Dr. Carolyn Brown is the Vice President of Medicine for Community Medicine at the ASPCA which provides basic and preventive care to pets living in underserved communities and HQHVSN surgeries to at risk cats and dogs via mobile and stationary clinics in New York City, Los Angeles and Miami. In this episode, she sits down with Dr. Andy Roark to discuss the push for a Spectrum of Care approach to veterinary medicine, pushback against the idea, and how that differs from what is currently being offered.
LINKS
JAVMA Article: avmajournals.avma.org/doi/full/10.24…ce=email-optin
ASPCAPro Spectrum of Care article resource: www.aspcapro.org/research/provide…ess-more-clients
ASPCA.org
ASPCAPro.org – ASPCApro.org provides tools and resources for animal welfare professionals, veterinary personnel and volunteers. We take a progressive approach to helping the country’s at-risk animals, promoting cutting edge research to advance the field.
Uncharted Podcast on iTunes: podcasts.apple.com/us/podcast/the-…st/id1449897688
Uncharted Culture Conference Oct 21-23: unchartedvet.com/uvc-culture/
Charming the Angry Client On-Demand Staff Training: drandyroark.com/on-demand-staff-training/
Dr. Andy Roark Swag: drandyroark.com/shop
All Links: linktr.ee/DrAndyRoark
ABOUT OUR GUEST
Dr. Carolyn Brown is a graduate of the College of Veterinary Medicine at Cornell University and has extensive experience in small animal medicine, shelter medicine and high quality, high volume spay/neuter HQHVSN) surgery including pediatric and TNR programs. Carolyn worked in general small animal private practice, at a for-profit low cost clinic and a large limited intake shelter and adoption center before joining the ASPCA in 2011. Carolyn is currently the Vice President of Medicine for Community Medicine at the ASPCA which provides basic and preventive care to pets living in underserved communities and HQHVSN surgeries to at risk cats and dogs via mobile and stationary clinics in New York City, Los Angeles and Miami. Dogs and cats in the care of shelters, rescue groups, foster programs and TNR practitioners also receive HQHVSN surgery through the department. In 2019, Community Medicine performed more than 68,000 surgeries. Carolyn determines and evaluates medical and surgical protocols for the department and maintains the program’s Standard Operating Procedure Manuals. She also leads a team that quantitatively and qualitatively evaluates the program’s medical standards of care and efficiency by carefully monitoring the metrics of the program on a monthly basis.
Editor: Dustin Bays
www.baysbrass.com
@Bays4Bays Twitter/Instagram
SHOW TRANSCRIPT
Dr. Andy Roark:
Welcome, welcome, welcome to The Cone of Shame Veterinary Podcast, I am your host, Dr. Andy Roark. For those of you who have listened for a while, you know that I have some concerns about accessibility in vet medicine. I worry about pet owners not being able to get access to care or not be able to afford it. I don’t want to live in a world where, only wealthy people get to have pets, that doesn’t seem right to me, it’s not what I got into this profession for and I think a lot of other people are having those thoughts. And at the same time, I don’t think it’s okay to continue to go on and not pay our support staff a living wage and to work until we burn out and to just, sort of, sacrifice ourselves to the profession.
Dr. Andy Roark:
So, that is a battle that I have been fighting for the last few years, really. And I’m looking for solutions and I’m looking for ideas. And in that vein, I’m happy to present to you today’s podcast. I’m talking to Dr. Carolyn Brown of the ASPCA and we talk about spectrum of care. There’s a JAVMA article about this that I’ll link in the notes. Spectrum of care is an approach to making care accessible. It is fundamentally changing the way that we think about and talk about medicine. There’s probably stuff in this podcast that you agree with, there’s probably stuff in this podcast you already do. I’m almost certain, there’s stuff in this podcast that you probably don’t agree with. That’s okay, this is all about exploring, it’s about looking at new ideas. These are ideas that I think are worth our thought and consideration. 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 Dr. Carolyn Brown to The Cone of Shame Veterinary Podcast. Thanks for being here.
Dr. Carolyn Brown:
Oh, thank you for having me.
