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Medicine

Can Bundling Diagnostics Make Your Practice Faster, Simpler and More Profitable?

July 28, 2022 by Andy Roark DVM MS

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.

Cone Of Shame Veterinary Podcast · COS – 151 – Can Bundling Diagnostics Make Your Practice Faster, Simpler And More Profitable?

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.

Filed Under: Podcast Tagged With: Medicine

Is it a Seizure, Heart Disease… or IMHA? (HDYTT)

July 20, 2022 by Andy Roark DVM MS

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.

Cone Of Shame Veterinary Podcast · COS – 150 – Is It A Seizure, Heart Disease… Or IMHA? (HDYTT)

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.

Filed Under: Podcast Tagged With: Medicine

The Vet At Noah’s Ark: Stories of Survival from an Inner-City Animal Hospital

July 14, 2022 by Andy Roark DVM MS

Dr. Doug Mader joins Dr. Andy Roark to talk about his new book, The Vet at Noah’s Ark: Stories of Survival from an Inner-City Animal Hospital. They discuss Dr. Mader’s career in inner-city LA during and immediately after the Rodney King trial in the early 1990s, Dr. Mader’s evolution as both writer and veterinarian, and Dr. Mader’s view of where veterinary medicine is going in the future.

From the publisher:

From renowned veterinarian Dr. Doug Mader comes a stirring account of his fight to protect his animal patients and human staff amid the dangerous realities of inner-city life and the Los Angeles riots—and a celebration of the remarkable human-animal bond.

The life of a veterinarian is challenging: keeping up with advances in medical care, making difficult decisions about people’s beloved companions, and, in Dr. Doug Mader’s case, navigating the social unrest in Los Angeles in the early 1990s. As one of the few exotic animal experts in California, he was just as likely to be treating a lion as a house cat.

The Vet at Noah’s Ark: Stories of Survival from an Inner-City Animal Hospital follows Dr. Mader and his staff over the course of a year at Noah’s Ark Veterinary Hospital, an inner-city LA area veterinary hospital where Dr. Mader treats not only dogs and cats, but also emus, skunks, snakes, foxes, monkeys, and a host of other exotic animals. This real life drama is set against the backdrop of the trial of four police officers in the Rodney King case, as well as the violent aftermath following their acquittal.

Cone Of Shame Veterinary Podcast · COS – 149 – The Vet At Noah’s Ark: Stories Of Survival From An Inner – City Animal Hospital

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


LINKS

The Vet at Noah’s Ark: https://www.amazon.com/Vet-Noahs-Ark-Survival-Inner-City/dp/1954641044/

Dr. Doug Mader’s Wedsite: https://www.dougmader.com/

Dr. Doug Mader on Facebook: https://www.facebook.com/douglas.mader.9

NEW 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

Douglas R. Mader, MS, DVM, Diplomate ABVP (Canine/Feline), Diplomate, ABVP (Reptile/Amphibian), Diplomate, ECZM (Herpetology), Fellow, Royal Society of Medicine

Dr. Mader received his DVM from the University of California, Davis in 1986. In addition, he completed a Residency in Primate and Zoo animal medicine. He is the consulting veterinarian for the Monroe County Sheriff’s Zoo, the Key West Aquarium, Dynasty Marine, the Sea Turtle Hospital, the Everglades Alligator Farm and the Theater of the Sea. Previously Dr. Mader owned the Marathon Veterinary Hospital, a double AAHA accredited 24 hr emergency/referral hospital. Dr. Mader is an internationally acclaimed lecturer and is on the review boards of several scientific journals. He has published numerous articles in scientific and veterinary journals, national magazines, and, is the author/editor and co-editor of three textbooks on Reptile Medicine and Surgery.­­ Dr. Mader’s latest project is his new book “The Vet at Noah’s Ark – Stories of Survival from an Inner-city Animal Hospital.”


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 veterinarian podcast. I am your host, Dr. Andy Rourke. Guys, I am here today with the one and only Dr. Doug Mader. We are talking about his new book, The Vet at Noah’s Ark: Stories of Survival from an Inner-City Animal Hospital.

Dr. Andy Roark:
Guys, this is a fun episode. It’s an interesting episode. Dr. Mader is such a wealth of information, obviously, on exotic animals. He’s written three textbooks. This book is stories. It’s stories from his life and career. It’s a one year time in his practice life. Man, he’s a smart guy. He also gives fantastic life advice. I just love hearing his insights on our profession. We get into all that today.

Dr. Andy Roark:
Guys, that’s enough for me. 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 and your veterinary career. Welcome to the Cone of Shame, with Dr. Andy Roark.

Dr. Andy Roark:
Welcome to the podcast, Dr. Doug Mader. Thanks for being back.

Dr. Doug Mader:
Dr. Rourke, thanks so much. Always appreciate it. It’s always fun talking with you.

Dr. Andy Roark:
Oh, you as well. I love having you on the episodes. You and I talked. Recently, we’ve done a couple exotic medical episodes. We talked about a [socotta 00:01:24] that got attacked in a dog attack. That was one of our recent episodes. I wanted to talk to you about things that you have going on that are not clinical cases, though. You are a prolific writer. You are someone that I have read their stuff for years and years and years.

Dr. Andy Roark:
You write medical pieces. You write opinion pieces. You write news. You have a regular newspaper column, and have for a number of years. Now, you have a new book. It is called The Vet at Noah’s Ark: Stories of Survival from an Inner-City Animal Hospital. Let me start off, why don’t you lay down your writing resume and origin story for me? How did you get started writing, and what has that been like?

Dr. Doug Mader:
I’ve always liked to write. I’ve always liked to read. I started writing creative writing back in high school. Been kind of a closet writer ever since. When I got to college, I wrote columns for the student newspaper. After college, I started doing newspaper or magazine articles, and continued with actual newspaper articles. I’ve written three textbooks, medical textbooks, and countless peer reviewed articles.

Dr. Doug Mader:
Well over 2,000 magazine and newspaper articles. Then under a pseudonym, I’ve written several short stories, but I’ve always wanted to write the great American novel, so to speak.

Dr. Andy Roark:
That’s amazing. I love when people are highly accomplished in vet medicine, and they have a hobby on the side. That’s something they do. The fact that you write under a pseudonym and write shirt stories, I think is awesome. I think more of us should have things that we’d get away from our regular day to day practice life and do like that.

Dr. Doug Mader:
Well, I tried to write this book under my pseudonym and the publisher said, “No, no, no, no, no, no, no. You have to use your real name.” My hero, and probably yours, and everybody in veterinary medicine, probably at some point read the James Harriet series, All Creatures Great and Small. For those of your listeners that aren’t familiar with him, he was a veterinarian in England, and he practiced back in the fifties and sixties. Then when he retired in the seventies, he penned a series of books.

Dr. Doug Mader:
Started out with All Creatures Great and Small, and then he had three sequels to that. He was a veterinarian in the countryside of Yorkshire, England. It was beautiful, rolling green hills, and friendly farmers baking him apple pies. His stories, he was an incredible writer. Just amazing. His stories were engrossing. You really felt like you were riding shotgun with him, as he drove in his old car through the countryside.

Dr. Doug Mader:
I probably read all of his books two or three times each, just because they were just so well written, and all about human and animal bond. It just was the magnet that took me into veterinary medicine, as I’m sure a lot of people, at least in my generation, felt the same way.

Dr. Andy Roark:
Yeah. I completely agree. I think one of the things that you have in your writings that are particularly interesting is you are, at least during the time of the writing here, you’re writing about the early 1990s. You were a general practice veterinarian, but your expertise in exotics is enormous. You were seeing a lot of exotic cases at the same time. I think that breadth of different types of cases that you see, I always think that’s really interesting.

Dr. Andy Roark:
I think this book is particularly interesting, in that it’s set in inner city LA in the early nineties in the backdrop of the Rodney King trial, and the social unrest that’s going on there as you and your staff navigate cases, and also the social unrest that’s going on at the time and in the area. Can you talk a little bit just about, sort of set the scene for me. What was going on at the time that you were telling these stories?

Dr. Doug Mader:
Sadly, Andy, the social unrest hasn’t really changed. We still see the same issues all around the country today. Back in the early nineties, for those not familiar with it, there was horrible, horrible situation, where a black motorist was pulled over and severely beaten by a group of police officers. It was probably one of the first times that something like this had been videotaped, because it was videotaped by somebody standing on their porch with an old video camcorder.

Dr. Doug Mader:
Then it got taken to the news stations. Of course, needless to say, once people found out about it, it caused quite a bit of rage, and just sadness. Really, people were upset about the way the whole thing went down. There was a lot of tension in the city. There were also some other high profile cases going on at the same time. The city was reaching this boiling point, right about that time that the book was written. The book takes place over one year. I wrote it in the first person. Technically it’s a memoir, but it actually reads more like a medical drama. It’s written in the first person, but it’s really about the human animal bond.

Dr. Doug Mader:
I like to make the analogy that I wanted to tell a story in a fashion similar to the James Harriet stories back in England. The difference though, of course, is where he drove a car through the beautiful rolling green, grassy hills and countryside. My situation was inner city, concrete, gangs, graffiti, drive by shootings, hookers, drugs, you name it. The common glue was that human animal bond.

Dr. Andy Roark:
Yeah.

Dr. Doug Mader:
Living in a situation like that and trying to do the best you possibly can to take care of people on their pets and prolong that bond. There’s some very trying circumstances. It was a challenge, hence the name of the book is The Vet at Noah’s Ark: Stories of Survival from an Inner-City Animal Hospital. There were some scenes, there were some episodes that were pretty hairy.

Dr. Andy Roark:
Yeah.

Dr. Doug Mader:
So far, the only criticism I received and everybody that’s read it, all the reviews of an extremely positive, but one person said they, they thought it was sad because of the whole situation with what was going on in the city and everything else at the time, which is true. It’s still sad today.

Dr. Andy Roark:
Yeah, no, I agree. I always love stories that have a backdrop that is interesting, and it can be poignant, and it can be challenging. I think as a lot of people look at the book today, and they think about where our world is now, and there’s a lot of existential anxiety, I think that a lot of us have, I think in a way, it’s nice to see that times have been hard in the past, and that the human animal bond rises above, and that we have a role to play and we can do things that are meaningful and important.

Dr. Doug Mader:
Yeah. I definitely agree with that.

Dr. Andy Roark:
You follow a number of different clients and a number of different cases as you sort of go through having the style of James Harriet. That was always my favorite thing is he would talk about the clients that he has. It was always amazing to me that I would read this set in 1800s, England. I would say, “I know those people.” Those people walk into our clinic today. People are people, wherever you are. Are there stories, are there individuals that you talked about in the book that still stand out in your mind? Do you have favorites?

Dr. Doug Mader:
Oh yeah. I’ve been a veterinarian, I’ve been in this profession for almost four decades. Sadly, we remember some of our success stories, and we remember some of the clients that are more colorful, so to speak. For me, a lot of the things that I remember are the cases that didn’t go well, because those are the ones that haunt me. Those are the ones that I lost sleep over.

Dr. Doug Mader:
There are some cases just like in human medicine, you do everything you possibly can. Face it, it’s a hospital, and animals come in, people come into hospitals, and they don’t always go home. That can be difficult. It’s one of those things that does lead to burnout. I think surrounding yourself with a great support group, and that would include staff, family, and friends, it helps you get through the bad days. Do I have favorites? Yes, I have favorites.

Dr. Doug Mader:
There’s some cases, this one’s not in the book, but I had to do a house call. It was a little old lady. She had to be in her mid to late seventies. She had a pet Congo fire eel that she kept in her bathtub. She’d had it there for 20 something years. Now, I don’t know how long Congo fire eels normally live, but it was actually in heart failure. This woman loved that eel. She had it there in her bathtub. Granted, it’s probably not the most natural place to keep a fire eel, but she fed it every day, and she was devastated.

Dr. Doug Mader:
It did eventually pass because it was in heart failure. Especially way back then, I don’t know about you, but I don’t have a ton of experience treating cardiac disease in Congo fire eels.

Dr. Andy Roark:
Nope.

Dr. Doug Mader:
We use what we learn in our dog and cat medicine. Then we try and apply it across species to some of these unusual animals. Yeah, there’s definitely, you hear about the young kids going into veterinary medicine. Like, oh, I don’t be a doctor. I don’t like people. The animal part is the easy part. It’s dealing with the clients is where the challenge can really come in. The animals want you to help them. Oftentimes, you have to get past that stonewall of a client to get them to allow you to treat the pet the way it needs to be treated.

