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Tailoring Veterinary Medicine: Lessons from Prego’s Spaghetti Sauce Story

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Last weekend, I read the best article I’ve ever seen about ketchup, mustard and spaghetti sauce. Now, I know what you’re thinking – how can condiments and pasta sauce be so intriguing? Well, this article taught me a valuable lesson about understanding our clients’ needs. If you have the time, I highly recommend hitting that link and settling in for an interesting ride.

My favorite part was the story about a man named Howard Moskowitz who, in 1986, was hired by the Campbell’s Soup Company to revamp their Prego spaghetti sauce line. Prego was in a slump and desperate for new ideas to compete with Ragu.

At the time, the standard approach would have been to conduct a focus group and gather feedback from consumers to determine how to improve the sauce. But things didn’t go as planned for Prego. The focus group sessions yielded frustrating results. The data collected seemed to lack a clear consensus, and it appeared as though no one could agree on how to enhance Prego’s sauce.

If you’ve ever tried to talk to your clients about what they want in a veterinary clinic visit, you’ve probably had a similar experience. While the idea that clients will simply tell us what we should do to serve them is attractive, I’ve personally rarely found it to be true.

However, this is where Howard Moskowitz had his breakthrough moment. Rather than giving up, he decided to reanalyze the data. And that’s when he discovered a pattern hidden within the seemingly conflicting feedback. It turned out that there were three distinct customer preferences when it came to spaghetti sauce: plain, spicy, and extra-chunky. The last turned out to be most important.

Instead of trying to improve their existing sauce, Prego did something bold and innovative. They decided to offer not one, but two varieties of spaghetti sauce. They kept their original sauce as it was and introduced a new, extra-chunky version, which no other brand had done before.

Prego Extra-Chunky was launched in 1989. Over the next decade, the category generated hundreds of millions of dollars for Prego. More importantly, it changed the industry. 

It was here that food companies came to understand that there is no “perfect product.” Different people have different preferences, and attempting to create a one-size-fits-all experience often leads to no one customer being completely satisfied. 

Since reading this, I’ve been thinking about how many veterinary clinics offer only one standard client experience. How many of us serve up medicine “original style” without considering the diverse needs and preferences of our clients? What if we were to acknowledge that people are looking for different things and strive to provide them with more variety?

I genuinely believe the future of veterinary medicine is going to be full of options for pet owners. I’m excited to see what veterinary entrepreneurs come up with to engage those pet owners who have never loved what we, as a profession, have been cooking. This is a fascinating time to be in practice!

Are Non-Compete Clauses Going Away in Veterinarian Contracts?

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Dr. Lance Roasa joins the podcast to talk non-compete clauses! There has been a lot of attention recently on FTC proposed rule makings around non-compete agreements, and some are wondering what’s in the future for veterinarian contracts. Dr. Roasa weighs in on what’s going on and what we can expect in the future.

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

LINKS

Drip.vet: https://drip.vet/

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. Roasa is a 2008 graduate of Texas A&M who has practiced in small animal, mixed animal and emergency settings and has bought, operated and sold over a dozen veterinary practices. He has completed a law degree from the University of Nebraska, is the past president of the American Veterinary Medical Law Association.

Dr. Roasa is a consultant for VIN and is a founder of Drip Learning Technologies, a veterinary continuing education provider. He also lectures in 13 veterinary colleges on the legal aspects of employment contracts, medical recordkeeping, veterinary malpractice and veterinary business as part of the curriculum. He serves as a national co-advisor to the Veterinary Business Management Association and regularly lectures to regional VBMA chapters and to the national association on the topics of growth, business metrics, and technology implementation.

Dr. Roasa also owns Santa Rosa Ranch, home to the largest registered Brangus cow herd in the United States.

EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Cone Of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I’m here with my friend Dr. Lance Roasa, who is a veterinarian and a lawyer, and he’s been on the episode or been on the podcast many times before. I always love talking about legal stuff with him. I love talking about what’s in contracts that veterinarians are signing and the practices they are using, and we are getting into non-compete agreements today. I’ve got a lot of questions. I feel like there are big seismic changes in non-compete language across the country and across different industries, and there is some FTC proposed rule changes that are shaping up. And I wanted to hear from Lance what those might look like and what he’s seeing in veterinary contracts. And that’s what we get into. So guys, if you got any interest at all in restrictive covenants, non-competes, non-solicitation agreements, non-service agreements, which are a thing we talk about, then this is a great episode for you. I hope you’ll enjoy it. I certainly did. Great, 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 everybody to the Cone Of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am here with my good friend, Dr. Lance Roasa. Lance, thanks for being here.

Dr. Lance Roasa:
Great to be here with you. Dr. Andy Roark. How are you today?

Dr. Andy Roark:
Man, I’m good. Summertime is here in South Carolina. It’s beautiful, but it’s hot. But that’s it for me. How about you?

Dr. Lance Roasa:
Same here. It’s exciting to be in spring. The kids are almost out of school. The teaching semesters, the veterinary schools are winding down, so it’s always a good summer.

Dr. Andy Roark:
So you do a lot of things, for people who don’t know, you do a lot of things like I do a lot of things and I’m like, “That guy does a lot of things.” You are a co-founder at drip.vet. Most people know drip.vet for the opioid education. And so I just recently took your two-hour opioid course. It’s the second time I took it. I took two years before that because I need it for my license every two years. And you had overhauled the whole thing. Nice work by the way. I was like, “I got to watch this thing again.” Nope, it’s all updated, refreshed, super good stuff. It felt very different. So props to you on that. But you also, you are hanging out on the VIN boards, drip.vet is part of the VIN family, and then you lecture all over the place of vet schools. Are you at 20 vet schools now? Something like that.

Dr. Lance Roasa:
Close to 20. Nobody’s really counting, but I think we’re at 18 or 20 vet schools, so I get to see a good percentage of the veterinary students as they enter their third year in veterinary schools. We talk about exciting stuff like the legal use of drugs and how to negotiate their contract and some stuff that I know that they’re just dying to hear about non-competes, which we’re talking about today. So that’s my job in the veterinary schools at this point.

Dr. Andy Roark:
All joking aside, people do get fired up about non-competes. You know what I mean? I am hearing a lot about it. It’s because of stuff going on with the FTC, but also a lot of vets are looking at their contracts. I think non-competes have become part of the battleground in recruiting. There are some big companies out there that have lots and lots of hospitals and they’re saying, “We don’t do non-competes.” And trying to use that as an advantage point in recruiting vets, things like that. I want to unpack this because this is an area where things are changing and people have a lot of interest. And so can you start to lay out for me traditionally what have non-competes kind of look like in veterinarian contracts?

Dr. Lance Roasa:
Sure. So I think to actually take a step back, let’s look at what non-competes kind of look like in society at large. And so in the American judicial system, so non-competes are centuries old. The case law in non-competes go back for literally hundreds of years. I mean even over as we borrowed a lot of our laws from England as we are breaking away as colonies. And so the battleground and the fight over non-competes in a business setting has been something that’s been going on for centuries. And so this is not a new debate, this is not a recent debate. This is the continuation of a long debate. Having said all of that, in veterinary medicine traditionally non-competes have been used sparingly through the sixties and seventies and eighties.
But really when practices starting going corporate, that’s when we really saw an explosion in the use of non-compete agreements. And so now at this point, nearly 99.9% of the practice of the contracts that I see contain a non-compete, especially from a state that will enforce a non-compete. And that brings up a really big point, is traditionally on the law side, non-competes are very, very state dependent, even to the point where they’re county or judge dependent. And we’ve got some states that will fully enforce non-competes and we’ve got some states, California is the biggest example, that will not enforce non-competes. And so you asked about where’s the legal standing, it’s really a state by state analysis to really understand what’s going on with non-competes. And traditionally that’s how it’s been forever.

Dr. Andy Roark:
I was reading recently that other professions have had non-competes kind of struck down. So attorneys and doctors, physicians I saw. And to me it seemed very much like a national thing. And the idea was having a non-compete might force people to break their relationship with their doctor if their doctor had to leave. Same thing with the attorney as you have a relationship with this attorney and then if they have a non-compete, they might be forced to leave, which would not allow you to maintain that relationship. And so the damage to that relationship was something that made sort of regulators say, in this industry these non-competes are not going to be acceptable. Am I getting that right? Is that across industries? Is that still state by state as well? Can you sort of speak to what that looks like?

Dr. Lance Roasa:
Yeah, you’re actually really close with that. It’s not necessarily-

Dr. Andy Roark:
Oh, good. I like to be at least in the neighborhood. That’s good.

Dr. Lance Roasa:
You’re definitely in the neighborhood. So on the legal side, it’s actually the legal ethics or what they call the professional responsibility will not allow attorneys to put other attorneys under a non-compete. And so it’s highly ironic that attorneys are asked to write non-competes for other professions, but they will not write a non-compete for their own profession. And the basis for that is exactly what you described, is it’s not a competition issue, it’s not a free market issue. It is the fact that the consumer of legal services in this case, their relationship would be highly damaged. And so if a lawyer leaves a law firm, then they’re welcome to take all the people that they served previously. On the physician side, what you’re referring to is some guidance that’s coming out from the AMA, the American Medical Association that says roughly the same thing. That physicians should not put other physicians under a non-compete for patient safety, for patient continuity, for the fact that that patients need to see a doctor continuously, not just the person that’s working at the hospital that day.

Dr. Andy Roark:
Yeah, that makes sense.

Dr. Lance Roasa:
Now, having said all of that, physicians and nurses and other healthcare providers are probably some of the people that are most affected by non-competes. So just because the AMA said, it does not mean that non-competes are somehow banned or not allowed in the human medical world.

Dr. Andy Roark:
Well, it’s interesting that you said doctors will not put other doctors under this. And I’m looking at the human medical world and I go, “Boy, there’s a lot of big corporations that own hospitals or medical groups or things like that.” Do they fall into that same category or is it something where you say, “Well no, these are not physicians putting other physicians, this is a different entity that’s getting physicians to sign a non-compete.” Is that different?

Dr. Lance Roasa:
It’s back to the corporatization world. And so it’s the fact that those hospitals that are truly employing those physicians are really corporations, honestly. So it looks a lot like if the AMA decided to put forth ethical guidance that said that veterinarians will not put veterinarians under non-competes. Well, a lot of hospitals are not owned by veterinarians. And so the AMA has no control over the corporate interests in our profession.

Dr. Andy Roark:
Interesting. Okay, all right. Lance, let’s start to talk about trends in the vet profession with non-competes. So I think back when I graduated about 15 years ago, non-competes were pretty standard and we were sort of instructed to pay attention to them. To pay attention to how much distance there was, how much time they would go for after you left your job, things like that. Have you seen a change or a trend in shrinking sizes, things like that? Or is it basically the same durations and distances that used to be, but they’re either in or out. So can you talk about general trends in that regard?

Dr. Lance Roasa:
Yeah, so there is a general trend on the legal side. So lawyers that write non-competes, to write them in the exact words are narrowly tailored. So to make them exactly what the protection of the business or practice in this situation needs. And so if you see a non-compete that is written by a lawyer that’s kind of studied on non-competes, they will try to write them in a very tailored way. And the reason for that is because they actually become more enforceable the smaller they are. Now you asked about timeframe, the timeframes still are almost always maxed out as what the law will allow. So some states, Florida, for example, 18 months, other states will presume that two years is reasonable. And so almost every practice and every lawyer that’s putting forth a non-compete is going to max out what the law will allow. The radius is very, very, very dependent on the practice locality, the practice type, et cetera.
The other thing that I really spend a lot of time teaching on, Andy, is what’s called the scope of practice. And so there’s three things to really look for. You’ve already mentioned the timeframe and the radius, but the third thing that is highly negotiable is the scope of practice. And so when you and I both graduated, there were a lot of mixed animal practices and there was an expectation that we would kind of do everything. But now practices are much more specialized. And so there’s day practices, they’re ER practices, there’s exotic practices, there’s small ruminate practices, there’s obviously equine practices. And so these non-competes that exempt all of practice, that’s a problem. And so what you see is practices start to say, “We’re only going to exempt daytime non-emergency practice.” Or, “Since we’re an ER practice, we’re only going to exempt competition in an overnight ER practice.”
And so the tighter that you can get that scope of practice allows that veterinarian to go on and do something else. But to answer your question, yes, these are constantly evolving. The other big thing that I see, that’s the difference when we graduated 15 years ago, is this use of the liquidated damages. And I think we’ve talked about this on a previous cone of shame podcast, but highly aggressive attorneys will write liquidated damages, which means that the damages are stipulated before you actually even breach the non-compete. And that’s a massive shift from what was in place 10 or 15 years ago. Non-competes are becoming more aggressive, but in certain situations they’re actually becoming more and more narrowly tailored.

Dr. Andy Roark:
If you dream of doing team training with your team, getting your people together, getting them on the same page, talking about how you guys work together in your practice, I’d love to help you. You can check out drandyroark.com and check out the store. I have two different team training courses. These are courses for teams to do together to get on the same page and to talk about how you do things. I have my angry clients course and I have my exam room toolkit course, and they are both available and there to come out. All right, guys, let’s get back into this episode. Well talk to me a little bit more about this calculating damages. So the stipulation that you’re calculating damages before the breach of the non-compete occurred, what does that mean, Lance? Help me get my head around that.

Dr. Lance Roasa:
Yeah. So usually there’s a provision that’s attached to the non-compete provision, which says something like, “If you breach the non-compete, the associate, the employee, or now former employee, will pay the practice.” And usually it’s a large sum of money, Andy.

Dr. Andy Roark:
Just a flat fee?

Dr. Lance Roasa:
Just a flat fee, a hundred thousand, $150,000 to breach the non-compete. And usually when a veterinarian sees that, they’re like, “Now wait a minute, I have to pay the practice money. I’m getting paid by the practice. I’ve got to pay the practice money back. So where’s this $150,000 coming from?” They’ll kind of throw a red flag and say, “Ah, this doesn’t feel right. $150,000 doesn’t seem right.” What smart lawyers have learned to do is write a per diem amount in lieu of a breach. And so they’ll say something like, “If you breach the non-compete, we’ll stipulate damages of a thousand dollars a day.” Well, if you breach the non-compete for 150 days, you’re at the same exact point, you’ve got to pay the practice $150,000. But to the veterinarian that’s skimming that contract and not really understanding the legal terms, they’re like, “Oh, a thousand dollars, whatever.” That doesn’t really draw the red flag like $150,000 line item in that contract. So it’s a way to sneak these liquidated damages provisions past associate veterinarians and get that signature.

Dr. Andy Roark:
All right. So that makes sense. I was actually surprised when you said early on that 90% of the contracts that you see still have non-competes in them.

Dr. Lance Roasa:
I would say 99.

Dr. Andy Roark:
Really?

Dr. Lance Roasa:
Yeah, no [inaudible 00:15:01].

Dr. Andy Roark:
I felt like I felt like we were moving away from that. I was hearing more and more people saying, “Oh yeah, we’re not doing those anymore.” But you’re not seeing that on the ground. Is that correct?

Dr. Lance Roasa:
No, there’s a couple of large practices that have moved away from non-competes, but overall the vast majority of practices still use non-competes. There’s a couple of commentators that have written and talked about abolishing non-competes or getting the profession away from non-competes, but I have to be honest, that’s just talk. I mean, in the real world, I’m not seeing it change at all.

