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Podcast

Making Practice Easier with Automation

March 29, 2023 by Andy Roark DVM MS

Mira Johnson CVPM CPA joins Dr. Andy Roark to talk about opportunities many veterinary practices are missing to lighten their load and speed up their work through automation.

In this episode, Mira discusses the benefits of decreasing human interaction in systems that are repeated (or simply are not enjoyable). She talks about identifying bottlenecks in practice and how to get started with the “core systems” a practice runs on. Dr. Roark explores how practices can calculate ROI for investing in automation, and asks about the most common pitfalls that practices fall into when beginning a path to greater efficiency through automation.

Cone Of Shame Veterinary Podcast · COS – 191 – Making Practice Easier With Automation

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

LINKS

JF Bell Group – https://cpasforveterinarians.com/

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

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Mira Johnson holds a Masters’ Degree in Financial Management and Accounting is a CPA, and is a Certified Veterinary Practice Manager. She is a managing partner in the JF Bell Group, CPAs for Veterinarians. Mira’s passion is helping veterinarians to start, manage and grow the practice of their dreams. She embraces the use of apps to help automate the business side of their practice. Her articles about financial automation and employee motivation have been published in Today’s Veterinary Business and dvm360.


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 today with my friend Mira Johnson. We are talking about making your life easier in practice through automation. Are there things that could be automated in your practice? Would it make your employees happier? Would it make your clients happier? Would it make your work go smoother? Guys, it’s amazing how many things we do again and again and again and just think that they’re part of our job. Boy, we get those things automated and it’s just one less thing to do. And boy, ounces make pounds. Your time adds up, a little bit of time on a task that we do again and again, again, ultimately over the course of a year that’s a whole lot of time.
And so anyway, I’m a big fan of automation. I’m thinking a lot in systems these days and how to make things flow more smoothly. And then also how to make it so that I enjoy my job and I’m doing new and interesting things and things that I’m good at and required for, and not so much things have just rote process that honestly could be taken off my hands and just done by an app. So anyway, that’s what we’re talking about today, guys. I hope you’ll enjoy it. Let’s get into this episode.

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

Dr. Andy Roark:
Welcome to the podcast, Mira Johnson. How are you?

Mira Johnson:
Good, how are you?

Dr. Andy Roark:
I’m doing really good. I’m glad that you’re back. For those who don’t know you, you are a CVPM, certified vet practice manager, and a CPA, an accountant at JF Bell Group. You have been on the podcast before you did a podcast with me about embezzlement in veterinary medicine recently. That was really, really interesting and got a lot of interest. I enjoy you, I read your writing in today’s veterinary business, and you and I are right now kind of doing the conference thing together as we were at VMX, and we are going to Western. And so I’m excited to get to see you in person and to travel a bit and be in your orbit. So thank you for being here.

Mira Johnson:
Thank you for having me. I’m super excited about this topic. It’s my passion, business automation.

Dr. Andy Roark:
Yeah, so it’s business automation. Now, you talked about this a little bit last year at WVC, and then you’ve got an article about it as well. But I think this is really interesting. I’ll tell you where I’m coming from in this is, as a business owner and a generally very busy person, there’s a lot of talk about efficiency. And so I’m really in this place in my life and it’s because we’re adding a lot of new employees and the company I run, Uncharted, is really growing a lot. We’re really thinking in systems and automations, and it’s just been something that I have really been stretching my mind and learning a lot about and getting really into. And so I think this is a fascinating topic. When we say business automations, why don’t you start there and go ahead and define turns for me and just open up at a high level, what do you mean when you talk about that?

Mira Johnson:
Yeah, when I talk about business automation, that means it’s some kind of process where we’re trying to eliminate the human to, or not completely eliminate, but minimize the human interaction. So it might be something that’s repeating all the time. It’s data entry. It’s mostly the boring stuff that is coming and going all the time when some kind of event happens, for example, like you said, or have a growing team. So it’s the hiring part, the onboarding employees, paperwork that’s related with it and stuff like that. So you’re trying to eliminate the human from the process or to minimize it and I think that helps also with accuracy. So that’s a big part for me, not that you are only automating it, but also you’re eliminating them because we’re all humans and we all make mistakes.

Dr. Andy Roark:
Yes. Oh yeah, I completely agree. Okay, so we start talking about the veteran practice, and this is really interesting to me. The things that pop into my mind that I see a lot are in our pharmacy, in our workflow in pharmacy, from people getting refills, things like that. There’s booking appointments, online scheduling, things like that. I geek out about all of these things. I do not think that we’re going to be replaced by robots. I am not afraid of artificial intelligence. I really am not. Basically, they do the parts of the job that we don’t want to do that are not fun, that are just sort of tedious things in where people make mistakes.
I look at these things as opportunities and freeing us up to do the things that are uniquely human, which is to be empathetic, to give patient care, to give compassion to pets and people, to all of these sorts of things that really matter. And so anyway, I geek out on this. I know that we have so many practices out there that are just really overwhelmed and really busy. When you start to look at a practice and I say to you, Mira, help me, help me, help make my life easier, help take work off of my people, what are the first areas that you start to look at with an automation lens?

Mira Johnson:
That’s a good question. Before I answer it, I do want to insert one thing that you said, “I am not worried that the robots will take my job.” So there’s actually a website that’s called willrobotstakemyjob.com, and you can put your profession in there and say, is that really going to happen? So willrobotstakemyjob.com and when you put payroll and timekeeping clerks and auditors and bookkeepers, it will come back with saying, you are doomed.

Dr. Andy Roark:
Done, done, and done.

Mira Johnson:
That is just hilarious. But for veterinarians, you guys are not doomed, which is great news, right? So no, you are correct. Your job will not be replaced by robots. But back to questions. So when I look in the practice, I try to see what is the parts that are the bottlenecks or what is the parts that maybe the practice owner does not like to do? How long does it take? So I like to look at the hiring process. How long does it take to hire a person? When we have a lot of practices that have recently had a lot of turnover, so when the new hire comes in, you give them the W4 to fill out, then you give them the handbook to read or whatever your process is.
But there’s usually lots of paperwork and that employee, the new hire is tied up for sometimes even a full hour till they go through all their papers. And sometimes the HR manager or the practice manager, depending on the size of practice, will sit that person and go through the employee handbook, explain stuff and stuff like that. So I think that’s a time that’s not well spent in my opinion. This can be all done electronic before that new hire walks through the door. So I like to-

Dr. Andy Roark:
Yeah, I completely agree.

Mira Johnson:
Automate that part first.

Dr. Andy Roark:
Yeah, that totally makes sense to me. I talk a lot about practice efficiency and looking at how practices run. There’s three things that I like to look at and I’m just curious how you feel about these when I lay them out. And so the three flags for me, I’m a big believer in looking at what you do in a day and so one of the exercises I always tell people to do… And I honestly do this and I do it every couple of years, I usually get one of the big flip charts, one of the big wall post-it notes, and I’ll keep it for a couple of days and I write down everything that I do for a couple of days. And I do my personal life in there as well because let’s be honest, my life doesn’t separate out.
Picking up the kids is part of my day and cooking dinner is part of my day, and I just look at my life as one whole. And that’s what I do in the clinic. It’s what I do at home. It’s what I do is my hobbies, and I write them all down. That may sound really silly, but most of us never audit our life and our time and what we really do. But I think it’s so important because it gives me clarity on like, oh boy, I do a lot of things. And then I look, there’s three things that I really look at. What are the biggest time sucks? Meaning where am I spending a lot of time that I don’t feel good about? The next one is, what do I repeat over and over and over again? I’m doing the same thing again and again and again. And the last thing is, what do I just not enjoy? And I am looking at those things and I am looking to delegate those things away.
Just like this is a ton of time and someone else could do it. And so I need to figure out how to make that happen. I am just repeating this again and again and again and that does not make sense. And I think that’s the biggest flag for automation. But I also really like your point of just going, I just don’t enjoy this. I don’t like doing it. I would much rather have an interface where someone could do this by themselves. But I think a lot of new client paperwork, I’ve seen practices that will have a new client come in and every time a new client comes in, it takes a half an hour of front desk time to get this person set up. And I go, this is bonkers because you do it again and again and again. So how does that feel when I lay that out as what are the biggest time sucks I don’t feel good about, what repeats again and again and again and what do I just not enjoy doing.

Mira Johnson:
Yeah, I think that’s well said. A hundred percent agree with that because once it’s repeating over and over, I usually approach it with like, I wonder if I can find an app for it. People come to me all the time and say, “Hey, Mira, I am repeating this and I’m doing this.” And I’m like, “Oh, there must be an app for it.” Because there usually is. And if there isn’t and I don’t enjoy the work, then I’m probably not as great at it as somebody who is passionate about and who can enjoy it. So then I will try to delegate, so if the human cannot be taken out.

Dr. Andy Roark:
Yeah, talk to me about finding an app. When you say, is there an app for it, ’cause that’s not a phrase that would go into my head. What do you mean? If I came to you and sort of said, Hey, I don’t know insert sort of process here, maybe you have an example. What does that look like?

Mira Johnson:
Yeah, let’s just say that for example, and I’m just going to go from my neck of the words, that if there is a client that says I process payroll by entering time cards in there and I have to calculate over time because I’m exporting this time card from a software and then I’m trying to retype it in here. Then my first thought is like, okay, how often do you do this? So biweekly. Okay. And it’s just you who can do it? Well, no, but I don’t really trust anybody. Nobody’s trained to do it. I’m just going to do it myself. It takes only a few minutes. And then my other question is how often is it accurate?
Because typing hours for a team of five might be accurate 99.9%, but once you have a big team of 50 and you have to type 50 time cards, that is a good chance that you’re going to… So at that point I would be like, okay, let’s see if there’s an app for it that can automate the process. So our problem is that we’re manually entering something that, in my opinion, could be integrated or exported. So integrated means with a push-up button, it will pull the information or push the information so you don’t have to actually manually export and import.

Dr. Andy Roark:
Yeah, okay. Yeah, that makes sense. I love that you asked the question, am I the only one who can do it. So let’s jump back to my exercise. When I write down all the things I do, I put it in three columns, and the first is things that I love, meaning this gives me joy and I don’t want someone else to do it. And then things that only I can do. And then the last column is everything else. And I’m real picky about what goes into everything into only I can do. And then the other thing is if I don’t love it and it’s not something that only I can do, it’s a hundred percent on the table for automation or delegation. That’s why I make that list is so I can look and say, how do I get rid of this?
Okay. All right. So it makes sense to me. So the first thing is I’m doing this again, I’m spending time. Let’s look for an app, let’s look for a system that already does it. Are there guidelines that you put forward when… First of all, are there flags for when you say, I’m going to start looking for automations at this point? And then when you start to look, are there resources that you really like? Are there ways that you look at this? Help me sort of think strategically about how to start setting these things up. Because I’ll tell you this, my worry when you say, is there an app for it? I’m going another app and there’s a pit of having 85 different programs that do one little thing. So help me with that.

Mira Johnson:
So I like to start with the core. So in the veterinary practice, the core is going to be a practice management software. So I’m going to look at it and say, okay, is it going to integrate? If I’m looking for a solution that has something to do with the practice management software, if it doesn’t, it’s outside of it, then I will look at the current software that I’m using. So back to my example on a payroll, I’m going to look at the payroll software that I’m using. Am I happy with it? Is it fully automated? Is it giving me everything I need as far as the onboarding goes and stuff like that? And then I’ll look, does it have its own timecard that I can use because it would be already built in. Now, if it doesn’t, then I’m going to look at apps that integrate with this software.
And yes, there will probably be, like you said, 85 of them. So it is a bigger task than it looks like sometimes, but I am not saying you have to look at all the 85 of them. I’m just saying try to explore couple, do a demo and then see which one’s best work for you. So sometimes we get really bulked down by like, oh my gosh, this is overwhelming, there’s 85 of them, how am I going to pick? So I like to reach out to the communities and see, okay, what is everybody using, what do they like about it? What do they not like about it? And then I can find out like, oh, majority of the people were saying they’re using this but it doesn’t track the PTO or you cannot request a time off from this time card. Or it maybe doesn’t calculate overtime based on California rules because they’re complicated.
So I am trying to always ask multiple questions to kind of get in the detail of what that app will do and what it will not do. So unfortunately there’s not a perfect app for anything in my opinion. So there’s always going to be something that you’re going to be like, well, maybe I don’t need this. I really need scheduling. So this app does not have a scheduling, but I do want a scheduling, so I’m going to go with this one. Even though I might not be able to calculate the PTO based on accrued time worked. That will reset every year or some complicated… And maybe then I’m thinking, well, it’s probably a complicated PTO anyway. I should probably look what other peoples are doing and replace that policy. But that’s a side note.

Dr. Andy Roark:
Gotcha.

Mira Johnson:
When it comes to practice management softwares, I do like to look at how we can help our people who are… Inventory is always a big thing. So how can I manage inventory and automate that process? So at that point-

Dr. Andy Roark:
Sorry.

Mira Johnson:
Go ahead.

Dr. Andy Roark:
Take it back.

Mira Johnson:
So at that point, I will look at the practice management software and I said, okay, so my inventory is all the products that I have on the shelves and then all the products are coming in and going out, as simple as that. How can I automate the coming in and going out and maintain the count that’s in there? So I don’t have to count anything that will be automatically in the software. There’s so much good practice management software that have inventory module built in and there’s so little practices that are using that. So that’s another thing that I think when we come to software, we usually develop our medical side pretty good.
We create templates, we put all the products in there and then we don’t have time or we don’t understand how it works and we hope that somebody else might figure out down the road. So we just don’t put the inventory in there when we buy it. So it’s not accurate and it’s just disservice to our own records because now we have no idea how many products we have on shelves unless I walk into the practice and count them manually.

Dr. Andy Roark:
Yeah, that totally makes sense. Hey guys, I just want to hop in really quick and give a quick plug. The Uncharted Veterinary Conference is coming in April. Guys, I founded the Uncharted Veterinary Conference in 2017. It is a one of a kind conference. It is all about business. It is about internal communications working effectively inside your practice. If you’re a leader, that means you can be a medical director, it means you can be an associate vet who really wants to work well with your technicians. It means you can be a head technician, a head CSR, you be a practice owner, practice manager, multi-site manager, multi-site medical director. We work with a lot of those people. This is all about building systems, setting expectations to work effectively with your people. Guys, Uncharted is a pure mentorship conference. That means that we come together and there is a lot of discussion.
We create a significant percentage of the schedule, the agenda at the event, which means we are going to talk about the things that you are interested in. It is always, as I said, business communication focused, but a lots of freedom inside that to make sure that you get to talk about what you want to talk about. We really prioritize people being able to have one-on-one conversations to pick people’s brains, to get advice from people who have wrestled with the problems that they are currently wrestled with. We make all that stuff happen. If you want to come to a conference where you do not sit and get lectured at, but you work on your own practice, your own challenges, your own growth and development, that’s what Uncharted is. Take a chance, give us a look, come and check it out. It is in April. I’ll put a link in the show notes for registration. Ask anybody who’s been, it’s something special. All right, let’s get back into this episode.
So talk to me a little bit about areas of opportunity for most practices in their PIMS because you put your finger on something that I really liked and you kind of blew my mind. Absolutely, practices look at their PIMS and go, how do we get our medical records the way that we want, how do we get the patient care things set up and things like that. And there’s much less emphasis put on setting up the business side of the PIMS. When you think about how practices are using their PIMS, are there patterns that you see? Are there really area of opportunities that you see people missing a lot of times? Talk to me about that.

Mira Johnson:
Yeah, I think the biggest part is that lots of PIMS are now integrated with other softwares, so not just from the medical side. So I can see that some people are like, well, I know my lab does integrate, but I haven’t figured out the integration. It’s probably complicated and it’s not going to work. Or maybe they tried it and didn’t work the way they wanted, so they kind of dropped their trying. But at that point I would reach out to the vendor and sometimes it can be really frustrating because they’re like, “Well, it’s not working because the other software is not set up, so reach out to the other software.” And then you reach out to your PIMS and they’re like, “No, you need to reach out to your lab. They will help you set it up.”
So sometimes there’s the back and forth, which can be really frustrating, but that is one of the things that if you have to pull your X-ray from like a… That it downloads the image to your computer and then you have to upload it to your practice management software, that is repetitive task. How many times do we attach it to a different patient? How many times do we not attach it at all? Because we forgot and we open it and we discuss it with a client and then we didn’t put it in there. So I think those are the low hanging fruit that I think will save you time and it will get your accuracy rates up and other things there with the vendor’s integration.
So if I’m buying from a big vendor, I would like to look if they do integrate or if I’m using a platform that combines all the vendors and you buy from only that platform, you can also possibly integrate that platform. So every time when you purchase something, let’s just say I order a vaccines, and when the purchase order is placed inside of the practice management software and then you receive it inside of the practice management software, your quantities automatically update. Instead of somebody when the invoice arrives, they’re like, okay, we got the vaccine so there is 25 rabies and I will go ahead and enter them as received in the computer. Again, you’re receiving, putting in the computer while that can be done with one push of a button or sometimes automatically.

Dr. Andy Roark:
Yeah, no, that absolutely makes sense. I resonate with your point about… You talk to the PIM system and they say, no, it’s the lab and the lab is like, no, it’s the PIMS. And you go, ah, this is a slog. And that brings me to my next question. So sometimes we look at these opportunities for automation and you go, this seems like a headache. It seems like… You go, this is going to be a nightmare to figure out. And so there’s a time investment in setting this up. The other thing is when we talked about apps and you say, well, surely there’s a software that does this or a package that does this, why don’t I pay for those? So it’s a subscription package or it’s a purchase upfront or things like that. A lot of people that I work with, and I’ve had this problem before too, they have a hard time understanding return on an investment for automation or knowing what it is.
So if someone says, Hey, we’ll do this, but here’s the service and this is what it costs, and I go, am I better off doing that or am I better off doing the kind of broken around about like workaround that I’ve done in the past? Do you have a way of looking at automation where you do return on investment calculations where you say, this is worth X dollars and I’m willing to pay for this service? Or is it sort of a gut feel for you where you try to say, boy, I really don’t like doing this, so I’m willing to pay more. Talk to me about calculating return on investment before you go in on automation. Because you’re going to get pushback when you say, Hey, I want to do this differently. And the regional director or your manager, whatever your field leader says, nah, I don’t know that if that makes sense to make that purchase. How do you look at those things?

Mira Johnson:
Yeah, I think if there’s an easy way to calculate the time that you spend on it, that’s probably the easiest way to convince somebody that it’s much easier to just pay for the subscription, then do it yourself. So for the payroll runs, that’s easy because you can be like, well, it takes me 30 minutes to run payroll for 50 people. It can take me five minutes to do that if everything is aligned. So you can put a price tag on that one. Now, on the little things like the uploads and downloads and stuff like that, that’s really hard to calculate the time. I mean you can, but it’s kind of nitty-gritty and it’s like, well, it took you only two minutes this time and then it takes you 10 minutes because you can’t find the file because somebody downloaded and changed the destination folder.
Oh, who was it? Oh, man. Anyway, so I just always say how about… Some of them come with a free trial, which is a nice kind of a hook because you get hooked on it and then you are like, I am never going back, torture me how much you want I don’t want to go back. So I would say take the trials. As far as calculating the return on investment, look at what else can you do with that time that will save you. And sometimes, especially like you said, the new forms for the new client, I think that’s not just… The things is that it’s not just your time, but it’s also the client time. They have to wait for you to put it all in while they can set it home, typed it in, and then it appears magically on your site. So I think the calculating the cost versus ROI is it can be tricky. So sometimes it’s easier to just jump in, take advantage of the free trial and then say it, did it really do what I wanted to do?
Because I think we get bold kind of with, oh, this looks great, this is all new shiny new thing that I can automate. And then you realize that you are spending more time on trying to make the app automated and work than it’s worth or which I see this a lot, is you just didn’t set it up right.

Dr. Andy Roark:
Yeah.