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 DrAndyRourke.com. Thank you to them. This is something I wouldn’t be able to do without their help.

Dr. Andy Roark:
God, it makes me so good to be able to offer this. Over at the Uncharted Podcast this week, me and Stephanie Goss are talking about, are you toxic? We got a letter in our mailbag from a veterinarian who is not happy at work. They are giving suggestions, and feeling shut down. They’re kind of resentful of it. They’re saying, “Am I a toxic person here? I’m starting to feel kind of toxic.” If you’ve ever been in this situation, this is a great episode to check out. Get it wherever you get podcasts. That is Uncharted Veterinary Podcast. It is this week. It came out yesterday, July the 13th.

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 clients, 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 Doctor Andy Rourke store. One of them is all about charming angry clients. The other one is all about building trust and relationships with pet 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 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. It is a way that you can keep giving your people tools, just to make their lives easier. That’s what they’re all about. If you’re interested, head over to DrAndyRourke.com, and just click on the store button. You can see what’s there.

Dr. Andy Roark:
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. 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 Doctor Amanda Doran. She’s doing a workshop called Mavigating Neurodiversity, your clients’ coworkers and self.

Dr. Andy Roark:
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.

Dr. Andy Roark:
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. Now, let’s get back into this episode. If you could go back and talk to yourself in the early nineties, is there advice that you would give yourself as you were going into this period?

Dr. Doug Mader:
Yeah, I know probably most people don’t make mistakes, but I certainly made more than my fair share of them. I wish I had the knowledge back then that I have now. I probably wouldn’t make the same mistakes, or if I did, I’d have a better ability to handle them.

Dr. Doug Mader:
One of the biggest things I could tell young doctors is know your limits, and don’t overstep your limits, and don’t be afraid to reach out for help. If you have a case that’s difficult, call an expert. Get a second opinion, refer it out. It’s nothing wrong with that.

Dr. Andy Roark:
Okay. I want you to unpack that a little bit, because when I look at you, I know you didn’t have formal training in the areas of expertise that you excel in today. You are, in my mind, the picture of the doctor who tries things, who educates himself, and steps out, and does these unique things. Your breadth of experience is just amazing.

Dr. Andy Roark:
How do you balance that, know your limits with what seems, when I look at you and the impression I have of you is someone who continues to push and grow, and who’s not afraid to do new things, and try new things, and educate yourself. How do you square those two things? How would you say that to a doctor?

Dr. Doug Mader:
Well, it’s different. In the last 35 years, things have changed quite a bit. I did, just to set the record right, my residency was in primate and zoo medicine. We didn’t do a lot of reptiles back then, but I also became very good friends with a veterinarian named Dr. Fred Fry. He was probably the grandfather of reptile medicine. He wrote the first two books on it. We met at a bookstore. I didn’t know who he was. We became friends before I knew who he was.

Dr. Doug Mader:
Then he took me under his wing. I was very fortunate in that although I didn’t have formal reptile training, I did have a friend who was probably one of the best reptile veterinarians in the whole world. To answer your question specifically, there will be crossroads in your career, where you have a case, whether it’s a dog, a cat, buggy, or a reptile that it needs help. You may never have done it before. You say, “Okay, I’m going to refer this to a board certified avian specialist.” The owners go, “I can’t afford it, or it’s too far away. I can’t take six hours and drive to the vet school or to the nearest specialist.”

Dr. Doug Mader:
You may have to try it, but I think the important thing is you need to be really upfront with the client and say, “Mrs. Smith, Fluffy here has got a kidney tumor. We need to go in and try and remove part of the kidney. I’ve never done this before. If you want me to try it, I’m willing to try it, but be aware that I’m straight up with you. This is new to me.” Now legally, if things go wrong, you’re still held potentially liable, even if you tell them that. Whenever possible, you always want to try and reach out.

Dr. Doug Mader:
Andy, the beauty of today is people like you. You’ve got a podcast. You help teach people. The internet is amazing. I didn’t have that in the early nineties. I couldn’t quickly look something up on the internet. You dig out the books, and you hope that you could find it in a journal or book someplace. Now, you can pick up the phone, and there are so many services available, where you can consult with experts in any different specialty area and come up with a plan.

Dr. Doug Mader:
Maybe I can’t refer Fluffy up to the University of Florida, which is eight hours away, but I can talk to one of the experts there, and they can kind of walk me through it. We do have a lot more available to us, the tools now that we didn’t have back then. You’re right. Sometimes you had to do things for the first time.

Dr. Andy Roark:
What’s your perspective of where vet medicines going today? You tell stories about the past, and you’re still very involved in our profession. Are you optimistic about the future of practice? Do you see this continuing on as a wonderful profession? Do you have concerns? As you look at the landscape and reflect back on the stories from your own career, what are your thoughts on the future?

Dr. Doug Mader:
Well, let me rephrase your question. If I had a chance to do it all over again, would I? Absolutely, I would. I love what I do. I love waking up in the morning. My goal is to do what I can to help the human animal bond. Let me expand on that, just to finish answering your question.

Dr. Andy Roark:
Yeah.

Dr. Doug Mader:
The human animal bond is the little kid with their pet kitten, or it’s the old man walking his dog in the park, or it’s the guy with the leather jacket and the snake around his neck. It could also be you and I going up and doing photography, and taking pictures of a bald eagle. That’s still a bond, or it could be the family going to the local zoo, and looking at the animals at the zoo. That’s still a bond. The human animal bond is really a broad category.

Dr. Doug Mader:
Whether I’m helping the woman with her bird that’s got the kidney tumor, or I’m working with fish and wildlife, and fixing a wing on a bald eagle that’s been shot, I’m still doing something to help that human animal bond. Then you and I can go back out there in two or three months, and see that eagle flying by again and take our pictures. That’s just what keeps me going. To answer your question, because I know I’m talking in circles, would I do it again? Absolutely. I love what I do. I love the people. I love working with the animals. I love the technical challenge. I love surgery, endoscopy, ultrasound. I love all of that.

Dr. Doug Mader:
Now, where is it going? That human animal bond’s not going away. People will always have pets. Even people that don’t have a lot of money still have that desire for companionship. It could be a goldfish. I know you’ve had bad days. We’ve all had bad days. How many times have you come home and you picked up the cat and you just hold it until it purrs? What does that do? Drops your blood pressure, centers you. Makes you find your zen. I used to have pet fish before the hurricane. My aquarium was six feet long, and it ran the length of the wall by my front door.

Dr. Doug Mader:
When I’d get home at night, all my fish would be waiting in the corner of the tank by the front door. As I walk past them, I’d say hello, and they’d all swim down to the other end of the tank, waiting for me to put my backpack down or whatever I had to do, so I could come back and feed them.

Dr. Andy Roark:
Yeah.

Dr. Doug Mader:
Now, of course, did they love me? I would like to say yes.

Dr. Andy Roark:
Yeah, sure. Of course.

Dr. Doug Mader:
I’m the guy with food. Absolutely. The bottom line is, those fish depended on me, and it always made me happy to be able to feed them and watch them enjoy their meals. To answer your question, I think the profession is here to stay. It’s changed. We have a lot more specialists now. You have a lot of people out there that can help you get through difficult, challenging cases that you had to struggle through before, sometimes trip and fall. Would I do it again? Absolutely. Absolutely. I would highly recommend to any young student coming through, or technician, that if you want to do this, pursue your passion. It’s good.

Dr. Andy Roark:
That’s great advice. I love that answer. The last question I have for you is, do you have any advice you would give to someone who has always dreamed about writing? They’ve always, kind of like you, they had an interest from the beginning. I think a lot of people struggle with fear of putting themselves out there, or thinking that why would anyone want to read what I have to say? Do you have advice for someone who thinks that they might enjoy it, but has not picked up the pen?

Dr. Doug Mader:
I think if you like write, the key is you should write at least a page day. I learned that years and years and years ago. I keep a journal. The story, by the way, just happen to have a copy right here.

Dr. Andy Roark:
Nice.

Dr. Doug Mader:
The story is true. It’s a true story. Everything in there comes out in my journal that I kept. The dates, the timelines, the people, the pets, they’re all real. I changed the names of most of the people in the book out of privacy reasons, people that were in the news, like Rodney King, and lot of the people that were in the news back then, the public figures, their names are all real. Write. That’s all, you just have to write. They say you’re not a writer until you’ve written at least a million words. To put that in perspective: one typed page is 250 words. Do the math.

Dr. Andy Roark:
Okay.

Dr. Doug Mader:
I have long since passed that. I’m probably up well over two million words by now. The thing is, you can always get better. It wasn’t that long ago I signed up for an adult education night course on creative writing. You can always learn, just like in veterinary medicine. You think that, oh, I know it all, but then you go to a conference, and you’re always learning new things.

Dr. Doug Mader:
If you like to write, and you want to write, just start writing. Keep a journal, keep a diary. Doesn’t mean you have to publish it, but the more you write, A: you’re going to have good memories. You’ll have stuff you can go back and reference. Then down the road, sometime when you get old like me, if you want to turn it into a book, you’ve got all that stuff already there. You just have to reword it so that it’s in a story fashion.

Dr. Andy Roark:
Yeah. Yeah, that’s it. I love that advice. Dr. Doug Mader, your new book is The Vet at Noah’s Ark: Stories of Survival from an Inner-City Animal Hospital. It is available in hardback and on Kindle. I will put links in the show notes. Where can people find you online?

Dr. Doug Mader:
DougMader.com. If you go to my website, and there’s links there right to the book, and you can actually purchase the book through my website via the publisher, or any number of online book sellers. All the major brick and mortar book sellers like Barnes and Noble are carrying it. It’s fairly easy to get.

Dr. Andy Roark:
Awesome.

Dr. Doug Mader:
Barnes and Noble has it out right now. It just came out last week. For some reason, Amazon, it’s going to be out on July 12th, but it is out there and it is available. So far, like I said, people seem to like it. The New York Post listed it as required reading, which was quite humbling and quite an honor. I never expected that. I was pretty flabbergasted, because right next to me was James Patterson. I’m thinking …

Dr. Andy Roark:
Oh wow.

Dr. Doug Mader:
That’s good company.

Dr. Andy Roark:
Yeah. Yeah. That’s fantastic. Well, congratulations. I am super excited for you. I’m super excited about the book. Guys, I’ll put links to all these things in the show notes. I hope you guys will check it out. Everybody, take care of yourselves.

Dr. Doug Mader:
Thanks, Andy. I appreciate it a lot.

Dr. Andy Roark:
That is our episode. Guys, I hope you enjoyed it. Thanks to Dr. Doug Mader for being here, again, and I put links to his book in the show notes. I hope you guys will check it out. Gang, take care of yourselves. Be well, see you soon. Bye.

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

Advice For and From the Next Generation of Vet Medicine

July 13, 2022 by Andy Roark DVM MS

Dr. Peter Weinstein and his daughter Brooke Weinstein, a current veterinary student at Oregon State’s College of Veterinary Medicine, join Dr. Andy Roark to talk about how veterinary medicine has changed over the last 20-30 years, and how it’s going to change in the future. Our guests talk about how the education of veterinarians today differs from the past, and what these changes will mean for how the profession evolves going forward.

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Cone Of Shame Veterinary Podcast · COS 148 Advice For From The Next Generation Of Vet Medicine

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ABOUT OUR GUESTS

Dr. Peter Weinstein attended Cornell Universityundergraduate and the University of Illinois to receive his DVM. After graduation, he worked as an associatefor three years before opening his practice.

As he was running his practice, he identified the need for increasedbusiness acumen to make his practice successful. Thus, while managing andpracticing full time, he attended University of Redlands to receive his MBA. As a result of the MBA, he was able to relocate, expand andsell his practice to a corporate consolidator.

Politically, he served as President of the SouthernCalifornia Veterinary Medical Association and the California Veterinary MedicalAssociation and President for VetPartners, the national consultantsassociation. He just completed three years as the Chair of the Veterinary EconomicStrategy Committee of the AVMA’s Veterinary Economics Division

In the veterinary industry, he acted as Medical Directoroverseeing the Claims Department for Veterinary Pet Insurance.

Dr. Weinstein has provided small business and corporateconsulting via his company, PAW Consulting

After 14 years, Dr. Weinstein retired from his role as theExecutive Director for the Southern California Veterinary Medical Associationto pursue other interests including teaching at Western University

He was the 2018 Speaker of the Year for the Western VeterinaryConference Practice Management Section. Andin 2021 for the VMX Practice Management section.

He co-authored with Michael E Gerber, “The EMyth Veterinarian-Why Most Veterinary Practices Don’t Work and What to Do About It”.