Dr. Andy Roark:
No, that totally makes sense. Talk to me about what’s going on at the national level. So there was sort of FTC proposed rule makings that were sort of in the headlines recently and people were talking about some of the Biden administration’s thoughts on non-competes and stuff. Talk to me about sort of what’s going on there.

Dr. Lance Roasa:
It was a pretty boring read overall, but what it does is it attempted to make the case that the FTC does have the ability to regulate non-competes across the entire country. And basically it said that the FTC is thinking about banning non-competes on a federal level. Now the thing that I really want to point out here is, is this is an extremely slow process when we’re going through what’s called the Administrative Procedures Act. What the FTC did is they opened a notice in comment period, and they allowed the American people and business interests to come and weigh in. The FTC will gather all those comments, read them all, and then ultimately deliberate internally on whether or not they want to proceed with some sort of actual rulemaking. And so generally speaking, this stuff takes years, if not decades to fully come to fruition.
And really what I saw when the Biden administration first issued, “Hey, FTC, do something about this.” And then in January of 23 when the FTC actually released this notice or this proposed rulemaking, I got a lot of comments just right off the bat. And actually a lot of anecdotal comments like, “Hey, these non-competes, they’re going to go away and I don’t have to worry about this anymore.” And I’m like, “Whoa, whoa, whoa, pump the brakes. This is really a time to hold your horses. Do not sign a non-compete with the expectation that the FTC is going to do something to nullify it. You’ve got to still negotiate it. You’ve still got to understand what it’s going to affect, how it’s going to affect your personal life if they don’t do something about it.” So it’s good that the FTC is giving this a look. It’s good that it’s getting some light shined on it, but it doesn’t mean that we can ignore non-competes any time for the foreseeable future.

Dr. Andy Roark:
Yeah. What do you think the future’s going to be like in non-competes? When I go sign a vet contract five years from now, do you think it’s going to look different as far as non-competes go? If you had to bet, what would your bet be?

Dr. Lance Roasa:
So we’re seeing a push across many states to actually change. And so I think that the state level has much more potential to actually change the enforceability of non-competes overall. Ultimately too, Andy, it depends a lot on the market for veterinary services. And so you mentioned earlier you’re seeing some people start to talk about it and a few companies start to say, “We’re not using non-competes.” If it truly does work out to be a recruiting tool and hasn’t necessarily so far, but if it truly does work out to be a recruiting tool, then you’ll see other companies follow suit. And so it depends on the state that you’re in. It depends on the company that you’re looking at overall. But I see non-competes sticking around for a little bit longer.
There’s a really big point that I want to make here when you’re looking at that contract though, and pardon my football analogy here, but my brain often thinks in football terms. But non-competes in my mind, in my legal mind, are really the running backs of the football team. They’re the ones that get their picture in the paper. They’re the ones that everybody talks about. They’re the ones that little kids remember the stats and all that stuff. But in reality, when it comes to lawsuits and when it comes to actually enforcing a contract, it’s the non-solicitation that really counts. And so I do want to point out that the states and the FTC and even these companies that we’re referring to, they’re talking exclusively about non-competes and doing away with non-competes.
However, no one, including the state of California, is talking about doing away with non-solicitation agreements. And so even if we do have some guidance or some rulemaking by the FTC within five years, Andy, that contract that you’re looking at in the future will likely have a non-solicitation. And that non-solicitation still is very prohibitive from being able to go and practice somewhere else. In fact, it can be argued that it’s more prohibitive because it doesn’t have a radius on it. Wherever those clients follow you, you can run into some issues. So what I’m saying is this is not an area of the law that’s going to go away anytime soon.

Dr. Andy Roark:
So my perception of non-solicitation agreements had always been like, “Okay, you can’t market or promote to clients.” If I’m leaving and I go somewhere else across town, what constitutes solicitation in most cases, Lance? Like if I just go there and start practicing, am I good? Or is it a problem if clients follow me over there? Help me sort of parse that.

Dr. Lance Roasa:
Yeah, there actually is a big distinction in what you’re referring to there. So the distinction that we’ve got to make is the difference in a non-solicitation provision and what the second would be a non-service or a non care provision. So two different action verbs, but a lot of times they get wrapped under the provision that is a non-solicitation. Now if you look back 10 or 15 years, they were all non-solicitation provisions, but as lawyers in veterinary medicine got more sophisticated, they started drafting these non-service provisions. And so back to the distinction between the two, the verb solicit or to solicit would mean exactly what you said, a targeted marketing, a targeted advertising. And keep in mind on the word targeted.
And so if the traditional word is, or the traditional action would be you’re going to pick up the phone and call someone, or maybe you run into an old client in the grocery store and you say, “I was at practice ABC, now I’m at practice XYZ. You should come see me there.” That is an active solicitation. Sending out a list to an email list to people that you knew that were clients. “Hey, come see me at practice XYZ.” That is a targeted marketing, and that is contrasted to if the contract has a non-service provision in it. And the way that those are usually worded is they’ll say something like, “The veterinarian shall not solicit or render services to a former client.” And so meaning that under a technical reading and also an enforceable reading of that, you could be standing in the exam room waiting for your 3:30 appointment, 3:30 appointment comes into the exam room, “Oh, Ms. Jones, I saw you over at a ABC Veterinary Hospital.”
That would be a technical violation of that non-solicitation/non-service provision. So I’m seeing more and more of these non-service provisions written in contracts, and it really takes a fine reading to understand the difference. But I think you can see how quickly a veterinarian could get wrapped up into a non-service provision. So my mind always goes to how do we combat this? How do we negotiate this? Well, number one, know the difference between the two and number two really work to get that non-service provision stricken out of the contract. Keep in mind, Andy, all of these are super negotiable. You just have to know what you’re looking for and how to ask for it taken out.

Dr. Andy Roark:
Yeah, no, that totally makes sense. Usually when you’re close to signing a contract and you’re excited to go there and the practice is excited to have you, that’s the time to bring up the non-compete and say, “Hey, this is kind of a headache here.” But it’s a whole lot harder to get out of it later on.

Dr. Lance Roasa:
Oh, absolutely. The time to negotiate these are before you get into them. I mean, this is a very important point. A lot of people that I work with, they say, “Hey, can you unwind this non-compete? I heard they’re unenforceable.” And it’s like, “No, we should have talked about this, you should have talked about this before we signed this.” That is the time that you have the leverage when you’re leaving a job. It’s like breaking up. I mean, it’s like a divorce, right? Nobody wants to be amicable during a divorce and it’s really hard to negotiate them then.

Dr. Andy Roark:
Yeah, no, that totally makes sense. Lance, thanks so much for being here. Thanks for talking all this through with me. I really appreciate it. I was blown away. The non-service agreement, I had not even considered that. That’s something that I think it’s amazing. I can’t believe that that’s something that’s increasing in its commonality. Anyway, so thanks for bringing it up. Where can people find you, drip.vet, if they’re fascinated by the legal aspects of our profession, if they need a little legal advice and they’re in practice, where can they reach you?

Dr. Lance Roasa:
Sure. So I hang out over on the VIN boards, on the regulatory and legal boards, and also on the practice management boards. I’m one of the consultants on those boards. And so if you’re a VIN member already, you can receive… we can talk about these things and obviously weigh in from other attorneys, and we answer a lot of questions over on those boards. Otherwise, I’m also at drip.vet, and so have a ton of legal continued education over there, classes on negotiation, on contracts. We go into deep dives on all of this stuff. And then if you are truly interested in it, and unfortunately, most of the people that I work with have already been burned by a non-compete. So it’s not too interesting as a student, it’s not too interesting in your first job, but you get burned by that paragraph and then it’s time to start paying attention.

Dr. Andy Roark:
Absolutely, awesome. Well, thanks for being here. Guys, thanks for tuning in. Thanks for listening. We’ll talk to you soon. And that is our episode. Guys, I hope you enjoyed it. I hope you got something out of it. As always, if you did, the kindest thing you can do is leave me an honest review online, wherever you get your podcast. Tell your friends, share the word, help other people find the podcast work that we’re doing here. Anyway, that’s all I got. Gang, take care of yourselves. Be well. Talk to you later. Bye.

Brachycephalic Dog Breeds: How Can New Research Help Your Patients

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Dr. Jules Benson, Chief Veterinary Officer at Nationwide, joins Dr. Andy Roark to discuss new research highlighting the health concerns present in brachycephalic and “extreme” brachycephalic dog breeds.

Nationwide logo

This episode is sponsored and made possible ad-free by Nationwide®!

LINKS

Nationwide® analysis of 50,000 dogs confirms brachycephalic breeds face increased health risks: https://news.nationwide.com/brachycephalic-breeds-analysis-face-increased-health-risks/

Spectrum Of Care: https://www.petinsurance.com/veterinarians/spectrum-of-care/

Respiratory Function Grading Scheme: https://www.avma.org/news/health-screening-test-rolled-out-brachycephalic-dog-breeds

All DAR Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Jules Benson, BVSc, MRCVS, is Chief Veterinary Officer at Nationwide. He is a veterinary industry strategist focused on ways technology and data can transform the veterinary profession and the lives of animals. A member of the Veterinary Innovation Council Board of Directors and MentorVet Advisory Board, he has nearly 20 years of experience in private practice, start-ups, marketing, and pet health data.

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 good friend, Dr. Jules Benson. He is talking about a new white paper. It’s a couple of white papers, actually, on brachycephalic dog breeds that have been out in the last couple of months. Guys, this is a fascinating discussion on the dark sides of brachycephalic breeds.
I love the little guys. Don’t get me wrong. But they got real health problems. And in this episode we talk about a huge data set that Nationwide has put out talking about the claims that they see in brachycephalics and extreme brachycephalics and how the differences break down between those two types of dogs. What’s an extreme brachycephalic, you say?
Hang on and you’re going to find out, but this is a great episode. We talk about what are the risks. We talk about where are they coming from. We talk about what can we do about them. We talk about how do we approach this as an industry. What are our options here? How bad is the problem? How severe is it? How great a risk? All those sorts of things. It’s really a fun conversation. You’re going to soak it up, I promise.
Gang, thanks so much to Nationwide for making this episode available ad-free. 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. Jules Benson, how are you?

Dr. Jules Benson:
I’m very well, Dr. Andy Roark.

Dr. Andy Roark:
Oh, thanks for being here, man. Hey, it’s so good to talk to you. I always enjoy when we get to catch up.

Dr. Jules Benson:
It’s been a long time since we’ve known each other. The industry is just this small.

Dr. Andy Roark:
I was actually thinking that when we got on. How long have I known you? It’s been years.

Dr. Jules Benson:
It’s been a decade, I think. Yeah.

Dr. Andy Roark:
It has been at least 10 years. I met you at one of the formal galas, I think. I think that’s where I met you, at one of the big conferences and it was a dinner thing.

Dr. Jules Benson:
There was a glass of wine involved.

Dr. Andy Roark:
And you had this great accent and I was like, “I also have a great accent.”

Dr. Jules Benson:
There’s silly voices, there’s Elmo and there’s me, and I think I’ve probably got the better end of that scale.

Dr. Andy Roark:
Love it. Oh, man. So for those who do not know you, you are the Chief Veterinary Officer at Nationwide.

Dr. Jules Benson:
That is true.

Dr. Andy Roark:
And you have been doing a number of really interesting projects. And so you’ve got some white papers that came out recently that I want to ask you about.

Dr. Jules Benson:
Yes.

Dr. Andy Roark:
And so here’s why I want to ask you about this. This is why I was really interested in this topic. So I’ve been on social media for a long time and I really like to share a lot of puppy and kitten pictures and joy of practice type stuff. And it’s probably been about eight, 10 years ago, when I would start to post pictures of certain dog breeds. At first, I would get tons and tons and tons of likes but I always would read through comments or people would send me emails and things, and I started to get some pushback on these beautiful, adorable puppy photos. And they were some very well-articulated arguments about me highlighting these dogs because they were brachycephalic dogs. And at first I was like, “You people.”

Dr. Jules Benson:
[inaudible 00:03:28] puppies.

Dr. Andy Roark:
“You need to find some joy in the world. Who criticizes puppy pictures? Really? How upset you have to be?” And then they continued to come. And as I said generally, unfortunately, they were very well-laid out arguments about the health detriments of brachycephalics and as our role as veterinarians, there’s a difference in taking care of pets and being accepting of pet owners and being encouraging of this thing that they love, and also not perpetuating breeding habits and things that lead to health problems. And we do have responsibility in that regard.
And those arguments, honestly, this is a place in my life where I initially did not like this position, but I looked at it and I looked at the data and what they were saying and ultimately, I came over to that side of the table to say, “Yeah, I still celebrate those pets when they come in,” but it’s extremely rare for you to find brachycephalics on my social media. Not because I don’t love them or think that they’re wonderful or beautiful, but just because I do have concerns about perpetuating the short nose in dogs and what that means for their health.
And so you guys put out, and it’s under your stewardship, these white papers come out from Nationwide, talking about brachycephalics and risks of brachycephalics, as far as their health and insurance claims that are being made. And so let me just pause right here for a second and say, can you tell me a little bit about the research you guys did and where it came from? Just at a high level.

Dr. Jules Benson:
Yeah, for sure. So we started this … One of the nice things about working in the insurance world, and one of the reasons that I’m still so drawn to it and so passionate about it, is that being an enormous, unapologetic data nerd, there are things that we can do. If you think about being in your practice and you can say, “Okay, how many dogs do we have with pancreatitis?”

Dr. Andy Roark:
Right.

Dr. Jules Benson:
You can run a search for cPLI tests that you ran, but you can’t really say how much do people spend on pancreatitis within your practice?

Dr. Andy Roark:
Right.

Dr. Jules Benson:
But the advantage we have is that when people send their claims in from veterinary clinics, so we’re getting the information from the clinic, we are typing those claims. So we know that it’s pancreatitis. We know that it’s brachycephalic. We know that it’s pneumonia. So we have really good classification of those data. So to me, being able to drill into those data and provide that back to veterinary healthcare teams and owners, that’s the real value of what we can bring to the table.
So for this, we did some work on cancer last year. We did three papers on cancer. We did one on aging pets and we’ll do another aging pets later this year. But brachycephalic was something we wanted to get into, just because it continues to be, and I don’t know how much you follow the news, especially in the UK, there’s a lot of really, I think positive activism about brachycephalic and about breed predilections in the UK.

Dr. Andy Roark:
Yeah.

Dr. Jules Benson:
The British Veterinary Association went point around using photos, did a really good job about, I think it was about 10 years ago, providing guidelines to industry who saying, “We don’t want you to show some of these dogs in these situations, and this is why.” It’s similar to using dogs with collars and tags. For a long time I think we’ve had a degree of activism in the industry to say you shouldn’t be using pictures of dogs without identification on because it sends the wrong message. And I think this is a similar vein in that of saying, “Okay, well.” So anyway, so we looked at brachycephalic dogs and were guided by the data.
The way that our team approach it is that we have hundreds of thousands of years of dog data to look at. And then we let the data guide us into what is most interesting about these? Where are we seeing the spikes in claims activity? Where are we seeing the massive differences between them versus other groups of breeds? So you have to classify those brachycephalic, then compare them against other purebred dogs that don’t have that defect if you like, in terms of forcing that soft tissue into a shorter nose by occupying the same space. And so we were always guided by the data, and so that’s where we arrived at this. And this is where we tripped into this extreme brachycephalic space.

