast · COS – 224 – Inter – Cat Aggression (HDYTT)

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

LINKS

Dr. Radosta Links: https://linktr.ee/drradostadogresources

Florida Veterinary Behavior Service: https://flvetbehavior.com/

Dr. Lisa Radosta Homepage: https://drlisaradosta.com/

Solensia (Zoetis)

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. Lisa Radosta graduated from the University of Florida College of Veterinary Medicine in 2000. She completed a residency in Behavioral Medicine at the University of Pennsylvania. During her residency, she was awarded the American College of Veterinary Behaviorists Resident research award two years in a row. 

Dr. Radosta is the owner of Florida Veterinary Behavior Service, a specialty behavior practice in southeast Florida and co-owns Dog Nerds, an online educational resource for owners whose pets have behavior disorders.

She is a sought after speaker nationally and internationally. She is a coauthor of several books including: Behavior Problems of the Dog and Cat, 4th edition and From Fearful to Fear Free. She is a contributing author for Blackwell’s Five Minute Veterinary Consult, Blackwell’s Five-Minute Veterinary Consult Clinical Companion: Canine and Feline Behavior, Decoding your Cat, Canine and Feline Behavior for Veterinary Technicians and Nurses and Feline and Small Animal Pediatrics. Her new textbook, Handbook of Behavior Problems of the Dog and Cat, 4th Edition is due out May, 2023.

She has published research articles in the Journal of Applied Animal Behavior Science, Journal of Veterinary Behavior and The Veterinary Journal and written review articles for Advances in Small Animal Medicine and Surgery, Compendium, NAVC, Veterinary Team Brief, Clinician’s Brief and AAHA Newstat. She has served on the Fear Free Executive Council and the AAHA Behavior Management Task Force.

She has been interviewed for many publications including Cat Fancy, Dog Fancy, Palm Beach Post, NAVC Clinician’s Brief, Sun Sentinel, WebMD, AAHA trends, Real Simple, Good News for Pets, Catster, DVM 360 and AAHA News Stat. She has appeared on Lifetime television, Laurie Live, local news in southeast Florida, Mitch Wilder’s Amazing Pet Discoveries, Nat Geo Wild, Animal Planet, Steve Dale’s Pet Talk and Dogs, CNBC and Cats and Scapegoats.  


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 today with a one and only Dr. Lisa Radosta. We are having a conversation about multi-cat aggression, or inner-cat aggression, I should say, but yeah, we start breaking it down. I asked her to set up a little case with three cats, and then just kind of open it to her, and, again, I love having Dr. Radosta on the program. She is so fun, and she tells great stories, and she’s just a wealth of information, and, man, she’s linking to all kinds of resources in this podcast. I’ll put them all in the show notes. Definitely hit the notes, take a look at all the stuff that’s there, but, man, this is a great episode. Let’s get into it.

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

Dr. Andy Roark:
Welcome to the podcast, Dr. Lisa Radosta. Thanks for being here.

Dr. Lisa Radosta:
Thank you for having me.

Dr. Andy Roark:
I always enjoy having you here. You have been a regular in the podcast. You are, for people who don’t know you, you are a boarded veterinary behaviorist. You are the owner of Florida Veterinary Behavior Service. You are an author of so many things From Fearful to Fear Free was just one of your books. You’ve written for the clinical handbooks. You have so much that you put out, and you’re such a source of wisdom. I so enjoy our conversations. So I wanted to come to you with a case, and I’ll sort of lay it out, but I want to get a general refresher on this topic, because I’ve seen it recently, and I want to make sure that my game is on point here.
So I’ve got a client, and she has three cats, and they are getting in fights, and so one of the cats is newish, but she has these three cats, and I just wanted to go ahead and start to get your take on apartment living, three cats, newish cat is not getting along; it’s not all-out war, and it’s just kind of one of those things where they’re having fights, but why I say the cat’s newish is because it wasn’t like, “Here’s the new cat, and it’s World War III.” It has been, at first, it was okay, and then it was not, and then it kind of was okay for a while, and just every now and then, they’re getting into it, and so can we talk a little bit about inner-cat aggression? Is that okay?

Dr. Lisa Radosta:
Yeah, let’s do it.

Dr. Andy Roark:
All right, three cats. Is that normal? Does that change how we approach this, as opposed to two cats? Let’s just start there.

Dr. Lisa Radosta:
Look, it makes it more complicated, but it doesn’t change our approach. So, number one, well, here’s generally going to happen, at least in my experience, is they’re going to bring you one cat, and they’re going to say Fluffy-

Dr. Andy Roark:
The culprit, the villain.

Dr. Lisa Radosta:
The villain. It’s always, “Fluffy X, Y, Z.” So you have to try, and I remember sitting with this elderly man. Sometimes you sit with these older people, and they are just a hoot. He was just a hoot, and every time he roadblocked me, he would do it with a big smile on his face. So then, with a big smile on my face, I would explain to him why he’s wrong. It was just a fun appointment. It was an inter-cat aggression appointment, but anyway, so they have these ideas. So the first thing I say is, “Okay, well, here’s the thing. It takes two to tango, and, most likely, at least in my experience, if you have arguments, both cats are involved. If there’s three cats arguing, three cats are involved.”
So here’s what they’ll say, “Well, when I put Cat 1 up, nobody argues, and everybody gets along. It must be Cat one,” and I say, “Well, Cat 1 changes the dynamic enough, but Cat 1 may not be the person, the cat, who’s causing the problem,” all right? So that’s the first thing, is we say, “Okay, just so you know, Ms. Jones, I’m going to need to see all the cats,” and the first step in every behavior appointment, I do not care what the presenting complaint is, I do care, but not for this talk, is to work the cat out. Cats don’t tell us when they’re sick, so you’re going to have to get a needle out, you’re going to have to draw some blood, you may have to take some x-rays, send them to… What is it? The Zoetis Solensia website, where they show the cats jumping. Love this website. I don’t know if I’m allowed to say products, but I do love that site, because the clients then can see, and one client videoed her cat doing every single activity, sent them to me so I could see it.
It was kind of fun, but anyway, the point is, I look for pain, I look for systemic disease, because maybe these cats were getting along in the beginning; somebody’s sick, someone’s irritable, someone’s acting differently. So everybody’s going to need a workup, okay? A lot of clients will push back and say, “I’m sure, I’m sure, I’m sure,” and I just tell them about my experience. “I’ve been sure, and then I treated a case through about eight months, and I couldn’t resolve the case, and you know why? Because as a doctor, I didn’t push hard enough for that lady to bring in her other cat, because the other cat needed a workup, too. So I’m going to you the best I can give you, and that’s everybody coming in, everybody getting a workup.”
So that’s the first step. Clients will bring you, because they bring their phone, videos and pictures. This is what I love. Do you ever watch the home improvement shows? And you know when they pull back the big barrier, and they see the house, and the person goes, “Oh, God!” Right? This is it. So then, they pull out their phone, she pulls out her phone, and I say, “Okay, show me the pictures.” This just happened to me, because she was sure she brought me the aggressor. I’m like, “Okay,” and so then the first picture is both cats sitting in a meatloaf position, so everybody’s defensive, both of them in a bright room, widely dilated pupils, and I went, “Oh, my God,” and she goes, “What?” And I go, “They’re both scared!” And she goes, “No!” I’m like, “Yes!” And she goes, “I can’t believe it!” I’m like, “Yes!” So then she [inaudible 00:06:11]

Dr. Andy Roark:
You were practicing a soap opera. I would just come and watch you work.

Dr. Lisa Radosta:
It is. So then she flips to the next one. I’m like, “Oh, that tail,” and this is a video, “That tail’s thumping. That cat’s agitated.” She goes, “It is?” I’m like, “Yes, it is.” So once you see the pictures, if you know anything about body language, and you might have a technician, a nurse, a doctor’s assistant, who knows a lot about body language, right? Once you start showing the client, “There’s the proof. That’s the radiograph, okay? That’s the MRI,” you’re showing the proof on her phone that everybody’s involved. Now, she’s coming in, right? So that’s step one.

Dr. Andy Roark:
Yep. Do you have resources you really love for body language for pet owners who want to learn more about it?

Dr. Lisa Radosta:
So if you go to my profile on Instagram or Facebook, you go to the profile, there’s Linktrees. There’s a Linktree for cat resources, a Linktree for dog resources, a Linktree for vets. So then you will see I update that all the time. I grab stuff from all over the place and stick it onto that Linktree. So there’s everything, from body language, to carrier training, everything. Yeah. Yeah.

Dr. Andy Roark:
Love it.

Dr. Lisa Radosta:
So yeah, the thing is, we want to educate people. We want to be preventative. I know we’re talking about treating, but what people need to know is about 50% of cats show some sort of conflict when they fight. So that’s the number one statistic we want to put into our veterinary brains. Cat is coming into you, first appointment, you’ve never seen this cat, just adopted into a family of a current client who has cats. You want her to know 50% of cats have an argument, and I want to tell you what an argument looks like: ears back, tail thumping, hissing. Because what they’ll say is they weren’t swatting, they weren’t biting, they weren’t chasing. That’s good, but that’s end of that spectrum. At the beginning of the conflict is ears back, tail thumping, hissing.
So when you see that, think of that as conflict. That means you don’t want to go farther with the introduction. What they need to know is 35% of those cats are still fighting at least once a week a year later. So we have to, as vets, go, “Here’s the thing: if you saw any of those signs, we got to go super, super slow. Maybe you need a cat trainer, right? Maybe you need to follow this handout that I’ve written for you, or that I have. Our new textbook has a handout in it for introduction. Actually, I think it’s on my website. So follow that exactly, because if you start the cats off right, the likelihood they’re going to be here in a year for fighting is a lot lower.