Dr. Weinstein has spoken and written extensively on practice management, team building, leadership, collegiality, marketing, and other topics focused on making the veterinary profession better for all those affiliated with it.

Dr Weinstein lives in Orange County, California with hiswife Sharon, two daughters (one a veterinary student at Oregon State), two dogs, and Bazinga, a Senegal parrot.

Brooke Weinstein is finishing her third year of veterinary school at Oregon State University Carlson College of Veterinary Medicine. During her time there, she has loved working with her community through free wellness clinics for the houseless community as well as conducting research on tick-borne diseases in the underserved community. Outside of school , Brooke spends time hiking, snowboarding, and exploring Oregon.


EPISODE TRANSCRIPT

Andy Roark:
Welcome everybody to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. I got a fun episode today. I am interviewing Dr. Peter Weinstein and soon to be Dr. Brooke Weinstein. Peter is a Brooke’s father, and we are talking about generational differences in veterinary medicine, basically, where are we going? And how do we feel about the future? And should we be comfortable with our kids going to veterinary school and coming into this profession? Should we be more than comfortable? Peter and I, and Brooke, all talk about where education is today and where it’s going for veterinarians.

Andy Roark:
We talk about what the future of the profession looks like. There is really good conversation here about the future of recession. Are we looking right down the barrel of the next recession? What does that look like? What’s that going to do to the salaries that we’re seeing for veterinarians and for support staff? Is it going to change the way that we practice? Is it going to change pet owners’ ability to pay for our services? And how do we adapt to that? How do we keep that medicine accessible? Wide ranging conversation topics, really fun episode. Guys, I hope you’ll enjoy it. I’m going to stop here and say, thank you. Thank you. Thank you so much. This episode is ad free. Thanks to the support of my friends at CareCredit. 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.

Andy Roark:
Welcome to the podcast, Dr. Peter Weinstein, and soon to be Dr. Brooke Weinstein. How are you guys doing?

Peter Weinstein:
Great, Andy. Good to see you. Oh, Dr. Roark.

Andy Roark:
You call me Andy, please. Yeah, let’s do first names. Let’s all do first names, so Peter and Brooke and Andy. That’s what we’ll go with this time. Brooke, how are you doing?

Brooke Weinstein:
I’m good. Having some break from midterm, so thanks for inviting me on your podcast.

Andy Roark:
My pleasure. Thanks for making time. Guys, I want to have you guys on the podcast and talk a little bit about generational differences in vet medicine. Honestly, I’m thinking a lot about the future of vet medicine and what it looks like as it’s changing, because we’re going to a rapid period of change. Then also I’m kind of looking at the future of vet medicine and I have a daughter, she’s 14 and she has decided that she wants to be a veterinarian. I’m going to be honest and say, I have some mixed emotions about that. I want to talk with you guys a little bit about sort of your experiences and perspectives on what the future kind of looks like and sort of your experience as Brooke has gone through her training and just generally overall your perspective on life in the profession and that sort of evolution as well. Is that Okay?

Peter Weinstein:
Absolutely.

Andy Roark:
Awesome. Well, cool. Let’s go ahead and start. Let’s do some quick bios. Peter, I’ve known you for a long, long time. You have been a mentor of mine since I blew my own mind this morning. I woke up this morning for whatever reason and I’ll be honest. I had school dreams last night and I wondered, do you guys have? I’m sure Brooke does. The exams coming, and I forgot I had a class. I, a 100%, had those dreams last night and I had exams coming up and I woke up and thought, oh my God, I’m not in school anymore. Then I thought I graduated in 2008 and then I did some math and I’m like, that’s 14 years ago, which blows my own mind. It’s been a minute since I was in school. Peter Weinstein, do you ever have dreams of exams or classes that you forgot?

Peter Weinstein:
No. It’s funny when you had school dreams, all I could remember was the dream of showing up to school naked when you were a kid and having to go. You never had that dream?

Andy Roark:
Oh, no, I did. Yeah, I totally did. Yeah, I still have those dreams. That’s funny. Brooke, do you wake up having panic dreams about your exams?

Brooke Weinstein:
Not often, if I do, it’s like, I completely did not make it to the test and everything from my car ride, from leaving home to class, everything went wrong and I just didn’t make it.

Andy Roark:
Oh yeah, you guys are much more balanced than me. All right. Back on topic. Peter, I’ve known you since vet school. You’ve been a mentor mine for a long, long time. You gave me some of the first advice that I ever got on being a presenter and speaker. I said to you, “Hey, how do you get to do more presenting and speaking?” You said, “You need to write more.” I still remember you telling me that, and we were on a bus at the AVMA convention. I was like, “Huh, that sounds like good advice.” It’s advice that I still remember you giving to me today and it turned out to be pretty good. It’s worked out pretty well for me, so thank you for that. You are also the author of the E-Myth Veterinarian. You have been the president of the Southern California Veterinary Medical Association. I’m just going off the top of my head right now. I don’t have anything written down. What else? You are the owner of PAW Consulting. What else am I missing or forgetting in your bio?

Peter Weinstein:
Andy, I have known you since you were Brooke’s age, when you were president of the VBMA at University of Florida. That’s when we first connected, and so this is almost like déjà vu.

Andy Roark:
Yeah.

Peter Weinstein:
Now, I mean, for the past, I just got done teaching my first year of the business and finance class at Western University so I’m giving back to the students by teaching at the vet school here in Los Angeles. I’ve done a whole bunch of different things within the profession, but now as I head into the twilight years, it’s really more focused on education and growing the profession and really disrupting it and creating a better future for Brooke and others, because I feel like I have an investment that will be maturing in about a year and a month. I’m hoping to get a very good return on my investment, but it’s not just Brooke, it’s 4,000 other veterinary students that are graduating this year, next year and all the years down the road.

Andy Roark:
Oh yeah, no. Yeah. Well, I know the students appreciate you being involved, and like I said, you’ve been a mentor for me. It’s funny before we even started recording, I was talking to you about my business and things that I’m doing and being like, “Hey, Peter, how do you look at this? Because you wrote that you met veterinarian, and you always have excellent insight to give. Brooke, you are in your third year at Oregon State, is that correct?

Brooke Weinstein:
Yeah, I have about a month left of my third year.

Andy Roark:
Oh yeah. And so, have you started clinical rotations yet?

Brooke Weinstein:
No, I get to start June 11th, I think.

Andy Roark:
All right, so coming up very, very… When people hear this, then you’ll be in your rotations.

Brooke Weinstein:
It should.

Andy Roark:
All right. Exactly. It’s been a long time coming. All right. Brooke, when did you decide that you wanted to go to vet school? Did you know from a really young age, or is it something you came to later sort of in your education?

Brooke Weinstein:
I’ve been asked this question a lot and I really can’t pinpoint anything. I feel like it was junior or senior year of high school when I kind of had to start thinking about college and I think it was just something I knew about. And so, my dad kind of shoved me into a hospital, obviously not his because he didn’t have one. It was like, well, if you can survive surgery and you’re still standing, then maybe it’ll work. And so then yeah, I survived that and I was like, might as well see if I like this and kind of applied to colleges with veterinary school in mind and I stuck with it, so yeah.

Andy Roark:
Peter, were you excited about that from the beginning when your daughter was going into college and starting to talk about pre-vet? What was your emotional experience at that time?

Peter Weinstein:
Woo.

Andy Roark:
All right. You were fired up?

Peter Weinstein:
I was fired up. I really was because I had sold my practice when Brooke was three or four or five or something like that. And so, she really wasn’t raised in a stainless steel cage, like most veterinarians babies are. And so, when Brooke was showed interest in becoming a veterinarian and I think some of it was nature, some of it was nurture and she would go to the zoo with my wife and help out at the zoo as well. I think she had some different exposures that maybe pushed her to that level. But when Brooke said she wanted to become a veterinarian, all I said is, Brooke, I’ll do whatever you want to do to help, but I’m not going to… I don’t feel that I formally pushed her one way or the other except open doors and give her opportunities.

Andy Roark:
Yeah. I think that there’s a difference in saying I’ll be supportive versus, hey, I’m sort of driving the bus. Brooke, did you feel pressured to go towards vet medicine because your dad was so involved in it?

Brooke Weinstein:
No, I don’t think he made a single decision for me, besides me just asking him where do I go? Then he was like, here’s this clinic, go there.

Andy Roark:
Oh, that’s fine.

Brooke Weinstein:
Yeah, no, vet school wise, he was like, wherever you get in.

Andy Roark:
Right. Peter, did you ever rethink that emotional response? Was there ever a time when you have thought in the last eight years when you have thought, maybe this isn’t the best place for my child to go?

Peter Weinstein:
Absolutely not.

Andy Roark:
No? Yours a hardcore no.

Peter Weinstein:
No, I was very much supportive. If I’m going to have the roles that I’ve had in the profession, as an advocate, as an educator, even as a disruptor, then it would be wrong for me to have any second guessings from that standpoint. I really have to feel that being an advocate for the profession as I am, that being an advocate for what my daughter wants is the right thing as well.

Andy Roark:
That’s interesting. I don’t know if I am sold on that. Here’s why, so you and I both love that medicine and we worked hard on it. There’s definitely things about that medicine that I look at and I go, I don’t know about this, or where does that go? And so, it’s funny that you say no, as an advocate, I’m sort of all in. I go as an advocate, I still have questions and things. Again, like I said, I’m honestly wrestling with these things, looking at my own kids, for example, the change in practice ownership in our profession, and we’ve got corporation and things like that. Where I came from is a little bit different in that, I thought that I was going to be a physician for most of my life.

Andy Roark:
Because my dad was a small town surgeon, and that’s kind of where I wanted to go. I had the experience, I got to be about my junior year in college and my dad, I was talking to him and I was getting ready to take the MCAT. And he said to me, he was like, “Son, I’m not sure I would do this if I were starting over now.” This is about human medicine. Man, I was kind of thunderstruck by that. And so, I ended up not going to med school and I have never regretted not going to medical school like that, but it was still that jarring thing at the time.

Andy Roark:
And so, I’ve had that experience of having this idea of something that I thought was great and then had it sort of rocked and then going, wow, well, this has fundamentally changed. And so, I kind of went through that. I look at that medicine and I’m still very positive and optimistic, but it has radically changed in the last 10 years and I see it continuing to change and so, I don’t know. When we look at things, when we gaze into our crystal ball and think about what the life of a veterinarian is going to look like in 20 years, do you think that looks significantly different from what it looks like now?

Peter Weinstein:
I probably would throw that on Brooke.

Andy Roark:
Yeah.

Peter Weinstein:
Where does she see her job and her future? I mean, she knows that I’m a workaholic, but I think it’d be interesting to see what Brooke thinks about her future and the future of the profession.

Brooke Weinstein:
I do think it will be different. I guess as a third year, going into fourth year, people are starting to think, or a lot of my classmates are starting to think about, where are they going to work? Are they going to go corporate? Are they going to go private? How many practices they’re looking at that they think are private, but are actually corporate? I think the increasing amount of corporate practices is going to just change the profession and how veterinarians or what your job as a veterinarian’s going to be, because people will have the opportunities to work three or four day weeks instead of the five day weeks for 12 hours a day. I think the work life balance will get better. I also see the push towards like referring in specialty practices over just the GPs doing everything, kind of how human medicine is a little bit, I guess. I think that’s going to continue to go that way is what it looks like, at least from where I am.

Andy Roark:
Yeah. Are you considering specialization doing a residency, things like that, or are you still interested in being a GP given that you perceive a shift in that direction?

Brooke Weinstein:
At this point, I don’t want to do more school.

Andy Roark:
Yeah, I get that.

Brooke Weinstein:
But yeah, I’m also at the point where I have no idea what I want to do right now.

Andy Roark:
Gotcha. Understand. Okay. Talking about this, so you sort of mentioned work life balance as something that you see coming in the future in vet medicine, and I do agree. I think that’s been a huge move from where we have been in the past and a big cultural shift. Brooke, when you start to look at the priorities that you have as a third year vet student, and then also the priorities that your classmates have, rank out for me, what do you think people care the most about?

Andy Roark:
I think a lot of people say, what do young doctors want? Or what do people coming out of that school want in their career? Or what are they looking for in a practice? I know with a very competitive hiring environment, a lot of people kind of want to know that. You mentioned the hours and work life balance off the top. What do you think are the main drivers for you and your classmates, as you start to think about where you’re going to go next and what jobs you would take?