Dr. Andy Roark:
Yeah.

Dr. Jules Benson:
I don’t know if were you familiar with that term before?

Dr. Andy Roark:
I wasn’t until I read it in the white paper. Yeah. You break them out into brachycephalic and extreme brachycephalic. So that was actually going to be my first question, is talk to me about that. Talk to me about that distinction.

Dr. Jules Benson:
So we had done some work with brachycephalics previously and I think one of the criticisms was that you’re including some breeds and not others and why are you’re doing that. And so I think we wanted to take a really science-based approach to this. And so in the white paper actually, there’s a methodology that goes along with it. We identify the 15 or so brachycephalic breeds that we use in the analysis. And those are all breeds that were identified in at least three peer-reviewed papers.

Dr. Andy Roark:
Okay.

Dr. Jules Benson:
So as we started looking at this, we noticed among the data there were some pretty big differences between a few of the breeds and the peer reviewed papers, several of them referred to extreme phenotypes and were classifying those quote-unquote “extreme brachycephalics.” And so whenever I present on these data and I ask people, “What are the extreme brachycephalic breeds that you would expect coming out of this?” People nail it, right?

Dr. Andy Roark:
Oh, yeah.

Dr. Jules Benson:
It’s French Bulldogs, it’s English Bulldogs and it’s Pugs.

Dr. Andy Roark:
Yeah.

Dr. Jules Benson:
And the diversion of those in the data is massive. And you can see in the white paper, I know you’ve taken a look at it, we could talk about some of the numbers, but just talking about brachycephalic dogs on mass I think is misleading unless you’re breaking them out into the … It really is specific breeds who are driving the difference in claims activity among that class of breeds.

Dr. Andy Roark:
Okay, yeah, that makes a lot of sense. When you look at brachycephalics in general, because you get claims from every different type of breed, and so it’s really great. One of my favorite things you guys do is put out just most popular breeds every year. And it seems like an easy data pool for you, but I’m always fascinated in what are the breeds that people are bringing to the clinics. And so talk to me a little bit about the popularity of brachycephalic dogs. Where are these in the frequency of the patients that we’re seeing?

Dr. Jules Benson:
So overall brachycephalic breeds, and we looked over the past decade or so and we said, “Okay, from 2013 to 2022, what is the change in popularity, if any of brachycephalic breeds overall?” So we’re talking about everything. Boxers, Cavaliers, Lhasa Apso, French Bulldogs. Is there a change in overall population? And there was a little bit of a bump. It was about 19% to 21% of our purebred dogs. So there was a bit of a change there, but when you actually break those out into extreme versus non-extreme brachycephalics, the positions are pretty much switched. It used to be that the non-extreme brachycephalics were much more popular. And over the past 10 years that has reversed. And we’ve seen a massive change in the upswing of extreme brachycephalics, and that is driven frankly by one breed. So the French Bulldog …

Dr. Andy Roark:
The French Bulldog.

Dr. Jules Benson:
… over the past 10 years, it was 19th most popular purebred that we insured in 2013, sorry, and it is now the third most popular breed.

Dr. Andy Roark:
Wow. Meteoric rise, to go from 19 to three and 10 years.

Dr. Jules Benson:
It’s a five times increase in the popularity of the breed in that book. So it’s stratospheric and it’s happened fairly gradually over that time. Because I think we think about those fads, the Chihuahua, the Beverly Hills Chihuahua, we see those things and overnight, suddenly there’s a million more of these dogs. But for Frenchies it’s been pretty gradual over the past 10 years. But it’s problematic. And we can talk about the data, but I think the normalization of some of the behaviors that we see and some of the health issues that we see, I think it’s a really tough situation. And I’ve talked about this before, being in the clinic with people who all they’ve wanted to do was get a dog that they want to bring in their home and love and everything else. And we know that sometimes pet families aren’t always doing all the research they can or they’re so captivated by the persona they see in the media or whenever else that there’s not always a good heart versus head conversation going on.

Dr. Andy Roark:
Well at this point it’s a self-perpetuating cycle. If you like say Frenchies, they’re everywhere. And so how could they be problematic? How could this be a problem when I just see them everywhere? People wouldn’t have them all over the place if they were a dog that had health problems. And I understand people just having that immediate knee-jerk reaction. This isn’t some strange rare breed you ever see. These are one of the most common breeds out there. They’ve got to be a good, healthy, vibrant breed. And you go, “That doesn’t … No.”

Dr. Jules Benson:
And it’s funny, we’ll talk a little bit later perhaps about how do we help this, but I think the popularization and even watching the Super Bowl ads, I think it was Miles Teller and his girlfriend were dancing around in a super fun ad of them having a great time with their Frenchie. And not that that can’t happen, it’s just one of those situations of how do you insert yourself awkwardly into that conversation and say, “Hey, fun police here. No fun for you.”

Dr. Andy Roark:
Yeah, I don’t like to be that too. Even as I said that last line, I’m like, “Oh, I don’t know.” You see people and they love their little Frenchy and the Frenchy is an adorable happy little dog and you say, “I don’t want to be the fun police.” And especially waiting until someone has made the lifetime commitment of the pet to then say, “Oh by the way, let me tell you some bad news,” that doesn’t feel good either. Now before we leave, I want to take this and turn it around into an action steps. How do we … Without stomping on people’s hearts and while still maintaining the trust and relationship that’s going to get them to bring their pet back so we can continue to work with them, what is it useful for us to say to them? But before we get into that, I want to just pause here for a second and say, we’re speaking in these vague terms about problems and claims spiking up. Lay out for me, what are the risks specifically that we’re talking about?

Dr. Jules Benson:
So I think the white paper delves into this in more detail, but very generally when we look at the category of things like respiratory disease or respiratory, is that how you guys say it? Can I [inaudible 00:14:26]-

Dr. Andy Roark:
Respiratory is how I say it, yeah. I also say brachycephalic, as you say brachycephalic, and clearly I’m not yielding on this.

Dr. Jules Benson:
I was recording something earlier, I think I said brachycephalic and brachycephalic two sentences apart and I’m like, “I to go back in, because I have no idea how to say this anymore.” So I think I say brachycephalic. So if you look at the respiratory disease category, and we’re talking about everything from infectious tragal bronchitis to pneumonia, all of those diseases, in extreme brachycephalic dogs compared to non-brachycephalic purebred dogs, they are five times more likely to submit a claim for respiratory disease.

Dr. Andy Roark:
Okay.

Dr. Jules Benson:
Five times. For ocular disease, it’s about the same. They’re about five times more likely to submit a claim for ocular disease. So these two syndromes we could talk about in more detail, Brachycephalic Ocular Syndrome, which frankly I wasn’t that familiar with. I just assumed that when I see those exophthalmic dogs, they’re going to have problems, but apparently this has been looped into a syndrome now, Brachycephalic Ocular Syndrome.
And then the other biggie really is Brachycephalic Obstructive Airway Syndrome. Which to me I think that’s the most terrifying area, because when we look at Brachial Obstructive Airway Syndrome, you can’t compare the rates of disease in Brachial Obstructive Airway Syndrome with non-brachycephalic dogs because it doesn’t exist. That was always terrifying to me. So we compared extreme brachycephalics to non-extreme brachycephalics and those extreme brachycephalics, of those, the French Bulldog is 17 times more likely to submit a claim for Brachycephalic Obstructive Airway Syndrome than all the other dogs that still have brachycephalic phenotypes.

Dr. Andy Roark:
That’s mind-blowing. 17 times more than the other brachycephalic dogs.

Dr. Jules Benson:
And a million times more than the non-brachycephalic dogs that don’t have Brachycephalic Obstructive Airway Syndrome at all. So again, the leap for me is we’re not just saying it’s much more common in these dogs. We’re saying it exists exclusively in this group of dogs and these dogs, this particular breed are 17 times more likely than the rest of them to get it Absolutely mind-blowing. So for BAOS, the other thing that we looked at specifically was if dogs are affected by BOAS, are they more sick in other areas? So if we compared BOAS Frenchies with non-BOAS Frenchies and it gets worse. So if you have a Frenchie with BOAS, they’re five times more likely to have a claim for pneumonia than a non-BOAS Frenchie.

Dr. Andy Roark:
Yeah.

Dr. Jules Benson:
They’re twice as likely to have a claim for spinal disease as a non-BOAS Frenchie.

Dr. Andy Roark:
Wow.

Dr. Jules Benson:
So these really extreme affected dogs, they’re not just sick with BOAS, they’re more sick with other conditions as well.

Dr. Andy Roark:
Well, I’m really surprised by the spinal condition. So it makes total sense. So the Brachycephalic Obstructive Airway Syndrome is like hypoplastic trachea, elongated soft palate, everted laryngeal saccules, stenotic nares, tiny little nostrils. So unless I’m wrong, those are four pieces of it. And so if you have those things then it makes sense that you’re more likely to have pneumonia. You’re not-

Dr. Jules Benson:
Esophageal disease with the negative suppression.

Dr. Andy Roark:
Exactly.

Dr. Jules Benson:
Yeah. Exactly.

Dr. Andy Roark:
Those things make sense. I completely understand. You get some sort of respiratory, possibly kennel cough, that advances, secondary disease following. That all makes sense to me, but spinal abnormalities is not something that I would immediately say, “Oh, that makes sense.”

Dr. Jules Benson:
Well, and so talking to a neurologist who’s also a board certified neurologist about this, and when I was at school we were told that Dachshunds were the poster breed for IVDD, for the [inaudible 00:18:05] disc disease. And I think, again, this is a stat out thin air that I was told, but that Dachshunds have a prevalence 10 times all other dogs rolled together, it was that extreme. And you look at it now, we’ll have data on IVDD coming out later this year, but now they’re similar. So Frenchies and Dachshunds.

Dr. Andy Roark:
No.

Dr. Jules Benson:
Absolutely.

Dr. Andy Roark:
No.

Dr. Jules Benson:
The prevalence of IVDD.

Dr. Andy Roark:
No, knock me over with a feather. No.

Dr. Jules Benson:
Yeah. And when we talk to a neurologist, they say that the degree of disease anecdotally, from what they’ve seen is more severe in the Frenchies than it is in the Dachshunds.

Dr. Andy Roark:
I have not been talking about this in the exam room at all. I still talk to the Dachshund owners when they come in with their Dachshund puppy, and it’s a wonderful pet. Let me just tell you what I recommend for all my Dachshund owners just to cover our bases. I have not been leaning into that with my brachycephalics.

Dr. Jules Benson:
Yeah, yeah. And again, it’s Frenchies more than others, but actually we see it in some of the English Bulldogs as well. And we haven’t even talked about eyelid disease or heat stroke or these other types of things, but they’re also amplified in dogs with BOAS. So the BOAS dogs, we’ve had some really interesting … And so-what out of this, what does this mean or what can we do about it? I think having these conversations, even IVDD I wasn’t really aware of either, because I haven’t been in practice full-time for 10 years and so I haven’t seen this explosion of dogs and I haven’t seen what apparently the clinicians say to me, “Yeah, it’s Frenchies in IVDD, that’s exactly what we’re seeing now.”

Dr. Andy Roark:
Wow, yeah.

Dr. Jules Benson:
And so I think getting the word out there, enabling clinicians to have better high quality conversations. And for us, taking some of the pressure off clinicians by providing the data and saying, “Hey, look at these data. This isn’t just me and my experience. This is hundreds of thousands of dogs and this is what we see and let’s create an awareness plan and an action plan from that.” And so everything from those dogs with the ocular syndrome, even down to if they have extreme exophthalmos or lagophthalmos, [inaudible 00:20:13] if you’re going outside or talking about topicals long term. Even educating owners, what it’s like when they call in and they say, “Does the eye seem painful?” And they’re like, “I don’t know, it’s red.” And it’s helping them understand the difference between injected sclera and what a painful corneal scratch looks like, I think getting that education up front I think will save eyes and will save people time and money.
And then around the respiratory disease, I think just helping them understand what they’re looking at. And in the kindest possible way, de-normalizing this. As this is something that is known in the breed, the snuffly-ness and the inability to breathe in certain situations, helping them understand that you should not be outside with your dog in extreme heat, that you should not be exercising your dog in humidity, that these are things that are actually dangerous to the health of your dog. And then even as we look at the other thing the data told us was that for Frenchies especially, it’s a disease of young dogs, we’re seeing those claims come in 75% of the time in dogs under two years of age.
So having a valuable conversation about early intervention. And we’ve talked to some researchers in Brazil and a couple of others who are … I think that the jury is out fully on the full benefit, but early surgical intervention with some of these extreme brachycephalics may actually lead to better outcomes. Maybe one of those situations, and peroneal neuropathy is the one we talking about, is an early surgical intervention actually better long term than waiting to put the three strikes on the block up. So I think this is a similar situation it looks like, and we’re still digging into the data on that.

Dr. Andy Roark:
So let’s start talking about taking this in a positive direction, right? Let’s talk about action steps. Let’s talk about education. We’ve already talked about when people come in and they’ve got these pets and they are excited about their new English Bulldog, their new Frenchie, their new Pug, that’s not the time necessarily to talk about choosing your breed after they’ve chosen their breed. So talk to me, if you had your magic wand and you were going to alter the way that veterinary medicine is talking, educating, working with pet owners right now, how do you start to approach this? What are some ways where you feel like we can make some inroads to start to, as you said, de-normalized the brachycephalics, which I like your way of putting that.

Dr. Jules Benson:
And I think you’re right, there’s two aspects to it. There’s, with all the love in our hearts and all our professionalism, how do we talk to the owners of these pets who already have them? We’re not suggesting they give them back or re-home them, whatever else you. You’ve made that decision, let’s help you have the best life with your pet possible. And so I think it’s exactly that. It’s as early on as possible having a conversation, raising their awareness of the abnormalities within the breed of basically saying, “Hey, you’ve got a breed with a great personality. But there are some known issues with that,” and I don’t think it’s that much different from talking to Great Dane owners about orthopedic disease. People choose their breeds and there are issues with them, some people know them, some people don’t. I think making sure people are aware of the diseases and of what the signs are of when veterinary interventions should be called on.
People don’t know what histo looks like. Histo is incredibly dangerous, and if people don’t know the first steps to take, same thing with eye stuff. The people letting eye stuff go, that’s how you lose an eye with a dog like this. And the same thing with the respiratory disease. Even making them aware of, there’s things that we use for cardiac disease, resting respiratory rate, and we can use that for compromise of the respiratory system as well. If you are looking your dog, hey, just tell you 20 seconds and count their breaths. How does it look compared to last week, compared to last month, compared to the month before? Just getting them into the habit of being aware that there are issues with their dogs. So I think that’s the first side of it. The second side is, is it possible to decrease the popularity of these dogs?
And again, this isn’t us being the morality police, but this is, can we reduce the overall suffering or increase the welfare of the dogs under our care? And I’ve had a lot of conversations with a lot of people in this space and I think there’s some great thoughts around more responsible breeding programs. I think the issue with that is that while there’s still a dollar to be made, I think irresponsible breeding programs will continue to crop up everywhere. As long as you can sell a French Bull Dog puppy for $5,000, I think you can talk to good breeders until you’re blue in the face. And I love the OFA, you’re bringing out a brachycephalic scoring index to try and increase the health of the offspring.
But I think it does come down to trying to sway the public and just having conversations exactly to your point around, “Hey, I’m thinking getting a new dog,” if you have the chance to intervene and to have a conversation about the dogs that people are thinking about getting and people loving the personalities, again, just encourage encouraging them to look at the data, to know what they’re getting into and having that emotional, financial and just overall management aspect of having a brachycephalic dog with BOAS or with Brachycephalic Ocular Syndrome. It’s a lot for people and sometimes they don’t know what they’re getting into. So I think if they see the personality, there are other breed that we could suggest that have similar personalities that don’t have some of the same problems.

