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Medicine

The Coughing Cat (HDYTT)

January 27, 2023 by Andy Roark DVM MS

Veterinary cardiologist Dr. Anna McManamey joins the podcast to talk about how she approaches the coughing cat. Is this a cardiology problem, or is it something else? If it is a cardiac problem, how do we even get diagnostics without putting the patient in danger? All that and more on this episode!

Cone Of Shame Veterinary Podcast · COS – 183 – The Coughing Cat (HDYTT)

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

LINKS

ACVIM Consensus Statements: https://www.acvim.org/news-publications/consensus-statements

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

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

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

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

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


EPISODE TRANSCRIPT

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

Dr. Andy Roark:
Welcome, everybody, to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am here with the one and only Dr. Mack, cardiologist at Purdue, is back and we are talking about the coughing cat. This is a great episode for working with these cases. It’s interesting what percentage of these are cardiac cases and what percentage is not, and how do you separate them, and how do you know. And so we go through that. This is quick and to the point. It’s a great episode. I took a ton of notes on this. Oh man, I just love having Dr. Mack here. Guys, you’re in for a treat. 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. Anna McManamey. Thanks for being here, Dr. Mack.

Dr. Anna McManamey:
Hi. It’s nice to be here.

Dr. Andy Roark:
Oh man, I love having you on the podcast. You’re so great.

Dr. Anna McManamey:
[inaudible 00:01:04].

Dr. Andy Roark:
I was just thinking back. I was just thinking about recently, when you and I met, and I just happened to sit next to you at a table at the VMX conference a year ago, and we started talking, and I was like, “This person is super fun. And so you’ve been on the podcast I think at least four times now.

Dr. Anna McManamey:
I think so, yeah.

Dr. Andy Roark:
And so anyway, maybe six. I don’t know. You’re up there. Gosh, I enjoy my time with you.
I got something super fun for you today. I want to talk to you about coughing cats. And when I was in vet school, I distinctly remember being taught coughing cats are an emergency and they’re a cardiac emergency, and so I just wanted to stop and run through that. I have had some stressful situations in my career where the coughing cat or the heavily breathing, gasping cat comes in, and I’ve had those patients die, and it is awful, and it’s scary and stressful. I just want to talk through that with you. Talk to me about the coughing cat, if you don’t mind, and how do you look at these cases, and what should general practitioners know?

Dr. Anna McManamey:
Yeah, I think it’s a great question, and I think there are kind of like two schools. I’ve had people that say, “Well, I was taught cats cough with CHF in school,” and then I have the others who are like, “Pretty sure they said they don’t cough with CHF.” So it’s still I think cats in general are so challenging even for cardiologists.
So I would say that anecdotally, so I’m still a young cardiologist, and I’ve been a doctor since 2016, but only a cardiologist for a year and a half, but anecdotally, it’s very uncommon for cats with pulmonary edema from heart disease present with cough. It’s unlike dogs. And I don’t think we still know. We all give this just it sounds good answer of, “Oh, their cough receptors are different.” But it is interesting to me that cats with pulmonary edema secondary to cardiac disease, they don’t tend to cough. I mean, they might have a cough, but it’s not like a dog with mitral valve disease or with DCM. So it’s interesting. I would say the ones that I have seen cough because of congestive heart failure have had severe pleural effusion or severe pericardial effusion. So I don’t think it’s fair to say that they never cough with CHF, but I do think it’s uncommon to be cardiogenic pulmonary edema as the cause. So if I have a referral for a coughing cat, we don’t roll our eyes, but we’re like, “Oh, it might not be even heart disease.” The animal may have concurrent heart disease, but we may have more work than just saying, “Oh yes, this is congestive heart failure.”
So typically when I have a coughing cat, ideally the most important test is going to be thoracic radiographs. That’s the most important thing. And I think you bring up a really good point that some of these animals are very fragile by the time they get to you. And we have that saying, “No animal should die in radiology,” and I think that’s very true. So things that you can try to do… My thing, I’m in favor of doing a dorsal-ventral view. Might not be great. Don’t get a hand in there. But just do something that gives you a quick snapshot. Does this animal have severe pleural effusion? Does this animal have severe edema? Or is there no edema, and this is an asthmatic cat with [inaudible 00:04:21] and bronchial coughing. So I think at least that view gives you something to work with.
I think treatment-wise, oxygen is never a bad idea unless the animal’s on fire.

Dr. Andy Roark:
Yeah, exactly.

Dr. Anna McManamey:
[Inaudible 00:04:37] oxygen. I think sedative-wise, butorphanol is my favorite, because it is probably one of the safest cardiovascular drugs we have, and it is a cough suppressant, so kind of two birds, one stone with that. I’ll use doses anywhere from 0.2 MGs per K all the way up to 0.5 MGs per K, IV or IM, for butorphanol in kittycats. But I think that ultimately that thoracic radiographs are going to give you the most important information in that nitty-gritty timeframe. Then I think if you have it, point-of-care ultrasound, so those little Sonosites that you can use to do cystocentesis on, I think that’s a great way to just look. Is there severe pleural effusion? I can tap that and stabilize this animal. Yes or no? That can be very helpful. Once you get skilled enough, you can actually start to look at chamber sizes of the heart, the left atrium in particular. But I think that that’s a little bit more specialized of a skillset and so not going to [inaudible 00:05:34]

Dr. Andy Roark:
I’ll be honest, that’s beyond me. I can see the heart. I can see it beating. I have not crossed that threshold of being able to [inaudible 00:05:40]. I’m like, “Yep, there it is.”

Dr. Anna McManamey:
Fluid, no fluid is really all you got to know. [inaudible 00:05:46]

Dr. Andy Roark:
All right, good. Now, see, that’s what I need, validation. I feel good.

Dr. Anna McManamey:
But when it comes to trying to decide, “Does this animal have heart disease? Does this animal have a thing I need to do further investigation for or start treatment for congestive heart failure?” I would say the nice thing about congestive heart failure is that it’s very treatable and it should respond very quickly to medications. So unlike… I always pick on pneumonia, but unlike pneumonia, where there can be a radiographic lag between when the pulmonary pattern shows up and when it resolves, congestive heart failure, it’s like it’s there or it’s not there. And then once you start giving a diuretic, it really should start working within an hour of giving that. So it’s something that’s easy to rule out if they fail therapeutic trial for that disease process. That’s the nice thing about it.
I think cats in general with heart disease, it’s everybody’s nemesis. They can be so tricky. They don’t have to have a heart murmur. I think having the presence of a murmur, the presence of a gallop sound, so it’s like that third heart sound that kind of sounds like a horse literally galloping, or the presence of an arrhythmia, those things would increase my index of suspicion that there is truly heart disease. But there are so many other reasons for cats to get those, so it’s not the most sensitive, but at least lets you go down that pathway.
So if I have any of those findings on my physical exam, then what I do is I do things like… I know it sounds kind of off the wall, but a T4, so including in my blood work check their thyroid level, because if I think this cat has heart disease, I need to rule out hyperthyroidism and I need to rule out systemic hypertension. So T4, blood pressure, those are going to be on my list if I’m going down the cardiac pathway.
The other test I think could be helpful is the BNP test. So this is the biomarker. I think I talked a little bit about it in one of the podcasts previously, I should say. But this is a biomarker that basically assesses for heart stretch. So it’s like the heart’s own diuretic, if you will. It’s a natriuretic peptide, so it’s released by the ventricles when they feel stretched, and it goes to the kidney and tells the kidney to urinate sodium, and then therefore water follows. So this tells you if the heart feels any type of duress. Doesn’t tell you why it does. It just tells you that it’s got some sort of disease going on. So there’s a send-out test and there’s a SNAP test, and you can use the greater severity of that number to help you say, “Is it likely CHF? I should treat this,” or, “Unlikely CHF. I need to go down a different pathway.”
And so I think it’s still the most prudent to rule out congestive heart failure, because, again, it’s the easiest thing to treat, fastest thing to treat, probably most life-threatening. And then once you’ve done that, then you can feel a bit more comfortable about doing things like treating for airway disease, chronic inflammatory airway disease, asthma, bronchitis, those kinds of things, which will need beta agonists like albuterol or steroids, which is always a little bit scary to do with cats [inaudible 00:08:58]

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

Dr. Anna McManamey:
Sure, absolutely. So I kind of teach it as there are three hypers whenever you see a thick left ventricle. So you could have primary hypertrophic cardiomyopathy, so HCM, which technically is idiopathic, so there’s just this innate thickening of the muscle and rearrangement of the fibers. There’s no underlying other disease. But you could also have something we call an [inaudible 00:10:22] phenotype, so it’s thickening of the left ventricle, but it’s because of systemic hypertension or hyperthyroidism, which is pretty common in our older cat populations.
So I could talk probably an hour about how the thyroid hormone affects the heart, but the nitty-gritty is that ultimately it puts the body in an upregulated metabolic demand. So we have hypertrophy of the heart muscle. Even if there’s no systemic hypertension, this still will happen. And they get fibrosis of those cells. The thyroid hormone acts inside the nucleus, so it affects the DNA of those heart cells, so it’s long-lasting change. And so these animals can get these thick ventricles, these dilated hearts, big left atrium, and still have congestive heart failure just because of hyperthyroidism. And so the nice thing with it is it’s reversible in a lot of cases.
So one of my favorite stories is a cat named Sylvester, who was 18 years old. He had never been to a vet ever. And he showed up in my residency dying. He went on the ventilator, and his thyroid was 13.4, his T4. And we were like, “This isn’t good. You’ve never been to a vet. Are you okay to manage heart failure ventilation and [inaudible 00:11:34] therapy?” And she did it. And that cat lived for three more years. It came off all of its heart meds. Ended up dying of like a gastric carcinoma. But I think-

Dr. Andy Roark:
[inaudible 00:11:44].

Dr. Anna McManamey:
I mean, something’s got to get them. But I think that it just reemphasizes the importance of looking for those underlying comorbidities that could be reversible and lead to a really more positive prognosis.

Dr. Andy Roark:
Yeah, that’s amazing. Cool, cool. All right, wonderful. That totally makes sense. It checks all the boxes for me. Is there anything else, any other pearls that you can think of to be looking for in these patients? Anything that tends to get missed when things get referred to you?

Dr. Anna McManamey:
Yeah, I think that for coughing animals that get referred, I think one of the biggest probably pitfalls is that there’s just not the time for that clinician to really get a good history on these patients. I think we’re also busy, and unlike academia where I’ve got hours to talk to clients in my day, you guys have to do these cases in like 15 minutes.
And so I think what I started doing was to have a history form that my clients filled out, so they filled it out at the time of the appointment or in the waiting room, whatever it is. And that just really helped me, because I think help having the knowledge of, how often is this animal coughing? When is it coughing? Is it self-limiting? Is there something that always incites this coughing? What’s the character of the cough? Do they have a video recording of the cough? Whatever that is, it really helps narrow down your differential list. And so if you don’t have the ability to run all of the tests, you can focus your energy on the things that are more likely. So I think the thing that gets overlooked the most is just really getting a good history and asking questions, sometimes repeating them, ’cause I feel like as a student, we always ask, “Is your dog vomiting?” They’re like, “No.” And then the doctor would go in, and they’d be like, “Oh yeah, five times a day. Vomiting [inaudible 00:13:29].”

Dr. Andy Roark:
Exactly.

Dr. Anna McManamey:
So I think it helps to just really hone in on that history question. And I think that’s something that gets missed quite a bit, just because of time.

Dr. Andy Roark:
Yeah, that totally makes sense. Are there any resources that you really like? Any tools in the toolbox that you’re like, “Oh man, I wish more people knew about this.”

Dr. Anna McManamey:
I think for cats in particular, it’s a little nerdy, but the ACVIM consensus statements. So this is the American College of Veterinary Internal Medicine. They publish these big old articles usually once every five years on a certain topic. You can Google it, ACVIM consensus statement. You don’t need special memberships to read these. And it’s basically a bunch of specialists’ just opinions/what is proven/what they would do with all of these situations. And so they have one for feline cardiomyopathy. They have one for mitral valve disease, systemic hypertension, pulmonary hypertension, hyperthyroid. They have them for everything almost. So I think those are really helpful, and they also are filled with references at the bottom, so if you want to learn more you can always go there next.

Dr. Andy Roark:
That’s fantastic. That’s great advice. Thank you so much. Thanks for being here. I always appreciate having you. Where can people find you if they want to reach out?

Dr. Anna McManamey:
Yeah, I think the easiest is probably on the Purdue Veterinary Medicine website, so I’m one of three cardiologists there. You can Google Anna McManamey in Purdue, and you should find me there. My email’s listed there, as well as some information about our clinic and what we do.

Dr. Andy Roark:
That’s outstanding. Thanks for being here. Hey, take care everybody. I hope you enjoyed it.

Dr. Anna McManamey:
Thanks, everyone.

Dr. Andy Roark:
And that is our episode, guys. I hope you enjoyed it. I hope you got something out of it. As always, if you did, share the episode with your friends. Honestly, I just want to share the learning, and that’s how we do it. Also, it always helps me if you write an honest review wherever you get your podcast. It’s how people find the show. Anyway, gang, take care of yourselves. Be well. I’ll talk to you later on.

Filed Under: Podcast Tagged With: Medicine

The Technician is Here. The Doctor is Remote.

January 26, 2023 by Andy Roark DVM MS

Dr. Katie Cutter, co-founder of BoosterPet, joins Dr. Andy Roark to explain how her practices utilize in-person veterinary technicians and remote veterinarians to provide wellness care to pets.

Cone Of Shame Veterinary Podcast · COS – 182 – The Technician Is Here. The Doctor Is Remote.

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

LINKS

BoosterPet: https://boosterpet.com/

Uncharted April Conference (April 20-22): https://unchartedvet.com/uvc-april-2023/

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Katie Cutter is a North Carolina native.  She received both her BS and DVM from North Carolina State University.  She then completed her small animal rotating internship in 2001 and her comparative ophthalmology residency in 2004 at Cornell University.  She became a Diplomate of the American College of Veterinary Ophthalmologists in 2004.  After spending time in private practice, Katie and her husband opened boutique specialty practices in New Mexico, Arizona, and Texas.  Katie recently co-founded BoosterPet with other like-minded veterinary revolutionaries who seek to make positive changes in the veterinary space. Katie and her husband have three kids, Zander (14), Zac (12), and Zoie (3), all to be run by the queen of the house, their Boxer named Sophie.


EPISODE TRANSCRIPT

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

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. I’m here today with Dr. Katie Cutter, she is the co-founder of Booster Pet, which is a chain of four hospitals in Washington State looking to grow and expand, and you’ll hear us talk about that in the coming episode. I want to say up front, this is not a sponsored episode. I don’t work with Booster Pet. I’ve not done any work with Booster Pet. I talk about how I sort of met Katie. I think that she and Booster Pet are doing something that is, whether you like it or not, it is innovative. And it is absolutely fascinating. You’re going to hear about their business model. In their wellness pet business, they have technicians working remotely with pet owners, and the veterinarian basically does telemedicine while the technician is there. And so the vet is not in the building while the techs are working with pet owners doing wellness exams. It’s their business. It is up and functioning in the state of Washington. And I heard about it and I was like, “I have to understand, I have understand how this works and what it really looks like.”
And that’s what our conversation is today. So guys, buckle up. I had my mind stretched and twisted in this conversation, and I think you will as well. 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. Katie Cutter. Thanks for being here.

Dr. Katie Cutter:
Oh, thank you for having me. I’m excited.

Dr. Andy Roark:
I’m looking forward. I’ve been looking forward to this. I met you just recently. I was talking to Dr. Bob Lester, who’s been on the podcast a number of times, and we were talking about leveraging technicians and technician utilization in the future. And I was sort of saying I very much can foresee a future where technicians are working much more independently from doctors than they have been at the past. And Dr. Lester said, “You’ve got to talk to Dr. Katie Cutter. She’s doing absolutely amazing things with her company Booster Pet.”
And so I went and I Googled and I’ve kind of blown away and I have questions and I want to understand what you’re doing, and then I just have a lot of questions.

Dr. Katie Cutter:
Perfect.

Dr. Andy Roark:
And so what I want to do is I’m going to let you lay this out. So before I do, let me just say real quick. So you are a veterinarian, you are a boarded veterinary ophthalmologist, you have owned boutique specialty practices, three of them, you have done so many things. You have just been named DVM 360’s Innovator of the Year, which is really cool. You’ve done a lot of things. Tell me about Booster Pet. Just lay out for me, what is your business model? How does this work?

Dr. Katie Cutter:
Yeah, well, Booster Pet was born on the idea that we can just do better in the vet space. So it’s no surprise to I think anyone who would be listening to this podcast that the veterinary industry has been in a crisis for a bit as far as staffing. And that crisis creates hamster wheel of problems that we ride out in the clinic every day. And a lot of what we see that create the stress in the veterinary clinic certainly result from some practice inefficiencies that we have. And we don’t leverage our talent in new and novel ways to create just a better life for the people that provide the services to the pet owners. And so Booster Pet is really focused on how can we provide a better life for our veterinary technicians, our veterinarians, so that they have more left in the tank to give to the community and to give to themselves.
So that’s the whole passion project that Booster Pet is. And so we started by saying, “Hey, our LVTs that are out there, they’re very, very capable and all too often they’re under leveraged in the clinic and we can really do a lot more with our LVTs.” And by doing so, we can actually raise their pay scale and create efficiencies in the clinic to take some of the burden also off the veterinarian. So to make everyone’s life a little bit better in the clinic. And so at Booster Pet for our wellness portion of the exams, we elevate the LVT into that physician’s assistant nurse practitioner kind of role by utilizing in-clinic telemedicine for part of their veterinarian support through those wellness exams.

Dr. Andy Roark:
Sot talk to me a little bit about that. So the way it was described to me was basically you have technicians that are working by themselves and then they have access to veterinarians through telemedicine to oversee what they’re doing. Is that accurate?

Dr. Katie Cutter:
It’s pretty accurate, yeah. So I mean, most times people are like, “How does that even work?” And then they come into the clinic and they’re like, “Oh my God, this is really, really cool.”
So for a wellness appointment, so a client would come in with their pet, the LVT and the VA greet the client, get them into the exam room, take the history and do the physical exam, things like that, put all the notes into the medical record. We leverage technology in the form of Bluetooth stethoscope, so heart and lung sounds get recorded and uploaded automatically to a database that can be accessed from anywhere, anything that can be documented with a picture or video, things like that we do. And when we’re ready for that veterinary consultation, the veterinarian Zooms into the exam room and has that interaction real-time but through that in-clinic telemedicine approach with the owner and the technician, they talk about what’s going on with the pet and usually it’s like, “Oh, well Fluffy is here for the DHPPL booster and we’re set to go with that.” Right?