Dr. Andy Roark:
It is my pleasure. You are the vice president of Medicine for the Community Medicine Department of the ASPCA. Is that correct?
Dr. Carolyn Brown:
Yep. That is correct.
Dr. Andy Roark:
What does that mean? What do you do in that role?
Dr. Carolyn Brown:
So, I oversee the quality and reach of medicine that the department provides. We provide preventive and basic care in New York City, Los Angeles and Miami, through stationary clinics and also mobile clinics.
Dr. Andy Roark:
You came into my radar this month, October 1, 2020, you were the first author on spectrum of care, more than treatment options, which was published in JAVMA. And I wanted to talk to you about spectrum of care. It’s something I think is really interesting, I think it’s starting to get discussed. I think it’s a big area that we need to move into in our profession and embracing it and talking a lot more about it. So, let me start really broad and just, sort of, ask you, what brought you to talk about spectrum of care? What is the problem that it addresses? And then we can go ahead and define spectrum of care, in that context.
Dr. Carolyn Brown:
So, spectrum of care is one mechanism we can use to increase access to care. And what it literally means is, offering treatment options to clients and patients, that range from the very simple, just monitoring cases or providing empirical care or palliative care, through a spectrum, a gradation, of increasing complexity and intensity, until we reach the most intensive, invasive and expensive treatment option. So, the spectrum of care is that full range and in order for veterinarians to increase access to care, we need to be able to access all of those options along the range.
Dr. Andy Roark:
When you talk about spectrum of care, in the individual vet clinic, are you talking about every clinic, sort of, having their own spectrum of care? Or are you talking about segmentation of clinics along the spectrum of care? Meaning, we have referral practices, we have, sort of, white glove concierge practices, we have more community focused practices. Or are you talking about, within a single practice, we should have, sort of, a variety of these services. How does that manifest?
Dr. Carolyn Brown:
I think it’s both. I think that there are certainly practices that are more geared to clients who come to the practice and expect very state-of-the-art care and are willing and able to pay for it. And there are clinics, at the other end, which I refer to as access to care clinics, that work with people and pet owners who have limited resources. But within any single practice, one should be able to offer a range of options, because there is no one treatment option that is the correct one for every patient and every family in a specific situation. And the options that we give should be tailored to that pet and that family’s needs.
Dr. Andy Roark:
When we start talking about spectrum of care, I hear a lot of people, sort of, say, is this a new idea? Haven’t veterinarians done this traditionally? And so, let me put that forward and say, how is, sort of, a spectrum of care approach different from what we’ve always done in vet medicine?
Dr. Carolyn Brown:
So, yes, veterinarians have always offered treatment options and we’ve always offered them, kind of, with our backs against the wall because we have to, not because we believe in them, not because we believe that there are multiple treatment options that are good medicine for each patient. And not because we believe that clients may want to choose different options, even if they are able to afford a certain option, they may choose another because that one fits better with their goals of care for their family and what they want for their pet.
Dr. Andy Roark:
So, when you put this forward, it’s not just about financial accessibility to you, it is very much about, sort of, a cultural fit or fitting. How did you put the values that they have for care for their pet, the family?
Dr. Carolyn Brown:
Yeah, exactly. And veterinarians generally assume that, the best treatment option for every pet is the most expensive, intensive and advanced. And there’s a lot of reasons why we think that, right? We think that because in society, usually, the most expensive thing is the best thing, so we’re a little brainwashed that way. And we also think that because our veterinary school training is done mostly at tertiary veterinary hospitals that have all the specialists and not only specialists but the best specialists, who are writing the books and the textbooks and the articles. And so, we come out of that school and we believe that there is one best treatment for every condition and that’s just not true.
Dr. Carolyn Brown:
It’s not true scientifically, there is very few conditions for which there is one proven best treatment option. And even if there is, what’s important to each family and what their goals of care for their pet are and what they would like to see happen for their pet, may be different than that best treatment. Even if it’s not about money, it might be about the pet’s temperament, that that pet doesn’t do well in the hospital. And so, if the treatment requires multiple visits or hospitalizations, the owner may choose not to pursue that treatment.