Mira Johnson:
So we are so excited. This is thing, like the practice management stuff, we’re so excited we get everything up and running and then we just don’t finish or we set up wrong because we don’t know what we’re doing. So we’re at this point like, oh, I don’t want to hire somebody who understands this. All the softwares usually have some kind of learning specialist or consultant that they can… It’s either free you or it’s a paid service that they can help you with. And I think those are the best money you’ll ever spend because you’ll never have that problem.

Dr. Andy Roark:
Yeah, yeah, that makes a lot of sense. I want to unpack that a little bit more. Are there pitfalls that you see practices fall into with automation? And so if someone’s like, I want to make my life easier, I really want to jump into this. And you’ve already touched on a couple of them I think as we go along, but can you put a bow on it for me? What are the pitfalls that practices fall into when they set out to try to automate some of their workflow?

Mira Johnson:
I think the biggest pitfalls is that you don’t set it up or you don’t set it up at all. So you just hook the apps and hope for the best. And sometimes we don’t check if it’s working. I had people who are like, “Well, it does integrate.” And I’m like, “I don’t see the result of the integration. It’s not appearing in your software.” “Well, it’s been set up a year ago, it’s working.”
It’s not. So we don’t check if it’s working. We just invested the money and we hope for the best, seems like at sometimes. And another pitfall is I think that we don’t realize the impact that it might have an overall team morale, so there’s all these things that we don’t see and can’t really put a price tag on. We just recently had at the beginning of the year two clients that they were trying to roll out their 401K. So there are fairly new practices and they’re both excited and we always push our practices that they’re doing well that first thing, you should take care of your people and 401K is a great investment for their future and it doesn’t cost that much money for you as a practice owner to do those. So the benefit is huge for both parties in my opinion. And so they both approach differently.
One went with an app that integrated, so the retirement plan was created, that you didn’t even know it was created, you pretty much just click a button and it said, okay, what kind of plan do you want? Talk to the specialist. And then it was created in the background electronically and when the time comes that the people were eligible, the system looks into your payroll system at the days that they were hired, make sure they work the amount of hours that they are supposed to be eligible and then it automatically just shoots them an email. And when the email was sent, I just said, Hey, you’re eligible to participate in 401K for a Fluffy and Duffy company and we would love you to participate and you can do it on your phone. So if a click of a button you are like, yeah, I would like to enroll, or you can say, no, I don’t want to.
And then it usually asks you, why don’t you want to contribute? And you’re supposed to answer it, which is kind of cool because you get a little feedback on why you’re not going to participate. And the second practice… Oh, so let me finish that one. So once they click on it automatically opened their account because it had all their social security, everything was in the background already tied up. So it was super easy to enroll, very easy. Now, the other practice, what they did is they went in a traditional way. So they found the plan administrator and then the… What is it called? The other party that helps you set up the… There’s a compliance and anyway, there’s two different companies that you usually have to hire. And then the broker came and talked to every employee and explained how important their retirement is. Left them a booklet with a link to the page where they can enroll enough. And off they went. So at the beginning of the year, the first practice that did everything integrated, they had 87% of enrollment. The other practice had 19% enrollment.

Dr. Andy Roark:
That’s amazing.

Mira Johnson:
And they were thinking, well, yeah, they just don’t want to participate. And I’m thinking, yeah, if you can’t do it on your phone, especially for the young crowds, I’m not going to do it.

Dr. Andy Roark:
Yeah, that’s interesting. Yeah, that makes a ton of sense. I have to sit with that a little bit. What does it mean if you can’t do it on your phone, we’re not interested in it? I think that that’s true and I think that that’s a lot of where education is going. And then also I just hadn’t really stopped and thought about as far as employee participation in programs and things like that. All right. This is interesting. I got a lot to sit and think about here. Mira, thanks so much for being here and for talking through this with me. I really, really appreciate it. Where can people find you online? Where can they learn more about JF Bell Group?

Mira Johnson:
Yeah, our website is cpasforveterinarians.com or jfbellgroup.com. And you can find us on social media LinkedIn, Instagram, and Facebook. And if you are looking for a place to start as far as your integration process goes, I always encourage people to reach out to their vendors. So if you have a practice management software rep, reach out to them and said, what are the best practices. Be part of communities like maybe VHMA, Unchartered veterinary community where you can talk to people and see what they’re doing. And I always say, don’t settle for the best practices. Do your own research after you are already in the app and you were integrated and said, what else can I do? How else can I make this better and efficient? Because I think it’ll save you so much time.

Dr. Andy Roark:
Oh, that’s so great. Thanks so much for being here. Guys, thanks for tuning in today. I hope you enjoyed it.

Mira Johnson:
Thanks, Andy.

Dr. Andy Roark:
And that’s it guys. I hope you enjoyed it. I hope you got something out of it. Thanks to Mira for being here. Gang, if you enjoyed the episode, let me an honest review wherever you get your podcast, share it with your friends. I always appreciate that type of support. It’s how people find the show and it just means a lot to me. Gang, take care of yourselves. Be well. I’ll talk to you soon. Bye.

Filed Under: Podcast Tagged With: Life With Clients, Team Culture

Representation and DEI in Practice

March 23, 2023 by Andy Roark DVM MS

Dr. Niccole Bruno joins Dr. Andy Roark to talk about an outstanding event she put on at the VMX conference, A Day in Veterinary Medicine, and her company Blend.Vet.

Niccole discusses the “pipeline problem” in veterinary medicine, and the lack of progress we have made (compared to the aspirations of our schools and profession, at least). She talks about what representation and inclusion look like in our education process and also in our practices.

Andy and Niccole talk about the intersection of DEI and hospital culture, and the opportunities for growth commonly found in veterinary clinics.

Finally, Niccole lays out some clear action steps that practices can make to improve their culture and support equity and inclusion in our profession.

Cone Of Shame Veterinary Podcast · COS – 190 – Representation And DEI In Practice

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

LINKS

Blend – DEIB Certifications: https://www.blend.vet/

Pawsibilities – https://www.pawsibilitiesvetmed.com/

PRIDE VMC – https://pridevmc.org/

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. Niccole Bruno is the CEO & Founder of blendvet, a veterinary hospital certification program in diversity, equity, inclusion and belonging (DEIB). She became interested in veterinary medicine as a child but lacked mentorship until she attended Tuskegee University for her undergraduate studies. Seeing representation and receiving support from her professors and classmates made the dream of pursuing veterinary medicine a reality. She attended Cornell University for veterinary school and along with her classmates became the founders of VOICE, a student organization to promote and celebrate diversity and inclusion. VOICE is now a national veterinary student organization and has since changed its name to Veterinary Students as One Inclusive Community for Empowerment. Dr Bruno graduated from Cornell University School of Veterinary Medicine in 2006.

Dr Bruno has practiced in small animal medicine and surgery for over 16 years, both in NYC/Long Island and Houston, TX. She has served in hospital leadership roles for over eight years. Dr Bruno realized the value leadership has in creating a diverse and inclusive hospital culture. As Medical Director, she became intentional in recruitment and retention of diverse individuals while creating a space for them to thrive. She continues to pay it forward by dedicating much of her time to speaking and mentoring students from all stages of the pipeline to increase representation for Black, Indigenous and People Of Color (BIPOC) students into the profession.

Following completion of the Purdue University Diversity and Inclusion certificate program in 2020, her awareness, continual exploration, and study into the diversity deficiencies of our profession, ignited her vision to create blendvet. Dr Bruno hopes that blendvet can be transformational, creating a space for collaborative learning for individuals and teams in diversity, equity, inclusion and belonging (DEIB). Through blendvet, Dr. Bruno will be executing pipeline programs at veterinary conferences to help promote and advance veterinary medicine for underrepresented students.

Dr. Bruno currently remains a member of the Cornell University Advisory Council, serves as an Advisory Board member for Pawsibillities, a mentorship platform and is a facilitator for MentorVet. In her spare time, she enjoys activities with her husband and two children, Cole and Addison. She loves traveling, her Peloton, football and binge-watching her favorite shows. She has a 15-year-old Shihpoo named Jimmy Choo and a Siamese mix cat named Sushi Roll.


EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:
Welcome everybody, The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I got a great one today with Dr. Niccole Bruno. She is the founder and CEO at blend.vet. We are talking about a really fascinating program that she did at VMX this year. We are talking about what Blend’s DEI certification for veterinary practices look like, and we talk about how our profession is moving forward and increasing the diversity that we have. Guys, super thought provoking episode. Niccole is amazing. You guys are going to love meeting her. Gang, 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. Niccole Bruno, thanks for being here.

Dr. Niccole Bruno:
Thank you for having me. I’m really excited to be here.

Dr. Andy Roark:
It is my pleasure to have you. Every year I go to the big conferences, so VMX and Western, and I meet somebody there who blows my mind. And at least one person, sometimes multiple people, but you are that person for me this year. I was so glad to meet you in person. I am so interested in what you’re doing and the energy that you have. And just I’m so happy to talk to you and so I appreciate you making time. I’ll tell people the story of how we met. We met at VMX and we were at a reception and there were a bunch of people there, and I had been there for a while. And someone was like, “Oh, you have to meet Dr. Bruno. You have to meet Dr. Bruno.” And I said, “Oh yeah, okay, absolutely, I’d like that.”
And so I met you and you were amazing and you were telling me about, it’s called A Day in Veterinary Medicine, which is a program that you ran at VMX, which is phenomenal and interesting and we’re going to talk about it a second. But you were telling me about that and we were talking. And while we were talking, these other people came over and they stood off to the side, which is not unusual and I’m just going to be…
False modesty aside, it’s not unusual for me because people will… especially at receptions of that conferences. People will come up and they’ll stand there and they generally like to say hi, or I’ve met them at places before and things like that. So you and I are talking and we come to this natural pause point and so then I turn to them and I say, “Hey.” And they’re like, “Hey.” And then they step between us with their back to me and they’re like, “Dr. Bruno, you’re amazing. I was in your lectures today and you are incredible.” And I didn’t catch my face in time, so I think I made that what just happened face.

Dr. Niccole Bruno:
I probably had the same face because I am… I’m not used to that. I’m like, of course they’re waiting for you. Why would they be waiting for me? I didn’t even see them because they were standing behind me. But yeah, that was… I was like, “Wow, what a way to meet Andy today.”

Dr. Andy Roark:
It was awesome. It was awesome because I was like, “Oh my God, she’s amazing. And other people recognize that she’s…” I’m clearly late to the game on the Niccole Bruno train. And it’s just like… It was awesome. But the enthusiasm they had coming up to you and the energy and the questions they had, and I was just like, “Oh man.” You’re doing stuff Niccole. You’re doing stuff that matters that people are getting really excited about. And so I left that conversation with such a full heart going, “This is awesome. She’s doing great things and people are seeing this.” And I felt so good talking to you. So that just made me so, so happy. And so anyway, I really wanted to have you on the podcast and I really appreciate you being here.

Dr. Niccole Bruno:
Well, thank you. And like I said, I think I’m trying to get used to that because it’s been two years of me really pushing this agenda in diversity, equity, inclusion in med. And so it’s surreal when those moments like that happen. But VMX was definitely… I know we just started 2023, but it was a fave so far. It was a really good conference.

Dr. Andy Roark:
Well, you got to hold onto that. You worked so hard. It’s so obvious. And we’re going to talk about what you’re doing at Blendvet and your other initiatives that you do. You work so hard. Hold onto that. When people come up and say, “Ma’am, what you said was really impressive, and really important to me and it mattered to me.” We call it holding the trophy at Uncharted. We hold the trophy. So you got to hold that trophy because you’re doing work that’s impacting people. So let’s start off. Before we start talking Blendvet, talk to me about a day in veterinary medicine. So I went there and I hadn’t heard much about this program and then in retrospect I look back and I was just fascinated. Can you just lay out… First of all, lay out the idea where it came from and then how the event went down?

Dr. Niccole Bruno:
Yeah, sure. So last year 2022, I was at VMX and it was the first time that I had been there for a while, so I forgot how large that conference was. And then especially post-Covid, it looked a lot larger because we had been hibernating for two years. But I went there and I realized that this pivot that I was making in my career meant that I was going to be in the speaker circuit a lot more. And VMX is held on MLK weekend every year. And historically, I’ve done community service during MLK Day because I feel it’s important. And I realized that I was never going to be home if I was going to be stepping into this speaker circuit and thought about the fact that we were sitting in Orlando during MLK Day and there was an opportunity to give back to the community of Orlando.
And for me, pipeline events or programs have always been very important to me. I’ve wanted to be a vet since I was 12 years old. And even growing up in New York City, there weren’t a lot of opportunities for me to pursue or get that exposure representation in veterinary medicine in those young age. And so I thought it was definitely an age group that we needed to target. And I thought about how it would be great if we could bring the students to the conference and let them get a chance to see us in our realm, so to speak, as opposed to me historically going to schools with all of these props for career day.
So I just pitched the idea to NABC and I said, “Let’s do a believe and belong in veterinary medicine and let students in underrepresented areas in Orlando come to the conference, and I will put together a faculty of amazing veterinarians and technicians throughout all of the diversity that we offer as veterinary professionals, dermatology, surgery, emergency medicine, and general practice. And let the students rotate through these workstations. Let them hear from us and how our journey was into vet med. Let them know that no two journeys are alike.”
And my younger sister’s also a vet. And even growing up in the same household, we have two completely different journeys in vet med. So I leveraged the team that I have as friends and colleagues and we put together this program. And then another important part for me was also allowing the parents to see what their role is in supporting students. I don’t think I could have made it in this profession without my mom who really found opportunities for myself and my sister when there were none. And so wanted her and give her trophy, so to speak. And she spoke with the parents and let them know this is how we as parents can support students into vet med.

Dr. Andy Roark:
What does your sister do?

Dr. Niccole Bruno:
So my sister is a veterinarian. She works for the ASPCA, she does forensics.

Dr. Andy Roark:
That’s amazing. That’s so great. Let’s start to unpack this a little bit. So I’m really interested in the profession as a whole. Diversity pipeline for our profession is something I’m really interested in. I think representation is really important. I think one of my positions is if we want to be the trusted voice of pet owners, then we need to represent pet owners and they need to see themselves at us. And that’s just a big part of us being approachable and building those relationships that we need to have. And so representation, I think it really matters even if you zoom all the way into just getting care for pets, there’s a big piece of that there. Can you give me your perspective on what the pipeline looks like in vet medicine right now, and just start to unpack where we are in terms of representation in the profession and how we’re doing as far as trying to increase our diversity?

Dr. Niccole Bruno:
Yes, I could definitely can. So over… I’ll start where we are currently. Right now as a whole is according to the US labor and statistics. In 2021, we were 93.3% White. Less than 2% are Black veterinarians. Less than 5% are Latinx, and less than 6% are Asian. So overall, less than 10% of veterinarians are diverse as far as racial ethnicity. So when we think about how does that go backwards into the veterinary schools currently, we’re still not seeing… although we’ve had an increase of applicants of… I’ll say the word BIPOC, but it’s Black, Indigenous, People of Color. We’ve seen an increase in those applicants, but we are still not seeing overall an increase in the representation of veterinary students. So according to the AAVMC in 2024, we were still about 75% White as far as veterinary students. So then we go back further into the pipeline where we’re going into colleges. And at a time… And again, these numbers are not new.
This has been going on since I was in vet school. But currently we are going to see a dip from the pandemic. We’ve seen a lot of students that have had to drop out of school, especially for due to socioeconomics or there has been an increase in BIPOC students that haven’t been able to remain in undergraduate enrollment and men. So again, in a profession that’s predominantly women, that’s another factor that hits us from a level of diversity. So we’re seeing this in real time happening. And of course if these students are not in the undergraduate pipeline, they certainly aren’t going to be applying to vet school, which is going to further widen that gap. So pretty much pipeline development is understanding that we need to find the source of where the problem is. And it’s really in all the stages of the pipeline, because when you go backwards even to high school or even into junior high school age years, there’s a problem with students may not be able to get at jobs or get opportunities to get exposure in junior high school to stay in the pathway into vet med.
Their high schools may not have support in as far as programming for them to be exposed to agricultural programs or veterinary medicine in high school. So then when they get to college, they have no idea about what it takes to be a veterinarian and how to start. And although we know that you can major in anything and get into veterinary school, we’re asking these students to dig deeper and see that they can be a psychology major and then go to vet school too. So the opportunities to support students in every stage of the pipeline is critical if we’re really going to be intentional about seeing our demographics change. And historically we haven’t been. And that’s why I’m really trying to shift the conversation to what can we do, and take advantage of the things that we already do well at. We have conferences every year, multiple conferences.
There’s an opportunity for us, especially when we are in the same city every year, to really start a program that allows students to grow with us and see how they develop into our profession. Even if they decide vet med isn’t for them, that’s a win too, right? Because we want people to really know and want to join this profession. But the hope is that by not only exposing them and then showing them what support can look like, because there’s so many people doing amazing work for pipeline that I’m still learning to this day. And it’s a great way to highlight where those places are to be able to guide these students to find them and continue their journey into vet med.

Dr. Andy Roark:
Yeah. I love your focus on pipeline and it makes a lot of sense to me. Can you go ahead, and let’s step to the side for a moment. When I sort of brought you on, I introduced you as amazing. But I didn’t lay down the fact that you’re practicing veterinarian, you’ve been a veterinarian for 16 years, you graduated pretty much when I did from school. And gosh, you’re a person. So you practice. You are a member of the Cornell University Advisory Council. You serve on the advisory board for Pawsibilities, which is a mentorship platform.
You’re a facilitator for MentorVet, which is the company that Dr. Addie Reinhardt runs and I’m a huge fan of hers. You just do all of these things. And you’re also the CEO and founder of Blendvet. And I want to start to talk about Blendvet a little bit. And so these are all the things you’re doing and you have this emphasis on pipeline, which I think is amazing. I want to come back to in a moment. Can you step over just to the side for a second and talk to me a little bit Blendvet and what your company does, what you do over there?

Dr. Niccole Bruno:
So a lot of what… My goal with starting Blendvet was to create a veterinary hospital certification program in diversity, equity, inclusion, and belonging. That stemmed from being a veterinary leader, because I used to manage veterinary hospitals, and seeing the values that leadership can display to create environments of inclusion in vet med, and realizing that if we are good as a hospital culture, that just mirrors into how we interact with community. So I felt like that was a way for me to really bring in and emphasize that training in DEI needs to be for all roles in a hospital because we all contribute to culture.
When I started to talk more about the reasons why we needed to improve our culture, why we needed to focus on all the roles in the hospital getting this training and creating a certification so that not only can our clients see that, “Hey, that’s a Blendvet certified hospital. I know that I could be welcome there.” But also our future colleagues as they’re joining, or even people that are looking for jobs as we speak, know that they can find a place or a workplace that they can thrive in.
And that was very important to me because I had been seeing so much of burnout from my colleagues, and I remembered times in my career where I was burnt out and it was usually when I didn’t feel included, when I didn’t feel like I belonged or I fit into places. And a lot of this stemmed from usually being the only person of color in that practice. I’m biracial, my mom is black, and my father’s Colombian. So I used to struggle on both sides when I would see our inability to engage with our clients because we didn’t speak the language. And I would try my best to speak as fluent in Spanish as I can, but also just seeing the disconnect in how we engage with our clients of color and wanting to do more. And so my goal with Blendvet was to create that opportunity so that we could learn how to be better together, but also be better for our clients.
And when I started talking about Blendvet more and more and more, my door opened more in veterinary students. Academia asked me to come and talk more about it, and I started to hear more from the vet students that these were topics that weren’t discussed in vet school, and this was information they wanted. These were experiences that they had already witnessed, either from their experience hours getting into vet school or as they were navigating clinical years. And in my mind, when I created Blendvet, I knew that I wanted to go backwards into vet school, but I needed to stay in the lane that I had been in for 17 years, which was practicing medicine.
And so I started there, but when the vet school doors opened, I jumped in there. And now we’ve started to do training within certain veterinary schools, whether it be their faculty training or the veterinary students themselves through lectures. And we are also still proceeding with our hospital certification program as well, which is what we’re starting this quarter. We’re going to be working with Rarebreed Veterinary Partners, and I’m really excited. We start next month. So when you say I’m busy, I’m like, “Ugh, that’s an understatement,” because it’s like I am… it’s surreal because this is what I’ve wanted and it’s happening in real time. And I’m excited. I’m excited for what it can bring. And then the pipeline was just literally the cherry on top. That pipeline event was everything.