Dr. Andy Roark:
That absolutely makes sense. I’m going to see if I can run down the OFA brachycephalic scoring index, and I’ll also put links to the white papers in the show notes here. Are there other resources that you really like that you’d point out?

Dr. Jules Benson:
I think the other side of this is that we’re trying to build this base of evidence-based medicine really to try and drive special care decisions. So I know that Dr. Emily Tincher came on and talked to you about that a little while ago and encourage people to check out that episode. But really, we can go to the spectrumofcare.com, which we’ll put in the show notes, but I think that that gives a really good insight as to another reason why we’re doing this. It really is about education boundaries, but it’s also about what are the best courses of treatment. So looking for the evidence base around things like early surgical intervention, for example.

Dr. Andy Roark:
Yeah, I think that’s fantastic. I’ll definitely link that up as well. Jules, where can people find you online? Where can they follow you?

Dr. Jules Benson:
LinkedIn is where I do most of my damage these days and people are welcome. Anything that we have that’s new, and I think it’s worth saying that I think the white papers, we love the work we’re doing there and we love the stuff we’re translating into the space, but great to keep an eye on us. I think later this year we’ll be making that more accessible for more breeds, more veterinary healthcare teams and more pet families. So we’re really excited about the work that we’re doing and what’s coming down the pipe, so watch the space.

Dr. Andy Roark:
That’s fantastic to hear. All right, thanks so much for being here. Guys, thanks for tuning in and listening. Everybody take care of yourselves.

Dr. Jules Benson:
Thanks Andy.

Dr. Andy Roark:
And that is our episode, guys. That’s what I got. I hope you enjoyed it. Thanks to Jules for being here. Thanks again for Nationwide for making this episode possible. Guys, take care of yourselves. Be well. I’ll talk to you soon.

Time for GPs to Take Back Skills They Gave Away to Specialists?

by

Neurologist Dr. Sean Sanders joins the podcast to talk about what a re-division of labor among general practice veterinarians, specialists and support staff might look like. Is it possible for us to improve affordability and access to care by giving more wellness care to technicians and supporting general practice veterinarians in taking back a variety of skills that they have given away to specialists over the last few decades? Let’s get into it!

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

LINKS

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. Sean Sanders is a Veterinary Neurologist and Neurosurgeon in Seattle, Washington, USA. Dr. Sanders is also involved with development, recruitment and operations of BoosterPet in the Greater Seattle area. He received his DVM degree from Washington State University and completed a residency in Neurology and Neurosurgery along with a PhD in Neuroscience relating to the study of Parkinson’s Disease. Dr. Sanders was a founding partner of Seattle Veterinary Specialists and author of “Seizures in Dogs and Cats” published by Wiley Blackwell. Dr. Sanders lectures nationally and internationally on topics related to Veterinary Neurology and Neurosurgery. In his spare time, he spends time with his wife and their pets, builds wooden boats and classical guitars, restores classic cars and enjoys, sailing, mountain biking, hiking and snowboarding.

EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome, everybody, to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am here today with my friend, Dr. Sean Sanders. You might recognize Dr. Sanders. He was on earlier in the year. He is a neurologist in Seattle, and we started talking last time he was here about changing roles for general practitioners and technicians in modern medicine. And he’s a big advocate for accessibility to care, and I wanted to get him back and unpack some of these things and say, “What does this look like? What does it mean when we talk about expanding the role of the general practitioners?” Because I know a lot of people think about general practitioners getting squeezed. They think about technicians doing more and more, and specialists doing more and more, and what’s left for the old general practitioner? I think Sean’s got a really good answer for that.
And the answer is that maybe specialists shouldn’t be doing more and more. Maybe as we push to keep access to care front and center and be able to get people the services they need, maybe it’s time for general practitioners to start picking back up some of the stuff that we used to do. And what are the barriers to that? We talk about that a little bit. What are the benefits to that? We talk about it. We talk about it from a financial standpoint, we talk about it from a career enjoyment standpoint, we talk about it from a pet healthcare standpoint. It is a really fun, really good conversation. This fits right into my recent thing of trying to get my head around what that medicine’s going to look like in the next 5 to 10 years. Man, I like Sean’s vision. I think it’s pretty good. I think we should really think about going in that direction. So anyway, guys, I hope you’ll enjoy this. This is a big make-you-think episode. Let’s get into it.

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

Dr. Andy Roark:
Welcome to the podcast, Dr. Sean Sanders. How are you?

Dr. Sean Sanders:
I’m good. How are you doing today?

Dr. Andy Roark:
Man, I’m doing great. I am really happy to have you back on the podcast. I really enjoyed the first time that we got to talk. I left with a lot of ideas and a lot of questions, and we just flat ran out of time last time you were here, and so I was like, “Well, I’m going to Sean back. We’re going to talk some more.” So yeah, thanks for making time.

Dr. Sean Sanders:
Well, I’m glad you asked me to come back, yeah.

Dr. Andy Roark:
Oh, my pleasure. So for those who don’t know, you are a veterinary neurologist in Seattle, and you do a number of things. You have a PhD in neuroscience and you’re a teacher, and you’re traveling to Germany in a couple of days to do some lecturing there as well. You also work in some telemedicine stuff. You have a lot of really interesting things going on is what I would say.
Well, getting back into the conversation I wanted to pick back up with you, it was really kind of about the future, the next 5 to 10 years of vet medicine for practitioners in the trenches and what it looks like. And the reason I wanted to talk to you about that, I’ve just been thinking a lot about this, and I just had an article that came out at the time that we’re recording this, and I wrote about standing back and looking at the profession. And I really see this tectonic shift going on, where we have a customer-driven world in a way that we haven’t in the past.
And so I’m looking around that I’m seeing things like Chewy coming into the space, and they dominate in customer service. And pet owners like their home delivery and they like working with them. And we’re having telemedicine come up, and pet owners are getting used to these services. And we’re having a problem with a shortage of veterinarians and getting people in to get the care that they want, and I don’t think pet owners are handling that very well.
My take on this really is if you have demand from pet owners and you have people who want to provide the services, our culture, our society, America in general, [inaudible 00:04:09] specific, I guess, is really set up to facilitate capitalism, which is, if somebody wants it and somebody else wants to provide it, for the most part, our society is set up to make those things happen. And I look at our profession, and we’re feeling a lot of change being thrust upon us. Like I said, telemedicine is really changing things. We’ve got talk about mid-level practitioners, things like that, utilizing technicians in a new and interesting way. All of these sorts of things that are meant to just make care more accessible, more convenient, and pet owners are kind of clamoring for them.
So I’m looking at that. I call that tectonic, because I think that the ground is changing, and I don’t know that we are going to be able to hold these sort of changes back. I think that ultimately pet owners know what they want, and they’re being offered a lot of things, and they’re going to push our profession in a way that is convenient for them. And I think our two options are trying to dig in our heels, and I think we’re going to get crushed, or to look at the landscape, say, “This is where things are going. Let’s reposition ourselves so that we can prosper in the new world that’s coming.”
So let me just stop there. As I say, I sort of just threw a lot at you. What do you think when I say that? Does that kind of match up with the general industry trends that you are seeing and the way you see our profession being affected?

Dr. Sean Sanders:
Yeah, I completely agree. I think looking back at veterinary medicine, or we could say medicine in general, it’s always been a bit of that kind of a patriarchal type of system, where the doctor tells you what to do, and you do it. Gone are the days of James Herriot, where he would tell you it’s time to put furballs back to sleep, because I’ve got a broken tooth. And so you would be like, “What? I don’t have any say in this.” And we’re getting into a time where veterinarians and clients have more of a symbiotic relationship, it’s more of a shared communication.
So as you mentioned, we’ve got this market-driven economy, where the clients are starting to shop around, and not only are they shopping around for products, but they’re shopping around for accessibility and cost. We know that there are inflection points with everything, and we see it in technology, and we are seeing it, I believe, in veterinary medicine right now. I think we’re at a kind of revolution right now, where the practice of veterinary medicine is changing. I went through one back in the late ’90s, when specialty medicine kind of came on the field, so to speak, where it moved from primarily focused in the universities to focused into the large urban areas, and now it’s just spread out and grown and grown and grown.
So I agree with you completely that we need to look at the profession, we need to stand back and look at the profession, and we need to decide what is this going to look like in 5 or 10 years, and we can be the drivers of that innovation. Always when you talk about change, that scares people. It’s natural for us to be scared about change. But if we look back and we look at things that have changed in our lives, just the digital camera, the personal computer, the taxi cab, all of these things have changed in a way that we can’t imagine going back to the way it used to be.

Dr. Andy Roark:
I agree with that. Let’s pick up on this. You mentioned the spread of specialty medicine. The last time that you were on, we were talking a bit about this, and we were talking about accessibility, and we were talking about a shortage of specialists and people not being able to get in for specialty care or limited funds and resources to get into specialty care and things like that. And your position, as you explained it then, was general practitioners have given away a lot of their, I don’t know, a lot of their utility in some ways to the specialists. They have stepped back and said, “Oh, this is going to be a specialist thing. We’re going to let the specialists do that.”
And now that it’s hard to get people in for specialty care or things like that, or they’re not willing to go, it may be time for general practitioners to really think critically about re-expanding their lane, if you will, and taking back on some of these. So let me put that back to you and say do you still feel that way? And if so, sort of start to set up for me what you think that system could look like.

Dr. Sean Sanders:
I think the root of it is with the general practice, but I also think it extends to specialists as well. When I started specialty practice in 2002, finished my residency, there wasn’t a lot in Seattle, there was no specialty center. And over the years, we developed this, specialists came together, we formed these large multi-specialty gigantic clinics, and we were there, ready to take the cases. And so we kind of trained everybody that you need to send the cases to us, because that’s where you’re going to get the best care.
And unfortunately, looking back at that, you may have been a veterinarian at that time that had 35 years of experience in doing splenectomies and doing enterotomies and GDVs, and all of a sudden, you’re kind of being told that, “Well, maybe you’re not the best person to do that anymore.” But I look back, and I say, “Well, who was a better person?” A recent resident who’s done maybe two on their own compared to a GP, who’s been out there doing them for years.
So I think to some degree, specialists, we had the effect of convincing people that they needed to send us the cases, and maybe that was the best thing for the patient, especially if you’re talking about the high intense cases, brain surgery, back surgery, adrenalectomies, the things that require a lot of capital intensive infrastructure to get going, like overnight management or endoscopy towers, things of that nature. But in doing that, I think what we did was we were so welcoming to all of these cases, and I won’t speak for every specialist, because I’ll get hammered if I do that, but I think I can speak for neurologists.
One thing that I commonly saw in practice, a big time suck for mem was just chronic management of seizure cases, and there is no reason why these can’t be managed in general practice. It just requires a patient and some basic drugs and knowledge. But what we found was that when I started my practice of specialty medicine, I kind of opened the doors, and I continually said, “Yes, yes, yes, yes, send me every case,” And so that’s what people got used to.
And so by doing that, I think that one of the things that happened was general practitioners probably got the impression, and it was a real one, that you shouldn’t be doing these cases. You need to send those seizure cases to the neurologist, because they’re the one best equipped to handle that patient. And there might have been some general practitioners out there, I’d like to hear from them that actually enjoyed treating seizures chronically. I know it’s not a fun thing for everyone, but I think in doing that, we kind of took away that self-reliance that people naturally develop on themselves or that problem-solving ability that they have to take care of their patients.
And over the years, that worked great. As our specialty clinics expanded, we started to take away cases from the general practitioner, we started to take cases away from universities. And so as that university caseload went down, you saw the training opportunities for residents and people who were going to go into general practice kind of got lower and lower. And it was almost like those cases were being sequestered in the specialty hospitals.
So I think over time what happened was people just got in the natural mode of, “Well, that’s how human medicine went. You sent the case to the specialist, and it got taken care of, and if something went south, then it wasn’t your problem, and so that’s kind of great.” Unfortunately, what’s happened now is that we’re at a point where specialty hospitals, large clinics are starting to shut down, because they don’t have enough staff. Costs are still going up in order to maintain a margin that the owners of the practices need, and so that’s creating barriers to care. And those barriers of care might be accessibility from time. I can’t get that patient in for six weeks, or it might be a barrier to entry due to cost, because it’s just not affordable for people to do things anymore.
And so I believe that general practitioners and specialists need to start looking at what they actually do in practice and focus their energies on the things that drive their passion and that they are truly equipped to do. So for me, personally, I really enjoy surgery so my time is best spent in the surgery suite, doing a two or three-hour surgery as opposed to in an exam room explaining to somebody why we monitor drugs for seizure management. We do it, but there might be others who enjoy that more, and they don’t like surgery. So I can use that as an example to say, “Well, how can I focus my practice on what drives me?”
And in general practice, I see, and I look at this, so I’m a veterinarian, first and foremost, and I’m a general practitioner, because I have pets, and I take care of all my own pets as much as I can. But when I run into a case where I need to get my pet in to see a specialist, and I can’t, and it’s happened to mem and I’m waiting six to eight weeks to see an oncologist or an internist, and I’m watching my patient, my pet decline, how do I solve that problem? Well, I reach above me and I grab a book. I start looking at the color pictures first, and then I start reading second, and I figure it out on my own. There is no reason we can’t do that for all of our own patients.
Of course, there are things that you can and can’t do, right? I’m not going to be buying a scope tower in my house and doing my own scopes, but I could certainly do if I need an aspirate and look at a slide of my own dog, or for that matter, I could probably do a splenectomy if I needed to. So I feel like if you’re a specialist or a general practitioner that if there’s something that’s a time suck in your day that’s taking you away from what you really want to do, then you should try to figure out what that is and take it off your plate, so you can focus on what you really enjoy doing.
I feel if you’re finding that your patients are not able to get the care they need, because one, they can’t afford it, or they can’t get in to see that specialist, maybe there are some things that you can do that used to be within the general purview of a practitioner, like those elective type of surgeries. By doing that, you will get better care or better access to care for the patient, probably more affordably, and then it will also allow the specialist, if they want to focus on the things that drive their practice. Keep the neurologist in doing brain surgery, if that’s what they enjoy, allow the surgeons to do adrenalectomies, if that’s what they enjoy, allow the interest internists to do the scopes, et cetera. That’s the perspective I’m coming from.

