Dr. Simon Platt and Dr. Andy Roark dive into neurology’s challenges, emphasizing individualized care and accessible diagnostics. Dr. Platt introduces a forthcoming neurology resource aimed at providing comprehensive information for neurology enthusiasts, all in the pursuit of demystifying neurology and prioritizing accessible patient care.
This episode is brought to you by Nationwide Pet Insurance.
LINKS
Upcoming Webinar with Dr. Simon Platt
ABOUT OUR GUEST
Dr. Simon Platt, a distinguished European and American veterinary neurologist with 23 years of academic expertise, embodies a passion for teaching, research, and clinical excellence. His extensive contributions encompass over 240 published scientific papers, including 70 chapters in renowned veterinary publications. Notably, Dr. Platt has co-authored five authoritative textbooks in veterinary neurology, showcasing his commitment to advancing the field’s knowledge base.
A trailblazer in academia, Dr. Platt has secured over $3 million in grant funding, led NIH translational research teams, and held pivotal roles within committees for ECVN and ACVIM. For over two decades, he has mentored neurology residents globally, while his dedication to education extends through the management of educational websites, notably featuring a pioneering 3D virtual-reality dog model for practical neurological examination teaching. Additionally, as the founder of SEVEN, a not-for-profit group, he established an annual southeastern regional clinical neurology conference, fostering collaboration and knowledge exchange within the field.
EPISODE TRANSCRIPT
Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I got a great one for you today I am here with Dr. Simon Platt. He’s a veterinary neurologist. I did not know him before we sat down to record. This is my first time meeting him. His resume is amazing and so I just start off with that. But he has done so much and he is so smart and man is he approachable and easy to talk to and I could listen to him talk for hours and hours. So anyway, I was thrilled to get to talk to him. He has this really interesting way of looking at neurology, this genuine desire to bring it to general practice and to make it not intimidating to GP’s and just to help keep care affordable and accessible for people. And you’re like neurology and affordable don’t tend to go together.
You got to hear what he has to say. It’s just been really good. It is a great conversation. Anyway, I’m actually doing a webinar. I am hosting Dr. Platt for a webinar December 13th. It is made possible by Nationwide. It is totally free for you guys. I’ll put a link in the show notes to register. It’s got RACE CE attached to it. It is a sweet deal. I am really looking forward to it. After our conversation today, I’ve got pages of notes. I’ve got a bunch of questions from our conversation that I’m sitting on until we get together. So anyway, that’s coming up. This is a great episode. I have talked long enough. Guys, this episode is made possible ad-free by Nationwide. Let’s get into it.
Kelsey Beth Carpenter:
This is your show. We’re glad you’re here. We want to help you in your veterinary. Welcome to Cone of Shame with Dr. Andy Roark.
Dr. Andy Roark:
Welcome to the podcast Dr. Simon Platt. Thank you for being here.
Dr. Simon Platt:
Thank you very much. It’s an honor and thanks for the invitation.
Dr. Andy Roark:
Well, it is a huge honor to have you here. For those who do not know you, you are a board certified European and American veterinary neurologist. You have published over 240 scientific papers. You have co-authored five veterinary neurology based textbooks. You have gotten a bajillion dollars in different research grants. You have have trained neurology residents for 22 years. This podcast is beneath you, sir. That’s what I think.
Dr. Simon Platt:
No, I’m still the poster child for imposter syndrome and after listening to all of that, I wondered it “Was that me? Where have those years gone?”
Dr. Andy Roark:
It’s a blink of an eye. But anyway, it is an amazing resume. I am happy to have you here for a number of reasons. The first one is I am going to be hosting you in a webinar. You and I are doing a webinar together on spectrum of care neurology cases on December the 13th. It’s made possible by Nationwide, which is very lovely of them. So it’s free for everybody, but I’ll be hosting you. It’s a one hour webinar. It’s got an hour of RACE CE on it. I’ll put a link in the show notes. It’s for people to register for that, but you and I are going to get to talk then. And before we did that, I always like to talk to people in sort of a more conversational format. And so I thought this would be a good opportunity for us to start to talk about something that I’m really interested in and that’s accessibility and it’s spectrum of care.