Dr. Andy Roark:
Yeah.

Dr. Katie Cutter:
Something like that. So these are only wellness appointments. And then when everyone comes to a consensus that we’re, “Okay, we’re on the same game plan, this is going to be what’s happening today,” the veterinarian peaces out and the LVT and MBA team complete the treatment and then the owner is able to go home and they were able to get an exam in a timely fashion, get the services that they needed in an economical way and were able to pay our techs more because they’re actually in a revenue generating capacity.
We also do have urgent care services at our hospital. So there is also some direct veterinarian action for cases that are new, new clients or every now and then there’s someone who schedules a wellness appointment, but you’re like, “Hmm, this actually doesn’t fit the parameters of what we feel is it would be acceptable for us to move forward with an in-clinic telemedicine appointment.” And so those will get shifted over to the urgent care side of the house.

Dr. Andy Roark:
That totally makes sense. Okay. Now questions. I’m imagining a sort of a space age white plastic room with a wall screen like Star Trek, you know what I mean? And the doctor appears and the doctor appears on the screen and everyone is there in the room together and they all sort of talk it out from start to finish. Is that accurate? I guess what I’m really digging at is there back channel communication because a lot of times my techs come out of the room and they’re like, “Look, before we go in there, you should know this.” I think any of us would wonder. “How do I get… Give me the heads-up here on what I’m walking into virtually.” Is there any sort of back channel communication? Is it all a hundred percent we’re all together in a room and we’d talk it through from start to finish in front of the pet owner? Help me see that vision.

Dr. Katie Cutter:
There’s both. So definitely when the technician is ready for the exam, we have a platform where the wellness veterinarian gets messaged, “Hey, I’m ready, and this clinic exam room one when you’re ready.” And so if there’s anything that the veterinarian needs a heads-up on, like, “Hey, they were 15 minutes late, but they have a dinner appointment here and we’re trying to speed this through,” or anything like that, “Hey, they came in for a wellness, but I really have a question about something I found on my exam, da da da da da.” That all happens through that… Initially through, it’s like a text messaging application, but then we can have real-time phone and video chat that can either be in front of the owner or not in front of the owner, depending on what would be most appropriate.
Yeah, because it would be kind of weird if you had some things that you needed to talk about discreetly sometimes in order to set the stage, every veterinarian needs to have a little bit of a stage-setting before walking into that room cold. And so yeah, we do have that system in place.

Dr. Andy Roark:
Not in a bad way. I’m just thinking of things like, “There’s some married couple here and they’re actively fighting with each other about something not related to the pet. And you should just know that before you go in there.” I’m just curious how those signals get sent. Those have saved me so many times and I was just curious.

Dr. Katie Cutter:
Right.

Dr. Andy Roark:
So tell me about visualization. So there’s a screen on the wall. Is that all that the vet can see is from the screen? I’m assuming, do you have other kind of cameras? You said you’ve sort of filmed everything. What do you get to see?

Dr. Katie Cutter:
Yeah, we don’t record the exams, just like regular veterinarian exams aren’t recorded. That would just take up a lot of database. But we do have other cameras that we can utilize that are portable. So if the veterinarians like, “Hey, I’d like to get a better look at the teeth or let me see that skin lesion, that hotspot that you were talking about,” something like that that we can Zoom into that and that can be real time or we can take pictures from that or whatever.

Dr. Andy Roark:
That totally, I was just like, “Let me see those ears.” Those are the things I was trying to think of. That totally makes sense. What are the pet owners think about this? It’s on your website, you’re very clear. You’re like, “This is what is going to happen when you get here,” which I think is great. I’m sure that they still don’t get it or they, they’ve got to be surprised. What do you hear from the pet owners when they walk in and they’re like, “No, you’re not actually going to shake the doctor’s hand.” What is that like?

Dr. Katie Cutter:
Yeah, most pet owners, especially this day and age, are so appreciative that they were just able to get in and be seen that they’re actually, they’re just super like, “Wow, this was different, but this was great and I got the service that I needed. I didn’t have to wait for weeks.” Or a lot of people are getting new puppies and there are a lot of clinics in our area at least that aren’t even taking new clients. So they have a puppy that needs a round of vaccinations, they’re getting ready to go out of town. They can’t even board the puppy until these vaccinations are completed. And we can usually fit them in within a couple of days at any one of our clinics.
And so they’re mostly just filled with gratitude. A lot of people got used to using telemedicine for their own health issues during COVID. So I think in a pre-COVID environment, it would seem super funky for owners to walk in and be like, “Woo, what is this?” But COVID changed the landscape for people’s comfort level with telemedicine for their own needs, for their children’s needs. And there’s an expectation that they should be able to get convenient care for simple things.
And unfortunately with the systems that we have in place at most clinics, it’s really hard to provide convenient care for simple things a lot of times when the clinic is swamped, their appointment schedule’s full, they’re short staffed. So the pet owners are feeling that. And so we need to… This isn’t the only mechanism, it’s a mechanism. And so what we see with the pet owners, is just that gratitude that’s there every now and then we have someone that’s like, “Dude, I’m not comfortable with this,” and we totally get it. Let’s help you find, find a more conventional veterinary hospital that would be a better fit for you.

Dr. Andy Roark:
Yeah, I think that’s, and seems like you have a really healthy approach on it. Do get, and I’m just thinking of this through the lens of being a veterinarian, tell me about client loyalty. Are there clients that are just like, do they connect to the veterinarian individually that way? Do you see people who go, oh, I only want to see Dr. Smith because when I go, she’s the one who appears on the screen and I like her? Or is it just a different dynamic when someone’s on the screen? I’m just trying to think about what that experience would be like. Have you noticed a difference there?

Dr. Katie Cutter:
Yeah. Well, I don’t think there’s necessarily a difference in the client loyalty. Our wellness veterinarians are amazing and we really search for people who can reach through the screen almost and make people feel really welcome. So I think a lot of our clients still feel a connection with a veterinarian.
What does shift is that we see a lot more loyalty to the veterinary technician. So our veterinary technicians are the ones that they do a lot of the handholding with the clients and a lot of the explaining, and “This is what’s going on and this is why we’re doing this today,” and things like that. And so they have a kind of front and center appearance with that client, which a lot of clinics don’t have in place. And so I would say the loyalty, they’re still loyal to the veterinarians, but we see a lot more loyalty bridging to the technicians.

Dr. Andy Roark:
Yeah, that totally makes sense.
Hey guys, I just want to hop in really quick and give a quick plug, the Uncharted Veterinary Conference is coming in April. Guys, I founded the Uncharted Veterinary Conference in 2017. It is one-of-a-kind conference. It is all about business. It is about internal communications, working effectively inside your practice. If you’re a leader, that means you can be a medical director. It means you can be an associate vet who really wants to work well with your technicians. It means you can be a head technician, a head CSR, you be practice owner, practice manager, multi-site manager, multi-site medical director. We work with a lot of those people. This is all about building systems, setting expectations to work effectively with your people.
Guys, Uncharted is a pure mentorship conference. That means that we come together and there is a lot of discussion. We create a significant percentage of the schedule, the agenda at the event, which means we are going to talk about the things that you are interested in. It is always, as I said, business communication focused, but lots of freedom inside that to make sure that you get to talk about what you want to talk about.
We really prioritize people being able to have one-on-one conversations to pick people’s brains, to get advice from people who have wrestled with the problems that they are currently wrestled with. We make all that stuff happen.
If you want to come to a conference where you do not sit and get lectured at, but you work on your own practice, your own challenges, your own growth and development, that’s what Uncharted is. Take a chance, give us a look. Come and check it out. It is in April. I’ll put a link in the show notes for registration. Asking anybody who’s been, it’s something special. All right, let’s get back into this episode.
What is the technician experience coming into this? Do you have technicians who show up and go, “This is not what I thought,” or, “This is… I don’t like this,” or, “This is more than I can chew.” I’m certain you have technicians who come in and go, “This is great.” Well, what is the technician experience? I’m sure it’s a mixed bag, but help me, how do they respond to it? Help me put my head around that.

Dr. Katie Cutter:
Yeah, so I find that technicians, we kind of have… Just with veterinarians, there’s kind of two main varieties of… Sorry, my daughter painted my fingernails there earlier this morning. So it’s a little… Looks like I just killed something here.
But no, so I feel like the technicians and the veterinarians kind of come in two flavors to be just really broad. There’s the ones that kind of the urgent care and the emergency medicine and the procedures, they kind of like that fast-paced, the sick cases. And then there’s the ones that more of the client interaction and the wellness cases. So we have technicians that come to us and there’s some technicians that overlap the entire spectrum. They work urgent care, they work procedures, they can work wellness, they kind of do it all. But we do sort through those technicians, the ones that really want to be client-facing and really the ones that want to be on those wellness cases.
And for them, the platform really resonates for them. I had one technician pull me aside last month and she had just been working with us for, I want to say it’s 30 or 60 days. She pull me aside and she was like, “Oh my God, I feel like this is rehab for techs.” And I was like, “Uh, can you explain that a little further?” And she’s like, “Typically, because our pay scale is higher, so we typically are drawing from a really experienced tech pool. And so these are technicians that have worked in the field for 15, 20 years and they have been in experiences largely where they just feel undervalued and feel like there’s not a next level for their career path, either financially or even just professionally. Like, ‘I’m kind of capped out at what I’m going to do.'” And so I think for those technicians that it’s really refreshing to be able to come into a place and be a part of a team and to have that leadership role in the clinic as well and to be trusted. So I think for most of our technicians, it’s a breath of fresh air for sure.

Dr. Andy Roark:
Oh, I’m sure. Are there special characteristics or traits you look for in technicians? Things that you say, this is really important in this kind of business model where you’re working more independently than you would at other places.

Dr. Katie Cutter:
Yeah. So here you go. Because the model is [inaudible 00:18:48].

Dr. Andy Roark:
Yeah, it seems like it takes a certain kind of person, I guess.

Dr. Katie Cutter:
Yeah, no, for sure. You have to really like people. You can’t just like the dogs and the cats and the puppies and the kittens you have to like their owners that come with them and really want to help the people, the pet parents that are in the industry. You have to work well with your teammates for sure. You’ve got to be a team player.
And then we also pair, like I said, most of the time these are highly experienced technicians, but we do a training period where we’re pairing you up with another technician for anywhere from two weeks is the shortest period of time, but sometimes it’s up to six weeks depending on how the transition is going.
Where there’s a lot of handholding to say, “Okay, this is how we greet a client. This is how we do the physical exam. This is how you document things.” There’s a lot of specifics that we go into with our procedures because we are different and we want to make sure that all the I’s are getting dotted and the T’s are getting crossed. And so we are more procedure-oriented than a lot of clinics are, just to make sure that clients have a consistent experience and our techs have a consistent experience. It is new and that consistency I think keeps everyone on the same page for sure.

Dr. Andy Roark:
You mentioned before you try to hire doctors that can reach through the screen and make people feel good or feel safe. Are there characteristics or traits in the doctors that tend to do this kind of work that you’ve seen? Is there a certain type of vet personality type when you meet them and say, “Yeah, you would be someone that we would probably do well here.” I’m just curious. So any personality pieces that you say, “These are the types of doctors that do well here.”

Dr. Katie Cutter:
You know what the most important doctor piece… I used to think, like, “Okay, you’ve got to love the pet parents.” And of course that’s a given. I mean, I think that’s just a good doctor in general. You’ve got to be able to connect sure with the people that are making the financial decisions for the pet in order to get your plans across. More than anything else is that we have to have doctors that value technicians. And I wish that that was something that was universal in our industry, but it’s not. And there are certainly lots of doctors out there that have practiced for quite a long time who haven’t worked with technicians in the capacity that we are advocating. And so if you come in and you’re like, “I don’t believe in technicians, I don’t believe they should be doing this,” then you’re probably not going to be a good fit for us.
So it’s really like, “Hey, are you a team player? Do you really believe in the techs and the staff and believe in the vision and the model? Do you want to change the industry and do you want to push it forward?” And so really it’s getting people that want to make a change for the better. Our whole mantra, the whole reason we exist is we want to improve the lives of the veterinary technicians. We want to improve the professional lives of our veterinarians. And so you’ve got to be dedicated to that cause And if you’re just doing this to clock in and clock out and you’re not in it to create that greater difference, probably not going to be the best fit.

Dr. Andy Roark:
That makes sense. Speaking of clocking in and clocking out, what are the veterinarian work schedules like? How does that work?

Dr. Katie Cutter:
Yeah, yeah. I mean, urgent care is urgent. I mean, there’s nothing novel on really what we do on that side of the house. So our wellness veterinarians, they can work remotely, which is a nice option for veterinarians to be able to have. We have a largely women workforce and as a mom of three and a CEO and fellow veterinarian, time, there’s not enough of it. And so to have options that I could still be a professional, I can still be a veterinarian, but I have more flexibility to do it a little bit more on the terms that suit me, is kind of a novel take on what a veterinarian can be expected to do in our field. And we need to have, I think, more innovators out there that are looking to be creative with the workforce that we have.
And so we can schedule and you can do, we have some veterinarians that have picked up a part day shift or a full day shift. We have full-time veterinarians, part-time veterinarians. And so usually it’s the clinic rounds. All the clinics get on a platform together at currently it’s 9:00, we’re switching it to 8:30 in the morning and we all round together. And so all the techs, the wellness doctors, everything, we’re all… It’s like a Brady Bunch Zoom meeting and it’s like, “Hey, this is what’s happening today teams, does anyone have any questions with anything on their schedule? Anyone have any questions about cases that you saw yesterday or blood work analysis or anything like that?” So to really keep that community feel going. And I think our wellness veterinarians especially appreciate that because you need to feel that connection with the clinic still. And that’s where our model differs from just a call-up telemedicine company is that the clients are in the clinic, you have your LVT, you have staff in the clinic, you actually have a fellow urgent care veterinarian there in the clinic. So you can provide some really meaningful medicine right there, boots on ground, but you need to feel connected to your team. You need to feel like you’re almost like in the clinic. And so we really strive to create that feeling and to create that community.
So every day before the day starts, everyone meets together based on the screen and we talk it out, talk what the day’s going to be like, anyone have any concerns, anyone need to leave early, anyone’s kid is sick that we need to find coverage for, things like that. The basic life stuff that happens. And so that both the community feel of things and the flexibility of the work schedule, not only in just the hours that we offer, but also the ability of being able to do it remotely, I think are novel concepts for veterinarians and very, very well received.

Dr. Andy Roark:
Yeah. Oh, I agree. So you have three locations now, is that correct?

Dr. Katie Cutter:
Four. Yep.

Dr. Andy Roark:
And they’re all in the state of Washington?

Dr. Katie Cutter:
They’re all, they’re all in the greater Seattle area and we’re looking to kind of double our footprint in 2023. I never sit still for long.

Dr. Andy Roark:
Yeah, right. Were there any sort of regulatory headaches? Were there things that you had to work around in order to start doing this? I’m sure that you got some pushback from veterinarians who were like, “You can’t do this.” Were there any actual challenges to you getting up and getting it going?

Dr. Katie Cutter:
Yeah, yeah. So initially we were able to get up and going under some COVID legislation that was favorable for us in Washington State. Recently, they’ve backed out of that legislation. The Board of Governors is reviewing more permanent legislation that would potentially be more compatible with what the COVID legislation was. With our marriage of both an in-house veterinarian there and the telemedicine things, we’re able to piece together protocols that check all of our boxes there.

Dr. Andy Roark:
Gotcha.

Dr. Katie Cutter:
It’s not always streamlined. I wouldn’t say it’s the most efficient process that certainly if we had legislation that could make it more efficient, we would be very favorable for that. But yeah, we’ve set up our protocols, like I said, dot every I and cross every T, that we have in place to make sure that we fall within the Washington State legislation. And really it would work in I’d say 49 out of the 50 states.

Dr. Andy Roark:
How stressful was that to open up a hospital using… Because these things are here in place and the pandemic happens and they make this legislation and you’re like, “That’s it. We’re going to start a business.” With this thing that was related to the pandemic, I don’t think I’ could have slept at night. How did you do that?

Dr. Katie Cutter:
I mean, definitely you do have some sleepless nights, but I think in the long run you got to have a passion and you’ve got to have… Your heart’s got be in the right place. You’ve got to be operating from a standpoint of, “Why am I doing this?” We’re not doing this to make gobs of money, although my investors probably don’t want to hear that, we’re doing this to change this space. We’re doing this to improve the lives of our veterinary technicians and our veterinarians because I think they’ve been overlooked and the stress that they feel in the clinic has been ignored for quite some time. So we need to start being better. We need to have better systems in place so that’s the driver through it. And so we did just focus when we first opened our clinics, we did just focus on the wellness model and then back added urgent care to it just because the wellness model is the part that’s really different.
And so just to say, “Hey, we think it’s going to work on paper, this seems great, but is this really going to work? Is this thing that’s an idea, once we turn it into a brick and mortar living entity, how is that going to fly?” And it went amazingly smoothly. And so then back adding urgent care and then knowing, we had a year and a half knowing that, “Okay, we’re able to do these things under COVID legislation.” But that whole year and a half working towards what are we going to do if when we don’t have COVID legislation and what would we want to do? What would we change to put it in a state that had conventional legislation? So those goals were never ignored. We were able to get up and running with some very favorable legislation, which really let us prove the proof of concept. Does this even work? And we found out, yes. And owners love it and technicians love it, and veterinarians love it. Okay, so now that we have that answer, now let’s put the systems in place to make it so this would be something that would be sustainable in almost every state.

Dr. Andy Roark:
If you could go back and tell yourself something when you were getting started with Booster, what would you tell yourself? What is the message you would send back in time?

Dr. Katie Cutter:
Yeah. Yeah, that’s a great question. So my husband always makes fun of me because I’m always… I come up with an idea and I’m like, “How hard could it be? Honestly, this just seems so simple.” And I’ve gotten myself into a lot of trouble with that. And so this is one of those things where it’s like, “Yeah, sister, this is going to be hard. This is going to be a little bit harder than you might initially think but it’s also all going to be worth it.” To go into the clinics.

Dr. Andy Roark:
That’s great.

