Medicine

Veterinary cardiologist Dr. Anna Mac joins us to discuss the case of Baguette, a 2 year-old english bulldog with brachycephalic airway disease and pulmonic stenosis. Dr. Mac covers the diagnostic workup, treatment options and likely outcomes. This is a common condition in a common breed… and you won’t want to miss this episode!

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

LINKS

Purdue University College of Veterinary Medicine: vet.purdue.edu/

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

What’s on my Scrubs?! Card Game: drandyroark.com/training-tools/

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:
Hey guys, if you’ve listened to this podcast for any time at all, you know how much I care about keeping pet care accessible to pet owners and how much I hate when people don’t have the resources they need to take care of their pets or staff included. Guys, if you are here, you are probably pretty hardcore about pet healthcare. FIGO Pet Insurance helps you and your clients prepare for the unexpected so that you never have to make the tough choice between your pet’s health and your wallet. Whether these pets are eating out of the trash or diving off of furniture, pets, don’t always make the best decisions. We know that, but with FIGO, you can, and pet owners can. Designed for pets and their people, FIGO allows you to worry less and play more with customizable coverage for accidents, illness, and routine wellness. To get a quick and easy quote, visit figopet.com/coneofshame. That’s F-I-G-O-P-E-T.com/coneofshame. FIGO’s policies are underwritten by Independence American Insurance.

Dr. Andy Roark:
Welcome, everybody, to the Cone Of Shame veterinary podcast. I am your host, Dr. Andy Roark. Guys, I have a great episode for you today with my friend, cardiologist and rising legend, Dr. Anna McManame or Dr. Mac, as she is known at Purdue, where she is an assistant clinical professor. Gosh, she’s awesome. She is such an excellent teacher. I met her just by chance early this year. This is her third episode of the Cone Of Shame and I can’t get enough of her. She is so matter-of-fact, and to the point and just a good teacher. She just reigns pearls of wisdom down on me as I ask her these questions, and I am a better doctor having talked to her.

Dr. Andy Roark:
Guys, today, we are talking about a young bulldog who comes in to have brachycephalic airway surgery and that’s when we find the heart murmur. Ultimately, we end up talking about pulmonic stenosis in the bulldogs. Super fascinating conversation, really interesting. Man, bunch of stuff I’m going to be looking out for in the future that I’m not looking out for in the past. You learn. You know better and you do better. That’s what medicine is. Guys, you’re going to love this. Let’s get into it.

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

Dr. Andy Roark:
Welcome to the podcast, Dr. Anna McManame. How are you?

Dr. Anna McManamey:
I’m good. How are you, Andy?

Dr. Andy Roark:
I’m so great. Thanks for being back. This is your third time’s on-

Dr. Anna McManamey:
It’s been fun. Yeah.

Dr. Andy Roark:
… on the podcast. Well, you have been a very popular guest in the past, as I looked at our YouTube. As we’re recording this, your video with me came out less than a week ago, and it’s got like 100 and something views already. That’s pretty good since we just started doing YouTube. You’re doing good stuff. You’re fun to talk to so thanks for being here.

Dr. Anna McManamey:
Thanks for having me.

Dr. Andy Roark:
Man, always. I’m just going to apologize right ahead of time. I might not be at my best today because I’m going through some stuff and this is going to be hard to hear but my wife used the last of the almond milk that I was planning on for my smoothie. She didn’t say anything. She just left.

Dr. Anna McManamey:
She just left.

Dr. Andy Roark:
She just left. I found a recycling bin. I was like time for my smoothie and it wasn’t there, and so my world is kind of on fire. My love is to lie. It is what take away. I just want to apologize for that. While I get over my feelings of loss and contemplate a smoothie with tap water, like a peasant would have. Yeah, exactly. Anyway, I have a case that I would like to change the topic to, and talk to you about. Are you ready for it?

Dr. Anna McManamey:
I’m ready.

Dr. Andy Roark:
All right. Cool. I have a bulldog, a little-ish bulldog. She’s about two years of age. Her name is Baguette, which is a fun bulldog name. Baguette, the two-year-old bulldog. Her face kind of looks like a baguette. I guess kind of a squish, maybe a croissant face.

Dr. Anna McManamey:
Is she a French bulldog?

Dr. Andy Roark:
She’s not. She’s an English bulldog, which is really… Someone missed a trick there. She’s in for a stenotic airway surgery. Her little nostrils are just completely pinched closed. She’s about years and this was recommended. She has come in, and we’re getting ready for the surgery. I’m sculpting a heart murmur on this two-year-old dog. She seems asymptomatic. She’s bouncing around. There’s no coughing. There’s no nothing. I just wanted to go ahead and pull this out for you and sort of say, what are your thoughts when I’m looking at this little brachycephalic dog that’s got a heart murmur. Are those things related? Is this something I need to be worried about? What kind of monitoring should be looking at? Just start to unpack for me, how do you treat that?

Dr. Anna McManamey:
Yeah. I would say that we actually see this scenario, not uncommonly. Some of these dogs, maybe they’ll even have a clinical sign of “exercise intolerance”. They get out of breath quickly. The most logical thing is it’s their airway because these breeds-

Dr. Andy Roark:
Yeah, because she can’t breathe. I would 100% be like, I know what I got. Ding, ding, I know what this is.

Dr. Anna McManamey:
Got it. Done. On really close examination, once they’re either sedated, pre-anesthetically or they just stopped wiggling, someone hears a murmur. I usually have a rule that if I ever have someone that says, “I hear murmur in a dog younger than about three to five,” I keep inching my ears up because sometimes we’re not catching these congenital murmurs as early, but I’d say solidly if the patient’s less than three years of age and the murmur is a three or more, I consider that likely congenital heart disease that warrants further evaluation.

Dr. Anna McManamey:
I’ll say with bulldog, their anatomy just doesn’t lend itself nicely towards clean auscultation. Some murmurs are really hard to hear. You can’t tell over their referred airway noise, they’re snorting or their chest confirmation that you can’t hear the noise loud enough. Any time, I have a brachycephalic that’s a bulldog in particular, or any of these pity terriers that are now getting more and more bully-like. My top differential’s pulmonic stenosis in those dogs. We’re seeing it happen so commonly that even if they’re asymptomatic or we think they’re asymptomatic and I hear murmur that’s louder than a three, it’s a young dog, I’d be worried about pulmonic stenosis. That murmur is usually on the left side of the chest, but can radiate to the right side of the chest. I would recommend a further workout before anesthetizing that dog.

Dr. Andy Roark:
Okay, cool. Let’s start to unpack what that workout looks like in general practice. I agree with that. I would say to the owners, “Hey, I’m a bit concerned about this.” They’ve been great. They’re here for airway surgery. They’re invested in the pet. I’m happy to talk to them about taking a closer look. What does that look like in your mind?

Dr. Anna McManamey:
Yeah. One of the things that, I think not many people think to do, but something that I actually recommend doing is if you have even just a lead to ECG. Just an ECG machine that you would use for an anesthetic patient, it doesn’t have to be diagnostic. Doesn’t have be anything fancy but if you have that ECG lead, I’m looking for access deviations. I expect a sinus rhythm, so P, Q, R, S and T, but dogs with significant right heart remodeling, we can see that the QRS complex, it looks inverted, so they have a really deep S wave, even in lead two. It tells us that more of their electrical energy is actually going towards the right side of their heart rather than the left side. That can sometimes be a nice tip-off that they might have right side of the margin.

Dr. Anna McManamey:
Now, there definitely can be false negatives. It’s just something that’s relatively cheap and usually, if you’re there contemplating anesthesia, you have the equipment anyway. Something that’s relatively cheap, doesn’t cause any invasive procedures at all. It’s something I’d consider. I think that doing chest x-rays has its place, but sometimes can be not really any superior than just sending them straight for echo. If you’ve got a client where they’re not really convinced that they want to move forward with a cardiology assessment, with an echocardiogram, you could offer baseline chest radiographs. The purpose is to try and see, is there severe cardiac enlargement? If we’re looking for pulmonic stenosis, it’s going to be right-sided enlargement. This is going to be a widened cardiac silhouette on the lateral views. It’s going to be a loss of a cranial waste. Then on the dose eventual projection, we’re going to look for a big MPA bulge. There’s a big bulge that we see over there, but nothing is going to surpass the ability of an echocardiogram to really diagnose the cause of that murmur.

Dr. Andy Roark:
Yeah, I’ve not heard anyone say the phrase loss of a cardiac waste in 14 years. It’s like I remember that phrase and no one said it to me a long time.

Dr. Anna McManamey:
Well, coming back from the-

Dr. Andy Roark:
Really, it just came flashing back. I was in a classroom in Gainesville, Florida. I was like, oh yeah. My recollection of radiographs, just stepping to that, yes, cardiac enlargement. Do you see the actual stenosis in these? Can you see in the vessels, anything like that as 100% just looking for signs of change in the heart itself? I’m just trying to get my head around… I’m just trying to remember back to what that looks like in severe, so pause. In my recollection, there were radiographs in that school that I looked at that 100% showed the pinch stenotic of vasculature coming out. Is that is a thing that we’re ever going to see, or are we a 100% assessing the heart itself?

Dr. Anna McManamey:
With traditional radiography, you’re not going to see that because you’re just going to see soft tissue and blood superposed. Those are going to be the same opacity. In the good old days, they did radiograph angiograms. In school, they probably showed you some really cool images where they did an injection of contrast and then looked at a radiograph. You can see that level of stenosis and you can see the heart chambers. Now we use echo for those things. Then we do angiograms in our cath labs when we’re doing procedures.

Dr. Andy Roark:
Got you. Okay. Talk to me a little bit about the echocardiogram. I know that most of the GPs are probably not running them. Just easy to find. Is there any pearls or words of wisdom, anything that I want? When I refer this, if I have an internist come and look at things like that, do I want to say anything to them or just go, it’s an echo and they’re going to look and they’re going to be, here’s your problem.

Dr. Anna McManamey:
Yeah. No, it’s a great question. I think this is sometimes a little bit of a delicate subject, especially amongst cardiologists and other specialists that do have the ability to do advanced imaging. I think most cardiologists feel that any congenital case, it’s probably best served by being echoed by somebody that has a lot of practice or has the ability for, even if they’re a radiologist that’s variable trained or an internist, sending those out for review by a cardiologist, just because some things are very basic and very simple about it, but there are other little nuances that are really important. Just because they only have one congenital heart disease, doesn’t mean they couldn’t have a second one that’s hiding. That’s really important for us because that is going to impact the way we treat those cases, the prognosis we give and the interventions we recommend. Ideally a cardiologist, if you can. Otherwise, someone with good echo technique, has a machine that’s specifically for echo and then has the ability to get that read by for you.

Dr. Andy Roark:
Got you. No, that’s a good reminder. That makes a ton of sense. Hey guys, I just want to jump in here real fast and give a shout out to Banfield Pet Hospital, for making our transcripts available. That’s right. We have transcripts for the Cone Of Shame vet podcast and the Uncharted veterinary podcast. You can find them at drandyroark.com and at unchartedvet.com. This is part of their effort to increase inclusivity and accessibility in vet medicine. We couldn’t do it without them. I got to say, thanks. Thanks for making the content that we put out more available to our colleagues. Guys, that’s all I got this time. Let’s get back into this.

Dr. Andy Roark:
Am I going to see anything if I do a blood pressure check on this patient? A lot of times, we’ll get patients in and just first thing we do, is check their blood pressure as we’re surgery prepping them. Am I going to see abnormalities there?

Dr. Anna McManamey:
That’s a great question. For better or for worse, the pulmonic and the systemic circulations are completely separated by the lungs. There’s no way to check what the pressure in the right side of the heart is with a systemic blood pressure. We have to rely on using our central venous pressures. A chief way to do it is look at the jugular veins. If the jugular veins are distended or bounding, where you can see the pulses, which is challenging in English bulldogs, I will say, but if you can see those things, that tells us there’s elevated right atrial pressure. If they have ascites already, distended abdomen, that would be an indication, but sadly, there’s no way short of really sticking something down into the heart to get a measurement of those pressures.

Dr. Andy Roark:
Got you. Okay. Are there breeds where you can pretty easily see the bouncing jugular veins, because I’m like, that’s a diagnostic test that I want to do now. I want to see that.

Dr. Anna McManamey:
Yeah. Yeah. It’s really cool. It’s kind of like horses. They can be normal up to about a third of the neck, out of the thoracic inlet. If you’ve got a really fit athletic dog that comes in and they’re super excited, you’ll actually see them sometimes just pulsing in the neck, but the ones that we’re looking for, the pulses that go all the way up the neck or where the jugular veins are so distended, you can see them just by wetting the fur with alcohol. You can actually see them standing up. My trick for the ones that are more difficult is to hold off the jugular vein like I would for venipuncture, so hold off at the thoracic inlet, find the vessel and then let go with my thumb. If I can still feel the vessel the same, it’s still that distended, I know it’s abnormal.

Dr. Andy Roark:
That’s super cool. I’m desperate now to see that so I can point across the treatment room and say to my technicians, “That dog has elevated right systolic pressure,” and they would look at me like Merlin walked in. I’ll be like, I can tell. I won’t tell, no, I didn’t. Just no. I can smell it.

Dr. Anna McManamey:
Exactly. Just wave your hand over. This dog has very systolic pressure.

Dr. Andy Roark:
Yes, exactly.

Dr. Anna McManamey:
It’s really helpful. It’s really helpful it and it’s for any cost. This could be a patient with bad heart disease. This could be a patient with bad [inaudible 00:14:48] disease, pulmonary hypertension. The same is true with the only tricky one is with tamponades. If you’ve got pericardial effusion in tamponades, you’ll likely see jugular pulsations, so helpful too.

Dr. Andy Roark:
Well, let’s fix this. What are my treatment options? What am I going back to the pet owners with when I say, Hey, unfortunately, this is what I found? Obviously, we’re not going to go do this procedure today. Instead, we’re going to work up a new treatment plan. What do you think that treatment plan looks like?

Dr. Anna McManamey:
Typically, it all starts with diagnosis. Again, going back, getting that echo, finding our formal diagnosis and then probably, the more important parts of how significant is it? There’re grades of pulmonic stenosis and there’re types of pulmonic stenosis. The most common kind of pulmonic stenosis we see is truly of the valve itself. It’s where the valves leaflets, they all formed like they were supposed to, except they never separated into three leaflets. We just have this mush of leaflets that are doming. They never open all the way so it’s a valvular pulmonic stenosis. We used to call these type A, meaning they were very amenable to going in and doing a balloon procedure, which we’ll come back to in a second. The other type is this type B morphology, which is, unfortunately, what the bulldog seemed to be plagued with more often.

Dr. Anna McManamey:
That’s where the whole anulus itself, so the circumference of the valve is smaller than normal. The whole thing just is underdeveloped. Those animals may not be as amenable to balloon procedure, but we have to echo to find that out. There’re other levels of obstruction but again, the valve is the most common. French bulldogs are in a class of their own. They get this obstruction above the valve as well. We call it a supravalvular stenosis but again, echo answers that question for us. Once we know what kind, we have to know how bad is it? We use a few variables to help us with that. We’re basically just trying to say, is this obstruction mild, moderate, or severe? The easiest way is to use the speed of blood leaving the right ventricle tract obstruction, so it’s just like the garden hose effect.

