Life With Clients

This week on the Cone of Shame Veterinary Podcast, board certified behaviorist, Dr. Leanne Lilly, joins Dr. Andy Roark to discuss the link between stress and the GI tract. Together they talk through treating the behavior case of Calix, a calico feline that will not stop defecating outside the litter box. 

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

This episode is brought you ad free by Hill’s Pet Nutrition.

LINKS

Hill’s Veterinary Academy: https://na.hillsvna.com/en_US/

Hill’s Prescription Diet GI Biome Feline:  https://www.hillspet.com/cat-food/pd-gastrointestinal-biome-feline-dry?cq_src=google_ads&cq_cmp=12261618915&cq_con=112560660650&cq_term=hills%20gastrointestinal%20biome%20cat%20food&cq_med=&cq_plac=&cq_net=g&cq_plt=gp&gad_source=1&gclid=CjwKCAiAloavBhBOEiwAbtAJO4TWaZ1xA4C5UP3CsqjqQHBL83bRYKlyAemu_QdHIECeeuC-GdSKPhoC6M8QAvD_BwE&gclsrc=aw.ds

Leanne Lilly LinkedIn: https://www.linkedin.com/in/mleannelilly

TVP Article: https://todaysveterinarypractice.com/nutrition/feline-stress-nutrition/

Charming the Angry Client Course: https://drandyroark.com/charming-the-angry-client/

Dr. Andy Roark Swag: https://drandyroark.com/store/

ABOUT OUR GUEST

Dr. Lilly is an Assistant Professor and the service head for the Behavioral Medicine Service at The Ohio State University’s Veterinary Medical Center. She received her DVM from the University of Wisconsin-Madison in 2011 and spent 4 years in the trenches of general practice. She completed a specialty internship in Behavior Medicine at the University of Pennsylvania. She followed that with a Behavioral Medicine Residency at The Ohio State University, where she then joined the faculty, teaching residents and veterinary students. She serves on the Ohio Veterinary Medical Association’s Behavior Education Committee, the ACVB’s exam committee, Low Stress reviewer for VIN through Cattle Dog Publishing. She has appeared in a webisode of Animal Planet’s Life at Vet U, over 75 print, and live interviews. She is Fear Free Elite and Shelter, Low Stress Handling Silver, and Feline Friendly Certified. When not working she enjoys kitten cuddles and landscaping.

EPISODE TRANSCRIPT

Dr. Andy Roark: Welcome everybody to the Cone of Shame veterinary podcast. I am your host Dr. Andy Roark. Guys, I got a good one for you today. We are talking about stressing cats. We have a cat named Calix that is defecating outside the litter box when mom travels. It seems to have a stress component, but it needs to get sorted out.

And so I have Dr. Leanne Lilly here with me to help sort that out. She is a boarded, veterinary behaviorist. She is on the faculty at the Ohio State University. She is a great person to talk to. I really enjoy her. We get into a GI brain interface. We get into the biome. We get into stress management.

We talk a lot about expectation setting with pet owners, which honestly, that’s… that was great. That was a really neat little pearl that I put in my pocket, and I’m gonna, I’m gonna set some expectations with pet owners a little bit differently. I think that was really good for me. Anyway, you’ll hear it. You can decide if it’s good for you, but I loved it. 

This episode is made possible ad free by our friends at Hills Pet Nutrition. If you have not checked out their learning platform, it’s called Hills Veterinary Academy. I’ll put a link in the show notes.

It is a fantastic place to get your learn on. Guys, let’s get into this episode.

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

Dr. Andy Roark: Welcome to the podcast, Dr. Leanne Lilly. How are you?

Dr. Leanne Lilly: I’m doing well, thank you.

Dr. Andy Roark: I’m so glad that you’re here. Thank you for coming on. For those who don’t know you, you are a board certified veterinary behaviorist. You are an assistant professor of clinical, how do you say it, assistant professor clinical for behavioral medicine at the College of Vet Medicine at the Ohio State University is?

Dr. Leanne Lilly: Yeah, yeah, we usually leave out the College of Veterinary Medicine as it’s sort of implied, because that is the most long and gamely title that I think I’ve come across. I mean, it sounds really important, right? So many words, but yes. 

Dr. Andy Roark: I imagine the old cop shows where they would like whip their badge out and you have one, but then when you whip it out, it just folds and folds and folds as your title keeps wrapping down. I love that you were here. You are… first of all you are fascinating for a lot of reasons.

You are so focused in Low Stress Handling. You’re fear free elite certified. You have done so much with stress management in shelter pets. You have a lot of expertise and experience in the field of stress management, I would say. So, how did you get into that?

Was it a conscious decision? Is that something that has evolved over time? How did you just sort of decide to be the stress doctor?

Dr. Leanne Lilly: Yeah, so it’s a little bit of both. The sort of long version goes all the way back to when I was eight. And I was not one of those people who knew they wanted to be a vet when they were a kid because I’m actually a needle phobe. But I had a dog who had seizures most often during thunderstorms. And so that sort of jump started my foray into the brain.

And then in vet school, in undergrad, actually, I did an undergrad in Biopsychology. So I studied the brain and behavior and neurotransmitters. Yeah. Then I went to vet school and then because of that background, I started collecting all these patients who were nervous in the hospital or hard to handle in the hospital or had anxiety components at home because it was very comfortable reading about a medication and say, okay, well, what does it do?