Dr. Andy Roark:
Yeah. This is why I wanted to have this conversation because I think you’re really hitting on things that I’ve seen in medicine, since vet school, that have been, sort of, the black and white model, that I felt like was, sort of, put forward was, a patient needs to be hospitalized and not hospitalizing always made me feel guilty. Even when I look at the specific situation, I look at the needs of the pet owners, I look at what they’re going to let me do. And I go, boy, treating this pet outpatient is going to be… First of all, it’s going to be what happens. And it’s just like, this is how this is going to go. And honestly, when I weigh the pros and cons, outpatient treatment just makes sense in this specific case.
Dr. Andy Roark:
But I feel like, a lot of us as veterinarians have this, sort of, guilt that was put on us in our training of, the gold standard medicine is the best medicine and we should always be striving to do the gold standard of medicine. Which means, if you don’t do the gold standard, then you’re coming up short. And as I’ve practiced years and years, I’ve come to really get a bad taste in my mouth about that idea and I, sort of, reject that idea that the highest standard of medicine is the “best medicine.” It just seems so case dependent to me. Do you agree?
Dr. Carolyn Brown:
Yeah, absolutely, it is. And there are a lot of barriers to veterinarians really successfully practicing a spectrum of care. And one of them is exactly what you said, it’s our own guilt and our own anxiety about strain from that gold standard that was placed in our brain so long ago. But in order for veterinarians to really effectively practice standard of care, to benefit their patients but also to benefit themselves and decrease their own stress and anxiety about practice, we have to embrace that multiple treatment options represent good medicine, that there’s not just one. What I hear a lot from veterinarians, when I talk to them, when I talk to veterinarians who work at access to care practices who are practicing or striving to provide lower cost medicine. One of the things I hear often is that, they feel like they are cutting corners, that they are making decisions or providing care that is substandard. And we really need to move away from that, we really need to accept that there are many different treatment options that represent good medicine.
Dr. Andy Roark:
Well, now we’re in the weeds, I think, a bit. So, I completely agree with your point about the training. I had Dr. Michael Blackwell on the podcast a couple months ago and we were talking about pet health equity and getting care for everybody and making it accessible. And he talked, I think, the words that he used that I liked were, we were in vet school sitting at the feet of the specialists and I do feel like that’s, kind of, a pretty good analogy for what it’s like in a lot of our training. And I like that you put, we are trained by specialists and we’re trained by specialists who write textbooks. And so, I think that that pressure is definitely there. When we talk about cutting corners and that feeling of cutting corners, when I said, we’re in the weeds now. I think that’s a murky part of our profession, isn’t it?
Dr. Andy Roark:
So, we talk about the standard of care and maintaining the standard of care and not going underneath the standard of care and then we talk about cutting corners. The problem is, nobody knows what the standard of care is. And I don’t know that it can be defined and it’s always changing but it’s how we’re measured. So, I think one of the pushbacks against accessibility in pet care, in some degree, is people go, well, I don’t want to get sued or I don’t want to end up in front of the state board because I didn’t do the thing that is a higher standard, I didn’t do a higher standard of care. And I don’t think either of us are saying, don’t offer people the option of doing higher standards of care, I think that that’s required. But there is, kind of, this nebulous, what is the standard of care? And that really determines whether or not we’re cutting corners.
Dr. Andy Roark:
How do you navigate that when people say, well, I don’t know what… no one wrote down what is reasonable and it’s highly subjective. How do we feel good about a spectrum of care when we don’t have a clean, clear standard of care?
Dr. Carolyn Brown:
Yeah. That is one of the big… That has been one of the things that it causes a lot of anxiety for veterinarians, right? Figuring out where that point is. And I think one of the things that happens is that, veterinarians default to the gold standard, to be sure that they are, at least, meeting the standard of care as defined in their practice act. But I think that one of the ways that we can let go of that anxiety is to understand that, all of those bad outcomes that happen, that veterinarians get sued, that their licenses get challenged, that there are bad reviews about them online, are mostly not about the medicine that they practice. Those complaints, those disgruntled clients, are happening mostly because of communication and because of a lack of bringing the client into the process and inviting them to be part of the decision-making process and being clear on what the expectations are of different treatments and different outcomes.