Dr. Anna McManamey:
If you take your thumb over the edge of a garden hose, blood, or excuse, water speeds up, and it creates a turbulent jet. Same thing in the heart. The smaller that opening is, the more turbulent the blood flow is. We can use the speed of blood flow to tell us how severe the obstruction is. Classically, anything over a pressure gradient of 80 millimeters of mercury is considered severe. Normal, to put it in perspective is less than five millimeters of mercury. We’re talking way, way, severe. These animals have thick right hearts. They might be symptomatic. They may not at the time of diagnosis, but the concern is that they will become symptomatic. They could develop congestive heart failure in their life. Honestly, by the time they’re five to six years of age, they could die suddenly from arrhythmia.

Dr. Anna McManamey:
It’s these severe categories that we want to treat. The two mainstays of treatment are medical versus interventional. The medical tried and true drug that we usually put these guys on is one called Atenolol, for some type of beta blocker. This is common throughout literature and things. I think there’s a common misconception that when we put them on Atenolol, it makes their stenosis better. It doesn’t do anything to the anatomy of the valve. What it does, is it reduces the workload on that heart and the myocardial oxygen demand in the heart. Beta blockers slow heart rate. They reduce contractility. Those are two determinants of cardiac oxygen demand. We’re trying to protect the heart muscle from arrhythmias, from progressive changes and trying to prevent their heart rates from getting too fast., so that way they hopefully have a longer prognosis and a better survival time.

Dr. Anna McManamey:
Ideally, we take them to the cath lab. That’s one of my favorite things to do. We take them to the cath lab and we do the balloon valvuloplasty. This is where we actually take our special catheters, go in through the heart and we can access through the jugular vein or the femoral vein. We go in and we basically inflate these special catheters. It’s a balloon. Inflate it across the bowel and we tear open those leaflets. The medical management is, of course, very cheap. Atonolol is a very readily available drug. It’s very cheap. Minimal side effects. Again, it doesn’t change their anatomy. It just protects their heart muscle from the negative effects of that disease.

Dr. Anna McManamey:
The interventional approach is usually going to be a few thousand dollars. It’s usually only available at specialty hospitals with cardiologists that also have a cath lab. Almost every academic institution does it. Not as many private practices do, but this is our bread and butter. We’re usually doing two to three of these a week at [inaudible 00:19:25], for example. Those dogs, we think, typically, have a success rate of about 80% of the time. Sometimes that valve stenosis re-narrows, and we have to do it a second time. Sometimes the anatomy is such that we can’t inflate the balloon appropriately or despite our best efforts, that valve doesn’t want to budge. Now, there’s even newer techniques like placing stents in there and doing some really cool stuff, but that’s all something that can be discussed with the cardiologists and that client at the time of the appointment.

Dr. Andy Roark:
Got you. Okay. Let me ask a potentially silly question, but it makes some sense to me anyway. If I have this dog and they have pulmonic stenosis and we’re talking about, let’s say medical management. We’re not going to go in surgery but we repair this. Is there clinical benefit to, at some point, when the patient is a stable, solid surgical candidate to doing this brachycephalic airway surgery, to open it up, to increase oxygenation to the dog. As I think about that, and I get 100% see in my mind, talking to the pet owners and saying, “Hey, this is where we are and we’re going through the process.” Then they panic and say, “Oh my God. Well, she’s so fragile. We definitely don’t want to do surgery.”

Dr. Andy Roark:
Is there a place where I say, “Well, let’s manage this. There’s still benefit to doing this airway surgery.” I believe that for the comfort of the patient. I do believe that but let me ask you, is there clinical benefit to a pulmonic stenosis patient, that’s a bulldog, to be able to breathe?

Dr. Anna McManamey:
Yeah. No, I think absolutely there is. It becomes this very delicate balance of, okay, well I found a heart disease in this pet. If it’s mild to moderate stenosis, you’re done. They can go get their procedure. They’re on some Atenolol. It’s fine. Well, then that severe category, you really think, wow, ballooning, this dog would make it a more stable anesthetic candidate. Doing its airway would make it a more stable anesthetic candidate. Actually, there are a number of these dogs where they have severe enough problems of both that I have them come to me. I balloon them and then have my surgeon do their airway before they wake up.

Dr. Andy Roark:
Wow.

Dr. Anna McManamey:
That’s what I’ll do. If I have a client that is dedicated to doing those things, we’ll do it. It makes my anesthesiologist happy because these dogs are not the fun ones to anesthetize. They’re hypotensive. Some of them have intra cardiac shunts. They’ve got shunting across their atrial levels. They’re not very fun to anesthetize if they have severe, severe stenosis, but you’re exactly right. A lot of these dogs, I do think can be more clinically affected from their airway than from their heart, at least at that point in time. Maybe there’s that acceptable risk that you have a skilled anesthetist who’s comfortable with a quick procedure, a surgeon who’s comfortable with a quick procedure to just make that dog clinically better in the short term.

Dr. Andy Roark:
Can you give me an idea of prognosis for mild, moderate and severe with and without surgery?

Dr. Anna McManamey:
Yeah.

Dr. Andy Roark:
Six answers. That’s a six-answer question.

Dr. Anna McManamey:
Well, I’ll lump it into three. If it’s mild to moderate stenosis, we rarely recommend interventional procedures for those dogs. There’s been enough evidence that for most dogs, as long as they’re in the mild to moderate category, they’re not expected to have negative side effects from their heart disease in their lifetime. It’s very uncommon. There are some exceptions to that, like larger breed dogs. It seems they seem to be a little bit more sensitive to even moderate degrees of stenosis. We use the changes to the heart more than anything. If their heart looks like it’s thick, we’ll say, let’s go do this and get rid of it, and try and give them their best chance at life for the severe dogs, so gradients over 80. This is, honestly, a very wide range of dogs because we’ve got tons of dogs that have gradients over 200.

Dr. Anna McManamey:
That dog is going to have a worse prognosis than the dog of 85, but they’re still both severe, so it’s a little bit fuzzy there, but the median survival time for dogs with severe stenosis without intervention is about five to seven years of age. Usually, those dogs are dying from their heart disease. That’s when we talk about its cardiac causes of death so it’s refractory heart failure, progressive syncarpy that can’t be controlled, exercise intolerance or arrhythmias and sudden death. Those are the more common outcomes that we’ll see, but usually, it’s probably around five years of age is when it really starts seeing to be the worst. With intervention, if we are successful, meaning we get them into at least a 50% reduction of their initial gradient, or whole [inaudible 00:23:52] to get them out of the severe category. If we do that, then they have, essentially, a normal life expectancy. That’s the cell. It sounds like a lot upfront, even if the dog is asymptomatic at that time, but we’re trying to get you years of quality of life with the dog dying from something other than the heart disease.

Dr. Andy Roark:
That makes total sense. Dr. Mac, thank you so much. Are there any final pearls, words of wisdom or pitfalls that I need to look out for as I head forward with this case?

Dr. Anna McManamey:
I would just say, I think you’ve done the best things. Everything else can be done, honestly, under the guidance of the cardiologist and just a team approach with everything, but the breeds I’d watch out for, every bulldog. Frenchy, English doesn’t seem to matter. Any terrier breeds, pit bull terriers, Norfolk terriers, west highland white terriers. Those ones are the most commonly affected. It could be any breed. Just every time you’ve got that new puppy in the room, listen really high up in the axilla region at the base of their heart to find these murmurs early.

Dr. Andy Roark:
That’s fantastic. Thanks again.

Dr. Anna McManamey:
You’re welcome.

Dr. Andy Roark:
That is our episode. Guys, I hope you enjoyed it. I hope you got a ton out of it. I know I did. Thanks to Dr. Mac for being here. Guys, take care of yourselves. Be well, talk to you soon. Bye.

Hypoglycemia trips veterinarians up in a number of ways. It has a variety of causes and some can be more challenging to pinpoint than others. In this episode, Veterinary Medical Internist Dr. Andrew Woolcock joins Dr. Andy Roark to discuss the case of a young hypoglycemic yorkie, before expanding the conversation to discuss hypoglycemia in general.

This discussion covers causes of hypoglycemia, appropriate diagnostic workups, and practical treatment approaches.

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

LINKS

https://www.vet.purdue.edu

GSD Shorthanded Virtual Conference: https://unchartedvet.com/gsd-shorthanded/

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

What’s on my Scrubs?! Card Game: https://drandyroark.com/training-tools/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Woolcock is a veterinary internist. He’s from the Midwest and did his schooling at Michigan State University, where he graduated with his DVM. After an internship at North Carolina State University, Dr. Woolcock completed a residency in small animal internal medicine at the University of Georgia. He joined the faculty at Purdue University in 2015, and is currently an Associate Professor of Small Animal Internal Medicine. Dr. Woolcock loves the complex puzzles that internal medicine patients present, and loves working with students as they put the pieces together. He loves all-things-medicine, because physiology is so fascinating, but he especially gravitates toward immune-mediated diseases and endocrinology. Dr. Woolcock enjoys his clinical practice, but also his research in oxidative stress, and the scholarship of teaching and learning. When he’s not at work, Dr. Woolcock is likely watching old movies with his husband and their dog, Auggie (not sure of what breed he is, so they invented one for him – a Miniature Fluftoffee).

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:
Hey, guys. If you’ve listened to this podcast for any time at all, you know how much I care about keeping pet care accessible to pet owners and how much I hate when people don’t have the resources they need to take care of their pets, our staff included. Guys, if you are here, you’re probably pretty hardcore about pet healthcare. Figo Pet Insurance helps you and your clients prepare for the unexpected so that you never have to make the tough choice between your pet’s health and your wallet.

Dr. Andy Roark:
Whether these pets are eating out of the trash or diving off of furniture, pets don’t always make the best decisions, we know that, but with Figo, you can, and pet owners can. Designed for pets and their people, Figo allows you to worry less and play more with customizable coverage for accidents, illness, and routine wellness. To get a quick and easy quote, visit figopet.com/coneofshame. That’s F-I-G-O-P-E-T.com, slash cone of shame. Figo’s policies are underwritten by Independence American Insurance.

Dr. Andy Roark:
Welcome everybody to The Cone of Shame veterinary podcast. I am your host, Dr. Andy Roark. I am back with internal medicine specialist, Dr. Andrew Woolcock, and we are talking about hypoglycemia today. We first start and talk about a little itty bitty young dog that has it, and then we go into the other reasons that you see patients that have hypoglycemia. This is a great short, to the point overview of a very common condition that can come from a lot of different places, so guys, again, I love this. This is one of those pearl episodes where you just breeze through it. It’s only about 15 minutes of actual interview, and you’re just going to get a lot out of it in a short amount of time. Again, thanks to Dr. Woolcock for being here. He’s amazing. 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. Andrew Woolcock. How are you?

Dr. Andrew Woolcock:
I’m doing very well. Thank you for having me.

Dr. Andy Roark:
Oh, man, my pleasure. I love having you on the podcast. You are, for those who don’t know, an internist at Purdue University’s College of Veterinary Medicine, residency at University of Georgia. You have been on the podcast not too long ago talking about, oh gosh, what did we talk about? IMHA.

Dr. Andrew Woolcock:
Yes.

Dr. Andy Roark:
Yes. It’s been so long it just disappeared from my brain. I wanted to get you back. I’ve got a case I want to talk to you about, and it’s sort of a general, general subject matter. Let’s just start with the case. I have got a young, like eight-month-old Yorkshire Terrier male, neutered, named Taz, and he is not looking good. He’s lethargic, trembling. Owners are really freaking out. He does not look like a normal happy, healthy dog. I did a little bit of blood work on him and the main finding that I have is hypoglycemia.

Dr. Andy Roark:
His glycemic index is low. His glucose is down there. I just wanted to go ahead and ask you about this. As I’m looking at this little dog and thinking okay, what am I looking at here? Why does this happen? I just want to make sure I’m not missing anything. Mom and dad are like what does this mean for the longevity of our dog? Is this dog defective? Did we get a lemon? All of those sorts of questions that you might have if your eight-month-old dog just suddenly stopped working. How do you treat that? Let’s go ahead and start to sort of set this up. What do you think about when you see hypoglycemia in a young dog?

Dr. Andrew Woolcock:
Yeah, so I think thankfully their young dog has not stopped working. It’s just that their young dog is working really hard and has a really rapid metabolism that needs a lot of glucose all the time to keep things running. In very young, very small breed dogs, think like hummingbird metabolism. We’re talking small, so things are moving quickly, so these are the breeds and at the age where they just need frequent access to food to be able to keep their glycemic index up.

Dr. Andrew Woolcock:
The reality is maybe this family’s been feeding the dog the same way, and ever so slightly this dog’s been really holding steady right at the cusp of being hypoglycemic and then skipped a meal, missed a meal, ate a little less, something like that, and that’s why the dog looks like it in this moment and they’re freaking out. Thankfully this is hopefully a very easy to address issue for this Yorkie, and you’re probably going to end up doing more client care in this scenario to help them understand that this is a problem that is very addressable and fixable.

Dr. Andy Roark:
Okay. I have a lot of Yorkies that are small and they stay small. Is the fact that I see this in young dogs, is that attributed to the fact that their metabolism slows down as they get a little bit older? Is that why I’m not seeing this in four and five-year-old Yorkies?

Dr. Andrew Woolcock:
I think it’s a combination of things. One is sure, yes, as they age their metabolism changes, but also when they are very young, their machinery to store glucose in the form of glycogen, their liver to respond to all the different hormonal influences that can regulate glucose nicely, their fat stores and muscle stores, which are a huge storage for energy, are just not quite as robust as they are once they’re at their adult size. They don’t have all the other machinery in place yet to kind of keep them balanced like they do as they reach adulthood.

Dr. Andy Roark:
Talk to me about how the presentation here is going to differ, how my thought process is going to differ when I’m looking at this eight-month-old dog versus when I’m looking at a six-year-old dog or a 10-year-old dog. Hypoglycemia presents for a number of different ways. Help me get my head around that. Let’s just jumping ahead and looking at other patients. What am I looking out there? What are my differentials? Just start to unbox the metabolic phenomena of hypoglycemia for me.

Dr. Andrew Woolcock:
Sure, yeah. I think at its very stripped down level you can think about hypoglycemia as being caused by one of three very broad categories. It’s either going to be insulin related, and we can talk about that separately, but it’s either going to be an increase in insulin, whether that’s naturally occurring like an insulin secreting tumor or something like that or it’s your classic diabetic dog who was given too much insulin. Either that hypoglycemia is related to insulin specifically or they’re hypoglycemia either because they have something that needs more glucose than they’re providing it, like in sepsis or with certain tumors or something like that, so there’s an increase in utilization of their glucose, or there’s a decrease in the production of glucose.

Dr. Andrew Woolcock:
That can come in your neonatal Yorkie that we were just talking about, very young where they’re just not eating enough, or other things that can cause a decrease of production of glucose are things like liver failure, since the liver is so integral to glucose metabolism, or even things like Addison’s Disease because we know that cortisol is a counter-regulatory hormone, basically does the opposite things of insulin. It is there to help continue the production and storage of glucose. In Addison’s Disease where you’re cortisol deficient, hypoglycemia would be a common presentation. Then certainly toxins and things can manipulate glucose as well.

Dr. Andy Roark:
Okay. What does your sort of general diagnostic workup look like for an older dog that comes in, main presentation is hypoglycemia?