What does it bind to? Who does it talk to? Is that going to be helpful in this symptomatology? And as I collected more cases, then of course I got to the end of my knowledge base. And then said, okay, there has to be someone who knows more about this than I do. Who are those people? which is when I discovered the diplomats of the American College of Veterinary Behavior.

I did a specialty internship and that sort of blossomed me further into that. And then I said, yes, this is absolutely what I want to do with my life. I went into residency and then I just hung on to academia because I love that ability to keep expanding the knowledge base both for myself and for my students.

And it gives me the opportunity to do things like. Study how behavior changes and how stress management and teach stress management. So that’s kind of how I got here. 

Dr. Andy Roark: That’s amazing. I have got a case that I think you are uniquely qualified to, to talk about. Maybe not uniquely, you’re super qualified, not uniquely qualified, but super qualified to talk about. I’ve got this case. Can I bounce it off of you? Is that okay?

Dr. Leanne Lilly: Absolutely. 

Dr. Andy Roark: Alright, cool., I have a two and a half year old female spayed domestic shorthair named Calix.

She’s a calico, and she… 

Dr. Leanne Lilly: Spicy. 

Dr. Andy Roark: Yes, a little bit, a little, a little bit she, you know, the technician’s face doesn’t necessarily light up when she comes into the hospital, but she’s a sweetie in her way, in her special way. She is here because she’s driving mom nuts with pooping outside the litter box.

And,  what happens is, it’s, it’s mom travels, mom travels for work, she goes away, and everything is fine, and then she goes away, or, boyfriend comes over and stays for a weekend, or some other, you know, sort of small thing, maybe some furniture gets moved. And now we’re backed up pooping out of the box again, and she’s going back to the doctor, and they’re doing a workup for GI stuff.

She’s had an internal medicine workup. There’s really nothing significant that they can find. They’ve scoped the cat and it’s sort of vague. It’s maybe it’s IBS, maybe it’s not, you know, we can’t really tell. A lot of sort of vague, vague symptoms and signs, and words like that being thrown around.

And so she’s really frustrated. 

Dr. Leanne Lilly: Nobody likes to clean up extra cat poop. 

Dr. Andy Roark: Exactly. And, the thing that she’s really grabbed on to is this “it’s when I travel.” And again, a lot of people will have the cats and they’re like, oh she’s punishing me. And we know that that’s not real. But it’s, that type of vibe that she’s, you know, she’s like, definitely seems correlated to my behaviors and me doing these things that she doesn’t like.

And so anyway, I’m talking with her. I want to do right by this owner. I want to try to fix this problem. I want to make sure this cat doesn’t get vilified, not that mom would try to do that, but you know what I mean? Like, I want to, I want right by her as well. So, let me just, Ask you about that and sort of lay it out and say, I’m looking at this case.

I’m kind of walking into it. Dr. Lilly, how do you treat that?

Dr. Leanne Lilly: Yeah. So taking a good history and finding out and confirming that this really does happen with these changes in the environment, changes in the schedule, changes in routine does very much make me think that this is stress related. And, I think what gets tricky about that is simply because we’ve identified it as a stress related problem doesn’t mean that there isn’t also a GI component to that stress related problem, because every time we look at it, the GI brain axis gets more complicated and more interesting, and it talks to each other bidirectionally.

So the stress can influence the GI tract and the GI tract can influence the stress. And so maybe what we’re having is the stress impacts the GI tract and then we get a vicious cycle until mom returns. And then if mom is stressed, now we have more stress at home. So that can become really overwhelming for everybody in the household really quickly.

And certainly anytime there’s a change in stool, you want to do your due diligence and make sure nothing has changed because just because the last fecal was normal doesn’t mean this fecal is normal. But if you’re going through that cycle, and we’re not getting what we need, then focusing on either the GI brain interface or the brain side may be very helpful in helping Calix and this owner get to a much better place in that regard. 

Dr. Andy Roark: I love the conversation, the GI brain interface, this is actually an area that I just sort of became aware of in the last year. And it’s rather amazing to look at what we can do with GI health, to have effects on other parts of the body. And so, I like this.

Mom does not want to pay for any more fecals. And again, I get it, and we’re always like, hey, just because it was normal last night. I, I get it, she’s at that point. And so, all of that makes sense, all of that tracks. The cycle of the stress buildup, things like that.

Where do you start to intervene? First of all, let me ask you about sort of getting this back on the rails. We have this cat. And, she’s defecating outside the box and mom is bringing her in yet again. What are your sort of pearls? What are your favorite things for trying to get these stress cases kind of calm back down and back on the rails?

Because let’s be honest, coming into the vet clinic is not helping this stress level that we have. Help me first to stabilize and then long term management.

Dr. Leanne Lilly: Sure, so some of those stabilizing is. It’s going to end up being client education and client management, right? The cat is not doing this for spite, the cat is doing this because it’s profoundly stressed out. It doesn’t seem like it, but take it as a compliment. Your cat loves you that much, and that can help reframe things and calm things down so that you have the bandwidth to then start doing an intervention at the cat level.

And then I really want to think about, is this cat’s GI tract working as perfectly as it could? Either all the time or during stress and then how can we support that stress. So that might include things like diet specifically for the GI tract because stress changes the microbiome. Even if we don’t get diarrhea, stress changes the microbiome.

Stress can certainly also decrease the rest of the health function and lead to additional non positive things. So hairballs, upchuck, this idea potentially of Pandora’s Syndrome launched by Tony Buffington. So we also want to look at that stress side and that, depending on the client, depending on the cat, that might be nutritional management of stress.

