Team Culture

Are Non-Compete Clauses Going Away in Veterinarian Contracts?

May 31, 2023 by Andy Roark DVM MS

Dr. Lance Roasa joins the podcast to talk non-compete clauses! There has been a lot of attention recently on FTC proposed rule makings around non-compete agreements, and some are wondering what’s in the future for veterinarian contracts. Dr. Roasa weighs in on what’s going on and what we can expect in the future.

Cone Of Shame Veterinary Podcast · COS – 203 – Are Non – Compete Clauses Going Away In Veterinarian Contracts?

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

LINKS

Drip.vet: https://drip.vet/

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

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Roasa is a 2008 graduate of Texas A&M who has practiced in small animal, mixed animal and emergency settings and has bought, operated and sold over a dozen veterinary practices. He has completed a law degree from the University of Nebraska, is the past president of the American Veterinary Medical Law Association.

Dr. Roasa is a consultant for VIN and is a founder of Drip Learning Technologies, a veterinary continuing education provider. He also lectures in 13 veterinary colleges on the legal aspects of employment contracts, medical recordkeeping, veterinary malpractice and veterinary business as part of the curriculum. He serves as a national co-advisor to the Veterinary Business Management Association and regularly lectures to regional VBMA chapters and to the national association on the topics of growth, business metrics, and technology implementation.

Dr. Roasa also owns Santa Rosa Ranch, home to the largest registered Brangus cow herd in the United States.

EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Cone Of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I’m here with my friend Dr. Lance Roasa, who is a veterinarian and a lawyer, and he’s been on the episode or been on the podcast many times before. I always love talking about legal stuff with him. I love talking about what’s in contracts that veterinarians are signing and the practices they are using, and we are getting into non-compete agreements today. I’ve got a lot of questions. I feel like there are big seismic changes in non-compete language across the country and across different industries, and there is some FTC proposed rule changes that are shaping up. And I wanted to hear from Lance what those might look like and what he’s seeing in veterinary contracts. And that’s what we get into. So guys, if you got any interest at all in restrictive covenants, non-competes, non-solicitation agreements, non-service agreements, which are a thing we talk about, then this is a great episode for you. I hope you’ll enjoy it. I certainly did. Great, 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 everybody to the Cone Of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am here with my good friend, Dr. Lance Roasa. Lance, thanks for being here.

Dr. Lance Roasa:
Great to be here with you. Dr. Andy Roark. How are you today?

Dr. Andy Roark:
Man, I’m good. Summertime is here in South Carolina. It’s beautiful, but it’s hot. But that’s it for me. How about you?

Dr. Lance Roasa:
Same here. It’s exciting to be in spring. The kids are almost out of school. The teaching semesters, the veterinary schools are winding down, so it’s always a good summer.

Dr. Andy Roark:
So you do a lot of things, for people who don’t know, you do a lot of things like I do a lot of things and I’m like, “That guy does a lot of things.” You are a co-founder at drip.vet. Most people know drip.vet for the opioid education. And so I just recently took your two-hour opioid course. It’s the second time I took it. I took two years before that because I need it for my license every two years. And you had overhauled the whole thing. Nice work by the way. I was like, “I got to watch this thing again.” Nope, it’s all updated, refreshed, super good stuff. It felt very different. So props to you on that. But you also, you are hanging out on the VIN boards, drip.vet is part of the VIN family, and then you lecture all over the place of vet schools. Are you at 20 vet schools now? Something like that.

Dr. Lance Roasa:
Close to 20. Nobody’s really counting, but I think we’re at 18 or 20 vet schools, so I get to see a good percentage of the veterinary students as they enter their third year in veterinary schools. We talk about exciting stuff like the legal use of drugs and how to negotiate their contract and some stuff that I know that they’re just dying to hear about non-competes, which we’re talking about today. So that’s my job in the veterinary schools at this point.

Dr. Andy Roark:
All joking aside, people do get fired up about non-competes. You know what I mean? I am hearing a lot about it. It’s because of stuff going on with the FTC, but also a lot of vets are looking at their contracts. I think non-competes have become part of the battleground in recruiting. There are some big companies out there that have lots and lots of hospitals and they’re saying, “We don’t do non-competes.” And trying to use that as an advantage point in recruiting vets, things like that. I want to unpack this because this is an area where things are changing and people have a lot of interest. And so can you start to lay out for me traditionally what have non-competes kind of look like in veterinarian contracts?

Dr. Lance Roasa:
Sure. So I think to actually take a step back, let’s look at what non-competes kind of look like in society at large. And so in the American judicial system, so non-competes are centuries old. The case law in non-competes go back for literally hundreds of years. I mean even over as we borrowed a lot of our laws from England as we are breaking away as colonies. And so the battleground and the fight over non-competes in a business setting has been something that’s been going on for centuries. And so this is not a new debate, this is not a recent debate. This is the continuation of a long debate. Having said all of that, in veterinary medicine traditionally non-competes have been used sparingly through the sixties and seventies and eighties.
But really when practices starting going corporate, that’s when we really saw an explosion in the use of non-compete agreements. And so now at this point, nearly 99.9% of the practice of the contracts that I see contain a non-compete, especially from a state that will enforce a non-compete. And that brings up a really big point, is traditionally on the law side, non-competes are very, very state dependent, even to the point where they’re county or judge dependent. And we’ve got some states that will fully enforce non-competes and we’ve got some states, California is the biggest example, that will not enforce non-competes. And so you asked about where’s the legal standing, it’s really a state by state analysis to really understand what’s going on with non-competes. And traditionally that’s how it’s been forever.

Dr. Andy Roark:
I was reading recently that other professions have had non-competes kind of struck down. So attorneys and doctors, physicians I saw. And to me it seemed very much like a national thing. And the idea was having a non-compete might force people to break their relationship with their doctor if their doctor had to leave. Same thing with the attorney as you have a relationship with this attorney and then if they have a non-compete, they might be forced to leave, which would not allow you to maintain that relationship. And so the damage to that relationship was something that made sort of regulators say, in this industry these non-competes are not going to be acceptable. Am I getting that right? Is that across industries? Is that still state by state as well? Can you sort of speak to what that looks like?

Dr. Lance Roasa:
Yeah, you’re actually really close with that. It’s not necessarily-

Dr. Andy Roark:
Oh, good. I like to be at least in the neighborhood. That’s good.

Dr. Lance Roasa:
You’re definitely in the neighborhood. So on the legal side, it’s actually the legal ethics or what they call the professional responsibility will not allow attorneys to put other attorneys under a non-compete. And so it’s highly ironic that attorneys are asked to write non-competes for other professions, but they will not write a non-compete for their own profession. And the basis for that is exactly what you described, is it’s not a competition issue, it’s not a free market issue. It is the fact that the consumer of legal services in this case, their relationship would be highly damaged. And so if a lawyer leaves a law firm, then they’re welcome to take all the people that they served previously. On the physician side, what you’re referring to is some guidance that’s coming out from the AMA, the American Medical Association that says roughly the same thing. That physicians should not put other physicians under a non-compete for patient safety, for patient continuity, for the fact that that patients need to see a doctor continuously, not just the person that’s working at the hospital that day.