Dr. Andy Roark:
Yeah. That’s so true. The number of board complaints we see tied to communication or as you say, being left out of the process and feeling surprised by how things went or feeling uninformed. I think that we understate that in our own minds and we overstate what role the actual medicine plays in ending up in those cases. You’re a whole lot more likely to end up with a board complaint because of how you communicated something, than how it actually turned out medically, in my experience. And, again, that’s not giving a pass to negligence, in any way shape or form, but I really resonate with your statement about this being a communication. And I always say, part of this is about building and maintain trust, right? It’s understanding where people are and giving them options and supporting them in their decisions, as they go along.
Dr. Andy Roark:
Hey guys, I just want to jump on in here real fast and share with you some quick news from across the Dr. Andy Roark and Uncharted Veterinary conference world. Over at the Uncharted Veterinary Podcast, Stephanie Goss and I are breaking down, what’s it like to jump from a small practice to a big practice? We’ve got a manager who is in a small practice, looking at what it’d be like to be a manager in a big practice. And she’s feeling a bit overwhelmed by the possible change and Steph and I talk to her about what you need to know to move between small and big practices. If you ever thought about making a change from a big to a small or small to a big, it’s a good episode to run through, I think it’ll make you feel pretty good about yourself in your knowledge and your skills. Also, on the Uncharted side, if you have not registered for our Uncharted Culture Conference, you’re about out of time. It is going to run October 21st through the 23rd, it is all about culture.
Dr. Andy Roark:
This is for team leaders who love culture, who love having a great place to work, who love making their staff happy, who like that go to work in a place that makes them feel good about the fact that they spend a tone of their time there. If you are a culture practice, you should be here. You should be here and you should hang out with other people who are all about culture. And so, that’s what we’re doing. It is a virtual event, so zero travel time. I’ll put a link down the show notes, you can always head over to unchartedvet.com and find more or information. Let’s get back to it.
Dr. Andy Roark:
How do you see this, sort of, unfurling in the future? So, let’s say that spectrum of care really is embraced by that medicine and by individual practitioners across the country. What does that look like, in your mind? How is a world where this is the norm, how does it differ from what we have now?
Dr. Carolyn Brown:
So, moving forward, the first thing that should happen when we’re deciding what treatment options to present to owners and clients is that, we should be having conversations with them about what they would like to see. What are their goals of care? What’s important to them? What do they think is important to their pet’s happiness? And how would they like to see things going forward? We also need to, right upfront, have conversations with owners about, what are their resources? What are they financially able to put toward the care of their pet? And another big resource that we miss is time, right? So, how much time are they able to devote? Are they able to come for many visits and spend time at home doing treatments? And so, the first thing is to have that, kind of, open conversation, invite clients to tell you their story, tell you about their pet, tell you about what is going on and what their goals are and what they would like to see happen.
Dr. Carolyn Brown:
Then, ideally, the veterinarian would take that information and on the other side of their brain, they would have all of the treatment options that are available. And what the veterinarian would do at that point is match the closest treatment option to what the owner is describing as what would match for them and present that treatment option as the first option. Not that you don’t present other options but you start with something that seems like it will match what the owner is looking for and their resources and then, work out from there. Traditionally, what we do now is start with the gold standard, right? We all present the gold standard first and whether we know it or not, we are influencing clients and imparting in them that, that is the best treatment and that is the one we think they should pick, that very first one that we chose.
Dr. Carolyn Brown:
And we know that because in human medicine, when people are making decisions about their own healthcare, the physician has a lot of influence. And we also know that when people are presented with a list of options, they just naturally gravitate toward that first choice. So, if the first choice is the gold standard, we’re communicating, consciously or subconsciously, to the client, that that’s the one, that’s the one they should pick. But if we start with one that better matches their goals of care and their resources, they have the freedom, the permission, to choose the one that is actually best for them.
Dr. Andy Roark:
Do you think there’s a danger of, that’s using spectrum of care as a justification to not advocate for a higher quality of care for pets? My concern is, if you gave me the out, would I get lazy over time and not advocate for a higher standard of care and just justify to myself and say, well, I gave them a spectrum of care and the first thing was some subQ fluids, some antibiotics and we’ll see what happens in the next couple of days. I always feel like we have to get up to advocate for our patients. Is there a danger of using spectrum of care to abdicate that position of advocate?