Dr. Katie Cutter:
And to see those technician teams working, to hear their stories of where they’re been and where they are now, it’s so fulfilling. And then our veterinarians that are looking, they’re burned out, they’re looking for a different opportunity for a different option. Even our urgent care veterinarians, because we do urgent care, of course, we can’t do anything just exactly like other people do it. So our urgent care is a little bit different too. No telemedicine involved in that, but we really believe in creating systems that are healthy.
We don’t believe in squeezing the lemon to get as much lemonade as possible. We want people to leave the clinic after their shift and still have part of themselves left in the tank. I want you to be able to go home and have energy to have dinner with your family, to go to your kids’ basketball game, to go to the gym, to go for a hike. Whatever it is that fulfills you are more than just your career. Yeah. “So it’s hard and it’s going to be harder than you thought, sister, but you’re going to start creating the change that you want to see out there in the world. And it’s worth it. It’s worth those sleepless nights.”

Dr. Andy Roark:
Definitely.
Dr. Katie Cutter, where can people learn more about Booster Pet? Where can they find you online?

Dr. Katie Cutter:
Oh yeah. So we have of course a webpage, www.BoosterPet.com. I’m always happy for people to reach out to me directly. So my email address is Katie.Cutter@boosterpet.com. And that’s K-A-T-I-E-C-U-T-T-E-R.
Yeah, I love to talk about what we do. I love to share ideas and have conversations about how we can make the space a better place. So I’m always encouraging people to reach out and let’s get dialogues going. But even more important than that, let’s turn these dialogues into actual concepts that start to change the space.

Dr. Andy Roark:
Thanks so much for being here, guys. Thanks for tuning in and listening. I hope everybody has a wonderful week.

Dr. Katie Cutter:
Thanks, Andy. I super appreciate it.

Dr. Andy Roark:
And that is our episode.
Guys, I hope you enjoyed it. I hope you got something out of it. Thanks to Dr. Cutter for being here and sharing what she’s doing. Boy, I got to sit with this one. This is, it made me think about what the future in medicine’s going to look like, and that’s always exciting to me. So anyway, guys, take care of yourselves. Be well. I’ll talk to you later on. Bye.

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

When ER Vets Get to Give Discounts

January 16, 2023 by Andy Roark DVM MS

Dr. Tannetje’ Crocker joins Dr. Andy Roark to talk about the idea of “intentional discounting.” What happens when veterinarians are able to openly discount (or even give away) services to pet owners in need? Let’s get into it!

Cone Of Shame Veterinary Podcast · COS – 181 – When ER Vets Get To Give Discounts

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

LINKS

Dr. Crocker’s Homepage: www.drcrockerpetvet.com

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

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Tannetje’ Crocker is a 2009 graduate from the Texas A&M University College of Veterinary Medicine. She is passionate about mentorship and empowering veterinary professionals to embrace the profession and find joy and success. Growing up Dr. Crocker competed on horses and was inspired to become a veterinarian. Since graduation she has worked as an equine ambulatory vet, small animal general practitioner, and emergency veterinarian. She currently lives in Texas with her spirited 10 year old daughter, funny 6 year old son, and supportive husband of 16 years.

She works as an ER Veterinarian for Veterinary Emergency Group in Dallas, TX. Recently she was excited to purchase Alta Vista Animal Hospital in Fort Worth, TX. She plans to continue her support of fellow veterinary professionals, both virtually and in person through her various endeavors.


EPISODE TRANSCRIPT

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

Dr. Andy Roark:
Welcome everybody to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I’m here with my friend Dr. Tannetje’ Crocker. This is a good episode. It’s going to roil some people up, though, there is definitely some interesting conversation and ideas here. We’re talking about discounting and vets discounting. And you guys can hear me asking the questions that I’m struggling with as we go through this interview. I like a lot of where this goes, and I end with questions of how does this scale? It’s really an interesting conversation. If you think about discounting in your practice or what that looks like, this is a really good conversation.
There’s a lot of interface here with spectrum of care. There’s a lot of interface here with keeping care affordable. There’s a lot of interface with Dr. Autonomy, meeting the mission and values of staff, all that stuff is here. And also, we got to run healthy, profitable businesses where we can set budgets and do strategic planning and pay for equipment and raises and continuing education and things like that. And so a lot of nuance in this conversation. Anyway, I’m going to stop talking about it. You guys should check it out, Dr. Tannetje’ Crocker.

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

Dr. Andy Roark:
Welcome to the podcast, Dr. Tannetje’ Crocker. How are you?

Dr. Tannetje’ Crocker:
I’m good. A little tired, but I’m excited to be here.

Dr. Andy Roark:
I know. You should not have done this podcast. You should have just been like, “I’m sorry, I’m working until the butt crack of dawn, and then I don’t have enough time to sleep and then talk to you.” You should have said that.

Dr. Tannetje’ Crocker:
If I do that though, I would never get anything done, because that’s the ER life. So I’m excited to be here. It’ll be fun.

Dr. Andy Roark:
For those who don’t know, you are a practicing emergency veterinarian, and you are a big presence on social media. And I think the world of you. I have really enjoyed getting to know you over the last year or two, and I love that you’re a positive voice for veterinary medicine. I like the stuff you do. When there’s so much negativity on social media, I like it. I like that you tell the truth about what it means to be a veterinarian and also emphasize the positive. I just think that’s a perspective that is valuable for people to hear, and just be reminded that we do cool stuff. So thank you for that.

Dr. Tannetje’ Crocker:
I started this whole thing because of that, so I’m glad it actually resonates and works. And I hear that a lot, where people say, “I had a hard shift or I had a hard day. Thanks for sharing.” But then also reminding me of all the very cool, very amazing things we do. So it-

Dr. Andy Roark:
Well, there’s a lot of people on social media and there’s a lot of people in vet medicine on social media. I don’t think that there are a whole lot of people, and I’m going to get blown up for this, but I think there’s space for more people to be honest about what medicine is, and talk about what they enjoy about it and what makes it good and what’s fun. Or look at it honestly and find the ability to laugh.
I think that’s what I’ve always tried to aspire to, it’s not toxic positivity. It’s not pretending that every day is great. It’s not telling people, “You should just smile.” But it’s being honest and saying, “No, this is a hard job, and there are some really good things here. And let’s sit with them for a second. Let’s look at them. Let’s pull them out. Let’s laugh about the hard parts together.” And I think that that’s so valuable and just… I don’t know. I don’t see a whole lot… I feel like social media has kind of drifted away from that in a lot of ways. And so it’s just, those people out there who are putting that positivity on I think are really important.
Well, you’ve got a talk coming up. You’re speaking at Western Vet Conference in Las Vegas in a couple of months, and I will see you out there. But you’re talking about something that I’ve really been interested in for a long time. And so we’re talking about discounting. And I think a lot about discounting, and the fact that as a doctor, I am often in the exam room talking to people about money, and some people can’t pay for the care that they need to have.
I feel like there’s been a lot of evolution this way in our profession, but when I came up, it was not uncommon for vets to change the prices, and just be like, “Oh, hey, ear cytology, it suddenly costs half of what it usually costs.” And they would just do that, and it was normalized. And I know people who would slam their fists on the table desk and say, “That’s embezzlement.” It was common practice back in the day of discounting prices.
And again, we have practice managers come in and do things like that now. Where they look at it and they say, “Well, we may just be able to take this off of here.” And it comes from a good place. The thing that I was always interested in is why do we discount? And how do we discount? And are we actually helping the people who need help when we discount? And that’s where your sort of talk on intentional discounting comes in. And so I’m going to stop talking here, and kind of turn it over to you for a second, and say, when you say intentional discounting, what do you mean by that? Because I want to make sure that we’re seeing the same vision.

Dr. Tannetje’ Crocker:
The emphasis is on intentional discounting. I feel like what’s happened over time is discounting has become a dirty word. It’s something that, honestly, I think we all still do, in some way, shape, or form, but we try to hide it. And maybe that is because we have management oversight, that we’re worried we would get in trouble for giving stuff away for free-

Dr. Andy Roark:
Sure.

Dr. Tannetje’ Crocker:
… or for discounting. Or maybe it’s because we work off of a certain production number or we’re trying to meet certain standards. And so the idea that we would just give something away is seen as a very negative thing. And what I want to talk about is reframing it as doing it intentionally with a purpose, communicating the value of what you’re doing to the clients, and actually making the experience better for the clients and you in the hospital setting. Obviously, I work ER, so finances are a huge thing. And fortunately, I work for Veterinary Emergency Group and one of our things that we say is, “We give shit away for free.” So we openly discount. [inaudible 00:06:33]-

Dr. Andy Roark:
You say that, that’s on the website?

Dr. Tannetje’ Crocker:
It’s not on the website, but that’s the thing that we say and we really truly believe in. So doctors have the ownership to do what they want with a case, financially, what they feel good about, and intentionally discount for a reason and for a purpose. And we can get into what some of those are.
But one of the first points-

Dr. Andy Roark:
Sure.

Dr. Tannetje’ Crocker:
… that people have to realize are everyone discounts. It happens. And I think a lot of times we’re sneaky about it or we see it as a negative, and we’re trying to restructure and reframe it to, “It’s happening already. Let’s spin it into a positive thing for the team and for the client.”

Dr. Andy Roark:
Okay, so I want to pause on this, because, actually, I’m with you at this point. So to me, I do think that at some point, when push comes to shove, we all end up looking at this crying pet owner, and saying, “I desperately want to help this person and I desperately want to help this pet and they don’t have the finances that they need.” And what I say to people is, “We need to own this as the cost of doing business in this industry. We don’t have people who are going to kick that person out onto the street. That’s not who we are. That’s not our culture. That’s not what we want it to be our culture.”
At some point, we are kind, giving people who want to serve. That’s what we want to do. And so there is a discount cost of doing business in medicine. I don’t think that’s ever going to go away. I think people who try to make that go away are going to have real problems keeping their staff motivated, feeling good about work. I think that the culture part, it all plays into this. I really like how you’re sort of setting this up.
I think, for me, one of the things, and you didn’t mention this, when we talk about discounting and where people come down, you talked about management oversight and you talked about production bonus and being injured there, I think a lot about fairness. And when I think about discounting, I think about, “Is it fair for me to give this person who’s complaining loudly a break and not this person who just sucks it up? And I don’t know what their struggle is, but they just suck it up and they don’t say anything and they pay their bill.”
And I kind of feel like I think I treated that person who sucked it up unfairly, and maybe rewarded the person who just griped and complained loudly, and who knows what that person’s real situation is. So anyway, I wrestled with the fairness part as well in discounting and said, “How do I get my head around this?”

Dr. Tannetje’ Crocker:
I think that one of the things that I would argue with is it’s not that-

Dr. Andy Roark:
Sure.

Dr. Tannetje’ Crocker:
… you discount because someone gets angry or because someone says, “This costs too much. How could you charge me for that?” It’s because you discount, because you have communicated what this pet needs, you have shown the value of what they need, and people just truly can’t pay for it. Whether it’s in that moment, whether you need to just buy them some time to maybe reach out to family and friends.
You’re obviously not going to do a $10,000 surgery for free. That’s not happening. But there are cases where you could do something and you could help the pet not be painful anymore. You could maybe stop the vomiting, so they can get to the regular vet if they’re in your ER. And you could do those things for free, not completely break the bank on the hospital side of things, but have the owners feel like you actually care.
And it’s not because they’re acting like jerks, it’s not because they’re asking for it. It’s because you’ve had a conversation and said, “This is what’s going on with your pet. This is what they need. This is what it’s going to cost.” And they have said, “We really and truly just can’t do that. It’s not an option.” Or, “That high number’s not an option. This is where we are. This is our budget,” and you have to work within a budget.
So let me give an example. I have had people come in and were really suspicious of a foreign body. Well, in our ER, X-rays are expensive. The emergency fee is expensive. But I need to see is this actually something surgical or not? And then we need to be able to talk through the options for surgery. So sometimes what I’ll do is I’ll say, “You know what? Let me shoot an x-ray no charge.”
Let me just shoot a lateral x-ray, no charge, see if there’s an obvious foreign body or not. See if this is something that I could maybe give Cerenia, and you could see your vet in 10 hours. Or is this something that we have to figure out how to get this dog surgery. And owners, just the fact that I’m willing to get an answer for that and give away a $120 x-ray is very valuable to them. And so we shoot the x-ray, we see a foreign body, and they say, “Oh crap. The dog actually needs a procedure.”
So now it’s trying to figure out how do we make that happen either in our hospital, can it wait until they go somewhere else? But it’s getting them an answer, and it’s kind of working with them as a team and establishing that trust and that communication, so that you can take the next step. Does that make sense?

Dr. Andy Roark:
I have questions. I have questions.

Dr. Tannetje’ Crocker:
That’s fine.

Dr. Andy Roark:
And so-

Dr. Tannetje’ Crocker:
That’s fine. But it’s not the jerk client that’s yelling and arguing. That’s not who I’m discounting. That might be who the-

Dr. Andy Roark:
No, no. No, I get that.

Dr. Tannetje’ Crocker:
… medical director is discounting. I’m discounting for the people who truly need something done for their pet in that moment, and they just really can’t afford it. Or they don’t have an answer, yet, that helps them move on to that next step financially and work through it.

Dr. Andy Roark:
Okay. I like this. So when we start to talk about what intentional means, now we’re starting to get into the weeds. Because I think what neither of us is talking about is willy-nilly takes $5 off of this, we’re not going to charge for that. And just kind of going through scattering discounts around.
And I really want to emphasize that, for me, I have seen that my whole career and it’s awful. It’s not-

Dr. Tannetje’ Crocker:
It’s not right.

Dr. Andy Roark:
I don’t know that it actually moves the needle in a way that matters. It’s bad for the practice. You can’t budget for the practice. You can’t set your profitability expectations, so you can raise salaries. You just can’t do these things when people are randomly giving away money here and there, and not charging for this and that. And I have seen those practices. I have seen those practices. And I remember in the past, and it’s been probably a decade since I saw these numbers, but I remember stuff about your average veterinarian gives away six figures worth of services every year.
And I believe those numbers. And I don’t know if they’re still true, I suspect they are, they’re just better hidden than they used to be. But this was kind of willy-nilly giving. And so I use this analogy when I think about discounting like this, and just sort of willy-nilly, we’re going to do a little of this and do a little of that. There’s two things. There’s the research with Adam Grant, so he wrote the book Give and Take.

Dr. Tannetje’ Crocker:
I love him.

Dr. Andy Roark:
And he had this research, where he talked about how people feel about charitable work. And so what he did was he looked at people who just help people throughout the day, and they would just do a little bit of this here and a little bit of that there. And they would just kind of along and along, they just help people. And then they looked at people who blocked time on their calendar, say, one morning a week, and they went to the soup kitchen. And they did three hours at the soup kitchen on Thursday mornings.
And he looked to say, “Who’s happier? Is it the people who give along and along throughout the day? Or is it the people who just have a block of time, and they say, ‘This is how I give, and this is where I give and I go and do it'”? And what he found was the happiness, the feeling of satisfaction and pride in the people who block the time and was like, “This is how we do it,” their happiness was a lot greater.
And so I think about veterinarians that kind of take a little bit off of this and take a little bit off of that, I’ve probably done things like that in my career and generally felt crappy about it the whole time. Because I feel like I’m not doing a good job, I don’t know if I’m really helping them. I worry about the fairness thing I talked about before. So that’s the first part.
The second part is when I think about impact that we have through giving, and I look at, it’s the difference from me in giving money to someone who’s panhandling beside the road versus donating a chunk of money to the local soup kitchen. And I’m not trying to put values on anything, and say, “You should do this or you should do that.” I feel like when I stop and say, “If I’m going to do a certain amount of good in the world, am I better off handing it out to people as I see them? Or am I better off rolling it together and doing something meaningful with it in an organized way?”
And I’ve come down in the second camp, and again, I’m not saying other people should feel this way. But I do feel like, “You know what? If I take a couple hundred bucks a month and do a thing with all of it as opposed to giving away 20 bucks whenever I pass somebody, I feel like I’m making a bigger difference.”
And so I take those two thoughts, the happiness and then the impact, and roll them together. And to me the way that we discount it needs to hit those buttons for me. I need to feel like I’m making an impact and then I need to feel good. Like, I’m not doing stuff I’m not supposed to, that I’m not coming up short as a veterinarian, that I’m being dishonest with my employer. All those things are important to me.
So as you started to talk about the intentional discounting and stuff, when you’re talking about the radiographs, I’m just trying to get my head around that. When you say, “Hey, we bring this pet in, let’s do a lateral radiograph, and just take a look.” I know there’s a lot of people who are going to scream and be like, “Standard of care!” And we can talk about what that looks like in a second. “One view, what are you talking about?” And I get it, and there’s people who are going to have that reaction.
My initial reaction is, what’s this system here? How is this intentional versus just being like, “Let’s just snap this”? Help me get my head first around the system part of it. Is there some guidelines about when we do this? Is there any sort of laid out system or process for making these decisions? Help me understand.

Dr. Tannetje’ Crocker:
I think there’s a couple important points. One, we do know that burnout is contributed to by not being able to practice the way you want to. So that feeling of everyone who walks in the door, you have to charge them every single thing. Someone’s looking over your shoulder. You can’t practice medicine the way that makes you feel good. There’s not access to care. You’re constantly being questioned about the standard of care, and there’s no ability to work in the gray zone, work with owners as a team, work within their finances, and actually help the pet, and feel good at the end of the day.
So when you have that dynamic, we know that, even if you’re practicing the best medicine in the world, you are charging, you’re making a ton of money, we still sometimes don’t feel good about what we’ve done. So it’s saying, “Hey…” Especially for the team as a whole, think about your technicians that have to go tell somebody, “Hey, your dog needs this. It’s going to be this much money.” And then have to work through the owners. They have no money. Why are we not helping their pet? And that feeling.
So I think it puts a team at a disadvantage if it’s just, when someone walks in the door, you have to get this money before we touch the pet, before we do anything. I just don’t think that’s a great way to work overall. And so at our hospitals, VEG, we are allowed to practice and make those decisions as doctors with what feels good. Some of the doctors I work with discount weigh more than me. I am actually one of the lower discounting doctors in the practice, but I have really great, I guess, client feedback that they’re happy with what I’ve done. I don’t have those crazy interactions in the ER where people scream at me over finances and not helping their pets.
So it’s looking at it at a case by case basis, and knowing what is most important, and what does the owner need in that moment? What does the pet need in that moment? Maybe you’re not going to work the pet up for every single thing they have going on. Maybe they’re vomiting, and you are going to give subcut fluids and Cerenia with the understanding that that is not the best thing.
That you do not know exactly what you’re treating, but you’re trying to buy time for that pet, or you’re trying to see if it works or it doesn’t. And if it doesn’t work, they need to find finances and come back to get a full workup. But it is operating, I guess, autonomously, am I using the right word? And being able to make-

Dr. Andy Roark:
Yeah.