Dr. Andy Roark:
Yeah, that makes sense.

Dr. Lance Roasa:
Now, having said all of that, physicians and nurses and other healthcare providers are probably some of the people that are most affected by non-competes. So just because the AMA said, it does not mean that non-competes are somehow banned or not allowed in the human medical world.

Dr. Andy Roark:
Well, it’s interesting that you said doctors will not put other doctors under this. And I’m looking at the human medical world and I go, “Boy, there’s a lot of big corporations that own hospitals or medical groups or things like that.” Do they fall into that same category or is it something where you say, “Well no, these are not physicians putting other physicians, this is a different entity that’s getting physicians to sign a non-compete.” Is that different?

Dr. Lance Roasa:
It’s back to the corporatization world. And so it’s the fact that those hospitals that are truly employing those physicians are really corporations, honestly. So it looks a lot like if the AMA decided to put forth ethical guidance that said that veterinarians will not put veterinarians under non-competes. Well, a lot of hospitals are not owned by veterinarians. And so the AMA has no control over the corporate interests in our profession.

Dr. Andy Roark:
Interesting. Okay, all right. Lance, let’s start to talk about trends in the vet profession with non-competes. So I think back when I graduated about 15 years ago, non-competes were pretty standard and we were sort of instructed to pay attention to them. To pay attention to how much distance there was, how much time they would go for after you left your job, things like that. Have you seen a change or a trend in shrinking sizes, things like that? Or is it basically the same durations and distances that used to be, but they’re either in or out. So can you talk about general trends in that regard?

Dr. Lance Roasa:
Yeah, so there is a general trend on the legal side. So lawyers that write non-competes, to write them in the exact words are narrowly tailored. So to make them exactly what the protection of the business or practice in this situation needs. And so if you see a non-compete that is written by a lawyer that’s kind of studied on non-competes, they will try to write them in a very tailored way. And the reason for that is because they actually become more enforceable the smaller they are. Now you asked about timeframe, the timeframes still are almost always maxed out as what the law will allow. So some states, Florida, for example, 18 months, other states will presume that two years is reasonable. And so almost every practice and every lawyer that’s putting forth a non-compete is going to max out what the law will allow. The radius is very, very, very dependent on the practice locality, the practice type, et cetera.
The other thing that I really spend a lot of time teaching on, Andy, is what’s called the scope of practice. And so there’s three things to really look for. You’ve already mentioned the timeframe and the radius, but the third thing that is highly negotiable is the scope of practice. And so when you and I both graduated, there were a lot of mixed animal practices and there was an expectation that we would kind of do everything. But now practices are much more specialized. And so there’s day practices, they’re ER practices, there’s exotic practices, there’s small ruminate practices, there’s obviously equine practices. And so these non-competes that exempt all of practice, that’s a problem. And so what you see is practices start to say, “We’re only going to exempt daytime non-emergency practice.” Or, “Since we’re an ER practice, we’re only going to exempt competition in an overnight ER practice.”
And so the tighter that you can get that scope of practice allows that veterinarian to go on and do something else. But to answer your question, yes, these are constantly evolving. The other big thing that I see, that’s the difference when we graduated 15 years ago, is this use of the liquidated damages. And I think we’ve talked about this on a previous cone of shame podcast, but highly aggressive attorneys will write liquidated damages, which means that the damages are stipulated before you actually even breach the non-compete. And that’s a massive shift from what was in place 10 or 15 years ago. Non-competes are becoming more aggressive, but in certain situations they’re actually becoming more and more narrowly tailored.

Dr. Lance Roasa:
Yeah. So usually there’s a provision that’s attached to the non-compete provision, which says something like, “If you breach the non-compete, the associate, the employee, or now former employee, will pay the practice.” And usually it’s a large sum of money, Andy.

Dr. Andy Roark:
Just a flat fee?

Dr. Lance Roasa:
Just a flat fee, a hundred thousand, $150,000 to breach the non-compete. And usually when a veterinarian sees that, they’re like, “Now wait a minute, I have to pay the practice money. I’m getting paid by the practice. I’ve got to pay the practice money back. So where’s this $150,000 coming from?” They’ll kind of throw a red flag and say, “Ah, this doesn’t feel right. $150,000 doesn’t seem right.” What smart lawyers have learned to do is write a per diem amount in lieu of a breach. And so they’ll say something like, “If you breach the non-compete, we’ll stipulate damages of a thousand dollars a day.” Well, if you breach the non-compete for 150 days, you’re at the same exact point, you’ve got to pay the practice $150,000. But to the veterinarian that’s skimming that contract and not really understanding the legal terms, they’re like, “Oh, a thousand dollars, whatever.” That doesn’t really draw the red flag like $150,000 line item in that contract. So it’s a way to sneak these liquidated damages provisions past associate veterinarians and get that signature.

Dr. Andy Roark:
All right. So that makes sense. I was actually surprised when you said early on that 90% of the contracts that you see still have non-competes in them.

Dr. Lance Roasa:
I would say 99.

Dr. Andy Roark:
Really?

Dr. Lance Roasa:
Yeah, no [inaudible 00:15:01].

Dr. Andy Roark:
I felt like I felt like we were moving away from that. I was hearing more and more people saying, “Oh yeah, we’re not doing those anymore.” But you’re not seeing that on the ground. Is that correct?

Dr. Lance Roasa:
No, there’s a couple of large practices that have moved away from non-competes, but overall the vast majority of practices still use non-competes. There’s a couple of commentators that have written and talked about abolishing non-competes or getting the profession away from non-competes, but I have to be honest, that’s just talk. I mean, in the real world, I’m not seeing it change at all.

Dr. Andy Roark:
No, that totally makes sense. Talk to me about what’s going on at the national level. So there was sort of FTC proposed rule makings that were sort of in the headlines recently and people were talking about some of the Biden administration’s thoughts on non-competes and stuff. Talk to me about sort of what’s going on there.