So what I mean when I say that to lay out some terms, I have concerns about keeping veterinary medicine available and affordable for pet owners. And so one of the things that is really interesting to me is looking at people like yourself who have such deep expertise in specialties and saying, what does this look like at the general practice level to do right by the patients? And it’s always that balance of advocating for patient care and for doing what’s right for the pets and educating the pet owners and also trying to meet pet owners where they are. And neurology is a particularly intimidating specialty to me when I look at it from this standpoint because it feels like very quickly we get to the multi-thousand dollar MRI machine. And I also have felt, I’ve had the feeling as a general practice doctor before looking at neuro cases of like, I can’t cut this, I can’t cut this. My medications feel fairly limited. It can feel like there’s not a lot of options when I’m looking at a neurology case. And so anyway, let me just pause there and open that up to you. What is your general philosophy when you look at neurology in an access to care capacity?
Dr. Simon Platt:
Yeah, I mean you touched on a lot there. I would have to admit neurology is very intimidating. That’s the first problem, not just to us as veterinarians. I mean, I remember starting out and to me I really hated neurology. We got taught by a stand-in neurologist who was our cardiologist. She admitted she hated it. She said, I’m not really sure what I’m doing here. I’ll teach you some neuroanatomy and then we’re away. And it didn’t really make sense. I thought, well, everything I see seems to circle, get steroids and die. This doesn’t really make sense. And so I was a bit scared of it. Now it’s intimidating on every level. The clinical exam is intimidating. Look at some of the other specialties and some of those are intimidating, but the clinical exam part, that’s not dermatology to me, very intimidating. But the clinical exam doesn’t seem that intimidating.
But for neurology, very intimidating check sheet based, you check these things, you don’t really know what does that mean, but I’ll just check it. No one’s watching and it doesn’t really add up. And so we need to get rid of that. That’s the first thing. But then it goes on because as you said, it seems like you can’t do neurology without expensive tests, invasive tests, and it seems that you can’t do neurology without surgery. And so I’ve approached it from the general practice background that I had where I was frightened of it, intimidated of it, trying to work out how on earth I could actually do it without some of those tests where we came from a background where MRI wasn’t actually being used. And so the spectrum of care approach was something that I kind of adopted early but didn’t really know how to articulate it, didn’t really know to say, well, this is spectrum of care.
To me it was all about individualized medicine, individualized for the client and for the pet. So for the client, you are individualizing it based on their personal circumstances, obviously finances, their geographic location, could they get places to do further tests? What’s going on in their life? Are they working 16 hours a day? So we’re making some decisions around that. And then we’re making some individual decisions around the patient as well. Because a patient that’s two years old that has condition A would be treated very differently from a patient who’s 19 years old that has condition A maybe has exactly the same signs. And so we’ve got to take those into consideration and that’s what all of us, I think, in this profession do. And so all of a sudden then it had a name of the spectrum of care. And I felt that’s helped because I feel right at the start we talked about poster children, but poster children.
I think for spectrum of care, one of them is neurology because we have to be able to offer a stepwise approach in diagnostics and a stepwise approach in therapeutics. And the problem that we have many times is that other specialties, other areas of veterinary medicine can do this based on a lot of evidence in terms of what the disease is. And we never get there because without a biopsy of the brain or of the spinal cord, we never have a precise answer. Whereas obviously if you’re dealing with liver disease, you may have a biopsy, you’re going to have other areas of veterinary medicine where it’s a little easier, a little cheaper, a little safer to get a diagnosis. For us, we’re always even spending thousands of dollars MRI type, you’re always guessing. And so I’ve encouraged our students to stand up and have a mantra and say, I’m a veterinarian. I love to guess. And that’s not playing down evidence-based medicine, because you need the evidence to piece together the facts that are given to you. Let me see this dog with this signal and these presenting signs and this neurologic exam piece, those pieces of the evidence together and come up with, well, what could it be and how would they respond to the treatment? So the evidence is out there for those aspects of the case, but not really of what exactly does it have.
Dr. Andy Roark:
So lemme jump in here because a couple of things that struck me. First of all the, for a moment I thought if I ever wrote about a book about neurology, I would call it circle get steroids and die. But now I think I would change that. I think I’m a veterinarian. I love to guess is a better title for the neurology book that I would write.
Dr. Simon Platt:
And the follow-up would be, I am a neurologist, I love steroids. And now some people will be tuning out and going, can’t believe he said that, but I know when the lights get turned out. That’s what the dogs and cats, that’s what we’re using. It’s just about appropriate use. So circling steroids and maybe doesn’t do so well, you need to know the dose of steroids. That’s the evidence in there.