Brooke Weinstein:
Well, I think after vet school, lot of my classmates just want some time to breathe. I feel like I’ve heard a lot of people looking for a four day work week, the longer hours, but less days of working. Honestly, I feel like at least with the people that I talk to the most, we haven’t talked about what we want from our jobs. I think we’re just kind of so excited to start fourth year that haven’t even thought about after that.

Andy Roark:
Oh, really? That was sort of a question I was kind of leading up to, do you feel, because I’ve sort of heard rumors that vet students seem to be making employment decisions earlier and earlier in their school time than they did in the past. That’s always just kind of been a rumor and I’ve never really been able to pin that down. Is that your impression that you think that people are making decisions about where they’re going to go? Are they taking jobs in their second year and in their third year, that then the way that I hear or is that fairly uncommon?

Brooke Weinstein:
I’ve heard the rumors. I know very few people who have, I wouldn’t say the majority or even half the class is like that. I think I only specifically know one person who has considered or has interviewed for a job in her third year. Maybe it’s different at other schools or maybe that’s just not this, I just don’t know who they are.

Andy Roark:
Interesting. Oh no, when I talk to vet students, I kind of get a similar answer of. I haven’t met a lot of vet students who actually are seeing that trend, but I do hear a lot of excited whispers. Peter, you’re teaching at Western, I mean, do you have a similar perspective? Do you think the timing of people taking jobs is changing?

Peter Weinstein:
We actually talked about this yesterday, it was the final class of the year, and I just had what I call AMA, Ask Me Anything. We talked about, I suggested that they’re a year from graduating and that they should be looking now. I would suggest there’s probably five to eight people in the class of 105 that have probably got hard job offers already, contracts. We started her talking about the economy as well because there’s this threat of a recession in the next 12 months and what impact that might have on the business of veterinary medicine and some of these highly inflated salaries, maybe I shouldn’t say highly inflated salaries, some of the growth in salaries over the past two years and what impact the recession may have.

Peter Weinstein:
I don’t think it’s too early now to be looking for a position a year from now. Especially if we look at Economics 101 that says supply and demand. Right now, there’s a huge demand and a small supply. If you can find someplace that you want to work in a location that you want to work, that gives you a life balance and mentoring and all of those other keywords, take it now, get the contract, get it signed, sealed and delivered, get a signing bonus or whatever you can from that standpoint and spend the entire of your senior year learning and not worrying.

Andy Roark:
Yeah. Where are you when you look into your crystal ball on the finances in the next 12 to 16 months? And what I mean when I say that is, we’re seeing rising, staff salaries, we’re seeing rising, doctor salaries, we’re seeing, quote unquote signing bonuses, which are actually retention bonuses for the most part to encourage people to stay on for multiple years. If there is a recession, right, we’re seeing we’re seeing rising inflation is the number one things that people are upset about. We’re hearing the fed talk about the economy running hot and taking active steps to clamp that back down.

Andy Roark:
If we move in a recessionary direction, are you of the mindset that medicine is a recession resistant industry and demand for doctors is so high because supply is so low that veterinarians will be fairly insulated from that? Or do you think that there’s a recession coming and we have a lot of exposure because of the private equity and the high multiples that people are paying and the upward trend in salaries where we’re going to see a significant pullback in the money being spent in medicine? Where are you in that? In between those two kind of think of it as a spectrum.

Peter Weinstein:
Dr. Roark, Andy, when you were a baby doctor between 2008 and 2012, we had the great recession.

Andy Roark:
Yeah.

Peter Weinstein:
Now, depending upon where you were in the country, there was a shortage of jobs, an overabundance of relief doctors, and some tremendous anxiety on the case of general practitioners in their ability to pay their bills, pay their staff. We had doctors getting laid off, et cetera. I don’t think we’re going to get to that point in the current situation. I think a lot of the escalation of salaries has been a response to the inability to find doctors for positions, especially at the corporate level, because they have an investment in a business that without doctors, no business.

Andy Roark:
Right.

Peter Weinstein:
And so, they’ve used money as a retention as opposed to culture. And so, I think what we’re going to start to see, and if you look at the trends economically in the profession right now, transactions are down. I mean, same period last year, we’re not seeing nearly as many people. Revenue is up about 4%, which is essentially fee increases. We’re busy because of our inefficiencies as a profession, but we’re not busy because people are… We’re not busy because we have a shortage of doctors, we’re busy because of the inefficient business model, the failure to leverage our staff, the failure to pay and keep our staff and a high turnover. There’s so many variables from that standpoint that we don’t have time to get into today. But what I do anticipate is we’re going to start to see a flattening out.

Peter Weinstein:
I think we had a perfect storm economically during the first two years of the pandemic where people had money, they weren’t going anywhere, they weren’t spending money on travel and then big screen TVs, they were sitting next to their pet and the pet had a hiccup and they thought it had brain cancer. And so, they would bring it in and have it seen and they would spend money because they actually had liquid income. But I think as we see this great retirement or whatever it’s being called, resignation, and we see less money being pumped into the people by the government, I think that spending is going to slow down.

Peter Weinstein:
I think [inaudible 00:22:01]. I think travel has increased in everything else, especially if you’ve been on an airplane, as I know you have. I think what we’re going to start to see is a normalization getting back to where we were to a degree in 2019, 2020, but then it’s going to be, how do we deliver veterinary medicine at that point in time? What’s it going to look like in terms of increasing our efficiency levels? Bottom line is I think we’re going to see a normalization and I think we’re going to see a flattening out, but I think we’re not going to see salaries drop. I just think we’re going to see a slow down in the growth of those salaries from that standpoint.

Andy Roark:
Yeah. That makes sense. Let’s talk about the impact of recessionary forces on pet owners and on spending because I think that you point that out rather astutely, are we going to see pet owners pulling back in their spending on pets? And if so, are we set up to deal with more cash strapped clients than we have been in the past? What does that look like?

Peter Weinstein:
It’s a great question because I think what we’re starting to see is almost a haves and have not economy.

Andy Roark:
Yeah. I hate it, but I think you’re right.

Peter Weinstein:
I asked it a couple of the meetings where I was speaking at, in the last 12 months, how many of you used fee increases as a barrier to access to care, to slow down the funnel of people coming in? 30 to 35% of the room said, “Yeah, we raised our fees with the hope that it would slow down people coming in.” The next question is, well, what did it? The answer was no.

Andy Roark:
Right.

Peter Weinstein:
Now, we have these fees that are up there, but we have people who don’t have the cash flow to make it happen. I think what we’re going to start to see is as happened in 2008 to 2012 delays of people coming in, so now, they come in a more critical stage. Pets ending up in the shelters because people couldn’t afford what they invested in and I think we’re going to have to look at some sort of normalization of fee schedules because we have really started to create a rift between what people can afford and what we’re charging.

Peter Weinstein:
Some of the communities that we do some work within LA, where people can’t afford veterinary care, it’s going to become even harder for them to be able to access veterinary care. And so, we’ve got to start to look at some of these spectrums of care and all sorts of different things that we’ve talked about to make veterinary services accessible, because I don’t think we’re underpaid and I don’t think we’re undercharging. I think we just haven’t created that whole value proposition for the client experience that people put a value in what we do yet.

Andy Roark:
Brooke, do you feel like vet students are getting some, or at least in your experience at Oregon State, do you feel like there’s part of the curriculum that’s focusing on talking to clients about money or accessibility to care? Is that something that’s kind of front and center in training today? Or is it something that’s kind of put off until after we get the medicine learned?

Brooke Weinstein:
Yeah. Well, we have one business course. I think maybe only my dad or maybe a few speakers did talk about finances and people’s ability to pay, but otherwise, no, it’s mostly just the medicine.

Andy Roark:
Yeah. I get that. You should always learn how to do the medicine first. It’s just one of those things where I guess, and this is the passion point of mine as well is, how do we communicate with pet owners and just sort of meet them where they are. I feel like there’s sort of growing interest and emphasis there, but it’s still, there’s so much to fit into a curriculum, but I still, I don’t know, I’d personally like to see more education in those type of hard conversations, just because I think that they’re coming.

Peter Weinstein:
Well, I think, Brooke worked with me in LA at some of the clinics and has been running clinics for underserved communities in Oregon. I think when you start to do that, you see how important pets are in people’s lives and how eager they are to take care of them, but they also have to feed their kids and put shoes on themselves.

Andy Roark:
Sure.

Peter Weinstein:
I think part of the curriculum really does need to be enhanced understanding of the entire population. They don’t need to take a course in economics. They need to take a course in understanding people and pets and communication and the human animal bond. I think that’s why Brooke has been involved with the Shelter Medicine Club, and I don’t mean to put words in Brooke’s mouth, but I’m happy for her.

Brooke Weinstein:
I mean, I could continue this if you want.

Andy Roark:
[Inaudible 00:26:38].

Brooke Weinstein:
Yeah, I kind of have a little bit different experience than probably a lot of people in my class. Also, last term, I worked at a wellness clinic that only gave vaccines, dewormers, preventatives, and stuff. A lot of people were coming in either because they couldn’t get an appointment at their primary veterinarian or just like the prices keep going up, and they’re like, I can’t afford that. Also, I guess going back to like where’s vet med going to be in 10 years? These pop-ups of wellness clinics, I think are also going to change why people go to general practitioners?

Brooke Weinstein:
Because I see a lot of people going to wellness clinics for their vaccines and preventatives to get them at lower costs. But then, the wellness clinics can’t provide any more care than that. Then they’ll start going to their GPs for when they actually have the ear problems and the eye problems and the skin problems. That’s also been really interesting for me to see because I’ve never actually seen a wellness clinic before, besides the ones that we do for the communities that are for free for the low income population, which I’ve also been a part of. It’s been really interesting seeing all of that from like kind of different levels of income.

Andy Roark:
Yeah. That totally makes sense. I’m fond of the saying right now the future is fragmentation. Meaning I think our profession is really going to split apart and you’re going to see how practice is doing a lot of different things, filling a lot of different niches. I don’t think that there’s going to be a uniform model at practice.

Peter Weinstein:
I know you were talking before that you couldn’t be an advocate. I think you have to be more of an advocate now. Andy, we have a broken profession, education model, association model, business model. Well, we, as doctors want to fix broken things. I think our role, yours and mine, is to identify where things are broken and come up with new solutions, different solutions, unique solutions, reconfigured solutions to help fix these things for the future. That’s why I’m an advocate because it forces me to think differently about how we can create this wellness clinic concept, the CVS clinic concept that the urgent care concept and all of these different things that retool this profession going forward because we ain’t going to get where we want to go by doing what we’ve done in the past.

Andy Roark:
Yeah, I agree with that. I think it’s funny for me, the fact that my daughter seems to be serious about vet school. I feel pressure to fix problems that I didn’t necessarily feel that much pressure to fix in the past. Like, oh, this isn’t going to affect me. I’m going to go on. And now, I’m like, oh crap, there comes [inaudible 00:29:29], we got to work on this. There’s a lot of that in my mind.

Peter Weinstein:
Yeah, welcome to my world.

Andy Roark:
Yeah. Oh totally. Brooke, let me ask you this. Is there advice that you got from your dad, the veterinary business consultant, business teacher, before you went into vet school that you have found to be very useful that other people would wish that they had gotten?

Brooke Weinstein:
Let me see if I can remember this.

Andy Roark:
I was just curious if there was anything that stuck out in your mind of like, “Yeah, my dad sort of told me this or he helped me understand this and it served me well?”

Brooke Weinstein:
I don’t know. I don’t think I can remember any exact words, but I feel like there were concepts in the words that he was telling me, kind of just like watch out for yourself because all you’re going to know is school. The amount of times, he was like, whatever happened in the news between the years that he was in vet school, he didn’t get.

Andy Roark:
Yeah. Yeah.

Brooke Weinstein:
I was like, okay, well, I will be prepared to live in a bubble for four years, but also cognizant of the fact that I need to look after myself when I can remember.

Andy Roark:
Yeah. Well, it’s funny you say that. When Peter was talking about the recession from 2008, 2012, I’m like I missed that. I was head down in my first job, I just learned in medicine and putting one foot in front of the other, but it’s funny. Yeah, I think that there’s a lot of truth to the idea of just putting our heads down and getting done what we needed to get done. I’m thinking a lot about these days about what do I have control over and what do I not have control over? I feel like if we look at modern media, we are bombarded all day every day with terrible things and injustices and hardships. I think that there’s a balance of not blowing those things off.

Andy Roark:
I’m not trying to ignore the problems in our society or not help other people. At the same time, I also don’t think that we can live all day every day, just immersed in challenges and hardships that we really don’t have any control over. You just take, for example, some sort of problems in our government. I know they’re hard to find, but I’m sure that they were there, problems in our government. I get one vote and I can be educated about who I vote for. Beyond that, there’s not a whole lot that I can do and I sort of have to figure out how invested this do I want to be, what is a healthy level of investment versus just me being upset all the time about things that I can’t control?