Dr. Lance Roasa:
It was a pretty boring read overall, but what it does is it attempted to make the case that the FTC does have the ability to regulate non-competes across the entire country. And basically it said that the FTC is thinking about banning non-competes on a federal level. Now the thing that I really want to point out here is, is this is an extremely slow process when we’re going through what’s called the Administrative Procedures Act. What the FTC did is they opened a notice in comment period, and they allowed the American people and business interests to come and weigh in. The FTC will gather all those comments, read them all, and then ultimately deliberate internally on whether or not they want to proceed with some sort of actual rulemaking. And so generally speaking, this stuff takes years, if not decades to fully come to fruition.
And really what I saw when the Biden administration first issued, “Hey, FTC, do something about this.” And then in January of 23 when the FTC actually released this notice or this proposed rulemaking, I got a lot of comments just right off the bat. And actually a lot of anecdotal comments like, “Hey, these non-competes, they’re going to go away and I don’t have to worry about this anymore.” And I’m like, “Whoa, whoa, whoa, pump the brakes. This is really a time to hold your horses. Do not sign a non-compete with the expectation that the FTC is going to do something to nullify it. You’ve got to still negotiate it. You’ve still got to understand what it’s going to affect, how it’s going to affect your personal life if they don’t do something about it.” So it’s good that the FTC is giving this a look. It’s good that it’s getting some light shined on it, but it doesn’t mean that we can ignore non-competes any time for the foreseeable future.

Dr. Andy Roark:
Yeah. What do you think the future’s going to be like in non-competes? When I go sign a vet contract five years from now, do you think it’s going to look different as far as non-competes go? If you had to bet, what would your bet be?

Dr. Lance Roasa:
So we’re seeing a push across many states to actually change. And so I think that the state level has much more potential to actually change the enforceability of non-competes overall. Ultimately too, Andy, it depends a lot on the market for veterinary services. And so you mentioned earlier you’re seeing some people start to talk about it and a few companies start to say, “We’re not using non-competes.” If it truly does work out to be a recruiting tool and hasn’t necessarily so far, but if it truly does work out to be a recruiting tool, then you’ll see other companies follow suit. And so it depends on the state that you’re in. It depends on the company that you’re looking at overall. But I see non-competes sticking around for a little bit longer.
There’s a really big point that I want to make here when you’re looking at that contract though, and pardon my football analogy here, but my brain often thinks in football terms. But non-competes in my mind, in my legal mind, are really the running backs of the football team. They’re the ones that get their picture in the paper. They’re the ones that everybody talks about. They’re the ones that little kids remember the stats and all that stuff. But in reality, when it comes to lawsuits and when it comes to actually enforcing a contract, it’s the non-solicitation that really counts. And so I do want to point out that the states and the FTC and even these companies that we’re referring to, they’re talking exclusively about non-competes and doing away with non-competes.
However, no one, including the state of California, is talking about doing away with non-solicitation agreements. And so even if we do have some guidance or some rulemaking by the FTC within five years, Andy, that contract that you’re looking at in the future will likely have a non-solicitation. And that non-solicitation still is very prohibitive from being able to go and practice somewhere else. In fact, it can be argued that it’s more prohibitive because it doesn’t have a radius on it. Wherever those clients follow you, you can run into some issues. So what I’m saying is this is not an area of the law that’s going to go away anytime soon.

Dr. Andy Roark:
So my perception of non-solicitation agreements had always been like, “Okay, you can’t market or promote to clients.” If I’m leaving and I go somewhere else across town, what constitutes solicitation in most cases, Lance? Like if I just go there and start practicing, am I good? Or is it a problem if clients follow me over there? Help me sort of parse that.

Dr. Lance Roasa:
Yeah, there actually is a big distinction in what you’re referring to there. So the distinction that we’ve got to make is the difference in a non-solicitation provision and what the second would be a non-service or a non care provision. So two different action verbs, but a lot of times they get wrapped under the provision that is a non-solicitation. Now if you look back 10 or 15 years, they were all non-solicitation provisions, but as lawyers in veterinary medicine got more sophisticated, they started drafting these non-service provisions. And so back to the distinction between the two, the verb solicit or to solicit would mean exactly what you said, a targeted marketing, a targeted advertising. And keep in mind on the word targeted.
And so if the traditional word is, or the traditional action would be you’re going to pick up the phone and call someone, or maybe you run into an old client in the grocery store and you say, “I was at practice ABC, now I’m at practice XYZ. You should come see me there.” That is an active solicitation. Sending out a list to an email list to people that you knew that were clients. “Hey, come see me at practice XYZ.” That is a targeted marketing, and that is contrasted to if the contract has a non-service provision in it. And the way that those are usually worded is they’ll say something like, “The veterinarian shall not solicit or render services to a former client.” And so meaning that under a technical reading and also an enforceable reading of that, you could be standing in the exam room waiting for your 3:30 appointment, 3:30 appointment comes into the exam room, “Oh, Ms. Jones, I saw you over at a ABC Veterinary Hospital.”
That would be a technical violation of that non-solicitation/non-service provision. So I’m seeing more and more of these non-service provisions written in contracts, and it really takes a fine reading to understand the difference. But I think you can see how quickly a veterinarian could get wrapped up into a non-service provision. So my mind always goes to how do we combat this? How do we negotiate this? Well, number one, know the difference between the two and number two really work to get that non-service provision stricken out of the contract. Keep in mind, Andy, all of these are super negotiable. You just have to know what you’re looking for and how to ask for it taken out.

Dr. Andy Roark:
Yeah, no, that totally makes sense. Usually when you’re close to signing a contract and you’re excited to go there and the practice is excited to have you, that’s the time to bring up the non-compete and say, “Hey, this is kind of a headache here.” But it’s a whole lot harder to get out of it later on.

Dr. Lance Roasa:
Oh, absolutely. The time to negotiate these are before you get into them. I mean, this is a very important point. A lot of people that I work with, they say, “Hey, can you unwind this non-compete? I heard they’re unenforceable.” And it’s like, “No, we should have talked about this, you should have talked about this before we signed this.” That is the time that you have the leverage when you’re leaving a job. It’s like breaking up. I mean, it’s like a divorce, right? Nobody wants to be amicable during a divorce and it’s really hard to negotiate them then.

Dr. Andy Roark:
Yeah, no, that totally makes sense. Lance, thanks so much for being here. Thanks for talking all this through with me. I really appreciate it. I was blown away. The non-service agreement, I had not even considered that. That’s something that I think it’s amazing. I can’t believe that that’s something that’s increasing in its commonality. Anyway, so thanks for bringing it up. Where can people find you, drip.vet, if they’re fascinated by the legal aspects of our profession, if they need a little legal advice and they’re in practice, where can they reach you?

Dr. Lance Roasa:
Sure. So I hang out over on the VIN boards, on the regulatory and legal boards, and also on the practice management boards. I’m one of the consultants on those boards. And so if you’re a VIN member already, you can receive… we can talk about these things and obviously weigh in from other attorneys, and we answer a lot of questions over on those boards. Otherwise, I’m also at drip.vet, and so have a ton of legal continued education over there, classes on negotiation, on contracts. We go into deep dives on all of this stuff. And then if you are truly interested in it, and unfortunately, most of the people that I work with have already been burned by a non-compete. So it’s not too interesting as a student, it’s not too interesting in your first job, but you get burned by that paragraph and then it’s time to start paying attention.