Things like supplements and probiotics and the generally recognized as safe type of products and diets that are specifically for stress, you might think about how do we combine those two things. We might reach for medications. I find a lot of people are hesitant to do that. For all the reasons that make perfect sense, is the medication safe?

There’s a, there’s actually just a stigma about behavior ,and psychiatric modifying medications. And how easy is it to get it into the cat? You know, we have a shortage of highly palatable flavored medications that are for stress. By which I mean we don’t currently have any FDA labeled ones except for Pregabalin, which is brand new.

So, if we can get something into the cat that the cat likes to eat, and it’s easy for the client, and it helps address either the GI side or the brain side or both, that sounds and feels like maybe we could have one stop shopping in a slam dunk for this case. 

Dr. Andy Roark: When you start to look at this, and that definitely makes sense as far as, a one stop shop, let’s be honest, convenience in cat medication is a, it’s a big driver, I don’t, I, I think convenient sounds like the wrong word, but it’s…

Dr. Leanne Lilly: Adherence, right? Can they actually do it? 

Dr. Andy Roark: Yeah, and again I tend to choose positive, uh, thoughts about, you know, pet owners when they come in and so everybody’s doing their best and it just, it’s easier just to

Dr. Leanne Lilly: But can we make it easier for them? 

Dr. Andy Roark: Exactly. Do you find that pet owners are kind of open to these types of conversations around nutrition? Do you think you get buy in? Are they like, yes, I like this, or are they sort of skeptical? that yet another food is going to help. In this case, you know, with Calix, they did some diet trials with internal medicine.

Now, granted, it’s not what we’re talking about, but I don’t know the pet owner necessarily differentiates what we’re talking about from the diet trials that she did before. What is that conversation like?

Dr. Leanne Lilly: Yeah. So I think buy-in has probably been better in the last couple of years as the idea that your GI tract influences your body has become more public knowledge, in the human side. But I think even without that, it’s about getting specific about. Why this particular diet in this sense, and recognizing that the hard work that they did to go through other diets and notice what those diets did and didn’t do.

So if you’ve done a hypoallergenic diet trial, say we tried a hypoallergenic diet. That diet, you know, it’s designed to keep the immune system from flaring up in response to the food. And the great news is your cat doesn’t need that highly expensive hypoallergenic diet. And that means that we have other options.

The diet that we’re talking about is potentially designed for whether we talk about a calming diet or a microbiome diet, right? Getting down into these about what it’s designed to do and how it does that and why that’s specific to Calix and why that may specifically help Calix in terms of the signs that we’re seeing.

If you have personal experience with those, I think that’s really helpful. If you have little samples in the room and you say, Hey, we can even just see which one Calix likes to eat. Cause guess what? None of these do any good in the dish. They have to get into the cat, right? Those things can really help buy-in.

And if you set them down and the cat’s like, I am absolutely going to gobble that up in the exam room. And normally Calix doesn’t eat in the exam room unless you whip out the high value churro. You’re like, aha. All right. Now we’re starting to look at easy and potentially successful. So I think those conversations really are about bringing the client along for the details rather than glossing over them to try and help them meet you in the middle, right?

We have all this stuff in our heads that we know about these things and why those two things are different and why this food is different from that food and why a novel protein is different from a hydrolyzed diet. And it’s really our job to bring the clients along in that information journey in a way that they understand.

So that also means being willing to stop, pause and say, what do you know about or what was your experience with? Or have you heard of the term GI brain axis, right? And see where they are and then try to find the stepping stones to bring them along so that what your thought process is actually makes sense to them.

Dr. Andy Roark: What does the client experience if we lean into like a biome diet or into a stress diet, something like that? There’s a lot of, there’s a lot of nutraceuticals in the world that have been sold to people and pets and some of them are amazing and they work really well and a lot of them people are like, I don’t really know if they helped or not.

If I want to set expectations for these types of diets and stress management cases, is this going to be a fairly stark change in the patient? Is this something where they’re probably going to see real improvement in a short period of time? Is this going to be a two week process of kind of re-regulation like what are they going to expect to see when they get back home?

And I know it’s very case specific individual specific But just how do you set their expectations of I fed this 20 minutes after I got home and it isn’t working. Yeah

Dr. Leanne Lilly: Sure. So some of that depends on which diet you’re using and the case, and where your target and your stress points are. So for Calix, for example, if the stool gets a little bit soft every time we defecate outside the box because the boyfriend came over or we moved the furniture or we traveled, then we may actually see clinical improvement, at least in the stool quality within 24 hours, which to my end, that’s great.

The cat may still be defecating outside the box, but for the client, that means they’re not picking up gross poop anymore. Now they’re picking up solid poop. And so you can highlight that as right. Here’s your little ray of sunshine about that. Now, in terms of whether or not from a GI brain access, that’s sufficient on its own to help the cat manage in the stressful situation. You won’t know until the next stressful situation. And so I think that is a client expectation that you have to manage. I think the other thing is putting some objectives on that, right? It’s the last time Calix’s mom traveled for four days, we had 27 incidents of poop.

That’s a lot of poop. Traveled for four days. We had four poops. Back at having diary had four poops outside the box, and the next time they travel, we have one poop outside the box, right? That’s improvement. And so we need to try and get those objective measures so we can have those good conversations because the client goal is always zero, and sometimes it takes us some finagling to get there.

And so we want to be able to say, Hey, we took five steps forward, and it was amazing. I understand your goal is zero. We’re going to keep working towards that. So those types of details and adjusting those inside the case, I think, is really helpful for both the client and for you, right? If you know that objectively, then when they come back in for the recheck, you’d be like, Ah, four poops last time, like on average a poop per day out of the box.