Dr. Andy Roark:
Yeah. No, that makes sense.
Hey guys, I just want to jump in real quick and let you know I have a secret. I have something that is coming for you that is really wonderful. As you know, I love to have fun, I love to facilitate teams learning together, and laughing together, and getting to know each other, I like to make things that are kind of zany and off the wall that will bring joy into practice, and, guys, my team has been working so hard on something very special for you. It’s not a webinar, it’s not a conference, it’s not an event, it’s not a summit, it’s not a training program; it is something entirely different, and so I just want to give you a quick heads up that there’s something exciting coming down the pipes. If you want to get the inside scoop, you can hunt around the DrAndyRoark.com website, or some of my emails, and see if you can find the question marks.
Look for some question marks, and that will link you up to some information, and some clues, and you can start to make your way towards figuring out and finding out what I got for you, but anyway, it’s going to be something really fun, and really exciting, and I can’t wait to share more with you soon. Now, let’s get back into this episode.
Okay. I love the idea of getting in the phones, I love the videos, I love working with the cats, things like that. How do you start to… You and I talked in the past about it, and you had made a distinction between the two different drivers of cat aggression. Do you want to start there as far as how you weighed into these?

Dr. Lisa Radosta:
Yeah, so you’ve got the cat who a new cat’s introduced into the home, and there’s conflict, and that conflict could be over anything. It could be one cat is fearful, it could be one cat is not well, one or more, it could be that the resources in the house aren’t plentiful enough, et cetera, et cetera, and the way we educate those clients looks really different than the way we educate the second group of clients. Those are clients whose cats, these are often littermates, not always, but often, that get along really well. I mean, they sleep in a pile of cats, which is one of the ways we figure out if cats are actually BFFs, and then they’re in a situation where one cat gets really scared, and redirects aggressively toward the other, and the relationship is forever changed. When I see that second group of cats, at least, in my practice, way better prognosis, because a couple of reasons. They had a good relationship prior. They had something to go back to, right? And also because usually clients get them to us pretty quickly because they’re shocked at what’s happening. It feels urgent because of the change in the behavior.

Dr. Andy Roark:
Yeah. No, that makes sense. Okay, so we talked about, I love the idea of setting the expectation, “This is going to take time, this is going to be a process.” Is there anything else you do to sort of set up expectations like that at the beginning?

Dr. Lisa Radosta:
Yeah. So one of the first things we do is educate. Here’s how cats live. If you ever had a barn, or barn cat, which I did, you pour out the food, and the cats come together, right? But then the cats scatter, and you notice the ones that are hanging out together look the same, bunch of ginger cats, bunch of tuxedo cats. Why is that? Because cats live in matrilineal colonies. So I tell the client, “Look, the moms, and the sisters, and the aunts, and the grandmas, they all live together, and they take care of each other’s babies, but God help you if you’re another cat, and you’re not related, and you try to come into that group, because they’re going to be aggressive toward you. So let’s normalize that what your cats are doing normal, right? Let’s also normalize that they’re not sisters, they’re not family, they’re roommates, but you did not ask them if they wanted a roommate. You just got another cat, right?” So let’s first empathize for the kitties. That’s the first thing.
The second thing, it depends on the situation. If the situation’s really bad, so if I say seek and destroy, cat sees other cat, goes after it, then I’m going to explain to them that this is going to be a challenge. “These are ways we can treat this. We can separate. We could separate forever. You could live with your cats separated. That is the cheapest thing to do. That is what your cats want, and you will divide your time, and your cats’ time will be divided. Number two, we can medicate and manage them. They can be together when you’re there to interrupt them. All across the board, of course, we’re going to do environmental enrichment, that’s a given, and then the third option is to do behavior modification with a cat trainer.
That’s going to be done virtually almost 100% of the time. That is going to be six months of your time. We’re going to meet every two weeks, and I just want you to know that, a lot of times, after six to eight months, the cats relapse and have a fight. So I want you to think about this as marriage counseling. I don’t know if you’ve ever been to any sort of relationship counseling. It’s just how I talk to people, and you don’t have to tell me that you have, but what I can tell you is that that’s not a fix. Sometimes those people are triggered again, and they fight again, right? So your cats are going to be in that situation, too. So whatever you do is up to you. I’m here to be a part of the solution. Here’s the options.”

Dr. Andy Roark:
Yeah, that makes sense. I always ask about environmental enrichment, because I think it’s so useful, and it’s so often overlooked by pet owners, and it does so much for the quality of life of cats. What are your go-tos for feline environmental enrichment? What do you love?

Dr. Lisa Radosta:
There’s a book called The Indoor Cat, which is a great, great book that is all about enrichment. That’s all that the authors write about in that book. So I tell clients to get that. Of course, I send them to our resources, but here’s the troubleshooting point, because I think the veterinarians and the veterinary nurses and technicians listening to this podcast have a lot of knowledge. Where’s the troubleshooting? When you say, “I want you to enrich the environment,” first of all, I was shocked when I got a follower on Instagram who DM’d me to say, “What is enrichment?” I had done like five posts on enrichment. “What is it?” So watch your lingo. People don’t know what that means. Okay, does your cat have stuff to do?
And then here’s the next thing they say, “Yes, my cat’s got a toy box full of toys. My cat doesn’t need anything,” and I say, “Okay. You’ve got to break through that challenge. That challenge is coming. So either you break through it by getting ahead of it,” which is what I try to do to say, “One thing we need to do is enrich your cat’s environment. Enrichment is giving your cat stuff to do and engaging all five senses, and I know, because you’re here, that you’re an amazing pet parent, and I know, because your butt is in that seat, that you got a full toy box full of cat toys, and I also know that my husband is going to walk into my closet tomorrow and say I have enough black high heel shoes, and he will be wrong, right? Because he will think I’m plenty and rich, but shoe-wise, I’m not, and your cat isn’t either.” So that is the way I talk to them, and they’ve got a smile on their faces. Now, they’re like, “Oh, that’s funny.”
So then we talk about the five senses, and we talk about rotation. Your cat is so smart, and he’s got the same toys in front of him every day. That is no fun, right? So we’re going to rotate; three toys in the drawer, bring out three new toys every day. Plus, there’s the toys that he has in his box. I tell them my three-step process for finding what your cat loves. Number one, you go on to whatever your search engine is, you Google, let’s say, “Cat toys,” and you just spend an hour shopping. You spend your budget for that month, and then you get those in the mail, and then you log, with your pen and paper, on your phone, what your cat played with, and you write down the exact characteristics in detail. Month two, spend your budget on only toys that have those exact characteristics. Repeat. By month three, you will have what your cat likes, and go forward from there, rotating and keeping it new and fresh for him.

Dr. Andy Roark:
Yeah. Oh, I love it. That’s amazing. Are there any common pitfalls that you see? Are there any mistakes that I should look out for, anywhere that I mess this up, or make my life harder?

Dr. Lisa Radosta:
Yeah, I mean, the clients, every part of our job, they push the limits too soon. I didn’t give all the cephalexin. I don’t even think we used cephalexin. You could tell me, because I don’t do skin anymore, but I didn’t give all the antibiotic. “My dog looked pretty good,” right?

Dr. Andy Roark:
It’s good enough we stop, yeah.

Dr. Lisa Radosta:
It’s good enough we stopped. So what we’re going to see is the cats are going to fine behind the closed. So the client’s going to call you, or email, or text you, and say, “I opened the door. I just wanted to see,” but the problem is, and this is what I have to explain to them, “The problem is that one negative, it takes me 1,000 positives to outweigh that one negative. So you can’t break the rules, and we did it this time, we’re going to let it go, but you can’t break them in the future. “

Dr. Andy Roark:
Yeah, that makes total sense. Oh, man. Dr. Lisa Radosta, you are amazing. Thank you so much for being here and talking through this with me. I always enjoy our time together. I have got a ton of links I’m going to be putting down in the show notes so that people can go and find. Let’s go ahead. I’m going to put you a link to your website. Are there any other resources? Talk a little bit about your social medias. Clearly, you’re active on Instagram. Where can people find you?

Dr. Lisa Radosta:
Yeah, @DrLisaRadosta is where you’ll find me, and we post on everything behavior in little digestible bites; dogs, cats. We’re living and breathing it, and I love it.

Dr. Andy Roark:
Sounds great. I will add those links as well. Guys, thanks for being here. Take care of yourselves, everybody.
And that is it, guys. That’s what we got for you. I hope you enjoyed it. I hope you got something out of the episode. Thanks so much to Dr. Lisa Radosta for being here. Thanks to you for being here and listening. Yeah, if you like the podcast, do me a favor, leave me an honest review wherever you get your podcasts. It means the world to me. Anyway, that’s all I got. Gang, take care of yourselves. Be well. I’ll talk to you soon.

Filed Under: Podcast Tagged With: Life With Clients, Medicine

Translating Human Medical Experiences to Vet Med

September 14, 2023 by Andy Roark DVM MS

Kelsey Beth Carpenter RVT, or Vet Tech Kelsey as she’s known to her adoring fans, is a registered veterinary technician, singer/songwriter, and all-around creative genius. Her humorous takes on veterinary medicine can be found across the internet, and today she joins the podcast to discuss what she has learned about veterinary medicine from her own journey as apatient facing a chronic medical issue.