Dr. Andy Roark:
Absolutely, awesome. Well, thanks for being here. Guys, thanks for tuning in. Thanks for listening. We’ll talk to you soon. And that is our episode. Guys, I hope you enjoyed it. I hope you got something out of it. As always, if you did, the kindest thing you can do is leave me an honest review online, wherever you get your podcast. Tell your friends, share the word, help other people find the podcast work that we’re doing here. Anyway, that’s all I got. Gang, take care of yourselves. Be well. Talk to you later. Bye.

Is Interpersonal Conflict In The Way Of Work?

May 26, 2023 by Andy Roark DVM MS

“If we could just stop having interpersonal issues, we could get the actual work done!”

I’ve heard countless leaders and managers say something along this line. I’ve said it myself. Do you know why this sentiment is flawed? It’s because managing interpersonal relationships is doing the work.

As a leader, spending time to help your people build relationships, collaborate effectively, and feel good about being together isn’t a distraction from the job. It is the job. People who communicate and collaborate easily don’t tend to have problems with following protocols, helping others or holding people accountable. Getting your people into this space is not an annoyance. It’s probably the most important aspect of leadership.

If you’re pulling your hair out because you feel like you’re “wasting time” supporting and facilitating team members working through interpersonal issues, maybe it’s time to take a step back. Veterinary medicine is a deeply human profession. Helping teams feel good about their relationships isn’t a distraction from providing care. It’s possibly the single most important aspect of it.

Time for GPs to Take Back Skills They Gave Away to Specialists?

May 23, 2023 by Andy Roark DVM MS

Neurologist Dr. Sean Sanders joins the podcast to talk about what a re-division of labor among general practice veterinarians, specialists and support staff might look like. Is it possible for us to improve affordability and access to care by giving more wellness care to technicians and supporting general practice veterinarians in taking back a variety of skills that they have given away to specialists over the last few decades? Let’s get into it!

Cone Of Shame Veterinary Podcast · COS – 201 – Time For GPs To Take Back Skills They Gave Away To Specialists?

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

LINKS

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

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Sean Sanders is a Veterinary Neurologist and Neurosurgeon in Seattle, Washington, USA. Dr. Sanders is also involved with development, recruitment and operations of BoosterPet in the Greater Seattle area. He received his DVM degree from Washington State University and completed a residency in Neurology and Neurosurgery along with a PhD in Neuroscience relating to the study of Parkinson’s Disease. Dr. Sanders was a founding partner of Seattle Veterinary Specialists and author of “Seizures in Dogs and Cats” published by Wiley Blackwell. Dr. Sanders lectures nationally and internationally on topics related to Veterinary Neurology and Neurosurgery. In his spare time, he spends time with his wife and their pets, builds wooden boats and classical guitars, restores classic cars and enjoys, sailing, mountain biking, hiking and snowboarding.

EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome, everybody, to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am here today with my friend, Dr. Sean Sanders. You might recognize Dr. Sanders. He was on earlier in the year. He is a neurologist in Seattle, and we started talking last time he was here about changing roles for general practitioners and technicians in modern medicine. And he’s a big advocate for accessibility to care, and I wanted to get him back and unpack some of these things and say, “What does this look like? What does it mean when we talk about expanding the role of the general practitioners?” Because I know a lot of people think about general practitioners getting squeezed. They think about technicians doing more and more, and specialists doing more and more, and what’s left for the old general practitioner? I think Sean’s got a really good answer for that.
And the answer is that maybe specialists shouldn’t be doing more and more. Maybe as we push to keep access to care front and center and be able to get people the services they need, maybe it’s time for general practitioners to start picking back up some of the stuff that we used to do. And what are the barriers to that? We talk about that a little bit. What are the benefits to that? We talk about it. We talk about it from a financial standpoint, we talk about it from a career enjoyment standpoint, we talk about it from a pet healthcare standpoint. It is a really fun, really good conversation. This fits right into my recent thing of trying to get my head around what that medicine’s going to look like in the next 5 to 10 years. Man, I like Sean’s vision. I think it’s pretty good. I think we should really think about going in that direction. So anyway, guys, I hope you’ll enjoy this. This is a big make-you-think episode. 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. Sean Sanders. How are you?

Dr. Sean Sanders:
I’m good. How are you doing today?

Dr. Andy Roark:
Man, I’m doing great. I am really happy to have you back on the podcast. I really enjoyed the first time that we got to talk. I left with a lot of ideas and a lot of questions, and we just flat ran out of time last time you were here, and so I was like, “Well, I’m going to Sean back. We’re going to talk some more.” So yeah, thanks for making time.

Dr. Sean Sanders:
Well, I’m glad you asked me to come back, yeah.

Dr. Andy Roark:
Oh, my pleasure. So for those who don’t know, you are a veterinary neurologist in Seattle, and you do a number of things. You have a PhD in neuroscience and you’re a teacher, and you’re traveling to Germany in a couple of days to do some lecturing there as well. You also work in some telemedicine stuff. You have a lot of really interesting things going on is what I would say.
Well, getting back into the conversation I wanted to pick back up with you, it was really kind of about the future, the next 5 to 10 years of vet medicine for practitioners in the trenches and what it looks like. And the reason I wanted to talk to you about that, I’ve just been thinking a lot about this, and I just had an article that came out at the time that we’re recording this, and I wrote about standing back and looking at the profession. And I really see this tectonic shift going on, where we have a customer-driven world in a way that we haven’t in the past.
And so I’m looking around that I’m seeing things like Chewy coming into the space, and they dominate in customer service. And pet owners like their home delivery and they like working with them. And we’re having telemedicine come up, and pet owners are getting used to these services. And we’re having a problem with a shortage of veterinarians and getting people in to get the care that they want, and I don’t think pet owners are handling that very well.
My take on this really is if you have demand from pet owners and you have people who want to provide the services, our culture, our society, America in general, [inaudible 00:04:09] specific, I guess, is really set up to facilitate capitalism, which is, if somebody wants it and somebody else wants to provide it, for the most part, our society is set up to make those things happen. And I look at our profession, and we’re feeling a lot of change being thrust upon us. Like I said, telemedicine is really changing things. We’ve got talk about mid-level practitioners, things like that, utilizing technicians in a new and interesting way. All of these sorts of things that are meant to just make care more accessible, more convenient, and pet owners are kind of clamoring for them.
So I’m looking at that. I call that tectonic, because I think that the ground is changing, and I don’t know that we are going to be able to hold these sort of changes back. I think that ultimately pet owners know what they want, and they’re being offered a lot of things, and they’re going to push our profession in a way that is convenient for them. And I think our two options are trying to dig in our heels, and I think we’re going to get crushed, or to look at the landscape, say, “This is where things are going. Let’s reposition ourselves so that we can prosper in the new world that’s coming.”
So let me just stop there. As I say, I sort of just threw a lot at you. What do you think when I say that? Does that kind of match up with the general industry trends that you are seeing and the way you see our profession being affected?