Andy Roark:
And so, I think about that a lot with vet medicine too, and go, what is in my power and what is not? It’s interesting. I always sort of put this forward to a lot of vets and other practices. I think it’s important to be able to step back and look at the profession as a whole, but I think it’s a lot more useful and probably mentally healthy to be able to dial in and look at where you are and what you need to do and look at your practice and what your practice can do and what is available, in that specific context, because those are the things that you can control. But anyway, I’ve just been thinking a lot about dialing in and dialing out and so when we have these sort conversations about where is the profession going and what can we do for it, I always sort of try to file that away in the back of my mind.

Peter Weinstein:
Well, I think what I’ve been most proud of in watching Brooke through the first three years is her finding time for herself, whether it’s snowboarding, whether it is working the clinics and doing the research, but trying to have a balance in what she does. I think that’s something I neglected to do, I neglected to do after I was in practice. I don’t remember any music from the ’80s and early ’90s. Also, not getting sucked into a lot of the news, not getting inundated with what’s going on in the world because the little world is the veterinary school world right now, but you have to get out of that bubble as well. I think if you spend too much time surrounding yourself with your classmates, some of those naysayers, those negative people have an impact on you as well. I think finding that balance and understanding herself and her needs and watching that is very rewarding as a father.

Andy Roark:
Brooke, what is the thing that you’re most looking forward to in veterinary medicine? As you move towards graduation, what are you most looking forward to?

Brooke Weinstein:
Doing what I went to school for, just very basic. Yeah, I’ve been telling people this because we’ve had junior clinics. We’re basically shadowing fourth years during this term. We’ve gone from three years of sitting for 12 hours a day to going into standing for 12 hours a day. Our bodies are kind of hurting just from the four hours of shadowing. But yeah, I’m just excited to just do what I went to school for.

Andy Roark:
Yeah. That’s awesome. Peter, as the parent of a veterinary student, and then also as a lecture and teacher at a veterinary school, what is your number one piece of advice for people who are entering the profession? What is the thing that you think will serve them well going forward?

Peter Weinstein:
I think we need to bring fun back into veterinary medicine.

Andy Roark:
Amen.

Peter Weinstein:
I think that we take ourselves too seriously at times, and it makes it very stressful work environment. I think we create a lot of our own mental health issues and there are external variables as well, but I really do think that hospital owners need to shut down and take people to the movies or bowling or the improv, or just hear Andy Roark, whatever. But I do think we need to take back control of ourselves and I think we need to have some fun and we need to make sure that fun is one of our core values.

Peter Weinstein:
I think we’re so focused on other things that we lose track the fact that we are people too. That if we are not healthy, we can’t take care of our clients and our patients. And so, if I was going to give a message to my colleagues, and if I’m going to give a message to the next generation is, “Yeah, take your job serious, but take life and have some fun with it as well, and make sure you go out and engage in the world and be a contributor in the world, but have fun doing so.”

Andy Roark:
Well, I think I’m going to take what Peter said and then what Brooke said and kind of put it together, I think in my mind, because I think you guys are both right on. I completely agree with putting fun back in what we do. I think that we should, we need to find the fun in just being in practice. I think that’s important for our long term happiness and to Brooke’s point about just being excited about doing the job, I think that we get sucked up into this big picture of what we’re supposed to be and this great meaning and purpose and the truth is we should remember to be happy just seeing appointments. We should be happy just to do vaccines and get to meet a family that’s excited about their new kitten.

Andy Roark:
Just to find enjoyment and fixing a urinary tract infection or lancing abscess, like that stuff is amazing. We get to do that for our job. I think that we have a bad habit, at least I do, is you forget that it’s awesome and we stop looking at it as awesome. We focus on the sort of existential headaches and hardships that we really don’t have any control over. And so, anyway, I just wanted to put those things together. I think that’s my big takeaway from our discussion here is, remember to have fun. And the other thing is, remember that what we do is awesome and people are excited, they would love to do what we do, and they think what we do is fascinating.

Andy Roark:
We should remember to enjoy doing it. When I say we enjoy doing it, I mean, enjoy doing the small things, enjoy seeing the appointments, doing the easy stuff, fixing the coughing dog. Like we should be proud of that and we should enjoy the process of doing it. Guys, thank you both so much for being here. I really, really appreciate your time.

Peter Weinstein:
Andy, thanks for the invitation. It’s not often that Brooke and I are actually together for 30 to 45 minutes and have a chance to talk. Thank you for bringing the family together. It was a nice thing.

Brooke Weinstein:
Yeah, thanks for having me on too.

Andy Roark:
Thanks guys. Thanks everybody. Take care of yourself. And that’s our episode. Guys, I hope you enjoyed it. I hope you got something out of it. Thanks again to CareCredit for making this podcast possible ad free. Gang, take care of yourselves. Be well. I’ll talk to you soon. Bye-bye.

Filed Under: Podcast Tagged With: Medicine, Perspective

The Shy Sulcata (HDYTT)

June 29, 2022 by Andy Roark DVM MS

Dr. Doug Mader joins the podcast to discuss treatment of a wounded tortoise that won’t come out of his shell. This 10 year-old Sulcata was attacked by a dog and needs care, but has pulled back tightly into his shell making treatment difficult.

In this episode, we discuss tortoise sedation and analgesia, antibiotic therapy and feeding tube placement.

Cone Of Shame Veterinary Podcast · COS – 146 – The Shy Sulcatta (HDYTT)

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


LINKS

Dr. Mader’s New Book: https://www.amazon.com/Vet-Noahs-Ark-Survival-Inner-City/dp/1954641044

Dr. Mader’s Website: https://www.dougmader.com/

Dr. Mader’s Facebook page: https://www.facebook.com/douglas.mader.9

NEW 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

Douglas R. Mader, MS, DVM, Diplomate ABVP (Canine/Feline), Diplomate, ABVP (Reptile/Amphibian), Diplomate, ECZM (Herpetology), Fellow, Royal Society of Medicine

Dr. Mader received his DVM from the University of California, Davis in 1986. In addition, he completed a Residency in Primate and Zoo animal medicine. He is the consulting veterinarian for the Monroe County Sheriff’s Zoo, the Key West Aquarium, Dynasty Marine, the Sea Turtle Hospital, the Everglades Alligator Farm and the Theater of the Sea. Previously Dr. Mader owned the Marathon Veterinary Hospital, a double AAHA accredited 24 hr emergency/referral hospital. Dr. Mader is an internationally acclaimed lecturer and is on the review boards of several scientific journals. He has published numerous articles in scientific and veterinary journals, national magazines, and, is the author/editor and co-editor of three textbooks on Reptile Medicine and Surgery.­­ Dr. Mader’s latest project is his new book “The Vet at Noah’s Ark – Stories of Survival from an Inner-city Animal Hospital.”


EPISODE TRANSCRIPT

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

Dr. Andy Roark:
Welcome, everybody, to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I’m back today with the man, the myth, the legend, Dr. Doug Mader, exotic veterinarian and writer extraordinaire. Dr. Mader has a brand new book out it’s called The Vet at Noah’s Arc: Stories of Survival From an Inner-City Animal Hospital. We’re not talking about that today, but I am going to get him back on the podcast very soon, and we’re going to talk about his book.

Dr. Andy Roark:
Today, he’s helping me out with a medical case. We are talking about an African spurred tortoise that has trauma. It’s been slashed up a bit, and it’s doing that thing that tortoise do where it has pulled its legs into its shell as tightly as it possibly can, and I can’t do anything with it. Guys, if you see tortoises, if you see turtles, this is a great episode for just a refreshing on how to work with them.

Dr. Andy Roark:
Guys, I got to tell you, this is what has me stumped. I go, I can’t do anything with this patient. Doug made it to the rescue. Guys, this is a fantastic set of little pearls to have in your pearl box, I guess. Not to a box of if it’s pearls, unless you want to put pearls in your toolbox. You can do that. I have a pearl box for medical pearls and Doug Mader is filling it up. And that’s what we’re doing today. Guys, that’s that’s enough of that 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. Doug Mader. Thanks for being here. Dr.

Doug Mader:
Dr. Roark, Andy, thank you so much for your invitation. I really appreciate. It’s quite an honor.

Dr. Andy Roark:
I love having you here. I’m not going to lie, whenever I have guests on the podcast, I take notes. I make this podcast because I want to be a better doctor and I want to learn. Buddy, I don’t know that I’ve ever taken as many notes as I did last time you were on the podcast. I filled up. I’m trying to make it quietly as I turn pages to get more of your pearls of wisdom. Thank you for being here. I have a case, and I’d be honest, I’m a bit flummoxed, and I need your help.

Doug Mader:
All right.

Dr. Andy Roark:
All right. Again, I’m embarrassed to ask this, but it’s true. I have a 15 kilogram, so 30… Yeah, 22 pound tortoise, I have one of the sulcata tortoises, the African spurs.

Dr. Andy Roark:
This is a 10 year old tortoise. The owners have this beast and let it run around their backyard. Unfortunately, not funnily, it was attacked by a dog. And so this tortoise has been injured. The owners say that the injury is significant. I believe that’s true.

Dr. Andy Roark:
Doug. I can’t see this. It has pulled back into its shell and I can’t really work with it. I don’t know how to examine this patient, much less, how to sort of treat these wounds. And so, let me just reach out with that big, broad opening and say, how do you treat this? How do right by this patient?

Doug Mader:
Yeah. You know what, Andy? Sadly, that’s a fairly common scenario, and don’t be at all embarrassed about asking that kind of question because-

Dr. Andy Roark:
It’s super embarrassing. I don’t know how to do this.

Doug Mader:
[inaudible 00:03:39] I mean, a dog or a cat comes in and you put your hands on him and do an exam and look at the paw, look in the ear, open the mouth. How do you that to an animal that’s a black box, when in like this? And you have to remember that, for these tortoises, they can’t fight back. Their response to fear, to pain, to anything, is to suck into their shell, right?

Dr. Andy Roark:
Yeah.

Doug Mader:
The dog attacks it and treats it like a big moving raw hide and chew it to pieces. And then they bring it to you, and now you want to handle it and carefully, with loving hands, protect it and take care of it. It doesn’t know any better. All it knows is that it hurts and it’s scared and it’s had a bad time, so it’s going to suck in even tighter.

Doug Mader:
Of course, if you try and grab it, a foot or a head or a tail, what’s it going to do? It’s going to fight you and pull back even more. So, don’t be embarrassed-

Dr. Andy Roark:
[inaudible 00:04:27].

Doug Mader:
That’s a good question. That’s a challenge. It really is.

Dr. Andy Roark:
And I’m pulling on these legs that I know are injured. You know? I know that this is where this thing got bitten and I’m like, “I don’t want to pull this guy’s leg out.” I mean [inaudible 00:04:39]-

Doug Mader:
Your point is great. If you fall off your skateboard or your bike or whatever, and you break your arm, do you want that doctor grabbing your arm? No, you don’t. Okay. Analgesia number one, okay?

Dr. Andy Roark:
Okay.

Doug Mader:
Don’t be afraid to sedate this animal. Now, here’s your biggest challenge that you’re going to have, is to convince the client that it’s okay to sedate an injured animal. Because so often times, they’re like, “Oh, I read on the internet that if you sedate a reptile, they don’t breathe and they die.” That’s not true. So, you’re fighting Dr. Google.

Dr. Andy Roark:
Right.

Doug Mader:
You need to be able to wordsmith it. I know your clients adore you and you have their trust, but maybe this client’s a new client, has never met you before. You’ve got to be able to convince them that, “You need to trust me and respect that I’ve done this before. Your pet tortoise, A, is in a lot of pain and, B, is afraid and, C, I need to be able to get to him and help him. I’m going to have to give him something for pain so that he’s not hurting, and something that sedate him so I can do a proper exam. And that allows me to make him feel better, and I know that’s what we both want.”

Dr. Andy Roark:
Yep.

Doug Mader:
So, what do we use? Okay. I’ve been doing this now for almost 40 years and my go-to drug, hands down, across the board for reptiles, Steelers.

Dr. Andy Roark:
Okay.