Cone Of Shame Veterinary Podcast · COS – 223 – Translating Human Medical Experiences To Vet Med

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

LINKS

Back to School Webinar Series: https://drandyroark.com/webinars/

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

Kelsey Beth Carpenter is a Registered Veterinary Technician, social media manager, singer/songwriter, speaker/performer, and content creator. Kelsey has enjoyed working in emergency hospitals across California for over a decade. At her most recent clinic, she fell in love with the open hospital concept, and is passionate about teaching others how to implement this structure in their own practices. Kelsey also works as the Social Media Manager for DrAndyRoark.com, a Content Specialist for the Uncharted Veterinary Conferences and Community, and the manager of her own growing brand, Vet Tech Kelsey. With a background in the arts, Kelsey is passionate about the power of creativity, the importance of humor, and the magic that happens when art and science overlap. In her free time (what’s that?), she can be found hiking, writing goofy songs about Veterinary Medicine, and dressing up her Chihuahua even though she swore she would never be “that person”.


EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome, everybody, to the Cone of Shame Veterinary podcast. I am your host, Dr. Andy Roark. Guys, I’m here with someone who is near and dear to me in my heart, the one and only vet tech Kelsey, that is Kelsey Beth Carpenter, RVT. Kelsey is an RVT. She is a media personality. She has been doing social media for me for years, and she’s part of the uncharted team, and she is genuinely a wonderful, funny, very, very insightful person. And it’s a bit of a personal episode today. Kelsey has been having some medical challenges over the last couple of years, and she has spent a lot of time on the human side of healthcare as a patient. And we were talking, and we sort of laid this out in the episode as we get started, but what are the things that are in human medicine that are good that we might like to see more of in vet medicine? And what are the things that we have learned in human medicine that we do not want to see in vet medicine? Or what insights can we gain from being a patient of human healthcare that will help us do a better job of taking care of pets and pet owners?
And that’s what we talk about this episode. It’s really kind of a sprawling episode, but it’s all on that theme and topic. It’s really interesting. Kelsey is just such a wonderful person, and she’s just really insightful, and she’s obviously thought a lot about this. And so anyway, this is a really neat way to think about practice and how practice works and just to kind of check and say where am I stacking up here? Am I doing the things that turn people off? Or am I doing the things that are going to make our visits positive experiences? So anyway, guys, check it out. 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. Kelsey Beth Carpenter, how are you?

Kelsey Beth Carpenter:
I’m pretty darn good. How are you doing Dr. Andy Roark?

Dr. Andy Roark:
People are having a deja vu. They’re like I’ve heard that voice before. Yeah, she sang the theme song that you just listened to right before you got to this point in the podcast. But yes, Kelsey Carpenter, you are an RVT. You are a media personality. You are best known-

Kelsey Beth Carpenter:
Am I?

Dr. Andy Roark:
For singing a song called My Dog Ate Weed, I think. You are the social media manager for Dr. Andy Roark.

Kelsey Beth Carpenter:
Who’s that?

Dr. Andy Roark:
I don’t know. If people don’t know, it’s kind of on you. You’re a part of this too. So if they have no idea who I am, I’m not the only one responsible for that. You are here with me.

Kelsey Beth Carpenter:
Most of the time. If it’s a good thing, you were responsible. If it’s a bad thing, it’s typically me.

Dr. Andy Roark:
Totally. That’s part of a social media manager’s job, is like I need someone to throw under the bus when I drink too much and decide-

Kelsey Beth Carpenter:
Of course.

Dr. Andy Roark:
To go on social media and say inappropriate things.

Kelsey Beth Carpenter:
Which happens frequently.

Dr. Andy Roark:
All the time. It’s all the time.

Kelsey Beth Carpenter:
I think I was just really a strategic hire. It was sort of like who’s going to make me look really good on this team? And it’s like Kelsey, because when Andy can’t find something, he can’t find a document in the Google Drive, it’s okay because Kelsey can’t find the Google Drive. So it’s just sort of I’m just a strategic hire. I think every company should have one.

Dr. Andy Roark:
Right. Your job title is foil. That’s not true. You were a very strategic hire, because you are magnificent and lovely and wonderful and creative and super funny and super fun. And since I started doing social media 15 years ago, you have always got the positivity and the energy that I think is so important to kind of put out into the world and kind of what we always wanted to do. And you just radiate that as well. And I feel blessed every day that you show up to work. So that’s one of the many joys of my life. So thank you for being that person.

Kelsey Beth Carpenter:
Thank you, Andy. I feel the same way. And now also I have it on audio recording. I could play-

Dr. Andy Roark:
Listen back to it.

Kelsey Beth Carpenter:
Back to myself. Also, next time you fire me on a team meeting, I can go ahead and play that for everyone. Remember you did like me at one point.

Dr. Andy Roark:
Yeah, that happens a lot as well. That often happens. Yeah. So we were talking, and we were sort of talking with the rest of the team recently and you brought up an idea for a podcast, and then you were immediately voluntold to do the podcast, and here you are. So let’s go ahead. How do you want to open this up? Yeah, how do you want to open this up?

Kelsey Beth Carpenter:
Well, I was listening to one of your episodes recently, and now I’m blanking on which one it was, and you guys were talking about how to make clients feel heard in an exam room. And as I was listening to it, I was thinking back on all of the doctor’s appointments I’ve been through, because I’ve gone through a major medical experience over the past few years and all of the things that have made me feel heard and all of the things that I would… Ultimately I’ve seen so many doctors lately, and every time I go to a doctor’s visit, I think here’s what I would do differently if I get back into the clinic one day. Here’s what I would change about how I talk to clients or how I put someone in a room or how I discharge people, just because of what I’ve now experienced being a patient myself so many times.

Dr. Andy Roark:
Well, I thought that was great because my wife has gone through a major medical event in the last year, and I had the similar experiences of things that I’ve watched, how they’d impact her. And then I’ve been along in a lot of these appointments and things as well. And I thought this would be really fun just to go through and break down what we’ve seen in human medicine that is good that we would like to point over and then things in human medicine that are not good that we definitely don’t want to point over. And so I think that’s fun. The intention is not to throw shade on human medicine-

Kelsey Beth Carpenter:
Of course.

Dr. Andy Roark:
But I do think we’re crushing them. I think there’s so many good things about vet medicine-

Kelsey Beth Carpenter:
Not to throw shade.

Dr. Andy Roark:
That is not good-

Kelsey Beth Carpenter:
We are superior.

Dr. Andy Roark:
Not to throw shade. Yeah, I don’t want them to feel bad about that, but let’s just call a spade a spade. It’s a lot of really good things in vet medicine that got lost in human medicine, and I think that that’s worth calling out. So yeah, let’s go. How do you want to start?

Kelsey Beth Carpenter:
Well, I’ll just say this though. So we’re not trying to, yeah, throw shade on human medicine. Also not trying to say our veterinary professionals, our fellow veterinary professionals aren’t already doing many of these things, because some of them are so basic, but I think for me it’s like I had been working in veterinary medicine for 10 years, and I kind of stopped thinking about some of the things I do. A perfect example is callbacks. It’s so routine. I sit there and I do 15 callbacks in the morning, and I don’t even think twice about it. And then when I became a patient myself, realizing what that actually does for people. So there were just multiple things. I guess we could kind of just start at the top of an exam maybe.

Dr. Andy Roark:
Yeah, sure. I mean, I’m totally up with that. So we’ve been in a number of different exams over the last years and stuff, and a lot of things that we take for granted, that medicine really matter, just a warm welcome, just confirming that someone is in the right place, that this is the plan, just sit here, we will take care of you. I think that that’s so important. I think the other part that I would say here is the idea that someone actually caress that you understand what’s going on is important. I remember talking to a nurse as I was leaving an appointment one time, and I was like, “I just want you to know this is a whirlwind, and I do not feel like our questions got answered. And now we’re kind of getting dumped out the door, and the doctor’s in the next appointment.” And she was like, “Okay, well, I’ll pass that on.” And I doubt that they did, but it’s just such a simple thing to be like, “Hey, we’re going to make sure you understand what we did here.” And I had not felt that way in a long, long time.

Kelsey Beth Carpenter:
Yeah, absolutely. And it’s really hard… When you get to a point where you’ve been doing this long enough, you forget what people don’t know. Like something as simple as, “I’m going to take your dog back for x-rays,” what can the client expect? What are they supposed to do while doing that? Just the simplest things. But you started to mention just saying something as simple as making sure you’re in the right place, honestly, it’s the first simplest thing. You actually have a point about this, and it was in one of your lectures that I watched once about building trust and how every little thing you do in the exam is building up that trust level. And that first thing is just using names, introducing yourself so they know who you are and saying the patient’s name or the client’s… For me, I’m the patient… or saying the pet’s name. It just already builds that little tiny bit of trust and starts you off on the right place.
I can’t tell you how many times a doctor has walked into a room and be like, “All right, so we’re looking at this today.” And I’m like how do you know who I am? There could be another Kelsey here. How many times have I had three Fluffies sitting in the waiting room, and I could pull the wrong one? So it’s something so simple like that I never thought twice about until I had to be a patient myself.

Dr. Andy Roark:
Yeah. No, I completely agree with that. And I get it. People are busy. And you go in for a medical procedure, and they’re like, “You need to be here at this time,” because the doctor is doing their procedures, and they’re just stacked back to back to back.