Dr. Sean Sanders:
Yeah, I completely agree. I think looking back at veterinary medicine, or we could say medicine in general, it’s always been a bit of that kind of a patriarchal type of system, where the doctor tells you what to do, and you do it. Gone are the days of James Herriot, where he would tell you it’s time to put furballs back to sleep, because I’ve got a broken tooth. And so you would be like, “What? I don’t have any say in this.” And we’re getting into a time where veterinarians and clients have more of a symbiotic relationship, it’s more of a shared communication.
So as you mentioned, we’ve got this market-driven economy, where the clients are starting to shop around, and not only are they shopping around for products, but they’re shopping around for accessibility and cost. We know that there are inflection points with everything, and we see it in technology, and we are seeing it, I believe, in veterinary medicine right now. I think we’re at a kind of revolution right now, where the practice of veterinary medicine is changing. I went through one back in the late ’90s, when specialty medicine kind of came on the field, so to speak, where it moved from primarily focused in the universities to focused into the large urban areas, and now it’s just spread out and grown and grown and grown.
So I agree with you completely that we need to look at the profession, we need to stand back and look at the profession, and we need to decide what is this going to look like in 5 or 10 years, and we can be the drivers of that innovation. Always when you talk about change, that scares people. It’s natural for us to be scared about change. But if we look back and we look at things that have changed in our lives, just the digital camera, the personal computer, the taxi cab, all of these things have changed in a way that we can’t imagine going back to the way it used to be.

Dr. Andy Roark:
I agree with that. Let’s pick up on this. You mentioned the spread of specialty medicine. The last time that you were on, we were talking a bit about this, and we were talking about accessibility, and we were talking about a shortage of specialists and people not being able to get in for specialty care or limited funds and resources to get into specialty care and things like that. And your position, as you explained it then, was general practitioners have given away a lot of their, I don’t know, a lot of their utility in some ways to the specialists. They have stepped back and said, “Oh, this is going to be a specialist thing. We’re going to let the specialists do that.”
And now that it’s hard to get people in for specialty care or things like that, or they’re not willing to go, it may be time for general practitioners to really think critically about re-expanding their lane, if you will, and taking back on some of these. So let me put that back to you and say do you still feel that way? And if so, sort of start to set up for me what you think that system could look like.

Dr. Sean Sanders:
I think the root of it is with the general practice, but I also think it extends to specialists as well. When I started specialty practice in 2002, finished my residency, there wasn’t a lot in Seattle, there was no specialty center. And over the years, we developed this, specialists came together, we formed these large multi-specialty gigantic clinics, and we were there, ready to take the cases. And so we kind of trained everybody that you need to send the cases to us, because that’s where you’re going to get the best care.
And unfortunately, looking back at that, you may have been a veterinarian at that time that had 35 years of experience in doing splenectomies and doing enterotomies and GDVs, and all of a sudden, you’re kind of being told that, “Well, maybe you’re not the best person to do that anymore.” But I look back, and I say, “Well, who was a better person?” A recent resident who’s done maybe two on their own compared to a GP, who’s been out there doing them for years.
So I think to some degree, specialists, we had the effect of convincing people that they needed to send us the cases, and maybe that was the best thing for the patient, especially if you’re talking about the high intense cases, brain surgery, back surgery, adrenalectomies, the things that require a lot of capital intensive infrastructure to get going, like overnight management or endoscopy towers, things of that nature. But in doing that, I think what we did was we were so welcoming to all of these cases, and I won’t speak for every specialist, because I’ll get hammered if I do that, but I think I can speak for neurologists.
One thing that I commonly saw in practice, a big time suck for mem was just chronic management of seizure cases, and there is no reason why these can’t be managed in general practice. It just requires a patient and some basic drugs and knowledge. But what we found was that when I started my practice of specialty medicine, I kind of opened the doors, and I continually said, “Yes, yes, yes, yes, send me every case,” And so that’s what people got used to.
And so by doing that, I think that one of the things that happened was general practitioners probably got the impression, and it was a real one, that you shouldn’t be doing these cases. You need to send those seizure cases to the neurologist, because they’re the one best equipped to handle that patient. And there might have been some general practitioners out there, I’d like to hear from them that actually enjoyed treating seizures chronically. I know it’s not a fun thing for everyone, but I think in doing that, we kind of took away that self-reliance that people naturally develop on themselves or that problem-solving ability that they have to take care of their patients.
And over the years, that worked great. As our specialty clinics expanded, we started to take away cases from the general practitioner, we started to take cases away from universities. And so as that university caseload went down, you saw the training opportunities for residents and people who were going to go into general practice kind of got lower and lower. And it was almost like those cases were being sequestered in the specialty hospitals.
So I think over time what happened was people just got in the natural mode of, “Well, that’s how human medicine went. You sent the case to the specialist, and it got taken care of, and if something went south, then it wasn’t your problem, and so that’s kind of great.” Unfortunately, what’s happened now is that we’re at a point where specialty hospitals, large clinics are starting to shut down, because they don’t have enough staff. Costs are still going up in order to maintain a margin that the owners of the practices need, and so that’s creating barriers to care. And those barriers of care might be accessibility from time. I can’t get that patient in for six weeks, or it might be a barrier to entry due to cost, because it’s just not affordable for people to do things anymore.
And so I believe that general practitioners and specialists need to start looking at what they actually do in practice and focus their energies on the things that drive their passion and that they are truly equipped to do. So for me, personally, I really enjoy surgery so my time is best spent in the surgery suite, doing a two or three-hour surgery as opposed to in an exam room explaining to somebody why we monitor drugs for seizure management. We do it, but there might be others who enjoy that more, and they don’t like surgery. So I can use that as an example to say, “Well, how can I focus my practice on what drives me?”
And in general practice, I see, and I look at this, so I’m a veterinarian, first and foremost, and I’m a general practitioner, because I have pets, and I take care of all my own pets as much as I can. But when I run into a case where I need to get my pet in to see a specialist, and I can’t, and it’s happened to mem and I’m waiting six to eight weeks to see an oncologist or an internist, and I’m watching my patient, my pet decline, how do I solve that problem? Well, I reach above me and I grab a book. I start looking at the color pictures first, and then I start reading second, and I figure it out on my own. There is no reason we can’t do that for all of our own patients.
Of course, there are things that you can and can’t do, right? I’m not going to be buying a scope tower in my house and doing my own scopes, but I could certainly do if I need an aspirate and look at a slide of my own dog, or for that matter, I could probably do a splenectomy if I needed to. So I feel like if you’re a specialist or a general practitioner that if there’s something that’s a time suck in your day that’s taking you away from what you really want to do, then you should try to figure out what that is and take it off your plate, so you can focus on what you really enjoy doing.
I feel if you’re finding that your patients are not able to get the care they need, because one, they can’t afford it, or they can’t get in to see that specialist, maybe there are some things that you can do that used to be within the general purview of a practitioner, like those elective type of surgeries. By doing that, you will get better care or better access to care for the patient, probably more affordably, and then it will also allow the specialist, if they want to focus on the things that drive their practice. Keep the neurologist in doing brain surgery, if that’s what they enjoy, allow the surgeons to do adrenalectomies, if that’s what they enjoy, allow the interest internists to do the scopes, et cetera. That’s the perspective I’m coming from.