Dr. Tannetje’ Crocker:
… those decisions to be able to sleep better at night. So I don’t know that I answered your question just now, but I want to make sure that everyone understands that you have to work in a model and in a culture and in a hospital that is trusting of their doctors and their team overall. And there’s really not a set plan, right?

Dr. Andy Roark:
Yeah, okay.

Dr. Tannetje’ Crocker:
That it’s based off of those interactions one-on-one. Does that help at all?

Dr. Andy Roark:
It does. It does.

Dr. Tannetje’ Crocker:
And it’s being open about it. You’re open about it. You’re telling the clients. They know what you’re doing. You’re not [inaudible 00:19:00]-

Dr. Andy Roark:
I think that’s interesting. I think that’s what you’re talking about, it’s basically veterinary medicine that I’ve seen a million times, just being really open about what’s happening as opposed to, “Shh, don’t tell anybody.” It’s an interesting concept.

Dr. Tannetje’ Crocker:
You know how we say, drop that pet on the… All the time, and I’ve worked so many places, “Oh, look, the pet fell on the x-ray machine, and we took x-rays. Oh, look like…” Right? I mean that happens-

Dr. Andy Roark:
Yeah.

Dr. Tannetje’ Crocker:
… all the time. You’re like, “Well, let’s just do it.” But not really be open about it and not really charge for it. And I’m like, “No, be open about it. Say, ‘I’m going to take this x-ray for free. Let’s get some answers. Okay, guess what? Your pet has bicavitary effusion. We need to put them to sleep.'” But we got you an answer and you feel better about it. And what I suspected has been confirmed.

Dr. Andy Roark:
I cannot look at you in the face and tell you I have not stepped on the x-ray pedal and said, “Oops,” before.

Dr. Tannetje’ Crocker:
Yes.

Dr. Andy Roark:
Okay. Yeah, we’ll just… Real talk here.
Hey guys, I just want to hop in really quick and give a quick plug. The Uncharted Veterinary Conference is coming in April. Guys, I founded the Uncharted Veterinary Conference in 2017. It is a one-of-a-kind conference. It is all about business. It is about internal communications, working effectively inside your practice. If you’re a leader, that means you can be a medical director. It means you can be an associate vet who really wants to work well with your technicians. It means you can be a head technician, a head CSR, you can be practice owner, practice manager, multi-site manager, multi-site medical director. We work with a lot of those people.
This is all about building systems, setting expectations to work effectively with your people. Guys, Uncharted is a pure mentorship conference. That means that we come together and there is a lot of discussion. We create a significant percentage of the schedule, the agenda at the event, which means we’re going to talk about the things that you are interested in. It is always, as I said, business communication focused, but lots of freedom inside that to make sure that you get to talk about what you want to talk about.
We really prioritize people being able to have one-on-one conversations to pick people’s brains, to get advice from people who have wrestled with the problems that they are currently wrestled with. We make all that stuff happen. If you want to come to a conference where you do not sit and get lectured at, but you work on your own practice, your own challenges, your own growth and development, that’s what Uncharted is. Take a chance, give us a look, come and check it out. It is in April. I’ll put a link in the show notes for registration. Ask anybody who’s been, it’s something special. All right, let’s get back into this episode.
I think that’s really interesting, all right. And I think this is really, really interesting, and this is why I want to talk with you about it. When I look at where medicine’s going and rising standard of care, meaning, we get more and more advanced in what we can do and what the gold standard of care is, and significant increase in prices and that’s higher wages, which is good. This is the thing is I want people to make a living wage in vet medicine. I want them to be taken care of and I grip my teeth, and go, “Ugh.”
I talked to practice owners last week at the Uncharted Practice Owner Summit, and a number of them said pretty straightforward, “The average member of my staff could not afford to be a client in my practice, and that bothers me at a deep level.” And I thought that was very sort of vulnerable, candid conversation. But I see that as well and go, “Man, I don’t want to…” I think it’s hard to keep people motivated when they say I’m performing a service that I couldn’t afford to have, and telling everyone this is what they need to do and this is what it means to be a good pet owner.
And so I think that what you’re talking about, and we sort mentioned the standard of care before about doing the one lateral view, this is very much at the heart of what the spectrum of care conversation looks like in practice. There’s a lot of hand waving of, “Spectrum of care and what does it mean?” And this is what it actually looks like in the practice is going, “Yeah, I understand two views are better than one. I get it. I understand that they’re exponentially better than one. I get it. That’s not what we have the resources to do. And so we’re picking the better of not great options here.”
And so I think you’re really very much getting into functional standard of care or spectrum of care kind of work. And then integrating the finance part of that too is to go, “Well, there is spectrum of care, and then there’s also how do we make this affordable?” And there’s a lot of different ways to do that. I think it’s got to be a multimodal approach to keep care affordable, and to help pet owners out.
Talk to me a bit about what tracking this looks like. Because I want to believe that this is very much not the old school, the vet kind of does what they want and nobody tracks it. It’s like, “Oh yeah, I don’t know what he… We just give stuff away.” But I have to believe that the modern version of intentional discounting, if you go this way, it’s got to be built on tracking, so that we can see what we’re doing, so we can see what we’re giving away.
I think to me as I listen to this, I go, “That’s got to be what’s different, is by making it an open thing we talk about, we can at least track it, we can budget for it, we can understand it.” It’s not kind of old school vet clinic, where the books are a ledger in the back and they never balance it. It can’t be that. Help me understand the tracking, the measuring, the monitoring.

Dr. Tannetje’ Crocker:
I am going to put it on the bill, and I’m going to zero it out so the owner sees what the value is. When I add that discount in, it’s going to be under me. And so I can, with my medical director, look and see where I fell on the discount side of things, how much I discounted. But another component of that is your NPS. So people that rated you after their interactions with you, your net promoter score, what was that score?
So are you making clients happy? Are clients leaving and they are willing to recommend the practice to other people? Are they leaving good reviews? So there’s a lot of value in having clients be happy, in not having those really negative interactions in your practice that are traumatizing for all involved. So you’re balancing out those two things. You can’t look at it as just, how much did you discount?
I work hard enough and I make enough money that it’s okay if I discount a little bit. And I either get a client to do more for the pet, because I got them an answer or I get them to be happy and then recommend us and leave good reviews, and do things that are positive for the practice, then constantly having this caustic interaction with clients fighting over money.
I think it takes a little bit of a maturity. I see a lot of the younger vets that I train come in and they do, as soon as something gets a little uncomfortable with the client, they just want to give something away. And I’m like, “That is not it. That’s not it.” You’re finding something you can do. It’s a pain injection. It’s something that you can do, because you’re truly listening to the client. You’re listening to what the pet needs. They feel like you care, they trust you, you’re communicating what you’re doing, and that maybe it’s not everything you would like to do, but you’re trying to help.
And there is value in that that comes out that is almost immeasurable. But you can track things like net promoter score, and you can track things, how much you’re discounting, just to keep up with it.

Dr. Andy Roark:
Oh, talk to me more about net promoter score for veterinarian. That’s a term I’m very familiar with from the conference business, where we look at marketing and happy customers coming out of our events. But I haven’t heard that as a term that we track for veterinarians. So break that down for me a little bit, please.

Dr. Tannetje’ Crocker:
Every client that leaves your practice, leaves your hospital should get some sort of follow up. Now with the way things are electronically, you should be able to send a message, “Thank you so much for bring fluffy in,” whether it was for the vaccines. “We hope they’re doing well. If you get a chance, please fill out this survey about your visit.”
And what you’re looking to do is get people who actually reply to those surveys. You’re looking to see what was their visit. So if it’s one to 10, you ideally want only above sixes. People that are nine and tens and sometimes eights are willing to promote you. So they’re willing to talk about you outside of the practice, talk about their experience, and that is really valuable. People that are a little lower had a great experience, but they’re probably not going to tell people about it. And then anything under a six in general, you’re like, “Eh, we could have done a dramatically better job.”
But you’re looking to see what was their experience based on a lot of different categories, and where they kind of rank you. And you can do that and get enough data to see as a veterinarian, as a team, based on who they’re shouting out, how are we doing? How are we communicating? How are we interacting with people? And you should have a positive net promoter score. So you should have something that is higher. And I have a high net promoter score and I also discount.
And so I guess it’s not one or the other, but I think it is a good thing to sit down as a team and say, “How are we doing? What’s the perception of what we’re doing? How does the team feel about what we’re doing? How did the clients feel about what we’re doing? How does management feel?” It is an overall discussion. But when your culture is one where you can give step away for free, so that you can go home and sleep at night, it’s not something that’s hidden. It’s something that’s celebrated. We helped people. We helped their pets. And that’s just a different way of looking at things.

Dr. Andy Roark:
Are there guidelines on when you think the discounting is okay or things that are put forward? So I love that you say, “I discount because I see this as an opportunity. We’re making this difference.” And you also own the fact that there’s this natural tendency that when somebody gets upset at you, you can make them happy by giving them things.
And that’s very true. There’s so much nuance here. There’s so much nuance between. “We do not reduce our prices in any way, shape or form. They are what they are. And if you can’t pay them, then you need to go somewhere else.” And, “Just come on in. Just tell me, what do you feel comfortable paying? And that’s going to cost.”
There’s a lot of space between that. Lots of shades of gray here. Try to give me something tangible to put my feet on as I drift through this space, of this feels in bounds and this feels out of bounds. Are there guidelines something that I could communicate to someone else other than, “Let see how you feel”?

Dr. Tannetje’ Crocker:
SoI think I have some personal guidelines that I share with other veterinarians. There’s obviously a point, I don’t give away thousands of dollars of free stuff, but if there’s an emergency C-section and I’m worried that the pet’s life is in danger, the puppies’ life is in danger, and I know that I can skip some of those things that we can be considered standard of care.
Ideally, on a emergency c-section, you’re doing full blood work, full imaging, catheter, you’re doing all the things, you’re hospitalizing them for a while afterwards. There’s a lot. There’s some things that I can probably cut out of there, and make sure the patient is stable enough for surgery, but get the surgery done and help the pet and help those puppies. And I can discount it right down. I still need to charge a certain amount, but I can discount some things out.
And so it is looking at the case, but I’m not going to take a hit by car pet that has a completely shattered backend, pulmonary contusions, and the owner has no money for the follow-up care that this pet needs after their emergency visit. I’m not going to just give them $10,000 worth of hospitalization and management. So there needs to be the potential for a good outcome. There needs to be a pet that is not suffering, that if what you do and not maybe getting an answer, you’re not going to prolong suffering or make something worse for a pet. There needs to be the ability to communicate other resources.
So we have a lot of rescues and organizations we work with that we can direct people to, to get additional funding. And one of the biggest things that I try to teach young veterinarians is, if you give people time, people find money. So I have-

Dr. Andy Roark:
Yep, I agree with that.

Dr. Tannetje’ Crocker:
… a lot of owners that I will say, “Let’s do A, B and C. I will discount this, and take your pet home. If they continue to do what you came in for, come back. We need to do a full workup. We need to do more of a treatment, or we need to hospitalize. This is what that would look like.” And you would be surprised how many owners come back in 12 hours and say, “They started throwing up again, but I called Aunt Susan and I now have the money to hospitalize.”
So for me, I don’t do it on cases that the pet is suffering, that I know I can’t help them, I can’t save them. I don’t do it on cases where I think there’s something that I medically would cause an issue if I just made a guess. But I think after 14 years, I have a pretty good idea of what’s going on with a majority of pets. And so there is that innate understanding and ability to say, “I can do this. It’s not going to make it worse. And I am here if something changes and does get worse.”
It’s not a. “Let me do this, send you away, don’t ever come back here.” It’s a, “This is one step, but we might have more steps in the future.” And setting them up for that possibility and setting them up for the next thing. So it’s all about communication. I mean that’s really what it comes down to, right?

Dr. Andy Roark:
Yeah. Well, the part when you say, “If you give people time, they’ll find money,” that really tracks with what I’ve seen. How many times have I had a case in and treated it empirically, because that’s what we had the resources for and said to them, “This is not ideal. If the limping continues, if vomiting continues, if whatever, I will see you back tomorrow, and we’re going to need to do these other things.” And what I’ve found is that people tend to come back, if they need to. And when they come back, they have accepted what we’re going to do, and they’re generally much more prepared for it. And if you think about the cases that you see, I think most of us in the rooms will have that experience. That totally makes sense.
Talk to me a little bit about, “We still need to charge a certain amount,” is sort of what you said. And there’s things like hard costs. It’s one thing to say, “Well, I’m going to step on this x-ray pedal and make this digital image here to look at.” It’s another thing to say, “I’m going to go to surgery for two hours and spend a lot of anesthesia and pain medicines and tech time and things like that.” Those are just different things.
Does that come into your calculations at all? Walk me through any sort of guide rails, because you seem like you have them. Because you’re saying like, “Oh, we can do something here, but we can’t do everything here.” And do you have any sort of thoughts like that come in as far as how much you’re doing?

Dr. Tannetje’ Crocker:
Yeah, so in the ER there’s some really simple, like a blocked cat, a GDB, a hemo abdomen that needs a splenectomy, a mesenteric torsion. Those are just some things I saw the last couple days. I need to have very frank conversations with those owners about what that pet needs, what possible outcomes are, and financially, what it could look like. And I need a deposit and I need a substantial deposit for those. I am not taking those pets to surgery until there is a very clear understanding of what is going on with these pets.
And so there is no rushing into surgery if the owners have just no finances, because you don’t know the outcomes and you don’t know how long those pets might need to be hospitalized. And there’s too many uncertainties. And it’s not fair to this pet to not be able to do everything you need to for them. But if you have a golden doodle that looks great, that threw up three times, and maybe ate something, but maybe didn’t, and palpates normal and is happy and healthy. And you have a conversation, the owner says, “It’s Christmastime. I just got a lot of presents. I just really can’t afford to do all the x-rays and all the things.”
In those moments, I either say, “I really am worried about something significant,” so maybe I do an x-ray real quick for free, and I can take two views and no charge it. It’s not going to break the bank but I’m going to have them pay for subcut fluids and Cerenia and the emergency fee if everything looks okay on x-ray. And so it doesn’t mean it’s all or nothing, with a lot of these cases. I have a lot of owners that say, “I have $200.” Okay, I’m going to work within that $200, do what I can. But if they also need Clavamox to go home or an antibiotic, I will do the antibiotic, maybe, for free.
And so I think the thing that we have a hard time with as veterinarians, it’s like everything has to be black and white or there has to be rules. And unfortunately, this is a very innate thing. It’s kind of doing it a couple times and communicating and realizing what does and doesn’t make sense. Making sure you’re very clear about what you’re doing and the value of it. But I think the big picture you have to have is why are you doing it? How does it help the team? How does it help the pet?
And when you look at it that way versus what are all the possible negatives from it? Or what makes it hard or tricky? It gets easier and easier on a case by case basis. But it is hard for me to say, “This is it. These are the rules. And if you do this, it’ll work for you.” Because it’s very dependent on the practice and it’s very dependent on the communication, and it is a case by case basis. But I think being transparent about discounting has a lot of value in veterinary medicine, when done the right way.

Dr. Andy Roark:
This has been great. I have a lot to sit with here. I like your point on transparency. I do think that this is really where the rubber meets the road on spectrum of care, in a lot of ways. I mean, I think that are talking openly about things that have gone on, and it’s just sort of the built-in cost of doing business in the profession. I think you’re hitting on all these sorts of things. I’m going to sit with this a little while. So this has been outstanding. You are doing this presentation at Western Vet Conference in Las Vegas in February, I believe.

Dr. Tannetje’ Crocker:
Yes.

Dr. Andy Roark:
It’s February, right?

Dr. Tannetje’ Crocker:
And we’re going to do it on a, I’m going to try to do a case-based one, where we can actually say, “Let’s talk about these cases. Let’s look at this case. Why would we discount? How did we discount? How did it play out?” To give people like a little bit more of a tangible experience around it.

Dr. Andy Roark:
That sounds great. And then where can people find you online, Tannetje’?

Dr. Tannetje’ Crocker:
I am on all the social media platforms, Facebook, Instagram, TikTok, dr.tannetje.crocker. I do have a website, drcrockerpetvet.com. So if you need somebody for a speaking engagement, if you just want to connect, I love networking and hearing about things going on in veterinary medicine. And I absolutely love this profession and could talk about these things all day. So thank you so much for having me on, Andy.

Dr. Andy Roark:
Oh, absolutely. I’ll put links to your socials down in the show notes. Guys, thanks for being here. Take care of yourselves.
And that is it, guys. That’s the episode. I hope you enjoyed it. I hope you got something out of it. I hope you got a good amount to think about. If you did, as always, the kindest thing you can do is share with your friends. Spread the word, spread the joy. Help people know about what we do in the podcast. Write me an honest review wherever you get your podcasts. All that stuff is super helpful. Gang, thanks for being here. Take care of yourselves. I’ll talk to you later on.

Filed Under: Podcast Tagged With: Medicine

Anesthesia Crash Cart Crash Course

January 12, 2023 by Andy Roark DVM MS

The original Anesthesia Nerd, Tasha McNerney, is back on the podcast! In this pearl-packed episode, Tasha runs through her anesthesia crash cart and breaks down what she has ready to go and why. This is an excellent refresher for anyone who wants to cement their emergency anesthesia drugs into memory.

Cone Of Shame Veterinary Podcast · COS – 180 – Anesthesia Crash Cart Crash Course

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

LINKS

Veterinary Anesthesia Nerds: https://www.veterinaryanesthesianerds.com/

Recover Initiative Drug Chart: https://acvecc-recover.org/

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

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Tasha McNerney obtained her CVT in 2005 and has worked clinically in the areas of anesthesia and surgery ever since. Tasha obtained her CVPP (certified veterinary pain practitioner) designation in 2013 and became a veterinary technician specialist in anesthesia in 2015.

Tasha has been a featured speaker on various anesthesia and pain management topics at several international veterinary conferences. Tasha is the author of many articles and blogs on anesthesia and pain management related topics.

In 2013 Tasha created the Facebook group Veterinary Anesthesia Nerds, which has over 65,000 members taking part in education and exchange of ideas from all over the world!

Tasha is crazy and bought a 1920’s fixer upper and is now obsessed with home improvement tutorials on YouTube. She lives in Philadelphia with her husband, son, one perfect cat, and one jerk cat. Trust me that cat is a jerk.