Kelsey Beth Carpenter:
Of course.

Dr. Andy Roark:
And it kind of feels like a cattle train where you’re just getting pushed, a shoot where you’re here and then you’re here and you better not be late because they’re going to be upset. And I think that you can be efficient and you can move things through, but I think that we should actively work against making people feel like they’re widgets being pushed through the widget press. You know what I mean? And I’ve had that. I think there’s definitely a balance of efficiency and getting things done and then also just taking a moment to confirm to the person, “I recognize that you’re a human being, and I’m also a human being. And this is my name, and if you need anything you can call me.” I think that that’s really good.

Kelsey Beth Carpenter:
I think that’s a huge one for me, so one of the biggest ones that I just didn’t really think much about when I was a tech before, is just the acknowledgement. We talk about making people feel heard. To me, that’s not a complicated concept at all. To me, it is as simple as someone comes in, I put them in a room with their dog, and they say, “Bella’s here because she’s been vomiting. We tried doing a bland diet. She vomited three more times this morning.” We go straight into, “Okay, let me go ahead and start getting her vitals.” I’m not saying that’s wrong, but the simple statement of saying, “Wow, that sounds really rough for both of you.”

Dr. Andy Roark:
Yeah, “That must’ve been scary.” Yeah.

Kelsey Beth Carpenter:
Huge, I mean, because you think about the fact this client has been up all night, they’re cleaning up puke out of their lovely carpets, they’ve been through it, they’re exhausted, they’re stressed. It happened to me in an exam once, I… In my total time just going through my recent development of fibromyalgia and everything, I actually had to tally up how many doctors I’ve seen in total. And the last time I tallied it, which was about six months ago, I was up to about 70.

Dr. Andy Roark:
Wow.

Kelsey Beth Carpenter:
So I have a lot of experience. And I remember the first time I saw a new psychiatrist, and he was just taking a basic history on what was going on with me. And I explained to him about my chronic pain and fibromyalgia and what I’d kind of been through, and I was doing it very much in my vet tech way of, “Here’s the data that you need,” right?

Dr. Andy Roark:
Yeah.

Kelsey Beth Carpenter:
And he just literally stopped and said, “Wow, that sounds like you’ve really been through a rough time.” And I was like it’s not computing. I don’t know what to say to that. No one had ever… At that point, I was about two years into it, and I don’t think a single doctor had said to me, “That sounds really hard.” And it’s not that they’re not thinking it. You guys talked about this in another recent podcast. It’s not that we aren’t thinking it as doctors or veterinarians or technicians. It’s that we’re just in efficiency mode and we maybe don’t say it out loud. The compassion is there. It’s just sometimes making the extra effort to verbalize it, that’s huge, right?

Dr. Andy Roark:
It doesn’t take a whole lot. I completely agree. But yeah, it’s easy to get head down and just… The classic thing, and I talk about this a lot with emergency medicine, is when you’re an emergency doctor or you’re an emergency tech, you just see emergencies all day long. And this emergency is just the thing that we’re doing for 20 minutes right now before we do the next one. But to the pet owner that’s there on emergency, this is a once-in-a-lifetime experience. This is one of the worst days of their lives.

Kelsey Beth Carpenter:
Exactly.

Dr. Andy Roark:
And the dichotomy of those experiences is very real. And I just think we have to be conscious and aware of what the other person’s experiencing in order just to not have them feel like they’ve been pushed through the machine.

Kelsey Beth Carpenter:
Yeah. My favorite thing, one of the first things I would always tell newer assistants or technicians when I was training them, was my little secret for how I interact with clients is I pretend that every single client is a good friend of my mom’s-

Dr. Andy Roark:
Oh, that’s fun.

Kelsey Beth Carpenter:
Because how are you going to treat a friend of your mom’s if they come in and they’re like… Well, first of all, you’re going to go in the room and be like, “Oh my God. Hi, I’m Kelsey. I’m Cassie’s daughter.” You’re going to introduce yourself. You’re going to be like, “This must be Bella. I’ve heard about her,” you know?

Dr. Andy Roark:
Yeah.

Kelsey Beth Carpenter:
And then when they talk about Bella’s been vomiting, you’re not going to be like, “Okay, let me go ahead and get vitals.” You’re going to be like, “Oh my God, that sounds terrible. Oh, I’m so sorry you’re going through that.” How do you treat someone who’s like your second cousin or your dad’s friend from high school? How do you treat that person? That’s how I try to pretend, that’s what every client is to be, and it helps me say those things out loud, that we’re all already thinking them in our heads anyways.

Dr. Andy Roark:
Yeah, I like that a lot. I think some of the interactions we’ve had recently with nurses have made me think a lot about the technician role in communication between patients, our patients, our clients and doctors, where… We had some experiences recently where you know that I’m a big believer in empowering technicians, and I feel like in human medicine they have made big strides in empowering nurses to be communicators. And I do think that we can absolutely learn from that. I’ve seen that go really, really well, and I’ve seen it go really badly to a point it was a really frustrating experience. And the difference for me in the experiences that we sort of had is when the nurse is the point of communication and they feel like an advocate or someone who is trying to help you, that is different from the nurse as the gatekeeper who says, “I’m not going to… Nope. I’m telling you what the answer is, and I’m not going to take your question or answer. Go to the doctor.”
So for example, my wife was talking to the doctor about something, and I’m sure she wouldn’t mind me saying, but she’s very active. She works out, she exercises, and so she has a procedure. She wants to know how long is it until I can be back doing the things that I want to do? And she’s pretty aggressive in that.

Kelsey Beth Carpenter:
Yeah. No, let’s just be honest. It’s not she’s just active. She’s a badass. She’s a verifiable badass. Let’s say it as it is.

Dr. Andy Roark:
She’s over the top badass. Yeah, that’s true. But anyway, so she’s like, “Hey, look, I am taking badass time off here, and I would like to get back to my badass self.”

Kelsey Beth Carpenter:
Exactly.

Dr. Andy Roark:
“And can I do that?” And the doctor was like not a big deal, but then the nurse was like, “Oh, no, no. You don’t do anything. Don’t lift anything more than 10 pounds until your recheck in like six weeks.” And Allison was like, “That’s not going to happen.” And Allie really wants to do what she’s supposed to do. She wants to be smart. And so she got mixed messages from the doctor and from the nurse. And the nurse did not seem to take her seriously and wasn’t willing to go back to the doctor and say, “Tell me what you were thinking here.” She was like, “No, these are the rules.” And it very quickly became this adversarial feeling that I have not had in other instances. And I go, wow, this is how leveraging your support staff for communication kind of goes off the rails. And then it became I don’t want to talk to the nurse. I want to go around her because I don’t feel like they’re on the same page. And that was an interesting part to me of how you leverage and utilize your techs. You still got to communicate with them. You have to be accessible. They can help you, but it’s almost like by closing off the line of communication, you end up undermining trust.

Kelsey Beth Carpenter:
Oh, absolutely. Yeah, getting those mixed messages, it’s what starts to, like you’ve said before in these lectures, starts to drain that trust bucket that you’ve started filling up, right? Exactly. And you lose faith because then it’s that feeling of who am I supposed to trust? I don’t know now. I don’t know. That nurse could have been doing this much longer than that doctor, or vice versa. I don’t know who’s right. Yeah, that’s hard.

Dr. Andy Roark:
Talk to me a little bit about continuity of care. You said you’ve seen like 70 doctors. So I can guess what maybe that experience is like, but I could be completely wrong. So talk to me about your feeling of consistency and continuity when this has been your experience.

Kelsey Beth Carpenter:
The continuity is nice if you can do it. It can’t always happen, but I think there’s ways that lack of continuity can still be done successfully, if that makes sense. So for example, okay, I’ll give this example. My mom and I, we go to the same medical center, and it’s kind of like a tight-knit thing. And so my mother and I both have the same primary care physician, so share doctors.

Dr. Andy Roark:
Sure.

Kelsey Beth Carpenter:
We also have the same physical medicine and rehabilitation doctor as well. And so one of-

Dr. Andy Roark:
Do you carpool?

Kelsey Beth Carpenter:
I wish.

Dr. Andy Roark:
Do you drive together?

Kelsey Beth Carpenter:
We’re not that cool yet. I just realized we also do have the same physical therapist. We did once have our physical therapy appointments back to back, and that was weird. It’s all really becoming a family affair, and I don’t know whether I am enjoying that or having questions about it. Anyways, so one of the beautiful things is, for example, our primary care doctor saw my mom the other day because she finally came down with COVID, the VID, and my mom was like, “Yeah, I’m really worried. What if I gave it to Kelsey?” And immediately the doctor knew who she was talking about and was able to reference things that she would’ve only known, but she made these notes to herself. We all have places we can make notes. And it’s the continuity of having seen her numerous times and her taking the time to remember who’s connected to who or what’s going on here.
The last time I saw her, she was like, “How is it going with this supplement?” That kind of continuity is so valuable. But meanwhile, I think there’s a way that it can be done successfully where you don’t always have to be there. So one thing that I think is very important is creating a plan. And I think it’s one thing that many of us, I think, could improve on in any field. And I’m going to tie this together, I promise. We’re going to go on a journey, and then we’re going to come back.

Dr. Andy Roark:
I’m trusting you. I’m trusting you.