Dr. Andy Roark:
Yeah, so you just get me so excited but also tired. You get me excited and tired. Because-

Dr. Niccole Bruno:
I’m tired. Yes.

Dr. Andy Roark:
Well, of course you are. You’re working across… It’s a massive problem. It’s a massive problem. And you have integrated yourself into all these different places and just in our short conversation, you can already see how you’re putting the pieces together, which is… this is why I think you’re so fascinating and I’m such a big fan of what you’re doing. But you’re like, “Okay, well obviously we start at the pipeline, and we talk about bringing people in. And then we need to attract these people, and we need to retain these people, and we need to make sure these people succeed and grow. So we’re starting to figure out how do we adapt culture that we have, which is a White culture. How do we adapt that so that it is inclusive and people can feel comfortable and they want to be a part of the culture that we have.”
And so you’re laying down all of these pieces and it’s really this ecosystem of how the individual pieces clicked together and work. But you’re clearly thought about this a lot as far as where are the biggest priorities and what needs to happen in order to build long-term success. And so I love how you think. I love how strategic you are about this and I love the fact that you’re very action oriented. And so it doesn’t surprise me at all that you’re working with students and that they really want to hear what you have to have to say.

Dr. Niccole Bruno:
Yeah, it’s been very, very rewarding working with the students. They’re a reminder, right? Of what we want.

Dr. Andy Roark:
Aren’t they wonderful?

Dr. Niccole Bruno:
Yeah. Yeah, they are.

Dr. Andy Roark:
Hey guys, I just want to hop in really quick and give a quick plug. The Uncharted Veterinary Conferences coming in April. Guys, I founded the Uncharted Veterinary Conference in 2017. It is one of a kind conference. It is all about business. It is about internal communications working effectively inside your practice if you’re a leader, that means you can be a medical director. It means you can be an associate vet who really wants to work well with your technicians. It means you can be a head technician, a head CSR. You can be a practice owner, practice manager, multi-site manager, multi-site medical director. We work with a lot of those people. This is all about building systems, setting expectations to work effectively with your people. Guys, Uncharted is a pure mentorship conference. That means that we come together and there is a lot of discussion. We create a significant percentage of the schedule, the agenda at the event, which means we are going to talk about the things that you are interested in.
It is, as I said, business communication focused, but a lot of freedom inside that to make sure that you get to talk about what you want to talk about. We really prioritize people being able to have one-on-one conversations to pick people’s brains, to get advice from people who have wrestled with the problems that they are currently wrestled with. We make all that stuff happen. If you want to come to a conference where you do not sit and get lectured at, but you work on your own practice, your own challenges, your own growth and development, that’s what Uncharted is. Take a chance, give us a look, come and check it out. It is in April. I’ll put a link in the show notes for registration, ask anybody who’s been, it’s something special. All right, let’s get back into this episode.
The vet students are always… I get so energized when I work with vet students because they’re excited about the profession. They see these endless possibilities and they’re ready to go and they want to change the world and change their profession. And I always leave the vet school so fired up because they’re inspiring in a fresh eyed look at what we’re doing, and they just remind you how awesome our profession is. So can you talk a little bit about this? I want to hear more about the certification. So you said, we talk about having all rules in the hospital trained in DEI. Talk to me about what that looks like. So if a practice owner said to you, “Hey, you know what? I’m interested in this. Help me understand what my people would learn.” What is valuable knowledge for them even look like? Because most of us, we’ve never had anything like this. We don’t really know what that is. So can you start to help me see that picture?

Dr. Niccole Bruno:
Sure can. So first thing that I felt was really, really important was having it on an LMS where we had an opportunity to take it at our own pace because we’re busy, and so we can’t really… it’s really hard to collaborate, get everybody in the hospital together at the same time, it’s like… I remember having luncheon learns and right when the rep is about to start, you have that emergency come in or the phone call. So it’s really hard to have that timed learning opportunity. So they will be asynchronous modules through our LMS. But before that, we have our hospitals take our Blendvet culture assessment and we have developed an art to what we think would be the right way to assess culture and from a hospital’s perspective, but any workplace actually. And then once we get the culture assessment, then we meet with the leadership team and we present the results and we create a workshop of like, “This is some areas that we feel need to be focused on.”
We really need to emphasize training. And it might be we need to be better at knowing what our biases are. We may need to look at allyship a little bit better. So that’s a way that we can get live training, right? And then just get that connection with them, understand maybe stories or situations that have happened to really feel like they’re not in this alone. And then afterwards we introduce the staff, and with now the leadership knowing their role in supporting their staff through their LMS, and they will go through modules under each element or value of blend. So I didn’t really mention what Blend stood for, it’s not an acronym, but the Blend itself stands for the values of what I feel create a great hospital culture and that’s one of the inclusivity. So B, stands for building relationships. So how do we build these relationships with our team, realizing communication looks different, how do we lead?
So leading with empathy, with vulnerability, which I felt was very, very important, especially during the pandemic. It was a skill that not every leader had and it definitely drove the difference in how cultures responded or how our staff responded. Education and equity are the ease. So understanding that we need to create equitable environments, but also we need to constantly seek education. It’s not a one and done. DEI is constantly evolving. And so understanding that this is an opportunity to take that first step into the journey of DEI. N, stands for navigating the unknown. So those are the things that everybody just wants to avoid. And unfortunately those are the things that really start the toxicity in a hospital culture, the things that we avoid. So how do we handle difficult conversations? How do we handle when current events are going on and they’re affecting groups of people that we don’t even know how to start having those conversations.
But if there’s a foundation of trust, if we’ve had that relationship, it’s easier to have those conversations. And then D stands for diversity, inclusion and belonging. It’s understanding that all of those pieces is what helps not only create an environment where we feel safe to come to work, but we perform better, we thrive better, we get things done faster together. And so all of those elements have modules. So all the values have modules underneath them. And what I’ve been doing over the last two years is really identifying people in the industry that are passionate about DEI, but speak to a certain topic related to those modules. So we have the great Mia Carey that talks about allyship and she’s the CEO of PrideVMC. So she really lays the foundation of what that looks like as an ally. But we also have people of the LGBTQ plus community talking about what it’s been like to be in their shoes.
One of a module that went really well in our academic launch was our module with Christina Wetzel. And she spoke about what it’s been like to be deaf in our profession, and not only as a technician, but now as a veterinary student and ultimately what it will be like as a veterinarian. And so what I’ve found is that when we need to learn about DEI. Yes, the definitions matter but how they make people feel, the application part, the lived experiences, that’s what you don’t get from reading in a textbook, or how does this apply to my life and how can we make it better so that we don’t have others in our hospitals or as our clients feel this way? And so when I speak, I usually lean on experiences that I’ve had happen to me where I’ve been marginalized or a client didn’t want me to do surgery and what that felt like, but also put it back on what should leadership have done in this moment?
What should we as a hospital have done or had in place so that our colleague didn’t feel marginalized, or that we wouldn’t allow this client to come back through our door again? Or what do we have in place so these clients know this is not the way to behave because we are not going to tolerate it. These are all the things that my hope is Blend will have people start thinking about. My goal is not to tell you how to run your hospital, but it’s to give you that framework, those bones, so that you create your blueprint of like, “This is the communities that we work with. This is what we don’t have. We need to hire to fill in that gap so that there are no language barriers.” So that’s the purpose of Blend. So they go through these modules. There’s reflective activities, there’s opportunities for the hospital to partner with Blend to have a facilitated conversation to really tie in the module together.
And then to become certified, we ask hospitals to do some community service, which is why the pipeline events really are helpful for me to let them see how we can do that very easily. But also internally, what are you going to do in your hospital to make it better for your staff, for your clients that come into your doors? And that can be what they deem is the next best step for them, by putting that all together and really making a commitment to that educational process and that evolution and then actually creating the actionable step, because… You’re correct in that, I’m very action oriented. Doing-

Dr. Andy Roark:
Yeah, I love it.

Dr. Niccole Bruno:
… that is what makes you a more of a Blend certified hospital and because you’re taking the next step.

Dr. Andy Roark:
Well, as you lay this out, the commitment to service. And you and I talked about that when we first met, and you had mentioned about service and how it fit into your dream for Blend as well. And we start with this conversation in the pipeline and then we go with it, and we talked about service and then how that feeds back into this pipeline and go, “God, Niccole, you’ve built this beautiful thing.” It makes sense and it works. And I’m just… Anyway, I keep saying how impressed I am. Well, it’s-

Dr. Niccole Bruno:
Thank you. I appreciate it.

Dr. Andy Roark:
So let me ask you this. So we’ve already sprawled across every aspect of practice from recruiting at the undergraduate and pre undergraduate levels all the way up to practice leadership. And it’s like, this is a broad swath here. So it’s clear that you think it at a high level and you think about the profession as a whole. If you were queen of veterinary medicine for a day, what would you be your worst, the profession? So like a magic wand and say, what would you like to see? How… Again, magic wand in hand, how would you love to see our profession mobilize in order to increase diversity, equity, and inclusion? Are there specific steps or areas that you say, I would love for us to focus on these areas or to see these types of actions? What would that look like?

Dr. Niccole Bruno:
I think it’s a combination of the training part of wanting to be better for who we are serving right now. But I also think it’s a part of understanding that you have to give back. And I know that it’s hard for us sometimes because we are very… we’re pet centric, right? We are veterinarians, we want to take care of the animals, but the animals belong to the people. And if the people aren’t on board in connecting with us or understanding the health concerns of the patient, we’re not getting the compliance and the pet is not getting better. So it’s a whole circle of life, so to speak. For me, I want my colleagues to, again, like I said, I’m not trying to tell them what to do, but I want to give them opportunities to fit in with what makes sense.
What’s your niche? Some people are really great with working with younger kids. There are programs that exist for K through four. There’s programs for junior high school age. There’s programs for high school. Challenge your veterinary schools of what are we doing to improve pipeline? Do we have a program in place? How can I help? Pawsibilities. You mentioned I’m on the advisory board. It’s a great opportunity for people that may not have the time to show up during the day, but it’s a way to virtually support a student that might want to enter it. I think that if could wave my magic wand, it would be to ignite in all of my colleagues an opportunity to do bee of service, not just for what we do daily, but to think about the pipeline and think about the future of our profession.
And I know… And it’s like I said, it looks differently for different people depending on their skillset. Mine is definitely pipeline development. My sister, just to throw her out there, she is very passionate about access to care. That’s been her pathway into vet med with the ASPCA. And so I tell her all the time, “When you’re finished with your master’s program, come on down and let’s create an access to care event for…” But the point is that we all have an opportunity to step into that service mindset and give back. And I think that that’s ultimately what I would do if I was queen of vet med for the day.

Dr. Andy Roark:
I love it. Yeah. Tell me a little bit more about Pawsibilities. It’s not a group I know a whole a lot about.

Dr. Niccole Bruno:
Oh, yeah. Well you should totally have Dr. Marcano on. But Valerie Marcano is someone that I feel like we probably are sisters on vet. But we have a lot of… She actually knows my sisters, so we call ourselves sisters. But she went to Cornell for undergrad and went to Georgia and during the… they had a hackathon at Georgia and her husband, who was the co-founder for Pawsibilities, they pitched a virtual platform opportunity for underrepresented students to learn about veterinary medicine and all of the ways to support them through pipeline development. So it’s an opportunity, if you wanted to join Pawsibilities, you could go to pawsibilitiesvetmed.com, and there’s a way that you can sign up as a mentor or you can be a mentee. But either way, you would be having to take a… about an hour and a half, course in what is the role of a mentor, what is the role of a mentee, what are barriers that students that are underrepresented may encounter?
So you have a little bit more knowledge base about it. And then once you’ve passed the test and you’re in, it’s almost like another social media group where you can see what other students… they can ask questions. There might be somebody in Alaska saying, “I really want to do marine biology. How do I start?” And somebody that is in that industry can come in and counsel them offline, on an email or they can connect with that person and really start a relationship that consists of a mentoring mentee type of relationship. So it’s allowed me… sometimes I’ve had students reach out to me to ask me about things knowing that I’m from New York, what opportunities or what hospitals did you shadow at? And sometimes I’m like, “Well, you know what? I have a sister who’s a vet that lives in New York, so I can connect you with her.”
So sometimes I am a connector and sometimes I’m giving the advice. But especially during the pandemic where people couldn’t get experience hours at hospitals, it was a way to support students that really didn’t know where to start. They were isolated from school, they didn’t know what to do. So it was a way for us. And Pawsibilities does sometimes monthly workshops to help students with the application of vet school, or just scholarship opportunities. So either way, it’s just a way for us to give back if we don’t have the time as far as showing up at an event. But we can do it off hours because you can always answer an email at any time.

Dr. Andy Roark:
Oh yeah, that’s great. Where can people find more about you? Where can they more learn more about BlendVet?

Dr. Niccole Bruno:
So definitely head to my website, www.blend.vet. We have so many opportunities for you to learn more about the program, but also just the resources that I have held during my journey into this DEI space of what’s helped me, certain books, certain podcasts. So it’s a way that we’ve just tried to condense that information. And if anyone is interested in learning more about the hospital certification program or just outside speaking events, we can always sign up on our wait list and then somebody will get back to you. But we are hoping to continue our work showing up at conferences and providing some DEI content there. So that’s another way to meet us as well.

Dr. Andy Roark:
That’s fantastic. Dr. Niccole Bruno, thank you so much for being here. Thanks for all the work that you are doing in our profession. I am so glad I got to meet you and talked with you. I can’t wait to get to talk with you more in the future. Guys, thanks for tuning in today.

Dr. Niccole Bruno:
Thank you so much for having me.

Dr. Andy Roark:
And that is what I got for you guys. I hope you enjoyed it. I hope you got something out of it. Thanks a lot to Dr. Bruno for being here. I’ll put a link to blend.vet down in the show notes. You guys can check that out. As always, if you liked it, if you got something out of this episode, please leave me an honest review wherever you get podcasts or share it with your friends, or you just want to try to get the word out and help people find the work that we’re doing here on The Cone of Shame. Anyway, guys, take care of yourselves. Be well. I’ll talk to you later on.

Filed Under: Podcast Tagged With: Team Culture

The Future of Independent Practice Ownership

March 16, 2023 by Andy Roark DVM MS

The days of veterinarians owning the majority of veterinary practices seem to be permanently behind us. Does this mean that practice ownership by veterinary healthcare providers is coming to an end? Economist Dr. Matthew Salois joins the podcast to discuss the future of ownership and equity in veterinary medicine.

Cone Of Shame Veterinary Podcast · COS – 189 – The Future Of Independent Practice Ownership

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

LINKS

Veterinary Study Groups: https://www.veterinarystudygroups.com/

Uncharted Veterinary Conference: https://unchartedvet.com/upcoming-events/

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Matthew Salois, PhD is currently the President of the Veterinary Study Groups, Inc. (VSG), where he is responsible for enhancing the economic and cultural success of more than 1,800 veterinary member practices.

Most recently, Matt was the chief economist and head of the veterinary economics division at the AVMA between 2018 and 2022, where he applied his skills in economics, business, and communication to support the daily lives of veterinarians.

From 2014 to 2018, he served as director of global scientific affairs and policy at Elanco Animal Health, supervising a team of scientists in veterinary medicine, human medicine, animal welfare, economics and sustainability. His group devised and executed scientific engagement strategy, and built collaborative partnerships with universities, non-profit associations and scientific societies.

Matt is also an adjunct professor of applied economics at the University of Florida, where he previously taught and advised graduate and undergraduate students. He earned his Ph.D. in Applied Economics from the University of Florida and holds an M.A. in Economics and a B.S. in Health Services Administration from the University of Central Florida.


EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am back with my friend the economist, Matt Salois. We are talking about practice ownership. We are talking about equity for veterinarians and vet professionals. What is possible in this modern world of corporatization where there’s private equity groups buying up practices, we have corporate practices, we have a wide variety of opportunities for ownership. What do we need to know? How does this work? How does it look in the future? Is the old style of practice ownership dead and gone? Is private equity going to stick around the way that it has or is that a passing phase? Guys, we unpack all this stuff. 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. Matt Salois. Thanks for being here again.

Dr. Matthew Salois:
Hey, great to be here. Thank you.

Dr. Andy Roark:
I always appreciate your time. So you’ve been on the podcast a number of times. For those who don’t know, you are a PhD economist, you are the president of the Veterinary Study Groups. You work with the VMG Groups, the Vet Management Groups quite a bit. And you have been a guest on this podcast at least three times now.

Dr. Matthew Salois:
Awesome.

Dr. Andy Roark:
Best you believe it. I don’t know how big an accolade that is.

Dr. Matthew Salois:
No, it’s a big one.

Dr. Andy Roark:
Probably gets pretty low on the CV, but-

Dr. Matthew Salois:
No, really great to be here. Weird conversations.

Dr. Andy Roark:
Oh, I always do. There’s just a number of things I’ve been really interested in recently and you’re sort of in a position to help me look at it outside the box and to see what’s possible. And so, one of the things to you, I’ve always been interested in practice ownership. One of the things that really attracted me to vet medicine was this idea that you could captain your own ship. I think it was really, my father was a physician, but he had his own little surgery center that was just him and two nurses and just small town in North Carolina and that’s what he did. And I think there’s something beautiful about that. And so that type of autonomy I think has always been really interesting and really, I don’t know, I had a romantic view of it I guess.
And then the other part of it is when we talk about, I look a lot at student debt for veterinarians and the whole time that I was coming up, student debt was getting larger. A lot of people were going, “Oh, well there’s an easy way out of this and it’s practice ownership.” And I always thought that was a little bit of mischaracterization of the truth, but I got the concept of it.
And so now I’m looking at increased corporatization in vet medicine. What I wanted to do was talk to you a little bit about how that changes this independent business owner landscape and is practice purchase or practice ownership in going forward, how viable is that going to be? Is it going to be widespread? I’m starting to hear a lot more about different models where there is equity inside of corporate practices, things like that. Those are the conversations I want to have today is I kind of want to understand the landscape for owning equity in a vet practice going forward. And so if you could start off, can you start us at a 10,000-foot level and say, tell me the story of practice ownership, Matt, just get me started on where we’ve been and where we’re going.

Dr. Matthew Salois:
Yeah, really happy to. I’m really excited we get to have this conversation. It’s a deep passion for me, practice ownership in large part why I’m with VMG today. It’s such a tremendous opportunity to, I think, enhance the wellbeing of yourself as a practice owner and more importantly to be put into a position where you can influence so much that happens within the practice. So much of our conversations talks about veterinarian wellbeing and I don’t know if you’ve ever been in this position, Andy, around, oh, I wish the boss would do this. I wish the boss would do that.

Dr. Andy Roark:
Oh yeah.

Dr. Matthew Salois:
You’re in that position. You can make those changes that you so desperately crave.

Dr. Andy Roark:
I will turn it back around, too, and say it’s funny. Later in life I learned that when you’re the boss, you say things like, “Ah, I wish the staff would do this. I wish the doctors would…” It never ends. I always thought when I’m the boss, it’ll be easy. It’s like, no, it’s not easy.

Dr. Matthew Salois:
No, it’s harder, but at least you’ve got autonomy there or more or less, you’re always coupled to somebody.

Dr. Andy Roark:
That’s true.

Dr. Matthew Salois:
In consolidation, corporatization, it’s definitely changing the landscape. And I will say that I think there’s plenty of room for every type of practice, for every size, every aspect of how you define ownership in this profession. The number of veterinary practices continues to grow. Yes, the number of practices that are corporate continue to grow too, but so does the total number of practices that are here parallel with population increases of pets and demand for veterinary care. It’s still such a tremendous runway of opportunity for someone aspiring to be a practice owner.
And I think we need to do a better job as a profession building those aspirations. And I think building transparency and awareness around what it really means to be a practice owner, what it takes, what it involves, as well as the benefits that it imparts. I mean, you said it, your father was the captain of his ship. And I don’t know if this was your father’s story. I don’t know if you had these experiences with him before he owned his own practice and life after he owned his own practice. If you could share if there was a big change in his overall wellbeing and happiness or not. But I see it in veterinarians that become practice owners. It’s amazing.