Next time, we only had one out of the litter box. Maybe it was on the last day. Maybe it wasn’t. Doesn’t matter, right? We’re making progress. So those types of things can help both the client. As well as you for your management because then you don’t have to guess. 

Dr. Andy Roark: That is exceptional expectation setting. I think it means, it means, because you’re exactly right. Their expectation is zero. I will feed them this food ,and I will have no more problems. I think saying zero is our goal and know that it may take some time to get there. There are intermediate improvements that we’re probably going to see before we get there.

I just think that that’s really smart communication. That’s fantastic. All right, great. I really enjoy talking with you. I could sit here and ask you a million questions about the GI brain interface and just I, this is an area I’m still really, truly, deeply interested in and I want to keep learning about.

If someone is into, if someone’s really into this conversation and they’re like, I want to learn more about biome, I want to learn more about the GI brain interface and stress management, what are your favorite resources? Where do you send people?

Dr. Leanne Lilly: Yeah. So it depends a little on whether they’re looking for client side or, you know, white paper side. White paper side, of course, I’m biased to my colleagues, no offense to anybody else doing wonderful research out there. It’s just that I got to see it develop on both sides. So I’m like, Ooh, it’s shiny.

So we actually have some pretty good papers on this coming out through JAVMA in the last couple of years. So that’s actually relatively readily accessible, for the veterinary community, 

 More research is coming out every day. So, ask me again in six months, I’ll probably have more places to look.

Dr. Andy Roark: I’ll link up some articles and everything for people in the show notes, things like that. What did you like for client facing? 

Dr. Leanne Lilly: For client facing things get a little bit messier, because it’s such a novel field. And so they change a little bit. Veterinary partner has a couple of handouts about. Basic urine and defecation outside the litter box and that it’s not for spite and those types of things.

And I think that can be really helpful if it comes from multiple places. They have some supporting documentation about IBD. We have a handout, it should be available on the Indoor Pet Initiative that’s called IBS. It’s about stress with a little apostrophe ignoring the A, because I’m a literary nerd, and I think that that’s really helpful as a bite size piece of information to give people or to think about, okay, here’s how someone else talked about this.

How might I reframe that for my specific client? Cause nothing is one size fits all. 

Dr. Andy Roark: Yeah, absolutely. Leanne, where can people find you online if they want to kind of follow your work and what you’re up to?

Dr. Leanne Lilly: Yeah, so I have a LinkedIn page. It’s just my name, M. Leanne Lily, and then the clinic web page does a pretty good job of keeping things up to date and posted for resources at the vet.osu.edu/behavior page. So those are pretty good places to find out what I’m up to. 

Dr. Andy Roark: That sounds fantastic. Awesome. I will put links to all that sort of stuff. Thank you so much for being here. Gang, thanks for tuning in, everybody. I hope you found something helpful and useful that you can put into practice. So, I have to go see Kalix and get this sorted out. So, thanks a lot, everybody.

Dr. Leanne Lilly: Thanks, Andy. 

Dr. Andy Roark: And that’s it. That’s what I got for you. I hope you enjoyed it. Thanks to Dr. Leanne Lilly for being here. Thanks to Hills Pet Nutrition for making this episode possible. As I said, if you haven’t checked out the Hills Veterinary Academy, take a look at it. It’s a great site. It’s a great resource. Um, yeah, I just, um, I’m a big fan.

Anyway, I hope you guys will have a look. Take care of yourselves, everybody. I’ll talk to you next week. Bye bye.

Dr. Christopher Pachel joins Dr. Andy Roark on the Cone of Shame podcast to discuss the intriguing case of Caliente, a seven-year-old calico cat exhibiting inappropriate urination. Despite the pet owners attributing the behavior to behavioral issues, the duo explores the underlying medical complexities. Tune in as they expertly navigate this conversation by validating the pet owners while shedding light on potential medical conditions driving Caliente’s actions.

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

LINKS

Dr. Christopher Pachel: www.DrPachel.com

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

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Chris Pachel is a board-certified veterinary behaviorist and is the owner and lead clinician at the Animal Behavior Clinic in Portland, Oregon. Dr. Pachel lectures extensively worldwide, teaches courses at multiple veterinary schools in the United States, and has authored numerous articles and book chapters for veterinarians and pet owners. He is a sought-after expert witness for legal cases and serves on the Editorial Advisory Board for dvm360. He is also a Vice-president of Veterinary Behavior for Instinct Dog Behavior and Training, as well as co-owner of Instinct Portland, which opened in the fall of 2020.

EPISODE TRANSCRIPT

Dr. Andy Roark: Welcome everybody to the Come to Shame veterinary podcast. I am your host Dr. Andrew Roark. Guys, I got a great How do you treat that episode today? I am here with vet behaviorist, Dr. Christopher Pachel. He is a boy. He is fun. He has got, he’s just, he’s got such great energy and I love how he talks about what he says and how he says it.

It’s one of, this is one of those conversations where you hear just, he’s just pearls, he’s just scattering pearls everywhere. And it’s just, you could hear him in the exam room having these conversations. And I was just like, I’m writing that line down. Ooh, I could hear me saying that and I just got so many things that I would actually say to a pet owner.

Such a good conversation. So much fun. We are talking about medical conditions that masquerade as behavior problems. So this is a behavior consult that’s not. it’s anyway, it just, I love his perspective on this. Really good conversation. I think this is good stuff to file away. Anybody who likes behavior is going to love this episode.