Kelsey Beth Carpenter:
We’re going to go on a little island, and then we’re going to float on back to the mainland. Okay, so I think one of the most important parts is to create a plan with your patient or your client and say, “Okay, this is what we’ve decided to do today. If this does not work, here are some other things that we might consider going forward.” And that doesn’t always happen. And sometimes it’s just, “All right, we’re going to prescribe you this medication,” and it leaves people, like myself, I’ve often felt sort of abandoned. It almost feels like the doctor’s saying, “All right, I’ve given you this medication, and I’m done with you.” And I kind of feel like, okay, well, if this doesn’t work, I don’t know what to expect. And many of us have brains that we like to plan ahead, okay, if this doesn’t work… How long do I wait to see if it doesn’t work?, that kind of thing. So you create this plan, and it doesn’t have to be detailed. It doesn’t have to say what dosages you’re going to give of some other antibiotic, just we are going to try this or this.
And then the beautiful thing about that is it helps your team. So now if I have to go back in through urgent care because whatever my primary care physician did didn’t work, there are now really clear notes in my primary care physician’s record about what we discussed or the next plan, or is the next thing we’re going to try. And so now this urgent care doctor’s going to say, “It looks like you guys talked about trying this as the next thing. Do you want to go in that route?” And now I feel like there is still continuity, even though I’m not seeing the first doctor that I saw. And I feel like I haven’t been abandoned. I feel safe seeing another doctor that I’ve maybe never seen before because my first doctor took the time to say, “I’m not leaving you with this. I’m going to say, ‘Here’s this, and here’s what we’re going to do if it doesn’t work,'” you know?

Dr. Andy Roark:
Yeah.

Kelsey Beth Carpenter:
So that’s important, I think.

Dr. Andy Roark:
I love that. So I can rant about medical records in vet medicine with the best of them. And so I definitely have my own position and soapbox. The very, very short version is we should think about what the purpose of a medical record is, because people write books, and I don’t think that people get trained very well in what’s required and what’s not. And the point of the medical record is to document what happened and why it happened, meaning how was the decision reached?

Kelsey Beth Carpenter:
Exactly.

Dr. Andy Roark:
Why did we not do this or why did we do this, but how was the decision reached? And the last part is what is the plan going forward? And that last part is mission critical for being able to pass cases between doctors at your practice.

Kelsey Beth Carpenter:
Exactly.

Dr. Andy Roark:
And it’s just the number of medical records I see that doctors don’t jot down even the most basic, “Hey, if this doesn’t work, we’re going to recheck blood work and consider… I don’t know… trying a different medication.” That gives the client some idea of what will happen next. If something goes bad or they just don’t get resolution, they’ve already said, “Okay, we’re going to go do this blood work.” There is a plan. They know what they’re doing. And I’ve had the exact same experience that you have had in medicine of getting a plan. And they’re like, “No, you’re just doing this now.” And I’m like, “Well, for how long?” And they’re like, “I don’t know. Forever? We’ll see.”
And so that’s not at all uncommon. And, again, my guess would be that there’s some liability fear in human medicine where they’re like, “I don’t want to take you off of medicine.”

Kelsey Beth Carpenter:
Of course.

Dr. Andy Roark:
“Just stay on it forever.” Again, I’m telling myself stories too, but I think sometimes in human medicine they’re like, “I’m going to put you in this medicine, and at some point you are going to get tired and decide it doesn’t work, and you’re just going to stop, and I’m not going to have to tell you, but then if it ever becomes an issue, you’re the one who decided to stop it, not me”. And so I don’t know about that, but I think the idea of having a plan and communicating a plan, I think it’s absolutely true. You don’t have to have a master plan either.

Kelsey Beth Carpenter:
No. Exactly.

Dr. Andy Roark:
You just don’t want to feel like you’ve been pushed off into the ocean in your little dingy, and it’s like, well, maybe we’ll bump into each other again.

Kelsey Beth Carpenter:
Exactly.

Dr. Andy Roark:
Something more than that, yeah.

Kelsey Beth Carpenter:
Well, And ultimately, like we’re saying, this doesn’t have to be some extensive conversation. It’s, “We’ve chosen to do this today. I want to hear from you in two weeks. And if it’s not working, we can consider some recheck blood work, and there’s another medication that we could try as well.” That’s as simple as it needs to be. And that one sentence saves numerous people so much time if that first medication doesn’t work. If it ends up with another doctor, it saves that doctor time. It saves the client time, or the patient time because they can know what’s going to happen. If you end up seeing the same patient again because it’s not working in two weeks, saves you time. You don’t have to go through the whole conversation of options again. You’ve already set out your plan. So even though it sounds like I’m saying do all these extra things, I think ultimately it’s actually a time-saver for everyone.

Dr. Andy Roark:
The patient portal experience in medicine, I’m a big fan. That is something I would actually like to see in vet medicine. I’m confident we could do it in a way that does not generate a ton of extra work for us, but just the ability to have your own little thing and you go and you log in, and you can pull up your blood work from the past, and you can look at radiographs or you can do whatever. Or you have the ability to send messages to the doctor, and it’s like I totally get people being like, “I don’t want clients to have immediate access to me.” Look, they’re getting access to you anyway. They’re calling. They’re being put on hold. You’re going to talk to pet owners. Go ahead and figure out how you want to do it and come up in a way that’s convenient and easy and safe and secure where you have everything documented.
And it’s just… I don’t know… the patient portal stuff, I think they’re pioneering it in human medicine. And I think that that is something that I can absolutely see us in vet medicine doing and saying for our clients, “This is kind of what your portal looks like,” and then also just the benefit of if your pet ever ends up in the emergency clinic, you can be like, here’s what we have. And I know we already have services like that. We have a number of sort of record-sharing services that work great. VitusVet is the one that was popping into my head. I know there’s others as well, but getting to the point where that’s expected, I think that’s something that’s coming.

Kelsey Beth Carpenter:
Yeah. The value of seeing things as well, at least in the practices that I’ve worked in, it’s very rare that a doctor will go over x-rays with a client without showing them the x-rays so they can point out, “This is what we’re looking at.” And there’s incredible value in that, because you see that’s my pet up there. This is what was actually done. This is what I’m paying for. This is what my doctor’s seeing, and this was what it means. That visual representation is so important. And I think sometimes that’s part of what’s missing in some of our client education. They don’t have access to their blood work. We go in and say, “The BUN and creatinine is elevated, and so we’re worried about the kidneys.” If I wasn’t in medicine, that would not process anything for me. But if it’s written out in front of me and I see the big red highlighted, oh, this is an abnormal value, now I’m going to remember that. And so I think you’re totally right. I think the portal is the best way to go. And also I think it’s an incredible opportunity for technicians. I think so many technicians are often looking for new ways to be involved in veterinary medicine that maybe isn’t blowing out their back every two seconds. And I think that’s an incredible way that we can allocate work to technicians for sure.

Dr. Andy Roark:
Yeah. I think that that’s a big part of where technicians are going in vet medicine, is in the communication, customer service sort of realm. I just think there’s so much opportunity there for sure. And again, I know everybody has different learning styles. It’s been interesting for me to recognize how much some sort of visual learning is important to me. The doctors that I’ve been most impressed with have been the ones who have visual aids.

Kelsey Beth Carpenter:
Absolutely.

Dr. Andy Roark:
Like a whiteboard, and they’re like, “All right, this is what we’re doing, and this is what it looks like.” And they’re just simple diagrams, but I was like, oh, I feel so much more informed of just understanding what’s going to happen and why it’s going to happen. But it has made me think a lot about my time in the exam room and how I want to use those tools and how much of a difference it can make for people.

Kelsey Beth Carpenter:
Yeah, it’s why I’ve always been so passionate about working in an open hospital, is that when people get to see what is being done, they retain so much more information. I always say clients can come back after being in the open hospital and be like, “My pet received subcutaneous fluids yesterday and an injection of Cerenia,” but it’s because they watched it happen. If you came and told me that’s what you did to my pet, there is no way my brain would remember that if I wasn’t in medicine. But seeing it is really different for sure.

Dr. Andy Roark:
Define open hospital for people who aren’t familiar with the term.

Kelsey Beth Carpenter:
It basically functions as if you were going to a pediatrician where you get to stay with your pet, as… I was going to say as humans stay with their children in that same way. I don’t know why that sounded funny to me in the way I said that. As humans stay with their skin babies, the clients get to stay with their fur babies.

Dr. Andy Roark:
Yeah, I think we should call pets babies and humans skin babies.

Kelsey Beth Carpenter:
Skin babies.

Dr. Andy Roark:
I think we should not call pets fur babies. Just call them babies-

Kelsey Beth Carpenter:
Just babies.

Dr. Andy Roark:
And then make humans call them skin babies.

Kelsey Beth Carpenter:
Congratulations on your new skin baby. We’re going to start something new here.

Dr. Andy Roark:
Oh, it’s going to totally catch on. Oh, yeah.

Kelsey Beth Carpenter:
This is going to catch on like wildfire.

Dr. Andy Roark:
I feel it already. Mothers are going to just go right to this as a concept. All right.

Kelsey Beth Carpenter:
There’s something that you said earlier that I wanted to touch on too that has been something that I think is maybe the biggest thing I’ve learned from being a patient. And we were talking about choices and how you come to a certain decision and then what you’ll try next and those kind of things. And one thing I found being a patient myself and going through a really difficult time and I didn’t have a clear diagnosis, and it was a rough case, I am essentially the 20-year-old geriatric, cancer and kidney disease and liver failure cat who’s mostly bones that comes in that you dread getting because they have a lot of questions. That’s me. I’m that patient. Okay?

