Medicine

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.

Veterinary Internist Dr. Andrew Woolcock joins the podcast to discuss a 6 year-old Cocker Spaniel with an acute onset of lethargy, inappetance and depression. She also had a single collapsing episode that might or might not have been a seizure. Could this actually be IMHA? Dr. Woolcock talks through his diagnostic workup of choice and a variety of treatment options.

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

LINKS

ACVIM consensus statement on the treatment of immune-mediated hemolytic anemia in dogs: https://pubmed.ncbi.nlm.nih.gov/30847984/

ACVIM consensus statement on the diagnosis of immune-mediated hemolytic anemia in dogs and cats: https://pubmed.ncbi.nlm.nih.gov/30806491/

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

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. Andrew 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:
Welcome, everybody, to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andrew Roark. Guys, I’ve got a great one today with my friend, internal medicine specialist, Dr. Andrew Woolcock. We are talking about IMHA in the Cocker Spaniel, which is a breed that is super common to have IMHA. Guys, I love talking to Andrew. He’s awesome. This is a great episode, you’re going to get a ton of pearls in a short amount of time. 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. Thanks for being here.

Dr. Andrew Woolcock:
Yes. Thank you very much. My pleasure.

Dr. Andy Roark:
All right, man. It’s my pleasure. I’m so glad to have you on here. I do love to have conversations with the internists. You guys, the number one person I refer to is the internist. And so it’s great to have somebody on and talk through these cases. You, my friend, are an internist at Purdue University College of Veterinary Medicine. You are a Midwest guy, you did your residency down at the University of Georgia, go Dawgs, which is near my neck of the woods.

Dr. Andrew Woolcock:
Yes.

Dr. Andy Roark:
And I wanted to bring you in today and share a case with you. Is that okay?

Dr. Andrew Woolcock:
That sounds great.

Dr. Andy Roark:
Great. This is a game I call how do you treat that? I’m going to lay out a case and walk me through it and make sure I don’t make a fool of myself.

Dr. Andrew Woolcock:
Okay. Okay, I’ll do my best.

Dr. Andy Roark:
Excellent. You’re like this is possibly a steep order. I get it. Okay. I have in exam room three a six-year-old female spayed Cocker Spaniel named Liza. Liza was fine until yesterday, according to the owners. And then this morning, Liza is, and here’s nonspecific for you, lethargic, doesn’t really want to eat, has to be hand fed, she seems depressed. And then what happened recently that really set them off was she collapsed. Mom thinks that this may have been a seizure, dad thinks it might be heart disease, but they are really fixated on her collapse. On a quick physical examination, she’s got elevated heart rate. Her mucus membranes are pale, maybe slightly yellow a little bit when I’m looking in her mouth especially.

Dr. Andy Roark:
Just because she was pale, I did just a quick PCV total solids. PCV’s low, it’s under 18. So I’m definitely worried about some bleeding disorder. Total solids seem normal. But the serum itself is red and the texts were like, “Hey, you better look at this.” So when they spin it down, I’m still just getting red, yellow sort serum in my PCV, which hey, maybe that’s nothing, maybe it’s something. I want to bring Liza to you and just say, “Andrew, how do you treat that?” Where’s your head when I lay this case out? Where do I need to go from here?

Dr. Andrew Woolcock:
Yeah, thanks very much. First of all, yeah, let’s do our best for Liza, I’m guessing Liza with a Z here.

Dr. Andy Roark:
Yeah, totally.

Dr. Andrew Woolcock:
And so I think one of the best things that happened already is that on intake when it is discovered that Liza had this collapse episode, it was triaged to the point where she’s already in the back and you’re doing some triage diagnostics, which I think is great because the owners, when they see a collapse episode, of course that’s very dramatic, very scary. And so for them to already be bringing you differentials like seizure or heart disease is wonderful. And so then you’re in the back going, “Okay, is it one of those two things or should I be concerned for something else?” And the pale mucus membranes to me always makes me think, “Okay, we’re dealing with some poor perfusion issue. We’re not getting oxygen to the tissues that we’re hoping.”