Dr. Andrew Woolcock:
Yeah. I think if it’s an older dog presenting with hypoglycemia, maybe you find it just on your alpha track or bedside blood glucose, so that’s the piece of information you have. The best next thing to be doing is full lab work because on a CBC you’re already going to be able to identify let’s say a really severe inflammatory leukogram, maybe left-shifted toxic changes to your neutrophils that are going to move you in the direction of the septic cause for that hypoglycemia. On your chemistry profile maybe you’re going to see changes that would indicate liver dysfunction or maybe you see electrolyte changes that push you towards an Addison’s diagnosis and things like that.

Dr. Andrew Woolcock:
Really, those pieces of blood work are going to be extremely helpful just to start moving you in the direction of which of those you’re dealing with. Then I think if you’re not finding evidence on CBC or chemistry to move you in the direction of toxin, sepsis, Addison’s, liver disease, then just make sure you’ve got some serum saved that you can test insulin levels on that serum because a paired insulin/glucose ratio is the way to start thinking about insulin secreting tumors or something like that. I don’t think I would ever do that straightaway, but one of the pitfalls I see people run into is that by the time they start thinking about testing serum for insulin, they’ve already given the dog a bunch of dextrose and they’ve already supplemented, and they’ve already manipulated the whole glycemic index, and then it becomes a lot more difficult to test for that or evaluate that, so just make sure you save a little bit right at the beginning when you’ve got that hypoglycemic pet.

Dr. Andy Roark:
That makes sense. Hey everybody, I’m just jumping in with two lightning fast updates. Number one, if you have not gotten signed up for the Get (beep) Done Shorthanded virtual conference in October, it’s October 6th through the 8th, you need to do that. If you are feeling overwhelmed in your practice and you want things to go smoother and faster, if you do not want to watch webinars, you want to actually talk about your practice. You want to do some discussion groups, you want to do some workshops where you actually make things and work on things and ask questions as we go along, and have round table discussions and things like that that’s really going to energize you and help you figure out actionable solutions that you can immediately put into practice to make your life simpler and more relaxed, I got you covered, buddy.

Dr. Andy Roark:
But you don’t want to miss it. Go ahead and get registered. Mark yourself off at the clinic for the time so that you can be here and be present and really take advantage of this. I don’t want it to sneak up on you. I know October seems like a long way away. It’s not. But go ahead. I’m going to put a link down below and then when registration opens we’ll let you know it’s open and you can grab your spot. But you do not want to let this sneak up on you.

Dr. Andy Roark:
Check out our Get (beep) Done Shorthanded conference. It’s going to be a great one. This second thing I’m going to tell you about is Banfield. Thank you to Banfield Pet Hospital for making transcripts of this podcast available. You can find them at drandyroark.com. They are totally free and open to the public and Banfield supports this to increase accessibility and inclusion in our profession. It’s a wonderful thing that they do. Guys, that’s all I got. Let’s get back into this episode. Let’s talk about emergency presentation of hypoglycemia. How aggressive do you get on this? Where are your levels? Where do you go from a one alarm fire to a two alarm fire to a five alarm fire?

Dr. Andrew Woolcock:
Yeah. I think your one alarm fire is maybe the young Yorkie, Taz, that you presented at the beginning, who presumably has an appetite and whose hypoglycemia so far is presenting as yes, the dog looks rough but he’s just lethargic and not acting himself, and so as long as he seems neurologically with it and normal mentation, then in that dog, the emergency stabilization may be as simple as let’s offer him a food that has a high glycemic index, high calorie, and get him eating.

Dr. Andrew Woolcock:
I do not think that every hypoglycemic patient, even in the ER, I don’t think every single one needs immediate dextrose bolusing and things like that because in fact, sometimes that kind of messes with the system a little bit and causes insulin surges and all these things that you aren’t intending. If you have a patient that has a normal mentation and has an appetite and wants to eat, whose hypoglycemic signs are mild, food may be all you need in the emergency stabilization.

Dr. Andrew Woolcock:
But that two, three, five alarm fire, those are going to be the patients that really present with some severe neurologic side effects from their hypoglycemia or have already suffered a hypoglycemic seizure, whether they do that in your clinic or they come in postictal. That’s going to be a patient that you aren’t going to really want to rely on consuming food, because that may not be safe for them and that’s where dextrose supplementation becomes key.

Dr. Andy Roark:
Let’s talk about that. Any words of advice, guidance, on dextrose supplementation? I always have a little bit of panic as I’m getting ready to give IV dextrose and always go, “I want to make sure I do this just right.” Give me some pearls on doing a good job in dextrose supplementation that are going to get me the results that I want with the lowest stress on me and the team.

Dr. Andrew Woolcock:
Yeah. I think that thankfully this is a medication that is readily accessible in most clinics and has a very wide safety margin, so you can feel good even if you can’t remember the dose and you’re scrambling, and you’re looking around, give some and you’re fine, but a great general rule is half a mil to one mil per kg of 50% dextrose is a wonderful place to start as a bolus. Then something that I think would help a lot of clinics so that they’re not in that nervous state between boluses of how are they going to handle this, is their glucose just going to drop again, how often do I need to be checking, is once you’ve identified that they need a dextrose bolus, then it’s very reasonable to start them on a constant rate infusion of an IV crystalloid.

Dr. Andrew Woolcock:
Start them at a maintenance fluid rate or higher if you think they’re dehydrated, and add dextrose to those fluids. We often start them on 2.5% dextrose because then at least you know that you can attend to other emergencies that come into your clinic, things like that, and you’re not going to be feeling that anxiety about are they just going to plummet again and am I going to miss it? Are they going to have another seizure? When do I need to reach for another bolus? Starting them on a CRI gives you a push-in to then recheck, and the 2.5% CRI that you start may not be enough and maybe you’ll increase that over time, but I think that’s a nice way to continue to address the problem while you’re realistically waiting on maybe that CBC chemistry to be performed or things like that.

Dr. Andy Roark:
Right. That makes sense. I’m assuming that the amount of time that we’re going to have them on a CRI treatment schedule is probably going to depend largely on what we decide the underlying cause is. Correct?

Dr. Andrew Woolcock:
Yeah, absolutely correct. I think if this is a patient who you do ultimately identify as septic, and now you’re searching for a source of sepsis, then they may remain on some kind of dextrose supplementation for awhile as you identify that septic source, but if it’s a dog who ate something that had xylitol, an artificial sweetener that causes hypoglycemia, then maybe they just need their supplementation overnight while you deal with the toxicity and get them through a shorter period. I think it really just depends on the cause.

Dr. Andy Roark:
Say that we’ve got that dog that ate xylitol, or we’ve got that dog that’s been septic, and we’ve been treating with antibiotics and we feel like the patient’s getting better and starting to eat again. Do you look at the patient and say he’s looking pretty good at this point or do you use diagnostics to guide you as you withdraw dextrose supplementation?

Dr. Andrew Woolcock:
I think probably a combination of both. I think absolutely clinical signs are going to be the biggest part of it, but certainly once you’re making the decision to stop dextrose supplemenation there’s going to be a window of time between stopping it and them getting low enough to show you anything clinically that you would love to see that trend before you allow them to get lethargic and seizuring and things like that.

Dr. Andrew Woolcock:
Monitoring blood glucose is going to be important and something that we have started doing more of for people that are doing this or may not be familiar, are using interstitial glucose monitors. Those are like the FreeStyle Libre, something that can be placed on the skin that can measure the glucose in the interstitium and it saves you from having to poke or draw more blood or things like that. If you’ve got that patient who you think this is going to be a long-term issue that can be really helpful in the hospital.

Dr. Andy Roark:
Yeah. That’s super cool. That’s not something I’ve gotten to try yet, but I think that’s pretty fantastic.

Dr. Andrew Woolcock:
Yeah, and obviously the accessibility of small capillaries to use a glucometer are very easy, but those patients that are very small, that you’re finding yourself drawing blood four or six times a day and you think gosh, I’m a vampire at this point I’m taking so much blood, it’s a really nice way to sort of move away from the blood product and be looking at the interstitium.

Dr. Andy Roark:
What are the pitfalls? What are common mistakes? What are things that trip up doctors, technicians, when we start talking about hypoglycemia?

Dr. Andrew Woolcock:
Yeah. I think that to me, probably the biggest pitfall is to get too much tunnel vision about how critical the acute phase of hypoglycemia is and therefore assume that the underlying cause must also be quite severe, because I think a lot of times people worry. In the Yorkie, the young Yorkie, people feel at least comfortable with that setting, but the dog that comes in that’s unexpectedly hypoglycemic, I think it’s natural to assume that they may be septic or have an infection and it may be natural to reach immediately for antibiotics and hope that you’re going to clear it up that way. I think one thing I just encourage people to do is take a step back and really make sure that the remaining blood work you do continues to support that assumption of critical disease because in a lot of cases it doesn’t.

Dr. Andrew Woolcock:
You can start to suspect something less concerning or something that is not necessarily critical like a septic patient and maybe that starts to take you down the pathway of Addison’s Disease or maybe starts to move you towards an insulinoma, which of course is still not a great diagnosis, but is one that you can take a little bit of time with to assess and to start to think about imaging and things like that. I think the biggest advice I would have is to not just assume hypoglycemia means infection and make sure that the rest of your evaluation supports that if that’s where you’re headed.

Dr. Andy Roark:
That makes total sense. Are there any other resources that you would point people towards, anything, I just sort of think of nutritional management, things like that, that you’ve found particularly valuable?

Dr. Andrew Woolcock:
I would not say not something specific for hypoglycemia. However, I think nutritional management or nutritional textbooks are really good to have and then also even a clinic that doesn’t have an ER component to their clinic, having some kind of critical care textbook, whether that’s physically or an eBook version, are really helpful for those settings where your a day general practice and you’re hit with a true emergency situation, and you’re going, “Gosh, I don’t remember what the stabilization plan is for this or the dose for this drug that’s in my crash cart that I never use,” stuff like that. I think making sure you’ve got that resource available is great.

Dr. Andy Roark:
That’s awesome. Andrew, thanks for being here. I really appreciate it.

Dr. Andrew Woolcock:
Sure thing. Thank you.

Dr. Andy Roark:
And that’s it. That’s what I’ve got for you guys. I hope you enjoyed it. I hope you liked the episode. If you did, if you’re watching on YouTube, hit that subscribe button. If you’re not, wherever you get your podcasts, if you’d love to leave us a little review that means the world to me. Yeah, if you like learning, check out the drandyroark.com website and take a look at our store. We’ve got some training tools. I have a Charming the Angry Client course and an Exam Room Communication Toolkit course. Both of them are on demand. Both of them are very, very good. They are both very flexible and they are a great way to learn with your team. Guys, until next time, take care of yourselves. I’ll talk to you later on.

Veterinary cardiologist Dr. Mac is back on the podcast! We are talking about an 8 year-old Maine Coon Cat named Jerry who came in for limping… and who happens to have a very large heart on radiographs. How concerned should we be? How much deeper should we investigate? What do we tell the owners? This and more coming up in this episode of the Cone of Shame!

LINKS

Purdue University College of Veterinary Medicine: https://vet.purdue.edu/

Believing We Can – Leading a Solution Oriented Team: https://unchartedvet.com/product/solution-oriented-team-workshop/

Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/store/

What’s on my Scrubs?! Card Game: https://drandyroark.com/training-tools/

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:
Hey guys, if you’ve listened to this podcast for any time at all, you know how much I care about keeping pet care accessible to pet owners and how much I hate when people don’t have the resources they need to take care of their pets, our staff included. Guys, if you are here, you are probably pretty hardcore about pet healthcare. Figo Pet Insurance helps you and your clients prepare for the unexpected, so that you never have to make the tough choice between your pets health and your wallet. Whether these pets are eating out of the trash or diving off of furniture, pets don’t always make the best decisions, we know that, but with Figo you can, and pet owners can. Designed for pets and their people Figo allows you to worry less and play more with customizable coverage for accidents, illness, and routine wellness. To get a quick and easy quote, visit figopet.com/coneofshame. That’s F-I-G-O-P-E-T.com/coneofshame. Figo’s policies are underwritten by Independence American Interest.

Dr. Andy Roark:
Welcome everybody to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am back with my friend, cardiologist Dr. Mac from Purdue University’s College of Veterinary Medicine. She is amazing. Guys, we are talking about big cats and big hearts. We’re talking about a Maine Coon cat who’s in for limping, and when we take a radiograph of the shoulder, we see his heart’s really big. What do we do with big hearts in cats? Heart disease, cardiomegaly, in cats is a interesting subject area. It’s a point of a lot of debate for cardiologists. I want to make sure I’m getting it right, or at least starting my clients off down the right path so that we can figure out what to do together. Gang, super great episode. Really good information, so many pearls. Dr. Mac is amazing, I hope you agree. 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 back to the podcast, Dr. Anna McManamey. How are you?

Dr. Anna McManamey:
I’m good. How are you?

Dr. Andy Roark:
I am so good. I am so thrilled to have you back. How have you been?

Dr. Anna McManamey:
I’ve been good. How are you doing?

Dr. Andy Roark:
I am okay. My mom is coming to visit this weekend and she’s supposed to be here anytime, and so-

Dr. Anna McManamey:
Don’t mind me.

Dr. Andy Roark:
… I sent her a message and I was like, “Don’t come in my room, Mom. I’m hanging out with my friends. I’m hanging with my friend.” It’s a language that she would understand and would come back to her from the past. So, we’ve got to get this done, because my mom’s coming over.

Dr. Anna McManamey:
Sounds good.

Dr. Andy Roark:
All right. Here we go. I’ve got a case for you. It’s probably nothing, it’s probably dumb, it’s probably nothing. I’ve this big, handsome, Maine Coon cat who thinks he’s a dog. You know those cats?

Dr. Anna McManamey:
My favorite cats.

Dr. Andy Roark:
My favorite cats, too. The cat people are like, “Oh, I thought you liked cats?” And I’m like, “I like cats who act like dogs,” and they’re like, “Shut up.” No, I’m kidding. I love cats. But there is something about the big cats that think that they’re dogs, it just makes me smile. And that is our friend. Jerry. Jerry is, I said eight years old, so middle-aged, getting on towards later senior years there. But anyway, Jerry’s in for limping, limping on one of the front legs, and we snapped shoulder rads and we got some chest in there. Jerry has a big heart, and I counted rib spaces, but just looking at Jerry he’s just got a big heart and it does not look normal. I look at a lot of cat chest in my time and I see a big heart and I know what a big heart looks like, and I think he’s got a big heart.

Dr. Andy Roark:
I don’t hear a murmur or anything when I listen to this, he’s not asymptomatic, he’s literally here for orthopedics in the front leg. What do you think when I tell you that I see that in Jerry, how do you treat this?