Dr. Andy Roark:
Yeah, no, I really like that. I really particularly like your self-driven approach to this, because you’re right. I always say, “Well, you know what? What should we do about education and these things?” And the truth is if I wanted to, it’s been a while since I’ve done an enterotomy, I just don’t have a … I practice regularly, but not enough to be doing surgical rechecks and things like that, and I sort of stepped away from surgery a couple of years ago.
But I do think about it sometimes, what if I wanted to pick this back up? What if this is where I wanted to go? Would I need to go back to some sort of hands-on education course, or is this a thing where I can line up my own mentorship opportunities, jump in, watch a couple of these things, get somebody to maybe shadow me doing one or two, because I’ve done them before, and just sort of pick that back up.
And the truth is there’s a lot of resources and opportunities for me to get these skills in my own way if I just decide that I want to do them. So I do really like that idea of just put in the work, pull the books, get the insight, and there’s never been more resources and support asa there are now.
If you dream of doing team training with your team, getting your people together, getting them on the same page, talking about how you guys work together in your practice, I’d love to help you. You can check out drandyroark.com and check out the store. I have two different team training courses. These are courses for teams to do together to get on the same page and to talk about how you do things. I have my Angry Clients course and I have my Exam Room Toolkit course, and they are both available and there, so come out. All right, guys. Let’s get back into this episode.
Can you expand this idea out to support staff for me? Because I know this is something you and I have talked about before as well. So I love this idea, I love the general concept of where you’re going, and to me, it’s just the obvious ripples out from this is that the thesis, the idea of you should figure out where your time is best spent and spend your time there. Well, why wouldn’t that ripple out to the front desk and to my technicians and things like that? So can you sort of color in those lines a little bit for me? How do you see this? If we lean into the idea that you’re putting forward, which I really like a lot, how does that ripple out to the support staff? What does their path look like?

Dr. Sean Sanders:
Well, I think from a very selfish perspective, if the veterinarian looks at what they enjoy doing, and then they try to focus their career on that path, something’s got to give, because chances are, you’re in five different lanes of your practice. You’re going to be on the wellness lane, you’re going to be in the non-well, the chronic care, the procedures, the elective surgeries. If you’re covering all of those lanes, but you only want to be in one or two, then you have to figure how are we going to cover those other lanes?
So if wellness is your thing, if you like the preventative medicine talks, if you like looking at blood work for yearly checks, if you like taking care of healthy pets, then you have to figure out a way to not do those other things, and that might be giving it up to a colleague. If your thing is dentistry, if you just want to line them all up on the table all day long and do dentistry after dentistry, somehow you’re going to have to get out of that wellness lane so that you can have time to do that.
And one of the things we can do, we’ve talked about this before, is we can utilize our support staff, especially our veterinary technicians, to the highest degree possible within the practice act that your state allows. So allow them to do the things that the state gives them the opportunity to do. I go into practices every once in a while, and I see veterinarians cleaning the ears of pets, and I see the technicians holding the pets, and that’s great if that’s what you enjoy doing. But then when I talk to the veterinarian and they say, “Boy, if I could have more time to look at the cytology, I would love that, because I love looking at cytology, or I want to do more procedures, and I hate cleaning ears.” Well, you have a perfectly capable staff member that’s able to clean ears within the scope of their practice act.
And so I think we need to open up the fact that by allowing our staff to utilize the skillset that they’re trained to do, we’re going to give them greater opportunities to grow with the profession, they’re going to be more of a revenue generating part of our practice as opposed to just a support piece, and it’s going to allow us to focus our career where we want to go, because they’re going to be scraping off those low-hanging fruit things that allows them to expand into more of that mid-level practitioner role.

Dr. Andy Roark:
That totally makes sense, and I think that’s been the aspiration for a while, as far as leveraging our technicians. Talk to me a little bit. I think when most veterinarians look at where they spend their time and they think about things that they would like to maybe get out of, there’s a lot of client communication that falls into that, that takes a significant amount of time in things. You’ve had sort of an interesting career in working with technicians in different ways with BoosterPet and things like that. Talk to me a little bit about how you can see support staff moving into the client-facing and client communication space. Do you feel like there are significant opportunities there for us to change up how we’re practicing and engaging? And if so, what do those opportunities look like?

Dr. Sean Sanders:
Anyone, whether it’s a veterinarian or a staff or an LBT or a VA, we all have inherent strengths and weaknesses, and some of those might be communications, some of those might not be. So first of all, you have to define do you enjoy being that communicator? I absolutely loved spending three hours with a client, talking about seizures, drawing on my whiteboard, making them understand it. I love the connection that I got when they understand something, but that’s not the best use of my time, and I would get drawn into it. My staff would be tapping me on the shoulder and saying, “Hey, we got to get you over here to do this. Stop talking.”
So first of all, it’s identifying the people in your practice that love doing that. Second of all, it’s just a matter of repetition. So giving the same talk over and over again, albeit there are going to be some nuances, but given the same talk over and over again about seizures is something that pretty much anybody can do, or it could be flea control or parasite prevention. It could be just wellness in general. Those are things that I’ve seen in our practice work very well at the technician and the VA level.
That allows the veterinarian to get to the next case while that technician is talking to the owner and educating them about, “This is why we’re testing for this disease,” or “This is why we’re using this preventative, and this is what you need to know. And this is when your pet needs to be vaccinated.” These are topics that are happening so routinely on a day-to-day basis that people get excited about them. Staff love to talk about wellness, they love to have that client interaction. And I think it allows them to expand their opportunities of growth within the veterinary space to be more than just a “Go get me this” type of person or a “Hold this” or a “Clean that” type of person. It allows them to be our colleagues basically in healthcare.
I utilize my nurses to the maximum ability that I could in my practice. It wasn’t me talking to the client about what to do with the next level of seizure medication increase. It was my nurses talking to the client, and then they would come to me and say, “Hey, so-and-so is doing this. It’s already on phenobarbital. What do you want to do?” And I would say, “What do you want to do?” And they’d say, “Well, we are going to just increase it by 25%, check levels in two weeks.” I’d say, “Yep, let’s do that.” You still have to be responsible for the case, but I 100% believe that we can support our coworkers, to give them learning opportunities within veterinary medicine, so that they can grow and, more importantly, so they can stay in the practice of veterinary medicine and not leave for something or some other industry where they may feel more valued.

Dr. Andy Roark:
That totally makes sense. I love that approach to the old, “What do you want to do?” I had a case earlier today, we had a possible parvo dog coming in, and my technician was like, “Well, what do you want to do with it?” And I said, “Oh, what are you going to do with it?” And they’re like, “Oh, I was going to have him stay in the car, and I was going to go to a fecal sample, and we’ll do a parvo test.” And I was like, “You know what? That sounds like a great plan, man. Let’s do that.” It’s one less decision I have to make, and the other thing is just it’s coaching, and you’re just growing better and better people.
So when you start to think about this and where it’s all going, are there things, what are you most excited about? When you look ahead and you go, “Oh, man. I would love to see this happen in the next 5 to 10 years. If we as a vet profession could get our ducks in a row, this is where I would like to see us go.” Is there anything like that inspires you?

Dr. Sean Sanders:
I think the thing that gives me the most hope is just the idea of access to care. And by that, I mean timely access to care, and I also mean affordability of care. What I’ve seen in the last several years is just the costs of veterinary medicine go up at the specialty level, where it’s basically become that type of advanced care is really for the rich. Every pet is a luxury, essentially. We don’t really need them to survive, but they’re family members. I’ll just share a little story, and I’ll try to keep it very vague, but a couple … Did I talk about my neighbor last time?

Dr. Andy Roark:
I don’t think so.

Dr. Sean Sanders:
Okay. Well, in between our last talk, my neighbor calls me up, and she says, “Sean, I don’t think Sadie’s doing very well. She seems to be having a hard time breathing.” So I go over to her house, and it looks like her dog’s abdomen’s bloated. It feels mushy. She’s got no pulses. Her limbs are cold. I think she’s probably got a splenic rupture or something like that, a splenic mass. We spent about an hour-and-a-half just trying to get a specialty hospital within the area. I think we called six or seven different specialty hospitals to get her in that night. It was a Saturday night, about 7:30. Couldn’t find a single surgeon that was working that night or on call.
So I called my old hospital that I used to own, and I said to one of the ER doctors, and I was using the doctor card on every one of these I called, and I said, “Hey, I’m coming in. I got my neighbor’s dog. I think she’s going to need an evaluation, probably a hemo abdomen.” And he was like, “Well, we don’t have a surgeon on call tonight.” And I said, “Well, I did one in vet school, so she’s either going to die on my hands, or she’s going to die in the ER.”
So we ended up taking her there, and thankfully, the criticalist at the practice was just finishing up on a foreign body and a cat. So the criticalist was doing surgery, because the surgeon was out. And they did a fast scan on the dog, and they decided, “Yeah, she’s got a splenic mass, and she’s bleeding into the mass.” So they decided we’re going to give her a transfusion, keep her overnight.
So the first thing I learned that night was that what if that criticalist had not been there? Was I prepared to do a splenectomy in that dog? I probably would’ve done it. I’m pretty sure she would’ve been okay, but yeah, it had been 25 years since I did one of those. It was a junior surgery, so it was a while ago, and that dog wasn’t recovered. So I don’t know if it would’ve gone so well, but it would’ve been better than the dog just kind of crumping out on use.

Dr. Andy Roark:
Sure. Wasting away, yeah.

Dr. Sean Sanders:
Right, right. The second thing that shocked me was, and I won’t give any specifics, but it was the estimate for the surgery. It blew me away, and it’s hard to shock me, but it was probably five or six times more expensive than a surgeon friend of mine down in Orange County would’ve charged. And so there was this insanely huge disparity between what a person could afford to pay and what it actually cost to do. And I’m not talking about slightly off, I’m talking orders of magnitude higher. And these people, they were able to do the surgery and the dog did have the surgery the next day with the criticalist.
But I think about how many animals don’t get that access to care just because of the cost. And if we can take some of those really high cost procedures and put them back into the hands of the general practitioners, and I’m talking guardrails here, I’m not talking adrenalectomies or anything, I’m talking like elective surgeries, enucleations, GDVs, things like that. Things that when I was preparing to go into vet school, the vets I worked with were doing all of these things in their practice, and they were doing them because they had no choice. They liked doing it, plus there were no specialty centers at that time where I lived. So they either got sent to the university or they got handled in-house.
So I think what gives me the most excitement is that if a veterinarian can expand their practice by doing things that they’re passionate about and be able to do those at a cost point that’s going to save the client a ton of money, but still make the veterinarian a ton of money, then I think that that supports the industry as a whole. It will raise up our standing back in the communities as the person who can solve problems for people. That idea of self-reliancy and problem solving, I love the idea that we can learn to do that again.

Dr. Andy Roark:
Dude, that’s awesome. I love that vision. Sean, thanks so much for being here. Where can people find you online?

Dr. Sean Sanders:
I’m somewhat dark. I’m only on LinkedIn. And as I mentioned before, I think at that time I had 34 connections. I might have 39 now.

Dr. Andy Roark:
Oh, that’s good. Well, I’m glad to see the first appearance on the podcast really move the needle for you.

Dr. Sean Sanders:
Yeah, yeah. Get in line.

Dr. Andy Roark:
Yeah, exactly right. Awesome. Thanks so much for being here. Guys, thanks for tuning in. Take care of yourselves.

Dr. Sean Sanders:
Thanks a lot.

Dr. Andy Roark:
And that’s it, guys. That’s what I got for you. I hope you enjoyed it. I hope you got something out of it. Thanks to Sean for being on. As I said, I really left this conversation just fired up about, “Oh, this makes some sense.” I like this. I like the idea of being a problem solver. I like the idea of GPs picking back up to their scalpel or picking up the tools that they might have referred away and let other people use in the past. I think that it allows technicians to grow in their roles and to take a lot of stuff off of our plates and to earn a living wage for themselves and provide pet owners with quicker access to care, and it still keeps us with full schedules, doing work that matters. I really love what Sean was saying about it puts us back as being seen as people who step in and fix things. And that’s what I’ve always wanted to be. So anyway, guys, I hope you enjoyed this as much as I did. Take care of yourselves, everybody. Be well. I’ll talk to you later on.

Publix Supermarket & Turning Clients into Fans

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Tyler Grogan CVT, Creative Marketing Director at Uncharted Veterinary Conference, joins the podcast to discuss her favorite grocery store and how to turn veterinary clients into loyal fans.

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

LINKS

Links to Amazon.com are affiliate links and help support the show. (They’re also much smaller than normal links and easier to copy when typing up show notes!)

A Piece of the Pie: https://amzn.to/3L74Itz

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

Tyler Grogan is a Certified Veterinary Technician with experience in specialty, emergency and general practice. She currently serves as the Creative Marketing Director for the Uncharted Veterinary Conference where she focuses on brand building, marketing, storytelling across multiple digital platforms, and exploring new ways to elevate the client experience.

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 one of my good friends, Tyler Grogan, CVT. She is the creative marketing director at the Uncharted Veterinary Conference, and I am talking with her about a lecture I saw her do back in December on turning clients into fans. And we talk about sports fans, we talk about Tyler’s not at all strange obsession with the grocery store Publix and the experiences that they create and what she’s learned from the Publix’s supermarket about veterinary clients and building client loyalty. This is a really fun conversation. This is an idea conversation if you like those conversations where people are talking about sort of abstract things and you go, “Oh man, this is really getting me thinking in new and interesting ways,” you’re going to love this episode. Gang, without further ado, 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. Tyler Grogan, how are you?

Tyler Grogan:
I’m good. How are you Andy?

Dr. Andy Roark:
I am doing so good. It is so good to see you. I do enjoy when we get to catch up, which is very often since we live in the same town and we work for the same company and all those sorts of things. But I get to see you a lot, but I always enjoy seeing you. For those who don’t know you, you are a certified veterinary technician. You have been in social media and marketing for a number of years now. You are the creative marketing director for the Uncharted Veterinary Conference, which is where you and I both work. And yeah, you are always a breath of fresh air and one of the most positive people that I know, and I have just been so happy to get to know you over the last like what, six, eight years now. Something like that?

Tyler Grogan:
Yeah, we’re coming up on a decade of knowing each other.

Dr. Andy Roark:
Are we really? I was thinking it was getting up there.

Tyler Grogan:
Yeah, we met, I believe it was, it was then NAVC, but now VMX conference once upon a time. And then I showed up at Uncharted and haven’t left. So you’ve been stuck with me since.

Dr. Andy Roark:
Yeah, that’s true. You showed up for a conference and ended up with a job, and that’s how that went.

Tyler Grogan:
My plan worked brilliantly.

Dr. Andy Roark:
Well. I wanted to talk to you about some work that you’ve been doing. You have a lecture that I got to see back in December, and it’s called Turning Clients into Fans. And I wanted to bring you on here, one, because it’s our 200th episode of the podcast, and I was like, who do I want to talk to? I want to talk to my friend Tyler, just someone who I have gotten to be really close with. And then number two, I love when we take two different ideas and squish them together to understand the world. It’s how my brain works, it’s one of my favorite things. If people have ever heard me talk about time management, I talk about Red Dots and I talk about dragons, and I just talk about all of these wild things because I think that thinking about disparate things and then squishing them back into the question at hand or vet medicine specifically, I think that lets us see things in a new and interesting way.
And so you did this presentation that I got to see, called Turning Clients into fans, and you talked about Publix, the grocery store, in terms of how we should treat veterinary clients. And I want you to lay down your story and your thesis on how Publix informs the way we should think about seeing pet owners.