Dr. Andrew Woolcock:
And that’s either because of a blood pressure issue, a state of shock, maybe heart disease, or as we now know with the PCV total solids, some very severe anemia. And likely in a dog who’s very ill, it’s some combination of those things, poor perfusion and anemia, or anemia with hypotension, or something like that. So already with this case, the anemia is a big concern and is a high yield problem that if you pursue, we’re likely to get to the bottom of.

Dr. Andy Roark:
Okay. Go ahead and start to lay down what does your initial diagnostic workup of this dog look like? So I told you PCV total solids, you just lay down a couple of things. You mentioned blood pressure. Where do you go? So mom and dad, they’re obviously very concerned. I just did a very quick test. What is your initial battery of tests on this dog and why?

Dr. Andrew Woolcock:
Yeah. Great. So because of the collapse episode, I think in addition to doing the PCV total solids which you’ve already done, the blood pressure to evaluate for hypotension, if you’ve got an ECG nearby, just to make sure that we don’t have an obvious cardiac arrhythmia or something like that then that’s a quick thing to do given that the collapse episode is being reported. But already with the anemia, you can at least suspect that there’s a chance that there is a cardiac arrhythmia without that being the primary cause. But at least good to evaluate for. But now that you know that you’ve got such a severe anemia, you can probably link that to the lethargy, poor appetite and likely the collapse episode that they’re seeing.

Dr. Andy Roark:
Right.

Dr. Andrew Woolcock:
So completing the remaining parts of your physical exam may reveal some of the other things we expect to see with anemia, like probably a heart murmur, likely to be quite tachycardic and tachypneic as compensation for that anemia. And then you’re going to evaluate on your physical exam for any other things that can help you move toward one of the three main causes for anemia, whether that be blood loss somewhere, a hemolytic process, or bone marrow disease or decreased production, although that can be difficult for you to detect anything on your exam. So in reality, you’re looking for markers of loss or hemolysis. So do you see bruising? Do you see obvious hemorrhage somewhere like in the mouth, coming from the nose, on your rectal exam, things like that? Are you detecting pain, distended abdomen, decrease or dull sounds when you’re trying to auscult the chest? Anything that would indicate to you that you’re looking for evidence of blood loss.

Dr. Andy Roark:
Yeah.

Dr. Andrew Woolcock:
Especially to explain the acute decline of this patient. So that would be the very initial thing before you’re really reaching for true diagnostic tests that just aren’t in your own hands.

Dr. Andy Roark:
Yeah. That totally makes sense. So yeah, we’ve got anemia, start looking for blood loss, yeah, with palpation, auscultation, all the things. Okay, that totally makes sense. If I go through this process, I’m not finding fluid in the abdomen. I stuck an ultrasound probe on there, just looked around looking for free fluid in the abdomen. I don’t see anything. The lungs generally auscult normally other than rapid heart rate that I can hear. So at this point, I’m getting interested in hemolytic disease. Let’s talk root cause analysis. So if I have a hemolytic disease in this dog, right, there’s idiopathic hemolytic disease, there’s also cancer related hemolysis, where do you go from there? Does it matter to you in the moment what you’re looking for? Are you trying to differentiate underlying pathology right now? Or are you just trying to stabilize the patient? How do you balance those things?

Dr. Andrew Woolcock:
I think that right now, stabilizing the patient is going to be key. But some of the root causes or the causes for hemolysis are going to be really important in determining the steps immediately following stabilization because they’re really going to guide the long-term therapy. So I think at this point, we turn our attention to the color changes that you’ve already described. The mucus memory maybe had a slight yellow tinge to them, the serum on the PCV total solids tube, which is a really helpful piece of information, was red to maybe orange in color. So it had a change that didn’t clear when you [inaudible 00:08:33] again. And to me, those are some real clear clues that there’s a hemolytic process going on. And so from there, you can pursue further diagnostics.

Dr. Andy Roark:
I want you to unpack that for me a little bit. So PCV total solids, you’re a big fan of this initial step. And I’ve heard you explain this before, but just real quick, run me through all the information that we get out of this simple PCV total solids test. Write that down for me.