Doug Mader:
A combination Theledomine and Zelezopan. Theledomine is a dissociative like ketamine. Zelezopan is a benzodiazepine, like Midazolam or Valium. It’s a great combination drug. Why do I like it? A, because it’s a cocktail. B, because the Theledomine does offer some analgesia. C, it works quickly. So, you get this 10 kilogram tortoise, and sulcatas, I start with 10 mgs per kg, IM in the front leg, but I’ve gone up as highest 30, because sulcatas, I have found of all the species, all the different tortoise species, sulcatas tend to be one of the most difficult to sedate.

Doug Mader:
I start with 10 mgs per kg, give it a half an hour, and if there’s no relaxation, give it another 10 mgs per kg. Most of the time, it takes about 15 minutes, if the patient is warm. Now, it’s South Carolina and the animal’s out playing in the snow, which it shouldn’t have been, and it comes in hypothermic, 100 mgs per kg is not going to work. The animal has to be warmed. If you warm them up to their preferred temperature zone, which for a sulcata is about 90 degrees…

Dr. Andy Roark:
Okay.

Doug Mader:
… they’re going to respond like a mammal. Okay?

Dr. Andy Roark:
Hey everybody. I just want to jump in real quick with a couple of updates. Gang, before I do, though, I got to get a shout out. I got to get some love to Banfield Pet Hospital. Guys, they have stepped up and supported us in getting transcripts for both this podcast and the Cone of Shame Veterinary Podcast, which is the other podcast that I host. They do it to increase accessibility and inclusion in our profession. That is a big point for them right now, is something that they are doing for our whole profession and industry. And they stepped up and put their money where their mouth was and said, “How can we help you?” And I said, “Hey, this is a thing that people have asked for, and it’s a big lift for us.” And Banfield said, “We got you, buddy.”

Dr. Andy Roark:
They have made this happen, so if you want transcripts for our podcast, we got them. Head over to unchartedvet.com. You can see all of our podcasts and you can see transcripts for those. Feel free to share them and help us get the word out. But I just got to give some love to Bandfield, because they didn’t have to do that, but they did, and it is awesome. So, thanks to them.

Dr. Andy Roark:
Over at Uncharted online on June 29th at 8:30 PM, Eastern time, 5:30 Pacific, that is PM, not AM. Not doing 5:30 AM Pacific thing. Guys, over at Uncharted online, so you can join from anywhere, my friend, the one and only practice management goddess, Stephanie Goss, is doing her teamwork mind meld, setting expectations for team communication. Guys, do your teams struggle from a lack of accountability? You’re like, people don’t do what they say they’re going to do, and people don’t follow up the way that they should, and people don’t communicate in a way that stuff actually gets done. And they are making assumptions about what is going to happen that are not realistic, and it is continuing to cause problems between the team and management,

Dr. Andy Roark:
Guys, I see this all the time. Stephanie Goss’ workshop is all about setting expectations for how the team is going to communicate. Just think about how much you need that. Gang, this is a two hour actual workshop. Come with your camera. Come ready to talk about your practice. So, this is going to be stuff that you can take home and plug right into what you are doing and actually make a difference in the way your practice functions and to take this back and engage it with your team in a way that’s going to make a difference.

Dr. Andy Roark:
Guys, I hope you’ll check it out. Stephanie Goss is amazing. Uncharted Workshops are, they’re uniformly pretty freaking and fantastic. I do love them. I’ll put a link to that down in the show notes. Guys, as you might have heard, my brand new exam room communication training course, it launched on June the 7th. It is my 17 tips, tools, tricks, and hacks to make you and or your team more effective in the exam room.

Dr. Andy Roark:
Guys, this is the stuff that I lecture on all over the world, is my absolute best material. I wanted to make it available to everybody. I have people who always come up to me after my talks and say, “That was great. How do I teach my staff to do that?” And I got you now, buddy. I’ve got you covered because you can take this to your team. It is a hundred percent module.

Dr. Andy Roark:
It is broken up into five-minute modules that you can drop into your staff meetings, tag it onto the end of a team training meeting. You can do it in the morning huddle. You can go through and everything stands alone, so you can pick the things that you like, skip the ones that you don’t. You can look and say, “We need this the most in our practice. Let’s do this.”

Dr. Andy Roark:
Guys, the course pays for itself. If there’s one thing that you take and you give to your team and they go, “Oh, light bulb moment,” the fact that it’s made to go back to your team and be interactive, which means everything comes with discussion questions. So, you can say to your team, “How do we do this? What does this look like in our practice? How could we do this better? What opportunities do we have for improvement here?”

Dr. Andy Roark:
I give you those suggested wordings and questions to ask so that you can get your team to engage. Guys, I’m super proud of this. I’m super happy. For the first 30 days, so until July the 8th, it’s $100 off. Is a launch special. I don’t want this to slip past you. If you’re like, “I want to try that out,” grab it now. Grab it while it’s got $100 off. I’ll put a link in this show notes, but guys, I hope you love it, and you enjoy it. If you haven’t checked out my Charming the Angry Client course, it’s built in a similar model. It’s been very, very popular. People who have had it can tell you about what it’s like. You feel free to ask, because it has gotten very good reviews, and a lot of people have gotten a lot of mileage out of this.

Dr. Andy Roark:
But guys, I want you to be able to train your team, specifically your team, not some generic team. I want you to train your team in a way that’s going to work in your practice. And this is why I made this tool, so it can get taken and used as you want to use it. So, it supports your culture and your practice and the way that you guys work.

Dr. Andy Roark:
Anyway, I hope you’ll check it out. Like I said, I’m over the moon that has launched, and boy, it’s been a lot of work for me and my team, but I think it’s going to be totally worth it for those of you who check it out. All right. Let’s get into this episode.

Dr. Andy Roark:
Yeah. How long does it take to warm a… I think I misspoke at the beginning. We’re talking about 15 kilograms, so 33 pounds. If this tourist is cool, how long are we talking about to warm it up to a temperature that I’m going to be able to work with it well?

Doug Mader:
Excellent question. That brings up two real, very important side points. Number one, I’ve heard people say gradually warm them, and that’s baloney. If it’s an emergency, warm them up. If you have an incubator, I’d set that incubator at 95 degrees Fahrenheit and take that tortoise and put him in there.

Doug Mader:
How long does it take? To answer question number two, about 24 hours.

Dr. Andy Roark:
Okay.

Doug Mader:
Point number three. It is the rare reptile that can’t wait 24 hours to be properly warmed up and hydrated. If it is not warm, all the medications you give are not going to work. They’re not predictable. Okay. Let’s just jump ahead and assume that the animal was brought to you this morning. You were in surgery. Your awesome technician put it in the incubator. You went ahead and you took a spot temperature with it, with a gun, or maybe you’re lucky enough to get a cloaca and get a cloacal temperature, and it’s 88 degrees.

Doug Mader:
Okay. Telazol. I like it. I’d start with 10 mgs per kg, IM in the tricep. They have a hepatic portal system. So, if you give it in the back legs, first pass effect, it goes through hepatic conjugation, and it has been well documented that it minimizes the effect of the Telazol. You give it in the front legs. Boom. They go down like that. 15 minutes, 30 minutes maximum, totally relaxed.

Doug Mader:
You can extend the limbs, do your exams, get your radiographs, extend the head, access either jugular vein, get a blood test. Telazol, 10 mgs per kg. What else can you use? I’ve heard people say they don’t like Telazol because you have to reconstitute it, and if you don’t use it within 14 days, it goes bad. If you’re like me, I go through a bottle a day just about, it seems like. But you can put it in a freezer, too. It’ll last.

Doug Mader:
If you don’t want to use Telazol, you can use dexmedetomidine.

Dr. Andy Roark:
Okay.

Doug Mader:
50, 5-0, micrograms per kilogram, IM in the front leg again. There’s a first pass effect with a hepatic portal system. You can reverse the dexmedetomidine, but remember, dexmedetomidine is a really good analgesic.

Dr. Andy Roark:
Yeah.

Doug Mader:
And that is not an anesthetic dose. That’s a sedative dose. That’s enough to open their mouth and intubate them if you wanted to induce them with ISO. But oftentimes, I don’t reverse it. The reason I don’t is because it’s such a great analgesic. Takes about the same amount of time. I do know some people, throw in a little bit of ketamine with it, but a few studies that have been done have shown really that ketamine doesn’t make a lot of difference. So, I just go straight 50 micrograms per kilogram of the dexmedetomidine.

Doug Mader:
You can use midazolam. I like it because it can be IM. I usually use about 0.2 to 0.5. On a sulcata, I’d probably use 0.5 mgs per kg, IM, and that takes a little longer to work, about an hour. And then you can reverse it with [inaudible 00:15:07] if you need to. That’s not an analgesic. That is just a sedative. But again, my go to drug of choice, hands down is Telazol, and I’m going to circle back to that. And one of the reasons I really like it is the dose is really small.

Doug Mader:
If you get yourself a big sulcata that weighs a hundred kilograms, which is not unrealistic, okay?

Dr. Andy Roark:
Wow.

Doug Mader:
And you’re only giving 2 CCs. Whereas you might be giving 20 CCs of dexmedetomidine.

Dr. Andy Roark:
Right.

Doug Mader:
What’s easier to do?

Dr. Andy Roark:
Yeah, absolutely. Yeah.

Doug Mader:
[inaudible 00:15:37] is awesome stuff. Okay.

Dr. Andy Roark:
Gotcha.

Doug Mader:
Get that animal in. You warm it up. Even if you have to wait a little while, warm it up. If it’s got some obvious surface injuries to it, on a heating pad, start using warm water, flushing it, cleaning it, addressing the surface wounds. Once that patient’s, afterward it’s warmed up a bit, give it the sedative. Once it relaxes, then you can do your proper exam. Get your radiographs, get your blood work, address wounds.

Doug Mader:
Now, if you’re one of these animals that have severe, severe wounds, and some of these dog bites can be horrific. I mean, large pieces of flesh torn off, and you can’t really graft reptiles well. They don’t have a subcu layer. It’s hard to do sliding graphs and punch graphs. But the beauty of a reptile is that they have a tendency to granulate in, from the outside in. I’ve had animals come in with horrific, giant defects that with proper wet to dry, honey bandages, things like that, will heal in four to six months.

Doug Mader:
Now, if you have to change the bandage on this guy every day, okay. You give him the Citizol today. He wakes up, he’s doing better. The next day, you go out to change his manage and he’s doing this again. Okay, we need to sedate him again. Don’t fight him. Why do you want to grab that injured limb that we talked about and give him more pain? Just sedate him again. I think of one case that I have that was attacked by a pack of dogs, and it was literally sedated every day for four months. And we actually had to rotate between Telazol and dexmedetomidine and midazolam, because it kind of developed a resistance to the Telazol. We were giving it 40 mgs per kg, about three to four weeks into it, and it was still fighting the sedation. So, then we switched to dexmedetomidine.

Doug Mader:
Don’t be afraid to sedate it every day. I did my residency in primate medicine, and when we would get these primates that would get in these large monkey brawls, we would literally have to put them under every single day to change wounds.

Dr. Andy Roark:
Wow.

Doug Mader:
And it’s amazing how well they do. And it’s so much easier to sedate them, do the wound care and the vet care and then let them wake up, than it is to try and stress them and use [inaudible 00:17:39]. We don’t want to do that.

Dr. Andy Roark:
Yeah, definitely.

Doug Mader:
It comes in, you sedated, you do your wound care. Of course, utmost importance, address analgesia. If there’s wounds, it’s perfectly appropriate to use an antibiotic in these cases, and it’s going to be a gram positive in this situation, because it’s environmental. If it’s a dog bite, you worry about the anaerobes, so bacteroides, [inaudible 00:18:00] Peptostreptococcus. All the things found in dog mouths.

Doug Mader:
You might want to use something along the lines of subtazidine, because that gets your environmentals, and it’s about 80% effective against your anaerobes. I think that’s a good go for something like a dog bite. If you went with a fluoroquinolone, wouldn’t be my drug of choice. You would want to use something like a penicillin or maybe a metronidazole for the anaerobes, in a bite wound. But again, that wouldn’t be my first line of choice.

Doug Mader:
Analgesics, I like Ketofen, and it’s easy to give injectably. And then the other thing, too, is when this animal is out, when you have it under sedation, go ahead and put in a feeding tube. Now, because there’s that old adage, if the mouth works, use it. And I can’t stress out enough to veterinarians and the technicians and the pet owners. If the mouth works, use it.

Doug Mader:
Now you can give them oral fluids. You can give them oral antibiotics. You can give them oral analgesics, and you can give them calories. And the beauty is, they handle these feeding tubes so well, and then as the animal’s feeling better, you can pull the tube without sedation and the little fistula where the tube was, heels up like in a dog and a cat.