Tyler Grogan:
Yeah. So I love that you called it a thesis because as I dove into this topic, it definitely started to feel a bit like a research paper, which is always fun. I’m a naturally curious person. So it actually came up as a question in 2019 before the pandemic when we were at Fetch in Kansas City, and I saw a talk by Bill Schroeder about marketing. And he briefly touched on how there are fans for different businesses, and he actually used Uncharted as an example of a company that had fans. And so that always kind of stuck in my head. And I’ve always had that kind of question in the back of my mind of, okay, well it makes sense, but how does it get to that point? And so I took that from there and really thought about sports. And in veterinary medicine right now we’re experiencing a lot of change and we went through a lot of change, and that comes with a lot of new team members and a lot of new processes and a lot of new things.
And so it kind of made me ask this question. So again, putting thing one thing to another thing, kind of like how your brain works of how do sports have actual fans that endure so much change? They endure change for their staffing, their teams on a regular basis. And yet someone who is a fan of a sports team is a fan of the team. And I was like, okay, there’s this bigger question of how do you create this enduring, because really they’re customers, how do you create this enduring fanship? And Publix is a great example of a business taking some of those concepts.

Dr. Andy Roark:
I want to pause here for one second because I really like this idea. I’ve not really honestly processed it that way because when you look at professional sports, you have these free agents and you have people who come and they turn over and they get traded. And I know people who are absolutely rabid fans of a sports team. And I’m like, man, all of the people who are on that team, were not on that team five years ago, and they won’t be on that team five years from now. But the fans are often, they seem much more loyal than the actual players on the team, in a big way. And I understand there’s economic drivers for that. But I think this is really interesting.
It’s also really, honestly for a second, I kind of recoiled when you said, these fans are our customers. And I’m like, “Customers? Like I’m a Florida Gator customer?” And the truth is, yes, I am. I have a very expensive degree that I purchase from the University of Florida. And boy, their merchandise is ridiculously expensive. And yet, I still buy it and people buy it and give it to me because that’s where I’m from.
But you don’t think of fans as customers. But at their root, that’s exactly what they are. So I like that. And I had not really considered the idea of looking at this as a way of insulating vet practices against staff turnover because sometimes we have veterinarians that leave and sometimes we have staff that leave. And that’s just unfortunately, it’s part of the job. I don’t think there’s anything insidious about it other than people always, they have lives and they have spouses and they have needs and they move away to be close to family and things like that. And so how do you build this attachment to the team as opposed to the individual? I love that. So with you there. Talk to me about how Publix interfaces with US professional sports teams.

Tyler Grogan:
All right, so stick with me here. So like you said, you kind of recoiled at the thought of a fan being a customer, and I had a similar reaction of, wait a minute, but it makes sense. We’re spending money to participate in these types of things. And so again, the bigger question was how do we create this enduring fanship, and then how does that translate to business? And so sports was kind of a huge thing to look at and really translate to veterinary medicine. So I started thinking about what businesses do I consider myself a fan of and why? And the first one that came to mind was Publix, and it’s a grocery store for those of you who are maybe not from the south or the United States that have not heard of it, but it’s a grocery store chain in the southeast.
And I would say that I am a fan of Publix and there are people out there that are true fans of Publix. And that means that they’re out there buying merchandise or if you live out of state, they’re telling you that if you go visit this area of the country, you should go to Publix and have a Pub sub. It’s that level of involvement. And so what were they doing as a business that was creating that same level of, I want to be involved in this, I want to spend money here, I will choose this over any other place and that loyalty. So it was an easier leap for me to kind of think about, okay, let’s look at the business side of this rather than sports teams to really translate it to vet med.
And so it boiled down to a couple different areas of customer service, which were exceeding expectations consistently. So setting expectations of what you’re going to get. When you walk into a Publix store, it’s going to feel the same. You’re going to have a good experience. If you walk up to a counter and ask for help, they’re going to help you. It’s just always a positive experience. So meeting and exceeding expectations, and that’s on a consistent basis.
And then the other thing is creating an emotional attachment, which this one hit right on the head for me because vet med, we immediately have that leg up on any other business. We are going to establish emotional connection with our clients and customers right off the bat because a big part of their identity is their pets and being pet parents. And we have a great opportunity to connect with them on an emotional level that most other industries don’t get that. So we already have half of it, pretty much set up for us. The second half is really about meeting and exceeding expectations on a consistent basis. So what can veterinary practices do to accomplish that? There’s so many different things.

Dr. Andy Roark:
I’m going to pause here for a second. I want to unpack this connection with Publix a little bit more because I want people to really understand it. And I think you did a really good job in the presentation of laying this out because I agree, my wife will drive past three grocery stores to get to Publix. It is the one. We have our Publix, it’s the one that we go to. I ask her why we do this, and she says, “Well, it’s because I know where everything is.” And I go, “But, how did we get to that point? Why did we not stop at the other grocery stores before we came here so many times that you now know where everything is? What got us to this place?” Because I do agree that now there’s the comfort, there’s a familiarity, there’s all these things.
And I do think that’s part of it. It’s called perceived switching cost. So this is true, and I learned about this in human medicine, but then it applies to vet medicine and applies to everything’s. In my wife’s mind, there is a switching cost, which means if we went to a different grocery store, she would have to figure out where specific things are versus she just knows where they are right now and this is easier. So there’s a cost of switching going somewhere else. And so that’s where we are now, but how do we get there? And so talk to me a little bit more about the fan experience for a grocery store, and I like some specific examples of how did this get created? How did this get built?

Tyler Grogan:
Yeah, for sure. So I’ll step back for a second to the sports example and this connection here. So part of making someone a fan of something is how they’re introduced to it, and there’s usually some level of socialization to that. So for sports, it’s usually my family was a fan of this team, and therefore I’m a fan of this team and within proximity of my home, et cetera. For something like Publix, for example, my mom would always shop at Publix. And so now I shop at Publix and I know what they can do if you need your seafood steamed for you, they’ll do it for you before you take it home so your house doesn’t smell like fish. That’s the level of customer service that they’re offering.
And so how do they reach that point of fanship? Well, again, I bring it back to they’re consistent. I walk in there and I know exactly what to expect. They are not only going to meet my expectations, but they’re going to exceed them. For example, I became a fan of Publix, starting from being a small child, but I recently moved to South Carolina, as you know. And when I walked into my local Publix, which was the first order of business, I walked over to the deli counter and they have usually a type of turkey that is one of my favorite for lunch meat sandwiches. I didn’t see it, I asked, they didn’t have it. And I was a little disappointed, which I think the deli counter attendant could tell. And I left without my turkey. And it was, oh man, this is like a thing, it’s just something that makes me feel comforted and I’m at home, but I can’t get it. So it’s no big deal.
Well, the next time I went to Publix, probably the week later, I went over to the deli counter to find maybe a new alternative, and there was the turkey in the deli counter, and I was like, “Whoa, wait, they have it.” And so I got myself a pound of it, I’m planning to eat it all week long, very excited. And now it’s still consistently there in the deli counter. And it’s not always on display, but they always do have it in stock. And I can’t help but feel like I was the person that made them keep that in stock. And I’m one customer out of hundreds that walk into that store all the time. That’s the level of types of things that happen at Publix that make people continue to go back and be a fan and recommend them above all others. So that for me was a moment of, “Oh, this is a new level. This is beyond loyal customer. This is, I’m going to tell people the story.”

Dr. Andy Roark:
Yeah. I like that. I think that’s a great example. It’s sort of probably a small thing from them is to say, “This was something that was requested. Let’s try it. Let’s see if anybody buys it.” And they got it. And people do buy it. One person, Tyler Grogan, who shows up every week and buys a pound.

Tyler Grogan:
It might only be me. I believe that it might only be me, but I want to think that people around might also buy the turkey and be like, “Wow, whoever thought this up, they had a great idea here.” But it makes me feel good to know that they have this, maybe it is just for me.

Dr. Andy Roark:
I imagine them hiding behind the counter and they’re like, “Hey, it’s her, it’s the turkey girl. Get it out the back.” And they go in the back and they get the same turkey and bring it forward, and then they put it back way after you leave.
If you dream of doing team training with your team, getting your people together, getting them on the same page, talking about how you guys work together in your practice, I’d love to help you. You can check out drandyroark.com and check out the store. I have two different team training courses. These are courses for teams to do together to get on the same page and to talk about how you do things. I have my Angry Clients course, and I have my Exam Room Toolkit course, and they are both available in there. Check them out. All right guys, let’s get back into this episode.
So I love it. I like this a lot. Go ahead and start to help me see the vision of how some of these concepts translate to vet medicine. What does it look like to start to apply some of these principles in a hospital?

Tyler Grogan:
Sure. This is so exciting, I love this part. So George Jenkins, the founder of Publix, was quoted to say, “Astonishment is not a feeling people soon forget.” And so I think about in vet medicine, these moments of when can we take it from this was a good experience to this was a memorable one, to this was something that really was meaningful for me. And we have so many opportunities to do that. It really is about setting the strong foundation of when I come to this vet practice, this is what my experience looks like, this is what I can expect, this is the level of transparent communication that I can expect from the entire team, from the practice. So setting that strong foundation is definitely step one.
But beyond that, you can create those moments. I think our friend, Dr. Michael Miller, does a really good job of this. An example that I love is during the pandemic when everyone with curbside, he started having a little post-it note packet in his pocket of his jacket, which I just rhymed. Great. I just decided to rap about it. He would have a post-it pad with him and he would take a photo with the pet, write a little note personally to the client, which could have even been just something as simple as, “Thanks for coming today,” and he would send that back out with the pet to the car. And he was just doing that on a regular basis and his clients loved it.

Dr. Andy Roark:
Sure.

Tyler Grogan:
They’re posting about it on their social media. Yeah. And so he took it from this, they’ve already established their curbside protocols and procedures and they’re following those. And then he took it to another level of just adding this little extra step and make someone feel special and seen that day and those little things can really add up to creating that experience and turning someone into somebody that’s going to become a fan for you.

Dr. Andy Roark:
That’s awesome. Man, that’s great. That’s a great example of just astonishment. I can imagine this thing coming out and you never expect it and it’s super cool. I guarantee those photos made it onto people’s refrigerators, like the old magnet on the fridge. I have no doubt. That’s what I would’ve done. And I love that. I’m also, a big Michael Miller fan. He’s been on the podcast a couple of times.
The last time he was on, we were talking about something, I think the title of the episode was like Leaders Shouldn’t Eat Last. I think it’s basically what it was. My favorite Michael Miller line was basically he was talking about being sort of a servant leadership to the extreme to point where he’s like, “Boy, we’ve created a job that no one else would want to do, and that’s a problem.” So anyway, he’s such a neat guy and he’s such a deep thinker and I’m not surprised that’s where that comes from. All right, I love it like it a lot. So we’re looking for those sort of types of ways of exceeding expectations, it’s sort of astonishing people and things like that. Do you have other examples or other things that you see that that stand out as ways that you’ve seen practices build fandoms?

Tyler Grogan:
Another really powerful example that I think speaks to the emotional connection piece of being a fan, it actually comes from an unexpected place maybe, which is euthanasia. Those are some of the most emotional moments for our clients in the times that we’re interacting with them, that we have this opportunity to create those connections. And if we meet and exceed expectations during those experiences, then those are the people that’ll come back with the pet that is the new addition to the family after that difficult loss. The card that goes out in the mail, maybe a few days afterward to them could be that little extra step. Some of these things we kind of think of as our normal because we are experiencing them on a regular basis. But for someone that maybe this was their pet of 20 years, this might be the first time that they’re experiencing this loss.
And to have that little extra checking in on them, or even just a quick email. For example, could be that extra step that makes me feel really, really important to these people. And I’m not just a person that walked in one time, I’m a person they care about. And so those are really powerful moments that we can connect with people in such a strong way. And so that’s another example. Outside of the practice, I heard a story recently of a company that they provide AutoShip for foods. And so a friend of mine’s family had a pet that passed away. They emailed the company and said, we need to cancel this AutoShip. And they were very nice emailed back and said, “Of course, we’ll cancel that for you. We’d just ask that you donate the food that you already have to a local shelter.”
But then they took it to the next level and they sent them a small bouquet of flowers to their home. And for a large company like this, that might have been just a very, very small investment. But that led to this family feeling very personally connected to this company and therefore, walking down the street of their neighborhood, telling all their neighbors about this experience. And who are they more likely now to maybe also get foods for their pet from? So it can be really powerful and have a lot of ripple effects to just make those little extra steps.

Dr. Andy Roark:
Yeah, I think that’s fantastic. That makes a ton of sense. So you talk about consistently exceeding expectations. I think that that’s an important thing. I think a lot of us, we have wonderful interactions, we’ll have a great conversation and we’ll say, “Oh, I saw this opportunity, I jumped in and helped this person. And it made me feel good, and they even wrote a thank you note because they were so impressed with it.” Talk to me a little bit about the consistent part of it. How do we start to build consistency into programs like this, in your mind?

Tyler Grogan:
Yeah, sure. So some of it comes down to setting up protocols and processes for your practice, which those, again, were kind of coming out of a time of significant and rapid changes during the pandemic. And so some of those processes might look radically different than when you opened your practice. A good example may be just your appointment protocols. How long in advance are we confirming appointments? How long are we going to expect people to be waiting? What are we letting them know? What are our steps because we are so busy at this point? What are our steps to letting people know that we’re running behind, or what our expectations are we setting around maybe how long they’ll be in the lobby or in their cars before they come in?
Some of those things, just sitting down and looking at those processes can really help to establish some consistency right off the bat. And then what I think is maybe the step to exceed the expectations is to set yourself up for success in those processes. There’s nothing to say that we could get this client in a room within 15 minutes of their arriving, but if we tell them that it may be a 25-minute wait and we get them in 10, that’s succeeding expectations. We’ve set ourselves up to succeed. We do this really well with things like lab work where we let them know perhaps that we know we’ll get the lab results back in three, four business days if it’s a regular testing. But we’ll let them know we’ll get back to them within seven to 10 business days. And then when we call them way ahead of that, it’s an exceeding of expectation. So yeah, there’s so many opportunities to just set yourself up for success. So I think there’s a lot there to dig into.
And you can look at one thing at a time. It seems like it can be overwhelming if you sit back and look at the whole picture. But I love something that you say, which is pick a hell and make it pretty. Pick something that is something you do all the time. Maybe it’s the thing that you’re known for, you’re known for your low stress handling appointments and you do really well with very fearful cats, for example. Look at that process. What makes it great? Look at what you’re doing now and you already know it’s doing well for you. And then where can you add in a couple layers of, we know we can do it this well, let’s say that we’re going to do it this well and set ourselves up to exceed their expectation. Let’s also give them a small toy when they leave without saying anything about it at any point before their visit. And then it’s going to be this extra step, this little extra thing that is part of your process, but it’s behind the scenes. So it’s exceeding expectations from the client perspective. There’s little things like that.

Dr. Andy Roark:
That makes a ton of sense. Tyler, for people who are inspired, who are fired up, who want to get deeper into this head space, do you have favorite resources that you recommend? Anything that you like or draw inspiration from?

Tyler Grogan:
Yeah, so when I was diving into learning more about Publix and their customer service, I did come across a book called A Piece of the Pie. It was written by an executive of their HR department, who was there for 25 years. And it’s got a lot of great stories of these moments of exceeding expectations that I really, really enjoyed. So that’s a great resource if people are interested in learning more.