Dr. Andy Roark:
I love it. I always love specialist secrets where they’re, I will tell you I have a hundred percent referred patients to a specialist because, and I knew they were going to give steroids, but I didn’t have the guts to do it. And so I gave it to them and they took the liability and they did it. So it sounds to me like what you’re saying. I just want to clarify that. So first of all, I love the fact that you come from a place in the general practice background and this was intimidating and neurology was scary. I can resonate with that. And I think a lot of other people, it sounds to me like what you’re saying is because getting an actual indisputable diagnosis is so hard, that makes it much more challenging to break neurology down into sort of a clear diagnostic step to a clear diagnostic path that we could walk through because we don’t end up with enough evidence because we don’t often get all the way the diagnosis. And so the fact that we don’t come with that diagnosis makes it harder to teach doctors. This is step one, this is step two, trust your instincts. This is step three. Is that sort of what you’re getting at there?
Dr. Simon Platt:
Yes. But there has to be still somehow a step one, step two step here. And I think therefore with neurology it’s going to be different. What we will use is the evidence behind the presenting signs, for instance. So our presenting signs could be sudden onset or slow. They could be accompanied by pain or not. They could be progressive or static. And so we’ll look at neurology as a series of presenting signs that will help us try to narrow down what the problem is. And so one of those other presenting signs will be, is it asymmetric or not? And so for us, if we’ve got asymmetry, however we see that either just on observation or on taking it further with a hands-on exam, that’s a factor we’ll throw into speed of onset progression of disease, presence of pain or not, because those things will help us narrow down our differential diagnosis list.
I dunno about you, but originally I was taught to think about neurologic diseases using that pneumonic damn knit V and I didn’t know I remember that what that was. So we shuffle the letters around and we’ve come up with vitamin D and I used to teach at Georgia and no one knew what that was. And so I shuffled that around and said vitamin D, and then everyone got it. And what we’re talking about here is the letters, right? Those letters of that acronym there, those letters V for vascular will go down all of those mechanisms of disease and look at, well, what would you present? So if you are vascular that’s in the brain, that would be a stroke. You are sudden onset, you are asymmetric, you are non-progressive. And so now I look at the dog and say, could you be that next thing eye for inflammatory?
You are subacute to chronic, you are progressive, you are often patchy, multifocal, you’re asymmetric. Could you be that? So our step-by-step approaches is let’s answer some questions. Question one is are you really neurologic? Right? That seems like an odd question because many of the times we know straight away they’re dragging their legs or they’ve got a head tilt, but sometimes we’re obviously presented with a case that can’t jump into the car anymore or go up the steps. And so is that orthopedic or neurologic? So step one, are you neurologic? Step two, where’s your disease? And I don’t want then people to become intimidated further by neurology and say, oh no, this is where neuroanatomy comes in because really we’re looking for is your disease in the head or out of the head? That’s where the separation of disease types occur. So our next question then, where’s the disease in the head out of the head?
And then the third question is using this clinical reasoning approach where we try to look at how you are presenting asymmetric, progressive and sudden onset. For instance, we’re going to look at those differentials, V for vascular, I for inflammatory, T for trauma and toxin A for anomalous. We go down the list. And so our step three is what could you be? And at that stage we can communicate with the owner and say, here’s two, maybe three possibilities. And of those we could maybe narrow those down with some further tests and we’ll show you how we’ll do that. So we might not need to advance all the way to the most expensive and invasive tests. And if the owner says “We haven’t got any money for any of those tests,” then we look at those two or three possibilities with an eye for treat for the treatable, and again, stepwise go with the least invasive, maybe the cheapest, maybe the most effective potentially medication. If that doesn’t work, we’ve got a plan for step two and three. So yeah, diagnosis and treatment will still have that stepwise approach without really knowing what they’ve got.
Dr. Andy Roark:
Do you find that walking through this process and you get down to, is it in the head? Is it out of the head? And then sort of going to the owner and saying, all right, here’s a bucket. And I guess that’s kind of how I think of it is I can’t tell you what it is, but I can kind of tell you what bucket it’s in. That allows me to start to have some realistic conversations about what treatment wouldn’t involve or what further diagnostics would involve. We can start talking about prices of things and what options are going to be available to them. I don’t have to know what the answer is, but I have to tell them where I think this path ultimately probably goes or what that journey looks like. And then we can start to talk about where they are, what their resources are, what their intentions are, what their feelings are. Is that kind of how you of look at this and how this sort of shakes out into helping guide people and give them insight when you don’t have a diagnosis?