EPISODE TRANSCRIPT

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

Dr. Andy Roark:
Welcome everybody to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am here with my dear friend, Tasha McNerney. We are running through the crash cart. This is such a great episode. This is the most stripped down, practical, just refresher on Anesthesia crash carts, that I’ve ever seen.
Honestly, I say at one point in this episode, I wish that they’d broken this down like this for me in vet school, because this is a beautiful thing. If you’re a student, a tech student, a vet student, just bookmark this one, because this is great. If you are like me, been a while since I ran through the crash cart and really was, I know exactly what this does and why it does it and how it does it and how much I use. Man, this is a great episode for you. So, quick to the point, Tasha’s amazing. 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, Tasha McNerney, how are you?

Tasha McNerney:
I’m good. How are you?

Dr. Andy Roark:
I am so good. It is so good to see your face again. You are one of my favorite people. You and me go way back, way back.

Tasha McNerney:
Way back.

Dr. Andy Roark:
You were here visiting my house when the pandemic hit and I’ll never forget-

Tasha McNerney:
Yes.

Dr. Andy Roark:
You and I started the pandemic together.

Tasha McNerney:
Yes. I have great memories of visiting four different stores, looking for canned goods and then finally buying all the beans at a CVS in some random South Carolina town.

Dr. Andy Roark:
I still have those beans, a 100%. I’m, these are my survival beans. My wife’s [inaudible 00:01:48].

Tasha McNerney:
Yeah, well just save them.

Dr. Andy Roark:
She was, we’ll never eat these. And I’m, look, as long as they’re there, I’ll sleep well at night, but as soon as you throw away my emergency beans, I’m going to be, what are we going to do if society ends?

Tasha McNerney:
Yeah. It was a good time.

Dr. Andy Roark:
When the world went sideways, you and I took action. That’s all I’m going to say. And most people-

Tasha McNerney:
Oh, 100%.

Dr. Andy Roark:
Did not, but we did.

Tasha McNerney:
No. People were, is this happening? And we both looked at each other and were, oh, we’d better stock up this pantry. Even though it wasn’t my pantry. I was, I’ll help you stock up this pantry.

Dr. Andy Roark:
Oh, you were with me.

Tasha McNerney:
I had gotten a call from my husband at home saying everything is off the shelves. It’s pandemonium here. And at that same CVS I bought two boxes of pasta and took them back in my luggage with me, because I was so worried that I wouldn’t be able to find pasta when I went home.

Dr. Andy Roark:
Yeah.

Tasha McNerney:
Yeah.

Dr. Andy Roark:
Oh man. It’s great to be with an anesthesia specialist because when the world goes haywire, they take action. And I felt that was instinctual for you.

Tasha McNerney:
Oh, 100%. I always joke with the anesthesia, is that we are very cool, calm and collected. When everything is crashing in the ER or in the OR, or wherever we are, it’s very much, okay, here’s the problem, where do we go next? All right. And we start this checklist. It’s very much cool, calm, and collected in anesthesia.
And the joke is that we’re dead on the inside. And sometimes I would agree with that, in that we’re not going to be the people freaking out, oh my God, everything is crashing, go get this for me. Really? You know that actually with me, you know that things are real bad if I get very calm and monotone. And if I say, okay, what I need you to do next is turn off that vaporizer and can you hand me the epinephrine? Okay. Things are going down. Things are going down.

Dr. Andy Roark:
Yeah. Oh, man. Oh yeah. You are a bit dead on the inside though. That’s just [inaudible 00:03:55], different.

Tasha McNerney:
A little bit. And that’s fine. Yeah. And you know what? Listen, I got a therapist, we’re working on it. We’re good.

Dr. Andy Roark:
I think a lot of people could stand to be more dead on the inside. I think it would probably be… We all know of people who should be a little bit less alive inside. It would help them.

Tasha McNerney:
Just calm down.

Dr. Andy Roark:
Totally. All right. For those who don’t know you, you are a veterinary technician, specialist in anesthesia. You are the founder of the Veterinary Anesthesia Nerds Group. It’s a Facebook group, it’s a website, it’s conference. This thing has grown to… How many people are involved, engaged with the Anesthesia Nerds Group now?

Tasha McNerney:
We have about 65,000 members around the world right now.

Dr. Andy Roark:
Yeah, it’s awesome. It is super awesome. It’s super bonkers. And I could sit here and sing the praises of the anesthesia nerds. I’m all about practical education. I really like to learn stuff, that I’m, I’m actually going to use this. And that is what you guys are all about. So I really love it.
I’m super glad that you’re here. I thought of you recently when I was… I had a pet under anesthesia and I can’t remember why, it was an emergency of some sort. And I had this pet under anesthesia and it just dipped there for a second. So when you pause for a second and you’re, is this going to be an issue? And then it stabilized and then comes back out.
And I thought I could use a refresher on the crash cart. That’s exactly what I took away from that specific instance, was it was an emergency that came in. I can’t remember what it was. It went under anesthesia to get fixed. And I thought, eh, you know what? Let’s just freshen these skills back up.
And so I wanted to get you in and just say, run through the crash cart with me real quick. Let’s do a 100% refresher on what’s in my crash cart, what’s it do, what do I need to know about it? And just make me feel the dust has been blown off my crashing patient knowledge. Is that okay?

Tasha McNerney:
Oh, yeah. Let’s do it. Ooh, there’s probably a lot to cover, but we’ll maybe put it into categories when you’re looking at your crash cart. And again, I just want everybody to know that I’m talking about this in the context of an anesthetic crash cart, not necessarily your ER crash cart, which is probably going to be a little bit different.
But when we look at our anesthetic crash cart or what we want to have in that top drawer of our anesthesia machine or on hand during any anesthetic event, that’s what I’m going to talk about here. If that’s cool with you?

Dr. Andy Roark:
Yeah.

Tasha McNerney:
All right. So first of all, in an emergency, again, when I say to you, hey, things are not looking good, can you turn off that vaporizer? And then one of the first things that I want you to do is pull out, are real emergency drugs. And when I say emergency drugs, with anesthesia in mind, when I’m talking about are emergency things like atropine and epi and then our anesthetic reversals.
So these are really the two big things in our crash cart. We know that we want to have atropine or anticholinergic that we will use in emergencies because it has a very fast onset, shorter duration of action than glycopyrrolate. But again, in an emergency, we want that fast onset, all right?

Dr. Andy Roark:
Mm-hmm.

Tasha McNerney:
Now there’s some stuff, and I will let you guys listening at home do some research, because I think this is very, very interesting. Looking at the newer research that has come out in the past couple of years, especially starting in human medicine, asking, is there really any benefit to using atropine during a code or a CPR event? And the human medicine, human literature has actually found that there isn’t, and they actually don’t really use atropine anymore during emergencies.
And if you look at the newest recover guidelines, they actually state that atropine is not necessarily beneficial, but they don’t know if it’s really going to do any harm either. So if you feel you still want to keep that in your back pocket, you’re probably not doing any harm. But it’s a little different than we thought 10 years ago, that we don’t necessarily know that it’s really doing a lot during our CPR events or our code events. But I still will get it out. And I will say that my anesthesiologist will still have us give it during an emergency.
Our next is epinephrine, and that’s because we want that vasoconstriction. We want to make sure that our blood pressure stays tight. We want to make sure that we are delivering oxygen to the tissues to where it needs to go. So again, our emergency drugs.
Then we need to get rid of whatever anesthetic… Again, if this is a true anesthetic emergency, we want to make sure that we have reversals in our crash cart to reverse every single drug that can be reversed. Now, most of the time with anesthesia, we are administering opioids. So that means that we need naloxone first and foremost in our crash cart. So if we have an opioid on board, we want to make sure that we reverse that opioid with naloxone.
Second, most common drug class that’s used are benzodiazepines, things like Midazolam or things like Valium. And we have a reversal for those. And a lot of clinics don’t even carry the reversal. But I would say if you’re utilizing things like Midazolam or Valium in your clinic, you need to carry the reversal, just in case things get crazy. And the reversal for those, is a drug called flumazenil. It’s a little more expensive than naloxone.
And again, a lot of people don’t keep it regularly on their shelves. But I would say that if you have an emergency, you want to have at least one bottle of flumazenil or at least one in your OR if you have an anesthetic emergency. The next reversal agent that is very important would be Antisedan or atipamezole. So this is going to reverse your dexmedetomidine, or if you’re in a practice that is still using xylazine, you would want your reversal to be yohimbine, although you could use in atipamezole as well, working on those receptors.
So you want to have Antisedan for your dexmedetomidine, right? So if we came into an urgent situation, we want to make sure we have access to atropine and epi and the reversals for all of our drugs. Now, if you’re utilizing ketamine in your protocol, we don’t have a reversal agent for ketamine. So just realize that if you know things get crazy and you start reversing everything, that ketamine is still going to be on board. We don’t necessarily have a reversal for that.
Now, this is just for an emergency. I will say that there are a couple other drugs that I do think of as always having in my crash cart. One, maybe for some anti-arrhythmogenic effects. And then one for if we start to see maybe some irritation or something like that under anesthesia. And one of these is lidocaine, and the other one is diphenhydramine.

Dr. Andy Roark:
Okay.

Tasha McNerney:
I like to keep these on board, especially with our patients that are not hemodynamically stable, certain breeds. If we see a ventricular tachycardia under anesthesia, so again, this is a ventricular tachycardia. And when I say that, I mean a beat that is greater than 160 beats per minute.
So if we see something like this, again, that is going to be not great for forward movement of blood and cardiac output, which delivers oxygen. So we always want to make sure we have lidocaine available as well. Especially in these more critical patients, you might need to give a two mg per kg lidocaine bolus if you see that your patient is in V tach.
Now again, the reason I mentioned the rate is because sometimes I’ve gone into clinics where they’ll see what they describe as a slow V tach or a ventricular escape beat, where they’ll see it, but maybe the rate is still only around a 100 beats per minute or 110 beats per minute. We don’t treat those with lidocaine. That could actually make it worse. So lidocaine is for those ventricular tachycardic emergencies.
And then diphenhydramine, I usually like to have it on board because sometimes my surgeons will note, hey, I see that this patient has had a reaction to either… Maybe they have severe clipper burn or they’ve had a reaction to the chlorhexidine that’s been used to scrub their skin and now they have hives. So if we see something like that, we want to make sure that we can administer some diphenhydramine to them.

Dr. Andy Roark:
Okay, that makes sense.

Tasha McNerney:
Those are some emergency drugs. And so of what I like to have on my anesthesia crash cart. Now, these are adjunct drugs that I’ll talk about really quickly. And this is more blood pressure drugs.

Dr. Andy Roark:
Okay.

Tasha McNerney:
Because we know that inhaling anesthesia, along with a lot of the drugs that we are going to administer, like acepromazine, like propofol, like alfaxalone, these drugs are going to cause a decrease in cardiac output and vasodilation, which is going to lower our blood pressure. We know that hypertension’s going to happen, we want to be ready for it.
Now, most of the time you have a normal healthy hemodynamically stable animal. Something like lowering your vaporizer setting or administering a fluid bolus as a five mil per kg, is going to get you where you need to go for some animals. But for other animals, especially if you have a longer procedure in mind, we want to make sure that we’re not just letting that blood pressure and that mean arterial pressure dip consistently below 60, because then we know that oxygen delivery to really important tissues is going to be compromised.
And that’s why I always like to have some blood pressure drugs ready and available. Now, I’m not saying that every clinic has to have all of these blood pressure drugs, but the three that I keep on me at all times are going to be dopamine, dobutamine, and ephedrine. And dopamine is a mixed alpha and beta, and that’s why I really like it. If you have a patient, a cat that’s under anesthesia for dentistry, and we know that we’re going to do 12 extractions, it’s going to be a long procedure, but their blood pressure is already not doing so great, and they are also an elevated kidney value patient, and I want to make sure that they don’t get too hypotensive, then I’m going to start dopamine on this patient.
Again, we’re going to have alpha effects and we’re going to have beta effects, which means the beta is going to help to increase the heart rate in the contractility. And the alpha is going to give you a little bit of a squeeze on those vessels. Similar to another alpha active drug, dexmedetomidine.
Now dobutamine, and the reason I like to have dobutamine around is because for some animals, like your mitral valve disease patients, like your chronic heart failure patients, these little Shih Tzus that come in and they have heart disease. These guys, if we’re about to do a long procedure on them and they get hypotensive, they’re going to do better with dobutamine. And that’s because dobutamine primarily exit beta receptors. These little dogs sometimes can’t handle, with the heart disease can’t handle the vasoconstriction that comes along with alpha activation and dopamine. So we will go with dobutamine for these guys, because it’s having a party at the beta receptor. It’s all beta all the time. And that’s why I want to have dobutamine for those specific heart cases.
And then I also like to have ephedrine. And ephedrine is one of those because it is very cost-effective. It’s very versatile. You can give ephedrine as a one-off and it’ll last for about 30 minutes. So I find ephedrine very helpful. It’s an alpha and beta, very similar to dopamine. But unlike having to set up a concentrate infusion like you do with dopamine, you can give a one-off of ephedrine. Now you have to dilute it out. So make sure if you’re getting a vial of ephedrine, you are diluting this out. So you have maybe a one mg per mil concentration.
But then you could give a dose of it. And sometimes if I say to my clinician, well, I’m already tried the vaporizer, I’ve maybe tried giving… I don’t think the heart rate is an issue, and you’re telling me we still have 30 to 40 minutes left of this dentistry, but I need to do something about the blood pressure. If I don’t have access to dopamine, or I don’t want to take the time to set up a CRI. I can maybe just do a one-off of ephedrine.
And that’s really effective because again, ephedrine like dopamine effective at the alpha and beta receptors, and we get about 30 minutes of activity. So that’s what I keep in my back pocket, if I just need a quick something, and I don’t want to set up or I don’t have access to set up, a syringe pump and an infusion, et cetera.
And then some other things, just like equipment that I like to keep with me at all times is an extra endotracheal tube, an extra laryngoscope. And if you are at a practice that has access to it, certainly paddles for fibrillation. Now, again, remember if we are going to use paddles, this has to be a rhythm that’s a shockable rhythm. We’re not going to shock V tach.

Dr. Andy Roark:
Yeah.

Tasha McNerney:
But if you see it’s really critical, things go south and crazy and your patient is in V-fib, then we can shock that rhythm. But I will also tell you that I’ve worked in plenty of places that don’t have access to paddles and they’ve done okay with that.

Dr. Andy Roark:
Yeah.

Tasha McNerney:
Okay. But this is just equipment. And the reason I’ll go back to the laryngoscope and the tube really quick, is on the off chance your patient during movement from induction into the theater gets extubated, during the off chance that moving the patient around on the table, they get accidentally extubated. I want to make sure that I can quickly re-intubate that patient.
And again, a laryngoscope is going to be the best way to do that because it’s going to give me visualization of where I’m going with the tube, if there are any problems, et cetera. I want to be ready for those problems. And that becomes, especially, especially important, if you’re dealing with brachycephalic patients. Always have an extra tube and laryngoscope ready to go.

Dr. Andy Roark:
Yeah, that totally makes sense. This is amazing. I did not have this as clearly broken down for me in vet school as you just did. This would’ve been so helpful, 15, 20 years ago. This is amazing.

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

Dr. Andy Roark:
All right, wonderful. Talk to me about some dosages. So are there dosage calculators that you really like? Because there you are and you’re doing the procedure and this is a stressful time and things start to go off the rails. What do you do to keep those things top of mind for you in a useful way where you say, okay, this is what we need? It’s not just epinephrine to effect, although that works.
But how do you track that information? How do you keep that in a very handy format? Because you just know it, you’re just… I know you know it, but is that the best way to approach this?

Tasha McNerney:
It’s probably not the best way to approach it, because again, unless you’re really dead on the inside and you can block everything out and just go to your Rolodex of drug dosages, nevermind that thing’s beeping and people yelling. Again, I can do it, but I think that’s just because, I don’t know, my brain functions a little bit differently.

Dr. Andy Roark:
I’ve had people say, how much? And I show them with my fingers like this much, and they’re, that’s not scientific.

Tasha McNerney:
That’s not a… Nope. Don’t do that, you guys at home.

Dr. Andy Roark:
Yeah, don’t.

Tasha McNerney:
But certainly I would say for anybody who is interested, look at the VECCS website. They have a lot of really great things. Look at the RECOVER Initiative, that’s going to give you a really nice dosing chart. And I do know that if you go to RECOVER and look at the RECOVER Initiative and their website, they also have posters that a lot of clinics will use, that give you the dosages of, based on weight. They have a quick weight chart.
So a lot of ERs and emergencies will have this just hanging in their practice where they have a really nice weight chart that’s busted down between atropine, epinephrine, reversal drugs, things like… Again, if you’re in an ER setting and things get really crazy, you want to bust out the vasopressin, things like that.
So I really would recommend RECOVER because that’s probably the most up-to-date guidelines as far as what the research is saying, new updated dosages and having it easy and accessible. Another thing that I do recommend that every practice does is take those dosages and make an Excel spreadsheet or an emergency drug calculator, print that out based on the patient’s current weight and have that ready to go.
The time to print it out and put it into the Excel spreadsheet is not when everybody’s screaming and the dog’s losing a lot of blood. We want to make sure that we do that beforehand. And again, because it’s a really stressful time, it’s nice to have this printed out and checked beforehand. Because again, when things are really crazy and you’re really stressed out and your clinician says to you, okay, I need you to give a certain mg per kg dose, and then your brain is, wait, how much does this patient weigh? What’s the concentration? And you’re trying to do this quick math, doesn’t usually work out well. And those precious seconds that you’re taking to calculate out this drug can make a huge difference.

Dr. Andy Roark:
Yeah, that’s fantastic. I’ll put a link to the RECOVER Initiative drug doses in the show notes, so people can check that out. I don’t think I need a link to Microsoft Excel, but…

Tasha McNerney:
No. I usually say… Because people can make their own Excel, again based on what they have in their clinic. Because I don’t think that every clinic maybe has vasopressin ready to go for their solutions.

Dr. Andy Roark:
Yeah. No. I love that. I think that makes a ton of sense. What are the most common pitfalls that you see? And what are the things that people are either putting together on a crash cart or using what’s on their crash?

Tasha McNerney:
I think that most common pitfalls, at least from an anesthetic perspective that I see, is that there’s not a regular checking of the crash cart and whether or not the drugs are expired or whether or not we have enough volume of the drug ready to go.

Dr. Andy Roark:
Yeah.