Dr. Andrew Woolcock:
Yeah. It’s an incredible test. It’s a small micro hematocrit tube that gives you a huge amount of information because not only in Liza were we able to identify that her PCV is less than 18%, so quite a severe anemia, but you can also identify things like the total solids, which we already have learned is normal, and that can help us to deprioritize things like blood loss where you’d expect to be losing all that protein as well. And then the serum color is something that we don’t often think about but can be incredibly helpful because we’ve all spun a bunch of PCVs, hundreds of them. And so often, the serum color is clear and so we think nothing of it.

Dr. Andy Roark:
Right.

Dr. Andrew Woolcock:
But those times where the color is abnormal, it can really start to guide us towards an underlying disease process. The red discoloration can be really helpful for hemolysis. The yellow discoloration also helpful for hemolysis or for liver disease or something like that. So the serum color can be really helpful. And then even some smaller things like looking at the buffy coat, if it’s a huge buffy coat, then you know this patient is highly inflammatory, lots of white blood cells and circulation. So it’s a lot of information from a small tube.

Dr. Andy Roark:
Okay. So we’ve brought this patient in and we done our diagnostic batteries. We have a general idea acutely of what’s going on. The owners are going to ask me prognosis, how do you have that conversation especially if you’re not exactly sure what has caused this? What guidance do you give to them? Because they’re going, “Doc, how severe is it?” And they’re looking for some guidance for me. I still feel largely in the dark at this point. As far as what the long-term prognosis is going to be. I don’t expect you to have a crystal ball and have the answers, but how do you handle those conversations?

Dr. Andrew Woolcock:
Yeah. It is a challenging conversation because at this point, you have enough information to say to them that you are suspicious of a hemolytic process. But from there, your responsibility as a veterinarian is to try and determine is there a secondary or underlying cause for this hemolysis? And if there is, some of those are very fixable, very treatable, even curable, whereas other ones pose other challenges. But if ultimately you settle on an idiopathic cause, which is the most common in terms of canine hemolytic anemias, then prognosis is really and unfortunately dependent on the ability of the client to move forward with treatment.

Dr. Andy Roark:
Yeah.

Dr. Andrew Woolcock:
A dog like this, who’s already decompensating for an anemia is very likely to need blood product. And that’s only in the initial phase.

Dr. Andy Roark:
Right.

Dr. Andrew Woolcock:
Then you’re starting immune suppressive therapy, which can sometimes be months of therapy and a lot of doctor visits. But if the client is able to support their pet through that and comply with what can be a really challenging treatment course, then the prognosis can be fair to good in these patients. I think over the last 25 years when you look at the literature, survival rates used to be abysmal. And now more and more new literature, because of the greater availability of blood product and the greater knowledge and access to different medications, I think has helped us to really improve our success with this disease. But it’s still a long road.

Dr. Andy Roark:
Okay. No, that absolutely makes sense. I think that I can have that conversation in a reasonable way. 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 feel 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.

Dr. Andy Roark:
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. 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 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, little team building educational activity that might make your people laugh. Anyway, I want you guys to know that’s there. I hope that you will check it out.

Dr. Andy Roark:
In the Uncharted Veterinary community, guys, we’re doing a workshop that I’m super proud of. It is my friend, the one and only Dr. Amanda Doran, and she’s doing a workshop called Navigating Neurodiversity, your clients, coworkers and self. This is all about navigating interactions with different people and creating a culture that is supportive of neurodiversity in the workplace. Guys, this is not a workshop that I have seen before. I am super excited to have it, I think these are conversations we need to be having. I’m really proud to be a part of the Uncharted Veterinary community and being able to help bring out workshops like this. As always, this workshop is free to our Uncharted members. It is $99 to the public. I will put a link down in the show notes. And now, let’s get back into this episode. Let’s talk about beyond a blood transfusion, right, especially if we’re having what seems to be a rapid drop in the PCV since no concerns last night. And then today, we’re having these things.