Dr. Andy Roark:
That’s so great. I love stories like that where you can just pull examples from, and I walk around with an encyclopedic knowledge of customer service stories of Publix. The staff after a while is like, “Here he goes again,” and I’m telling Publix customer service stories. Perfect. I’ll put a link to that in the show notes. Tyler, thank you so much. Where can people find you online? Where can they see the wonderful work you do for Uncharted?

Tyler Grogan:
Yeah, so I am doing some workshops this year for the Uncharted community. That’ll be out for anyone who’d like to attend. So keep an eye out on our website for those coming out. If you’re in the community, I’ve got some things in there including some more information about this topic, and you’ll probably see me around any of the Uncharted events that are going on. So keep an eye out for me there. And definitely say hi if you’re coming to any of our Uncharted events, because I love to meet new people.

Dr. Andy Roark:
Oh, awesome. Tyler, thanks so much for being here. Guys, thanks for tuning in. Take care of yourselves.
And that is the episode. Guys, that’s what I got for you. I hope you enjoyed it, I hope you got something out of it. As always, if you did, share with your friends, write me an honest review wherever you get your podcasts. It is how people find the show. It always means the world to me. Gang, take care of yourselves. Be well. I’ll talk to you later on. Bye.

Low-Cost Veterinary Clinical Diagnostics

by

Dr. Ryane Englar joins Dr. Andy Roark to discuss her new book Low-Cost Veterinary Clinical Diagnostics.

A practical guide to maximizing the diagnostic value of in-house quick assessment tests (QATs)

In Low-Cost Veterinary Clinical Diagnostics, the authors provide a hands-on resource designed to facilitate healthcare delivery across the spectrum of care.

Historically, clinicians have been taught to apply the gold standard approach to the practice of medicine. However, recent advances in veterinary medical care and associated technologies have made practitioners question whether a one-size-fits-all approach is truly best. After all, when we perform diagnostic tests, are we testing out of the desire for completeness, to cover all bases for the good of the patient? Or are we testing because we are expected to?

The reality is that gold standard care is not always advisable and not always possible. In clinical practice, veterinarians frequently encounter obstacles that limit their approaches to case management. Cost of care is a significant constraint that requires practitioners to rethink which diagnostic tests are essential.

Not every patient requires a complete blood count (CBC), chemistry profile, urinalysis, and fecal analysis to obtain diagnostic value. This text suggests that the “best” approach to case management be determined by the situation, the context, the patient, and the client.

While sophisticated panels of tests may remain the recommended approach to case management, Low-Cost Veterinary Clinical Diagnostics outlines entry-level, in-house diagnostic blood, urine, fecal, and body cavity fluid tests: how to perform them as well as the breadth and depth of patient-specific data that can be gleaned from quick assessment tests (QATs).

Readers will also find:

  • A thorough introduction to patient care considerations, communication strategies that facilitate cost-conscious shared decision-making
  • Comprehensive explorations of quick assessment tests (QATs) in hematology, including packed cell volume (PCV), total solids (TS), buffy coat analysis, blood smears, blood glucose, blood urea nitrogen (BUN), saline agglutination tests, and activated clotting time.
  • Practical discussions of quick assessment tests (QATs) involving urine, including urine color, dipstick analysis, specific gravity (USG), and urine sediment analysis
  • Pragmatic evaluation of fecal analysis, including considerations surrounding fecal color, volume, consistency, and odor; saline smears or wet mounts, and fecal flotation.
  • Discussion on body cavity fluid analysis
  • Sample case vignettes, complete with question and answer (Q&A)

Perfect for veterinary practitioners, veterinary technicians, veterinary and veterinary technician students, Low-Cost Veterinary Clinical Diagnostics offers a quick and easy reference guide to maximizing diagnostic value in those cases where care is cost-prohibitive.

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

LINKS

Low-Cost Veterinary Clinical Diagnostics (Published by Wiley-Blackwell): https://www.wiley.com/en-us/Low+Cost+Veterinary+Clinical+Diagnostics-p-9781119714507

Also available on Amazon:
https://www.amazon.com/Low-Cost-Veterinary-Clinical-Diagnostics-Sharon/dp/1119714508/ref=tmm_hrd_swatch_0?_encoding=UTF8&qid=1676300614&sr=8-1

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

Ryane E. Englar, DVM, DABVP (Canine and Feline Practice) graduated from Cornell University College of Veterinary Medicine in 2008. She practiced as an associate veterinarian in companion animal practice before transitioning into the educational circuit as an advocate for pre-clinical training in primary care. She debuted in academia as a Clinical Instructor of the Community Practice Service at Cornell University’s Hospital for Animals. She then transitioned into the role of Assistant Professor as founding faculty at Midwestern University College of Veterinary Medicine. While at Midwestern University, she had the opportunity to teach the inaugural Class of 2018, the Class of 2019, and the Class of 2020. While training these remarkable young professionals, Dr. Englar became a Diplomat of the American Board of Veterinary Practitioners (ABVP). She then joined the faculty at Kansas State University between May 2017 and January 2020 to launch the Clinical Skills curriculum.

In February 2020, Dr. Englar reprised her role of founding faculty when she returned “home” to Tucson to join the University of Arizona College of Veterinary Medicine. She serves as a dual appointment Associate Professor of Practice and the Executive Director of Clinical and Professional Skills.

Dr. Englar is passionate about advancing education for generalists by thinking outside of the box to develop new course materials for the hands-on learner. This labor of love is preceded by six texts that collectively provide students, clinicians, and educators alike with functional, relatable, and practice-friendly tools for success:

• Performing the Small Animal Physical Examination (John Wiley & Sons, Inc., 2017)

• Writing Skills for Veterinarians (5M Publishing, Ltd., 2019)

• Common Clinical Presentations in Dogs and Cats (John Wiley & Sons, Inc., 2019)

• A Guide to Oral Communication in Veterinary Medicine (5M Publishing, Ltd., 2020)

• The Veterinary Workbook of Small Animal Clinical Cases (5M Books. Ltd, 2021)

• Low Cost Veterinary Clinical Diagnostics (John Wiley & Sons, Inc., 2023)

Dr. Englar’s students inspire her to write so that they have the resources that they need to not just survive but thrive in clinical practice.

EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary podcast. I am your host, Dr. Andy Roark. Guys, I’m here with my friend Dr. Ryane Englar today, and we are talking about her new book, Low-cost Veterinary Clinical Diagnostics. Man, I get super geeked out about this. She’s hilarious and amazing, and she may take over the world. Definitely listen to the end of this podcast when we talk about her struggles in finding laboratories that would work with her and ultimately working with a crime scene investigation unit. Only veterinarian type problems here, only veterinarian type problems.
So anyway, she is incredible. This is such a fun conversation about the basics that we have put down and forgotten in vet medicine, about using sight, smell, sound, feel, I don’t want to say taste, but you knew I was thinking it. It’s all of those things where we’ve gotten pretty dependent in a lot of ways on our fancy diagnostics. And they’re great, they are wonderful, but boy, there’s some value in really just using our eyes and having experience of looking at samples. And is it possible that we could be extracting a lot more knowledge from just the most basic tests? Yeah, I think probably so. I’m curious what you guys think.
But anyway, just check this out. It’s such a good conversation. She’s really got me inspired to start looking at my game and figuring out where are the simple little holes in my basic knowledge that would make me a better vet and that would help me take better care of pets with basically no cost to the pet owners, just looking at what we’re already doing and getting a little bit more out of it. So anyway, guys, fun episode. Let’s get into it.

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

Dr. Andy Roark:
Welcome to the podcast, Dr. Ryan Englar. How are you?

Dr. Ryane Englar:
Great. It’s good to be here. Thanks for having me.

Dr. Andy Roark:
Oh, always enjoy you. You’ve been on the show before and I was thrilled to have you back and I wanted to have you back because you have a new book out. For those who don’t know, you are an associate professor and executive director of Clinical and Professional Skills at the University of Arizona’s College of Veterinary Medicine. That is a long title. And you’re an author. This is not your first book, is it?

Dr. Ryane Englar:
No, this is number 11 if you count the ones that I been partners on.

Dr. Andy Roark:
Not quite the first book, no. But yes. So you have a brand new book out called Low-Cost Veterinary Diagnostics, and I was like, that’s an interesting title and I love that you have a book on this. And so I want to open this conversation up and basically just sort of say, tell me at a high level, tell me what this book is about. Let’s just start there so that I’m not picturing something in my mind that’s not true.

Dr. Ryane Englar:
Yeah, absolutely. The book started out, the original intent was to develop a clinical skills guide or manual for our students really with respect to blood diagnostic test, urine and fecal results. But then it quickly expanded into what it is today, which is really a tool that can be used by vet students, new graduates, seasoned graduates, veterinary members of the whole team so vet techs, really even clients for some degree. And what it is is really looking at what are the tests out there that are point of care that we use each and every day, and how can we maximize the data that we obtain from them?
And the classic example I’ll give from vet school is that by the time I got to fourth year vet school, the internists or a generalist on any service would say, here’s a patient, here’s the vignette, tell me what test you’re going to run. And I graduated from Cornell University. Very proud to be a graduate there. But every answer for every vignette was, we need a CBC, a chemistry panel, a urinalysis, two to three view chest reds, an abdominal ultrasound, maybe an MRI. So quickly it expanded and that was the gut reaction of that’s what they want to hear good, but we quickly lose sight sometimes of, and I learned that as an educator, why are we doing that?
If we’re going to ask a client to run a test, what do we need that for? What are we looking for? How are we going to interpret it? And so there’s a lot of information we forget. So the book was born out of what can we get and drill down and get the max out of a PCV. There’s an entire chapter on assessing the color and turbidity and smell of urine. A chapter on fecal consistency, fecal color, fecal odor. Really looking at expanding that tool set so that if we are in situations where we have to scale back, what can we do? And really, let’s not feel bad about scaling back. Let’s be like, yeah, let’s get the most out of this data, whether that’s blood, fecal or urine testing.

Dr. Andy Roark:
That’s fascinating. A lot of the mentors I had in medicine, they were much older than me. I think that’s often the way that it goes. And you kind of come in and they’re at the end of their career and they’ve got so much experience and so much knowledge. And there’s a couple of them, Dr. Mikey Schaer pops to mind. And that guy didn’t seem like he needed any diagnosis. He could just feel the pat and say, ah, I think it’s probably this. And darn if he wasn’t right all the freaking time.
And you always wonder, that stuff is so powerful. And he would just beat the drum on… He would ask you, “Where do you want to start?” And the answer was the physical exam. And if you said a bunch of stuff, he would shoot you down, which is rare because most people would said exactly what you said, which is we’re going to need this litany of tests and this big workup. And he would say, “Physical exam.” And then basically he’d be like, and then we’re going to see what we have and then we’re going to make a plan from there.
And he was so good. He was that guy who could walk in to the treatment room and he would sniff the air and point at a pet and go, that pet has parvo. And he was right. He was, that one right there, that’s got parvo. And it was incredible. And so I really love where you’re coming from. So I guess let me say this, if veterinarians, if vet technicians had more of this type of knowledge and were more comfortable just using their eyes, their ears, their nose and their touch, and looking at patients and looking at samples this way, where do you see the biggest areas of potential impact in taking this approach? What are things that you see that there’s such an opportunity here and we’re not pursuing it? What does that look like?

Dr. Ryane Englar:
Yeah, absolutely. I think for me, really it’s a matter of spectrum of care. And it’s really looking at cost for factors. Obviously looking at how can we partner to create a tailored treatment plan and diagnostic plan for a patient who may not be able to do the litany of tests So that’s kind of the first easy pass. When you look at the title, you say, oh yeah, that’s what it’s about when I can’t do everything. But then if we put that to the side and we think about it on a deeper scale, how do we actually create that partnership and communication with our client of putting that plan forward?
So if I’m going to convince a client to do test X, Y, or Z, I really need to make a case for Y. And what information am I going to get out of there and what am I going to do with that information? So we have to have not only the plan, but the expectation of, if I do this and I find result X, Y, and Z, how will that actually allow me to better treat your patient? And so I think it opens up those communication windows. It allows questioning, which I think sometimes we get that defensiveness of why is someone questioning why I want to do this certain test? And it can say, oh, well, let me tell you why. Let’s have that conversation about what is my hope for this pet so that we can actually make it custom so that we can apply what we need and the knowledge we have for pet specific care.

Dr. Andy Roark:
So one of the things I like a lot about you and is one of the reasons I first really wanted to talk to you is that as a professor of clinical and professional skills, you kind of walk this line between a clinical approach and then also a communication aspect, which is things that I’m most excited about. I really love that medicine from a challenge standpoint of knowing what to do medically and then also being able to communicate and negotiate, advocate for the pet, build a relationship with the pet owner and get them on board.
How does an approach like what you’re talking about change the way that we communicate with pet owners? Is it a different type… Do you break these out and you’re, oh, suddenly are you pushing more to say, let’s start with a PCV and then we’ll run a full blood panel based on what we see. Or do you go with a full blood panel and just extract extra amount of information? How do you parse that, I guess? And then how does that really, when the rubber meets the road and you have these skills or you have this focus on really looking deeply at what we’re doing and extracting the most information possible out of it, how does that change the way that you communicate?

Dr. Ryane Englar:
Those are all great questions. Man, I wish we had 22 hours straight on this podcast. So everybody gets some popcorn, sit down, it’s going to be a while. No, I’m kidding. I think the hardest part, is it does depend on the patient. It depends on the presenting complaint, and ultimately there’s immense value and wealth to doing some of those more advanced diagnostics. So an emergency situation, I may be more apt to opt for full panels, but I think where it really helps is in situations where we may want to do everything but can’t, there’s a limitation. Maybe the limitation is cost, that’s the most obvious, but maybe the limitation is we might not have the equipment. Maybe we don’t have every upgraded coagulation panel profile we need or would want. So we have to scale back and we have to say, well, what can I do now?
Maybe it’s a weekend and our machine is down and we don’t have the ability to get what we need, even if the client could afford that. And so I think it’s saying, what can we do and having a transparent conversation with the client. This is what I would like to do and why, and then it becomes a dialogue. And when that owner, which we’ve all been in that situation says, I’d love to do everything and I can’t. I can’t because of X, Y, or Z, cost is often a factor. Okay, let me prioritize, this is what I want to do, and this is actually how I can get the similar information.
It may not have every single panel item that a chemistry profile would, but this is what I’m going to do, and with this test, I can run out X, Y, and Z. And I think a great example, right, is the blood smear. The blood smear, I remember in clinical year, every single case that walked in the clinic, it didn’t matter how the blood was run, you had to run as a student, many blood smears that we went through, 10 and 15 and 20. We were so bad at creating them, but by the other point-

Dr. Andy Roark:
It wasn’t that we went through them, it was just that we were so bad at making them. Personally, I would take a dozen slides to get one that I was comfortable showing to another student like, oh, this is mine.

Dr. Ryane Englar:
That’s an A+. I went through a hundred, and then Cornell probably flagged me. It’s probably in my system in some records somewhere of all the boxes I went through. But that blood smear, so in school, we got used to looking at it and then-

Dr. Andy Roark:
I leverage my technicians that way. That was my workaround was I never got good at it. I just go, leverage your technicians. Not because I can’t make a blood smear, that’s not why, but because I value them, that’s why I let them do it.

Dr. Ryane Englar:
No. And you know what, they’re the ones who soar in our clinical skills lab teaching our students how to do it. So I’m all for that. I think where we get weak is we forget to look at those blood smears or have someone who has to go look at them, right?