Dr. Anna McManamey:
Yeah, that’s a great question. So, the cardiomegaly in a cat, especially on radiographs, I think, always should alert to the possibility that there could be cardiac disease, especially because the most common kind of cardiac disease in a cat can be really difficult to pick up on radiographs alone. So, anytime I think there’s a big heart, for a cat, I think it’s worth further investigation. The fact that he came in for limping, I think we have to keep in mind, “Is this the weird presentation for an aortic thromboembolism?” So, tying the whole picture together. Again, I think it warrants for the workup of his heart a little bit. So, we have to figure out, “Well, what are we going to be to offer this cat in that setting versus future steps?” So, I would say the easiest things to do when you have a cat at your practice and you don’t have a cardiologist next door, would be to…

Dr. Anna McManamey:
You’ve already done the thoracic radiographs, you’ve seen the big heart. I’d say, “Ooh, cardiac disease is very possible. This is a breed of cat, this is an age of cat, this is a gender of cat that get heart disease,” so working that up a little bit further. It’s an old enough cat where we could see secondary changes from hyperthyroidism, we could see secondary changes from high blood pressure. So, a very basic screening for cats that are over the age of seven, honestly, for me, I do recommend a T4 and I do recommend a systemic blood pressure. Those are accessible, easy to do, just ruling out raging systemic disease that could be causing the heart changes. And then for this guy, the other things I would do, again, just because he’s breed, [inaudible 00:06:09], and gender at risk, he’s got limping and he’s got a big heart on radiographs, is this is a good time to do one of those NT-proBNP, so that biomarker that we talked a little bit about last time.

Dr. Anna McManamey:
So, the BNP, just as a reminder, is that B-type natriuretic peptides, something that’s released by the heart, by the ventricles, when they feel stretched. So, it can be a pressure overload, a volume overload, or a systemic disease process like hyperthyroidism or systemic hypertension. Anything that makes the heart unhappy, it can release this hormone. And so, the NT-proBNP is a send-out test, so it does take a little bit of time, but there are SNAP tests available. So, these are from IDEX, they’re just like a SNAP heartworm or SNAP parvo test. You take a few drops of their blood, put it in the well, wait three minutes, and you get your answer. That one is nice, I think, for these more time-sensitive cases. It basically gives you a qualitative answer, so it tells you, “Yes, there’s likely significant heart disease,” or, “No, there’s likely not significant heart disease,” whereas the send-out test is a quantitative, so it gives you an actual number. But those would be the things I would start with in that cat today, and we can talk a bit more about what I want to see, if you have any questions so far.

Dr. Andy Roark:
No, that totally makes complete sense to me. I have a couple of questions, but I want to go farther down the path before I come back around to them. So, I’m good with this. This all makes sense. This all seems very doable. I am 100% on board. Where do we go from here? What are you expecting to come back? What are you concerned about finding?

Dr. Anna McManamey:
Yeah. So, if I think this catch really has significant heart enlargement, I’ve ruled out hyperthyroidism, I’ve ruled out systemic hypertension. If my BMP result comes back as abnormal or greater than the reference range, at least greater than, honestly, 200 is my number, but the reference range goes to 100, but I just want it to be more [inaudible 00:08:10]-

Dr. Andy Roark:
Oh, gotcha. Okay.

Dr. Anna McManamey:
… if that makes sense. So, the SNAP test, the cutoff is 270, that’s the cutoff, picomoles per milliliter. So, if I get an abnormal BMP result in this cat, I’m going to say, “Your cat likely has structural heart disease.” The lameness, truly, it could be a musculoskeletal issue or a muscular issue, but it could have been a weird transient thrombotic event. So, you can decide, can I get this cat to a cardiologist quickly to make that final diagnosis, or am I going to hedge my bets and maybe even put this cat on a prophylactic blood thinner? Just because if it really is an ATE and we really get a high BNP result, the chances of that being from heart disease are much more likely. Otherwise, I would say we just need to get them seen by a cardiologist to determine what the severity of that heart disease is.

Dr. Anna McManamey:
If you take the lameness part out of this cat’s case altogether and you just took these radiographs as a screening for something else, same thing. If you get a high result, I’d say, “It’s time to go to the cardiologist,” if you get a normal result or a low result, I’d say, “The cardiac enlargement on radiographs is probably not significant for that animal.” There is still a chance, and I still think if that client is interested in a workup, always appropriate to refer, because we know that an echocardiogram is still the gold standard for diagnosing [inaudible 00:09:35] heart disease in a cat. But in that exact moment, having that tool to fall back on, I think is helpful.

Dr. Andy Roark:
Hey, guys, I just want to jump in with a couple of quick announcements. I have got to thank Banfield, the pet hospital, for making transcripts of this podcast possible. Guys, in an effort to increase inclusivity and accessibility in our profession, to get people the information and to make sure everyone is included, Banfield has stepped up and made transcripts possible. You can find them at drandyroark.com. Thank you to them, this is something I wouldn’t be able to do without their help. God, it makes me so good to be able to offer this. Hey, gang, let me ask you a question. If you could make clients easier to handle for your veterinary team, would you do it? Would you make the client experience better for yourself and the people that you work with? Well, if your answer is yes, I just want you to know that I have worked really hard to help make this happen. I have two online, on-demand courses in the Dr. Andy Roark store. One of them is all about charming angry clients, and the other one is all about building trust and relationships with vet owners.

Dr. Andy Roark:
Guys, I worked really hard on these. This is the culmination of over a decade of lecture that I have done around the world and working on these topics. It is my best stuff broken up into 5 to 10 minute modules that you can just drop into staff meetings. You can put them wherever you want, it doesn’t have to be a big deal. You can use them in morning huddles, but it is a way that you can keep giving your people tools just to make their lives easier, because that’s what they’re all about. If you’re interested, head over to drandyroark.com and just click on the store button and you can see what’s there. I’ve also got What’s On My Scrubs? Card game, which is just something fun, a little team-building, educational activity that might make your people laugh. Anyway, I want you guys to know that that’s there, I hope that you will check it out. On Wednesday, August the 10th, my good friend, Senani Ratnayake, RVT is doing an Uncharted workshop. She is doing Believing We Can: Leading a Solution-Oriented Team. What do decision making processes actually look like in your practice?

Dr. Andy Roark:
Get your team to solve problems and find solutions with tips and tricks from this workshop. Guys, Senani is amazing at walking people through how to connect with their team, how to communicate positivity, how to get people in a positive and productive head space to move forward, and to solve their own problems. If you want that for your team, head over to unchartedvet.com, I’ll put a link down in the show notes, but get registered. It is on Wednesday, August the 10th, 8:30 PM Eastern time, 5:30 PM Pacific. It is $99 to the public. It is, as usual, almost always, free to Uncharted members. If you’re like, “Man, they do so many good workshops,” don’t forget to check out the Uncharted membership. I would love to have you in our community. I would talk to you if you were there, because we have a nice, vibrant, active community where we help each other. And if that sounds usual, check it out. All right, guys. And now, let’s get back into this episode.

Dr. Andy Roark:
Let’s just say that we run these tests, we run the proBNP, we do all the things. We get normal results back and we say, “Okay. Still big heart, but we’re not seeing these abnormal structural change markers,” things like that. Do you recheck that cat? Are you going to get this cat back in a year or six months and recheck, what does that look like?

Dr. Anna McManamey:
I think it’s a great question. I think the follow-up’s really important and we can’t forget it. So, I would say 6 to 12 months, I would recheck the same things.

Dr. Andy Roark:
Repeat the rads and compare them, obviously, to the previous year. All right. That totally makes sense to me. When we look at this, we said we’ll probably need to do an echo to get any insight into this. So, I practice in South Carolina and we talk a lot about heartworm disease and we talk about heartworm disease in cats. Is there anything else you would do to differentiate cause, other than the echo, which it seems like that’s cutting to the chase and just saying, “Hey, look, we know we have a large heart. We know we’ve got some abnormalities in here”? I guess I’m dancing around the obvious next step, which is we’re going to get an echo, but anything else that you would add or consider in that phase?

Dr. Anna McManamey:
Yeah. So, heartworm disease in cats is relatively different from the dogs, enough so that it’d be unusual, but not impossible, to see just a big heart from it. So, typically with cats, we look for changes in the lungs a little bit more so, but you could heartworm antigen and antibody test that cat. It’s important to remember to do the antibody test, as well, for cats. But you totally could do that, to just further rule out some things. A lot of practices are getting point-of-care ultrasounds. It doesn’t have to be the full echo machine, I have to be careful of what I say, but if you have a point-of-care ultrasound and you’re just trying to rule other things out, like paracardial fusion. Does this cat have a fusion around its heart and that’s why the cardiac silhouette looks big? If you’re skilled and have the equipment to do that, you could always do that. But again, like you said, the frustrating things, usually, they have to come get an echocardiogram for the definitive diagnosis.

Dr. Andy Roark:
I want to explore the connection that you mentioned early on, just because it’s always worth looking into potentially simple answers. I’ve got a cat that’s limping and a cat with a big heart, are those things related? So, we talked about the aortic thromboembolism as a possibility. When I go back and talk to the pet owners and I say, “Hey, we’ve got a large heart. We’ve done our proBNP’s SNAP test and I want you to go see the cardiologist,” and they say, “Well, okay. But what about the fact that his leg still hurts?” What do you talk about that? Are there things that you would do for pain management in the meantime? Are there ways that you would investigate that intersectionality and say, “Yes, I think that this limping and this heart disease are together,” or, “I’m strongly suspicious of it, I’m mildly suspicious of it, or I’m not suspicious of it”? How do you tease that apart to give them some guidance why the cat is still not fully weight-bearing?

Dr. Anna McManamey:
That’s a great question. So, with the lameness alone, I guess it goes back to what a classic ATE looks like, a classic aortic thromboembolism. It can be in any leg, so it can be just a front leg, so we just can’t forget, it doesn’t have to be the back legs. But the classic things are they’re painful-

Dr. Andy Roark:
I was going to say, screaming pain. I would expect to really hear about this.

Dr. Anna McManamey:
Yeah. They’re painful, but they’re painful for the short term. They are really painful at the beginning and then they lose that sensation over a day or two. They usually have some change to their blood flow, so sometimes you can pick it up because their limb is cold or they don’t have a palpable pulse, where you can’t get a Doppler blood pressure to work on that leg. I try to use my physical exam more so than doing the diagnostics of lactates and blood glucose. I can totally use those things, but then it involves you poking a cat and risk [inaudible 00:16:43] to try and do that. But I think the biggest things that help differentiate a vascular event from a neurologic or an orthopedic event is that temperature of the leg is probably the most important, and then, unfortunately, that lactate and blood glucose differential, those can be helpful. But we see cats that have this partial emboli, they go very transient and they’re just lame.

Dr. Anna McManamey:
And so, I think you have to keep it on your list for that client, but in that moment, you need to take care of that patient, so some type of pain management. Typically, if I know it’s an ATE, I’m going to use some type of an opioid, but tons of people will use Onsior, for example, so some type of an NSAID. That’ll work really well for your musculoskeletal pain. You can do gabapentin, that could work for neuromuscular or just in general pain, but you’ve got to do something for the comfort of the animal. In terms of, if I really think this cat could have had an ATE, the most important thing for me to do, aside from the current management, is trying to prevent another one from happening. And so, the somewhat good news is that a typical dose of Plavix or clopidogrel in a cat, at least short-term, is probably not the end of the world. So, I think it’s just risk benefit again, of that client, of that patient, talking to them about the importance of trying, it versus the side effects of doing so.

Dr. Andy Roark:
So, treat the patient in front of you was basically what I heard. I’ll be honest, when you said ATE, I kind panicked and I was like, “Oh my God,” and everything I know about thromboembolism went out the window. I just forgot everything, I was like, “Ah, what do I do?” I’m back into control now. I feel like if this was a severe thromboembolism, I would know it, I would see it. I would recognize what it was. I would feel the cat’s foot. I would do all the things. I’m back to being comfortable again. I’m like, “Okay.” It’s like when you have limping cat and the specialist says, “Well, have you thought about this horrific thing?” And you’re like, “No,” it was that. The panic moment has passed, I’m back in control. I feel good. Okay. I have a plan. I think I know where to go with this. I still don’t feel like I have a lot of clear advice for the owner, other than we’re going to work this up and if it’s abnormal, we’re going to go down this pathway. It sounds like we have to see what this is.

Dr. Andy Roark:
But we’re going to go along for the ride and investigate. Are there any final words of advice that you have, or things that I should say to the pet owner to set expectations for what’s coming? Just because they’re going to start on this path and we’re going to start a cardiology workup, is there things that they should know before they get into this?

Dr. Anna McManamey:
Cat heart disease is always going to be challenging, and so I think you don’t want to scare a client, without the need to, but it’s important not to overlook some of those even subtle things, like the cardiomegaly and the lameness, could those be correlated or not? And so, I think just being honest, just being open and saying, “Look, we screened, we haven’t found any significant evidence that supports severe cardiac disease, but this is something we’re going to follow-up with in the future, and we’re going to do it by a recheck blood pressure, a recheck diet and recheck BMP level.” Say, “In the future, monitor for recurrent lameness, monitor for any collapsing episodes, shortness of breath.” Anything like that, you know where you’re going to go first. And you already have your baseline diagnostics, which, honestly, is going to be really helpful moving forward with this cat.

Dr. Andy Roark:
Yeah. I completely agree. I’m not a big fan of scaring people, I don’t like that. And at the same time, I really do feel like a lot of pet owners blow off health risks of their cat. I think it’s because cats are stoic and hide pain and illness and things like that. But I think leaning a little bit more heavily into, “Hey, you need to understand this is going on and we’re going to follow up on it,” that makes a lot of sense to me, as opposed to just overcomforting like, “Oh, don’t worry about it,” because I’m worried I’m not going to get that cat back if I don’t impress that on them. Okay. Awesome. This is so helpful, I really, really appreciate it. Thank you so much for being here.

Dr. Anna McManamey:
Thank you for having me.

Dr. Andy Roark:
And that’s it, guys. That’s what I’ve got for you. Thanks again to Dr. Mac for being with me. I’m such a fan of hers. Gang, take care of yourselves. Be well, enjoy practice, keep learning and growing as doctors and technicians, because, gang, that’s all there is. It’s continued growth, it’s lifelong learning. All right. See ya, everybody. Bye.

Dr. Andi Flory, an accomplished veterinary medical oncologist, joins Dr. Andy Roark to discuss the OncoK9 multi-cancer early detection test, a “liquid biopsy” capable of detecting 30 different types of canine cancer.  

She explains why this test is so different from traditional aspirate and biopsy approaches, what scenarios it might be used in, and how its utilization may increase longevity and quality of life for some cancer patients. She reviews the CANDiD Study and discusses sensitivity and specificity of the OncoK9 “liquid biopsy” test across various types of canine cancers.

This episode has been sponsored by PetDx.

LINKS

PetDx home page

The CANDiD Study; Summary: Clinical validation of a next-generation sequencing-based multi-cancer early detection “liquid biopsy” blood test in over 1,000 dogs using an independent testing set: The CANcer Detection in Dogs (CANDiD) study

OncoK9 Cancer SAFE Tool: The OncoK9 Cancer SAFE™ (Screening Age For Early detection) tool uses data from over 3,000 cancer-diagnosed dogs to determine the age at which it may be appropriate to start annual cancer screening for your dog.

Resources page: Browse supporting resources, including our clinical validation study, continuing education (CE) programs, research publications and posters, and product documentation.

ABOUT OUR GUEST

Dr. Andi Flory, DVM, DACVIM (Oncology)
Chief Medical Officer, PetDX

Dr. Flory is a specialist in medical oncology with nearly two decades of experience practicing and publishing in the areas of early cancer diagnosis, treatments, trials, and novel diagnostic test evaluation. A diplomate of the American College of Veterinary Internal Medicine in oncology, Dr. Flory graduated from the Ohio State University of College of Veterinary Medicine and completed additional training at Florida Veterinary Specialists and Cancer Treatment Center in Tampa, Florida, and Cornell University.