Dr. Simon Platt:
Yeah, we’ll have those two or three possibilities or buckets where we can say if you have disease, a bucket one, let’s say it’s possible stroke. If we do nothing, this is what happens if we treat, what are we treating with? What’s the advantage and disadvantage of doing tests? For instance, if it’s a stroke, there is no specific treatment. And although with tests such as MRI, you can gain more confidence, there’s nothing definitive and they’ll get better many times in the next two or three days. And so we’ll offer owners, well that path takes you down, do nothing for two or three days. If they get better, you’ve got your answer. And then bucket B, this case will get worse if we do nothing. So again, then we’ve got some help there by just using time on our side as a diagnostic, and this is what you’ll get with bucket B.
Let’s say it’s inflammatory. If we do just blood tests, this is what we’ll get. If we do an MRI, this is what we’ll get If we do C, S, F, this is what it’ll cost, pros and cons of each of those things. And again, we can often help the owners feel comfortable with not going to the extent of doing all of those tests by saying this is the difference it will make if we do the tests. Because ultimately this whole thing about I’m a veterinarian, I’m a neurologist, I’d like to guess MRI sounds like it should give you the answer, but it doesn’t. It’s not often definitive, it just improves your confidence level. And so many times we’re still looking at it and saying, I don’t really know. Is that a tumor? Is that inflammation? And so then we’re still guessing and we’re still then going to treat for the treatable. So I know in a may say, well, what was the advantage of even doing that? And that’s a killer comment because that means we haven’t communicated upfront that you might actually get no benefit of doing these tests.
Dr. Andy Roark:
Do you have or have you had any sort of apprehension about sort of trying empiric therapy when you don’t have those types of diagnostics? When I look at the sort of medications we reach for in our neuro cases, I think I always worry, what if I’m wrong? What if I put this dog on an anti-seizure medication and that’s not the right play? Or what if I reach for steroids and this is not the right play? I don’t tend to have nearly that much apprehension in internal medicine cases or dermatology cases and I don’t necessarily know why, but it’s something scary about, I don’t know, maybe it’s just those, my experiences with those medicines, they still kind of feel like voodoo to me in some ways. Maybe that non-steroidals don’t feel like voodoo to me or antibiotics don’t feel like voodoo. Does that make any sense at all?
Dr. Simon Platt:
Absolutely. Because I think in the past we’ve been taught to be scared of neurology because if you don’t know all of your neuroanatomy inside out, then you can’t do neurology. Not true. If you don’t have an MRI, you can’t do neurology. Not true. And therefore you feel, well if I don’t really know what the disease is, how can I come up with treatment and the brain and the spinal cord, they shouldn’t be messed with. If I get this wrong, they die. Well, I think that’s the same with multiple diseases. I’d be scared of treating a dog with cystitis. So I mean it depends where you come from. So for me, I have no problem with empiric therapy as long as I’ve had a completely transparent discussion with the owner to say this is what I think’s going on. Two possibilities, three possibilities. This is the best thing for the dog right now.
If we are aiming to see if we can get some improvement, how far will it go? Maybe we don’t know what happens if it doesn’t work. We need a plan B. What’s the worst that could happen if it doesn’t work? And then the owner has a chance to come back and say, well, I don’t like the worst option. What would I do to avoid that? And we can discuss whether tests at that stage are going to help or not. And sometimes they say, well that’s great that you say now an MRI will help but I still don’t have any money. Well, so we’ll address the discomfort that comes from the fact that empiric therapy is an unknown by saying, well if we do nothing, I’ve got more of a known for you. And that is there’s going to be progression potentially or there’s going to be pain. So the empiric will focus on quality of life and so making sure they’re comfortable above all else. But then also looking at, well if you have something that’s treatable, what could it be? If I’m looking at inflammation in the brain versus the tumor in the brain, I’m going to go with treating inflammation because that’s likely to have a more positive effect than anything I can do for the tumor regardless of how much money that you have. And there’ll be some collateral benefit for the tumor if I use anti-inflammatory steroids.