Dr. Andy Roark:
Okay.

Kelsey Beth Carpenter:
So one thing that I learned is that I experienced an incredible burden of responsibility to care for myself. There was an incredible burden of I am the only one who can make these decisions, and hopefully they are the right ones, but my life hangs in the balance based on these decisions that only I can make. And I realize that I have that same feeling when it comes to my dog Birdie, that I have an incredible burden of responsibility, that I am the one making decisions for her life. And it’s almost even harder. At least if I’m making a decision for myself as a patient, I’m the only one who gets hurt if I make the wrong decision. If I’m making the decisions for Birdie and I make the wrong decision, let’s say I don’t take her to urgent care and I see if she gets better on her own, she’s the one who gets hurt because of that. And that is an incredible burden. That’s really heavy on your shoulders.
And so one thing that a doctor said to me recently, which made a huge difference, was I was seeing a new doctor, and we went over all of the things that I’ve tried so far for my chronic pain. And a lot of them were things that she normally has to tell people about. And she’s like, “Wow, you’ve really done your research. You are doing everything you need to be doing right now. You are doing everything right. Keep up what you’re doing.” And I, after that appointment, sat there and cried because I was so just like I needed that validation to say I am making some really good decisions. I’m doing the right thing. And it took a huge weight off of my shoulders. And I think that’s the biggest thing that I would change, is when I go to put an urgent care patient in a room, because yeah, Bella’s been vomiting for a couple days, being able to say to a client, “Gosh, you made the right call, bringing her into urgent care today. I’m definitely glad you brought her here,” or if the client decides, “I don’t think I’m ready to hospitalize her. I’m going to monitor at home,” saying, “I think that’s a reasonable choice. And we have a plan in place in case it doesn’t work,” that kind of validation is really huge.
And I think that’s the biggest thing I never thought about until I was a patient myself and I felt that burden on my shoulders.

Dr. Andy Roark:
Yeah, that’s a great point, is people want to know that they’re a good pet owner, and they want to know that they’re doing the right decision. And they always ask themselves if they’re overreacting. You can see it in pet owners’ eyes, should I have come? Maybe I’m-

Kelsey Beth Carpenter:
Absolutely.

Dr. Andy Roark:
Just being paranoid, and just that validation of, “No, you are doing the right thing,” yeah, that’s great. Kelsey Carpenter, where can people find you online? You are such a joy.

Kelsey Beth Carpenter:
Mostly silently, quietly, privately being a keyboard warrior behind the Dr. Andy Roark Facebook page.

Dr. Andy Roark:
Facebook page.

Kelsey Beth Carpenter:
I am under Vet Tech Kelsey on Facebook and Instagram, and that is it.

Dr. Andy Roark:
That is it. No, I saw Facebook launched their new sort of Twitter-like platform today.

Kelsey Beth Carpenter:
Oh, was it Threads?

Dr. Andy Roark:
Threads, yes.

Kelsey Beth Carpenter:
I’m hearing all about that, and I’m a little… I know I’m 34 when I start going, “These darn new social media platforms-

Dr. Andy Roark:
I know.

Kelsey Beth Carpenter:
“We don’t need them. I refuse to sign up for Threads.”

Dr. Andy Roark:
That’s great that you’re a social media manager for an old fart who’s like, “I don’t want to do that thing.”

Kelsey Beth Carpenter:
And I don’t want to do it either.

Dr. Andy Roark:
And you’re like, “Good, because I don’t want to do it either.” [inaudible 00:33:35].

Kelsey Beth Carpenter:
My favorite part is like Andy Roark doesn’t want to dance on TikTok, and I’m like neither do I with my Bachelor of Arts in dance.

Dr. Andy Roark:
That’s so great.

Kelsey Beth Carpenter:
I won’t touch it.

Dr. Andy Roark:
Oh, I love it. All right. Kelsey, thanks for being here. Guys, I hope you guys enjoyed the episode. I think there’s so much to think about here. I always enjoy sitting back and going what does this mean for vet medicine? So anyway, guys, take care of yourselves. Be well, everybody.
And that’s it, guys. That’s what I got for you. Thanks for being here. Thanks to Kelsey Beth Carpenter. Check her out on the social medias, if that’s where you hang out. She really is amazing and wonderful. Be well, everybody. I’ll talk to you soon. Bye.
Hey guys. I just want to jump in real quick and let you know that my Back to School webinar Series is winding to a close. I’ve had a bunch of webinars on recently. They’re done by me. They’re done by guests of mine. I’ve got one more live one coming up. It is on Tuesday, September the 19th. That is at noon Eastern time, 9:00 AM Pacific. It is a one-hour presentation. It has one-hour of RACE. It is a presentation by me. I will be getting the team on board with the spectrum of care approach. If you listen to the podcast very much, you know that I’m big on spectrum of care. I think it’s important to balance the quality of care that we put with affordability and accessibility to pet owners. This is about talking to the team about those concepts and getting everybody in the same place so we feel good about providing quality care and striving to meet pet owners where they are. So anyway, like I said, that’ll be one hour RACE. It’s me doing the presentation, getting the team on board with the spectrum of care approach. It is Tuesday, September the 19th at noon Eastern time. It is sponsored by Nationwide.
Also, I have got a webinar on demand for you. It is from Ceva Animal Health. It is called Updates in Canine Pancreatitis, Treatment Innovation with Fuzapladib Sodium for Injection. If you haven’t seen this presentation before, it is a great presentation. It’s super, super action-oriented on dealing with pancreatitis, and it talks all about the new drug on the market, Panoquell-CA1. So anyway, that is on demand. You can watch that webinar right now. I’ll put links to all this in the show notes. Okay, let’s get back into this episode, but I hope to see you on the webinar on September the 19th. All right, bye.

Filed Under: Podcast Tagged With: Care, Life With Clients, Perspective, Vet Tech Life

A Pirate Looks At Vet Med

September 13, 2023 by Andy Roark DVM MS

Last week one of my idols died, and last night I had a dream about him. It wasn’t a particularly exciting dream. Just me and Jimmy Buffett sitting and talking in an empty theater. I wish I could remember what we talked about, but I can’t. I just remember him smiling and laughing and me feeling like everything was going to work out fine.

When I was a kid, my dad would play Jimmy Buffett albums on the record player. I remember the album covers for “Havana Daydreamin’” and “A White Sport Coat and a Pink Crustacean” had “Roark” written on them in black sharpie for some reason. I still have no idea why. My favorite song was “Gypsies In the Palace” and it was all about people throwing a wild party at Jimmy’s house while he was away. I thought it was hilarious.

I suspect I was shielded from some of Buffett’s bawdier songs like “Why Don’t We Get Drunk and Screw,” but I knew that song because my dad would sing a parody version to our basset hound, Edsil. He changed the lyrics to “Why don’t we get loose and chew?” and generally sang while Edsil worked on a rawhide bone. To this day, whenever I see a basset hound, I immediately think of those lyrics and sing them out loud if I think I can get away with it.

I’ve seen Jimmy Buffett play live about a half dozen times (some I remember better than others) and I bet I’ve listened to more of his music than any other performer over the course of my life. His music, however, is not why I’ll always remember him. 

I’ll always remember Jimmy Buffett because of what he stood for, and what he taught me about life (and medicine). Buffett symbolized the loveable hero who was far from perfect. His songs gave us the chance to embody a pirate, a sailor, a smuggler or a lover who was destined to fail spectacularly… and who would laugh about it when it was over. 

I’ve written recently about how much fear I see in veterinary medicine – fear of failure, fear of irrelevance, fear of losing control – and Buffett’s songs showed a life and a perspective that could laugh those fears off. His self-deprecating sense of humor was refreshing, and it made us feel that our own struggles and shortcomings weren’t something to be ashamed of as much as they were a membership card to the best club around.

Buffett’s songs were never about striving or achieving. They didn’t celebrate the acquisition of wealth or status. All he made us want was a pair of flip flops and a frozen drink we could make in our own blender. His music made us feel that holding on for the weekend was enough, and that we deserved to relax for just getting through the insanity of the world around us. God that’s a perspective so many of us in veterinary medicine should get more comfortable with.

Jimmy Buffett taught me a lot about being present in the moment, experiencing the world with a joyful and mischievous heart, and trying not to take anything too seriously. His songs also taught me to accept that life will be both hard and beautiful. In the song He Went to Paris, Buffett tells the story of a man seeking adventure who ultimately loses his wife and child. The song ends with the man at age 86 and the line “some of it’s magic, some of it’s tragic but I had a good life all the way.” I think this may be one of my favorite song lyrics.

Finally, I learned lessons from Buffett on what it means to age well. When I was in my 20s, I loved his songs about parties and cocktails. Then when I got to my 30s, I was moved by his songs about finding meaning in life. Now in my 40s, I enjoy the songs he wrote about his children. Maybe when I get into my 50s, I’ll discover that I like his more recent music. Who knows?

If Buffett had been in his 60s still writing songs about drinking until he couldn’t remember things, that would have just been sad. But he didn’t do that. He celebrated that part of his life and then found inspiration in the next phase, and the phase after that, and the phase after that. When I think about how I want to age, I want to be like him. I don’t want to cling to what worked in the past, but to be comfortable with and true to where I am in the present. I think this is the essence of aging gracefully.

I hope I told Jimmy all this in my dream last night. It’s what I would want him to know, and it’s what I’ll always remember about him. Goodbye to the original Parrot Head. You brought so much joy to this world. Thank you, and… Fins up!