Dr. Andy Roark:
Yeah, no, I really like that. I really particularly like your self-driven approach to this, because you’re right. I always say, “Well, you know what? What should we do about education and these things?” And the truth is if I wanted to, it’s been a while since I’ve done an enterotomy, I just don’t have a … I practice regularly, but not enough to be doing surgical rechecks and things like that, and I sort of stepped away from surgery a couple of years ago.
But I do think about it sometimes, what if I wanted to pick this back up? What if this is where I wanted to go? Would I need to go back to some sort of hands-on education course, or is this a thing where I can line up my own mentorship opportunities, jump in, watch a couple of these things, get somebody to maybe shadow me doing one or two, because I’ve done them before, and just sort of pick that back up.
And the truth is there’s a lot of resources and opportunities for me to get these skills in my own way if I just decide that I want to do them. So I do really like that idea of just put in the work, pull the books, get the insight, and there’s never been more resources and support asa there are now.
If you dream of doing team training with your team, getting your people together, getting them on the same page, talking about how you guys work together in your practice, I’d love to help you. You can check out drandyroark.com and check out the store. I have two different team training courses. These are courses for teams to do together to get on the same page and to talk about how you do things. I have my Angry Clients course and I have my Exam Room Toolkit course, and they are both available and there, so come out. All right, guys. Let’s get back into this episode.
Can you expand this idea out to support staff for me? Because I know this is something you and I have talked about before as well. So I love this idea, I love the general concept of where you’re going, and to me, it’s just the obvious ripples out from this is that the thesis, the idea of you should figure out where your time is best spent and spend your time there. Well, why wouldn’t that ripple out to the front desk and to my technicians and things like that? So can you sort of color in those lines a little bit for me? How do you see this? If we lean into the idea that you’re putting forward, which I really like a lot, how does that ripple out to the support staff? What does their path look like?

Dr. Sean Sanders:
Well, I think from a very selfish perspective, if the veterinarian looks at what they enjoy doing, and then they try to focus their career on that path, something’s got to give, because chances are, you’re in five different lanes of your practice. You’re going to be on the wellness lane, you’re going to be in the non-well, the chronic care, the procedures, the elective surgeries. If you’re covering all of those lanes, but you only want to be in one or two, then you have to figure how are we going to cover those other lanes?
So if wellness is your thing, if you like the preventative medicine talks, if you like looking at blood work for yearly checks, if you like taking care of healthy pets, then you have to figure out a way to not do those other things, and that might be giving it up to a colleague. If your thing is dentistry, if you just want to line them all up on the table all day long and do dentistry after dentistry, somehow you’re going to have to get out of that wellness lane so that you can have time to do that.
And one of the things we can do, we’ve talked about this before, is we can utilize our support staff, especially our veterinary technicians, to the highest degree possible within the practice act that your state allows. So allow them to do the things that the state gives them the opportunity to do. I go into practices every once in a while, and I see veterinarians cleaning the ears of pets, and I see the technicians holding the pets, and that’s great if that’s what you enjoy doing. But then when I talk to the veterinarian and they say, “Boy, if I could have more time to look at the cytology, I would love that, because I love looking at cytology, or I want to do more procedures, and I hate cleaning ears.” Well, you have a perfectly capable staff member that’s able to clean ears within the scope of their practice act.
And so I think we need to open up the fact that by allowing our staff to utilize the skillset that they’re trained to do, we’re going to give them greater opportunities to grow with the profession, they’re going to be more of a revenue generating part of our practice as opposed to just a support piece, and it’s going to allow us to focus our career where we want to go, because they’re going to be scraping off those low-hanging fruit things that allows them to expand into more of that mid-level practitioner role.

Dr. Andy Roark:
That totally makes sense, and I think that’s been the aspiration for a while, as far as leveraging our technicians. Talk to me a little bit. I think when most veterinarians look at where they spend their time and they think about things that they would like to maybe get out of, there’s a lot of client communication that falls into that, that takes a significant amount of time in things. You’ve had sort of an interesting career in working with technicians in different ways with BoosterPet and things like that. Talk to me a little bit about how you can see support staff moving into the client-facing and client communication space. Do you feel like there are significant opportunities there for us to change up how we’re practicing and engaging? And if so, what do those opportunities look like?

Dr. Sean Sanders:
Anyone, whether it’s a veterinarian or a staff or an LBT or a VA, we all have inherent strengths and weaknesses, and some of those might be communications, some of those might not be. So first of all, you have to define do you enjoy being that communicator? I absolutely loved spending three hours with a client, talking about seizures, drawing on my whiteboard, making them understand it. I love the connection that I got when they understand something, but that’s not the best use of my time, and I would get drawn into it. My staff would be tapping me on the shoulder and saying, “Hey, we got to get you over here to do this. Stop talking.”
So first of all, it’s identifying the people in your practice that love doing that. Second of all, it’s just a matter of repetition. So giving the same talk over and over again, albeit there are going to be some nuances, but given the same talk over and over again about seizures is something that pretty much anybody can do, or it could be flea control or parasite prevention. It could be just wellness in general. Those are things that I’ve seen in our practice work very well at the technician and the VA level.
That allows the veterinarian to get to the next case while that technician is talking to the owner and educating them about, “This is why we’re testing for this disease,” or “This is why we’re using this preventative, and this is what you need to know. And this is when your pet needs to be vaccinated.” These are topics that are happening so routinely on a day-to-day basis that people get excited about them. Staff love to talk about wellness, they love to have that client interaction. And I think it allows them to expand their opportunities of growth within the veterinary space to be more than just a “Go get me this” type of person or a “Hold this” or a “Clean that” type of person. It allows them to be our colleagues basically in healthcare.
I utilize my nurses to the maximum ability that I could in my practice. It wasn’t me talking to the client about what to do with the next level of seizure medication increase. It was my nurses talking to the client, and then they would come to me and say, “Hey, so-and-so is doing this. It’s already on phenobarbital. What do you want to do?” And I would say, “What do you want to do?” And they’d say, “Well, we are going to just increase it by 25%, check levels in two weeks.” I’d say, “Yep, let’s do that.” You still have to be responsible for the case, but I 100% believe that we can support our coworkers, to give them learning opportunities within veterinary medicine, so that they can grow and, more importantly, so they can stay in the practice of veterinary medicine and not leave for something or some other industry where they may feel more valued.