Dr. Andy Roark:
I know it’s more art than science probably, would you hear of those types of drops? Do you anticipate a continued drop? If you see this, are you a wait and see person? If this presents to me, if a PCV of 18 and they say she was fine last night, in my mind, I’m picturing the trajectory, the downward slope of what’s been going on and I’m concerned it’s going to continue on, I’m going to go ahead and push hard for blood product at this point. Do you agree with that? Do I have a little bit more leeway than I think? In your experience from the time that they come in, what is the risk that they continue to decline rapidly versus by the time they come in, they’ve generally stabilized?

Dr. Andrew Woolcock:
Yeah. With the acute presentation that lies ahead, I think that your instinct to be more aggressive in the way that you’re recommending stabilization in blood product is appropriate because I think that these are patients who will continue to hemolyse their red blood cells and continue to decline in their clinical state. And because of the fact that we know the bone marrow is going to take three to five days before it’s really able to respond to this drop, we’re not going to have that time to let them start to resolve this on their own.

Dr. Andy Roark:
Yeah. Okay, that makes sense. Let’s go ahead and start talking about immunotherapy if you don’t mind. Can you go ahead and walk me through the thought process there and the most up to date treatment approach for trying to get this back under control?

Dr. Andrew Woolcock:
Yeah. I think if we can fulfill the diagnostic criteria for IMHA, which I’m happy to talk about, then treatment wise, gold standard is immune suppression and still we reach for old reliable of corticosteroids of prednisone because that is a medication that at immune suppressive doses has some of the broadest immune suppressive effects of any drug out there in terms of suppressing every type of leukocyte and complement and antibody responses, it suppresses it all, and it has the added benefit of doing it pretty rapidly. So you’re able to start seeing immune suppressive effects within 48 to 72 hours of starting that drug. And we don’t have anything else out there that can do it that quickly.

Dr. Andrew Woolcock:
So in this disease, it is absolutely the mainstay. There is of course lots of information out there about other drugs that can be added to steroids to help with this disease. And as of now, we don’t have a lot of consensus about if there is one that is superior to the others. But we at least have some criteria that we try to use to guide when we would add a second drug. And so for me, that is often a patient who isn’t responding to steroids in the first few days.

Dr. Andy Roark:
Okay.

Dr. Andrew Woolcock:
A patient who needs more than one blood transfusion within a 24 hour period, that’s something that we’ve chosen as a marker of severity of the disease process. A patient who’s suffering really quite severe side effects of their steroids. And we want to use this second medication as a means to taper that steroid more quickly to try to relieve those steroid related side effects. And then probably the fourth criteria that I often use when I’m thinking about choosing a second agent is if I’m dealing with a very large breed dog. Now Liza being a Cocker Spaniel is not a large dog so she may not be a dog that I’m immediately thinking about needing more than just steroids.

Dr. Andrew Woolcock:
But large breed dogs, as we all know, are so susceptible to high dose steroid side effects, especially things like muscle loss, atrophy, ligament, laxity, weakness, et cetera. And so we just can’t get away with high dose steroids and large breed dogs like we can in some of our smaller breed dogs. And so if it is a Labrador, something bigger than that, then I’m often using more than just steroids to try and get them off of the steroids sooner.

Dr. Andy Roark:
Talk to me a little bit, I’ve got a couple questions here, but I want to stay on this large breed dog thing for a second because I totally understand what you’re saying and that resonates and makes sense with everything that I’ve seen. What is your go to right now in the Labrador, in the Rhodesian Ridgeback, in the big dog that’s 90 pounds that presents for this? If you’re wary of steroids, what are you reaching for right now, Andrew?

Dr. Andrew Woolcock:
Yeah. So I still reach for steroids, but I think when you look at the formularies that cite an immune suppressive dose of steroids as being between two and four milligrams per kilogram per day.

Dr. Andy Roark:
Yeah.

Dr. Andrew Woolcock:
And then you have your Labrador patient who’s, I don’t know, 40 kilograms.

Dr. Andy Roark:
Yeah.

Dr. Andrew Woolcock:
And so now you’re looking at starting at something like 80 or 100 milligrams of pred per day, that’s a lot of steroid and can really do a lot more harm than good. So I still do start steroids, but I try and dose them more based on body surface areas. And so oftentimes, they may end up with about 50 to 60 milligrams of pred. And that’s often the cap that I use almost regardless of the size of dog. But then I think it’s natural to be fearful that you’re not accomplishing what you’re hoping to in terms of immune suppression. So on top of that, I add an adjunctive agent and I would say the two that I use most commonly are cyclosporine or mycophenolate are the probably two immune suppressive medications that I use in addition to steroids.