In 2019, she treated a small dog named Poppy for pancreatic cancer. Poppy lost her battle with the disease, but left an indelible mark on Dr. Flory, leading her to a newfound passion for cancer genomics. Soon after, Dr. Grosu tapped Dr. Flory to launch PetDx and serve as its first chief medical officer.

Prior to PetDx, most recently she co-directed the oncology internship and served as a medical oncologist at Veterinary Specialty Hospital in San Diego. Dr. Flory founded the medical oncology service at a sister hospital, Veterinary Specialty Hospital – North County. Prior to that she was a staff oncologist, resident advisor and co-chief of the oncology department at The Animal Medical Center in New York City. She has served as a principal investigator for national and international multi-site clinical investigational studies.

Dr. Flory is constantly expanding her knowledge in cutting-edge areas of veterinary medicine. She holds a certificate in genomics from The Johns Hopkins University along with certificates in cancer genomics and precision oncology, and genetic testing and sequencing technologies from Harvard Medical School. In addition, Dr. Flory is a skilled lecturer. An avid snowboarder and passionate foodie, when not keeping up with two preschoolers, Dr. Flory loves to travel, spend time with her husband, sons, their cat Mochi, and dog Cheyenne.

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 got a great one for you today. I’m learning all about liquid biopsy. It’s a new diagnostic tool, that honestly I did not know much about until very, very recently. I’ve been hearing a lot about it. I’ve been seeing lecture tracks at vet conferences. I’ve been seeing articles coming out and started reading about it, and I’m like, “Man, this is really, really interesting.” And so I am so thrilled that Dr. Andi Flory, boarded veterinary oncologist, is on.

Dr. Andy Roark:
She is from PetDx, and she’s talking to me all about liquid biopsy, how it works, why it works, when to use it, what the benefits are of early cancer detection, what type of sensitivity and specificity from this test we can expect, the cost of the test. All the things that you need to know if you’re interested in trying this out in your practice, but guys, I got to tell you I’m excited about this. I love the idea of catching cancer really early and being able to do more about it. And so, anyway, I’m enthused. I want you guys to check this out. I hope that you will be as excited as I am. This episode is made possible ad free by PetDx. Guys, let’s get into this episode.

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

Dr. Andy Roark:
Welcome to the podcast, Dr. Andi Flory, thanks for being here.

Dr. Andi Flory:
Thank you so much for having me, one Andy to another, really lovely to be here.

Dr. Andy Roark:
I know, a couple of Andy’s hanging out talking to each other, it’s a great thing.

Dr. Andi Flory:
Yes.

Dr. Andy Roark:
For those people who don’t know you, I want to share a couple of your bonafides here, because you have done a lot of things and you are wildly impressive. You went to vet school at the Ohio State University. You did your residency at Cornell. You are a boarded veterinary oncologist, internal medicine specialist in oncology. You practiced at the AMC in New York City, you practice in Australia, and then also at vet specialty hospital in San Diego. One of the things that I am most impressed with you is you tend to be involved in internship and residency programs. I see you as co-directors of those programs, and you have a background in teaching. You’ve also done a ton of research on cancer, early diagnosis cancer testing, developing treatment plans, and things like that. And so I am, I am thrilled to have you here to talk today.

Dr. Andi Flory:
Thank you so much for having me. Really exciting to be here.

Dr. Andy Roark:
Well, cool. I wanted to go ahead and start to talk to you about a diagnostic test technique. Sorry, stumbling all over the place. I want to talk to you about a diagnostic technique that I started seeing more and more about in the last, probably three to six months, and it’s the liquid biopsy technique. And so just, can you go ahead and just start out at a really broad scope? What do we mean when we say liquid biopsy? What is this test?

Dr. Andi Flory:
Yeah, liquid biopsy is essentially the ability to detect cancer, but instead of by taking a tissue biopsy where you’re actually taking a little piece of where the suspected cancer is, you’re taking a usually minimally invasive sample of a liquid that’s easily accessible in the body. And so if you think about the different liquids that our patients have in their body, there’s blood, is something that we’re very used to collecting, but there’s also other liquids like urine, effusions, some cerebral spinal fluid. So those are the other liquids that you could consider. And so liquid biopsy is essentially the sampling and analysis of biomarkers that are present in biological fluids in the body, and usually can be sampled through minimally invasive means.

Dr. Andy Roark:
Okay. So when I first heard the term liquid biopsy, I had this idea that when I was highly suspicious of a cancer or when I was like, “I’m looking at a mass here.” This would be a technique similar to normal biopsy, where I see a problem area or area of concern, and I sample it, and I say, “Tell me what this is.” But when I’m reading and learning about liquid biopsy, it seems to me the great power in this test is the screening, the preemptive power of liquid biopsy. Can you comment on that a little bit?

Dr. Andi Flory:
Absolutely. I think that’s one of the most exciting uses of liquid biopsy. So there’s kind of a, there’s about six different kind predefined uses of liquid biopsy, and screening is really the first one. Screening basically means using any sort of testing to try to identify disease in a healthy patient, in a healthy and asymptomatic patient, right? Where disease is not yet suspected. And so when we specifically use this to detect cancer, we’re thinking about an asymptomatic population of pets that, in this case dogs, that don’t currently have symptoms, the veterinarian nor the family suspects cancer in this individual, but they’re at higher risk of developing cancer, maybe because of their age or because of their breed. So this would be an ability to test these dogs that we know just get a lot of cancer, or they tend to be at high risk for cancer, to try to identify cancer, even before they start to show clinical signs. And that’s just like people get, right? Like we get mammograms, and PSA tests, and colonoscopies all in an effort to try to find cancer earlier because we know there’s treatment benefits to finding it earlier.

Dr. Andy Roark:
Well, this is the part that really speaks to me. And so this is what I get really excited about, because we all have these pet owners who have lost a boxer, they’re a boxer family, or they’re a golden retriever family, or they’re a golden doodle family, and they have lost pets to cancer before, and they are like, “I don’t ever want that again. I want to be vigilant.” Or, “I’m terrified of my dog dying at a young age of cancer.” Which is probably the number one cause of death in dogs. And so to me, being able to do a screening test seems like something that they are going to be very excited about. When I talk about, I’m talking about my A clients too, the ones who are like, “Yep, I’m going to do whatever I can do to extend the life of my pet.”

Dr. Andy Roark:
And so not being able to talk to someone who has a, either a high risk breed, or they’re getting into a high risk age group, or it’s just someone who just says, “I’ve had this experience before, and I want to sleep soundly at night.” To me, that sounds like a fantastic benefit to be able to offer. And so that’s really why I got so amped up about liquid biopsy. Let me put a pin in that before we start to unpack it, because I have a lot of questions about how viable and feasible that is, but let’s talk for a second about the use of different kinds of fluids. And so one of the things you brought up is you said, you can sort of use, you can use urine, you can use fusions, things like that’s. That’s not something that I was really familiar with. Are you saying that when we tap that cat or that dog’s abdomen, or we’ve got this sort of persistent urinary tract infections over and over again, that we could potentially use fluids like that in order to do liquid biopsy and look for cancer detection?

Dr. Andi Flory:
So specifically for urine, there already is a test, there’s a test called the BRAF test that’s available through Antech. And that is a urine based liquid biopsy, essentially, where you take a sample of that dog’s urine and you send it in and they look for a specific, basically marker of cancer. And that is, it’s pretty specific, meaning if you get a positive result, it’s pretty likely that that’s what that dog has. And so that’s an amazing test. I love that test. It’s really changed the way that I think that we can manage, especially complicated cases that are just hard to get a diagnosis on, to say, “Is cancer present in this patient?” The kind of the screening tests though, like the tests that are used to detect multiple cancers are really blood based tests.

Dr. Andy Roark:
Okay. Yeah, that totally makes sense. All right. Well, let’s start to get into the screening a little bit. Can you give me sort of a high level of how valuable is a screening test for cancer? So talk to me a little bit about latency period in cancers, and when we could start to potentially see signals, flags in like a liquid biopsy, as opposed to when we normally see clinical presentation, how much time are we talking about here?

Dr. Andi Flory:
That’s a great question. We don’t truly know the exact answer in every cancer, and especially for dogs, like we know in people. I can tell you that cancer does not happen overnight. And even in those dogs where you see those super fast growing masses, like I’ve seen mass cell tumors that are doubling in size every 24 hours, right? And I’m sure we’ve all seen those, that just are growing like just so fast. However, the cellular changes that started, even what looks like a rapidly growing mass, have been present for a very long time. It’s not something that literally has only been there for a matter of days, or even weeks.

Dr. Andi Flory:
In models of human cancer it takes up to about 25 years to go from that initial abnormality in the DNA to becoming a clinical cancer syndrome that’s recognized because of signs and symptoms. Now we don’t know what that kind lag period is, but it’s not a day and it’s not 25 years, so it’s somewhere in between. In dogs, maybe it’s a year, maybe it’s two years, maybe it’s six months in really aggressive disease. We just don’t know those answers yet, but it’s really exciting to kind be able to figure that out and to know that there is a lag period. And what that means is that there is a period of time where cancer is truly present in the body at a molecular level, and it gives us a window to be able to detect it sooner.

Dr. Andy Roark:
We know that when we talk about cancer, we’re talking about a huge variety of problems that we kind of lump together into just cancer, right? And different types of cancer and things like that. Can you speak a little bit to the variability of different types of cancer and how it would intersect with this? I mean, are there cancers that shed, or shed less or are much less harder to detect than others? Are there cancers that liquid biopsy is better at finding than other types of cancers? Help me sort of get my head around that.

Dr. Andi Flory:
Yeah, that’s a great question. Not all cancers are kind of created equal when it comes to being able to be detected by liquid biopsy. Some are going to shed a lot of their biomarker into the blood, which makes it easy to detect. And some actually might shed their biomarker into a different liquid in the body. I talked before about urinary tract tumors, if you think about where they are shedding their biomarker, they’re going to be more likely to shed it into the urine than they are into the blood.

Dr. Andi Flory:
And so for, specifically for when a urinary tract cancer is suspected, for example, you might be better served by going directly after the urine rather than the blood, so there is some biologic difference there. Also, if you think about the blood-brain barrier, and cerebral spinal fluid, and the potential that that biomarker might not be as present at high levels in the blood for central nervous system tumors. So some of it is biologic, a lot of it has to do with biology. And some of it just has to do with size, like how much volume or quantity of tumor there is in the body, kind of also means how much biomarker there is around, and potentially how much there would be likely to be found in the blood.

Dr. Andy Roark:
Yeah, I was looking at the CANDiD study, which covers a lot of stuff about liquid biopsy, and I’ll put a link to it in the show notes so people can check it out and download it. And it was talking about the sensitivity of sort of the main cancers that we see. So we’re talking about the three most aggressive canine cancers are lymphoma, hemangiosarcoma, and osteosarcoma, and they were reporting an 85% detection rate on the big three. Does that kind of track with experiences that you’ve had or kind of what you’ve seen?

Dr. Andi Flory:
Yeah, I mean, so the CANDiD study, or the CANcer Detection in Dogs Study was a really big effort that we performed at over 40 clinical sites around the world. We, the study involves 1100 dogs with and without cancer. And so in that study, for the dogs that had one of those three diagnoses, lymphoma, hemangiosarcoma, or osteosarcoma, the OncoK9 liquid biopsy test was able to detect that cancer in 85% of those cases, which is just phenomenal, because those are really the most aggressive cancers that we see in dogs.

Dr. Andy Roark:
Well, lymphoma, hemangiosarcoma, and osteosarcoma, pretty, pretty darn calm. And then when you start talking about your breeds that are predisposed for these specific cancers, the value seems really high. I know a lot of rottweiler owners that would 100% love to screen for osteosarc on the regular, because they’ve gone through that experience of having osteosarcoma in one of their rotties. And yeah, when I just look at that, I go, “Oh, that seems pretty impressive.”

Dr. Andi Flory:
Yeah. I think there’s so many breeds like that too, right? Like the people that are just really into their breeds, whether they’re dog show people, or their breeders, or they just love the breed, when they love that breed and they’re really, really into it, and they also know which breed, if their breed gets a lot of cancer. So I think that they’re, it’s one of the most common questions that I get as an oncologist is, “What can to try to detect in my other pet?” After a family’s kind of gone through cancer treatment. And so once they know about it in a particular breed, then they really want to know, what can they do to find it earlier?

Dr. Andy Roark:
Well, it’s that creeping dread. You look at your dog every day and you say, “This was the litter mate to my other dog who died of cancer.” And they do, they chew their fingernails. And it’s funny because we know that you could do a test and it could be negative in six months from now, or a year from now it might not be, but that belief that they have looked and there was nothing there when we looked, that’s significant peace of mind for people.

Dr. Andi Flory:
100%. Those exact words that I was going to use is peace of mind. And this test when you, especially in the screening population, has a very high, and these are numbers that, maybe as veterinarians, we’re not as used to kind of thinking about, but when you’re thinking about, if you’ve run a test on a patient and you want to know, well, how much can I trust the result of this test? You need to think about the positive predictive value and the negative predictive value. And the negative predictive value when using it as a screening test is about 95% to 96%, meaning that’s really good piece of mind when you’ve run it as a screening test, meaning this is an asymptomatic dog that you, as a veterinarian, do not suspect cancer in, and you get a negative result, 95% to 96% chance that dog does not have cancer.

Dr. Andy Roark:
Yeah. That, yeah, that’s really solid. And then flip it to the other side is to say, “What are the chances?” Because this gives me nightmares, I don’t want to give somebody a false positive. I don’t want to be like, “Oh, this, I’m sorry to tell you this.” And then it turns out that this was a false positive. So what are the probability of a false positive?

Dr. Andi Flory:
So the false positive rate in study was only 1.5%, which is really, really low. Meaning 1.5% of the dogs that enrolled as presumably cancer free dogs got a positive result. And a few of those that ended up testing positive, we actually diagnosed cancer in. So we found cancer in some, some of the others we ended up following, some of them were lost at follow up. Some of them, unfortunately, had passed away before we kind of figured what going on. But when you look at positive predictive value, so if you run the test, again it depends on how you run it, if you run it as screening test versus as aid in diagnosis, meaning you did cancer in this patient. Then the positive predictive values are between about around 70% to about 96%. Meaning that the majority of patients that do receive a positive result will, in fact, be found to have cancer.

Dr. Andy Roark:
Talk to me a little bit about the benefits of catching these cancers early. So we talked about the, sort of the big three lymphoma, hemangiosarcoma, osteosarcoma, sort of 85% detection rate. And then when you look at the top eight most common cancers, lymphoma, hemangiosarcoma, osteosarcoma, soft tissue sarcoma, mass cell tumors, memory gland carcinoma, anal sac adenocarcinoma, and malignant melanoma, the detection rate is about two thirds. It’s about, it’s 62%. And so a high detection rate, two thirds of the time they’re going to detect cancer in those eight common types of types of tumors, types of cancer. What is the benefit of detection? Because I see, I could hear the words of some clients saying back to me, “Well, I don’t want to know.” Or what is the benefit of finding out early? And so as an oncologist, can you talk to me a little bit about the benefits of early detection from a clinical standpoint?