Filed Under: Blog Tagged With: Perspective

Nutritional Purr-spectives: Feline Health and Clinical Nutrition

September 11, 2023 by Andy Roark DVM MS

This week, Dr. Andy Sparkes joins the podcast to discuss his role as co-editor in the Purina Institute’s brand new Handbook of Canine and Feline Clinical nutrition. Dr. Sparkes and Dr. Roark walk through the chapters on feline idiopathic cystitis and urolithiasis while discussing what’s new and important in the newest edition of the handbook.

Cone Of Shame Veterinary Podcast · COS – 222 – Nutritional Purr-spectives: Feline Health and Clinical Nutrition

This episode is brought to you ad-free by The Purina Institute!

LINKS

Get the new Purina Institute Clinical Nutrition Handbook for free!

CentreSquare: https://www.purinainstitute.com/centresquare

ABOUT OUR GUEST

Dr. Andy Sparkes BVetMed PhD DipECVIM MANZCVS MRCVS graduated from the Royal Veterinary College (London) in 1983, and after four years in practice joined the University of Bristol as a resident in feline medicine. After the residency, he completed a PhD, and was then appointed as Lecturer in Feline Medicine. In 2000, he moved to the Animal Health Trust in the UK where in 2008 he took over as Head of the Division of Small Animal Studies. In 2012 he was appointed as Veterinary Director of International Cat Care and the International Society of Feline Medicine (ISFM), and since 2019 he has been an independent consultant. Andrew has published widely, is a diplomate of the ECVIM and is the founding and current co-editor of the Journal of Feline Medicine and Surgery.


EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome, everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I got a good one. I am here today with my friend Dr. Andy Sparkes, and he is a, for those who don’t know him, he is… How do I describe him? Oh man, he does a lot of stuff. We’ll get his accolades at the very beginning of this episode. He is a feline medicine specialist. He is one of the co-editors of the new Purina Institute Clinical Nutrition Handbook. That’s a big deal, and we talk about that. We talk about talk feline cystitis, we talk about urolithiasis. We talk a lot about the handbook.
So just to fill you in real quick, the Purina Institute Clinical Nutrition Handbook is a magnificent resource and it’s 100% free. You can grab a copy of it in the show notes right now. I just got to pause and say, I love that Purina has done this. I love that they’re putting this out. I love that they’re giving away free. Just grab yourself a copy, grab two. They’re free. You can get as many as you want. Back the truck up. They’re digital copies and you can have them. But guys, this is a great resource. I love that they’re putting it on.
We talk about how it came together, about how to best use it, we talk about how it’s different for other resources that are out there. So all that stuff is woven into some really good pearls of feline medicine. Gang, let’s get into this episode. Oh, and this episode is made possible ad-free by the Purine Institute. Let’s do it.

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

Dr. Andy Roark:
Welcome to the podcast, Dr. Andrew Sparkes. Thanks for being here.

Dr. Andy Sparkes:
Thanks very much. Thanks for the invitation.

Dr. Andy Roark:
Oh, it’s my pleasure. You are fascinating. You are a feline specialist. You have been in academia and private practice. You have been all over the place. You are an editor or co-editor of the Journal of Feline Medicine and Surgery. You are a co-editor on the new Clinical Nutrition Handbook that Purina has just put out through Purina Institute. You do so many things, and so I appreciate you making time to be here.
I wanted to talk to you a little bit about specifically the Clinical Nutrition Handbook that Purina is putting out. So this is kind of a big deal. This is a pretty monumental size project that’s being put out and they’re putting it out for free, which I think is absolutely wonderful. I love it. Can you start to go ahead and just give me an overview of what were the goals going into this handbook?

Dr. Andy Sparkes:
Oh, yeah, interesting. I think when it was set up to produce this second edition, which is effectively a complete rewrite of the handbook, I think the key goal was to provide information on clinical nutrition that is really accessible to everybody in the veterinary healthcare team across the world, literally. So this is designed to be a kind of global resource. And behind that I think is this vision that we need to have meaningful nutrition conversations at every appropriate appointment in the clinic. And the resources to be able to do that should be available to everyone, and that’s really what we envisage this handbook would help achieve.

Dr. Andy Roark:
So how do you set that up from a structural standpoint? How is it different from a textbook? One of the things I really like about this resource is the hyperfocus on practicality and the ability to use it in between appointments in a very efficient way. How do you structure that differently from a textbook to make it accessible like that?

Dr. Andy Sparkes:
Yeah, good question. So I think three things that I think are worthwhile highlighting is its global focus. So it really is designed to be a global resource relevant to anyone in the world. There’s a collection of over 40 international authors that contributed to this handbook.
Second thing is every chapter is really focused. There is enough information within each chapter to get a good handle on the background of the particular disease or condition that’s being talked about, but really focusing in on understanding nutritional recommendations as well. So that’s a kind of tough ask when you’re dealing with international specialists to really focus in and make the information succinct, but that has been really well-achieved, I think, and to make this really practical. The chapters are short. They’ve got a good overview of the condition, but it’s really focused on understanding those nutritional recommendations and really putting that into practice.
So you’re absolutely right. I mean, this is designed to be a handbook that is used in consults. There’s material that’s really readily accessible, so in consults and between consults as well, just to have a look and see what’s going on. So up-to-date, really relevant information.

Dr. Andy Roark:
It seems like it would be really challenging to get specialists from all over the world to come together and write in a uniformly accessible way. Was that a challenge or was it pretty easy to get people to line up?

Dr. Andy Sparkes:
It’s always a challenge, and I would have to pay tribute to the lead editor on the book, Catherine Lenox from Purina Institute. She did all the heavy lifting on this and was twisting arms and getting people to write to a deadline. Honestly, I’ve never been involved in authoring or co-authoring, editing a book where the timeline was so short and so much was achieved within a short period of time.
So yeah, it’s challenging, but we got there. And I think also it has to be said that using an international group of authors, we chose people that were specialists in their field, not just nutritionists. We’ve got specialists in internal medicine and behavior, in surgery, all sorts of specialists that are contributing, and essentially they’re enthusiastic about getting people engaged with nutrition in their particular specialties and making this work. So, it’s been good.

Dr. Andy Roark:
When you sat down and kind of envisioned what this resource would look like, did it turn out that way or were there significant changes? Were you surprised? Did it morph or evolve from what you originally envisioned?

Dr. Andy Sparkes:
So I think in all honesty, when I sat down and looked at the kind of finished product and read some of the chapters that, as an editor, perhaps I was less involved with and less familiar with, I was super pleased with the way that it came together. I think that we have achieved what we set out to achieve. It is always challenging and it’s challenging keeping it brief and succinct and really practical, but at the same time, having sufficient information there to make it genuinely usable and useful. But I think we got that balance pretty well right, and I’m really pleased with the outcome.

Dr. Andy Roark:
What was it like to edit and then also have chapters that you wrote in the book? Was that different? Was it interesting writing your own stuff and then switching over and trying to sort of edit and read other people’s stuff, or was that pretty easy?

Dr. Andy Sparkes:
I didn’t find that too difficult to be honest, but it was kind of interesting. As I said earlier, Catherine Lenox at Purina Institute, she did all the heavy lifting. So she edited every single chapter, and then she worked with myself and Dr. Ronald Corbee from Utrecht University, and we were the co-editors with her, and we got to look at half the chapters each in terms of editing and contributing suggestions.
So Ronald and Catherine looked at my two chapters and came back to me with suggestions for improvement. It’s a good kind of organic process I think. Having at least a couple of people looking at chapters and making suggestions for improvement and refinement, it makes it good at the end of the day.

Dr. Andy Roark:
You have more than one chapter. You have a couple of chapters in this book.

Dr. Andy Sparkes:
Yeah. So idiopathic cystitis and urolithiasis, calcium oxalate and struvite stones in cats.

Dr. Andy Roark:
What are the significant updates in idiopathic cystitis from between the first and second edition? I know that there’s been some growth, and as I said, that we sort of overhauled the way the handbook was done. So what are the big takeaways? And we will start with idiopathic cystitis.

Dr. Andy Sparkes:
Yeah, yeah. I always enjoy writing reviews or book chapters like this because it gives you a chance to refresh yourself on all of the up-to-date information. And one of the things that always strikes me is how much we don’t know. I mean, there’s stuff that we do know, but there’s a lot of stuff we still don’t know. And that is definitely true of idiopathic cystitis. Worldwide, idiopathic cystitis probably accounts for about 60% of cases of lower urinary tract disease in cats that we see, but we still really don’t have a good handle on this disease. We don’t know if this is one condition or if it’s a syndrome with a lot of underlying causes.
A lot of talk obviously about the role of stress in idiopathic cystitis and stress perhaps as an underlying cause or major contributory factor to it as a disease, and there’s some fascinating research that’s been done in that regard. But I think that the picture honestly is still really unclear about that. We don’t really have a strong handle on how stress is actually involved, and indeed, the difference between cause and effect because if you’re looking at a cat, and a lot of the research has been done in cats with chronic long-term, quite severe idiopathic cystitis, and in those sort of cats, you don’t really know.
When you observe indicators of stress and perhaps maladaptive stress or abnormal stress responses, is that a cause of the disease or is that an effect of the disease? Because these cats are painful. They’re going through a lot of significant disease there, and so the disease itself is going to be causing stress for the cats. So I think although we assume that stress may be involved in the pathogenesis, I’m not sure that we’ve really been able to tease out how much it’s a cause and how much it’s an effect of the disease. So there’s still a lot of work to be done in that respect.
Definitely looking at stress and trying to improve stress in the environment and minimize stress, that’s always going to be helpful because that’s going to improve the welfare of the cat, whether or not it’s a trigger for the disease. So definitely worthwhile looking at that.
But I think the really interesting thing when you come to idiopathic cystitis, there’ve been a whole bunch of clinical trials looking at different drug therapies and interventions. The only clinical trials, controlled clinical trials, that have shown a positive effect from an intervention are looking at dietary intervention. And there are, to my knowledge at least, there are at least three studies that have been published which have shown a significant effect of dietary intervention. So stress may well be important, and certainly we need to be looking at stress in these cats, but we need to be looking at their diet as well and optimizing their diet.
Exactly what the most optimum diet is for a cat with FIC, I don’t think we have that sorted out yet, but certainly there are some good indications from some of the studies that have been published at least.