Tasha McNerney:
So for instance, [inaudible 00:22:36] I would give you… Yeah, to actually do what we need to do. Yes, I may have a bottle of atropine in there, but if there’s only 0.4 mls, that might not get me where I need to go.
So having somebody check that before the procedure. And I’m a huge fan of checklists. You guys know me, I love checklists. I love anesthesia checklists. If you haven’t read the checklist manifesto, please do yourself a favor and read this. It’ll change the way you practice.
But certainly having checklist in anesthesia and having somebody to go in before the anesthetic event even happens, check that anesthesia machine, check that cart, make sure the lidocaine is in date. Make sure that you have a bottle of glycopyrrolate ready and available. Make sure that if you’re going to use dopamine, again, you have enough volume to make up your CRI. I’ll just give you an example. I was doing, I was helping out anesthesia on a 62 kg-

Dr. Andy Roark:
Wow.

Tasha McNerney:
Great Dane.

Dr. Andy Roark:
Yeah, it’s 140 pound Great Dane.

Tasha McNerney:
Great Dane.

Dr. Andy Roark:
Holy crap.

Tasha McNerney:
In for a CT procedure. And I went to look at the crash cart in our anesthesia machine in CT, and I’m looking at it and I was, we only have one ML of atropine in this bottle. So, I have atropine and it’s in date, but again…

Dr. Andy Roark:
That’s not going to make one side of his mouth [inaudible 00:23:53].

Tasha McNerney:
If something goes crazy with this patient, now I have to run to a whole other side of the hospital to get more atropine because that one ML is not going to be enough for that Dane.

Dr. Andy Roark:
Yeah. Yeah, that totally makes sense. Awesome. Tasha McNerney, thank you so much for being here. Where can people find you online? Where can they learn more about Anesthesia Nerds?

Tasha McNerney:
Yeah, so the Veterinarian Anesthesia Nerds is currently a Facebook group, and that’s where we do a lot of our discussion and case-based stuff. But you can also find us on the website, veterinaryanesthesianerds.com. And on the website we have links to the Veterinary Anesthesia Nerds podcast, as well as a calendar of events.
So you can see where all of us are speaking. And when I say all of us, I don’t just run Anesthesia Nerds by myself. I am joined by Darci Palmer, who’s a VTS in anesthesia, and she works out in Alabama. And then I’m also joined by Steven Satal, who is a VTS, not only a VTS in lab animal, but also a surgical research anesthetist and just a wealth of information there.
So we have a calendar, so you can see if you wanted to come hear us talk or lecture. We have a calendar on there as well. And then we have a contact form as well. So if you have something that you wanted to ask the Anesthesia Nerds or you wanted to request some help for something, you can get us there.

Dr. Andy Roark:
That sounds fantastic. Awesome. Thank you so much for being here. Guys, thanks for tuning in. Take care of yourselves. Have a wonderful rest of your week.

Tasha McNerney:
Thanks for having me.

Dr. Andy Roark:
And guys, that’s what I got for you. I hope you enjoyed it. Hope you got something out of you it. Thanks again, Tasha, for being here. Guys, if you liked it, if you enjoyed this episode, tell your friends, share this thing, because really, this is great information.
Always, always feel free to write us an honest review, wherever you get your podcast. That means a lot. Gang, I will talk to you later on. Be well.

Filed Under: Podcast Tagged With: Medicine

Evidence-Based Medicine, Access to Care and Pet-Family Centered Communication

January 9, 2023 by Andy Roark DVM MS

As the gold standard of care (and price of medicine) go higher and higher, is it time to get serious about formalizing a spectrum of care approach? Dr. Emily M. Tincher, Senior Director of Veterinary Relations at Nationwide Pet Insurance, joins the podcast to talk about combining evidence-based medicine and advanced client communication strategies to protect and improve accessibility and affordability of veterinary care.

Cone Of Shame Veterinary Podcast · COS – 179 – Evidence-Based Medicine, Access to Care and Pet-Family Centered Communication

This episode of the Cone of Shame is made possible ad-free by Nationwide Pet Insurance!

LINKS

Nationwide Spectrum of Care Page: www.spectrum-of-care.com

Nationwide Veterinary Analytics: https://www.petinsurance.com/veterinarians/research/

JAVMA spectrum of care publications:
https://avmajournals.avma.org/view/journals/javma/259/7/javma.259.7.712.xml

Preparing Veterinary Students… Spectrum of Care: https://avmajournals.avma.org/view/journals/javma/259/5/javma.259.5.463.xml

Vetsuccess Industry Tracker: https://vetsuccess.com/resources/veterinary-industry-tracker/

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Emily M. Tincher is a collaborative and data-driven leader who advocates for a pet-parent centered approach to communication and medicine through spectrum of care approaches. She is a second-generation veterinarian and a 2016 Auburn University’s College of Veterinary Medicine graduate. Emily has practiced clinically in small animal emergency and general practice.

As the Senior Director of Veterinary Relations at Nationwide Pet, she oversees operations and strategy in the veterinary space, including industry relationships and outreach to veterinary students, veterinarians, and veterinary teams. Emily serves on the AVMA Early Career Development Committee and is President of the Board of Directors for the Veterinary Leadership Institute.

Outside of veterinary medicine, Emily enjoys traveling with her husband Kyle, competing with her horse (Blue) in the sport of Eventing, and endlessly spoiling her two perfect dogs (Tuxedo and Cricket) and rotten orange tabby (Exploding Poptart).


EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome, everybody, to the Cone Of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. I’m here with my good friend, Dr. Emily Tincher. She is talking with me about Spectrum of Care. She talks a lot about Spectrum of Care. I ask her hard questions about what does Spectrum of Care look like? How is it different from we’ve done in the past? How do we balance making care accessible with advocating for what’s best for pets?
Those things can be challenging when we want to make sure care is affordable. And at the same time, we want to make sure we’re still pushing to do the most good that we can do in the world for the pets. And it’s just, I don’t know, it’s really interesting conversation. Guys, I enjoyed the heck out of this. I hope you’ll enjoy it too. This episode is made possible ad free by our friends at Nationwide Pet Insurance. Gang, let’s get into this episode.

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

Dr. Andy Roark:
Welcome to the podcast, Dr. Emily Tincher. Thanks for being here.

Dr. Emily M. Tincher:
Thank you so much for having me.

Dr. Andy Roark:
It’s my pleasure. Is this your first time on the podcast? I think it is.

Dr. Emily M. Tincher:
It is my first time on the podcast, yes.

Dr. Andy Roark:
That’s amazing to me. You’re a good friend of mine and have been for a long time. I think the world of you and I have known you for years and years. We met way back in the day. I think I had graduated from vet school and you were a vet student. I may be just being very generous to myself in my age.
But we met through the VBMA, which is the student business group. And then, I’ve stayed involved in that as a national advisor for years. And you have stayed involved in well. For those who don’t know, you are the senior director of vet relations at Nationwide Pet Insurance. You are doing a bunch of stuff. Got your hands all over these white papers that have been coming out from Nationwide. They’ve got, just a variety of topics.
It’s different cancer rates according to dog breeds. There’s some senior pet stuff that’s come out. You guys have some new stuff coming out. I think about brachycephalic pets pretty soon. And you’ve just got all this research stuff coming now. And then you are lecturing all over the place on Spectrum of Care, which is an interest of mine and we’ve talked a lot about that. And so yeah, that’s what I wanted to talk to you about today. But it’s surprising to me that I haven’t had you on the podcast before. That’s an oversight on my part. How’s it been?

Dr. Emily M. Tincher:
Well, I’m just so excited to be here now. I know we’ve been grateful to just like a bad penny I guess. I keep showing up. From starting as a vet student at Auburn, came in and lectured to our VBMA. And then yeah, we were involved when I was on the national VBMA board and was an advisor with you before I step back now as a founding and platinum sponsor of the VBMA that Nationwide is. And so, get to remain involved just in a different way now building curriculum part.

Dr. Andy Roark:
Oh, yeah. I forgot you were at Auburn.

Dr. Emily M. Tincher:
[inaudible 00:03:19] at Auburn [inaudible 00:03:20].

Dr. Andy Roark:
I forgot you were at Auburn. You get to do really cool stuff. Yeah, you still go to the vet schools. You guys have some student development programs going on. You get some programs through the vb, a brown Spectrum of Care. You’re getting to do cool stuff, Emily.

Dr. Emily M. Tincher:
We do cool.

Dr. Andy Roark:
That’s super awesome.

Dr. Emily M. Tincher:
We spoke at every vet school this year about Spectrum of Care between the spring semester and the fall, which was a lot of fun to get their feedback. And hear the students’ interest in just trying to find ways to meet pet families where they are. And asking questions about how does evidence-based medicine fit in and how do we navigate all the challenges with providing the care that we recommend. Oh, it’s just been, it’s really cool. I’m excited to get into it with you.

Dr. Andy Roark:
All right. Let’s start to talk about Spectrum of Care in general. Just go ahead in your own words, define the term Spectrum of Care for me. And that just to get us on the same page of this general topic.

Dr. Emily M. Tincher:
Yeah. We did not come up with this definition for the record of Spectrum of Care at Nationwide. We used a published definition that came from a couple of JAVMA publications, that Spectrum of Care is providing a range of diagnostic and treatment options for pet families across basic to advance that meet their needs and their goals with relation to their values and their resources. Of course, including finances being one of the main ones. But that acknowledging that there are many different ways to treat everything from wellness to most conditions that we see in practice.

Dr. Andy Roark:
Okay. Talk to me a bit about how you see Spectrum of Care as a rising topic and trend in vet medicine. What is the integration of Spectrum of Care look like compared to what vet medicine has looked like in the past? A lot of times we talk about Spectrum of Care and a lot of people like, “That’s what we’ve always done.” Help me get my head around how this vision of the future with Spectrum of Care looks different from what we’ve historically done.

Dr. Emily M. Tincher:
In many ways it doesn’t necessarily look different from Vet Med of many years past. I’m a second generation veterinarian. My parents are both vets and I grew up in their rural practice that they owned in Kentucky. And watching them practice across all the range of socioeconomic statuses of the pet families that they served, I really saw that you can do a lot with a little. And you can also offer people the opportunity to refer or to have advanced level care if that’s what they’re seeking and have the resources to support.
What I think is really important and a critical component of offering a Spectrum of Care is making sure that we integrate the evidence-based medicine that’s available, knowing there’s not as much as we would like in veterinary medicine with pet family centered communication. And so, we could talk a little bit about some exciting research that we completed this year at Nationwide in partnership with my genomics advisors that work towards communicating in a pet family centered way.
I think there are many people that are practicing a Spectrum of Care right now. What I think is often not discussed is how to do that as a vet student and a new graduate. When I watched my parents growing up, they practiced the Spectrum of Care. They just, they maybe didn’t have a term to call it that, but they practiced the Spectrum of Care.

Dr. Andy Roark:
They didn’t have a marketing slogan for it. Yeah.

Dr. Emily M. Tincher:
Right. It’s helpful though to have a term and to have definitions that we can all get behind and work towards. I think the pendulum is swung with academia to where, for quite some time, we were focused on excitingly and fairly the increased specialization. And it took I think a little bit of time for our profession to notice that there were some challenges associated with the awesome education that specialists can provide.
And we need them very much. But sometimes there is a little bit of an oversight or a lot of an oversight on but what does it look like when people can’t or don’t want to pursue the most advanced level of care? Especially as we have new diagnostics, we have new drugs that are awesome, allow us to do more than we ever have in the past.

Dr. Andy Roark:
Sure.

Dr. Emily M. Tincher:
They also cost more. And that’s not necessarily veterinary medicine. I think one of the greatest challenges that we see is that veterinary medicine, the advanced level of care getting more expensive. And if we can only think that you deserve to own a pet if you provide that advanced level of care that pets are a luxury, we’re in trouble.
Not only is it unrealistic, but pet families are not considering what their vet thinks before they go get a pet. We want to serve the diverse population of pet families that are out there that do have over 50 million owned US cats and dogs. Then we are going to have to meet them where they’re at a little bit with what their goals are and what their needs are.

Dr. Andy Roark:
Yeah, okay. That’s a lot to unpack and I like it. First of all, let me say, I think you really put your finger on how I feel about this. Because I like to ask questions that I struggle to answer myself because I’m like, “Oh, maybe Emily will have a better answer than I do.” I think when you talked about a pendulum, I think that’s where I am as well.
And so, when we talk about Spectrum of Care and giving people options, I think a lot of people go, “Well we’ve given options forever.” I think that you’re exactly right, is when we zoom in on how we train new graduates and an increasingly high gold standard of care. To me, that’s the pendulum swing of, I love that we have pushed towards increasing our capabilities and what we can do and how we educate our doctors.
And at some point, I do think it’s time to swing back a little bit the other way and say, “And just because theoretically we can do something doesn’t mean that that’s going to be the best course of action for this individual pet owner.” I also, from a wellness standpoint, think that if we set ourselves up as doctors as I’m only a good doctor if I get people to do the highest technical standard of care possible, I don’t think that’s realistic. And that may sound foolish, but I know young doctors who grade themselves that way.
They’re like, “Well, I couldn’t get this person to do a TPLO.” And I go, well, why did you think you had that? All you can do is recommend and advocate and you’re not going to be able to magically enable people to give their pet of TPLO. You’re going to have to talk about medical management sometimes. And that’s not ideal. That’s not what we aim for, but it’s not a failure on your part if that’s just not in the cards with this patient.
And real skill as a doctor comes from being able to look at that and saying, “Okay. What other cards do we have to play here to get the best outcome possible in this case?” I really like that a lot. I think that I want to ask…

Dr. Emily M. Tincher:
There’s a small piece I want to dive into that you just mentioned there that it may not be ideal if a pet family doesn’t choose a TPLO. Well, I mean there’s some great evidence base that I’d love to that that example you brought up is one where we do have great evidence-based medicine. That there are other options like a lateral suture, for example, that can have a very similar outcome to a TPLO or a TTA referral historically, usually to see a board certified surgeon.
Now, the best possible outcome may be to go see a surgeon with the lowest chances of complications. However, talking to pet families about their options, that range of basic to intermediate options, my definition that I’m trying to use more and more is that the ideal or best outcome, the medical component is included, but that the best outcome is the best outcome for the family.
If for them, they’re anxious about surgery, about anesthesia, even if it’s not just about costs, maybe there’s a comorbidity for the pet. It might be that basic care is the best for that particular family for multiple reasons in addition to finances. Or it may be that if your practice offers that more intermediate approach of a lateral suture, which not everyone has that skillset, the ability to perform that surgery. That’s in addition to meeting that family where they’re at with their goal to stay with you as a general practitioner can help keep the revenue within your practice if you have the ability to perform that surgery.

Dr. Andy Roark:
Well, I’d also would add to that too, when we think about what is success. I like to take the long view on these things as well and say trust in the relationship is also a factor of success for me as well. I definitely seen people go in and aggressively advocate for a path of care and get it done. And then that client will do it. And then they go home and they’re like, “I’m not going back to that person. I felt pressured. This isn’t what… In hindsight, I felt pressured into this course of action. I didn’t want to do it and I don’t really like that veterinarian.”
And so I’d say, well, now we won the battle but lost the war. Especially if those people are reluctant to go back to a veterinarian and it affects care in the future. And so, I always try to say that the outcome for me is not the best outcome today. It’s the best outcome over the life of the pet and the life of multiple pets underneath one client.
I want to dive in a little bit and take apart some of the stuff that you said earlier because I think that this is an interesting way that you’ve built this up when you talk about spectrum care. You talked about evidence-based medicine and then you talked about communication. And sounds like you’re putting those two things together.
And so, you threw around the term evidence-based medicine and then when we talked about the TPLO, you got to unpacked it a little bit. Talk to me about those two things. We’re going to start with evidence-based medicine, then I’m going to talk to you about the communication. We can get into the genomics research and stuff like that as well.
Just unpack that for me. When you say evidence-based medicine, this is a phrase I’ve heard for the last couple decades is thrown around. I think when I talk about Spectrum of Care and look at Spectrum of Care, one of the things I really struggle with is what is good medicine? And what is an acceptable standard?
And I think a lot of us have a certain level of fear because we talk about malpractice. Malpractice is failing to meet the standard of care, which is not written down anywhere. It’s a concept that lives in the minds of the people who will be reviewing your work. And I think that that is a scary idea. And so, help me get my head around what is evidence-based medicine? What is actually out there that’s useful? And what do you see as the future of this and its impact on our profession?

Dr. Emily M. Tincher:
Yeah, I think it’s a great point to bring up. And it’s a common challenge that we have been discussing, not alone certainly, with other organizations to say, “What does it mean to uphold a standard of care, which is what we are legally and ethically required to uphold as veterinarians.” Everything that is above the standard of care, can fit into a Spectrum of Care that range from basic to advanced.
But yeah, how do you know what meets the basic needs? What is the minimum for any particular thing that you are seeing for the day, whether it’s well care or whether it’s something with a sickness or an injury? Well, it’s great when we have evidence-based medicine, i.e. there are some actual research studies, ideally publications that allow us to say, “We know that this particular condition has this particular outcome with this particular treatment in some cohort of dogs.”
Now, sometimes we have that and I think a parvo is one that I love considering for a Spectrum of Care. Say, okay, it’s a pretty common challenge that we have to treat in veterinary medicine. And there is, we have a advanced level protocol of hospitalization that typically has about a 90% success rate. And then we have an intermediate level option for pet families with other components to consider having to come back and forth to the practice every day to meet the Colorado State protocol for outpatient management.
That particular protocol has an 80% success rate. Eight in 10 dogs will do well with outpatient management versus nine in 10 with hospitalization. And the difference in costs is drastic. It’s often thousands of dollars. Talking to pet families about their odds, the pros and cons of the decision that they make. And having the confidence to make those recommendations. I think all of us as applied scientists feel better about knowing what the options are and recommending them in a way that can address the concerns any particular pet family has, when we have that evidence-based component to lean upon.
You mentioned some of the white papers that we’ve published. We are trying to add to that with our over 40 years of experience in pet health and over 1.1 million pets insured at Nationwide, we have a lot of data. And so we’re trying to analyze that data. We have a dedicated pet health analytics and insights team led by our chief veterinary officer, Dr. Jules Benson, where we are trying to add to that, but it’s a mammoth task. Leaning on evidence-based medicine is huge for Spectrum of Care, knowing we aren’t going to have all the information that we want most of the time.