Dr. Andy Roark:
That totally makes sense. I love that approach to the old, “What do you want to do?” I had a case earlier today, we had a possible parvo dog coming in, and my technician was like, “Well, what do you want to do with it?” And I said, “Oh, what are you going to do with it?” And they’re like, “Oh, I was going to have him stay in the car, and I was going to go to a fecal sample, and we’ll do a parvo test.” And I was like, “You know what? That sounds like a great plan, man. Let’s do that.” It’s one less decision I have to make, and the other thing is just it’s coaching, and you’re just growing better and better people.
So when you start to think about this and where it’s all going, are there things, what are you most excited about? When you look ahead and you go, “Oh, man. I would love to see this happen in the next 5 to 10 years. If we as a vet profession could get our ducks in a row, this is where I would like to see us go.” Is there anything like that inspires you?

Dr. Sean Sanders:
I think the thing that gives me the most hope is just the idea of access to care. And by that, I mean timely access to care, and I also mean affordability of care. What I’ve seen in the last several years is just the costs of veterinary medicine go up at the specialty level, where it’s basically become that type of advanced care is really for the rich. Every pet is a luxury, essentially. We don’t really need them to survive, but they’re family members. I’ll just share a little story, and I’ll try to keep it very vague, but a couple … Did I talk about my neighbor last time?

Dr. Andy Roark:
I don’t think so.

Dr. Sean Sanders:
Okay. Well, in between our last talk, my neighbor calls me up, and she says, “Sean, I don’t think Sadie’s doing very well. She seems to be having a hard time breathing.” So I go over to her house, and it looks like her dog’s abdomen’s bloated. It feels mushy. She’s got no pulses. Her limbs are cold. I think she’s probably got a splenic rupture or something like that, a splenic mass. We spent about an hour-and-a-half just trying to get a specialty hospital within the area. I think we called six or seven different specialty hospitals to get her in that night. It was a Saturday night, about 7:30. Couldn’t find a single surgeon that was working that night or on call.
So I called my old hospital that I used to own, and I said to one of the ER doctors, and I was using the doctor card on every one of these I called, and I said, “Hey, I’m coming in. I got my neighbor’s dog. I think she’s going to need an evaluation, probably a hemo abdomen.” And he was like, “Well, we don’t have a surgeon on call tonight.” And I said, “Well, I did one in vet school, so she’s either going to die on my hands, or she’s going to die in the ER.”
So we ended up taking her there, and thankfully, the criticalist at the practice was just finishing up on a foreign body and a cat. So the criticalist was doing surgery, because the surgeon was out. And they did a fast scan on the dog, and they decided, “Yeah, she’s got a splenic mass, and she’s bleeding into the mass.” So they decided we’re going to give her a transfusion, keep her overnight.
So the first thing I learned that night was that what if that criticalist had not been there? Was I prepared to do a splenectomy in that dog? I probably would’ve done it. I’m pretty sure she would’ve been okay, but yeah, it had been 25 years since I did one of those. It was a junior surgery, so it was a while ago, and that dog wasn’t recovered. So I don’t know if it would’ve gone so well, but it would’ve been better than the dog just kind of crumping out on use.

Dr. Andy Roark:
Sure. Wasting away, yeah.

Dr. Sean Sanders:
Right, right. The second thing that shocked me was, and I won’t give any specifics, but it was the estimate for the surgery. It blew me away, and it’s hard to shock me, but it was probably five or six times more expensive than a surgeon friend of mine down in Orange County would’ve charged. And so there was this insanely huge disparity between what a person could afford to pay and what it actually cost to do. And I’m not talking about slightly off, I’m talking orders of magnitude higher. And these people, they were able to do the surgery and the dog did have the surgery the next day with the criticalist.
But I think about how many animals don’t get that access to care just because of the cost. And if we can take some of those really high cost procedures and put them back into the hands of the general practitioners, and I’m talking guardrails here, I’m not talking adrenalectomies or anything, I’m talking like elective surgeries, enucleations, GDVs, things like that. Things that when I was preparing to go into vet school, the vets I worked with were doing all of these things in their practice, and they were doing them because they had no choice. They liked doing it, plus there were no specialty centers at that time where I lived. So they either got sent to the university or they got handled in-house.
So I think what gives me the most excitement is that if a veterinarian can expand their practice by doing things that they’re passionate about and be able to do those at a cost point that’s going to save the client a ton of money, but still make the veterinarian a ton of money, then I think that that supports the industry as a whole. It will raise up our standing back in the communities as the person who can solve problems for people. That idea of self-reliancy and problem solving, I love the idea that we can learn to do that again.

Dr. Andy Roark:
Dude, that’s awesome. I love that vision. Sean, thanks so much for being here. Where can people find you online?

Dr. Sean Sanders:
I’m somewhat dark. I’m only on LinkedIn. And as I mentioned before, I think at that time I had 34 connections. I might have 39 now.

Dr. Andy Roark:
Oh, that’s good. Well, I’m glad to see the first appearance on the podcast really move the needle for you.

Dr. Sean Sanders:
Yeah, yeah. Get in line.

Dr. Andy Roark:
Yeah, exactly right. Awesome. Thanks so much for being here. Guys, thanks for tuning in. Take care of yourselves.

Dr. Sean Sanders:
Thanks a lot.

Dr. Andy Roark:
And that’s it, guys. That’s what I got for you. I hope you enjoyed it. I hope you got something out of it. Thanks to Sean for being on. As I said, I really left this conversation just fired up about, “Oh, this makes some sense.” I like this. I like the idea of being a problem solver. I like the idea of GPs picking back up to their scalpel or picking up the tools that they might have referred away and let other people use in the past. I think that it allows technicians to grow in their roles and to take a lot of stuff off of our plates and to earn a living wage for themselves and provide pet owners with quicker access to care, and it still keeps us with full schedules, doing work that matters. I really love what Sean was saying about it puts us back as being seen as people who step in and fix things. And that’s what I’ve always wanted to be. So anyway, guys, I hope you enjoyed this as much as I did. Take care of yourselves, everybody. Be well. I’ll talk to you later on.

The Well-Leveraged Technician – How Do Practices Actually Get There?

May 2, 2023 by Andy Roark DVM MS

Ken Yagi, MS, RVT, VTS (ECC), (SAIM) joins Dr. Andy Roark to talk about how practices actually go through the process of increasing their delegation to and utilization of technicians.

Cone Of Shame Veterinary Podcast · COS – 198 – The Well – Leveraged Technician – How Do Practices Actually Get There?