Dr. Andy Roark:
Okay, so let’s unpack that a little bit because there’s… Okay, so first of all, I still love the idea of being a business owner. One of the greatest things that I aspire to in my life is to create a wonderful workplace for other people. That just means a lot to me. I really want to create a great place for others to work in. And I think it’s a responsibility, but it’s also a passion project and it’s a worthy challenge. And then also, I like the autonomy of making this into the image that I want it to be. Business ownership has been a wonderful challenge that I’ve been very glad that I took on.
At the same time, it is a challenge. I had a guest on a while back and then I had another guest on who argued with the first guest. And the reason was, and I’m trying to remember where the original statistic came from, but basically we were going over some data on burnout and the data that was presented said that the practice owners were less likely to burn out than other professionals. And so, one of my later guests said, “I heard that on the podcast and I thought, that can’t be true.” So he contacted the first guest and what was told was the way that burnout is calculated is your plan is planning to leave the job. So practice owners didn’t burn out, because they didn’t plan to leave the job because the barriers to exit were much higher. And so anyway, I think that that’s an interesting sort of way to talk about does practice ownership make people happier? Are there these psychological benefits? What’s baked into those numbers?

Dr. Matthew Salois:
Well, it can and it can also make your life miserable as can any decision that you embark on in life. But I don’t know, I have to go back to that podcast episode. I can speak to data at the AVMA, because I helped collect and analyze that data years ago when I was with the AVMA around wellbeing metrics for associates versus practice owners. And it was very clear that wellbeing in terms of lower burnout, higher levels of compassion satisfaction, it was clear in practice owners and it wasn’t about whether or not they were wanting to leave the profession. We compiled those metrics based on the professional quality of life, surveyed the pro qual…
And so lots goes into that, a number of different variables and indicators there. And what we always saw, and the AVMA still continues to see over time, is that practice owners have lower burnout and higher overall levels of wellbeing. I kind of chalk it up again to this captain of your ship and in control of your own destiny kind of thing. Now it doesn’t mean that’s always going to be the case, right?

Dr. Andy Roark:
Sure.

Dr. Matthew Salois:
You could be in a very difficult situation as a practice owner and be very miserable and maybe want completely out of it. I think like all things, it depends on the actions that you take, the people that you work with and the culture that you create within your business. I think it revolves around how that looks.

Dr. Andy Roark:
It’s funny. I think that sort of tracks with my experience. Definitely there’s a lot more stress on your shoulders of making payroll and you carry a lot of responsibility. I guess I can definitely buy into the idea that autonomy and the ability to impact your surroundings at a much greater level than other people who work in the practice are. I can definitely see that being something that would keep people in business ownership and that could increase overall satisfaction.
I heard a story not long ago and it was heartbreaking. So one of my friends was going to buy the veterinary practice that she worked in and she’s an associate vet and she saved up for three years to be able to get the down payment that she needed to buy this practice. You can probably see where this is going. So then it was time to do the evaluation on the practice, and they did, and her numbers worked out, but there were corporate buyers who were also interested in the practice and it sort of came at around the same time that she was going to try to make this purchase. And they came through and offered multiples well above what she was able to pay. It was something like, let’s say the practice was valued at $2 million and they came in, they were like, “We’ll give you 3 million.” And the owner said to my friend, “Can you match that?” And my friend was like, “No, I can’t. The bank won’t loan me that much money.”
And so the practice was sold to this other group and there’s not a villain in this story. I really don’t, I don’t think any of us can look at a veterinarian trying to retire and say, “Well, you should have left a million dollars on the table.” I would’ve been heartbroken just like my friend was. And I don’t think that she was wrong, and I don’t blame her if she feels resentful. But I hear these types of stories. So, Matt, can you comment on some of the challenges of purchasing a practice today, of coming into practice ownership in the modern era?

Dr. Matthew Salois:
Yeah. I mean, and you name probably the biggest one there, which are what seem to be absurdly large multipliers that no individual average human being can compete with, especially when you’re looking at private equity groups with deep pockets that have seemingly endless cash flow to pour into veterinary medicine. I think that definitely creates some frictions and difficulties. I think our current environment around inflation and whether or not we are in or will soon be in a recession may soften what we’re seeing there in terms of consolidation and multipliers.
But it pains me to hear stories like that, and yet it shouldn’t be a deterrent either. It didn’t work out in that instance. So try smaller, try buying into a different practice, something that doesn’t have quite the multipliers on it. And you’re right, you mentioned she was saving up for a few years. I mean, it’s definitely a long-run plan. This isn’t something you can think about wanting to do, and then two years later you do it. And this is why I think we need to talk more about it and instill this in the schools, in the program, so that you can be on, at a minimum, a five-year plan post graduation so that you can start preparing the saving, looking at loan options. The opportunities are out there.

Dr. Andy Roark:
Yeah. So I want to step back here for a second. Can you define the term private equity? I know we throw that term around a lot. I don’t know how many people know exactly what that means when we say, “Oh, private equity has deep pockets.” Translate that for me if you don’t mind.

Dr. Matthew Salois:
Loosely, private equity being a collection of investors, pulling their money together and then investing in different areas where they’ll buy up assets, they’ll potentially restructure those assets, invest in those assets, build efficiencies, create more profit from them, and then sell those assets at a gain. I mean, that’s basically what private equity is trying to do. They’re not generally in the long run. They’re here to come in, make an investment, and generate a return within a three to 10-year time horizon and even 10 years might be pushing it. And that’s basically it.

Dr. Andy Roark:
Hey, guys, I just want to hop in really quick and give a quick plug. The Uncharted Veterinary Conference is coming in April. Guys, I founded the Uncharted Veterinary Conference in 2017. It is a one-of-a-kind conference. It is all about business. It is about internal communications working effectively inside your practice. If you’re a leader, that means you can be a medical director. It means you can be an associate vet who really wants to work well with your technicians. It means you can be a head technician, a head CSR, you can be a practice owner, a practice manager, multi-site manager, multi-site medical director. We work with a lot of those people. It’s just all about building systems, setting expectations to work effectively with your people.
Guys, Uncharted is a pure mentorship conference. That means that we come together and there is a lot of discussion. We create a significant percentage of the schedule, the agenda at the event, which means we’re going to talk about the things that you are interested in. It is always, as I said, business communication focused, but lots of freedom inside that to make sure that you get to talk about what you want to talk about. We really prioritize people being able to have one-on-one conversations to pick people’s brains, to get advice from people who have wrestled with the problems that they are currently wrestled with. We make all that stuff happen. If you want to come to a conference where you do not sit and get lectured at, but you work on your own practice, your own challenges, your own growth and development, that’s what Uncharted is. Take a chance, give us a look. Come and check it out. It is in April. I’ll put a link in the show notes for registration. Ask anybody who’s been, it’s something special. All right, let’s get back into this episode.
What do you see as the role in private equity going forward? So we saw private equity coming in and spending a lot of money in the last couple of years. Is that going to continue as you look into your crystal ball? Are we going to continue to see this type of investment? Is this sort of a short-term play? Does this create opportunities for practice ownership among veterinary professionals in interesting ways later on?

Dr. Matthew Salois:
Yeah. I think veterinary medicine will always be, and has been for quite a while, a very attractive place for private investors, equity groups to invest in, particularly because, one, there’s stable growth. We continue to see the number of pets grow and demand for veterinary care grow. It’s also very recession resilient, not recession proof. I don’t think any market or industry really is, but certainly resilient. And so in periods of economic downturn, sluggishness, it’s a good place to invest in because you can maintain steady cash flows or at least mitigate losses that you would’ve in other industries and other areas like travel, tourism, entertainment, those things really take a nose dive during those types of economic environments.
But I think we will see some slowing down here in large part just tied to what’s happening in our economy. The realm of cheap money is done, negative and zero interest rates, those days are over and the money’s more expensive now because of inflation and what we’re seeing happening there. And so it’s becoming more expensive to invest. So I think that’s going to naturally slow things down a bit. I also think eventually, whether it’s next year or a few years from now, we’re going to see some slowing down because the top oil has been mined here. So there’s definitely a sweet spot that a lot of private investors are looking for medium-sized practices that have at least two to three doctors that they can grow into something more and then sell at a profit, at a gain there. That’s been happening for years. And so it’s getting more difficult to find those practices. Still plenty of them out there, but obviously more of them have come under some type of private equity umbrella over the last few years.

Dr. Andy Roark:
Is there opportunities with private equity umbrellas? If the idea is to turn these over for profit, does that create opportunities for independent practice purchase later on, or are those practices… I know the idea is obviously to increase revenue, so they may be very well priced outside of an independent professional’s purchasing price forever, but talk to me a little bit about that.

Dr. Matthew Salois:
Yeah, absolutely. I’ll add here, when we look at what we call corporate practices, which I never really liked that phrase because it’s just very misleading. I mean, really the only true corporate practices out there are the Mars practices. They’re the only company that’s truly incorporated under the eyes of business law. The others are under private equity umbrellas, and they operate very differently than an incorporated business because they’re managed by investors there.
And here, touching on what you just asked, opportunities to hold equity into that company are becoming more and more common. And it’s changing, I think the nature of what we think of as ownership. Yes, it is still and always will be 100% independently-owned business. That’s still very much a part of veterinary medicine. And now we have this new landscape of ownership where you can maintain equity ownership into the practice or more increasingly into the parent company that’s invested in that practice. And that’s important to recognize, because it’s still under the umbrella of ownership and what happens in the future is, yes… So inevitably most of these investors will be looking to sell. So there may be opportunities to buy those practices back. Some of these may incorporate and just become incorporated in true companies there selling to an outside agency that’s interested in that. The landscape’s going to continue to change. That’s clear.

Dr. Andy Roark:
Can you give me some examples of what these types of equity programs would look like? So when we talk about having equity inside of a larger corporation, everything from, you said equity in an individual practice to the larger companies. Give me kind of a menu, if you will, of what these different options look like?

Dr. Matthew Salois:
Yeah, I mean, it’s almost like the sky is the limit here. I’ve seen many different types of structures in terms of how they’re designed, and I think it continues to evolve and that’s going to continue unravel. I mean, I think sort of the meat and potatoes of it, the 101 version of this is the owner sells to a private equity group, and that person maintains anywhere from a five to maybe 15% equity stake into that company, into that organization. And so based on earnings, at the end of every year, they receive equity value based on that.
More and more what I’m seeing is that that’s not just singled out to the owner that sold. I’m seeing equity for professionals all across. And some are offering equity ownership into the whole staff, having a percentage stake in the earnings of the company as well. And I think we’ll probably see that become more common because it’s an important, obviously, income stream for people. It’s definitely an incentive to recruit and retain people that other businesses and practices may not be offering. So it’s going to help you compete for talent there. But it can be designed any number of different ways, but ultimately it’s based on the earnings of the company. And then based on that you receive either a check or shares that can be paid out once you’re vested, so to speak.

Dr. Andy Roark:
It totally makes sense. I’ve seen this a number of times with associate doctors. Because if you buy a practice and all the doctors leave, what have you bought in some ways? I’ve definitely seen that and it definitely makes sense to me for a retention standpoint. So when we’re talking about equity like this, the idea, like you said, is you would have ownership of either this individual practice or this larger entity, and then you would either get a check, like a disbursement of funds, or you would convert to more ownership. And so I guess the ultimate idea is this is your long-term investment and later on at some point you’ll be able to convert this as you sort of cash out your investment, correct?

Dr. Matthew Salois:
That’s right, yes.

Dr. Andy Roark:
Are there other upsides to these types of deals? Are there things that people really like about them?

Dr. Matthew Salois:
Well, I think it keeps them connected. So you think about an owner who’s selling and they’ve spent years building this practice, it could be hard to let go of that. And maybe some just want that, right? Like, “I’m done. I’m out.” Go buy a yacht and sail or whatever, and that’s fine. But for many, they want to stay connected. They’ve built something and they want to continue to see it grow and succeed and not necessarily leave the people that they’ve built this with behind.
So I think the biggest benefit to a structure like this is that it keeps them connected. And the investors gain from this too, because they don’t necessarily want a complete vacuum of institutional knowledge here. They’re not in the business of running practices, they’re in the businesses of helping them grow and then sell them for a profit. They’ll want the right people in place to help drive that mission forward. And oftentimes that involves keeping the people that have built this on the ground so that they can propel it to the next level.

Dr. Andy Roark:
That makes sense. Are there downfalls, pitfalls, downsides to these types of deals that you see? Is there any small print problems that surface later on?

Dr. Matthew Salois:
Yeah. I think some of the downsides to the investors can be when they find themselves suddenly having to manage a practice and they know nothing about that business. That can be challenging, particularly in a tepid economic climate like we’re in where maybe it’s just the growth and demand wasn’t what you thought it was. So you need to buckle down a little bit. But I think the downsides from the veterinarian who’s in this is decision-making, if that’s impacted. So obviously the investors are the majority here. Is everything top down?
And I think that’s where these practices run a very wide distribution. And why I say the corporate label is so unfair, because I think it creates this thought process of corporate telling the practice everything, medical or nonmedical. And I think that’s grossly unfair because there are so many that support and empower local level decision-making within their practices. They have their HR guidelines and they have their processes and procedures on a number of things, but they empower professionals, the veterinarian to make the medically best decisions to use what they feel is the best medicine. And so if there was a downside there for them, it’s the lack of that empowerment. But I’ll say there are so many out there that support that type of empowerment, which is encouraging.

Dr. Andy Roark:
Matt, if you had a young veterinarian who came to you and he or she expressed interest in practice ownership and they said, “This is something I’ve always look forward to. I like the autonomy. I like the idea of creating a culture and really having my hands in it and I want to work on something that I feel tied to or feel that I’m really able to put myself into.” How would you advise that person if they said, “I don’t know how to get started, I don’t even know what my options are.” Can you lay out a basic advisement strategy you’d give?

Dr. Matthew Salois:
Yeah, and here’s where we’re talking to a financial advisor would be wonderful, I think first and foremost, and having those conversations. And if you haven’t had one on your podcast, that would probably be a awesome next one to do. I’d say great, start now. You can always save for something without knowing exactly what you’re saving for. Just start saving, that’s important. And then be transparent, talk to the owner, let them know that this is what you’re thinking of and try to find out if the owner’s even interested in selling to you or to any veterinarian for that matter. And you can get hopefully the cards out on the table now. Is there a future? I mean, there could always be that situation like you started with the young veterinarian friend that you mentioned where you think you’re going to, but the sale doesn’t work out.
But either way, you can identify with your current owner if they’re interested in that, and then you maybe can work towards a plan to do that in the next several years. And if not, you can start looking for other opportunities to buy into practices. And you don’t necessarily have to buy 100% outright. So look for those opportunities where you could co-buy into a practice with another doctor or a number of other doctors there where you’re co-owning that practice together. Certainly in some ways that’s more complicated, but it softens the blow in terms of what you need in order to buy into that practice.
And then talk to owners, understand their history and their journey, what it’s taken, what they find as the biggest challenges, what they find most worthwhile and rewarding about it, and trying to get into that position of understanding the business more and more of veterinary medicine. I think that’s the important thing and very limited is given in the schools. This is really something that you learn along the way, right or wrong. And so taking those opportunities to the extent that you can with your current owner and others to build that up, build that skillset up over time.

Dr. Andy Roark:
Yeah. Are there any specific resources that you really like for people to look out to, didactically if they said, “What should I read?” Do you have favorite resources?

Dr. Matthew Salois:
Well, I think being a student of leadership never hurts anybody. I think learning more around leading people, and I think that’s the biggest challenge for any and every owner, they will tell you. People are delightfully complicated and getting people to work together in a way that brings together engagement and a positive work, you’ve got to cultivate that. That doesn’t usually happen on its own. And so I think learning leadership is important. You can read books and you can attend webinars and things, but I think there’s no better study for that than working under a great leader. If you look at your leadership and you’re just not happy, well, maybe you need to find another place where you can really learn what good leadership looks like.
And then understanding practical business, how to manage a profit and loss statement, a P&L, I mean that’s definitely a skillset. And understand the nature of strategy is really important around, if you want to grow, what are the steps taken to support that growth, and then how do you execute on that? That’s a learning skill. And you can get a degree and you can get an MBA, but that doesn’t mean you’re going to be good at strategy and execution. And so looking at opportunities to reinforce that will be an important avenue of opportunity.

Dr. Andy Roark:
Yeah, that totally makes sense. Matt, thank you so much for being here. Where can people learn more about Veterinary Study Groups? Where can they find you online?

Dr. Matthew Salois:
Yeah, at our website, veterinarystudygroups.com. Learn more about our mission and vision and how we support practice owners in the profession. And you can find me on LinkedIn where I occasionally post about data and the economy and sometimes I’m funny with a dad joke here and there.

Dr. Andy Roark:
Awesome. I’ll put links into the show notes. Guys, take care of yourselves. Be well everybody. Thanks for tuning in.

Dr. Matthew Salois:
Thanks so much.

Dr. Andy Roark:
And that is our show, guys. That’s what I got for you. I hope you enjoy it. I hope you took something away from it. I hope it was interesting. As always, I’d love it if you’d leave me an honest review on iTunes or wherever you get your podcasts. It lets other people know about the show so they can find it and check us out. Anyway, gang, take care of yourselves. Be well. I’ll talk to you later. Bye.

Filed Under: Podcast Tagged With: Team Culture

Master’s Degrees, Mid Level Practitioners, and the Future of Veterinary Technicians

March 8, 2023 by Andy Roark DVM MS

Dr. Bonnie Price, Director of Lincoln Memorial University’s Master of Veterinary Clinical Care Program, joins the podcast to discuss LMU’s new master’s program for technicians, its objectives and the pushback against the program. Dr. Price and Dr. Andy Roark also discuss the current state of technician credentialing and what the future looks like for the technician profession.

Cone Of Shame Veterinary Podcast · COS – 188 – Master's Degrees, Mid Level Practitioners, And The Future Of Veterinary Technicians

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

LINKS

LMU Master’s of Veterinary Clinical Care: https://www.lmunet.edu/college-of-veterinary-medicine/academics/graduate-studies/master-of-veterinary-clinical-care

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. Bonnie Price has worked in veterinary education eight years and currently serves as the Director of Lincoln Memorial University’s Master of Veterinary Clinical Care Program, the first MS program in the US designed specifically for credentialed veterinary technicians to build on the knowledge and skills learned in AVMA CVTEA accredited programs. Dr. Price is the former chair of the LMU’s Department of Veterinary Health Science and Technology at LMU and led the department through curriculum revisions, new program development, and enrollment growth.

Dr. Price has lectured for undergraduates, graduate, and professional students across multiple disciplines (including veterinary technology, pre-vet, pre-med, nursing, conservation biology, master’s students, medical students, and veterinary students) with the goal of creating interdisciplinary collaborations and developing leadership skills very early in students’ training.

Before training in veterinary public health, they completed their undergraduate work in anthropology and biochemistry and participated in primate fieldwork and conservation studies throughout Central America and West Africa, which fostered a strong commitment to culturally competent and multidisciplinary approaches to improve health and wellness at the interface of animals, humans, and the environment.

Dr. Price serves on the Board of Directors for Pawsibilities VetMed, which aims to actively increase the diversity of the veterinary profession based on gender, race, ethnicity, non-traditional career path, sexual orientation, socioeconomic status, religion, disability status, and veteran status through a novel pipeline approach to recruitment and retention.

Dr. Price is also an active member of PrideVMC’s Mentorship Working Group and DEI Working Group, which exists to promote and uphold PrideVMC’s commitment to diversity, equity, and inclusion among its members, the larger LGBTQ+ community, the field of veterinary medicine, and all communities served by veterinary medicine.

Dr. Price earned a BS in Biochemistry, a BA in Anthropology, and a DVM and MPH from the University of TN.


EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I’m here today with the one and only Dr. Bonnie Price. She is the Director of the Technician Master’s Program as it’s informally known at LMU. Man, this is a lightning rod program. A lot of people have a lot of strong feelings about this, about a technician master’s degree. Why are we doing this? What does it allow technicians to do? Is this the path to the mid-level practitioner? Do we need to stop it before that happens?
I get her in and ask her really hard questions, and we talk about a lot of things. We talk about where the program came from. We talk about what someone would do with a master’s that they get after being a credentialed technician. We talk about the return on investment on a master’s like this, and then we get into the mid-level practitioners and we talk about what that looks like and where we are in that debate as a profession and how a master’s program like this would fit into mid-level practitioners if they were to come around.
So guys, I think for those of you who watch the industry and think about the future, I think there’s a lot of meat for you to stick your teeth into if you’re into meat. Otherwise, a lot of audio tofu if you’re into that, but there’s a lot here. That’s what I’m saying. There’s a lot here that I think you guys will enjoy. So 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. Bonnie Price.

Dr. Bonnie Price:
Thank you so much for having me.

Dr. Andy Roark:
Oh, man. It’s my pleasure. So you and I are just meeting for the first time. I am so glad to get to meet you. My friend Bob Lester, Dr. Lester, who’s been on the podcast a number of times, he speaks so highly of you. I am so interested in technicians, obviously, in technician job tracks and in accessibility of care. Boy, you’re doing something really interesting that I want to talk about.
So for those who don’t know you, you are an Associate Professor of Vet Medicine at LMU, which is Lincoln Memorial University, and you are the Director of their Master’s of Veterinary Clinical Care, which is some people are calling it the Technician Master’s degree, something like that. I want to talk to you about what that is because I have heard things I think are true. I’ve heard things I think are not true. I just want to sort this out with you and understand what’s going on.
So let me start. I want to start really broad and just say to you, I’m looking at our profession and the biggest problem that I’m seeing right now is a labor shortage, specifically in veterinarians. I know I’m vet-centered because I am a practicing veterinarian, but I look around and I say, “Guys, we got too many cases. We got more cases than we can see and we have technicians who want to do more and they would like to earn a living wage, which seems reasonable to me.” So this feels like a problem that has a fairly straightforward answer in my mind when I say, “We’ve got more work we need to do. We’ve got people who want to do more work, and we’ve got people who would like to earn more salary.” That seems reasonable to me and paints a picture of where I think our profession should go. How do you feel when I say that? Does that line up with what you’re looking at? Am I off base? Talk to me about how you see technicians in our profession right now.

Dr. Bonnie Price:
Okay. So yeah, I agree with everything you just said. The one thing I don’t know if I agree with is the straightforward solution. So I think that the problem becomes a lot more complicated when we start looking at all the pieces. So we’ve got this-

Dr. Andy Roark:
Let’s do this. You’re so right, and I’m here for this. Let’s do it.

Dr. Bonnie Price:
Okay. So I think we definitely have a workforce shortage. I’m not sure why, but there is some disagreement among some professionals saying that, but I don’t think there should be. I think maybe overall, maybe we have enough veterinarians to cover the needs of the country, but then when we start looking at the places where we need veterinarians, we don’t necessarily have them, right? We definitely don’t have an enough technicians. We’re in a situation where a lot of practices are using veterinary assistants to do technician work.
So we definitely don’t have enough credentialed technicians. We’ve got credentialed technicians leaving the profession and really high numbers. I’ve read lots of different statistics, but some of them say that the average lifespan of a technician in their profession is seven years. They become credentialed technicians, they leave within seven years.
So I think that when we start to pull apart the threads, what are the problems that we’re seeing? There’s a lot. So we’ve got this issue of what’s the scope of practice of technicians and how is that scope of practice protected state to state. So are technicians the only ones able to do technician work? No, in most states, no. Is the title of technician protected in most states? No. Is there a requirement to be a credentialed technician? In many states, no. So we’ve got this mess of veterinary technology that I think veterinarians are to blame. I think we can say that because we’re both nuts, right, Andy?

Dr. Andy Roark:
“I think it’s your fault, Roark.” That’s what I heard.

Dr. Bonnie Price:
A lot of the power in this profession is in the hands of veterinarians.

Dr. Andy Roark:
Oh, yeah.

Dr. Bonnie Price:
So we really need to understand what’s going on with technicians so that we can start solving this problem and then give the power to them, right? So once we figure out what’s going on, help them, give the power to them to do with their profession what they want to do. That’s how I feel about it.
So I guess I think the best thing to do, and maybe we start with what this master’s program is that we’ve made. So you mentioned you’ve heard a few things. You’ve heard some things that maybe are true, some things that maybe aren’t true. I think you’ve maybe have heard things that were at one point true and now are no longer true.

Dr. Andy Roark:
Yeah. Let me lay this out a little bit. Okay. So now we’ll start to get into it because you already touched on some of the things that I’m talking about. So my understanding is that you guys have rolled out this new master’s program in its, as I’ve heard it called a technician master’s program, but it’s the Master’s of Veterinary Clinical Care. There’s a lot of people who say, “Well, this is a path to a mid-level practitioner,” which is a whole other can of worms, but the idea being this would be something in between credentialed technicians that we have now and veterinarians where this would be the perfect educational path to have technicians that work without supervision from a veterinarian, let’s just say, and all of this is hypothetical, and there’s no legal structure to support this happening or any of those things.
Some people say that this is the path to creating the mid-level practitioners. I think that some people get really bent out of shape when they hear that because they feel like it’s maybe not something that they like and they’re like, “Oh, is this is wedging that door open.” There’s other people who say, “No, this is an advancement of a veterinary technician as a career path.”
Then you hear a lot of the things that you touched on yourself where vet technician credentialing is such a quagmire right now. The whole thing is so messy and bogged down. I think there’s so much frustration. I really think that’s a huge reason why the vet nurse, whether we call technicians nurses or not, it’s a massive ugly debate. I think a lot of it comes down to frustration about licensing and protection of technician abilities and making the certified vet tech position valuable.
So there’s just so much frustration there. The whole thing just devolves into pieces. So that’s the nasty ball that I’m looking at. So yeah, as we start to talk about the master’s program, just start with me at the beginning and just say what’s the goal of a master’s program. Why would we do this? What are we trying to accomplish?

Dr. Bonnie Price:
Okay. Let me start earlier than that. Let me start with before … I came on board as director of this program February 22, 2022. So it was 2/22/22, which is cool start date.

Dr. Andy Roark:
Easy to remember.

Dr. Bonnie Price:
So I’ve been with the program about a year at this point. Our first class started this last fall. So when the program was originally conceived, this was, I mean, really, I think pre-pandemic that people first started talking about this Master’s of Veterinary Clinical Care Program. So that was before I was on board, but I was with LMU. So I did hear a little bit about it, and I was pulled in from time to time because before I took this job, I was the department chair of the undergraduate veterinary programs at LMU, so the pre-vet program and the veterinary technician program.
So the original idea for this program came about at a veterinary innovation council meeting, and some people were talking about workforce shortages, and the idea of a mid-level provider came up. The idea was a mid-level provider could solve a lot of these problems that you brought up right at the start. We’ve got workforce shortage. We need people in to see clients. We need to improve practice efficiency. We need to improve access to care in the profession.
So the mid-level provider was the innovation that came from that meeting. So a number of those people that were involved in that conversation are associated with LMU in different ways, either on the College of Veterinary Medicine Advisory Board, former employees of LMU. So they started saying, “Well, what could LMU do about this?” So they wanted to create a master’s program that was truly more of a mid-level provider when you think of a physician’s assistant kind of thing, right?
So a lot of the early conversations about that program are rooted in that origin. So over time though, it’s evolved. So once I started getting involved, my background is in vet tech education, and so I had some thoughts about where the master’s program should go. I had some concerns. So one of my biggest concerns was that there’s no, as you mentioned, laws to support a scope of practice for a mid-level provider, right? So in every state in the country, the only person that can establish a VCPR is a veterinarian. The only person that can diagnose, prescribe, prognose, perform surgery is a veterinarian. So we can’t create a program for somebody to do those things if they can’t legally do those things.
However, having worked with technicians for about 10 years at an associate’s and bachelor’s level with the undergrad programs, I knew that many of my students were frustrated that they didn’t have more opportunities to advance their education, and having talked with other tech educators, I knew that there was a need for advanced education for technicians.
So veterinary technology is, from an educational perspective, really unusual profession. So veterinary technician programs are accredited by the CVTEA through the AVMA. There’s one set of accreditation standards or skills and knowledge that they need to know, whether it’s associate’s program or a bachelor’s program, there’s one set of skills. Does that make sense?

Dr. Andy Roark:
Yeah.

Dr. Bonnie Price:
So there’s no distinction in the accreditation between an associate and a bachelor’s level. So really, if you look at it from that perspective, veterinary technology is a profession made up of individuals with associate level skills and training. That’s unusual for a healthcare profession to only have somebody at that associate level. So we’re starting to see bachelor’s programs. There’s about 28 in the country right now.
So the guidance that they have from the CVTEA is to build on those associate level skills that are accredited, but there’s not a distinct set of bachelor’s level skills the way there is in … If you look at human nursing, there’s a set of things you learn at the associate level. There’s a set of standards at a bachelor’s level, a set at the master’s, a set at the doctoral level. So this to me is interesting.
So then when we start looking at technicians, technicians, I mean, you love technicians as much as I do it sounds like. Technicians are smart and they want to learn more about what they’re doing and they don’t have an opportunity. I know a lot of technicians, including some DBMs that teach in my program that were technicians who wanted to learn more. They didn’t have anything to do, but go to vet school. So I’ve seen really smart technicians, we lose them to vet school.
Over the years being a tech educator, I’ve thought, “What if there was an opportunity for techs that wasn’t going to vet school if they wanted to get a master’s or a doctoral degree?” So that was where I was coming from when I came into these conversations about this program.
So we’ve got this set of things that these guys wanted to do originally, which is improve practice efficiency, improve access to care, and I thought a really strong technician workforce can do that. If we utilize the technicians that we have now to the top of their license and then if we make opportunities for technicians to learn even more knowledge and skill and veterinary technology, scientific theory, medicine, then we can have a really, really strong technician workforce. So we can have tiers. We can have people up to, I mean eventually, I’d love to see a doctoral degree. We’re technicians, but I think we’re there.
It’s like the VTS, so the vet tech specialist. Having more people with more knowledge in their field is only going to improve our profession if then we as the veterinarians use those people. So the first part, my agenda is to create an educational pathway for these technicians that want to learn more about what they’re doing.
Then the second part is to actually teach veterinarians what a technician is, how they’re educated, what they can do. So the second thing that I’m doing at LMU is I’m actually going to start teaching in the veterinarian curriculum talking about those things, who is a vet tech, how are they educated, what are the skills they know, how do you use those skills efficiently in a practice, how do you delegate work, that kind of thing. So that’s where the program went, right? So now, what the program is is we are a master’s program for credentialed veterinary technicians, and we build on the knowledge and skills learned in those CVTEA accredited programs at a master’s level.

Dr. Andy Roark:
Okay. All right. I want to say this back to you and make sure that I got it, okay? So what we have right now is we have credentialed veterinary technician programs, and those tend to happen at either an associate level or a bachelor level, but they basically turn out the same degree even those investments may be different. Is that right?

Dr. Bonnie Price:
I mean, sort of. I don’t want to say they turn out the same degree, but technically, there isn’t any guarantee of difference. Does that make sense?

Dr. Andy Roark:
Right. Yes, exactly right.

Dr. Bonnie Price:
I know vet tech bachelor’s programs are really good. I know a lot of people at work.

Dr. Andy Roark:
I get that. So I guess what I’m looking at now is we’ve got these credentialed programs. So we have an associate level and a bachelor level, and so they turn this out. There’s also the veterinary technician specialty program, which is like going into specialty and being boarded, but it’s very specific in a certain topic. So what you’re talking about is adding in a master’s level as well to broaden the learning path beyond getting your credentials. I think that that’s very, very true for technicians.
I think one of the reasons that we lose technicians so much is they come up, they get their certified vet tech degree, and then this is your life forever, and they go, “You mean I’m done? I’m 26 years old and I’m done?” They’re like, “Yup. We hope you enjoy this because there’s nowhere else to go,” and they leave the profession. I think it’s a real problem.
I think that is also a problem, just so you know, with general practice veterinarians. I think that that’s something. There is a lot of people who get their DVM and then after a while, they feel stale and it’s like there’s not a clear growth pattern beyond that. I think that that’s a problem in our profession.
So you were talking about adding in this master’s degree. It’s not the same as a technician specialty credentialing. You know what I mean? It is continuing down that developmental pathway. So that makes sense to me I guess as far as what it is.
My question is when we get to this point, what functionally does this look like? So we’ve already talked about the problem with having the bachelor’s and the associate’s and functionally when they come out, there’s no protected difference between those degrees. How is the master’s program going to be different from that? What does this unlocked for them I guess is the question.

Dr. Bonnie Price:
Yeah. So for me, the master’s program, I mean, it’s the same way an associate program or a bachelor’s program isn’t a set specific career, but I think it sounds to me what you’re asking is clinically what can they do differently or just-

Dr. Andy Roark:
No, I mean, honestly, if you said to me, “This master’s is a path into industry,” I would say, “Okay,” and I would understand that that’s what it was. If you said, “This is a path to teaching in other veterinary technician programs,” I would say, “Okay.” I get that, but that’s really the question I’m putting back to you is to say, let’s say that my daughter, Jacqueline, who loves vet techs and can see that as a potential job, let’s say that she … She’s 15, she’s always away. Let’s just say that she gets her CVT and she’s looking at this program and she would say, “Dad, I want to go to this program,” and I would say, “Yeah, what are you going to do with that degree, Jacqueline?” Help Jacqueline answer that question.

Dr. Bonnie Price:
So I think there’s a lot of things to do, and I think you said a couple of them, right? So the same way there are jobs for associate level technicians in all of these places, there, I think, are jobs for master’s level technicians in these places. So right now, I know a lot of techs with master’s degrees. The master’s degrees they have are in things other than their field, other than veterinary technology. So business, education, with maybe some random, I think I know one with a history master’s, right?
So here, we’ve got more knowledge about veterinary technology so right away, opportunities in education. So we can get really into the weeds. This is my area as a academic administrator, but we can get super into the weeds about rules about who can and cannot be faculty at different colleges, but it’s difficult, particularly when you get to four-year institutions. It’s difficult to have technicians as instructors and faculty because of institutional accreditation requirements for terminal degrees.
So if we’ve got a technician who wants to teach at a four-year college in a technician program, right now, the terminal degree in veterinary technology is a bachelor’s degree. So they could not teach any … Technically, the only degree that they would be allowed to teach would be at associate’s level. Does that make sense?

Dr. Andy Roark:
Yeah.

Dr. Bonnie Price:
So then we get into these tricky ways to get around that at a lot of four-year colleges, where they get different master’s degrees and maybe some certificates in veterinary tech, right? It just gets complicated. So what ends up happening because it’s easier is veterinarians end up teaching technicians how to be technicians when we know that veterinarians don’t know what technicians can do. It should be up to the technician to do it.
So as we start increasing education levels terminal degrees for technicians, then they’ve got more opportunities in an academic setting to get faculty and instructor positions. With those kinds of positions come things like research opportunities. So then we can have technicians doing research in the field, advancing veterinary technology and veterinary nursing in that way.
So I think there’s a lot of academic and research potential, but that’s not the only potential. I also think that clinically, the same way VTSs can bring a lot to the table clinically, a master’s level technician is going to be able to bring a lot. So our students are going to have that same focus as a VTS, but they’ve got a broader knowledge. So instead of just an anesthesia focus or an emergency critical care focus, we’ve got a broader knowledge in surgery, anesthesia, internal medicine.
So here, within the existing practice acts, I think there’s a lot more that VTSs and master’s level technicians will be able to do without delving into that diagnosis, prognosis, prescribing, surgery. So if we think of, I know clinics that use ECC or internal medicine VTSs to do initial triage, do initial patient assessment, come up with differential diagnoses, I mean, we’re not diagnosing, we’re just preparing a differential list and getting those diagnostics started before a veterinarian sees that patient, and that is all within existing practice. So if we’ve got these really smart master’s level technicians, we can start to improve efficiency and practices that way.
So I’ve got about 30 students in this first class. Most of them are working in small animal practice, and the majority of them are in leadership roles. A lot of them are responsible for training programs within the practice. One of the big conversations that we have is just about the realities of their practices.
Now, ideally, they only want credential technicians doing the work that credential technicians should do, but there are workforce shortages everywhere. Some of my students are the only credentialed technicians in their practice. So they’re kind of practice manager, head technician, and they’ve got to train these veterinary assistants to do things. So understanding veterinary technology and medicine and all these things at a higher level is already helping them make better decisions in their practice in terms of leadership and leading their technician and assistant teams.

Dr. Andy Roark:
Okay. That makes sense to me. I can see that.
Hey, guys, I just want to hop in really quick and give a quick plug. The Uncharted Veterinary Conference is coming in April. Guys, I founded the Uncharted Veterinary Conference in 2017, it is a one-of-a-kind conference. It is all about business. It is about internal communications, working effectively inside your practice. If you’re a leader, that means you can be a medical director, it means you can be an associate of vet who really wants to work well with your technicians, it means you can be a head technician, a head CSR, you can be a practice owner, practice manager, multi-site manager, multi-site medical director. We work with a lot of those people. This is all about building systems, setting expectations to work effectively with your people.
Guys, Uncharted is a pure mentorship conference. That means that we come together and there is a lot of discussion. We create a significant percentage of the schedule, the agenda at the event, which means we are going to talk about the things that you are interested in. It is always, as I said, business communication focused, but a lot of freedom inside that to make sure that you get to talk about what you want to talk about. We really prioritize people being able to have one-on-one conversations to pick people’s brains, to get advice from people who have wrestled with the problems that they are currently wrestled with. We make all that stuff happen.
If you want to come to a conference where you do not sit and get lectured at but you work on your own practice, your own challenges, your own growth and development, that’s what Uncharted is. Take a chance. Give us a look. Come and check it out. It is in April. I’ll put a link in the show notes for registration. Ask anybody who’s been, it’s something special. All right. Let’s get back into this episode.
Talk to me about the pushback against this program because there are definitely people who have strong negative opinions. I’m personally surprised when I see this, but do me a favor and lay down the push against this program for me in a way to understand where people are coming from.

Dr. Bonnie Price:
So I think the biggest pushback I get and, honestly, so honestly, it’s the concerns I had. So I took this job because my dean is going to kill me. I shouldn’t say this, but I’m going to say it, Andy. Okay. So I was asked a couple of times if I was interested in this position and I kept saying no.

Dr. Andy Roark:
“Oh, my God! I don’t need that kind of stress.”

Dr. Bonnie Price:
Yeah. I was like, “No,” because I knew, right? I knew that everyone would be looking at it. I had a great job. I loved my job as department chair with the undergrad programs working with undergrads, but I did see this as a really great opportunity to advance education for technicians, and I had some concerns that I thought if I can get in, I can put the breaks on things a little bit and we can be a little more organized about our approach, if that makes sense.
So the concerns that I had coming into it were we don’t have any laws to support a mid-level provider. I do not like the term mid-level provider because I think everyone’s definition of what that is is different, right? We can all say that word and no one is talking about the same thing. So I don’t like the term mid-level provider, and I wasn’t, honestly, I wasn’t even sure when I took this job, if I liked the idea of a mid-level provider, period, but my opinion on that has changed and I’m happy to talk about that later.
Originally, this program had different requirements for entry. So it wasn’t only for credentialed technicians, and so I thought, “God, it really needs to be right.” So there were lots of issues I had with it. I think the pushback that I’ve gotten since I’ve started the job, and I appreciate the profession’s honesty. I feel like people feel very comfortable telling me.

Dr. Andy Roark:
Oh, yeah, no, they’ll tell you, they’ll tell you what they think.

Dr. Bonnie Price:
Yeah, because I want to incorporate it, right? So I really do value the feedback I’ve gotten from people, but I think the biggest concerns I’ve had is how can you promise somebody that they’re going to be able to practice more sure after graduating, right? That’s not what the program is. I mean, years ago, that’s what the program started as, but that’s not what it is now. So it’s really a master’s program for credentialed veterinary technicians.
I think the other pushback, the other biggest pushback I get is return on investment. So that’s a phrase I hear a lot, ROI, “What’s the ROI of this program?” So that one is really interesting to me, and the answer is I don’t know. We don’t know because this is the first class.