Guys, let’s get into it. 

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

Dr. Andy Roark: Welcome to the podcast, Dr. Christopher Pachel. How are you?

Dr. Chris Pachel: I am doing fantastic, Dr. Roark. How are you today? 

Dr. Andy Roark: I Man, I’m so good. I’m so glad that you’re here. You and I have sort of circled around the same circles for a long time. We’ve got a lot of mutual friends. And we only got to meet recently, and you are so fun. I really– Every time I talk to you, I leave with a smile on my face. I caught up with you and we started to sort of talk shop a bit in Orlando early this year and you were laying out a couple of lectures and I was like, Oh man, this is really interesting stuff.

And so I’m so glad you made time to be on the podcast. For those who don’t know you, you are a boarded veterinary behaviorist and lecturer. I have a case that I wanted to run by you if that’s okay. right. He’s making the anticipatory evil genius finger sign.

Alright, here we go. I have got a seven year old female spayed calico cat named Caliente, who goes by Callie for short. And she is urinating inappropriately. And this is not Unusual for her this has kind of been going on and on the owners are not really big on diagnostics they have said no she is spicy It is the spiciness that is causing Caliente to pee outside of the box and they seem pretty adamant about it I am as this problem persists, I am less and less okay with this, but, I’m going to have to wade in and talk to these people.

Their position is, she’s seven years old and has always been spicy and this, she’s just doing this because she’s unhappy. And so I just wanted to kind of run that back to you a little bit and say, When you get these cases that people say, this is a behavioral case or this is anxiety, things like that.

How straight away do you buy that? And what landmines do I need to look out for in these presentations?

Dr. Chris Pachel: That’s such a great question. And that scenario is so incredibly common where an owner comes in with a I almost said a premonition. That’s not exactly right, right? But that’s sort of a a pre existing idea about what’s going on here. And I find that for a lot of clients. So when that happens, even as they’re giving me the answers to my question, I can almost feel them trying to lead the responses into a different direction where everything comes back to, you know, her emotionality.

She’s got big feelings. She’s really spiteful. So therefore, yeah. That becomes the explanation for a lot of things. And so when I recognize that as a bit of a tip off, my first response is typically to say, you know, it sounds like, you know, your Cali or Caliente, you know, her really, well.

And I’m excited to get to know her right alongside you. I’ve got some additional questions for you to really be able to, make sure that if this is a behavior issue, we really figure out what we’re going to do about it and how we do that. In the meantime, I’m also going to be listening for other things that could actually be there because of an underlying medical issue that might not be all that obvious right at first glance. So if it’s okay with you, let’s dive into some of those questions and let’s see where the conversation takes

Dr. Andy Roark: Oh, I love that from a conversational standpoint just the opening up of you are clearly in tune with her. You are– this is great. I am so glad you are here. I really like that approach and then just introducing the idea there may be other things go off, Chris. That’s really a really nice introduction. I like this opening the conversation.

So great, so you start to put those things forward, what are we talking about here when we see these things coming in? So talk to me a little bit about the medical conditions that manifest as behavior, if you don’t mind. 

Dr. Chris Pachel: absolutely. So there’s a number of them that I would say we see with increased frequency compared to others. And certainly in a case like this, where the primary concern is elimination outside of the litter box, you know, certainly, you know, we might tease that out. Are we talking about stool?

Are we talking about urine? And we might go down that systems based approach. They’re really wanting to, I guess, in the ideal world where everything is convenient and nothing costs Money we’d be able to get those diagnostics to rule those things out. But my clients have the same sort of pushback that yours do and that everybody listening to the podcast, you know, it, isn’t necessarily convenient.

Maybe Caliente has different ideas about how she wants to donate a urine sample today, and so we’re flying blind a little bit with our diagnostics. So all of that to say, I’m looking for underlying, you know, issues relative to the urinary tract. So anything that’s creating you know, increase urine volume or urgency and whether that’s a urinary tract infection or stones or even some of the other systems and that’s perhaps some of the endocrine disorders like hyperthyroidism or diabetes that may impact urine volume or the overall patterns for elimination.

And then we broaden it even further to say, is there anything that might be causing discomfort? And especially when we think about a seven year old cat, we say, oh, well, she’s young and healthy. Therefore, it’s probably unlikely that it’s a medical issue. And yet, the more we learn about cats and things like osteoarthritis, the more we start to recognize some of those patterns that even for a cat who is urinating outside of the litter box, that can be discomfort, right?

She has to crouch, she has to posture. She has to walk on, you know, a shifting stand, sort of a surface that can cause discomfort for some cats. We also find in those cats where discomfort is an issue, even sometimes seeing a differential response between urination and defecation, knowing that the physical posture that cat needs to assume for those two elimination events is actually different.

And we can see a lot of specificity of one patter over the other.

So I’m looking for all of those things within my clinical history, within my observation, and certainly within my physical exam.

Dr. Andy Roark: I talked to a dog owner this morning who came in and the present presenting complaint was He’s an old dog. He’s a Westie and 17 year old Westie and he said oh, you know, his biggest problem is that he holds his urine. We have to really convince him to go and my immediate question was around mobility and pain and things like that.

Chris, can you talk a little bit about the interface between pain, discomfort and behavioral presentations? Just, I know that’s sort of a broad topic, but how often do you see this? How often do things make their way to the behaviorist and you’re still, and you’re still thinking about pain or discomfort?