Dr. Andy Roark:
Yeah. Okay

Doug Mader:
Again, it’s a reptile. In this case, they may have gotten injured very quickly, but healing is going to take time. You got to give some of these wounds three, four, five months sometimes, depending on how bad it is, and they will heal.

Dr. Andy Roark:
So, setting expectations for the clients, because this makes perfect sense. And the feeding tube makes a ton of sense. For those tortoises that we think we may have to sedate, say, we’re doing bandage changes daily or every other day, and we’re expecting a couple of months to granulate in. In your experience, if I have a patient like this and I have to sedate them the first day and I have to sedate the second day, should I be going ahead and prepping the pet owner to say, “Hey, this is what’s it’s going to be for the long term”? Or do you have patients that get more on board?

Doug Mader:
You bring up really good point. I talk like everything is a perfect world, and we’d like it to be, but we know it isn’t. Many of these cases, they’re going to heal. They’re going to get better, you just have to be patient, but you need to prep the client that this animal may take six, four to six months of bandage changing. Intense initially, progressively getting less and less and less, but you’re looking at a lot of money. Make sure they understand that, because I mean, to sedate that animal with Telazol or dexmedetomidine every day, you’re looking at some bucks, plus the [inaudible 00:20:29] time, the bandage time, the doctor assessment time, the follow-up, blood work or cultures, or drugs.

Doug Mader:
So, “You know what? Your pet’s going to be okay, Mrs. Smith. But you should be aware, it’s not going to be better by Monday.” And frequently what I’ll do, is I have a lot of drama. I’ll walk over to the calendar in the room and I’ll flip forward two or three months. I say, “You know, it’s March right now. April, May, June. Probably June, July, right about here on the calendar. I think, that might be pretty close to where we’re getting the resolution.” When we see the pages flipped, they understand, we’re not talking about a week’s worth of drugs.

Dr. Andy Roark:
Yeah.

Doug Mader:
If they’re willing to buy that commitment, great. And you know what? I always believe that the patient comes first. It doesn’t hurt my feelings if they want to buy the meds online. I don’t care. I want that pet to get better. I’ll write the scripts for them. If they want to do the bandage changes at home. If they’re comfortable with that, I’m good with that.

Doug Mader:
I want that human-animal bond, we need to preserve that. And whatever we need to do to help them within their financial constraints, get to that end goal of a healthy pet, that’s what we got to do. So much of what we do is the art of medicine, the art of veterinary medicine, as opposed to just the drugs and everything else.

Dr. Andy Roark:
No, I agree. This is fantastic. This is super helpful. I feel like I’ve got some tools in the toolbox and I know the ways to use them. To get a good exam, to start to take care of this patient, to get us back on the road to healing. Are there any last pearls that you have that I should keep in mind as I approach a case like this? Are there any pitfalls that I should make sure that I avoid?

Doug Mader:
Yeah. You know what? I think we hit most of. There’s a couple things, and again, this could be a future podcast. We’re assuming that most of these wounds are soft tissue wounds, but we also know that big dogs, when they bite turtles, they can damage the shell. Cracks in the shell have to be approached like a fracture because the shell is living bone, so we treat it like we would treat any bone fracture.

Doug Mader:
Punctures in the shell we need to treat almost like they were punctures into the thorax. Reptiles don’t have a diaphragm. They don’t have a negative space, but if you puncture their shell and pathogens and bad stuff get inside, it can cause [inaudible 00:22:46]. So, you need to treat those as open wounds. It’s funny, because I probably haven’t used fiberglass on a turtle shell in 30 years.

Doug Mader:
Everything I do now is wet to dries or honey bandages. I love wet to dries. And these shell wounds, even big defects will regranulate and grow new bone from the inside out. It’s amazing how reptiles heal. I always joke and it’s really not a joke, because people think I’m smart. I’m not, I just picked an animal that’s very good at healing, and I tend to be their spokesman. Reptiles are pretty amazing animals, we just have to be patient

Dr. Andy Roark:
That’s amazing. Doug, thank you so much for being here. Where can people find you online?

Doug Mader:
Well, if you want to try and get a hold of me or find out more, I do have a website, it’s called dougmader.com. I also have a good Facebook page. My contact information is on the website. If you need some help, reach out. I’m good about answering email questions. My goal, Andy, is just like yours, and that is I wake up every morning and I want to do everything I can to support that human-pet bond. Any way that I can help you and your technicians, our colleagues and our clients, keep that bond growing and staying alive, I’ll do what I can. You know what? Thank you so much for the invitation and it means a lot. It really it’s quite an honor to be invited. Thank you.

Dr. Andy Roark:
Thank you, my friend. And that’s our episode. Guys, I hope you enjoyed it. I hope you got something out of it. Dr. Doug Mader is flipping amazing. Check out his book, The Vet at Noah’s Ark: Stories of Survival from an Inner-City Animal Hospital. He is a fantastic writer. He’s an amazing educator.

Dr. Andy Roark:
As I talked at the very beginning, he has such an impressive resume. He is someone that I look up to and, man, I aspire to be able to teach like he does in some capacity, on some topic, someday. I just, I appreciate Dr. Mader for being with us. Guys, take care of yourselves. Be well. I’ll talk to you soon.

Filed Under: Podcast Tagged With: Medicine, reptile, tortoise

How Burnt Hills Veterinary Hospital Started Home Delivery for Diets

June 27, 2022 by Andy Roark DVM MS

*** This episode is made possible ad-free by Purina ProPlan VetDirect***

Have you started home delivery of therapeutic diets yet? In this episode, Dr. Matt Duemler tells the story of how and why Burnt Hills Veterinary Hospital took up home delivery. He talks about how he discussed it with the staff to get them on-board, and what his experience has been like so far.

Cone Of Shame Veterinary Podcast · COS 145 How Burnt Hills Veterinary Hospital Started Home Delivery For Diets
Purina Pro Plan Veterinary Diets Logo

This episode is made possible ad-free by Purina ProPlan VetDirect.


LINKS

Purina ProPlan VetDirect: https://www.proplanvetdirect.com/

Purina Institute: https://www.purinainstitute.com/

Burnt Hills Veterinary Hospital: https://www.burnthillsvethosp.com/

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. Matt Duemler – Burnt Hills Veterinary Hospital, Burnt Hills, NY. There are very few people in this world I would change lives with! I have had many blessings in my life but finding a career that not only provides me the ability to support my family but also gives me a purpose each and every day has been one of the best. The old saying is “Find a job you enjoy and you will never work a day in your life”. This is so true!

Providing animal care has always been a part of my life, since growing up on my parent’s farm in Perth, NY. A graduate of Broadalbin-Perth, my college years were spent first at St. Lawrence University where I majored in Neuroscience and studied abroad in Denmark. I was then fortunate to be accepted to and attend veterinary school at the University of Tennessee. Throughout school, the complexities and capabilities of medicine left me in awe. I knew I wanted to spend my days helping people, and combined with my fondness for animals, veterinary medicine became a no brainer.

Every day is different, and I love it! I especially enjoy the days I spend in surgery putting Humpty Dumpty back together again. I have challenged myself to learn advanced techniques allowing me to treat a variety of issues. I have completed multiple advanced training courses and received a variety of professional certifications. This training allows me to evaluate a patient from start to finish.

I am able to perform the diagnostic test necessary such as diagnostic ultrasounds, repair multiple orthopedic issues including fractures, cruciate repairs and patella luxation, general surgical procedures such as removal of kidneys, spleens and gall bladders, as well as advanced certifications in regenerative medicine techniques such as Stem Cell and Platelet Rich Plasma therapies. There is no better moment than when a family is reunited for the first time after seeing a loved one battle through an illness. Our patients are resilient and very often inspiring.

When not “working” on animals, I spend my days with my beautiful wife and 2 amazing children. We have built our forever home here in Burnt Hills, the same town in which my mother-in-law grew up. My children will be able to learn in the same classrooms she did. Family and community have always been important to me. This is one of the main reasons my wife and I agreed to take over the leadership of the hospital. We are very proud to lead the community’s best veterinary hospital, while continuing its rich history of being a family run business. Unfortunately, in today’s veterinary community, being a family run business, centered on family values, is a rare commodity.


EPISODE TRANSCRIPT

Dr. Andy Roark:
This episode is made possible ad-free by Purina Pro Plan Veterinary Diets.

Dr. Andy Roark:
Welcome, everybody, to the Cone of Shame veterinary podcast. I am your host, Dr. Andy Roark. Guys, I am here with a fantastic guest today. My buddy, Dr. Matt Duemler, he and his wife are co-owners of Burnt Hills Veterinary Hospital in Burnt Hills, New York. A quick aside, plug: Matt, like so many of us, is looking to hire associates and support staff so if you’re in the Burnt Hills, New York area and you’re like, “That guy sounds awesome.” Maybe give him a call. That’s it, Matt. That’s as much of a plug as I’m doing for you. I promised to help. That’s all I got.

Dr. Andy Roark:
Gang, I am talking with Matt today about home delivery. Listen, I am a huge fan of the idea of home delivery and subscription services in vet medicine. Guys, we need to make vet medicine and pet health convenient because convenience trumps all right now and it’s only getting more that way. And automatic payment, subscription payments, things that keep one-time, big-lump payments to a minimum, I think that stuff is financially critical for the health of our profession going forward and us being able to get care to pets and to pet owners.

Dr. Andy Roark:
So guys, that’s what we’re talking about today is how Burnt Hills Veterinary Hospital set up direct delivery in their hospital. I asked Matt the hard questions: how did you get your team on board? What did this look like? What were the headaches? What were the push backs? What did the clients say? What did they like? What did they not like? And we just run through it all. Guys, I hope this will be a super useful episode for you. I love to hear how real practices are doing real, interesting things. And I think that is what we’re doing here. Gang, without further ado, 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. Matt Duemler, how are you?

Dr. Matt Duemler:
Hi Andy, I’m doing well today. How are you?

Dr. Andy Roark:
I’m doing great. I appreciate you making time to be here. You have a fascinating story. You have something that I really geek out about. And so I feel like I’m going to kind of ambush you with my enthusiasm here and I’m sorry about that, but I’m just going to lay it out. So just for those who don’t know you, you are a co-practice owner with your wife, correct?

Dr. Matt Duemler:
Correct.

Dr. Andy Roark:
At Burnt Hills Veterinary Hospital in New York, it’s an 11-doctor practice. Just real quick, tell me about how you became the practice owner at Burnt Hills because it’s a head-slapping story that I think a lot of people will relate to.

Dr. Matt Duemler:
Yeah. So when I was in veterinary school, my grandmother came here for a pet and she raved of the doctors here. So I actually did my externship here as a student and fell in love with the place and came here right out of the veterinary school and had two great mentors who really advocated for us to learn procedures and do more and were not just, “Refer everything,” It was very hands-on, do as much as you can and I fell in love with it. 13 years later, they decided it was time for them to retire and the way the world was going, they did not want to sell to a corporation. They wanted to keep it family-owned. And so my wife and I decided that it would be a good opportunity for us to step up and continue the practice running the exact way that we had been practicing for years and wanted to keep it that way.

Dr. Andy Roark:
Yeah. So let me ask you this, were you the driver of this or was your wife? Who was the one who was like, “I want to do this.”

Dr. Matt Duemler:
I was the driver. Yeah. My wife loves the medicine but we do kind of divide it a little bit where I do more business stuff and she does more of the medical directing.

Dr. Andy Roark:
Yeah. Okay. I just always think that’s interesting, when you have a married couple go in and I always wonder how hard one spouse has to push the other. I remember one time my wife and I had just moved to South Carolina and we thought we had housing lined up and we did not. We got there and the apartment we were renting fell apart and so we were homeless in South Carolina and we had to find a place to live. We had two little kids at this time. I mean like, baby and four years old.

Dr. Andy Roark:
And so we were driving around and I found this house on Craigslist and a bunch of frat guys had lived in it and we got there and it was a dump. And the guy was like, “Hey, I haven’t had time to clean it up yet.” And I was just like, “We’ll take it.” And it was the one time in my life that I totally said, “We should do this,” when my wife was like, “No, I don’t know.” And I remember the stress that that caused me until it worked out to be OK. But yeah, I always think that “Hey, we should do this,” conversation is interesting.

Dr. Matt Duemler:
My boss and I had had a conversation for a few years like “When you retire, we’ll do this,” we worked through this for a few years, kind of planning and they kept saying, “No, not yet, not yet.” And I remember clear as day, I went, I said, “Hey, Dr. [inaudible 00:05:14], my wife is pregnant.” He’s like, “Oh great, congratulations,” blah, blah, blah. The next week he said, “Hey, we’re going to retire this day.” Awesome. So yeah, my son was born in September and we purchased the practice in January.