Dr. Andy Roark:
You’re talking to a guy who has a master’s degree in zoology. I have that and I go, “Yeah, it’s kind of …” I think ROI is a great question. Like I said, if my daughter wants to go, I’m going to ask her, “What does it get you?” I have a master’s in zoology and it did not unlock thousands of wealth for me, just so you know. I don’t know that I can justify having it, but I loved it and I did it and it informs the way that I think, and I am a better student of life because I had this experience and I have this knowledge and the process of going through it and just doing something I was passionate about. So I totally understand that.

Dr. Bonnie Price:
So that’s funny because I threw that question. I threw the ROI question out to my students in a discussion board last fall. I was like, “All right. What’s the ROI, guys?” I actually have a student whose bachelor’s degree is in, I think it’s business administration, something business, right? She said, “Listen, the first thing we learn in school about ROI is that financial ROI is not the only kind of ROI. It’s not the only way you measure returns.”
So a lot of my students, the ROI for them is what you just described, “I know more about this thing. I’ve got this education. I can do more at my job with it.” I will say that most of my students have already negotiated for more money once they finish this program or they’ve negotiated for their employer to pay for part of it or all of it. So they’re already doing that. The program itself is a really affordable master’s program. So right now as we’re recording, it’s around $20,000 for the whole master’s program, which isn’t bad.
The other pushback I get … So ROI is the big one. I don’t know how much more on average these students are going to make when they graduate, but I do know that they have definitely come into this understanding that they may or may not make more even though they’ve made that decision. The other thing … Oh, I lost my train of thought. Hang on.

Dr. Andy Roark:
Well, I’ll jump in and say it’s interesting too how people think about education in a lot of ways. A lot of it is a confidence thing for people. A lot of it is feeling like they’re capable of doing other things. There are some people who feel like they could never stand in front of a class and teach if they didn’t feel like they had credentials that clearly empower them to do that. You might say, “Well, you don’t technically need a master’s degree to do that work,” but I do think for some people it’s almost an emotional need to say, “I feel like I need to really have this knowledge if I’m going to present myself in this way.” So I don’t know. It’s just a different type of ROI. It’s definitely the money. You could say, “Well, you could save $20,000 and not do it,” but if you say, “Well, I need $20,000 to believe that I have this opportunity,” you can do that math for yourself.

Dr. Bonnie Price:
Yeah. I’ve got one student who works in veterinary technician education right now, doesn’t hold an instructor or faculty position. Once they complete this, they will, they will be eligible for that, which comes with, I mean, I think within a year or two, the program will have paid for itself. The other thing about master’s programs is … The other pushback I hear is that master’s programs have the worst lifetime ROI in terms of how much you pay for it and-

Dr. Andy Roark:
I get that.

Dr. Bonnie Price:
… the money that you’re going to get.

Dr. Andy Roark:
I get that.

Dr. Bonnie Price:
Let me tell you this. So I’ve been in education a while, and that, if you look at all of them together, that’s true. If you do an average of all master’s programs together, that’s true. I think the most popular master’s program in the country is an MBA and that has a negative return of investment, surprisingly, right?

Dr. Andy Roark:
That’s interesting.

Dr. Bonnie Price:
Negative return of investment. The ones that have the highest return of investment are master’s degrees in healthcare professions. So I’m hoping, I mean, obviously, we don’t know that it’s going to be the same for veterinary healthcare, but I’m hoping that that’s going to hold true for veterinary healthcare the same way it does for human healthcare.

Dr. Andy Roark:
Yeah. We are always, always optimistic about the future. I’m super optimistic for technicians in the future in vet medicine. I really think there’s huge upward potential there. I think that’s already tracking that way. So I am optimistic. I hope you’re right there.
Let’s talk a little bit about mid-level practitioners because that always comes up into this and people say, “Is this the path?” I’ve heard people say, “When human medicine started doing mid-level practitioners, they already had training programs before this was licensed to actually happen.” So I’ve heard that put forward in relationship to the program that you’re running.
So talk to me a little bit about mid-level practitioners. Really, I like what you said as far as when we say mid-level practitioners, everyone has a different picture in their head. I have 100% found that to be true. So when you say mid-level practitioner, what are you talking about? Then let’s start to talk about how that intersects with what you’re doing.

Dr. Bonnie Price:
Yeah. So I think in the sense that I think of it, well, I think of it in a few ways. One of the ways that I think about it is just I ask myself the basic question, “Would I be okay with …” and I do, I’m in the camp that if we have this advanced practice provider or mid-level provider in veterinary medicine, I think it should be a technician. So in my head I think, “Would I be comfortable working with a technician who does some level of diagnosis, prescription, even minor surgery?” and the answer is, “Yes, I would.” If I had training that I could feel good about, I have worked with VTSs and I’ve worked with people that aren’t even VTSs that are smarter than me. I know you’re like, “Hey, did you think about this?” and I’m like, “I did not think about that.” So I know. I know that techs could do it, right?
I live in a part of the country where almost all of my healthcare providers are either nurse practitioners or physician’s assistants. They are wonderful. I mean, I know that this isn’t something that only a veterinary can do. I’ve worked, I’ve got an MPH. I’ve worked in parts of the world where non-healthcare providers are trained to do specific skills. So for example, they’ve got … So I’ve worked in parts of Africa where people who have not gone to school to be doctors or nurses are trained how to do one surgical procedure, and they do that surgical procedure better than doctors and nurses from other parts of the world, right?
So this isn’t something that I think only a veterinarian can do, but we’ve got to agree on what we’re comfortable letting technicians do that encroaches into those four things that only a vet can do right now. In the UK, vet nurses are already, veterinary nurses are already performing minor surgical procedures. They’re doing disbudding without a veterinarian present. They’re doing mass removals. You know what I mean? So we’ve already got that in other parts of the world.
So I think the conversation, look, I think let’s start here at this baseline and then maybe set some goals for the next few years, five years, 10 years, but let’s start a conversation about rather than saying, “Do we want a mid-level provider?” let’s say, “When are we comfortable delegating to a highly trained technician, a VTS or a master’s level technician?” I think that we can agree on something. I think that we as a professional, we as veterinarians, we can be absolutely agree that there’s some things that we’re comfortable delegating.
I think for me also, being in a rural setting, it is hard for me. If I need to get healthcare for my animals outside of hours, I don’t have access, right? So then I start talking to technicians about, “Well, gosh, why couldn’t we get creative about how we’re using telehealth to establish VCPRs via telehealth with maybe a highly trained technician present? Let the animal …” Do you know what I mean?
So I think that we can start talking about these things and agreeing on things that are sensible. I think the first step is to figure out what are the real concerns that people have? So the things that I’ve heard about mid-level provider concerns, the one that I hear most commonly, and this one frustrates me the most is, “Well, look what it’s done to human medicine,” and I don’t know what that means because when I look at it, I think it’s improving-

Dr. Andy Roark:
Yeah, no, I get that. That’s a good question.

Dr. Bonnie Price:
I can go see a healthcare provider now because there’s a nurse practitioner in my town that I see. So I think more specifics there would be helpful. I think other concerns are what are these people going to be doing, but we can come up with a list. We can come up with a list of things that they’re going to do. We can come up with educational accreditation standards. We can come up with all these things if we just sit down and figure out what we’re scared of and what we’re okay with.

Dr. Andy Roark:
Yeah, no, that makes sense to me. I thought a lot about this, and I agree about mid-level practitioners looking differently in different people’s minds. I can imagine three or four different ways that something like this might look. It’s everything from the doc in a box model that we have now where in the human medicine you have a nurse practitioner at CVS by themself doing the thing, all the way over to basically the dental hygienist who’s working very independently in the building with the doctors. I could see we’re nowhere close to the dental hygienist model. We’ve talked about it for a freaking as long as I’ve been in the profession, and I don’t know that we’ve really … We’ve migrated in that way some degree, but anyway, I think this thing can manifest a lot of different ways-

Dr. Bonnie Price:
Yeah,. I agree.

Dr. Andy Roark:
… where technicians have autonomy to practice, to really take some of the workload off of veterinarians, to be part of the healthcare team, to have upward mobility in their training, in their education, in their income earning ability. I think all those things are really possible. The devil is in the details.
My worry in all of this is that people react so emotionally strongly that we can’t talk about it, and then veterinarians, I worry that veterinarians are going to take themselves out of the conversation, meaning, “I’m going to get mad. I’m going to dig in my heels. I’m not going to talk about this. I’m going to try to shut it down,” and then powerful external forces, namely pet owners, demanding service and entrepreneurs with money to make it happen coming in. They’re going to just make their own way and I don’t think we’re going to like it, and that, that’s my worry. So anyway-

Dr. Bonnie Price:
I 100% agree with you. So I was just going to say that … So the AVMA recently put out an article saying, “Oh, it’s not the time for a mid-level provider.” NAVTA, similarly, they did a survey among members saying, “Here are all these things. Where do you rank mid-level provider?” and it’s close to the bottom, right? So that’s fine. If you read what the AVMA said about all that, they’re legitimate concerns. We don’t have the laws in place. We don’t have the educational system in place, but those are things we can do, but what you just said is also my worry.
So we’ve got the AVMA doesn’t make the laws, right? NAVTA doesn’t make the laws. State legislatures make the laws about how we practice in our state. If we do start seeing pet owners lobbying together, industry lobbying together, we’ve got powerful organizations lobbying together, they can get in and start changing the laws. I think that we as a veterinary profession, veterinarians and veterinary technicians equal at the table need to have conversations about where we want this to go because I think that the pet owners, shelters, all of these other stakeholders are wanting to see change and they’re fed up, and it’s state legislatures that make the laws.

Dr. Andy Roark:
Right. That’s right. The cautionary tale that bothers me is the taxi drivers. The taxi drivers, I remember as Uber rolled over them, were clutching their medallions that they had paid for from the city that let them operate a licensed taxi and saying, “We paid for these. We have this agreement. The laws say that we’re the only ones who can deliver people around,” and all around them, Uber drivers just picked up their livelihood and drove away with it, and no one came in and protected them.
It was, yeah, the laws were set up for the taxi drivers and, yes, they did have a medallion and, yes, they did pay their dues and they did all the things they thought they were supposed to do, and when people wanted to ride an Uber and Uber showed up with a business model that worked and people who wanted to do the work, our country is set up so that the capitalists win.
I’m not commenting on good and bad and whatever, but it is what it is. I think about the frustration of those taxi drivers and I say I am concerned that those taxi drivers are going to be veterinarians who are pointing out what the state licenses or the state practice acts used to be and saying, “Oh, no, no, no. We are the ones who make that decision,” and I’m afraid that the rules change and we’re on the outside.
So I am not saying that to scare people. I think about it a lot. I think for me, I want to engage what pet owner desires are because I don’t think pet owners are okay waiting three weeks to get in to see us. So I think that I’m worried that by deprioritizing an issue that I think is important to pet owners and that looks like a massive business opportunity for outside forces, I’m worried that we are going to be reacting to what other people do to our profession instead of stepping forward as leaders of our profession, recognizing which way the tide is flowing and positioning ourselves in the most acceptable, most advantageous way possible.
I think 100% that there’s ways that technicians can have more independence and do more for us and veterinarians can benefit from that hugely. I also think there’s ways that the technicians can have more power and that veterinarians are damaged by that. A lot of it is how do you position yourself and how do you look at the situation and do you accept where things are going and read the writing on the wall and make some adjustments or do you dig in your heels until you get squished?
I hope that that’s not true, and I don’t mean to be morbid, but I really do look that way, regardless of whether you like the idea or not. I think you can say, “I like this idea,” or, “I don’t like this idea,” and in both cases, I still see these external pressures. I still see the way that things in our country tend to work, and I need to go ahead and position myself so that I can adjust and still be in a very good place while these changes happen.

Dr. Bonnie Price:
Yeah, and I feel like that’s the kind of pragmatism that we need to adopt, right? So if we close our eyes to this problem now, say we’re not ready as a profession and do nothing, we still won’t be ready in five years, right? All these external forces will maybe have moved on without us. So I think let’s be more organized as a profession and really have the conversations about what are the real legitimate concerns and how can we overcome those.
So one concern I hear a lot is in many states, nurse practitioners, I might be getting this wrong, either PAs or nurse practitioners can work independent of a physician. They can set up their own thing, right? So that I think is a big concern when people say, “Well, look what’s happened in human medicine.” I think that might be one of the things that they’re talking about, but we don’t have to do that. We can set our own rules. So if we’re organized now and we want people practicing under a veterinarian, then let’s start making those rules now. Do you see what I’m saying?

Dr. Andy Roark:
Oh, yeah.

Dr. Bonnie Price:
Get ourselves organized.

Dr. Andy Roark:
I have a podcast episode. It’ll be out when this episode comes live, but it’s not out as you and I are talking. I spoke with a founder of a company called Booster Pet, which is in the state of Washington, and it’s a practitioner. In Washington, technicians can work under indirect supervision from the doctors. Some of the practice stuff there was changed during the pandemic to allow establishment of a veterinary client, patient relationship virtually. So Booster Pet has a central clinical location, and they have wellness satellite locations where that do not have a doctor in the building, they have technicians and they have basically a telemedicine setup.
So the doctor appears on the screen in this building, and the technician does the wellness work, does everything. There has a video otoscope cameras to show the doctor thing, stuff like that, but there’s not a doctor in the building and the technician is working, and this is not an idea. This is happening in the state of Washington now.
I look at that and I process this and go, “The pet owners want it. It’s a lower cost examination.” I believe it’s a lower cost examination, but they can get in there, they can get seen. Sure, some people don’t want it, but there’s other people who say, “Wow, this is convenient, and I’m here for it.”
So anyway, again, I appreciate you referring to my view as pragmatic. That’s how I see myself. I am an optimist, but I am also a pragmatist, and you can balance those things. Anyway, I’m just looking at that a lot. As I said, I think this is an exciting time. I think this is a time of radical change in our profession.
Anyway, I really appreciate you taking time, Dr. Price, to come in and talk with me and just brainstorm. I could keep talking to you for another hour, for sure, but anyway, I’m going to let you go, but thanks for being here. If people want to learn more about the Master’s of Veterinary Clinical Care, where do they go?

Dr. Bonnie Price:
We have a website. So the easiest thing, honestly, to do is just Google Lincoln Memorial University Master’s of Veterinary Clinical Care and it’ll tell you the website because it’s, at the moment, not one of those easy short websites addresses, but it’ll take you to our website and you can check that out. That is the best way to do that, and that’s where all the information is.

Dr. Andy Roark:
All right. I’ll put a link in the show notes for people. I’ll run it down and it’ll be there, but otherwise, people listening can Google it. Thank you so much for being here. Guys, thanks for tuning in. I hope you enjoyed it. I hope you got something out of it. I will talk to you guys soon.
That is our episode. Guys, I hope you enjoyed it. I hope you got something out of it. Thanks again to Dr. Price for being here. Guys, thanks a lot for checking this out. If you enjoyed the podcast, if you got something out of it, do me a favor and leave me an honest review where you get podcasts. If you did not enjoy the podcast, wait and try another podcast and see what you think of that, and then see how you feel before you write a review. I don’t know. That’s just a thought. Anyway, guys, take care of yourselves. Be well. I’ll talk to you later. Bye.

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

Congestive Heart Failure Drug Crash Course

March 1, 2023 by Andy Roark DVM MS

Veterinary cardiologist Dr. Anna McManamey joins the podcast to give us a quick and dirty refresher on the Congestive Heart Failure drugs just about every clinic is carrying. This is a great episode that is perfect for anyone who wants to dust off their cardiology drug knowledge and feel comfortable with the congestive heart failure tools on your vet clinic shelf.

Drugs Included in this episode:

  • Furosemide
  • Pimobendan
  • Clopidogrel
  • Atenolol
  • Amlodapine
  • Analypryl
  • Spironolactone
Cone Of Shame Veterinary Podcast · COS – 187 – Congestive Heart Failure Drug Crash Course

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

LINKS

Cardiac Education Group: https://cardiaceducationgroup.org/

Practice Managers’ Summit – March 22, 2023: https://unchartedvet.com/upcoming-events/

Uncharted Veterinary Conference – April 20-22, 2023: https://unchartedvet.com/uvc-april-2023/

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. McManamey (aka Dr. Mac) is a veterinary cardiologist. She received her degree of veterinary medicine from the University of Missouri. She then completed a rotating internship at the Ohio State University followed by an emergency and critical care internship at North Carolina State University. She finished her cardiology residency at North Carolina State University and became an ACVIM diplomate in 2021.

Dr. Mac is currently an assistant clinical professor at Purdue University in Indiana. Cardiology is her favorite subject because it can be made as simple or as complex as needed. Furthermore, every animal has a heart and that means Dr. Mac gets to work with all kinds of species. Her areas of interest within cardiology are echocardiogram, congenital heart disease and interventional procedures, as well as emergency management of cardiac disease. She has a very supportive and patient husband along with three canine fur-children, one of which had a patent ductus arteriosus (of course).


EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:
Welcome, everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am here with the one and only, Dr. Anna McManamey, aka, Dr. Mack. She is a assistant clinical professor at Purdue. She’s amazing. I love talking to her. Guys, I got her in for this episode of just running through my congestive heart failure medications. She’s going to run through the cardiac medications on the shelf in relation to cardiac or to congestive heart failure, and just breaks down real quick. This is what you use this for, this is what I reach this for, this is what you pay attention for with this. Man, it is 15 minutes of just jam-packed education and pearls. So good, so useful, it’s great for veterinarians, it’s great for your technicians as well to listen to. Whether it’s a refresher for you or it’s just new information as you’re learning your cardiac medicines, this is a great episode. I’m so thrilled. Guys, let’s get into it.

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

Dr. Andy Roark:
Welcome to the podcast, Dr. Anna McManamey. How are you?

Dr. Anna McManamey:
I’m good, Andy. How are you?

Dr. Andy Roark:
I’m so good. It’s good to have you back, Dr. Mack. I love having you on the podcast. I’m super excited today, because I think we got one of these really, really, really useful episodes that people love. I wanted to run through the cardiac drugs in my clinic with you, and just a 100% get a refresher crash course of what’s on the average vet clinic shelf. When do you use it? When do you not use it? Just like that. I think it’s great. It’s great review for me. I did this with Tasha McNerney on anesthesia drugs in the anesthesia crash cart recently, and I just loved it. It made me feel so resharpened, and I just want to do that with you. Is that okay?

Dr. Anna McManamey:
I’m so excited. It’s great.

Dr. Andy Roark:
All right. Let’s do it. Where do you start when you look at your average vet clinic cardiac drugs?

Dr. Anna McManamey:
Yeah. I think, for me, there’s two categories that I would want to stock, and so being in the ivory tower, I’m very spoiled, like everything’s at my fingertips. But when it comes down to what I need to have there, and then I would say for the category of congestive heart failure management, I would include drugs, first and foremost furosemide. That’s going to be the go-to diuretic, it still is. Furosemide is also Lasix. It’s given that name, because it lasts six hours in the bloodstream, so it’s why it’s given the name Lasix.

Dr. Andy Roark:
I had no idea.

Dr. Anna McManamey:
… and that goal… Yes.

Dr. Andy Roark:
I had no idea that was true.

Dr. Anna McManamey:
I didn’t learn that till I was a resident. It’s not common knowledge, but that’s why it’s called that. Furosemide, any of the semide drugs, those are going to be your loop diuretics. They’re still the most effective diuretic that we have for treating congestive heart failure. The nice thing with furosemide is that it is oral, and as well as injectable. Having a bottle of injectable on your shelf, I think, is super important. You can give that subcutaneously, and you can give that intramuscularly, or you can give it IV.

Dr. Andy Roark:
Right.

Dr. Anna McManamey:
If I’ve got an animal that is clinical enough where they need oxygen support, I would recommend avoiding the subcutaneous dose. I would only do IV or IM, just because at that state, they’re not really perfusing their subcuta. But it’s nice, because you can give it any way you want and it’ll work. It works quick. It’s just still the best med.