Dr. Chris Pachel: I would say pain and discomfort is probably the most common underlying issue that has not been fully recognized or addressed in our patient population at the behavior clinic. And obviously that can come from a variety of different places, whether it’s a, You know, untreated allergies, and we’re creating itch and pruritus and discomfort in that direction, whether it is low grade chronic, you know, IBD, IBS type signs, and we’re seeing that, that visceral discomfort associated with gastrointestinal disorders, or whether we’re talking musculoskeletal issues, maybe it’s the partially torn cruciate, maybe it’s LS disease, or maybe it’s a type of discomfort.

You know, an old so as injury or who knows what it is, but you know, we see it over and over again, either as a direct cause of behavior change, you know, perhaps it’s that you know, like the dog you were just describing, maybe it’s a dog who’s now reluctant to go down the stairs when they go out into the backyard because They’re physically unable to do so comfortably.

And so we see that direct sort of cause and effect. I am uncomfortable, therefore I won’t do the stairs, or therefore I won’t go into the litter box and eliminate. So it’s a very direct correlation. And in other cases, it’s much more indirect, where we see, especially with some of the emotional disorders, or some of the emotional patterns, where we may see an animal who’s more irritable, maybe is not sleeping as well as a result of that discomfort.

And so now we’re dealing with more of the chronic effects of sleep deprivation and that effect on cognition and that again, irritability or altering threshold. So we may now have an animal who’s always been, let’s say a little bit sensitive to a particular stimuli or a particular set of circumstances.

And now we get almost a new on chronic presentation for that animal. Because they’re not as physically comfortable, which means they don’t have the same level of tolerance or resilience or threshold as they previously did when all systems were go.

Dr. Andy Roark: you’re, kind of blowing my mind. So orthopedics is something I got my head around a long time ago. Like I just, I’ve seen a lot of inappropriate urination, elimination because of back pain because of hip pains, you know, you see the creaky pets that are having, I get that one, but the untreated allergies presenting as behavior and like IBD as a behavior issue, that’s kind of shocking to me.

I get the sleep disorder as well. It’s kind of funny. I, it’s not one that I originally comes to, or immediately comes to my mind, but talk to me a little bit about that. What, is it like when the case presents for untreated allergies at the behaviorist?

Dr. Chris Pachel: Yeah. So what we’re looking for usually in a case like that is, you know, any little tip off. So if we’re going down the allergy perspective, for example, we may see that pruritus or itchiness, or if the owner is interacting physically with that animal, we may see avoidance or an animal who is, you know, shifting their body in response to manipulation in some ways.

We may see cases where, you know, even while we’re interacting with them, the animal pauses in the middle of a social interaction to itch or scratch or rub on the carpet or something along those lines enough to just sort of prompt the question of, do you see this at home? If so, how often? And, you know, and oftentimes again, owners have had it.

You know, they’ve had the observations, but I’ve never quite made the connection, certainly to that being a primary issue, or it impacting the other issue that they’re presenting the animal for. And that irritability is a huge piece of that.

Dr. Andy Roark: Hey guys, you know, probably the number one plea for help that I get from medical directors, from practice managers, from practice owners, from lead technicians, and especially lead CSRs is, “Hey, Andy, help me, help my staff to deal with angry and complaining clients. They need ways to help these people because angry clients, complaining clients, they need help is what they need. And, our people aren’t empowered or they aren’t trained in how to do that.”

And so why isn’t there more training for this? Why aren’t there more resources that make teams good at dealing with angry and complaining clients?

Well, the number one reason really is, the way that feels natural for your team, the skills that they have that they would bring into the situation, they’re different in every practice. So there’s not a bullet pointed. This is how you do it way. Which is why I end up in this place where people are like, “Andy How do I do this?”

Listen, I made a course it’s called ‘Charming the Angry Client’ and it is my course meant for teams or groups to work together on all about dealing with angry and complaining clients.

I use what’s called the Davidow model of organizational response, which is a super peer reviewed, empirically tested way, of addressing angry and complaining clients. And, I break it up into pieces so that it’s easy to digest. You can scatter it across a number of meetings, it is made to be watched with a couple people together. And then there’s discussion questions about how do we do this in our practice? What does this look like for us? What, when, think about a time that this happened and we saw it. How did we handle it?

Ooh, I also put a bunch of, example videos in there of me being an angry client. So I, I will just give it to ya. As here’s Andy with his pet, and he is upset, and then you can pause it, and then you can talk about right there, “What would we do with this? How would we handle this, guys?” And it is a great, low stakes way of getting your team to talk about what they would actually do.

Guys, there’s nothing more powerful than your team. Talking about what they would actually do and comparing notes, sitting and getting lectured at is nothing close to your team, whether it’s just your CSRs, whether it’s four of your technicians working together, whether it’s a whole staff meeting and a manager or owner or medical director leading the meeting and being the facilitator guys, I put a whole facilitator guide in there too. There is a whole hour long broken up in a module section on how to run an active training program using this course.

And that’s all laid out there and how I do it, how I work with big groups, how it works, small groups, all that information is there. Anyway, it’s called Charming the Angry Client. It is on the Dr. Andy Roark website. I’ll put links directly to it in the show notes. Guys, I hope you will enjoy it.

I think it’s really valuable. It is, honestly the most popular course I have ever put online. Grab yourself a copy. I hope you’ll get a lot out of it.

Let’s get back to this episode.