Dr. Andi Flory:
So from a veterinarian standpoint I can tell you, as well as from a client and a patient standpoint. From a veterinarian standpoint, I think about the diagnostic, what we call a diagnostic odyssey. This is like the period of time when you know something is going on with your patient, and depending on what the owner wants to do, it could take you two days to figure it out, or it could take you two months to figure it out, or it could take you six months. Because sometimes it’s like, “Well, I just want to do conservative management” “Okay, well, let’s try NSAID and come back in two weeks and let’s recheck.” Or, “Let’s try some liver support enzymes and come back in three weeks and we’re going to recheck the lab work and see what’s going on.”

Dr. Andi Flory:
And so by the time you get them to the point that they’ve what they want to do and do an ultrasound and figure out what’s going on, maybe it’s months down the road. And by this point, the disease has progressed, the dog is getting sicker. It’s costing more money in the long run to actually figure it out, and they’re not going to respond to treatment quite as well, because they’re, now they’re sick. When we figure out kind of earlier in the process, we sort of can take away a lot of those steps in the diagnostic odyssey. And what that means for us as veterinarians is, we actually have more options to be able to share with families. And I don’t know about you, but you have it different than I do as an oncologist. Usually I’m just meeting this family for the first time.

Dr. Andy Roark:
Yeah.

Dr. Andi Flory:
You’ve known this dog since they were puppy. You’ve known this family for years, typically. And to have to then, at the kind of 11th hour say, “Your dog has a hemo abdomen, we’ve really only got two choices.” Like, “You either can go to emergency surgery today, get a blood transfusion, do all of the things, or we have to consider euthanasia.” Like that’s a terrible thing to have to tell that family, right? And so if we can find it earlier before the hemo abdomen, for example, we as veterinarians have way more options we can talk to with the family about, but it also means that the clients are not spending all that time and money on that diagnostic odyssey.

Dr. Andi Flory:
They have more options to choose from and can choose what’s actually right for them. They can do it on their own terms, not at the emergency hospital in the middle of the night. And then for the patients, if they’re starting from a place where they feel healthier, they just have more likelihood to be able to respond better to the therapy. So I think there’s benefits for the vet and for the family, as well as for the patient.

Dr. Andy Roark:
No, that makes sense. Can we get into the nitty gritty a little bit and kind of how it looks in practice? Is that okay?

Dr. Andi Flory:
Yeah.

Dr. Andy Roark:
All right. Talk to me about handling and technique and things like that. So I have a patient in my treatment room right now. It’s a nine year old golden retriever and the owners say, “I don’t know, she’s, I feel like she’s losing some weight. And her blood work looks normal, but we’re really concerned about this because of history we’ve had with other golden retrievers.” Walk me through that. What does that process look like for me to get the sample, to transport the sample, and to get results?

Dr. Andi Flory:
Yeah. So veterinarians can get the OncoK9 test, really one of three ways. They can get it directly from PetDx. So one thing that I should say is that the test is looking for fragments of DNA that are in the blood, and these fragments come from the actual tumor cells. Now those fragments are very, very short lived in the body, they only last for minutes to hours, so they have to be stabilized with a very special blood collection tube. The tubes have to be provided, so that’s the first thing to know, is that the tubes have to provided and so there’s basically three ways to get the kit. You can get it directly from PetDx, or you get through diagnostic distributors like IDEXX and Antech also have the test.

Dr. Andi Flory:
So those would be the ways, you basically get the kit, in the kit is everything that you need to pull the sample, which includes two blood collection tubes, as well as a vacutainer system to basically pull the blood directly from the vein right into the tube, just like if you or I were to go to LabCorp today, that’s what they would pull our blood with, right? It’s just an easy, quick way to kind of pull two tubes quickly. The volume in the tube does have to be above the minimum fill line on the tube, which is 7 mLs. So the total tube volume on each tube is between 7 and 8.5 mLs, so that’s a total of 14 to 17 mLs of blood. A little bit more than we’re used to pulling for like a CVC chem, for example, but if you do kind calculations using circulating blood volume, this is a safe quantity to pull on the vast majority of the patients that we see, down to around a two kilogram body size.

Dr. Andy Roark:
That totally makes sense. Okay. So that answers my questions on handling things like that. What’s the turnaround time on a test like this, Andi? Is this, yeah, just when I send this away and the pet owner goes, “When are we going to know something?” Of course I want, help set me up for success. Give me some reasonable, realistic expectations, maybe a little bit of a cushion, just because we’re so busy in the summertime, things like that. So help me get my head around, what kind of timeframe are we talking about?

Dr. Andi Flory:
Yeah. So what’s nice is that these, I think these are like magic blood collection tubes. They stabilize the blood sample for seven days and they do it at room temperature. So you don’t need to fuss around with refrigeration, freezing, finding ice packs, all of that sort of thing. You literally just pop it back in the kit or you hand it off to the IDEXX or Antech courier, they take care of the rest, and the turnaround time from the time, and it gets overnighted to our lab, so we generally get it about hours later. And then it’s about, right now we’re at about 10 to 11 day turnaround time, but generally under 12 days, calendar days, you’re going to get a result back.

Dr. Andy Roark:
That’s excellent. That’s excellent. What is the, again, just ballpark price point, because that’s something that’s going to come up. Is this a $1,000 test? Is this, and I’m talking about what I would end up presenting to the pet owner. And I know that that varies with the practice, and the region, a million different things, I just want to try to get my head generally around kind of ballpark, what are we talking about from the pet owner experience? So like a $1,000 test, a $500 test, a $200 test, kind of where are we in there?

Dr. Andi Flory:
Yeah. So it’s, as you said, it’s totally up to each practice in terms of that’s up to them in terms of setting what the price is, what we’re finding is that the majority of practices are selling it to pet owners at around the $500 mark.

Dr. Andy Roark:
Okay. And that makes sense, and that feels right to me, as far as the sensitivity and specificity of the test and what kind of pet owners are going to be wanting this and what situations are we using it in? Do you have any final pearls, words of wisdom for me, best practices on introducing liquid biopsy into a practice, in communicating it to the team, to getting the staff on board with kind of doing this and using it? Anything like that that would help me, as a general practice doctor, take this into my practice and get good results with it and make it a good experience for people who are not as fired up about it as I am?

Dr. Andi Flory:
Yeah. I think there’s a few things. So one is to think about using it as a screening test. What we’re seeing a lot of practices do is, either roll it into a geriatric yearly screening kind of panel that they do, either that’s breed specific or just for any dogs that are over the age of seven, because we know that dogs over the age of seven have a nine times higher risk of developing cancer. The other thing that they’re doing that we’re seeing a lot of clinics doing is screening days, where they’ll have a cancer screening day, and then they just have families sign up and they come in and they get an OncoK9 test, maybe they do some imaging as well, like they have an ultra sonographer there. And they kind of have this day set aside as a cancer screening day. So they’re really kind of selling this message of, “Let’s be proactive and try to find cancer earlier for those families that are really interested in that.” I think that’s something interesting that we’re seeing out there.

Dr. Andy Roark:
I think that’s really neat. I always geek out about different ways to raise awareness of issues and making a certain day and saying, “Guys, this is important and we’re doing it this time.” I like that. What a neat educational approach.

Dr. Andi Flory:
Yeah. And then the other way that the test can be used is as an aid in diagnosis. So this isn’t a patient for which you do suspect cancer, like you mentioned that poster child nine year old golden retriever that’s losing a little weight, but it’s like, I don’t, what is going on with this pet? It’s not super clear. Or you’ve got a dog with a lameness and an aggressive bone lesion on radiographs, or you’ve got, you can see a mass on imaging, like on radiographs, but it’s just, it’s a challenging location to get to in the body. So this is where liquid biopsy can be used to identify, is this cancer versus is this something else on my list? So kind of help to narrow down that differential list and help the family understand what might be going on so that you can kind of direct that diagnostic workup a bit more quickly.

Dr. Andy Roark:
Are there any pitfalls I should look out for? Are there rookie mistakes that you see vets or vet techs making their first time out?

Dr. Andi Flory:
Yeah, I would say if you think about small, localized skin and subcutaneous tumors that are accessible, as a veterinarian you’re always going to get more information from a direct tissue biopsy than a liquid biopsy. So if you can reach it to aspirate it, definitely do that, liquid biopsy is not meant to replace that. It’s really, what liquid biopsy, I think, is really the most useful for, are the things that you can’t reach, the things that you don’t yet know about, the things that you’re unsure of, if it’s something else, anything within the body, in the chest, in the abdomen, in the nasal cavity, things like that, that you either know there’s a mass or you suspect there could be a mass, that’s where it excels.

Dr. Andi Flory:
But the small, localized skin tumor, like we have examples of, well, here’s a dog that has a mass and they do a liquid biopsy and it’s negative, but then they take it off and it’s a mass cell tumor, and this was like a six millimeter mass. And that’s not where, because of the size and the amount of biomarker around, it’s not going to be a kind of tumor where there’s going to be as much of detection with liquid biopsy. You’re always going to get more information from a direct, like FNA, for example, or actually taking that off and submitting for biopsy than a liquid biopsy.

Dr. Andy Roark:
Dr. Andi Flory, thank you so much for being here. I really appreciate your insight. This has been hugely helpful.

Dr. Andi Flory:
Oh, good. Well, it was great to be here and I’m excited to kind of just see veterinarians benefiting from this and just, it’s exciting to think about earlier cancer detection and what it can mean for our patients.

Dr. Andy Roark:
Oh, I agree. That’s the thing that really got me excited about this, is when you talk about latency and the things, the insidious weight loss that we see in senior pets. And I go, “Man, if we could catch that.” Especially if we have clients who are willing to go to see the oncologist and will consider chemotherapy, and I have more, and more, and more clients that are open to talking about those things, if they feel like there’s a reason to do them, if they feel like they’re catching it early and they can make a significant difference.

Dr. Andy Roark:
And I go, man, this is a possibility for us to, one, to do some good screening and make a difference and really add quality lifespan to these dogs that are dying of cancer. And then number two, this is a customer service that we can offer that we couldn’t offer before. And I just, I really believe that, as veterinarians, we sell peace of mind as much as anything else, and we should stop. We should stop apologizing for beautiful senior wellness blood works that come back. Like, don’t apologize for that, that’s wonderful. That’s what we want. And everybody can relax and we’ve got this great knowledge and that everything is fine. And I just, I would like to see us being able to do more and more of that stuff. So anyway, this makes me super excited. Andi, where can people learn more about liquid biopsy and PetDx?

Dr. Andi Flory:
Oh, great. Yeah. They can head over to our website, which is petdx.com. There we’ve got links to all of our peer reviewed studies. We’ve got case studies, so you can kind of check out how veterinarians are using it in the real world. And one exciting new tool that we just developed is called the Cancer SAFE tool, which stands for Screening Age For Early detection. There, you as veterinarian, or your pet parents can go and enter their pets breed and weight and figure out, when should I be starting cancer screening in my particular pet?

Dr. Andy Roark:
Very nice. I’ll put that link down in the show notes along with the CANDiD study. Thank you for being here, guys, everybody, thanks for tuning in and listening. I hope you got a lot out of this.

Dr. Andi Flory:
Great. Thanks so much for having me, Andy. Lovely to be here.

Dr. Andy Roark:
And that’s our episode, guys. I hope you enjoyed it. I hope you got something out of it. Thanks again to PetDx for making this possible ad free. Guys, if you have questions for me, shoot us an email. The email address is podcast@drandyroark.com. That’s podcast@drandyroark.com. I’m glad that you guys are here and I’m hoping to talk to you again soon. Take care of everybody. Bye-bye.

Dr. Natalie Marks joins the podcast to discuss how invoice bundling (the bundling together of diagnostics, specifically) can help inexperienced doctors develop, leverage technicians more effectively, increase profitability, make cases simpler for practitioners, and speed up our treatment of sick pets. She and Dr. Andy Roark also discuss advice for getting veterinarians on board with diagnostic bundling, what bundles make the most sense, and what common mistakes to avoid when introducing the concept to your clinic.

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

LINKS

Veterinary Angel Network (VANE): https://www.vane.vet/

Dr. Natalie Marks’ Website: https://marksdvmconsulting.com/

LinkedIn: https://www.linkedin.com/in/natalie-marks-dvm-cvj-54b0429a/

Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/store/

What’s on my Scrubs?! Card Game: https://drandyroark.com/training-tools/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Natalie Marks obtained her bachelor’s degree with High Honors in Animal Science from the University of Illinois in 1998, and then proceeded to obtain a Masters in Veterinary Medicine and Doctorate of Veterinary Medicine degree with High Honors from the University of Illinois College of Veterinary Medicine. She became a Certified Veterinary Journalist in 2018.

She has been a veterinarian at Blum Animal Hospital since 2006, co-owner until 2018 and current associate. Prior to 2006, Dr. Marks worked at Allatoona Animal Hospital just north of Atlanta, GA. Her media experience began in print when she created several monthly veterinary columns in multiple community magazines and was a frequent guest speaker for the German Shepherd and Bernese Mountain Dog clubs of Atlanta.

Upon her return to Chicago, Dr. Marks became very active in the Chicago Veterinary Medical Association, serving on the executive board. She was also a past board member of the Illinois State Veterinary Medical Association and an active volunteer to the American Veterinary Medical Association and American Animal Hospital Association.

Dr. Marks has received many prestigious awards in her career. She was awarded the Dr. Erwin Small First Decade Award, presented to a veterinarian that has contributed the most to organized veterinary medicine in his or her first decade of practice. In 2012, Dr. Marks was awarded Petplan’s nationally-recognized Veterinarian of the Year. In 2015, she was awarded America’s Favorite Veterinarian by the American Veterinary Medical Foundation. And, most recently in 2017, she was awarded Nobivac’s Veterinarian of the Year for her work on canine Influenza.

Dr. Marks is also very passionate about educating in all aspects of media, both locally and nationally. She has appeared on Good Day Chicago, WGN-Pet Central, NBC Morning News, ABC, CBS, NPR, WBBM, Northwestern University media channel and many local websites. Dr. Marks was featured nationally on the Today Show and CBS Nightly News during the canine influenza epidemic of 2015 and in multiple issues of JAVMA. She is a guest contributor in multiple media campaigns for Merck, Zoetis (formerly Pfizer), Boerhinger-Ingelheim, Ceva, Trupanion, Aratana, ScopioVet, and Royal Canin.

Dr. Marks is a regular columnist in Today’s Veterinary Business, Healthy Pet magazine, and Pet Vet, and has been published in Veterinary Medicine magazine, DVM magazine, Dogster, and Vetted. She is on the Advisory Board for Health Magazine and also was the host of numerous veterinary broadcasts for the Viticus Group (formerly WVC).

She is a desired national and international lecturer for many of the same companies at VMX, WVC, AVMA and regional conferences, and most recently was a featured speaker at Ceva Sweden’s Derm Day and the Royal Canin Global Symposium.

Dr. Marks finds the ideal combination of teaching/mentoring and improving the emotional health of pets in the Fear Free movement. She sat on the Fear Free Executive Council and is a national educator helping other private practitioners develop these techniques. She also led her practice to become the 7th nationally and first practice in Illinois to become a Fear Free Certified Hospital. She is an Elite Fear Free Certified Professional.