Dr. Andy Roark:
Okay, that’s super helpful. That definitely makes sense. I think it fits anecdotally with what I see. Anytime I have a dog over about 40 milligrams of pred, they pant, they drink, they pee, they drive the owner’s nuts, it seems to be a miserable experience for them. So that makes complete sense. I have 100% done those calculations, just been like, “This doesn’t seem right.” It seems like this is going to be miserable for everybody.

Dr. Andrew Woolcock:
Yeah. And I think if it was just going to be for a short course of steroids, something for a severe inflammatory response, allergic reaction, of course we know these large breed dogs can tolerate that. But when you’re talking about immune mediated hemolytic anemia for which they’re going to be on steroids, maybe four to six months, something like that, then you really start to worry about the long-term side effects of high dose steroids.

Dr. Andy Roark:
Well let’s talk about that because that’s another emotional part of this for me, because I do not want to be too soft and not get the job done. And so I feel this pressure to go heavy. And at the same time, I go, “Man, this is not a week. This is a long-term experience.” Walk me through your rationale on monitoring this condition. So let’s say that we get some 72 hour response and we feel like the patient’s doing better, we’re seeing an uptick in the cell volume. I’m starting to feel good about this. The owners are ready to go home, they’ve spent a good amount of money. They would like to try to nurse at home.

Dr. Andy Roark:
Talk to me about where we go from here. And again, they’re going to want to know how long are we in this for? And I want to set realistic expectations because I do not want them to get in their head they’re done with this in three weeks or six weeks, and then I’m fighting with them and saying, “Look, if you move too fast, this is going to be a problem.” And so it’s much easier if I can just set some good expectations at the beginning. Help me do that.

Dr. Andrew Woolcock:
Yeah. So one of the things that I think is a relief to clients is that it is not our goal that we normalize their PCV before they can go home, right? We just want to see that they’re stable. And so usually, my first celebration is when they plateau. If I gave them their blood product, they’re getting on their treatment and they’ve been sitting at 22% for 24 hours, that’s huge. That’s amazing that they’re holding steady. So once they’re home, then a few of the milestones we’re looking for to help us feel comfortable adjusting their medications are evidence of a regenerative response. So you want to see that their bone marrow does start to catch up and start to replace their deficit. And then you want to see some of those markers of hemolysis start to go away. So things like the serum discoloration that we already talked about, the icterus, the red discoloration, let’s hope that that has gone away. Some of the cell changes that you can see on a blood smear, like agglutination or spherocytes, you want to see that those have normalized.

Dr. Andrew Woolcock:
And then once a patient has been at home about two to three weeks and they are either in a clinical remission or approaching that, meaning their PCV is getting close to the normal range, that’s a very reasonable time to start a conservative taper of their steroids. And then often what I talk with clients about is I say, “Let’s get your calendar out and let’s start choosing a very regular time that we see you, somewhere between two and four weeks,” depending on your preference as a clinician, depending on how severe their disease process was, depending on how risk averse your client may be. If they are extremely risk averse, then maybe you don’t taper quite as quickly. And then just have them coming in regularly to have something at least like a PCV total solids checked in a physical exam. If not, occasionally evaluating a full CBC and use each of those time points to help give you the stamp of approval to reduce their steroid dose by usually about 20 to 25% at a time.

Dr. Andy Roark:
That makes sense. Any pitfalls I should look out for in this process? Where do people go wrong? Where do they move too fast? Where do they get faults that ends up coming back and biting them in the rear? What do I need to look out for, Andrew?

Dr. Andrew Woolcock:
I think the biggest thing that we worry about with IMHA is that it can be really easy to focus in on the red blood cells, because of course that is what is so dangerously low and we need to replace. But what we know about this disease is that one of the leading causes of death is that these are patients who are at a very high risk performing blood clots and having embolic disease. So whether that be most commonly a pulmonary thromboembolism or something maybe like an ATE in cats or to the brain or something like that.