Dr. Andy Roark:
Yeah, I love it. I would really love to continue to see these types of publications. Get the data out so you can publish something. I think the parvo is a great example. I’m really glad you brought that up. I mean just to be able to even just to know, hey, 90% success rate this way, 80% this way. You can have really clear conversations. You can have a clear thought in your mind about how you feel about what you’re advocating.
And I don’t know. There’s that, I remember earlier in my career saying, “Okay, I’m going to make sure that I document that these people declined hospitalization.” And that’s still good practice, but I felt a certain fear or moral weight of like, “Oh, I don’t know what’s going to happen when they take this pet and they leave. And am I impressing on them enough the dangers of leaving?”
You go, “Okay. Well, now I have some things to fall back on and some guidance where I can say they’re not going to be able to hospitalize.” And we can have this with our conversation. And they also know the choice that they’re making and I can give them that clarity. I think that’s beautiful.
Talk to me a bit about the communication part of this. And so, part of it is having a knowledge of what are options, what are inside our Spectrum of Care? What is between the gold standard and acceptable standard, what are our options in there? And then communicating those. Talk to me a little bit about your ideas about what good Spectrum of Care communication looks like.

Dr. Emily M. Tincher:
Yeah. It’s a great question and I’m going to answer it in a couple of parts. One being some of the really cool research that we completed this summer with Nationwide and partnering with Mind Genomics Advisors. And then the second one being piloting out that research and getting feedback from vet healthcare teams and feedback from vet students with our college program.
Part one is what does it look like to communicate with pet families in a pet family centered way. Avoiding judgment and trying to actively be sure that we are understanding what their goals and their values are as well as their resources. The finances component that we sometimes focus on can feel negative to pet families, depending on how we represent things. Not in a way that I think we mean for it to.

Dr. Andy Roark:
Sure.

Dr. Emily M. Tincher:
But I’ve had a pet family say to me that, “It felt like I was talking to my vet about and they seemed like a used car salesman.” I was like, “No vet wants to sound like that.” I’m confident that none of us want to come off that way, but I can understand it. It is important to have those financial discussions.
How do we that? And how do we shortcut the communications to get to the point of what do pet families really value? What are they looking for from us? And what are they looking for from veterinary healthcare? We try to identify that with a process that Mind Genomics has used mostly in human medicine to understand what are the subconscious drivers behind the choices that we make?
And I won’t go through the process for how we did it right now since it gets a little nerdy. But the output is that we identified three different viewpoints. Through instead of going through typical survey methods, they use a mixture of multiple types of sciences. Behavioral science is a big one that they lean upon. Even some food science ideas are included.
But getting to the idea of, “Okay, there are three categories of…” And we built messaging surrounding Spectrum of Care and how pet family, how specifically pet parents would respond to 36 different messages. And the end, we have three viewpoints.
The first one is one that’s focused on two things, optionality. They’re looking for their vet healthcare team to talk to them about the options available to them. And they’re looking to have a strong focus on what the evidence-based component, what the outcome for their pet’s health is going to be.
Second one is highly focused on a mixture of they’re cost conscious. But also, what does it look like to feel clinical empathy from their vet healthcare team that feel like they’re the best pet owner they possibly can be, while acknowledging that this group is pretty cost conscious. They’re looking for ways to either they’re unable or unwilling, they’ve got multiple priorities going on. They’re looking for different ways to have the best possible value for any plans that we present to them.
And the last one is a group that’s highly focused on how can we integrate our recommendations with their schedules in a convenience? How can we make the medications that we recommend or the follow-up schedule that we recommend as easy as possible for their schedule? While still all three groups seem very focused on what’s good for their pet, but that shows up in different ways for them.
The top finding that we have from this research is that, which leads to the implementation of this, everyone hates having the most expensive option offered first. I’m going to just let that sink in for a moment because that is how most of us are trained to present options to pet families.
And by considering that. But with that finding as a top finding, when we asked pet families how do they want us to engage in communication with them, with that as a top finding. We went back to the research and said, “Okay. Well, the interesting thing about the order that we present our recommendations in is that the first option,” and this is again, not research that we came up with but is well represented in a Spectrum of Care publication, Brown et al. if anyone wants to go look for more information, about the order that you represent, things is pretty cognitively biased.
There’s a ton of research in human healthcare that the first option presented is usually the one that people choose. But that does not mean people are later happy with that choice. Going back to your observation earlier that sometimes we do eventually get people to agree to the most advanced option. And they say yes to it, but later, they may not come back. They may reflect on that and say, “It wasn’t exactly what I wanted or needed for my family.”
The recommendation that we are going with, again with published research supporting it, is to instead use our research and we have a tool that will be releasing early next year that will help with this. To use our research to instead recommend the option that you think will fit best with the pet family first, make sure they have three options and then check in. And say, “Okay, which one do you think is the best fit based on this conversation that we’re having?”
And finally, be sure, of course, that you document that you have discussed all three options and why the pet family has chosen that option. To get back to the fear that you mentioned earlier of how do we make sure that we feel comfortable with the idea of a Spectrum of Care? Well, documentation is a very important part of that.

Dr. Andy Roark:
Yeah. This gets into the weeds pretty quick.

Dr. Emily M. Tincher:
It does.

Dr. Andy Roark:
I think the obvious places where this gets pretty hairy is how do you know which is the best fit for the pet parents? And so again, we’ve talked for a long time about not X-raying people’s wallets or guessing as to what they’re able or available to do.
And we all have pretty good research that also says people are not as transparent as they like to think that they are. People don’t tend to know what you’re thinking. And so, I guess that would be my first question is how do you know what fits well with the parents?
Then the other thing I would say is how does this interface with the idea that vet professionals have a responsibility to advocate for what’s best for the pet? And as opposed to making things easy on the pet owner. I think some of it comes down to what are your goals in the room? Yeah. And so, I guess I put that back to you. I know it’s a lot to unpack, but what does that look like? And to me, this is really where things get difficult to parse apart.

Dr. Emily M. Tincher:
How do you know what pet family’s goals are and their resources are?

Dr. Andy Roark:
Yeah, exactly.

Dr. Emily M. Tincher:
Yeah. It’s I mean in some way, we have to have a conversation. And no amount of research or tool that we can provide will be able to magically tell us, you still, every pet family’s going to be a little bit different. Have to have that conversation. Which begins, it’s not for the veterinarian to have, it’s for the whole healthcare team to have. Which is what I love about the resources that you put together is acknowledging that everyone has a massive role in these conversations. And from technicians and CSRs and then the vet is the final link in that team.
Is the research that we have can help shortcut that by asking a few questions. And a process that says, “Okay. In general, most of the time these are, people fit into one of three categories based on a couple of questions that we ask.” And what’s really important about that research is that we also ask the demographics associated with it.
Sometimes, there have been previous conversations around assuming that various socioeconomic levels or anyone with a different family or racial or ethnic background might have certain ways that they interact with their pet. And not only is that biased and ethically wrong, it’s also not founded in the research.
It’s almost a even split, whether you’re looking at age, income level, familial status, education level. Almost a even split across those three viewpoints, which is great. It was certainly what you hope to find is great justification for saying, “You can’t look at someone and just imagine what they might value. You have to have the conversation.”
And our process helps I think shorten that conversation. But it’s still, whether it’s a major life event has just happened, of course, we’ve had vet healthcare teams. We have people tell us, they do tell us things all the time. We’re such a trusted profession that I’m so grateful to be part of that people feel comfortable. Even as a ER vet, they’ve never met me before, feel comfortable telling me that they’ve just lost their husband, that their house just burned down. That they are going on vacation and therefore things are… Or they just got back from vacation yesterday. And so that’s uncomfortable to admit that that’s why your finances are tough, but it’s real life.
Having that conversation and asking, asking in a way that’s collaborative is I think step one, even though knowing it can be uncomfortable but it’s more uncomfortable. And cut to your second part of your question, doesn’t help pets get any care. If we only recommend something that’s not possible for the pet family, they’re getting nothing. If they walk away and say no or they say yes, but they never come back to see us again, in my opinion, that’s worse for the pet long term.

Dr. Andy Roark:
I really like that. That’s really good examples. What it sounds like you’re saying, I guess how it strikes me is this is what we’ve always done. In a lot of ways, it’s about building a trusting relationship and having good communication.
And I go back to relationship. It’s as you say this, I think about how transparent people have been in the past with me about what’s possible and where they are. And they go, “Oh.” I think probably a lot of us are doing this in a common sense way. I can say my take in the exam room is if there’s something that, based on our conversation, I think is the best fit for them, I generally say, “Based on our conversation, this is what I think is probably going to be the best fit for us.” And then I’ll say, “Alternatively, more aggressively, blank, or more conservatively, blank.”
And I give them those options. But it’s always been, I very much am aware and take advantage of the fact that the first thing that I say is going to have extra weight. Which is why I try to do the best job of saying, “This is what I recommend.” I think big things for me are just the basics. Blocking and tackling of exam room communication, which is open-ended questions.
Listen to people, ask to learn, not to respond. Try to understand where they’re coming from. Ask them some lead in questions about how do you feel about this? Or what would you think about this? Or what are your concerns? Or what are your goals for today? And things like that. And just try to extract those bits of information. But I think those are really good examples of what it looks like to listen to a person and then make a good recommendation based on your understanding of what they’ve shared with us.
I’ve always thought that it was cringe-worthy when, the idea being that a veterinarian would go into an exam room and listen to a person talk about how they just lost their car because it got repossessed. And then they turn around and make this recommendation, which is, “Well, here’s what we need to do.” And they give this very high price thing. And then offer some lower cost alternatives. That was like, “Didn’t you hear what I said when I talked about losing my car?”
And I just think that’s just basic common sense of being a good person and building a relationship. And playing against the long term. The goal is not to work today to is build a relationship with this pet owner that’s going to get them on board with taking care of their pet and communicating with me as a healthcare provider for the long term. I think you really answered that well. That makes a lot of sense.

Dr. Emily M. Tincher:
I think it’s more important than ever to have, I love the way you described, it’s a lot of core communication skills that they’re not new, but they are really important. But it’s more important than ever to employ them in a non-judgmental way.
I think we still have, estimates vary, but if you look at the access to care coalitions research, at least 50% of US-owned cats and dogs don’t see a veterinarian on an annual basis. And if you look at our partners at Vet Success who analyze on and sit on a very cool, free weekly tracker that the number of vet visits is going down. But the revenue and income associated with them is going up.
It’s getting more expensive to provide care. And that has implications for the pet families that we serve. It’s a challenging problem for sure, but it’s not sustainable, for us as a profession, to have fewer and fewer people coming in and bring their pets in. Nor is it serving the basic needs. I think we can all agree that pets deserve some amount of basic healthcare. Right now, we’re, staffing challenges notwithstanding, already not serving about 50% of the US-owned cats and dogs out there.

Dr. Andy Roark:
Yeah. Emily Tincher, you’re amazing. Thank you so much for being here and talking through this with me. You’ve thrown out a lot of resources, you have a lot of things going on. What are your favorite resources right now? What are the things that you want people to be most aware of?

Dr. Emily M. Tincher:
That’s a great question. One of the things that you could do to find our white papers. We talked a little bit about some of the evidence-based medicine we’re putting out into the world is petinsurance.com/petdata is where you can find them. We have a new Spectrum of Care website that will be launching in January, so stay tuned for that.
But you can also follow Jules or I on LinkedIn. And then, as far as additional resources for you’re just interested in Spectrum of Care, the Brown et al. paper that I mentioned, as well as England et al., which is published from the Ohio State, who are absolutely leading in a Spectrum of Care in education, are some great places to just to get started if you want to learn more about the topic itself.

Dr. Andy Roark:
Yeah, guys, I’ll put links in the show notes to all those things so you can just check them out there. Emily, thanks again for being here. Everybody, take care of yourself.

Dr. Emily M. Tincher:
Thanks for having me.

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 again to Nationwide for making this episode possible. Gang, take care of yourselves. Be well. Talk to you soon.

Filed Under: Podcast Tagged With: Life With Clients, Medicine

CBD, Labor Shortage, and Non-Economic Damages with Mark Cushing

November 9, 2022 by Andy Roark DVM MS

Mark Cushing Joins Dr. Andy Roark to review recent trends and policy battles in veterinary medicine. He discusses the veterinary labor shortage, telemedicine, nurse practitioners, lawsuit damages and CBD regulation. He also gives his predictions for the midterm 2022 elections and how they will impact veterinary medicine in the coming year.

Cone Of Shame Veterinary Podcast · COS – 169 – CBD, Labor Shortage, And Non – Economic Damages With Mark Cushing

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

LINKS

Practice Owner Summit: https://unchartedvet.com/practice-owner-summit-2022/

Pet Nation: https://amzn.to/3yNT8gj

Animal Policy Group: https://animalpolicygroup.com/

Mark Cushing Website: https://www.marklcushing.com/

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Mark is the Founder and Managing Partner of the Animal Policy Group, LLC, based in Scottsdale, AZ, Portland, OR, and Los Angeles. APG’s clients represent a wide-range of pet health, animal welfare and veterinary educational interests. Mark focuses his practice on providing high-level strategic advice, government advocacy, regulatory and policy services to animal health and veterinary clients with needs at any level of government, and universities and industry groups throughout North America. Mark is a frequent speaker at veterinary medicine and other animal policy conferences. He is a former partner of major regional and national law firms and served as an adjunct professor of law at the LMU Duncan School of Law in Knoxville, Lewis & Clark Law School in Portland, and the University of Oregon School of Law. He is an Honors graduate with distinction from Stanford University and the Willamette University College of Law. Most recently, Mark is the author of Pet Nation, a book released by Penguin Random House that illustrates an inside look at the forces behind how our pets transformed American society and culture.


EPISODE TRANSCRIPT

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

Dr. Andy Roark:
Welcome, everybody, to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I’m here today with the one and only, Mark Cushing. If you haven’t heard Mark before, you’re in for a treat. He’s very opinionated. He has got his fingers in a lot of pies. He knows a lot about how our industry works. And I’m just thrilled to have him here. Gang, we talk about everything from the vet med labor shortage, to nurse practitioners and telemedicine, to noneconomic damages and lawsuits too. And we focus on this [inaudible 00:00:41] CBD oil and CBD regulations. Gang, it is today a sprawling, sprawling conversation. We even talk some politics, we talk midterm elections and inflation and what that means or could mean for vet medicine in the coming year. It’s a really fun one. Gang, I hope you’ll enjoy it. Let’s get into this episode.

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

Dr. Andy Roark:
Welcome to the podcast, Mark Cushing. Thanks for being here.

Mark Cushing:
Great to join us as always, Andy. Hope you’re well.

Dr. Andy Roark:
I am. So I love having you here. For those who don’t know you, Mark Cushing is a lawyer. He is a founder and CEO of the Animal Policy Group. And he is the author of the book Pet Nation. I’ve had you on the podcast before. We’ve talked about the book. We’ve talked about a lot of things. You always come to my mind this time of year because I used to get to see you at the Banfield Industry Summit, which is a great event. But you are generally invited to share your perspective on the industry and where it’s going. And what are the hot topics in the coming year? And I love that, I love hearing you speak about that. You just always give me a ton of ideas.
And I just wanted to have you on the podcast today and kind of run … I think I’d like to sort of hear an overview because I didn’t get to hear you at Banfield this year. What are the hot topics you see coming down the pipes for the industry? And then one area that I know that you’re involved is in the legality of CBD. That was a topic that got really hot, and then it kind of seemed to cool down. And I’m sensing it’s warming back up and I’m seeing a lot more about it again. I wanted to talk to you about that. Does that sound okay?

Mark Cushing:
Let’s go. I’ll jump in on the first.

Dr. Andy Roark:
Yeah, take it from there.

Mark Cushing:
And Banfield punished the attendees by making them sit through breakfast to hear my overview. So I go about 180 miles an hour because I try to cover all the legislation the past year. We started out my group by looking at 25,000 bills and reduced it down to about 350. The point being, when you’re successful and financially, the industry as you know, 2020, 2021, now 2022 are each the greatest years financially than the year before ever, so that puts a bullseye on your back, and I kind of reminded the industry leaders that, that attracts attention. And it often attracts legislation of people wanting to help you, I.E, get a piece of your action, so to speak.
And what were some interesting trends this year? Industry wide, the conversation right now is dominated by the veterinary shortage and the vet tech shortage, period. And there has been reluctance, I think foolish on the part of some trade associations to acknowledge it because all you have to do is talk to a practicing veterinarian anywhere in the country, rural, suburban, urban, East, West, North, South, doesn’t matter. They’re in an acute shortage scenario. And the law of economics, as you know, Andy, means if you have a shortage of something, a shortage of supply of veterinarians, fewer people get care and the price of care goes up. Neither one of those are trends that people feel comfortable with.
I’m not trained enough to talk about the impact and the burnout on veterinary staffs, which is obvious. But we have this millennial and gen Z pet owner group, the largest cohorts of pet owners now in the country, they want to spend money on vet care, they want to treat their pets’ healthcare at the same scale that they take care of their own healthcare. And money really isn’t an issue, which is, quote, a great problem to have, but you’ve got to have enough caregivers to do that. And they’re frustrated. And the headwind we’re heading into will be people that were going to get a second dog, or a cat, or a second cat, or a third because they want playmates and they enjoy the first ones they have so much. But if you can’t get in to see a vet, I can see the conversation between a couple being, “Honey, why are we thinking about a second dog when we can’t get Sparky in to see our veterinarian for a month?” So that’s a tough issue, and it surfaces in different directions.
One is, and you know I’m an advocate for telemedicine. I wrote the first article for the industry back in 2015. I didn’t create telemedicine, I just watched what it’s done in human medicines. It’s legal in all 50 states and it’s now important. It’s a fundamental way people get care if they can’t get in to see a doc. And telemedicine is on the table now in a different context than just it’s convenient and I don’t want to leave my house, or I don’t want to go to a clinic. It’s I can’t get into a clinic. So the arguments against telemedicine become more and more theoretical and less and less real. Number one, number two, it’s opened the door for people to say, “Yeah, human medicine’s had PAs and nurse practitioners for 60 years.” Let me tell you what 60 years means. That means there’s grandparents, kids, and grandkids that have been PAs in this country. We have them all through the US. And again, we would have enormous medical deserts absent nurse practitioners and PAs.
So we’ve had 60 years to learn from it. Obviously, I’m a fan of that. Lincoln Memorial’s opened its first master’s program to create that. And that thinking’s changed. We find people saying, “We certainly shouldn’t fear competition from PAs. Good Lord, we don’t have enough vets as is.” And it would free veterinarians up to do more things, higher value things. So that conversation’s changed. You now see more states, they’re blue states, they’re mainly in the Northeast and Mid-Atlantic, look at noneconomic damages and saying, “We see all this literature where veterinarians say, ‘We treat your pets as family,'” which is true. They have that. They have a unique role in our lives that’s more like kids, and that is like certainly a chair or a skateboard. So why don’t we get the damage awards to include emotional damages, loss of companionship, that human medicine gets? And that’s a tough issue.
I’m still a strong critic of that idea, and my clients are. Why? Because all that does is drive up the cost of vet care, and therefore reduces access. Why is that? Because we pay 750 bucks for liability insurance, vets do now, versus 200,000 that an OB/GYN pays. And if you think that number doesn’t show up in new technology, defensive medicine, and rising costs, which shrinks access, so it’s an interesting debate. But that’s got some tailwind behind it, and we’ll see more and more states want to push that.