Finally, Dr. Marks is a serial entrepreneur, angel investor and consultant, and one of the newer members of VANE, the Veterinary Angel Network.

When Dr, Marks is not working, she treasures her time with her family and her three wonderful children: Sophia, Evan and Madeline. Dr. Marks loves traveling, scuba diving, cooking and spending time outdoors, especially anywhere there is a beach!

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 :
Hey guys. If you’ve listened to this podcast for any time at all, you know how much I care about keeping pet care accessible to pet owners and how much I hate when people don’t have the resources they need to take care of their pets, our staff included. Guys, if you are here, you’re probably pretty hardcore about pet healthcare. Figo Pet Insurance helps you and your clients prepare for the unexpected so that you never have to make the tough choice between your pet’s health and your wallet. Whether these pets are eating out of the trash or diving off of furniture, pets don’t always make the best decisions. We know that. But with Figo, you can and pet owners can. Designed for pets and their people, Figo allows you to worry less and play more with customizable coverage for accidents, illness, and routine wellness. To get a quick and easy quote, visit figopet.com/coneofshame. That’s F-I-G-O-P-E T.com/coneofshame. Figo’s policies are underwritten by Independence American Insurance.

Dr. Andy Roark :
Welcome everybody to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andrew Roark. Guys, if you’re a business nerd, I got a great one for you today. If you’re not a business nerd, it’s still worth checking out, at least to see if it’s your jam. See if it lights your fire. I really geeked out on this episode. Dr. Natalie Marks is here. She is a veterinary business consultant. She does a million things. She writes articles. She’s does media stuff. She’s a teacher. She’s still in practice. She’s a former practice owner. And I saw an article that she wrote. It’s in a little publication called The Fountain Report. Which if you like vet business and the vet industry, and you’re not familiar with it, it’s worth a google as well. Anyway, she is on today talking about bundling together diagnostic services. Meaning invoice bundling, where you have packages that come up for diagnostics. And she runs through what that looks like and why to do that. It is a really good conversation.

Dr. Andy Roark :
She makes really strong arguments for why this should be part of our practices even if just in small pieces. We talk about getting doctors on board. We talk about how this helps you utilize and leverage your technicians, which makes your day go faster and helps you offload and delegate more effectively if you’re a doctor who’s overwhelmed. There’s a lot of just benefits in getting through the day. She really makes a strong case that this type of bundling can increase your profitability in practice, but it increases your simplicity because you’re able to delegate more and it increases the speed with which you can go through cases while doing really good medicine. And so, anyway, it is worth a listen if you are looking at your practice and being like, “Man, I wish my job was easier and a little bit faster.” So anyway, like I said, I really did enjoy this episode a lot and geeked out on it. And I know I have a business nerd streak. More than a small one. A big one. But if that scratches your itch, I hope you’ll jump in and check it out. I really like this episode a lot. Guys, let’s get into it.

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

Dr. Andy Roark :
Welcome to the podcast, Dr. Natalie Marks. Thanks for being here.

Dr. Natalie Marks:
Oh, thanks for having me.

Dr. Andy Roark :
I am thrilled to have you here. I became aware of you when I read one of your articles recently on the subject that we’re going to talk about today. But since then, I did a little bit of research on you and you and I have gotten to talk a little bit and you are a person after my own heart. You are someone who gets bored really easily, and you do a lot of things. Coming from a person who also does a lot of things. You have a consulting firm. It’s Marks DVM Consulting. You lecture. You are a media personality. You do satellite tours. You invest in startups. You’re still in practice. You’re doing a lot of things. I love it. I think you and I are very much in the same camp of boy, doing a lot of different things keeps you engaged and it keeps you young. So thanks for being here.

Dr. Natalie Marks:
Oh yeah. Thanks for having me. I totally agree. I think that, especially in our profession where we tend to be very passionate people, a lot of times if we put that passion just into one thing over and over and over and over, I find it hard to recharge. So I like to challenge myself even getting into things that maybe aren’t necessarily my perfect wheelhouse, but maybe I have an interest and I want to develop and learn. And I think it’s a great way to keep things fresh and also to, like you said, stir up the pot so that you can really be engaged and find maybe even new passions you didn’t know about.

Dr. Andy Roark :
Did you always do a bunch of different things? When you entered vet medicine … So you graduate from vet school. Are you just only doing vet medicine at that time and then you branched out or were you one of those people who had three jobs plus vet school going on?

Dr. Natalie Marks:
I’m the latter. I’m a doer. Sometimes to my own detriment. You definitely need to work on boundaries and saying no, but I like to have my life be very busy. I function best when I am scheduled and have a lot of goals and projects going. I find myself to feel … When I’m productive I feel good about myself. So yes, I’ve always had a lot of different projects and a lot of different interests. I have three kids and they keep my world very scheduled too. So yes, I am one of those people.

Dr. Andy Roark :
I’m testing theories here. What are you like when you go on vacation? Do you go sit on a beach?

Dr. Natalie Marks:
No.

Dr. Andy Roark :
I knew it.

Dr. Natalie Marks:
It’s sad. I have to plan my vacations longer than the vacation actually is because it takes me about a day to decompress fully. To actually turn stuff off. I will occasionally sit and read a book. It depends. Like I said, I like to do things so I like doing excursions and hikes and whatever I can find. A cool boating adventure or whatever. I don’t like to sit still. I don’t know. Yeah.

Dr. Andy Roark :
I’m with you. And it’s funny. That’s why I wanted to ask that is my wife and I are terrible at relaxing. We’ll go to a beach and two hours into the beach vacation we’re like, “All right and what do we do from here?

Dr. Natalie Marks:
What do we do? Yeah. No, I’m the same way.

Dr. Andy Roark :
All right. I thought so. You and I are kindred spirits. I reached out to you because okay, you wrote this piece and it was just a random piece that I came across, but I’ve had this theory for a long time and you’re the first person I had seen who called it out in a clear way. All right. What I saw you write was you talked about invoice bundling for work life balance and just to help mentor vets and things like that. And you talked a lot about the benefits of invoice bundling. Now people are like, “I can’t believe this is something that Andy thinks about and what the theory is.” But it is.

Dr. Andy Roark :
When I started in practice … So I was a baby vet and I went to this practice and they were like, “Hey …” The vet goes in and they do what they do when you practice your medicine. And I did that and it was fine. But I’m a scattered guy in some ways. I’m a relationship person and I’m a big idea person and I’m charismatic and energetic, but I’m not the most organized person. And I also tend to get focused on what I’m doing and let other things that are peripheral go because I’m hyper focused on what I’m doing. And so when I left that practice, I went to another practice and they had clear wellness protocols and things set up where there was a system and the techs ran it. And my average transaction went way up just because I was doing all of the fecal testing, I was doing the routine blood work, I was doing more senior blood work. Things like that.

Dr. Andy Roark :
And as I became a more comfortable doctor and got much more experience, I don’t think that was as important as it was when I was a young doctor. But boy, I still remember back to going man, having this structure makes so much difference for me in being a complete doctor and working cases up effectively and just feeling like I’m not dropping balls and missing things. And so I’ve thought a lot about invoice bundling in that regard. And then also I’ve got this idea when we start talking about working with clients and pet owners. I call it opt out medicine versus opt in medicine. And I think a lot of us set up our practices and we’re like, “Hey, if the pet owner wants to do what’s best for their pet, they can opt in to that. And I really think that we should be shifting that paradigm and making it so if the pet owner doesn’t want to do what we believe they should do, they can opt out, but it’s on them to opt out rather than it’s on them to actively opt in to the care that we want to provide.

Dr. Andy Roark :
And so when I see you talking about invoice bundling, you hit a lot of those different buttons in my mind. And so let me ask you … Laying out why I’m interested in this and where I’m coming from and what excited me about the concept and the idea. Talk to me a bit about just starting at a high level, what do you mean when you talk about invoice bundling? What does that look like?

Dr. Natalie Marks:
Well, I think it’s covering quite a few different aspects of vet med. I owned a practice for quite some time here in Chicago and one of the challenges we always had was basically exactly what you said is we have veterinarians in all levels of practice. Those that are starting brand new out of school. Those that had practiced maybe for several years, but not with a great mentor. So had developed maybe some habits that they didn’t necessarily like as far as how they practice. And then of course, some senior clinicians that are feeling pretty good about what they’re doing. But when you run a practice, you have to think of a lot of things. You have to think about the wellness of your staff. You have to think about the financial health of your practice. You have to think about the medical quality of what you’re practicing. There’s so many things that go into the everyday.

Dr. Natalie Marks:
But one of the things that we have to always think about of course, is the revenue coming in. And of course, when I’m writing this for The Fountain Report, we’re thinking about decision makers and thinking about financial health too. How am I as a practice owner going to provide the best possible practice for my patients and my team? How can I continually add benefits to them? How can I provide a subscription to Talkspace for all of them? Maybe that’s my goal right now right?

Dr. Andy Roark :
Sure.

Dr. Natalie Marks:
But where’s that revenue going to come from? So one of the things that everybody knows of course is that mis-charges is real. It’s a big deal. And the other thing that we know is that vet med is about patterns. Not everything. Of course there’s zebras out there. But most of what we do is pattern. Pattern recognition, pattern of thoughts about how we work through cases. And I’m a pretty nerdy doctor at heart. I love internal medicine and detective work. And I love mnemonics and teaching. I’ve mentored so many people over my lifetime in 20 some years of practice that looking at algorithms and patterns and mnemonics, and here’s how we can group things together so that people are doing thorough medicine. Because what I found is that even if you’ve had the worst day, if you feel like you’ve worked up a case appropriately, or you found that diagnosis because you remembered what you were talking about and did a thorough workup and the client understood what you were saying, they understood the value, they said yes and you moved forward, that is probably the most personally rewarding thing a vet can have for many of the people I’ve mentored.

Dr. Natalie Marks:
So when I think about invoice bundling, let’s just take dermatology as an example. Right now, allergic dogs, itchy dogs is the number one thing that’s coming in to see us. In every insurance company claim. So we know itchy dogs is a thing no matter where you practice. So when you have an itchy dog that comes in, we want veterinarians to feel like, “Okay, I have an itchy dog. I pretty much know on my invoice bundling …” So I’ve done this before. “That there are several diagnostic tests that are available to me that in a perfect world, I should run. I should be doing a skin scrape. I should be doing a tape prep or a cytology. I probably in some cases will be doing a fungal PCR. Whatever the case may be, but these are things I should be doing.” Now to your point, the client may say, “Well, I only have blank amount of dollars so could you pick the best test out of those?” Or in a perfect world, you present it to the client. “This is the best thing that we can do. I’d like to rule all these things out because some of these things are super treatable. We won’t have to do lifelong meds if it’s not atopy. And this is what it’s going to be.”

Dr. Natalie Marks:
When we have that invoice bundle, meaning your practice management software is set up so all of those tests are bundled into a, let’s just say for this purpose, itchy dog workup. Then we know that all those tests are getting into the computer. We know that the client then sees, “Oh, we did all these things because my dog is itchy.” We don’t lose that charge. The veterinarian has an average client transaction, like you said, that is increasing and improving. And every time they look there, they’re reminded of that pattern. So the next time it’s easier to remember those tests.

Dr. Natalie Marks:
And for the brand new baby vets that are out there, they can put in itchy dog workup and go, “I forgot the skin scrape. Of course.” And the technicians also get involved and they already know what’s in that workup so they can be better in assisting in the room for efficiency. That’s the thing that’s killing us all right now is this horrible lack of efficiency the pandemic created. When we can have a technician and a veterinarian working together seamlessly as a team. They know this is an itchy dog. They know, “Okay, I’ve got my three, four tests that I know I want to run.” Technician is in there working alongside the doctor, doing some of these tests as the doctor is talking about the value and showing the value as the technician is performing a skin scrape or doing a tape prep in between the toes or whatever that might be. There’s efficiency, there’s value, there’s financial revenue, there’s best medicine. The client sees a team effort. I don’t see a downfall there.

Dr. Andy Roark :
No, no. Okay. I saw you setting this up and it clicked in my head before you said it. I think probably the coolest, most exciting part about this for me is the inclusion of the technicians. I’m a huge tech fan. It was funny. I was on a podcast recently. It’s called Vet Tech Cafe. Those guys are great. But they generally talk to technicians. I was one of the first doctors they’d ever had on the podcast. And they said, “Why are you such an advocate for technicians?” And I said, “Honestly, I’m going to be honest with you, I’m really not. I’m an advocate for doctors and getting the most out of your technicians and recognizing and rewarding and empowering and motivating your technicians, that’s good for the doctors.” And so I love techs, but I also fully deeply believe that leveraging our techs and getting more out of them, it makes the doctor’s life easier. It makes better medicine. It’s better patient care. It’s better at work life balance for doctors.

Dr. Andy Roark :
And so I believe that. And so when you started talking about setting up the bundle stuff, I go, man, the techs are going to know exactly what we’re doing, where we’re going, what to get. I’ve mentored a lot of technicians in the past and they’ll ask me, “What do you care about or what makes a really good technician?” And the answer for me of what makes a great technician is anticipation of doctor needs. Meaning they don’t stand and wait to be told this is what we’re going to be doing. They know what we’re going to be doing and they’re going to be doing it. And a lot of that is on the doctor. Meaning they’re not supposed to read your mind. That means you need to be clear about how we approach things and approach things in a systematic way that they can anticipate.

Dr. Andy Roark :
So does put it on the doctor to make it possible. But when you’re talking about this, I’m going, man, she’s got a system to lay these programs down in a way that makes sense. That makes financial sense. That’s clearly communicated and it sets expectations. It sets expectations for the doctor. I’ve been a doctor coming into a new practice. I don’t think it matters if you’re a new graduate or not, but you come into a new practice, you don’t really know what the expectations are. I’ve done relief work at different times and I come in and I’ll have that itchy pet and the techs will say, “Well, what do you want to do?” And I’ll say, “What is the clinic approach to this? Because I want to follow suit with generally what the standard of care is for this practice and how they approach it.”

Dr. Andy Roark :
And oftentimes they shrug their shoulders and go, “Whatever the doctor wants to do.” And I say, “Well, I’ll do it my way then.” But having this guidance, I do like that a lot. So all of that makes sense. And I really like it from an onboarding standpoint, from a communication standpoint, training standpoint, things like that.

Dr. Andy Roark :
Hey guys. I just want to jump in with a couple of quick announcements. I have got to thank Banfield the pet hospital for making transcripts of this podcast possible. Guys, in an effort to increase inclusivity and accessibility in our profession, to get people the information and to make sure everyone is included, Banfield has stepped up and made transcripts possible. You can find them at drandyroark.com. Thank you to them. This is something I wouldn’t be able to do without their help. God, it makes me so good to be able to offer this.

Dr. Andy Roark :
Hey gang, let me ask you a question. If you could make clients easier to handle for your veterinary team, would you do it? Would you make the client experience better for yourself and the people that you work with? Well, if your answer is yes, I just want you to know that I have worked really hard to help make this happen. I have two online on demand courses in the Dr. Andy Roark store. One of them is all about charming angry clients and the other one is all about building trust and relationships with pet owners. Guys, I worked really hard on these. This is the culmination of over a decade of lecture that I have done around the world and working on these topics.