Dr. Andy Roark:
Oh, man. That’s amazing. That’s some stress.

Dr. Matt Duemler:
It was little stressful. Yeah.

Dr. Andy Roark:
A little stressful. All right. Well, let’s talk about what we’re here to talk about a little bit. So here’s where my head is at. I have this vision of the future in my crystal ball where vet medicine is really focused on convenience for pet owners, because I believe that convenience is king, even more so than price, for a lot of pet owners. I think people are busy. They want pet ownership to fit into their life. I don’t think people like making extra trips to the vet clinic. I just look at my own life and running kids around to extracurriculars and making extra trips for pet food or things like that. That stuff is just… It feels like more of a hurdle than it ever did before. And so I’m looking at how does that medicine integrate into this “convenience first” culture?

Dr. Andy Roark:
And I’m looking a lot at home delivery of medications and especially diets and therapeutic diets. And I think that setting up home delivery and things like that, I think that keeps the veterinarian and the veterinary practice very much central in the nutrition conversation, also just in the therapeutics conversation. And the other thing is, I feel like as a society, people are getting much more comfortable with home delivery. There’s an Amazon box coming to my house every other day, of just random things. Dish soap showed up today and that used to never be the case. You know? I remember being very skeptical of Amazon and buying anything online 20 years ago. And during the pandemic, my wife and I used home delivery of groceries for the first time. And again, I never would’ve had somebody bring groceries or just even think…And now we’ve done it. And we’re like, “Well, it’s a thing.” And I know a lot of people do that and use it.

Dr. Andy Roark:
And so I’m really looking at practices, especially established practices, who have leaned into home delivery and have gotten their team to buy into it and are actually making it work and you are doing that. You are doing that with the Vet Direct platform from Purina. And I would like to kind of start real high like that with you and sort of say, first of all, what’s your experience been? Tell the story of kind of what you’re doing and kind of what your general impression has been.

Dr. Matt Duemler:
So I think like everyone else, COVID changed how we did everything. And we initially were all having our diets here, tried to sell our diets from the hospital. And when a lot of shortages happened with the different diets, it was really difficult to make sure that our patients were getting the right diet in the right amount of time, they weren’t running out, those type of things. So we did reach out to Purina, we did partner with them and very happy that we did in that we found…

Dr. Matt Duemler:
The way that we do it here is we keep a small bag of all the diets that we want to sell. And so the first day, when we’re talking to the owners about it, we can send them home with it right then, they don’t have to go and wait for it. They don’t have to order it, it’s there, they can have it, their dog can try it, and then they can sign up to get it shipped directly to them after that.

Dr. Matt Duemler:
And that has really… Like you said, the convenience is great. We also found that the freshness is a lot better as well. And so we have a lot of clients who do buy stuff from some of the online retailers. And what we found is when they’re ordering from Purina directly versus online retailers, the expiration date is usually a few months fresher from Purina directly.

Dr. Matt Duemler:
And so that really was a added bonus we weren’t expecting. And I think that people are also very cost-conscious. And if you’re in the veterinary hospital, you have a lot of things that you want to… Medicine you want to practice, drugs you want to sell, what have you. And if you can say to them, say, “Hey, try this bag and then order it directly from Purina.” And they’re like, “Oh, they’ll ship it to me?” “Yep.” It’s not like you’re trying to upsell them on something else, it’s something they’re more willing to try if they feel like you’re trying to make it more convenient for them, which we definitely are.

Dr. Andy Roark:
Yeah. So a couple things there, I hadn’t really thought about. One, the freshness thing never occurred to me. Like I just… It totally makes sense, did not cross my mind. The other part is… And we see this a lot, and this is why I’m big on the subscription sort of model. We’ve seen this when you have pets that come in and they’re getting their heartworm prevention, they’re getting their flea and tick prevention and then you’re talking about some blood work and a therapeutic diet. It’s just not going to happen. And it’s just because of that one-time expense versus if they don’t get flea and tick and heartworm prevention right now, they’re much more open to doing that senior blood work. Really, it’s kind of this weird mentality.

Dr. Andy Roark:
It’s kind of the mentality a lot of people have been putting forward with wellness plans for a long time. They’re like, “Oh, people will do stuff. It’s just that what they’re writing the check for today seems to really matter to them.” And so by sort of offloading or spreading out those costs, they seem much more willing to sort of go along. And so that makes a ton of sense to me.

Dr. Andy Roark:
I want to get into what this really looks like in practice, but the first thing I always got to say is, I think the question I get most often is how did your team receive this idea? We’re talking about during the pandemic. You’re like, “Hey guys, we’re going to start having this conversation. We’re going to start setting this thing up.” What was the reaction of the team when you rolled out something else for them to do during a pandemic?

Dr. Matt Duemler:
So if I break it down, I’d say our veterinarians, our doctors were very accepting of it, because we were already using a lot of Purina diets, so doctors were on board right away. Our staff, we kind of slowly rolled it out. We made one person our Purina point person. And whenever a client had a question about how to set up their account or how to order it, she would walk them through that. And I would say that’s probably the only glitch we had is that your initial setup of Purina is a little bit more complicated than going to Chewy and just clicking the button. And so we did have some non-computer savvy clients that Chewy’s much easier, “I understand the benefits. I’m just going go to Chewy.”

Dr. Matt Duemler:
And so we had one kind of point person who would go through every day and check, make sure that the orders were approved when they were needed. And the doctor would just write the note of what diet they wanted and they could approve that. And then, I think that the next thing that we did was every time that we received a request for food, whether it was to buy it from us or to buy it from our online retailer, we sent the clients an email stating, “Hey, we recommend buying it through Vet Direct because it’s fresher, it’s guaranteed,” all the different things that we liked about it. And “If you’d still like to get it somewhere else, great, but we recommend this,” and I’d say probably 75% of our clients follow that email and will go to Vet Direct and order it from there.

Dr. Andy Roark:
Okay. That makes sense. What kind of training did you do? Talk to me about the workflow in your practice to have these conversations. Is this a technician conversation, is it a doctor conversation? Who’s having the conversation and where are they having it?

Dr. Matt Duemler:
Yeah. So I think that the initial conversation always comes from the doctor and which type of food they recommend and why they recommend it. And therefore, the really nice thing with both the Purina food we sell here and if they get it from Vet Direct, we can tell the client very clearly, “Hey, try this bag of food. If your dog won’t eat it just either donate it to a shelter or what have you, but we’ll give you a refund for it.” And Purina has been really, really great at working with our clients on that and helping. So that’s the one fear, it’s like you said, you have this big bill already, now you’re adding on a $50 bag of food, but will he eat it? Will they eat it? Will they not? And it gets kind of rid of that issue.

Dr. Matt Duemler:
And then the second training really goes through our front-end team when people are calling to request these refills or requesting food in general, to be able to just kind of direct them to the website and direct them on different ways to order. And we have three main points that we make to them, why we recommend to order it there. And so they’re all kind of training those points. And if there’s more conversation we had, our doctors can have that, but it’s typically handled with our front-end staff.

Dr. Andy Roark:
Yeah. That’s nice to move it out of the exam room. What are the main questions or what are the main pushback that you get from clients? How do they receive these recommendations? Are there sort of standard responses or obstacles that you get from them?

Dr. Matt Duemler:
You know, I think for our brand-new diets, our brand-new clients who are taking those, again, they’re very happy to have that small bag to try and then to have it shipped to them later. They think that’s great. The challenge does come with clients who have already ordered it from an online retailer. Like you said, with those subscriptions and the way that they’re set up, they’re perfect. They do it very seamlessly. They feel like they’ve already purchased it. They’ve committed to these people. And it’s that’s a little bit of a bigger challenge. And I think those are probably the two main things is letting them know that they’re getting it fresh, they’re getting the best price and that we can still get it from someplace other than online retailers.

Dr. Andy Roark:
Yeah. Is there anything that you wish you knew when you started that you know now?

Dr. Matt Duemler:
So I learned a lot more about online retailers than I wanted to know, to be honest. So I think the only thing that was really difficult with the rollout of the Vet Direct is truly the initial sign up on the website is a little bit more difficult than Chewy or PetMeds or any of the other ones. And so we weren’t quite ready to answer those questions, why is it harder? Because we hadn’t done it yet. Now, I think we’re pretty well-trained in being able to walk them through and help them set that up.

Dr. Andy Roark:
Gotcha. Okay.

Dr. Matt Duemler:
I think the other point of it is the fact that we can get paid and never actually touch the bag of food is amazing.

Dr. Andy Roark:
Yeah. I’m sure. Keeping the vet involved in that is fantastic. When they go and they register, they indicate who their vet is or how’s that communication done? How do you sort of stay in that loop, I guess?

Dr. Matt Duemler:
Sure. So there’s two different ways. If you go to Vet Direct, you can search for your veterinarian and our name pops up or every hospital has a code. And so we do hand them a flyer with our code on it that gives them all the directions of “Here, go online, go to this website, punch in this code, order it.” And then the only thing that we have to do after they do that is approve it for a year or six months or however long we want to approve it for. But that proceeded pretty seamless, it works well.

Dr. Andy Roark:
What is your impression of compliance with this compared to before you were having home delivery? Do you feel like it moves the needle as far as how much of a therapeutic diet pets are getting or how long they’re staying on it?

Dr. Matt Duemler:
So I don’t know that I have those numbers accurately. My impression would be that because of the convenience, people are using it more readily. And we do it more, besides the food, things like FortiFlora or the probiotics, I think where, before they’d be like, “Oh, I’m on a probiotic, let me just pick up a random probiotic at the drug store.” It’s easy for them to click on Vet Direct and have it shipped right to them again. And so I feel like a diet, there’s not really other alternatives and people have been pretty… They either are going to use it or they’re not, but when you have the [inaudible 00:17:37] and the FortiFloras and those type of things, and they will start to look for comparables out there if it’s not convenient for them.

Dr. Andy Roark:
Perfect. No, that totally makes… I hadn’t thought about adding in the probiotics, things like that. Awesome. Well, Matt, thanks a lot for walking me through it. Any final words of wisdom, pearls for vet clinics that are thinking about adding home delivery, any pitfalls that you want to point out and be like, “Watch out for this”?

Dr. Matt Duemler:
I think that when you hear a lot of people lecture about the business aspect of veterinary medicine, there definitely are lectures who just say, “Eh, let your pharmacy go. You can’t compete with online. You can’t compete with at these bigger box stores,” what have you. And I disagree with that wholeheartedly. We have acted very aggressively in matching prices and helping with convenience, with setting up places like Vet Direct. We made the philosophy of partnering with really good companies and saying, “We want to provide the best. How do we do this together?” And whether it’s rebates or discounts or what have you, I feel like we’ve really been able to continue to offer the best medicine and keep those business profits and those incentives in our hospital to help fuel other things that we need, whether it’s new equipment or more staff, or we’re always hiring up with a plug out there for you.

Dr. Andy Roark:
Burnt Hill Veterinary Hospital. That’s fantastic.

Dr. Matt Duemler:
So I think that’s what our philosophy has been. Practice good medicine, partner with really good companies, good people. And the business aspect works out itself.

Dr. Andy Roark:
Are you doing home delivery in other product areas like parasiticides, things like that as well? Talk to me a little bit about that.

Dr. Matt Duemler:
Yeah. So we’re doing a in-house. So we have, with a couple of those products, been able to match them. And we’ll tell clients, say, “If you want us to ship them to you, we’ll ship them.” And the companies that we partnered with have been paying those shipping costs for us. And we’ve been able to both help financially by selling more products, but also take away some of the stress on our staff of having to receive the request, to validate the request, send them back. And that was a huge headache that we’ve really reduced significantly by using things like Vet Direct and also setting up our own kind of shipping to home from our products. And we haven’t used any of the big suppliers for online pharmacies. At this point, we’ve kept what we could in-house.

Dr. Andy Roark:
Yeah. That totally makes sense. Thanks for being here. Thanks for sharing your experience and expertise. I really do appreciate it.

Dr. Matt Duemler:
Well, thank you. It was very nice meeting you and very nice being on your show.

Dr. Andy Roark:
And that is our episode. Guys, I hope you enjoyed it. I hope you got something out of it. Special mega thanks to Purina Pro Plan Veterinary Diets for making this podcast episode possible. Guys, until next week, please take care of yourselves, be well. And don’t forget to enjoy the little things you find along the way in practice. Guys, that medicine is still a wonderful, wonderful place. Don’t lose sight of that. Take care, everybody. See you later.

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

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