Dr. Andrew Woolcock:
So blood clots are a real risk. And so making sure as a clinician that in addition to addressing the immune mediated aspect of this, that you’re also having them on some good prophylaxis to reduce their risk of clot formation is really important for these guys, because it’s shocking that they don’t really die of their anemia as long as you’ve got a client that can afford blood product and things like that, because we can always give them more red blood cells. But it’s the onset of a pulmonary thromboembolism that can make these guys really decline.

Dr. Andy Roark:
Okay. Talk to me a little bit about the anti-clot medications. What are your top choices for that? And are these medications cost prohibitive?

Dr. Andrew Woolcock:
Yeah. Well so thankfully, the answer to your second question is no longer the case. There are some really cost effective options. But in terms of what are the options out there, there’s two ways to look at this. You can either inhibit the clotting factors with something in the heparin family.

Dr. Andy Roark:
Mm-hmm (affirmative).

Dr. Andrew Woolcock:
Those are accessible, but can be a bit cost prohibitive and certainly can be challenging from the standpoint of administration and monitoring, right? So there are people that would advocate strongly to use a heparin and I don’t think that’s wrong. But case selection’s really important, that you’ve got a client that is able to give that medication because if you’re going to be sending it home, it’s a subcutaneous injection and you’ve got to have the ability to be regularly monitoring things like their clotting time. So I don’t use those all that frequently, but I think that there is a place for it and certainly the IMHA experts out there are somewhat split on what would be the best approach. But the other approach that is certainly more convenient and accessible would be an antiplatelet drug. So something that’s going to inhibit the platelets. And for a long time, low dose aspirin was used and that is still appropriate, but is somewhat falling out of favor just because we have some good research that suggests that about half of the dogs we use that in might have some degree of aspirin resistance.

Dr. Andrew Woolcock:
So we might not be achieving what we were hoping. And so the antiplatelet drug, clopidogrel, which is brand name Plavix, used to be somewhat cost prohibitive but now is available as a generic and is a mainstay for platelet inhibition. It’s a, irreversible platelet inhibitor, it does a really nice job of reducing that platelet function so that you don’t form clots and things like that. So that tends to be a lot of people’s go to for antiplatelet. And then there’s a newer drug, anti-Xa inhibitor called rivaroxaban that is getting a lot of attention and people are really excited about. And I think it’s going to be wonderful and there are already groups using it for things like saddle thrombus in cats. But that is quite cost prohibitive at this point. So I think there’s a lot of people just watching the market to see when that goes generic because I have a feeling it’s going to come in real handy for diseases like this in the future.

Dr. Andy Roark:
That’s fantastic. That’s great. I always love to hear, it’s like there’s something new and it’s looking real good and it’s in the pipeline, that makes me super happy. Andrew, thank you for being here. Do you have any resources that you really like in this subject matter, any place that you would say, “Hey, this is a good place just to pick up some more tips and pearls?” Anything that pops to your mind.

Dr. Andrew Woolcock:
Yeah. To me, something really exciting that happened, I want to say it was in 2016 or 2017, is that the Journal of Veterinary Internal Medicine published a consensus statement and they usually published two to three consensus statements a year, but that year they published a consensus statement about IMHA. It’s two full articles, one dedicated to a consensus on the diagnostics to be performed for IMHA and another article dedicated to treatment for IMHA. And they’re a fantastic resource and a great read. And I think what is interesting about them is that they actually reveal in so many ways the parts of IMHA for which we don’t have consensus yet because it’s still a work in progress and we’re still learning so much about this disease. But I think for people that maybe don’t see IMHA that often and are wondering what’s out there and what do I need to know, that’s a really great resource.

Dr. Andy Roark:
Outstanding. I’ll put a link in the show notes so that people can check it out for sure. Andrew, thanks for being here, man. I really appreciate it.

Dr. Andrew Woolcock:
Sure thing.

Dr. Andy Roark:
And that’s it. That’s what I 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 podcast, if you’d love to leave us a little review, that means the world to me. Yeah, if you like learning, check out the drandyrourk.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’re 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.