Dr. Andy Roark:
True.

Dr. Ryane Englar:
And so days go by, weeks, years, and I’m cringing to say it, but there were many a day in private practice for [inaudible 00:12:44] that, I’m going to look at the automated analyzers.

Dr. Andy Roark:
Yeah. Well, I think that’s really different.

Dr. Ryane Englar:
We should.

Dr. Andy Roark:
Sorry. I think that’s really defensible. You know what I mean? Of we’ve got these awesome analyzers and they do all the things. You know what I mean? And you go, why do I need to look under the microscope when I’ve got this beautiful scatter plot that lays out all of the things? You know what I mean? And as we have artificial intelligence, it gets easier and easier. I think in life in general, it’s getting easier and easier to be a little bit intellectually lazy of just being like, you know what, let’s just pop into computer and see what the round comes.
And I know that there’s a downside to that. I feel like there’s a downside to that as far as our… I think we all really want to be James Harriet meets Crocodile Dundee who can just… it’s like bush medicine where if there was… we take great pride as a profession in how well we would do in a zombie apocalypse. I don’t know if you’ve noticed that, but there’s a lot of people.

Dr. Ryane Englar:
There’s all the memes out there.

Dr. Andy Roark:
Yeah, there’s a lot of memes. There’s a lot of people who take great pride in how well they think that vets would do in a zombie apocalypse. Those are the people who need to buy your book. I’d be, if you think you would make it, you should have this book because this is how you’ll continue to practice after the zombie apocalypse. Anyway, that was sort of a bit of a digression, but it’s just to say I feel… It’s almost like it’s easy just to spend more and more time on the couch if you have a more and more comfortable couch. It’s almost like we have a more and more comfortable couch in a lot of ways with our diagnostics and stuff. And you go, boy, the ability just to look at the blood smear, that’s real. No one can take that away from you. And man, what a useful tool in your toolbox. And I can tell you, I am 100% guilty of just look at scatter plot. You know what I mean? And just go, oh, let’s see what we got here and go on.

Dr. Ryane Englar:
It’s absolutely me too, right? Easy. Like you said, I think that’s a perfect analogy about the couch. And so then what happens? We get the case where we can’t get that scattered plot and then we feel frozen and paralysis. And so having that ability to say, all right, let’s keep those skills fresh. We have a whole chapter in looking at the Buffy coat and how many times have I not looked at the Buffy coat in practice? And I’ll be honest with my students, I’m like, you know what, this textbook reignited a fire in me because it taught me the areas I got lazy or the things that I forgot or the things about the urine dipstick that I just took for granted. And then I realized, oh, that’s right, there’s a certain cleaner I cannot put in cats cages or dog kennel cages than an animal pee’s in the kennel in the hospital. I can’t just put the dipstick on that surface because it’s contaminated and now it’s going to cause a false positive or negative.
And so it has really cool little tips and tricks, some pointers. My co-author was amazing. Dr. Sharon Dial, she’s a clinical pathologist, so she filled in all the gaps that I had forgotten. So it was a learning experience for me. That’s what we hope. It’s really a celebration I want to think about it, not a critique or criticism of all the immense wealth of diagnostic testing we have. That has a place forever in my heart, of course, I respect it, but it’s looking at what else is there? Let’s celebrate what we can do when we are in that apocalypse, as you say.

Dr. Andy Roark:
Oh yeah. If you dream of doing team training with your team, getting your people together, getting them on the same page, talking about how you guys work together in your practice, I’d love to help you. You can check out drandyroark.com and check out the store. I have two different team training courses. These are courses for teams to do together to get on the same page and to talk about how you do things. I have my Angry Clients course, and I have my Exam Room Toolkit course, and they are both available and there so come out. All right, guys, let’s get back into this episode.
Well, I like this live. I’ve been thinking a lot about artificial intelligence recently. So the ChatGPT stuff I think is really interesting. I think it’s going to fundamentally change medicine. It’s definitely going to fundamentally change the way we interact with pet owners and the knowledge that they come with. These are big changes and they are right around the corner. And I look at that, and I do think a lot about how it’s going to interact with us. And I don’t think that artificial intelligence is going to replace practitioners. I think we need to adapt around it a bit so that we say we have these AI tools that are great and amazing, and also we should be just rock solid on the fundamentals so that we can leverage them to the maximum potential and know how to use them and still be entirely relevant and be confident and comfortable in our skin and in our role as the healthcare provider.
And so this book just really hits on that for me. I imagine what it was sort of writing this book, and to me you explained checking yourself and finding these areas. And to me, I think that that would be the most fascinating thing is I’m sure you sort of had these discoveries and unlocked these things that go deeper maybe than you had in the past. And you’re a very accomplished veterinarian. You’re boarded by the ABVP and you’ve been teaching this for a long time. But were there areas when you started to dig into the research for this book? Were there things that really unlocked for you? Were there areas that you were surprised by how much depth there was that you either weren’t using or weren’t really aware that you could get information from?

Dr. Ryane Englar:
Yeah, great point. I would say every single chapter, I think especially the ones that I had to write, and then Dr. Dial would go over them and we would sit side by side because each one of us would either lead a chapter or be the buddy up and help. And I think that for me, much of it was checking the knowledge that I knew and where did it come from? Like so many things in life, you have this saying or a motto or you’re like, I learned this 8,000 times in vet school, it has to be true. And then you write the book and you’re like, Hmm, is that real? Did that actually happen? Is that true? Did I make that up right? Did someone else tell me and I just assumed that it was true?
So I think for me, as with every book writing experience, just the literature review, finding out, oh, yes, that actually is documented and this is where it came from, is so helpful because then it does check yourself, is what I’m telling the next generation truly right or is it because I remember someone somewhere in my past told me to believe it and I just accepted it.

Dr. Andy Roark:
Were there any examples that come to your mind of things that you were like, oh no, this isn’t true?

Dr. Ryane Englar:
Gosh, I wish… You know what, there probably are thousands of them. I think for me it was just the reminder when we were going through I’m stuck on the same Buffy coat example of going through and when Dr. Dial and I reached and wrote the table of contents, I filled in what I knew, and she’s like, maybe we should do a Buffy coat chapter. And I’m like, what, the Buffy coat? What do I know about that?

Dr. Andy Roark:
Yeah, when you said that, that was the experience I had. Yeah, when you said that was the exact experience I had, was like, oh, the Buffy coat, what do I know about? Not much.

Dr. Ryane Englar:
Right. Or total protein, right? Again, I love to tell my students this because sometimes I think they just think I know everything, and I’m, oh no, that’s why there’s a library in my office, I need to reference stuff. Total protein, as a vet, I know how to get it right or my technicians use the refractometer, they get the value, they give it to me. I can interpret it, but how much do I really know deep? I can give you the differentials; high protein, low protein, but everything’s unpacking more and more so that it’s not just a one sentence answer. It’s let’s dig deeper beneath that.
And other areas of the book made me want to explore more. For example, you mentioned parvo, right, and smelling the smell of parvo. And for me, the chapter on fecal color odor consistency ignited my spark in another crazy area of my brain, which was why do clinical skills labs like the ones I teach, only focus on visual things and tactile things? There’s zero olfactory clinical labs in vet med and not in human healthcare, in the military, yes. So I’ve spent three years trying to create diagnostics work to develop olfactory cues that we can actually bring into the classroom. So in another six months-

Dr. Andy Roark:
You came up with a stink test.

Dr. Ryane Englar:
Yeah. So I’m working with a crime scene investigation lab on that, and they’re the only ones that would take bio samples because believe it or not, in my crazy quest, I found that most of the companies that use mass spectometry to evaluate scent are food companies like the cereal companies. Because if clients are like, my cornflakes stink, it smells like mold, we got to fix this, right? So they go to these labs. Well, I had lots of talks with these labs. They were wonderful people. I thought I was very clear about, we have fecal samples from dogs. And then we reached a point that was pivotal on every call. Wait a second, you would’ve sent fecal samples to my cereal lab? No, we’re not doing that. We’re not [inaudible 00:22:20]. So many doors got shut down, right?

Dr. Andy Roark:
Oh, yeah.

Dr. Ryane Englar:
They had them told and they’re like, wait, we’re not actually… So I finally found the crimes team investigation people, and now we’re hopeful, but-

Dr. Andy Roark:
This is amazing.

Dr. Ryane Englar:
That’s huge. So maybe in six months I’ll have that. I think the biggest downside is where are we going to test that? So nobody wants to be the Guinea pig in our faculty suite office to test the parvo scent.

Dr. Andy Roark:
Oh yeah, you have mad scientist problems. Did you know that? You run into the problems that great inventors like Dr. Frankenstein have run into again and again, which is people closing doors in your face, asking what you’re doing with a dead body, things like that. I love that you have a crime scene scene investigation team who’s, yeah, we’ll talk to you. That makes me so happy. What does a stink lab look like? I don’t know if that name’s going to stick. I don’t know if you like it, but to me, Ryane runs stink labs. What does this look like? Help me understand what this would even be like. I’m assuming that the old factory stuff is hard because it’s hard to quantify and say, oh, this is a five, this one’s a five. I don’t know how you do that with a smell. But yeah, it seems pretty sort of subjective. Help me understand, what does that look like from a training standpoint? I think it’s fascinating.

Dr. Ryane Englar:
No, that’s a great point. Basically what we’re looking at is we have to find the olfactory fingerprints of different disease processes in bio samples. And so parvo seemed to me the easiest starting point because it smells bloody. There’s this metallic component. If you pull all of us, there’s this [inaudible 00:24:14] component coming from the blood. And so my hope was we could find that compound in it. So you have to actually take a sample, pulverize it, there’s lots of ways to do that. And basically it has to run through a very fancy mass spectometry machine. That’s going to spit out a little pattern, we hope that can differentiate normal diarrhea that’s not parvo positive from diarrhea that is parvo positive.
So the hope is by going through enough samples, you can find the blueprint or fingerprint. So once you find the fingerprint, we now can identify what those compounds are and you can put them together kind of like a perfume factory into one little concoction. And it could be liquid or it could be infused on a little pad, kind of those scratch and sniff stickers that probably aren’t allowed anymore that we used when I was a kid. They’re probably very toxic, but haven’t seen them for a while to buy them for my niece. So something’s sketchy about that.
But the idea would be we would then be able to build that into a lab. And so the example I have, and it’s the only one I’ve found, when I was trying to figure out how to make this possible, I get a lot of simulation catalogs and I found one from a nursing program and they had a fake vomit, and they wouldn’t tell me what was in the fake vomit. They said, you’ll have to buy it.

Dr. Andy Roark:
It’s proprietary.

Dr. Ryane Englar:
Yeah, it’s proprietary. Buy it and call the manufacturer. So I said, all right, great. This was pre-crime lab. So I call, I order it. It arrives by FedEx. While I’m teaching another class, everything comes to this main depot. And all of a sudden students in my lab are, is somebody really sick in here? We’re in a classroom down the hall. They’re, somebody threw up. I don’t know where that’s coming from. And all of a sudden, a whole bunch of students run to the bathroom. They’re, we feel really ill. Somebody comes down from the main office, they’re like, Dr. Englar, there’s this package up front and it really stinks. And they hand me this box, and it had been crushed by the FedEx people. I love FedEx, no offense, but it was crushed. The whole thing was leaking this fluid and the whole… it smelled-

Dr. Andy Roark:
Mad scientist problems. That’s what this is.

Dr. Ryane Englar:
People were, don’t do it, Ryane. So now I’m going to have to do my test outside in Arizona because everyone does not want that. But especially after COE comes to visit, we don’t want the accredited bodies turned away. But my thought would be, if you can do this, parvo’s our first pilot. It’s very expensive and I have no grant money external to do it, so we have to do very few samples and hope for the best.
Then we could do things for the ketotic breath. You could do all kinds of different aromas, right? Pseudomonas for otitis, that horrible rancid smell that we all kind of know. And then we’re, we need to culture this here, that’s rank. It would be great to be able to recreate that. And it is, it’s very Jekyll and Hyde. So maybe my love of Broadway musicals has inspired it.
But things like that make me want to come to work, want to create things. Because if we can do that, then we know what… if you can just train someone to recognize that smell, but think about the utility at every other area. So if we forget just diagnostic, think about individuals that pass out in surgery because the smell of [inaudible 00:27:51] and they just need sensitization or desensitization. Or people who pass out because the smell of items in necropsy or the sight and smell of blood in surgery.
If you could partner with psychology departments and actually help individuals, maybe you could be the next neurosurgeon, but there’s some kind of a gap because blood smell makes you feel sick. So let’s recreate all of that, have its own little lab and figure out a way to get people to do what their strengths are. So yeah, I’m always thinking about things.

Dr. Andy Roark:
Well, I’ll tell you, I’ll help you out right here so I do escape rooms with my wife, and so we always go and we love them. And so anyway, we did an escape room and there were these little metal containers and they all looked identical except they had little holes punched in one end. And then there was this door and it had a little tray on it, and there were little symbols of different herbs and things like that. You would kind of sunflowers and things like that you would recognize. And the idea was you were supposed to smell these containers because they had a scent inside. And then when you put them onto the tray in the right order, the door would open. And I was just thinking that that could be like your exam. And when they put the things on the tray, the thing unlocks and they can leave. They can go home for the day and they’re done with lab. And so I don’t know, sit with that a little bit.

Dr. Ryane Englar:
Yeah, I love that idea.

Dr. Andy Roark:
It’s less mad scientists than you usually go, but-

Dr. Ryane Englar:
I could tone down a bit for you. I could make that work.

Dr. Andy Roark:
Or tone the door up a bit. I don’t know. I’m sure you can find a cursed door from an old temple, something like that, that would impress your colleagues. Anyway, Ryane, thank you so much for being here. I’m going to put a link to your book down in the show notes. Where can people find you? Where can they learn more?

Dr. Ryane Englar:
Yeah, absolutely. For this textbook, it’s published by Wiley-Blackwell. So you could go straight to the Wiley-Blackwell website for your country, right, the US, but there’s also European versions of that, and you can buy direct from Wiley-Blackwell. If you’re an instructor, I don’t know what the stipulations are, but there’s a link where instructors could request a free copy to look at, right, if you were thinking about incorporating it into your classroom.
So that’s the best reason to go to the Wiley site. Others, my students get a free access to the University of Arizona because we have an e-book user license that’s unlimited, but other students from other universities can go to amazon.com. Sometimes you’ll get a price break depending on how they do those algorithms. So I also have an author page on amazon.com, so you can also link to not just my other Wiley-Blackwell textbooks, but also my 5M textbooks and Taylor & Francis and Elsevier.

Dr. Andy Roark:
Awesome. I’ll put links in this show notes. Thanks for being here. Thanks for listening, everybody. Take care of yourselves.

Dr. Ryane Englar:
Thanks so much. Appreciate it.

Dr. Andy Roark:
And that is our episode, guys. That’s what I got for you. I hope you enjoyed it. I hope you got something out of it. Thanks to Ryane Englar for being here. Again, as always, if you enjoyed this episode, share it with your friend and or leave me an honest review wherever you get your podcast. That is how people find the show. It really means a lot to me. I always love it when people leave nice positive reviews and pats on the back and things like that, or even constructive feedback of things you’d like to see more of or things we could do differently. Anyway, guys, take care of yourselves. Be well. I’ll talk to you later on. Bye.