 I, I have felt less than. Sometimes, Chris, when I, you know, when I say to someone let’s, you know what, let’s try an anti inflammatory medication for a little bit and, let’s see what impact this has. I, I don’t know if that makes sense why I say I feel less than, but something, they come in and they have a question and I’m not, you know, I’m kind of feeling something or it’s a cat and I’m trying to do orthopedic exam and it’s not going very well, you know, something like that.

And I feel like I’m maybe faking it in a way of going. Ah, you know, well, maybe can we try this other thing first? How do you so when I sort of say that to you, you know what I mean? And you’ve got IBD you’ve got allergies or things like that one Is that sort of empiric treatment for the things that we’re seeing in the exam room when they present for behavior?

Is that a problem in your mind? And if so, or if not, then how do you usually layer those things together? In my mind, I’ve always thought, I don’t want to start going heavy on behavior stuff while I’m also introducing, An apparent treatment for a potential medical condition because then I’m not gonna really know what’s working or things.

And so I kind of send them away with empty handed from a behavior standpoint. And I’ll be honest. I kind of questioned myself and go, Andy, are you taking the easy way out? Because it’s a whole lot easier for me to treat IBD or you know, or especially orthopedic pain, things like that. That’s a whole lot easier for me to cut a script than it is for me to wade into that behavior conversation.

So I’ve always questioned myself and say, Andy, are you taking the easy, are you kicking this down the, kicking this down the path here? What do you think about those sort of thought, thoughts when I sort of put them out to you?

Dr. Chris Pachel: Yeah, I think what I’m having the conversation with that owner, I may say something along the lines of, you know, this sure looks like a behavior change and what you’re describing is consistent with a behavior change. Absolutely. Without question. You know, Cali better than I do. And sometimes, you know, some of these issues can be hard to detect, even in people who really care about their animals and are paying very close attention.

We know that from some of the studies, and I may go into a lot or a little bit of this depth when I’m talking with the client, but we know that for some of the studies, even when we have an underlying gastrointestinal issue, for example, they may not show any clinical signs until we run the diagnostics.

And so, you know, I’ve got this little inkling in the back of my mind that really wants me to make sure that there’s not something underlying this because, truthfully, if it is a pain related issue, I want your pet to be as comfortable as possible. So are you open to trialing this? As kind of a diagnostic challenge, we can go down this process, and if we do an anti inflammatory, or if we’re talking about GI disease, maybe we do a trial with a hypoallergenic diet for a period of time, and we say, let’s ask the question and answer it if we do this change And the behavior of your pet changes in response to That’s a pretty darn good confirmation that there’s something going on that we probably should take a closer look for And if it doesn’t Well, cool, then we got great information from that as well.

So we’re getting some information either way I really just want to make sure your pet’s as healthy as we think they are Before we go down the pathway of other interventions.

Dr. Andy Roark: I’m sure this really ties tightly to what the other condition is when I ask you this question. How long do you start to go down this alternative pathway? And, look for results before you say, okay, this is not what I thought it was going to be. I don’t know if I’m saying that very well.

I think, what I’m kind of digging for is, so let’s just say it’s allergies. Do you give the expectation to clients that We’re going to do this and in 48 hours this behavior should be gone, you know, or significantly reduced. And my thought too is in some cases there are– I just think about my own life and there have been things that have ailments or injuries that I’ve had and it’s caused me to sort of change my behavior and then the injury gets better and my behavior doesn’t change.

Let’s just say that, say for example, say I start sort of leaning on my, I lean on my left leg because my right hip bothers me. And then after a while, I just get used to standing on my left leg. And so if you take away the pain in my right hip, I’m still going to stand on my left leg. And you would say, well, Andy’s still standing on his left leg.

So clearly that wasn’t the answer. Does that make sense? Like, like how strongly do you, and I also know that when I said that, when I sent the pet owner home, they’re going to watch this pet like a hawk. They’re going to be like, is he fixed yet? Is he fixed yet? And so, how do you help? Yeah, exactly. help. What should I expect starting to have some of these therapies where there is behavioral symptoms from underlying conditions?

And what sort of expectations should I set with the pet owner?

Dr. Chris Pachel: Yeah, I think there’s two things that really stand out for me. One is If I’m going down that pathway of, let’s say, let’s go back to that allergy dog that’s with me in the consult room, for example, and I’ve recognized that they look a little itchy. I don’t know if that’s related to the medical issue or excuse me to the behavioral issue or not, but I want to make sure that the client knows what we’re monitoring.

So it’s not just, did we cure the behavior issue and it completely resolved? I’m trying in most cases to identify one or two observations that I can allow the client to look for that would suggest You know if we go down that pathway of an anti itch treatment of some case or something that’s affecting the GI tract Am I looking for changes in the frequency of itching, scratching, or licking on the GI side?

Am I watching for any changes in stool quality or the number of bowel movements per day? Something that is easily identifiable for the owner and that usually stems from something that I’ve heard or observed in either the client’s history or in watching their animal or asking some of these questions.

So I’m trying to find a couple of markers versus just saying, well, let’s try this food and see if he or she gets better and the client goes home and they’re expecting a miracle. They didn’t get a miracle. And so they report back not didn’t work. So part of it is trying to be very specific to the best of my ability in that moment.

What do I think we can monitor for even before we get to the big picture behavior issue? The second side of that is also If there is something where we have an interplay between medical and behavior, let’s say, for example, I’ve got a cat very much like Caliente, the one we were talking about earlier, let’s say the issue was not urination outside the box, but maybe this was a cat has a new onset of reacting aggressively when she’s picked up by the kids or by a visitor in that particular scenario.