Dr. Carolyn Brown:
So, I think there’s two points here. One is, definitely offer the gold standard, the most expensive and intensive treatment. That should not be left off the list but it shouldn’t be the first thing on the list. The second thing, and I’ve had a lot of conversations with colleagues about this, about the idea that, as veterinarians, our job is to advocate for the patient, right? That we are there to make sure they get the best care possible. And my attitude toward this is always or has become, over time, that advocating for something that is not possible for that pet is not really helping them. All it’s doing is making their owner feel inadequate, shameful that they can’t provide what their pet needs and not creating a good environment for the relationship between the veterinarian and the client.
Dr. Andy Roark:
No, that’s a great answer. I’m going to sit with that a bit. I like that a lot, I think that that’s totally… I think that’s a great approach. How would we change the way that we train doctors, in order to implement spectrum of care and to better prepare graduates for this? One of the things that I see with a lot of young graduates, I see frustration in their first jobs when they come out and they’ll go to a rural practice. And I’m not saying, not all rural practices, but they will go to an underserved community, they will go to, how’d you put it? Access to care practice. And it’s not at all like what they were trained on in vet school and I think that there’s a whole lot of uncertainty in that. And that, sort of, feeling of I’m cutting corners.
Dr. Andy Roark:
Well, if you did the medicine you’re doing now in vet school, yes, you would 100% be accused of cutting corners. But the reality is, this is a very different type of medicine and you are dealing in the realities of the community that you’re working in. How do we change training to help people grasp that? And also to have the knowledge to practice across the spectrum.
Dr. Carolyn Brown:
That’s a really good question and something that we struggle with a lot at the ASPCA. There are veterinary schools that are working really hard to update their curriculum, to include work in underserved communities, to include more realistic scenarios of what students will find when they go out into practice. What we try to say or the way that we try to frame it to our new veterinarians is to say, in order to really practice veterinarian medicine well, you could have lots of bells and whistles, you could have lots of diagnostics and you could just read out results but the real art to being a veterinarian and the real skill is learning how to take a really, really good medical history, so that you can get the clues from a client that you need to figure out what to do. Learning how to do a really, really sensitive exam so that you can pick up everything that you need to and being able to come to conclusions about what’s going on with that pet, through those means, rather than just shotgun testing everything at the pet.
Dr. Andy Roark:
Yeah. That’s fascinating. I really love that, the history and the physical examination as guiding diagnostics. We’ve heard concern in the vet community, over probably the last decade or two, about a move away from emphasizing the physical exam towards shotgunning diagnostics. And I think your point about this is a starting position of, gosh, I think that makes so much sense. It feels very actionable as well. One of my favorite things to do with vet students when they come and visit the vet clinic is, I will, at some point, take them aside and I will pick up a pet and I will put the pet in front of them and I will say, this is my pet and I’m giving it to you to do a physical examination. And the physical examination costs $62 and I want you to show me a $62 physical examination.
Dr. Andy Roark:
And I think that sounds like a financial challenge and I don’t mean it to be other than, what I’m really saying is, I want you to show me the value. I want you to show me… I’m giving you a number to put in your mind but I want you to show me a value in this physical examination. And it’s always fascinating because there are vet students that absolutely rise to the challenge immediately and they start to ask me questions about my lifestyle with my pet and what I do with my pet and they’re examining the pet and they’re telling me what they’re doing. And there are other students who really seem to, kind of, freeze and not know how to respond to that or how to get started.
Dr. Andy Roark:
And I do it not to see their response but I do it because it’s my way of really tying to drill home the importance of that physical examination and that rapport with the pet owner in, sort of, a tangible way. And I do it when they’re visiting from vet school, so that they can still go back to vet school and think about it and practice and get that, sort of, ironed out. So, no, I love it. Are there ways that you see people getting this wrong? Meaning, people who are experimenting with spectrum of care, they’re trying to be more accessible to pet owner and they’re stumbling or they’re missing tricks. Is there anything like that, that holds people up?