Dr. Andy Roark:
Okay.

Dr. Anna McManamey:
Next one my list would be pimobendan, which I do vitamin P. I’m very obsessed with this drug, but pimobendan, especially in dogs. In the canine world, pimobendan or vetmedin is going to be the go-to next drug, for me. This is one that has proven time and time, and again to be beneficial for these dogs quality and quantity of life, in the state of congestive heart failure. It’s even been shown to help these dogs, before CHF even happens, so a few reasons to keep it on the shelf, but this drug has two main mechanisms. It is classified as an inodilator. It’s a positive inotrope, meaning it improves the contractility of the heart. It does this by basically causing more of a chance for the actin and myosin to meet cross-link, and form a crossbridge.
It’s a calcium sensitizer which is unique, because it doesn’t change the amount of calcium inside of the heart cell, which like digoxin was an old, tried, and true drug that does do that. The downside of increasing the amount of calcium in the cell is it’s pro-arrhythmic. The benefit with pimobendan is that, it’s less likely to develop arrhythmia secondary to the drug.

Dr. Andy Roark:
Gotcha.

Dr. Anna McManamey:
The other benefit is that it is an inodilator, so it’s a vasodilator. It actually does decrease the afterload on the left ventricle, as well as sometimes the right ventricle, based on where it’s going to cause vasodilation. Typically, it’s the veins, so we don’t see systemic hypotension developed with this drug, which is another benefit compared to something like an ACE inhibitor, for example. Two big reasons why I keep pimobendan high on my shelf, or should say low on my shelf, but high on my list, because it’s something that’s good for really any type of acquired canine heart disease, whether it’s degenerative valve disease, or dilated cardiomyopathy.
I will use pimobendan in some cases of cat heart failure as well. If I had cat who has congestive heart failure, doesn’t have a loud murmur, then I feel a little bit more comfortable using that drug. It is definitely considered off-label for that purpose, so you do have to have that conversation with your client. But if I have a cat, especially these older kitties that already have a degree of kidney disease, it’s nice to conserve the amount of Lasix that I need for that patient, so that’s my drug two.

Dr. Andy Roark:
Gotcha.

Dr. Anna McManamey:
And then staying on the cat theme, I would say, having clopidogrel or aspirin, something for blood thinning. Basically, cats that have congestive heart failure, they’re going to have large atria. One of the side effects and risk factors for cats with big atria is aortic thromboembolism, so don’t forget to add that treatment arm in there. We have evidence in the veterinary community that clopidogrel outperforms aspirin, so that’s my choice is clopidogrel. There’s injectable medications you can use as well, but clopidogrel is the easiest, I think, for most clients, and it’s once a day, which is nice, and it’s affordable.
And then the other thing for cats, I would say, I don’t think it’s as of much of an emergency drug, but would be things like atenolol, which is a beta blocker. We used to use this a lot more commonly in cats, until we found out that doing large retrospective studies, and even some smaller prospective studies, atenolol in the asymptomatic stage of heart disease in cats doesn’t seem to correlate to longer survival. This all came from human medicine, but I do think there are still going to be some cats that will benefit from atenolol therapy. Those are usually cats that have loud heart murmurs, or cats that have tacky arrhythmias, so fast heart rates. Atenolol is also an anti-arrhythmic. It can be used for supraventricular arrhythmias as well as ventricular arrhythmias in the cat, and is usually pretty well-tolerated. I also will use atenolol in cases where it’s got a cat that has a thyroid storm, so thyrotoxic heart disease, atenolol can be useful for those cats too.

Dr. Andy Roark:
Hey guys, I just want to jump in here with a quick update. Have you seen the Dr. Andy Roark team training courses yet? Guys, over drandyroark.com, I have got resources for people who want to work with their team. I have my angry client course, and I have my exam room toolbox course. These are great little modules that are made to be broken up, and popped into staff meetings, so that you can cover a quick topic about either dealing with angry clients, complaining clients, or to talk about different tools in working with clients in the exam room. Guys, this is fantastic. I’ve got discussion questions to ask your team, so they can talk about what they do, and just is a great way for everybody to see the same thing together, to talk about what works in the practice, and what they think is important, and just to get on the same page. Anyway, I hope you guys will check it out. It’s over at drandyroark.com. I’ll put a link in the show notes. Let’s get back into this episode. Are you using atenolol in dogs at all?

Dr. Anna McManamey:
The only real indication for atenolol in dogs is obstructive heart disease. In dogs, the most common forms of obstructive heart disease are congenital, it’s subaortic stenosis, and pulmonary stenosis. In those animals, the atenolol is purely myocardial protective. Usually, I’m using that in the asymptomatic stages, and then adding in a diuretic once they develop congestive heart failure. But it’s rarely going to be a drug that I am pulling off in case of an emergency, if that makes sense.

Dr. Andy Roark:
Yeah.

Dr. Anna McManamey:
Usually, the cardiologist’s rule is don’t give a beta blocker to a vet patient. A patient that has active pulmonary edema, or pleural effusion, you probably run a greater risk of just worsening their heart contractility, and lowering their heart rate when they need those things in that emergency setting, but still one, I think, is worth having around.

Dr. Andy Roark:
Okay, perfect.

Dr. Anna McManamey:
And then the final one I have really is just in case is, but is amlodipine. This is a blood pressure medication. It is a calcium channel blocker. It really acts preferentially on the cardiovascular system, and just the vascular aspect. We don’t really see changes to the heart itself with amlodipine, but out in the blood vessels, it causes vasodilation. This is another drug I can use in two ways. Both of them have the same goal. The goal is to decrease the afterload on the left ventricle. If you are a cat or a dog, and you have systemic hypertension, well, amlodipine will vasodilate your blood vessels, drop your systemic blood pressure, and that decreases the work on that left ventricle.
Conversely, if I have a dog that has really bad mitral valve disease, really a lot of mitral regurgitation, even if they’re not textbook systemically hypertensive, so I’m talking about a blood pressure that’s less than 160 millimeters of mercury systolic, but greater than one 120 millimeters of mercury systolic. A small window, but a lot of dogs fall in there. I might use a little dose of amlodipine to drop that afterload on the left ventricle, because whatever pressure is in that aorta is the pressure that left ventricle has to generate to get blood to go forward. It’s this fun hemodynamic game I can play with severe mitral valve disease dogs. That can preserve the need for a lot of diuretics, and so I call it a fun hemodynamic game. I think other people are too.

Dr. Andy Roark:
No, I just love if that’s how you see it. I’m like, hi, this is a person who loves their job. I love it.

Dr. Anna McManamey:
Yeah. It’s just finding those balances, what can I manipulate to improve cardiac output? I would say, again, those big five drugs from me would furosemide, so my root diuretic pimobendan, my inodilator clopidogrel for kittycat, so it’s a blood thinner to prevent ATE, and then amlodipine, and atenolol just on standby for those instances where they might come in handy. I think other drugs that I have to talk about, but I don’t think have to be on your shelf for a quick grab are your ACE inhibitors, so the enalapril, vasopril, those pill drugs are very important to the long-term management of heart disease. These have definitely proven their use in congestive heart failure patients, long-term. Same thing goes with spironolactone, which is an aldosterone antagonist. The ACE inhibitor, and the spironolactone together do a really nice job blocking the RAS system.
Trying to prevent the formation of angiotensin II, and aldosterone, because both of those hormones are automatically activated in congestive heart failure. Ironically, they get upregulated when the patient is on a diuretic. We have two reasons the RAS system activates with congestive heart failure, the state of CHF, and the fact that we put them on a diuretic, so we need to suppress that system in order to have the best long-term prognosis. These drugs prevent the angiotensin II, and the aldosterone activity within the body. The reason cardiologists don’t like those hormones is, because those both cause vasoconstriction. That increases afterload on the heart. They cause water retention, and sodium retention, which increases the preload to the heart. They have fibrotic mechanisms, so they actually cause fibrosis within the heart, the blood vessels, and even the kidney, the glomerulus. Chronic activation of these is maladaptive. Those are my [inaudible 00:13:26] drugs.

Dr. Andy Roark:
Gotcha.

Dr. Anna McManamey:
Yeah.

Dr. Andy Roark:
Gotcha. I love it. Can you give me some wisdom, some of your little pearls on dosage and frequency with Lasix? It feels like voodoo to me, where you kind of go, “I don’t know, maybe a little bit more and I don’t, let’s just try six hours instead of eight.” I know that some of it is more art and science, but help me. How do you get your head around that? And then when you’re talking about adding your ACE inhibitor, and your spironolactone, stuff like that, I go, “How do I manage these things together?” Because I feel, it feels like a blunt instrument in my hand sometimes, Lasix specifically. Help me feel a little bit more, I don’t know, a little more nuanced in that usage, please.

Dr. Anna McManamey:
Sure. It’s a great question. I always teach, we always tell students, go look up the dose, and tell us what you want. But if you look up the dose of Furosemide, it’s like one to four mg per kg, once to six times a day. There’s such-

Dr. Andy Roark:
Yeah. It’s huge.

Dr. Anna McManamey:
The nice thing with a diuretic is that it is a high-ceiling diuretic, so you just keep giving more until you get the effect that you want. If you overdo it, you just scale back.

Dr. Andy Roark:
Right.

Dr. Anna McManamey:
Really, it’s very much an art, and a gut feeling. What I would say is a very standard starting place for Lasix therapy, I would say, in a dog, it’s usually two milligrams per kilogram every 12 hours.

Dr. Andy Roark:
Okay.

Dr. Anna McManamey:
In a cat. We’re usually a little bit more conservative. Again, most of them are a little bit older cats. They also might have underlying kidney disease, and their plasma volume volume is just different, so we usually do one mg per kg, every 12 hours. In cats, it’s usually a pretty standard starting dose. I would say that, if I’m going to start a diuretic, that patient is either about to be in CHF, they have enough clinical signs, and enough concern, or they’re already definitely in it.
When I start that medication, I’m not looking to take it away later. I’ve seen those protocols where you start them high, and then you taper them off of the drug. I don’t think that’s going to work for most of these patients. I pick a dose, I start there, and then really it’s about teaching the client to count breathing rates at home, and use clinical signs, and your blood work as well as any imaging you can acquire to help you fine-tune that dose. What I do with my patients when I discharge them from the hospital, I say, “You have the diagnosis, it’s CHF, congestive heart failure. We’re going to start a diuretic.” Again, two mg per kg BID for a dog, one mg per kg BID for a cat. I let them know this does increase urination, so they will be very thirsty, and they have to always provide water.
I also let them know that the medication takes effect about two hours after they get it orally, so they will really have to go potty about two and a halfish hours after it’s given. That can save some of the 2:00 AM trips outside, if you don’t give it at midnight. Those are the little pearls for the clients. And then really it’s, are their breathing rates less than 40 when they’re sleeping? Is the coughing improved? Are they eating? If they’re doing those things, I’m happy with my dose. If the breathing rates are over 40 when they’re sleeping, breaths a minute, if they’re still coughing a lot, I would increase my dose by about 25%, over the course of the day. If that’s still not helping, I’d say, “Probably, I need to get you back in, and see if we made an improvement radiographically of what’s going on, or am I targeting the wrong thing, what have you?”
Typically, my recheck plans are radiographs, physical history, and then looking at renal panels. The view in creatinine and the electrolytes, those things help tell you if you’re overdoing your drug. That helps me know if I need to scale back. I think using those two things together can help you make a more objective decision about what to do. But, in general, I start with that dose, two mg per kg BID for dog, one mg per kg, for cat BID, and then I go from there. If I’m not controlling clinical signs, I escalate my therapy by 25%, and that’s what I do every time. There are some animals where I think, if they’re older, more crunchy kidneys, I usually like to spread out my dosing a little bit more frequently. Instead of doing two doses in a day, see if they can do the same daily dose, but three times a day.

Dr. Andy Roark:
Gotcha.

Dr. Anna McManamey:
Maybe give the kidneys a little bit more of a break, and the body more time to recover that volume loss. And then really from there, we tend to start considering doses over eight mgs per kg per day. That’s when we’re in the, wow. These are really high doses of diuretics.

Dr. Andy Roark:
Gotcha.

Dr. Anna McManamey:
We either need to switch diuretics to a more potent one, or we need to escalate other therapies instead.

Dr. Andy Roark:
Gotcha. That totally makes sense. Man, this is fantastic. I really appreciate this. This was wonderful, wonderful, wonderful. It’s a wonderful refresher. I really appreciate your time. Dr. Mack, you are an assistant clinical professor at Purdue. Where can people find you online? Where can they read more? Are there any resources that you are a huge fan of, in the field of cardiology, that you wish people knew about?

Dr. Anna McManamey:
Yeah. You can Google me, Anna McManamey. I would put Purdue with it, because the other Anna McManamey in the world is a beautiful blonde, bombshell bodybuilder from Australia. She’s not me. I have a lot to live up to with that, yes. But Purdue, Anna McManamey, I’m on their website there. There may be some lingering stuff from the NC State as well. But that’s probably the easiest way. I think in terms of resources, I am a big fan of the Cardiac Education Group, and I think I’ve mentioned that before on a podcast, but it is just cardiaceducationgroup.org. It is sponsored by BI, but it’s really well put together. Many of my mentors help run that site. It’s got great drug formularies for dogs, and cats. It has the doses, what pallet sizes they come in, which is also very helpful, I think, side effects. They’ve got practice cases. I just think it’s a really good starting point. That and the VIN, I think are probably my favorite.

Dr. Andy Roark:
Yeah. Outstanding. I’ll put links in the show notes for that. Thank you so much for being here.

Dr. Anna McManamey:
You’re welcome. Thanks for having me.

Dr. Andy Roark:
That is our episode. Guys, I hope you enjoyed it. I hope you got something out of it. Special thanks to Dr. Mack for being here. Guys, if you enjoyed the podcast, leave me an honest review, wherever you get your podcasts. It really does help people find the show. If you’re like, this is great, share it with your friends. Spread the learning love. Anyway, gang, take care of yourselves. Be well. I’ll talk to you later on. Bye.

Filed Under: Podcast Tagged With: Medicine

Unaccredited Vet Tech Programs, Irregular Practice Acts & The Path Forward for Technicians

February 23, 2023 by Andy Roark DVM MS

Ken Yagi MS, RVT, VTS joins the podcast to talk about an unaccredited veterinary technician apprenticeship in the state of Washington, the quagmire that is technician certification standardization, the term “Veterinary Nurse” and how practices can change the way they leverage their support staff.

Cone Of Shame Veterinary Podcast · COS – 186 – Unaccredited Vet Tech Programs, Irregular Practice Acts & The Path Forward

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

LINKS

Veterinary Emergency Group (VEG): www.VEG.com

NAVTA: www.NAVTA.org

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

Kenichiro Yagi, MS, RVT, VTS (ECC), (SAIM)

During his 20 years in the field, Ken has discovered and refined his role as a veterinary technician by promoting compassionate and progressive care for patients and their families. He obtained his VTS certification in emergency and critical care as well as small animal internal medicine and achieved his master’s degree in Veterinary Science. He is currently the Chief Veterinary Nursing Officer for Veterinary Emergency Group and the Program Director for the RECOVER Initiative. He has been awarded the NAVTA Veterinary Technician of the Year award in 2016, the California Veterinary Medical Association Veterinary Technician of the Year award in 2016, and the California RVT Association of the Year award in 2017. Ken has co-edited the Manual of Veterinary Transfusion Medicine and Blood Banking and has published various text chapters and articles in various publications. He gives presentations internationally on topics in ECC, transfusion medicine, and the veterinary nursing profession.

Ken works to encourage further recognition of the vital role of the veterinary nurses and technicians through work with organizations such as the National Association of Veterinary Technicians in America co-chairing the Veterinary Nurse Initiative and serving as a board member of the Veterinary Emergency and Critical Care Society, the Academy of Veterinary Emergency and Critical Care Technicians and Nurses, and the Veterinary Innovation Council. He is also an advocate for the Open Hospital Concept, encouraging veterinary practices to invite the pet owners to “the back” as a part of the team.

Ken invites everyone to ask “Why?” to understand the “What” and “How” of our field, and to continually pursue new limits as veterinary professionals and individuals.


EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary podcast. I am your host, Dr. Andy Roark. Guys, I got a great episode for you today. I am here with Ken Yagi. Ken Yagi is so many things. He’s an icon in the veterinary technician world. He is also the chief veterinary nursing officer of VEG. He’s the former past president. He’s the past president of NAVTA, the the North American Vet Tech Association. A bunch of other things I talk about when he comes onto the show. Anyway, I’m talking to him about a new program in Washington State that is unaccredited that still funnels people into the technician licensing exam. And I’m like, “What is up with that and how does that work?” So we start talking about what an unaccredited technician program looks like, and then we talk about the [inaudible 00:00:53] that is credentialing and how it’s wildly different. There’s no standardization and what headaches that causes and how we get out of that.
And the last thing we end up is talking about the very end is if you want to use technicians differently in your practice, say you want to try to really leverage them, but you don’t know how to go forward with that, how do you do that? And I like that question because I ask Ken and you give a very nice succinct answer, and then I answered my own question after that. So if you want to hear what I think, I shared that with Ken even though he didn’t ask at the end of the episode. And that’s how this episode goes.
Anyway, I think it’s really fun. I think it’s really interesting. I am really thinking a lot about technician utilization as I look at our profession, which is wildly rapidly changing with telemedicine, with corporate acquisition, with pet owners wanting service and they can’t get into clinics, our capacity to see pets. All of these things are big deals and I think technicians are a big part of all of them. So technicians are a big piece. I don’t think people realize how important technicians are going to be in our profession, in our livelihood in the next five years and that’s what I think. So I really dig into that with Ken. Guys, I hope you’ll enjoy it. I hope you’ll get something out of it. Let’s get into this episode.

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

Dr. Andy Roark:
Welcome to the podcast, Ken Yagi. Thanks for being here.

Ken Yagi:
Thanks for having me.

Dr. Andy Roark:
Man, it’s my pleasure. For those who don’t know, you have a laundry list of accolades. You are a veterinary technician. You are a veterinary technician, specialist in emergency and critical care and internal medicine. You were the past president of NAVTA with the North American Veterinary Technician Association. You are the current chief of veterinary nursing officer at VEG, the veterinary emergency group. So you do a lot, you are a huge voice for veterinary technicians and you have been involved in our profession in so many ways and I wanted to reach out and talk to you today about a big mess. A big mess that I think is having real effects in our profession right now and it’s going to have effects in our profession going forward. And that is the technician credentialing mess.
So what I want to talk to you is about what the heck is going on with credentialing of veterinary technicians? How do we get into this quagmire and do you see a path out? So to provide some color to what I’m talking about is, it’s been this case for a while that we’ve had different states have different practice acts that allow technicians to do different things and some states have protections for credentialed technicians or licensed technicians that says, you must be a licensed technicians do these things. Other states don’t have that at all. So there’s real sometimes question to the benefit of getting licensed if other people can just do your job and there’s no protections for you and things like that. And that’s been the case for a while and that’s been a frustration.
But then I’m looking around and the state of Washington actually, they just approved this controversial veterinary technician apprenticeship program that basically goes around accreditation. It’s not accredited and it’s an apprenticeship which sets people up to take the technician’s licensing examination. And you go, well, that doesn’t seem right to have a non-accredited program that goes around our formal education structure but ends up at the same examination. But I see it happening.
So anyway, I’m looking at that and I’m thinking a lot about the future for technicians. I’m thinking a lot about the capacity of that medicine, how we handle pet owners who want to get care. And I’m very optimistic about technicians in that way. But boy, the mess about credentialing and what we’re able to do and the lack of standardization, it really in my mind is holding us back from leveraging our technicians in any a uniform way. So anyway, that’s a lot to lay on you. Let me just pause there for a second and say of everything that laid out, do you agree with that assessment or am I off base?