I may say, well, you know what? You know, sure, we can try a pain medication trial, and let’s monitor for gait, let’s monitor for movement up and down stairs, let’s monitor for ease of jumping on and off surfaces. I want to watch those things more so than just whether or not she’s more tolerant of being picked up, because If she has had an experience over the last day, week, month, or year where being picked up causes physical discomfort and we now have an emotional response to that, just making her feel better in this moment physically

isn’t automatically going to change that learned behavior or those sensitizing events that she’s experienced in the past. So I want to watch for signs that the intervention is making a difference on that underlying medical issue but I also want to make sure that i’ve set that stage for the owner to say “Hey, And if the behavior issue persists, it could mean that this is not in fact related to that medical issue, or we got two problems going on here.

We have a medical issue that started this whole process, but now she’s learned some stuff. She’s had some experiences, and we need to circle back around and actually address the emotional or learned component as well.”

Dr. Andy Roark: You know, two things I noticed in my conversation with you, and I had this impression when you and I first talked. Well, it’s three things, I would say. You do a phenomenal job of validating the pet owners. I, just, I love how you do that, and you are so on their side as you’re having these conversations.

I just think that’s exceptional. I really love how you set expectations as well. And just as a behaviorist, that has to be, it has to be a tool in your toolbox. You like, you have to, write in behaviors and, also manage many. I’m sorry. you have to reign in expectations and really sort of help them to understand what success looks like and what is reasonable.

And you just do that so well. And then, and the third thing I would just say about you that I love how you share what you say and how you say it because when I hear you say it out loud I just can a hundred percent internalize that and go. Yeah, that sounds good. I could see me saying that or I can see me saying some version of that. So I just wanted to say I just love how you do that.

Dr. Chris Pachel: Thank you.

Dr. Andy Roark: When you look at these cases of medical conditions that are sort of masquerading as behavior, kind of what we’ve been talking about, are there significant pitfalls that you see general practitioners falling into that can either be rare mistakes that are catastrophic? You make them or common mistakes where they show up in your clinic and you say, Ooh, I wish.

I wish this last doctor had asked this question. Are there consistent little blind spots or problem areas that we need to be aware of in these types of cases?

Dr. Chris Pachel: You know, I think this is actually something I was chatting with some folks about in Columbus this last weekend when I was lecturing at Midwest conference event conference as well. And we’re having some examples there where we make assumptions too soon, like when we’re busy in the clinic, right?

That client comes in, that animal comes in, we do a quick physical exam. We either find something or we don’t, we ask three or four questions and we get sort of that clinical picture. And You know, for example, it may be that dog who comes in. It’s a four year old Labrador. It’s gained some weight. It’s a little lethargic and, you know, and our brain is like, okay, well, it’s hypothyroid.

I’m just going to test the thyroid and let’s just see what happens, right? So we sort of make the assumption based on what’s most likely. And that is a part of our differential diagnosis, right? We are ranking the probability of those things. With that being said, I find there’s so many cases where we test the thyroid and it’s not a hypothyroid dog, then what?

And I think in many cases we sort of either lose the, skill set over time, or maybe don’t leverage that skill set of really running through that scheme of what are the developmental issues, what are the anomaly issues, what are the metabolic issues, and really running that comprehensive differential is to say, what else could this be?

So that I can run that process down because a lot of these cases, you know, whether I’m talking about dogs or cats or any other species, once we get a couple of questions and we tease out exactly what are we working with in terms of a data set or a breed or a signalman, when we identify what that medical issue is, oftentimes we, you know, we kind of go, well, yeah, that actually makes a lot of sense.

Now that I know all the pieces, Okay. But if we’re not looking at that sort of broad lens of what are all the things that could be, we’re going to miss some stuff. And I get it. I totally understand when we’re super busy, we’re in, clinic, we have to be efficient. So we have to think about that. But I think that the biggest mistake, if there is one here, is If it’s not what you thought it was at first, what else do you think it could be?

Before we go to the next assumption, really, what does it look like to really tease that out? How would we get that client on board for running some diagnostics? How do we rank or triage those recommendations in? You know, I almost said in the worst case scenario, but maybe it’s the best case scenario. If you’re not sure, reach out to a specialist.

So many of the folks like the veterinary behaviorist, like, like in my college, You know, we’re happy to hop on the phone call to be able to say, tell me about the case you’re navigating. Let me see if anything lands differently for my ear or my eye than what you considered, and let’s see if we can work it up together.

Dr. Andy Roark: Outstanding. Dr. Christopher Pachel thank you so much for being here. Where can people find you? Where, I know you’re, traveling, you’re lecturing if people are like, I wanna learn more from him. Where can they find you?

Dr. Chris Pachel: That’s a great question. So, the easiest place to track me down is on the website drpachel.com. So, D R P A C H E L dot com. And from there, you can link into any one of the different avenues, whether you’re trying to find me at the animal behavior clinic or at instinct, dog behavior and training, or if you want to link to any of the podcasts like this one that will end up being linked on that site, all of that is there in addition to webinars and travel schedules and all of that.

So that is the one stop shop that will get you to all the things that I do.

Dr. Andy Roark: That’s phenomenal. Thanks so much for being here. Guys, thanks for tuning in and listening. Take care of yourselves, everybody.

And that’s it. That’s what I got for you guys. I hope you enjoyed it. I hope you got something out of it. Thanks to Christopher for being here what he’s super fun. I just I really enjoy him. Gang take a look at his website check out what he’s doing. Anyway, take care of yourselves everybody. Have a great rest of your week. I’ll see you later on.