Dr. Carolyn Brown:
So, the best way I can answer that is to tell you how I got derailed in my own career. And it has to do with what we talked about a little bit earlier, with offering the gold standard as the first treatment. And clients automatically wanting that and really… you could see on their face, you could feel it, how bad they felt that they were not able to provide that to their pet. And I would often then have to backtrack in my conversation with the client and say, hold on, if you had all the money in the world, maybe you still wouldn’t want to do this. It requires a lot of time away from your pet, your pet may be painful or have a long recovery, maybe you wouldn’t want to do that anyway. But by putting that choice first, I opened up that door so that the client would feel that.
Dr. Carolyn Brown:
And I spent a lot of the rest of my conversation with the owner, trying to make them feel better about the choice they ultimately were going to take. And I think, that’s really the crux, to me, that’s the crux of the problem, is that we are so focused on making sure, number one, we cover our own butts by making sure we’re offering that gold standard and documenting that the client has refused it. And also, trying to make sure that we don’t feel that anxiety about the level of care that we perform, that we’re offering that care first. And I think really getting into the mind of the owner and offering the options in a way that really gives them the freedom to decide what they want. And sometimes we have experiences in our own lives and with our own pets that, kind of, highlight what we’re trying to do with others. And is it okay if I tell you a story about one of my pets?
Dr. Andy Roark:
Oh, please.
Dr. Carolyn Brown:
About 10 years ago now, I had a 12 year old Cocker Spaniel and I was giving her a bath and I felt a little nodule at her anal gland. And within a week or two, I had done an excisional biopsy and sent the sample off. And the biopsy came back as an anal gland adenocarcinoma and it had clean margins but the margins were very narrow. And I was able to have a consultation with a veterinary oncologist and she told me that, what she recommended was that, I go back in and do a wide excision. There’s not a lot of space around this anal gland, as that’s not a little dog. Anal gland [inaudible 00:28:16] on a little dog but she said, I should go back in and do a wide excision and then, follow up with radiation. I certainly had the financial means to be able to do that, I also had the time to do it.
Dr. Carolyn Brown:
The field that we work in, our employers are generally very, very understanding of our needing to take time off to care for our pets. And I thought about it a lot and decided not to do it. I decided, based on not wanting to put the dog through it, other things that were going on in my life at that time, I decided I was just going to watch it. I wasn’t going to do either of those things. And sometimes you make those choices and they have happy endings and sometimes they have sad ending. And I was very lucky that it was a happy ending, that she lived for another five years and passed away from something unrelated to anal gland adenocarcinoma and never heard from it again. But I think if I did not have the knowledge I had, if I were not a veterinarian, I would’ve had a much harder to choice or felt much more guilty about not taking the path that was laid out by the oncologist.
Dr. Andy Roark:
Yeah. No, that’s a great story. It resonates, I think, with almost all of us. I think we’ve all seen cases where we know what the gold standard of care is and we also know that if it was our pet, we probably wouldn’t go that way, for different reasons. So, I think that makes a ton of sense. Thank you so much for being here, Dr. Carolyn Brown. Your article in JAVMA, spectrum of care, more than treatment options, just came out this month. I’ll put a link to it in the show notes. Where can people learn more about you, the Community Medicine Department and/or the ASPCA?
Dr. Carolyn Brown:
So, there’s information about the article at aspcapro.org/research, where you can see an overview and also see links to other information about access to care and community practice. And if someone has questions for me specifically, I can be reached at carolyn.brown@aspca.org.
Dr. Andy Roark:
Thanks so much for being here. Guys, that is our episode, I hope you enjoyed, I hope you got something out of it. As always, if you did, please share it with your friends and honestly, the other thing you could do, that’s always a big help for me, is write an honest review on iTunes, wherever you get your podcast. It helps people find the show, it gives us some feedback, it’s a nice little pat on the back for me and the team for putting on the podcast every week. So, anyway, guys, take care of yourselves. I hope you’re getting ready to have a great Halloween and that things are going pretty darn well in your practice. All right, stay safe everybody. Bye.