Dr. Andy Roark:
Yeah. Simon, before I let you go, I want to jump back and do the vitamin D with you. And so just to run through it, it’s funny, the acronym is one that I heard back in vet school and it’s been so long and you bring it back up and we start to go through it. So just for our listeners to have it, vitamin D, we’re talking about the origin of a neurologic problem. V is vascular, I is inflammatory, T is trauma or Toxin A is anomalous.
Dr. Simon Platt:
Yeah. So anomalous being, yeah, you’ve been born with something. So in the brain that’s hydrocephalus in the spine. Then if you’re a frenchie, that’s a vertebral malformation. And then we’ve got M for metabolic. So that most of the time is a brain problem rather than a spine problem. Hepatic encephalopathy is a good example. And then we move to I for idiopathic, and that again is on the top 15 list of why people hate neurology because idiopathic, well isn’t that when I find nothing? So isn’t that everything? And so we have to get across that. Yes, you’re right. But idiopathic is for specific conditions. They’re loner conditions where there’s nothing else. So epilepsy, facial paralysis, vestibular, so they’re loner conditions, you’ll find nothing else. And then we’re down to N for neoplasia. And again, we’ll use all of our factors like the average age for brain and spinal neoplasia is eight, so we’re going to throw that in.
If you’ve got a two year old patient, then neoplasia is dropping lower on your list. And then N also is for nutritional, which for a while in my career fell off the map and now is right back on it because people think you should feed raw meat and bones. And so now we’re seeing a lot of nutritional problems hit the brain. And then lastly, D is degenerative in the spine. That is disc disease and myelopathy. And then in the brain really we’re dealing with old age degeneration, a little like Alzheimer’s, a cognitive dysfunction. So we use that list, that sort of acronym there to help us remember what exists in the brain and the spinal cord and we can just cross those off based on how you’ve presented. And so of that list based on your age, based on was it sudden or not based on is it asymmetric based on is if there’s pain, I could cross them off and say, I’ve got one thing left for you, two possibilities.
And maybe one of those isn’t treatable. And now we’ll talk about tests as to whether they will really help or not. And sometimes we won’t perform tests. If I have a seizure inpatient, for instance, 50% of them meridia pathic, and my evidence-based medicine is going to tell me that if you’re idiopathic, you’re pure bred, your age is between six months and six years, you have no neuro deficits. So if I see a two-year-old golden retriever with no neuro deficits having had a seizure, I’m probably not going to be advising MRI tell people, spend your money on the medication. If we need to start treating, if things start coming out of the woodwork in the next few weeks and things change, that may be the time to talk about being more aggressive.
Dr. Andy Roark:
I have about seven follow-up questions and I’m, I’m going to sit on them, I’m going to sit on them until your lecture in December. I could talk to you all day. I really appreciate you being here. Where can people learn more? Do you have favorite resources? And then where can people find you online?
Dr. Simon Platt:
Well, I’m on LinkedIn and so you could find me there. We’ve just actually opened, if that’s what they say, I’m sure it’s not a new website published. Is it? We’ve just released
Dr. Andy Roark:
Launched?
Dr. Simon Platt:
Launched. That’s best.
Dr. Andy Roark:
Unveiled?
Dr. Simon Platt:
What do people say that? launched is good? Yeah, we’ll go website, which is under construction, but you can start to get a feel of it. It’s for neurology for all ages, so to speak. And it’s called web-vetneurology.com. And so we’re going to expand that into hopefully extremely useful resource. We’ve got cases on there, we’ve got some literature on there right now. It’s not as useful as it’s going to be because we’ve got a lot of nuts and bolts, grassroots, grassroots information to add to it.
Dr. Andy Roark:
Perfect. That sounds fantastic. I’ll put links in the show note to all of that. Guys, thanks for tuning in and listening today. Simon, thank you for being here, gang, take care of yourselves, everybody.
And that’s it guys. That’s our episode. I hope you enjoyed it. I hope you got a lot out of it, man. I genuinely, I love this episode. Thanks to Simon for being here. Thanks for talking. I am looking to our, looking forward to our webinar together in December when we’ll be breaking this down in more detail and probably uses the visual aids and some slides and some things like that. So anyway, I would love to see you there. I’ll put a link in the show notes if you want to come to that free webinar, get some RACE CE, hang out with me and Simon. It’ll be a good time anyway, take care of yourselves, everybody. Have a good day. I’ll talk to you later.