Ken Yagi:
No, I think that the profession has definitely come a long way, but you’re right that there’s still a lot of work to be done before the credentials amongst all states are “standardized.” And I think there’s different things that we need to look at regarding that. I think you mentioned licensing in the sense of different credential titles being out there. The standards in terms of becoming credentialed should have been set pretty well amongst all states in that it requires an AVMA credit program degree passing the national examination called the VTNE and becoming registered, licensed or certified by either state governing bodies or private organizations that issue certifications to become a credentialed veterinary technician.
But then there’s the other pieces that you’re talking about. What does title protection looked like? Who can call themselves veterinary technicians? What does the scope of practice look like? Who can do what within the state and do they need to be licensed in order to do so? And all of those pieces could be slightly different depending on the state that you’re in, which makes it hard for people to know what a veterinary technician actually looks like. So in that sense it’s still a mess.

Dr. Andy Roark:
Well, it’s frustrating for me. I work a lot in practice efficiency and in running good teams and highly leveraging support staff. But speaking at a national and international level as I too, it’s really hard when what people can do in different states is so wildly different. I mean, some states that have no guidance or no empowerment of technicians laid out. And then I’ve got other practices in the state of Washington where you can have technicians that are indirectly supervised by veterinarians and they’re using technicians basically in buildings by themselves. And the doctors are coming in doing telemedicine appointments with the technicians, and it’s all clear and above board, but that’s how it’s set up in Washington. But I don’t know that moves to other states. It’s not something that you can say, “Well, we could do this here or there,” but I just use that as an example of the variability I see in how technicians can be used.

Ken Yagi:
Yeah. I think when it comes to scope of practice, the basic thing we can say is things like diagnosing, providing a prognosis, prescribing treatment and surgery is restricted to licensed veterinarians. And then everything else in veterinary medicine can be delegated to non veterinarian employees. So depending on the state, that needs to be a veterinary technician and depending on states, it could be anyone. And that’s the issue that we have. I think when you mentioned things like indirect supervision, there’s different levels of supervision that people need to have in order to provide certain things.
Obviously the higher risk tasks like surgical assisting, actually having like scrubbing in and having your hand in the abdomen and things like that needs to be immediate supervision that the veterinarian needs to be right there in order to do so while something like a blood draw could be done with indirect supervision where they might be somewhere within the facility or not even on the facility. And that’s all different and varied within each of the states. And it’s moving towards standardization in that AAV V S B recently put out a model regulation for veterinary technician and technologists scope of practice to outline what they should be able to do based on the level of supervision that they have.
So that’s like the goal that every state should be aiming towards to try to standardize. But that even then there’s different opinions within each of the states. When you have 50 different groups of people trying to form an opinion, it’s hard to come to a standard.

Dr. Andy Roark:
Stepping back to this Washington program. So you said in order to be a credentialed technician, you needed an AVMA accredited program with, this is not an AVMA accredited program. They do take the veterinary technician national examination and they do a state licensing test, but it’s not an accredited program. So are these credentialed technicians or are they going to be some credentialed assistant? I mean, and I don’t know, I’m just looking at this. They are trying to get my head around and say, what does this mean? Are these people going to get streamlined into the technician pipeline or are they going to not get streamlined? And this is going to be a thing of like, well, you’ve got this weird other certification that’s not exactly credentialing. Where does that go? Does that add to the disruption or is that going to flow into what we’re already doing?

Ken Yagi:
Yeah. So it’s a little bit complicated because it’s not a separate certification that we’re talking about. Actually, let me step back a second and say that the process is still ongoing, that they got provisional approval at the moment, but there’s an appeal process that people like Ashley Byrne, Ryan Frazier from Washington State Vet Tech Association, Ed Carlson, Ashley Seki from the National Association of Vets in America, they’re very much advocating for us along with the Washington State VMA and the AVMA in order to try to reverse this approval. But the provisional approval was that when people go through this apprenticeship program, they will actually be licensed veterinary technicians in the state of Washington. So the credential is the same, and so they’re being approved to do the same thing that people who have gone through the official accredited educational pathway would also have.
Now with that said, it’s a little bit different because this is what’s considered a alternate route of becoming credentialed that some states still have that allows people who don’t go through the standard AV merit program degree educational program and passing the national examination to become the credential technician in that particular state. So what does that mean? Well, I think it does mean that their education level’s going to be slightly different, so they’re trying to meet that standard in a different way.
So depending on how this apprenticeship program is set up and what their training process looks like and what the education that they get is, you would have two different kinds of people and it’s hard for us to make a judgment call on whether this program that’s being set up is going to be appropriate to create effective people who can safely practice as a veterinary technician or not. I think that’s something that somebody with expertise in taking a look at what a apprenticeship program would look like could tell us a little bit more about. But with that said, it didn’t go through the AVMA accreditation process because it utilized the state’s apprenticeship program approval process, which turned it into a little bit of a slight loophole that the state could use in order to create this pathway.

Dr. Andy Roark:
It feels like there’s a lot of people exploiting a lot of different loopholes right now in regard to medicine in general, but definitely to technicians, and I don’t mean that in a cynical way. I think it’s because there’s a ton of money pouring into vet medicine right now. I just went to the VMX conference and guys, our profession is fundamentally changing. The ground under our feet is breaking and shifting and it’s never going back and it’s just the amount of outside interest in what we do and the amount of outside money coming in is just absolutely huge.
So I feel like when people look at our profession and you see outside interest, whether it’s private equity or online retailers or things like that coming in, they look at our profession, they go, okay, well we’re going to make this work and there’s not enough doctors to meet demand or they’re not located in the right places. We’re not distributed correctly to meet demand and we have technicians and technicians are woefully underpaid and they want to do more things. The answer here is, we’re going to change the way we use technicians to get this work done. And I see a lot of leverage behind those dollars.
The people who are pushing all that stuff, they have real resources and they’re not interested in hearing about credentialing or how things have always been done. They’re interested in the outcome. So I’m seeing it’s almost like stress testing the system in a lot of ways. So I just look at that. When you hear me say this and say, I’m seeing a lot of influence and a lot of forces who have their own agenda and a lot of resources to back their agenda up. When you see them coming in, do you see the way that technicians are used changing radically right now or do you think that I’m making that up?

Ken Yagi:
No, you’re definitely not making it up because there’s different kinds of practice models that are coming in, different veterinary businesses that are being stood up and all them are going to need staff. So it really stems back to the shortage that we have and how do we fill that shortage with people that can provide the care that we need them to provide. So just taking advocate stance on this with that, I would say that if there is a veterinary technician shortage right now, the solution to that is to really elevate the profession. So what does that mean? If we want to have more technicians who can do the work that they can do, then make sure that they are clearly distinguished for having that credential and feel valued in that so they don’t leave the field. That we should pay them differently because of their credential. That they should be utilized for the education and that’s the way to do it, to keep them in the field that we have enough and more people wanting to come into the field so that we don’t have that shortage.
I think that feels like a long term solution because it takes a little bit of time to get that thing happening all over the place that people recognize this as not they want to come into. So then maybe that’s where your point comes in where if there are companies who are hospitals that are trying to fill the shortage with capable people going the route of on the job training, showing them how to do the procedures, perform the tasks and be able to do the more mechanical side of it without having the complete education behind it seems attractive because then you can get more people through to become credentialed. I think that’s the wrong way to go and I’ll be clear about that. I think that the education and people knowing the why we’re doing things behind the how and what we’re doing is definitely important and we shouldn’t deviate from that. But the solution to that really should be how do we get more people through the educational process?
I was looking at the apprenticeship program and it’s a three year experience program, so it’s going to take just as long as not four to get people through this program than the traditional education pathway. So it seems like it would be much more productive and better for the profession if we can get people through the educational pathway instead and provide the resources to do that.

Dr. Andy Roark:
Yeah. I don’t get me wrong, I completely agree. I was looking at it as well, and it’s like 6,600 on the job hours and three years. It’s not, send us your money and we’ll mail you a certificate. It is definitely not that. It definitely looks like it’s got some bones to it. So anyway, that’s why I wanted to talk to you about it was just to say I’m looking at this and it doesn’t look illegitimate as far as what it is, what they say that they’re going to do. I was just trying to tease apart what does accreditation mean and what does it mean when the AVMA says we’re not going to accredit it, and people are like, “We’re doing it anyway,” and then they go on.

Ken Yagi:
So I can add to that them, that’s a little bit different is that these people don’t have educational degree, so if they wanted to move on to have a bachelor’s degree in some science related degree or veterinary technology, they won’t be able to make that next step because they don’t have that associate’s degree. It also means that because it’s a non-standard pathway that they got credentialed in, if they decided to move to a different state and try to be credentialed in that state, they may not qualify. So they may not be able to practice in the way that they have been in the previous state. So it really, I think is a little bit more just to meet the needs of the hospital more so than trying to provide an opportunity for the people to continue growing and having a lifelong career.

Dr. Andy Roark:
Yeah. I agree with that. Hey guys, I just want to hop in really quick and give a quick plug. The Uncharted Veterinary Conference is coming in April. Guys, I founded the Uncharted Veterinary Conference in 2017. It is a one-of-a-kind conference. It is all about business. It is about internal communications working effectively inside your practice. If you’re a leader, that means you can be a medical director. It means you can be an associate vet who really wants to work well with your technicians. It means you can be a head technician, a head CSR, you can be practice owner, practice manager, multi-site manager, multi-site medical director. We work with a lot of those people. This is all about building systems, setting expectations to work effectively with your people.
Guys, uncharted is a pure mentorship conference. That means that we come together and there is a lot of discussion. We create a significant percentage of the schedule, the agenda at the event, which means we are going to talk about the things that you are interested in. It is always, as I said, business communication focused but of freedom inside that to make sure that you get to talk about what you want to talk about. We really prioritize people being able to have one-on-one conversations to pick people’s brains, to get advice from people who have wrestled with the problems that they are currently wrestled with. We make all that stuff happen. If you want to come to a conference where you do not sit and get lectured at, but you work on your own practice, your own challenges, your own growth and development, that’s what Uncharted is. Take a chance, give us a look. Come and check it out. It is in April. I’ll put a link in the show notes for registration asking anybody who’s been, it’s something special. All right. Let’s get back into this episode.
The point you made earlier that I want to circle back to that I think is really, really great and I think is really true and people should know it. I have a friend who is Melissa in Trek who I know she’s amazing. She’s a passionate educator, a die hard technician advocate and technician herself. And she teaches at the technician program near me. So I was talking to her and we were talking about when people are considering the technician program, they come in and they talk to her about going into a veterinary technology and she shows them the numbers and she says, “This is what your average credential technician makes and these are what the other programs we have at this school make.” And she’s like, “They see the echo cardiology technician, which is basically the same length program and it’s five times more money.”
And she’s like, “I just lose a huge percentage of them because they go, I can do this or I can do that. And it’s not like you’re saying, it’s $5,000 difference a year. It’s like, no, the salary’s more than double if you go into these other things that you’re qualified for. You have a science background, you have an interest in physiology, medicine, things like that, you’re already leaning in that direction.” And she says, “No wonder we have have a hard time filling technician school classes and things.” And I think she’s right. And I think that that’s what you’re speaking to. So let me push you on this a little bit, and I want you to look into your crystal ball in five years from now. What do you think is different, Ken, as far as technicians and how they work that is helping us move in that direction?

Ken Yagi:
There’s a lot of focus on technician utilization right now, and I think that we’re starting to realize that the fact that we’re losing people has a lot to do with people that feeling fulfilled in their career, which means that if they go through the schooling and they have a certain thought in their mind about how they’re going to function and they’re not being able to do the work that makes them feel meaning in their work is what’s leading to people leaving. So five years from now, hopefully all the concerted effort that’s going on right now is going to be fruitful that people in this field are going to learn how to utilize technicians better and will be utilized to the fullest extent and more people are going to be happy.
We’re doing things over here that’s called advanced practice veterinary nursing, which is at the highest level that we could have a credentialed technician, veterinary nurses here function, being able to take part in the physical examination process that they would make recommendations for treatments and while they perform the treatments, there’s a lot more advanced procedures that they could do on their own without feeling restricted by what’s normal for them to do. Those kinds of things will start happening where we start valuing the people who are very well-educated, very well experienced, combining the two to function in the way that we think they should be able to function.
And I think there’s certainly debates about whether we should be called veterinary nurses or veterinary technicians, but I do hope that we start to make the mindset shift that we are definitely in nursing in that it’s not just the science and technology that we handle. But it’s about the patient, it’s about the families, thinking about respecting all them and preserving their dignity through our care that [inaudible 00:23:2].

Dr. Andy Roark:
Well, there’s two pieces to opportunity for technicians I think. There must be a perceived value of technicians from inside of our profession, meaning the doctors need to allow the technicians to take work off their plate. The doctors need to recognize the value of technicians and say, “This is not a competitor for the spotlight. This is my friend, this is my colleague, this is my teammate.” And lean into that. So that has to happen for technician welfare to really improve. And I think that fixed a lot of things, that internal perception of drives the ability to pay people. But it also, and let’s be honest, I think a lot of times we talk about pay for technicians and pay for technicians and pay for technicians, and that is peace of it.
However, when I talk to technicians, pay is part of it, but I think at least as big a part is autonomy. It’s feeling empowered to be able to do work and to be involved and to make your own decisions and feel like you are having input and you’re not just an automaton waiting to be told what to do. That sucks. That’s not a career that educated and motivated people want to have. And honestly, I see at least as many techs leaving the profession because they feel like they’ve topped out, meaning there’s not more for them to do. Then the money. And I think the money is a constant drag of, hey, not only do I feel like I’ve topped out, but also I’ve topped out and I’m having a hard time paying my bills. And I think that’s a dark place to be, and I think that that’s why we’re losing tax at five years and seven years on average or whatever the number actually is. So I think that that’s so true.
The other part of this besides the internal perception of value is the external perception of value, which means in order for pet owners to pay for technician appointments, for technician services, for them to be willing to talk with the technician instead of the doctor, there has to be perceived value on the part of the pet owner. So when we talk about how we present our technicians, when we talk about what do we call our technicians, technicians or nurses, I think that there’s great value in using language that gets pet owners to see the value in the technicians. And I think it’s a worthy goal to say we’re going to educate them about what our technicians do. I think a whole lot easier path is to try to use language that they already understand and see value in.
And I understand that people don’t like the term vet nurse and I get it, and I’m not trying to argue with anybody. It’s just that I go, okay, well here’s the benefit. Regardless of how we do it, we have to get pet owners to see value in our technicians and not hold onto the old view of, “I want to talk to the doctor.” And you say, “Man, you don’t need to talk to the doctor. Quite honestly, you have a very competent person who is available and ready to talk to you and it’s not me.” And I think we have to do that internal sales job and that external sales job.
We talk about increased opportunities and things like that for technicians going forward, do you see more people or do you see driving factors in this being the technician specialties. Do you see more people doing VTS degrees or certifications in advanced areas? Do you see things like the master’s program at LMU starting to play a role in this advanced practicing or do you see an elevation of your classic credential technician, or a mixture of those things? Help me get my head around what this elevation, continued elevation looks like.

Ken Yagi:
Yeah. So is there more interest in VTS certification? Yes, definitely each year, and I know the most about the ECC Academy side, but each time the number of applicant grows, each time the number of examinee grows and depending on the year, the passing rate for the exam might be lower or higher depending on how people did. But with that said, we’re having more and more VTS is out there that have a heightened sense of awareness of what they should be doing. When you say working with autonomy and being empowered to do all the advanced procedures and making their own judgments based on their thought process. I think that the VTS certification process is particularly strong in people having the knowledge and being able to perform the procedures that relate to the specialty area. What I think is still variable is among that, how much clinical decision making ability do they come with and through their experience to gain?
And I think that’s where the master’s degree type educational pathway would be very helpful is that if we’re very good with the technical skills and the nursing procedures, but we need more clinical judgment skills, then that’s where the master’s degree could probably fill in. And that’s what it’s really tailored to do. Yes, there’s conversations about whether there should be a nurse practitioner like role or physician’s assistant role in veterinary medicine right now. And I know that the LMU degree is preparing people for something like that to happen, and that’s part of the intent. But even without that happening, people going through that master’s degree, I would think that comes out with better clinical judgment skills that makes them better partners for care with the veterinarians.
The one thing that I wanted to mention about the previous comment that you made about autonomy and empowering, I think one of the articles that talked about this Washington State program even used the term veterinary technicians are the right hands of veterinarians. And I look at that description and say, “That’s not true.” We’re equal peers, we’re professionals in our own that we have people who practice veterinary medicine and we have people who practice veterinary nursing or technology, whichever term you want to use. So then we really need to change our mindset in veterinary medicine as a whole as well of what a professional we actually are.

Dr. Andy Roark:
I like that a lot. If you are a doctor listening to this and you are just in regular general practice and you’re looking around and you have some credentialed techs that work with you and things and you said, “I want to work more collaborative with my technicians, or I want my practice to be a place that has some upper mobility for my technicians, or I really want to leverage my technicians and get a lot out of them and also give them a rewarding path to follow. But I don’t know where to get started or even what this looks like.” How do you advise people, Ken? People who say, “I only know the way that I was raised in the profession, but I want to see what the future might look like or I want to embrace technicians as colleagues, as teammates, as you said, I don’t know where to start.” How would you advise people?

Ken Yagi:
I think that’s one of the things that we’re all trying to figure out how to change the culture of veterinary medicine. There’s definitely conversations about if there were more veterinary and veterinary technology or nursing programs that were housed in the same campus and they learn side by side, would they have much better collaborative relationship to start out? And we have to start from the people coming into the field in order to truly change the culture. But I think just even asking that question to the people who are in the practice would be a really great place, place to start because who would be the best to give you more information about how we can work better together? Probably the people that you work with.
But there are definitely a lot of resources that are out there that the people who are out in the conference circuit talking about team-based veterinary care, how do you utilize technicians better? I think there’s all sorts of resources out there that we can take a look at. And I would also want the point with the great work that NAVTA’s doing these days in promoting and advocating for technicians and they can be as a resource as well.

Dr. Andy Roark:
Yeah, I love it. I’ll tell you in my own practice things I’ve found to be helpful just for doctors, they’re scared of letting go of the reins or saying, “This is how it’s always worked, and I don’t know about changing it.” Pilot programs are your friend. I think just saying, “Hey, let’s try this for a little while and see how it goes, and then we’ll reassess.” I think that’s a good way of starting to give your technicians more space in a way that the doctors can go, “Okay. Well, we’re all going to try this and we’re going to work with it.” I think that that’s good. I really love what you said about talking to your technicians. I think this is a collaborative experience and say, “What are your interests and how do you see engaging in this system?” And I just think that that’s such a healthy way to do it.
And the last thing I say is, if we’re going to make changes the way we practice, everybody needs to know what the goal is and feel safe. So a lot of times what happens is, I would say sit down and figure out how the doctors and technicians might work together in your practice in a way that would be mutually beneficial. And then step back and say, “Great. That’s where we want to go. What are the steps between now and there so that everybody feels comfortable and everybody’s trained, that everybody’s on the same page, and how do we break those steps up and how do we put them on the calendar and how do we slowly over the course of a year start to move in this direction again?” So you moving in a methodical way and you’re supporting people who are taking on new things. And this is the part a lot of people miss. How are you supporting the doctors who are giving things up? Because they often struggle a lot too.
So I feel like this is a gradual process, but I love that you say talk to the tech. I think that communication is absolutely key. But anyway, it’s just something I’ve been thinking a lot about and been working on them own business recently, so anyway. Hey Ken. Thank you so, so much for being here. Where can people find you? Where can they learn more about VEG and NAVTA?

Ken Yagi:
For NAVTA, it’s navta.net, it’s the website. VEG is veg.com. I am also on LinkedIn, Instagram, and Facebook or something like that. I post regularly. So would love to see a lot more of you having some of these conversations. I put out questions related to the profession out there all the time now.

Dr. Andy Roark:
Cool. Awesome. Thanks for being here buddy. Guys, take care of yourselves. Thanks for listening. Thanks for being here. Be well. And that’s our episode guys. Thanks for being here. Thanks to Ken Yagi for coming on and sharing his wisdom. If you enjoy this episode, if you got something out of it, go ahead and leave me in the rush review wherever you get your podcast. That means the world to me. Share it with your friends. It’s also how people find the show. Anyway, that’s it from me, gang. Take care of yourselves. I’ll talk to you soon. Bye.

Filed Under: Podcast Tagged With: Vet Tech Life

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