Dr. Andy Roark :
It is my best stuff broken up into five to 10 minute modules that you can just drop into staff meetings. You can put them wherever you want. It doesn’t have to be a big deal. You can use them in morning huddles. But it is a way that you can keep giving your people tools just to make their lives easier because that’s what they’re all about. If you’re interested head over drandyroark.com and just click on the store button and you can see what’s there. I’ve also got What’s On My Scrubs card game, which is just something fun, little team building educational activity that might make your people laugh. Anyway, I wanted you guys to know that’s there. I hope that you will check it out.

Dr. Andy Roark :
On Wednesday, August the 10th, my good friend Senani Ratnayake, RVT is doing an uncharted workshop. She is doing Believing We Can. Leading a solution oriented team. What do decision making processes actually look like in your practice? Get your team to solve problems and find solutions with tips and tricks from this workshop. Guys, Senani is amazing at walking people through how to connect with their team, how to communicate positivity, how to get people in a positive and productive head space to move forward and to solve their own problems. If you want that for your team, head over to unchartedvet.com. I’ll put a link down in the show notes. But get registered. It is on Wednesday, August the 10th, 8:30 PM Eastern time, 5:30 PM Pacific. It is $99 to the public. It is as usual, almost always free to Uncharted members. If you’re like, “Man, they do so many good workshops,” don’t forget to check out the Uncharted membership. I would love to have you in our community. I would talk to you if you were there because we have a nice, vibrant, active community where we help each other. And if that sounds useful, check it out. All right guys. And now let’s get back into this episode.

Dr. Andy Roark :
What pushback do you see in vet clinics to doing more of this bundling?

Dr. Natalie Marks:
Well, I think there’s two things. One is some people say, “Well, isn’t that cookie cutter medicine?” Or, “Isn’t that people telling you how to practice?” And I firmly argue, no. I’m not putting together or suggesting that we’re putting together extraneous testing. As an example, let’s go back to derm. The derm tests that I recommend in an invoice bundle are what dermatologists recommend as a foundation workup for an itchy pet, right?

Dr. Andy Roark :
Yeah.

Dr. Natalie Marks:
So I argue that actually what we’re doing is we’re creating, again, patterns within our veterinarians of how to think about practicing best medicine. And if the client does not want to do it, like you said, they opt out. They don’t have to do every test. They don’t have to do a single test at all. And I’m not saying that we run a skin scrape and a tape prep and a cytology and a fungal culture on a wellness exam who’s coming in for vaccines. This is for an itchy dog. So it’s very appropriate.

Dr. Natalie Marks:
So sometimes I get someone who says, “Well, I don’t like following protocols. I like to do rogue medicine and do it my way.” And I firmly believe every veterinarian should be an individual and practice the medicine they believe in, but what I am, again, advocating for here is to practice based on the experts in our field and what they recommend as, again, standard of care for a workup for these patients. So that’s one pushback I get. I guess the second thing I guess sort of goes along with that is, “What if I’m a veterinarian at a practice and let’s say we’re working up a Cushings patient and in my invoice bundle there’s ACTH stim and I love doing a low dose and I don’t believe in ACTH stims and I just argue that this is not the protocol I want to use.” Then fine.

Dr. Natalie Marks:
Invoice bundles are not set in stone. Whenever we set our invoice bundles up, we actually set them up at a doctor’s meeting. We had a dinner, we all sat down together and we beforehand asked the veterinarians to say, “Hey, what is your test of choice for a diabetic cat? What is your test of choice, blah?” And we worked on it together as a doctor team, which also brought us closer together, I think, as partners and colleagues. But if somebody said, “I absolutely have to do a high dose on every Cushings patient,” well, I want to know why. Because maybe they saw an article that I missed in a journal or maybe they were just at a CE where this is the brand new way to do this and we can improve. I love discussion.

Dr. Natalie Marks:
I love having people bring to the table what is working for them and why. Now, if anecdotally, somebody said, “Well, I believe that we need to feed every diabetic only green beans and that’s going to save the planet.” There has to be a little foundation to what they’re bringing. But I love having the doctors on the team come together and say, “You know what, I co-own the practice, but the doctors here, this is our practice. We’re shaping the medicine and we’re shaping the customer care of this practice all together. If I’m not here, I trust you implicitly 110% that my clients are seeing you.” So we have to do this together and as a team, come up with these bundles and I loved it. It really was very effective for our practice on so many levels, but I think most importantly, just the collegiality of the doctors, because we all truly believed in what we were doing.

Dr. Andy Roark :
Yeah. I love the analogy. I love the fact that you talk about we’re a team. One of my big things is vet medicine is a team game. And whenever I say vet med’s a team game, I do get some pushback from doctors as well, who say, “Well, I want to be an individual. I want to practice things the way that I want.” And I liken it to any other team. You can be a phenomenal soccer player and play in your own style with your own talents and skills, but you can’t just run all over the field. You have to stay in your lane and otherwise the team suffers and everything breaks down. It’s a spectrum of yeah, use your skills and your talents and do things the way you want. And at the same time, you need to stay on your side of the field so everybody else could feel safe and we can work together.

Dr. Andy Roark :
And so I completely agree with that. You put your finger right on one of the biggest pain points. We have a lot of managers and medical directors who listen to the podcast and I know that when we talk about this, the idea of getting the other doctors on board with these bundles and how we put services together, I think that’s the stuff of nightmares for a lot of people and they dread having these conversations. I am 100% with you. I don’t think that you roll these out to the doctors and say, here’s the packages. I think that that is going to go badly 99% of the time. I love your approach of bringing them together and saying, “We’re going to have a meeting and we’re going to talk about what this stuff looks like.” Do you have advice for being effective. When you bring groups of doctors together and saying, “Hey, we want to start bundling some services together for all the reasons that are laid out.”, how does that conversation go? What makes it an effective conversation?

Dr. Natalie Marks:
Well, I think there’s a couple things that help it be efficient and effective at the same time. First is I really firmly advocate in sending out prep work to the doctors. And right now you’re probably rolling your eyes at me. Prep work in today’s world. No one’s going to do it. Well, here’s the thing. And I’ve had to learn this with my kids in parenting. There’s two choices here. If the doctor is really interested in being a part of invoice bundling, they’re going to think about it. They’re going to think about, “Well, I don’t really know a ton about ophthalmology, so I’m going to let other people decide this, but I am a huge derm nerd and I want to be a part of what is challenged and put into our derm bundles.”

Dr. Natalie Marks:
So somebody is going to take the time. If they don’t want to take the time to be part of that conversation, that’s completely their choice. But the consequence to that is the bundles that come apart, you’re part of this team, and this is what the consensus is going to be. So feel like it’s the same thing. You don’t want to vote in the primary, you’ve got to just take what comes out of it. So this is the thing. We sent prep work and said … We didn’t invoice bundle everything to start. We did major stuff. So derm is a huge thing. Urinary cats, the big thing, comes into a lot of practices. Inappropriate urinating cats. Start with some bundles that you feel are you’re big offenders that come in and then give them prep work and say, I want you to come and have some ideas.

Dr. Natalie Marks:
And I think for some of them, I even gave them examples. “This is what I’m thinking. What do you guys think?” And then we had a time limit. So at dinner we sat down and say, “Okay, we’re going to spend 15 minutes talking about this.” And if it was totally all over the place and people were really passionate, we tabled it. Maybe waited until the next meeting to roll that one out. But I’ll keep coming back to derm because I think it’s an easy one and eyes are easy too. You have a red eye, there’s only so many tests we can do to check that out. The problem is that often we forget to do a Schirmer tear test or we forget to check a pressure. We just look for an ulcer and we miss a lot of that.

Dr. Natalie Marks:
In ophthalmology, in particular … Not to digress. But ophthalmology, I think is one area where so many practices are missing a huge profit center. Because in school, most ophthalmology rotations are pretty overwhelmed. There’s not that many cases that are different and it’s an elective. It’s not one that you sit on for eight to 12 weeks in a lot of our universities. So for me, my optha rotation was me and about 19 other students. And I was crammed into a corner watching a few fecal emulsifications. And I had a couple really nasty tertiary ulcers, but I didn’t do much. I mean, I maybe soaked a couple cases. But I didn’t do much and then all of a sudden I’ve got these cases and you forget what we’re supposed to be doing. So I think those are things that the medicine is pretty clear. These are the diagnostic tests. There’s not a lot of arguing about that.

Dr. Natalie Marks:
I don’t invoice bundle treatment. I want to be very clear about that. I invoice bundled diagnostics predominantly. But treatment … And this is probably something to respond to that pain point of wanting to be an individual. Here’s where you’re individual. This is where you can shine as an individual is in your treatment style and finesse about how do you treat that indolent ulcer or how do you perfect your Cushings hypothyroid cases or how do you treat lepto. Some of those things are going to be standard at the hospital, some of them are not. And so starting with invoice bundling, just start in the diagnostic realm. Let the doctors then have that individuality of saying, “I really love this insulin and I’m going to use this because this is where I’m comfortable.”

Dr. Natalie Marks:
Same thing with anesthesia. “This is the anesthesia protocol that I’m comfortable with and I need to be comfortable when I am performing these sedations and surgeries. I don’t want to be forced into something where I do not feel that I can relax and be the best doctor.” So maybe that’s something you aspire to, but I would not start there by any means. Gain the trust of the team. That is so imperative to a high functioning hospital is having the trust of the team, not just with management, but peer to peer. So that everybody says, “I’ve got my best interest at heart, but I also have yours. And I know that. And I show that.” And once you gain that trust, then you can expand into some of those things that are maybe not so clear cut.

Dr. Andy Roark :
Yeah. Doing a pilot program makes a ton of sense. Not doing everything at once, just starting. And I love the fact that you separated out treatment and diagnostics. That makes a ton of sense to me. All right. Are there any pitfalls in this that people should look out for? So let’s say that we’ve got people who are listening and go, “Do you know what? It makes sense to me to start to bundle some services. I want to try this out. I’m going to put some of these things together.” Do you have any words of warning going into this? Things that I want to make sure I do not … Any ways I can get myself in trouble that I could easily avoid?

Dr. Natalie Marks:
Yeah. I would say start with smaller bundles. I think one thing people like to do is go, “Oh, this is amazing. I’m going to put 19 things in a bundle so I capture every charge.” But I say start small and you can always add. As an example, let’s take optho. A dog or a cat comes in and they’re squinting. So three things that we would want to have in that bundle. Schirmer tear test, Fluorecein stain, and checking tonometry. There might be other things that you want to do later on with those cases, but we don’t need to then add in a saline wash and clipping around the eye or doing a fungal culture. Whatever you think that might be happening. Or checking for allergies. A lot of people think, “Oh, well I need to then add in the consequential components to this diagnostics or every differential that there could be for blepharospasm.”

Dr. Natalie Marks:
We don’t need to look for the zebras right away, I guess, is the thing. So start small. Start foundational. That’s that’s the key. Foundational workup for some of these guys is the best way to start. And then after a while your management team can look at it and say, “You know what, I’m going to pull all of my Cushings patients and I’m going to make sure that every single one of them had a urine culture. Oh, I guess they didn’t. Maybe we should talk about this at a doctor’s meeting and be like, ‘Hey …'” Or my favorite one is the PUPD workup. There’s five tests that diagnose about 90% of PUPD cases. So low colony urine count, bile acids, ACTH stim, abdominal ultrasound and lepto PCR. So if you have those on your invoice bundle for a PUPD workup, not every client is going to okay that. It’s a pretty involved financial workup.

Dr. Natalie Marks:
Maybe some will do it one step at a time. Maybe some will group them. Some will say no to everything and then some will do it all. But what it does is it gets in your mind, “Okay, if I tell my client most of the time, I’m going to find an answer on these tests and the client sees the value in the test, then we know 10% of the time there’s going to be a zebra, but the client knows that.” Like you said, it’s about setting expectations. The client knows ahead of time there’s still a 10% chance I’m not going to find the answer. Then at least again, you’re reinforcing, I have a good chance of finding it. I don’t want to say it’s 100%. I want you to have that clarity that you going in, you understand and acknowledge that if we do this whole workup, there’s still 10% of the time I’m not going to have the answer and we have to do some of these lesser known or sometimes more expensive tests to identify or even see a specialist. But it’s setting that expectation, I think.

Dr. Natalie Marks:
But I found that the veterinarians that use these bundles really start to be very quick on their feet of thinking in patterns. And their cases go faster. And I’m not saying they’re rushing. But they don’t have to rush out and look in a five minute console or look on their phone for deferential lists because you start thinking about, okay, I’ve got my five things for PUPD or I’ve got my four things for an itchy dog or whatever. And again, it’s not cookie cutter medicine. It’s that vet med is pattern based. Human medicine is too. It’s patterned based.

Dr. Natalie Marks:
There’s going to be the anomalies on either side but most of the time we’re in a bell curve and things are going to happen commonly. So I really like for people to think that way. And again, when you’re setting these up, set them up smaller first, so you’re in your bell curve. And then if you want to add things later that hit on your spectrum, that’s fine. But those are the ones you’re going to use less likely and that’s why I don’t like people to have to remember them all the time if that makes sense.

Dr. Andy Roark :
It totally makes sense. Dr. Natalie Marks, you are amazing. So impressive. I thoroughly enjoyed this. You have made my veterinary business nerd heart very, very happy today. I really enjoyed this conversation so much. Where can people find you online? Where can they learn more? You do so many things. What’s the best place to track you down?

Dr. Natalie Marks:
Yeah. Well, my website is marksdvmconsulting.com. It’s just a portfolio piece of what I’m doing and where I’ve been and where I’m lecturing. And I’m on Instagram at Dr. Natalie Marks. I don’t do a ton of social media. I’m probably an anomaly there. But I have some personal stuff on there. And then I still practice at VCA Blum, which is the practice I used to own. So you can check us out. And I’m also in Vane. So if you are interested, it’s a newer group to vet med. But if you are interested in startups and investing and sort of the Shark Tank approach to vet med, want to hear some really cool new products and technology that’s coming through, check us out. It’s the Veterinary Angel Network. And so we do a lot of really fun things. We were just out in Boston at the animal health summit and we have meetups and lots of cool presentations and pitches. So if you’re really into the business side of vet med and also again, what’s on the forefront of technology, that would be the place to check out for you.

Dr. Andy Roark :
Vane is V-A-N-E, not V-E-I-N. Not V-A-I-N.

Dr. Natalie Marks:
Like the weather vane.

Dr. Andy Roark :
Yeah, exactly, exactly. And it’s like, boy, vane can go a lot of different ways. So V-A-N-E. Thank you so much for being here, guys. The rest of you guys, take care of yourselves. Be well.

Dr. Andy Roark :
And that is our episode. I hope you enjoyed it. I hope you got something out of it. Thanks again to Dr. Natalie Marks for being here and sharing her knowledge. Guys, If you enjoyed this, if you’re watching on YouTube … First of all, if you’re not watching on YouTube and you’d like to see what the episodes look like, we have our interviews for Cone Of Shame on YouTube. You can jump over there to check it out. If you’re watching on YouTube, hit that subscribe button. If you are not, if you’re listening to the podcast, give us a rating. If you’re listening on an app that lets you do ratings, it’s how people find the show. It bumps us up in the search results. It’s super. It makes me feel good. It makes me feel like we’re doing work that matters and that’s worth something at least to me. I would appreciate it. So anyway, guys, that’s enough talking from me. Take care of yourselves. As I said before, be well. I hope to talk to you next week. All right. Bye everybody.