Dr. Andy Roark:
Yeah. And let me ask you about that because you’re actually the perfect person to ask this about. I think a lot about this, and whenever I hear noneconomic damages, I’ll be honest, I feel the muscles in my face tighten. You know what I mean? I feel the stress in my forehead come in because just to me, that seems catastrophic, I mean really. And I want you to talk me down here.

Mark Cushing:
It is.

Dr. Andy Roark:
Give me some … Don’t say, “It is.” I wanted you to say, “No, Andy. It’s bad, but it’s not awful.” But it just seems to me, I go, “Look, we’re trying to do everything that we can to provide access,” but when people start suing for six, seven figures when something goes wrong with their pet, suddenly we go, “No, I’m not doing this without an ultrasound, or I’m not doing this without a CT scan.” And I don’t see how that doesn’t just rocket the cost of care multiple times above what it is now. Am I wrong? Are there shades of gray that I’m not seeing here?

Mark Cushing:
You’re not wrong. The truth is, all lawsuits against doctors, the plaintiff’s lawyers that take those cases have them on contingent fees. You see the ads, the billboards in every highway in America. Doesn’t cost you anything. Mark Cushing, come see me, in a car accident, won’t cost you anything. It’s true. You don’t have an out of pocket cost. But they get a third of it. There aren’t lawsuits against veterinarians now with any scale or volume for a simple reason. Lawyers don’t get out of bed for one third of $2000.

Dr. Andy Roark:
Right.

Mark Cushing:
You don’t spend two years pursuing a case that you might make 600 bucks. So when you change that, two things happen. The number of lawsuit, when people recover … Your Shih Tzu dies at age 12, and they claim that the doctor negligently performed surgery, when the gates are open on whatever a jury things would emotionally reward you or compensate you for that loss, two things happen. Lawsuits get filed. Plaintiff’s lawyers get organized. TV ads start appearing of the sort, they ask if you’re in a certain group, asbestos, you’re in a certain group for something else. Now it’s: Are you a pet [inaudible 00:09:56] a pet in America? Have you lost a pet in your life? Really emotionally compelling ads.
The second thing that happens that’s even more troublesome is the insurance underwriters, if one state does that, they step back and go, “Wait a second. Our job’s to manage risk here. The risk just went up by X amount,” so now across the country, they start raising premiums to get ready for it. And then you bake that in, if you’re a veterinarian and you’re cost of doing business increases by $50,000 in the year, you don’t think you find a way to try to recover that. And so the rich can afford it, but we’ve never had healthcare for pets, nor have we had pet ownership be one that’s dependent on income, period.
I did a study nationally in 2015. People that made less than $30,000 a year owned dogs at the same percentage level as people that made over $100,000. And that goes away in this scenario. So there’s nothing good about it, and you might say, “Well, it compensates Mrs. Brown that loved that dog, and she got a nice check for a million five.” Well, actually, she got a million because her lawyers got $500,000. But is that worth it as a social policy? That’s why on the human side, you can’t make a claim for your brother, your sister, your favorite aunt or uncle, your favorite grandparent, your best friend, your girlfriend. It’s limited to your spouse or a child. And so the argument tries to shoehorn pets into being a child. My view is, and I’ve said it publicly, I’ve appeared in front of legislatures and debates all the time, I say pets aren’t children. Pets are a different species. In fact, of course they’re a different species. They’re dog and cat or some other pet.
But they’re also, they have a different relationship. In many cases, they’re nicer than kids. I have five kids. And the point is, you can’t simply say they are kids. They’re not. They’re something different. They live a short life, sadly. We’d all love our favorite dog to live to 60. Not the case, obviously, you know as a doctor. So that analogy, and we’ve won for all 16 years I’ve been involved in the industry. But the waves are bigger coming at us right now, and I don’t think it’s going to go away. So that’s bed news, I’m sorry to start your program off with [inaudible 00:12:24]. But we’re winning. The point is when we make the case that I just said, people go, “Oh, okay. I get it. I’m okay [inaudible 00:12:33].”

Dr. Andy Roark:
That seems obvious to me is you go, “Boy, the impact of this on people’s ability to have pets and pay for them is just so monumental.” It would be so sad to have to make those adjustments.
Hey guys, I just want to jump in real fast and give all of my practice owner friends a heads up. The Practice Owner Summit is coming in December. It is an Uncharted veterinary conference. It is only for practice owners. It is a summit, which means plan for it to be very hands on. You’re going to meet with everyone, other practice owners, everyone there basically is going to be a practice owner. I expect we’ll have 75 practice owners coming together in Greenville, South Carolina December 8th through the 10th. This is a program that I am super happy to put on and run it with my team at Uncharted. It is unlike anything that you’ve seen before. If you want to work on your business, you want to talk with people who get it and who understand the stresses of being an owner, come on and check it out. I’ll put a link in the show notes. Guys, let’s get back into this episode.
Let me ask you one more thing before we go on. So I thought a lot about this, and we say to people, “Your pets are family, and we treat your fur babies,” and we talk like that, I like that language in a lot of ways because it’s always been about raising the human animal bond, and emphasizing people’s connections to pet, and recognizing and honoring that connection.
At the same time, Mark, as I listen to these things and we talk about noneconomic damages, and then also the inability to get pets in to the clinic, and I say, we say, “This is your fur baby, but I can’t see you today.” No shade at all for not being able to get people into the clinic. I am 100% one of those people who says, “If you have a capacity in what you can see in a day, and when you surpass it, you can’t just push your staff harder.” That’s not how this works, and so no shade on not being able to get people in. However, do we need as an industry to start adjusting the language that we use when we talk about pets? So how does that feel when I say it to you?

Mark Cushing:
I have contractors all over my property right now, so I’m just waving them off saying I’m [inaudible 00:14:48]. I’m talking to this esteemed national veterinarian [inaudible 00:14:52]. So I’m a free speech guy. I’ve always believed strongly, not just as a lawyer, but as a citizen. So attempting to regulate language to me is a fool’s mission, Andy, even if it’s well-intentioned, you’ll never quite achieve it. And we’ve used those phrases about pets for 15, 20 years, and not had noneconomic damages come back to bite us. So I think we can manage our way through it at that level. What will change is that the plaintiff’s lawyers, who are busy with opioid lawsuits, following gun control lawsuits, following asbestos, following cigarette, following just fill in the blank, where the scale of reward is billion dollars, so you get a third of a billion dollars versus $100,000. You get a little more excited.
So when that groups turns their eyes, and I’ve waited for 16 years to see when that group shows up, their lobbying power is almost unbeatable, almost. That’ll be different, we’ll see, and language may have to change. But I think for now, we can continue to do it. And the nice thing is pet owners aren’t crying for those damages. That’s the other thing. Those cases always have people that have died horrible deaths, and they’re on the ads, and it’s super compelling. Well, people know pets live short lives. So it’s a different narrative to say, “My 13 year old retriever had to say goodbye.” Well, chances are in the next year, you would’ve had to. Does that sound callous from a lawyer? Sorry, but that’s sort of the reality of it.

Dr. Andy Roark:
No, I hear that. All that totally makes sense. No, this is insightful. I appreciate your insight. Let’s evolve this a little bit, and I want to swing over to CBD. This was a topic a couple years ago we heard a ton about, and CBD was everywhere, and the CBD stores were popping up. There were just new products really coming into the vet market. And then I felt like things kind of hit a stable point, sort of an equilibrium, and they sort of were normalized to some degree, and things sort of quieted down. And now I’m hearing a lot more about the legalities of CBD, sort of changes to access of CBD. Can you sort of start to lay that out for me? Why is this becoming an issue again?

Mark Cushing:
Well, it’s becoming an issue again because so many states have legalized recreational marijuana. A majority have legalized medical marijuana. CBD’s not marijuana, but the point is the culture is much more comfortable with it, number one. Number two, you’ve seen people get comfortable using gummies and a whole host of just CBD products themselves, and particularly when it relates to stress. The argument, I don’t want to keep giving my dog gabapentin because we’re driving eight hours down to Florida for Easter or something. Is there something that’s less aggressive and maybe has less residual, potential residual issues? So there’s that, but you now have legislation, and now, surprise, California has jumped to the head of the pack. And the legal standing right now of CBD supplements in California is that there is no restriction, no restriction on a veterinarian recommending or selling it from their practice to a client.
And there’s uncertainty, Andy, you know this because you’ve podcast all over the country. There’s uncertainty all over the country by veterinarians. Can I even discuss CBD with my clients? Let me just take issues one at a time. The answer is we have a thing called the First Amendment. You can talk about space travel, you can try to tell your clients the world is flat. You can talk to your clients about anything you want. You can. I mean, the truth is you can talk about it. So there’s no thought police, speech police zooming in from a vet med board saying, “Did I hear you mention CBD? Let me have that license of yours and we’ll kindly excuse you,” number one.
Number two, the problem has been the FDA. And let me tell you what the FDA hasn’t done, and it’s what they haven’t done that’s frustrating. So Congress passed in 2018, the Farm Bill. It was signed by the president. That means the language of that bill is the law of the United States. And that law said the following, “If it’s hemp based and the THC, the psychoactive level, that high level of the CBD and hemp, is below .3, that is legal in America.” That’s legal right now. And so if a supplement fits that category, it’s legal. A veterinarian can recommend it. And in my view, they could sell it.
Now what the FDA’s done is say, “Well, we won’t pronounce on that. We won’t make a statement.” So you have one agency sitting there that everybody looks to, being silent. But they will say, “If you’re a supplement manufacturer and you make a therapeutic claim, if you claim that supplement’s going to do something good for a pet, or it’s going to change their bodily structure or function,” that’s the language they use, then we’ll shut you down because only we can approve a therapeutic product. So CBD manufacturers have gotten a lot smarter. And you just pay attention to their marketing, and they’re not making the claims that they might’ve made or want to make, the truth is. So it’s not helpful in my view, and I’ve told the FDA that. It’s not helpful for them to not just step up and say, “We know it’s the law, if you fit this category, hemp based below .3 THC, you’re okay by us.” You can say we’re not going to regulate you, but we’re not going to punish anybody for using you.
So that’s the uncertainty out there, but it’s going to go the way that human marijuana use went. State after state, including SEC states, which tend to be very conservative, other than when they’re talking about SEC football, but states increasingly are saying, “Yes, marijuana, we can live with it within our culture.” And you’re going to see that trend. And so I think what’s going to happen is more and more states are going to say, “Veterinarians, officially, you can do this.” Right now, veterinarians are like, “I don’t know. I want someone to tell me for sure my license isn’t at risk.” And I’m involved, it probably won’t surprise you, but I’m involved with trying to get some of those reforms initiated in states that clarify it. The ones that have are Nevada and California right now on the veterinary side. And those numbers need to increase. And I think once more states do that, people will get comfortable.

Dr. Andy Roark:
What do you think as far as pace of this change? I mean, so Nevada, California, is this in five years, the majority of the states? I mean, I know we’re just sort of forecasting here. But is it a couple years, or is it much longer term than that? What are you thinking as far as timeline?

Mark Cushing:
I think a five year window’s a good way to look at it. And I’ll be disappointed if we’re not at the 10 to 15 states in five years, crazy successful, 20 states. I think in 10 years, over half the states will. And again, I think if you tie it to a veterinary client patient relationship, so you’re saying, and that’s what I favor, so you’re saying, “Yes, you can recommend and dispense, and you can administer in your practice if you need to, a product that fits that legal definition if you have a VCPR with the client.” Then I think we built in a whole set of standards and care that veterinarians have to bring to bear, rather than just sort of casually recommending to a friend, “Yeah, why don’t you try this?” So I think if we have safeguards, people get comfortable. And the key to me, Andy, is that the state VMAs not come out against it, and let … And you never know until you’re in the battle whether they’re going to come out.

Dr. Andy Roark:
Yeah. That makes sense. So getting my head around this, so when we talk about manufacturers that are doing more than .3 THC, things like that, are those not available for purchase in other states? Or owners are just, I’m assuming, ordering them online, it’s just they’re not coming through veterinary clinics. Help me understand that.

Mark Cushing:
Yeah. They’re not coming through veterinary channels, and it’s probably CBD for humans. And to me, that’s dangerous. I mean, I’m a baby boomer. I’ve been exposed to cannabis in CBD in my life. That will shock people. I did live in America in the 60s and 70s and 80s and 90s and now. Point being, a lot of people, I mean, sadly, some people are just taking marijuana in some manner, feeding it to a pet, which is very dangerous. And so that’s the mistake being made there. But people are saying, “Hell, it makes me feel good, and I weigh X number of pounds, so my retriever weighs 65 pounds. I’ll cut it in third, or I’ll cut it in half, or a quarter,” and not a good plan. But there is that going on, no question.
So I think what you want to have happen is let the … And I work with a company going through FDA clinical trials right now, so once you start to have standards that people understand, I’m surprised how many veterinarians don’t know about the Farm Bill, don’t know the hemp based less than .3 THC means something. They’re like, “Oh, what’s that? I never heard about that?” Well, that’s the law. And so we kind of have to get the word out, and I’m hoping that med boards and vet medical associations are comfortable saying, “Yes, that’s okay.” But I think they’re being told by lawyers, “You’ve got to be cautious here. Wait and see what the FDA does.” And I always say to people, “We can wait.” But the truth is, federal law already says the following, which you’ve heard me say. Don’t be afraid to adhere to federal law. And the FDA’s angle is, don’t make a special therapeutic claim about it, but you can get around that. And so smart companies use language that, that’s not claiming it’s going to heal this or cure that.

Dr. Andy Roark:
Got you. Well, let me wrap this up. I want to ask you one of your future facing questions because I’m always interested in your perspective. We’re going into midterm elections. We’ve got signs of continued inflation and prices continue to stay high, even with adjustments to interest rates from the Fed, things like that. Where do you see vet medicine in the next 12, 16, 24 months? Are there forces you’re expecting to be impacting us that are not yet apparent?

Mark Cushing:
I think that the Republicans will take the House back. Whatever your party is, the beauty of that is when we have dual governments, Republicans have this, Republicans have that, but both parties have some power. The pace of federal spending always slows down, and inflation is driven mainly by just massive federal spending that puts money into the market, into the world. And everybody says, “Well, that sounds good.” But then it has the effect we’re now experiencing. I think that’ll slow down fears about a recession. What’s changed in the narrative is inflation, inflation, inflation, oh, my God. Now we’re getting near. Oh, you read the Wall Street Journal today, everyone’s saying, “Recession likely.”
I think that threat will abate. That will cause people will calm down about: Do I have to start making adjustments in my lifestyle right now? Because there’s still jobs available, so if somebody wants a job, they can get a job. But I think you’re going to see that the recession threat and the scale of inflation, if just that one thing happens, Republicans take the house because that means that the Democrats can’t simply push through a spending plan that Republicans can’t stop, so I’m being very political in saying that. There’s things about Republicans taking control that I don’t necessarily like, but that’s one positive.
So the threat to veterinary medicine is there of a recession, but it’ll be on the edges of it. I do not see people saying, “I’m not going to feed my dog. I’m not going to feed my cat. I’m going to drive my dog to the shelter.” You know why people are giving pets back to shelters now? Because they can’t get veterinary care. That threat is independent of any national election. That’s a professional saying, “We have to open up avenues for care or remove barriers to care so people can get care other than going to a clinic,” because clinics have said, “There’s no room at the inn. Sorry, there’s just no room at this hotel. You can’t stay here.” So I’m less concerned for this industry than others about how a full on recession plays out. It’ll slow some things down for sure, but look at what’s happened.
Market Watch shows us every week that vet spending’s up from a year ago and up from the year before that, so that’s my one political ad for this interview, is that I like divided governments. You know why? Because it forces the extremes of both party, which drive most people nuts, myself included. It forces extremes to have conversations because you just can’t yell at each other all day if in fact nothing can happen if you don’t sit down because one side has to get buy in, and the other side has to get buy in, so that’s my hope. If not, I will tell you, it’ll be pretty interesting what’s going to happen. Tighten your seat belt and watch out.

Dr. Andy Roark:
Awesome.

Mark Cushing:
You heard it from the oracle. Yeah, there you go.

Dr. Andy Roark:
Mark Cushing, you are the author of Pet Nation. I’ll put a link to the book in the show notes for those who’ve not checked it out. There’s a podcast you and I have done in the past about it. It’s a very, very interesting read. I really enjoyed it. Where can people follow you? Where can they read more of your writing and your thoughts?

Mark Cushing:
Well, they can go to, I think it’s markcushing.com or marklcushing.com. I can’t remember if I have my dad’s middle name, Lewis. But animalpolicygroup.com for our business. And then Pet Nation, you can get every way possible. And if you like the sound of my voice, for some reason, you can get the audio version. And as you’re walking on the beaches in Carolina, you can hear what I have to say.

Dr. Andy Roark:
It’s like I’m walking on the beach with Mark Cushing, and it doesn’t get better than that.

Mark Cushing:
How could you top that? I agree. So Andy, great seeing you. Great questions, as always. You’re ahead of the game, and you just pull the rest of us along, so thanks a lot.

Dr. Andy Roark:
You’re very kind. Guys, take care of yourselves. And that is our show, guys. That’s what I got. I hope you enjoyed it. I hope you’ve enjoyed hearing thoughts and ponderings of Mark Cushing. As I may have mentioned before, Mark is the founder and CEO of Animal Policy Group. His opinions are his own, although I do very much enjoy hearing where his head is and hearing him talk and predict the future. So anyway, I hope you guys having him on here. Check out his book if you get a chance. Yeah, and that’s it from me, gang. Take care of yourselves. Be well. See you next week. Bye.

Filed Under: Podcast Tagged With: Life With Clients, Medicine, Perspective

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