Dr. Andy Roark:
Do you think that there’s a specific… Do you think different cats do better on different diets? I mean, as opposed to saying, “This is the diet,” have you found in your hands that some cats, for whatever reason, seem to respond much better to diet A and then other cats to diet B, or do you think it’s not that simple?

Dr. Andy Sparkes:
Yeah, that’s a really interesting question. I think with some cats, we definitely, at least anecdotally, we see good response to certain dietary interventions. So historically, when I’ve seen cases of FIC, a lot of my emphasis has been on trying to improve water intake, so switching to a wet diet if they’ve been on a dry diet or looking at other ways to improve water intake. And certainly from my clinical experience, I think there are some cats that respond pretty well to that as an intervention. But having said that, I think clinical experience can be misleading. So you have those control trials that we really need to be looking at to have good quality evidence for what we do.

Dr. Andy Roark:
No, and I completely agree with that. And actually, I was toying with asking this question and now you’ve landed right on it, so I have to ask it. But our clinical experience can be misleading, and we are human beings and we tell ourselves stories about the experiences that we have, and we look for trends and sometimes they’re manufactured.
So it was interesting when you were talking about the stress component, and I thought about how many times I’ve had people come in and say, “Oh, well, we had friends visiting,” or, “there’s workmen in the house,” and I can’t help but wonder, Andrew, if that’s… I can completely see that not being a factor and me having made it up because if you go looking for it and you say, “Was there anything that changed?” And they say, “Oh, well, we had a repairman,” and you go, “Aha, yes.” And the truth is that may be completely manufactured.
Are you sold on that type of narrative at all? If a pet owner says to you, “I heard this was stress and we had visitors from out of town,” do you kind of nod and go along with that and say, “Yeah, it could be,” or are you more skeptical than that?

Dr. Andy Sparkes:
That’s a really tough one. I have become more skeptical over time, I have to say. As you say, I think we’re very good at telling ourselves stories, and we’re very good at looking at ways to affirm what we already believe is true. So if you’re sold on the idea that this is a disease that’s caused by stress or is triggered by stress, then it’s very easy to find something that’s happened in the recent past that could have triggered that.
The more objective way of looking at that is to do case control studies and see if you can identify environmental stressors that are genuinely associated with cats that have idiopathic cystitis and are just seen in those cats and not in control cats.
When you look at case control studies, and there’ve been a few that have been published, there is really no consistent findings in terms of potential environmental stresses. You would think that something like a multi-cat household would be an obvious stressor where there may be conflict between cats in the household. You would think that maybe indoor-outdoor access may be involved or ready access to a litter tray, all sorts of other things. But these case control studies that have been published do not find any consistent environmental stressors that are involved in cats, and that makes me a little bit more skeptical.

Dr. Andy Roark:
That’s interesting. Oh, I completely hear what you’re saying. I am absolutely sure that I’m guilty of creating stories in my own mind around that, but anyway.

Dr. Andy Sparkes:
Oh, me too. Me too.

Dr. Andy Roark:
Well, it’s human nature and we all want to understand. It’s hugely frustrating to feel like this is a common problem, and this condition, it kills cats. I mean, this is the number one reason cats end up in the shelter, and it is a significant health risk for cats. And to say, “I feel like my knowledge of why this happens is so limited,” it’s a frustrating experience. I think we all want to feel that we have control and an understanding and insight that can be really helpful.

Dr. Andy Sparkes:
I mean, I definitely wouldn’t… I don’t want people to get the impression that I’m dismissing stress as a potential trigger or as a significant component of the disease because as I said, whether or not stress is actually triggering the episodes, these cats undoubtedly are stressed, they’re fearful, and they’re anxious because of the discomfort and so on that they’re in anyway. So I think it’s absolutely important for us to be considering stress and trying to minimize that in these cases. I think maybe the narrative that we have about this is a stress-induced disease might just be a little bit simplistic.

Dr. Andy Roark:
No, I like that. That makes total sense.
Talk to me a little bit about the urolithiasis. When you set out to write this, it’s clearly a staple when we talk about clinical nutrition and things like that, what were sort of the pearls and pitfalls that you wanted to highlight? And I say pearls, meaning what are the things that I think are most valuable for clinicians? And the pitfalls are what are the errors maybe or the missed opportunities that I see doctors make? So when you sat down to write the chapter, did you have objectives like that in your mind?

Dr. Andy Sparkes:
Yeah. I guess I wanted, again, just to look at recent literature that has been published in this area and really try and make this as up-to-date as I could. And looking at that, I guess there’s a lot of epidemiological information on stone formation in cats, which is mainly produced by the big laboratories where you submit stones to for analysis, whether that’s in the US or Canada or anywhere else in the world. And so there’s a lot of publications looking at epidemiological evidence for this.
We know that 90% of feline uroliths, more than 90%, are either struvite or calcium oxalate. Those are the two big ones for sure. I think there’s been some fascinating trends in the relative importance of struvite and calcium oxalate over the years where struvite used to be the dominant, certainly in the early ’80s, struvite used to be the dominant stone. There was a switch by the late ’90s for sure, so the calcium oxalate became more prevalent. Now, it’s perhaps a little bit more even again.
I think one of the things that did strike me, just going through all of that literature again, is that that’s potentially a misleading bit of information, though it’s very hard to draw information from stones that have been submitted to a laboratory which have either been removed surgically or may have been passed naturally. Stones that are submitted to a laboratory and looking at the composition of those stones and then trying to apply that to the general population of cats, that’s a tough one to do. So in terms of the genuine epidemiology of stone disease and the prevalence of these different stones, I think it’s a tough one to really get a proper handle on.
But the thing that really struck me, I suppose, is that even when you look at those figures, say roughly 50% of stones that are removed from cats right now end up being struvite stones, those cats didn’t need to go through a surgery. We can dissolve those stones with diet. So there’s a lot of cats that we’re still putting through surgeries that potentially could be resolved medically. I think that there’s a big opportunity there that we could avoid a lot of cats having to go under the knife.

Dr. Andy Roark:
That absolutely makes sense.
Dr. Andrew Sparkes, you were amazing. Thank you. Thanks for being here. Thanks for going through this with me. Are there any final pearls, as you start to look back and sort this work and put it out, is there anything else that you really want to make sure that clinicians take away from the chapters that you did? Any final parting words to say, “Hey, if you could give me one piece of advice going forward, what would it be”? I love the idea that a good percentage of stones can be dissolved and maybe we’re a little bit quick to go to surgery in those cases. I think that that’s something I’m absolutely going to put away and hold onto because that’s the type of information you like to have just nagging you in the back of your mind.

Dr. Andy Sparkes:
So, final thoughts. I guess I am a strong advocate of evidence-based medicine, and I think this handbook really helps us to achieve that. It provides succinct information, but it provides really up-to-date information and it’s unbiased information as well. The handbook doesn’t talk about commercial products. It’s talking about an approach to nutritional management of a whole variety of different diseases.
The book, I think you said at the top that this book is available free of charge. There is no charge for accessing this. All anybody has to do is sign up for communications at Purina Institute, purinainstitute.com, sign up for email alerts from them, and you get access to this resource completely free of charge. And Purina Institute itself, again, it’s not involved in promoting particular commercial diets. It’s about providing the science behind the nutrition, so they have a bunch of other resources there as well, including, well-pet nutrition. This handbook is focused obviously on disease management, but there’s well-pet nutrition there as well.
So I hope that this is going to be a widely used resource. I think it’s a lot of work gone into it and yeah.

Dr. Andy Roark:
I love this sort of model of distributing information from Purina. This thing is, I think it’s a PDF when you download it, and it’s just, I don’t know. I have a lot of PDFs. I just get a lot of information this way, and I keep them on my phone and put them on Google Drive and access it wherever I am. It’s an elegant solution. And the idea that you would get some sort of a reference material like this and said, “Oh, here you go, guys,” it makes me so happy. I love this project.
So anyway, Andrew, thank you so much for being here. Guys, thanks for tuning in and listening. Take care of yourselves, everybody. I will put links to Purina Institute and then also directly to where you can pick up the handbook in the show notes. Take care everybody.

Dr. Andy Sparkes:
Thanks so much.

Dr. Andy Roark:
And that’s the episode. Guys, I hope you liked it. I hope you got something out of it. Thanks again to Purina Institute for making this episode possible and also making the Clinical Nutrition Handbook possible. As I said, I’ll link it in the show notes. Go ahead and grab a copy for yourself. Take care everybody. I’ll see you later on.

Filed Under: Podcast Tagged With: Medicine

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