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

LINKS

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

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Kenichiro Yagi, MS, RVT, VTS (ECC), (SAIM)

During his 20+ years in the field, Ken has dedicated his career to reimagining veterinary nursing. He obtained his VTS certification in emergency and critical care as well as small animal internal medicine and achieved his master’s degree in Veterinary Science. He is currently the Chief Veterinary Nursing Officer for Veterinary Emergency Group, and the Program Director for the RECOVER Initiative. Over the years, he has received the Veterinary Technician of the Year award by NAVTA, the Veterinary Technician of the Year award by the California Veterinary Medical Association, the RVT of the Year award by the California RVT Association, and the AVECCTN Specialty Technician of the Year award. Ken co-edited the Veterinary Technician and Nurse’s Daily Reference Guide for Canine and Feline, and the Manual of Veterinary Transfusion Medicine and Blood Banking, and publishes articles and presents internationally on topics in ECC, transfusion medicine, and the veterinary nursing profession.

Ken works to bring further recognition of the vital role of the veterinary technicians and nurses through work with organizations, being a Past President of National Association of Veterinary Technicians in America, and President of the Veterinary Emergency and Critical Care Society. He is also an advocate for the Open Hospital Concept, encouraging veterinary practices to invite the pet owners to “the back” as a part of the team.

Ken invites everyone to ask “Why?” to understand the “What” and “How” of our field, and to continually pursue new limits as veterinary professionals and individuals.

EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I’m here with the one and only Ken Yagi talking about how do you actually start using technicians more aggressively, holistically a assertively, than you have in the past?
How do we actually delegate stuff to technicians so that doctors get on board and the change actually gets made in the practice? That’s what I want to dig into. So Ken and I always talk high level stuff. We’re not doing that today. I really… What do you say in the practice? What are the steps that you have to take to try to change the way that a practice functions and really starts to utilize those technicians to take things off a doctor’s plates? And how do you get the doctors to allow the technicians to do that?
That’s what Ken and I get into today. It is a super fun episode, guys. I hope you’ll enjoy it. Let’s get into this episode.

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

Dr. Andy Roark:
Welcome to the podcast, Ken Yagi. Thanks for being here.

Ken Yagi:
Thanks for having me.

Dr. Andy Roark:
Oh, always. I love having you on the show. You’ve been on a number of times.
For those who do not know you, you’re an RVT and a veterinary technician specialist in emergency critical care and small animal internal medicine. You have been the President of NAVTA, the North American Vet Tech Association, and you are currently the Chief Nursing Officer at VEG.
I didn’t miss anything, did I? I know I miss a lot. First of all, your bio just rolls on. It’s like the Iliad, but I think those are at least some of the points.

Ken Yagi:
Yep, sounds good.

Dr. Andy Roark:
Anything I should add that I woefully left out?

Ken Yagi:
The NAVTA is the National Association of Veterinary Technicians in America, no longer North American.

Dr. Andy Roark:
What did I say? The North American Vet Tech Association? I just make stuff up sometimes. Yeah.

Ken Yagi:
Yeah.

Dr. Andy Roark:
I’m sorry. Hey. Yeah, we pride ourself on factual accuracy here on the Cone of Shame and I’m glad that you caught that.
All right, enough of that. Let’s talk brass tacks here, Ken Yagi. You and I, when I usually have you on, we talk at a high level about where technicians are going and how technicians interface with medicine overall. And we future-cast a lot and things like that.
And that stuff is always fun and I do really like it, but I am about as pragmatic as they come when I get into how do I actually get things done. I like to get things done. And I look at a lot of practices and I think I see a lot of my colleagues who are like, “Yes, I want to use my technicians more.”
And I see a lot of techs who are like “Hey, buddy. Put us in, coach. We’re ready.”
But we’ve got these established systems and workflows and ways that we’ve done things in practice. And breaking out of the old way of doing things is hard. And a lot of people say, “I want to do this, Andy, but it’s scary.”
The idea of giving up control and saying, I’ve been doing catheter placement forever and I know that I’m really good at it. And so the idea of letting people who are not as good as me do it, is terrifying and it doesn’t make any sense. And I go, “Well, you have to give people repetitions and a chance to use their skills. It’s not fair to not let anyone do stuff and then dunk on them because you do it better than they do it.”
I go, “Well, that’s dumb.”
But still, this stepping back part is really, really hard. And so what I wanted to talk with you about today is how do we actually make a change in a practice that hasn’t been leveraging their technicians? So yeah, I want to get into the weeds and pick your brain about things that you’ve seen, where practices have actually made changes. And people who have been established techs have not come out and gone into a new practice, but they’ve gone into an established practice and over time they have grown in that practice and that practice has evolved.
Because medicine changes, guys. And I really think that if you’re practicing medicine the way you were five, 10 years ago, then you haven’t grown and it’s time to grow. So I want to help people grow today.
So Ken, when I lay that out at first, how does that sound?

Ken Yagi:
That sounds great, so let’s get right into that.

Dr. Andy Roark:
All right, so let’s go to work. So where do we start here?
I’ve got my practice and I’m like, I don’t know, am I lever… I think I’m leveraging my technicians, but I don’t really know. Help me get my arms around what I’m even looking at here.

Ken Yagi:
Yeah. So I’ve been looking into this quite a while and I have survey responses and things like that. When it comes to… One of the reasons why people don’t get utilized, it’s actually kind of surprising to see on the survey. There’s a response that says we don’t have issues with utilizing technicians, and that one actually gets picked the most.
And so it made me think about, well, maybe people don’t actually realize that just being busy and having people run around like crazy and trying to get things done is different from well utilized technicians because that’s just busy people that are trying to get everything done. And the other thing might be that they’re just not aware of what good utilization looks like.
I have a quick exercise that I just want to throw out there that’s sure for everyone that we can do, and that’ll be a good place to start. I’m going to read off 10 different things that could be done in a veterinary practice and the people who are listening, I want you to think about whether that’s gets done most of the time by a doctor or by your nurse, and keep track of that and we’ll tally it at the end.
The first one is IV catheter replacement. Next one is calculating fluid rates. Hospitalized patient assessment. Urinary catheterization for urine collection. Client education on diabetes. Ultrasound exam. Anal gland expression. Nasogastric tube placement. Creating an anesthetic plans and administering it. And then the last one is unblocking cats.

Dr. Andy Roark:
I’m at five. I’m just going with by what happens in the practice where I work. So I was like, I’m at five. I’ll be honest.

Ken Yagi:
Yeah, yeah, exactly. That’s what we want to be doing. So for you, five of those fit into technicians are doing it most of the time, is that correct?

Dr. Andy Roark:
Yes.

Ken Yagi:
Yep. So then if you take a quick tally of that, so that’s like 50% out of 100% for me, because all of these things should be able to be done by a technician with supervision, of course, but a well-trained one.
And so then I would say that you have 50% potential of utilizing technicians better in your practice.

Dr. Andy Roark:
Yeah. I believe that. I think there’s the possibility to get better. I think that’s why… Honestly, you write the book you want to read, the reason I want to have this podcast. What does evolution like that look like in the practice where I work?
And so yeah, I know that there’s upward possibility. So that totally tracks to me.

Ken Yagi:
So, the first step is to go through this thought process to take a look at what happens in your practice, which of those could be done by technicians that you’re not utilizing them for. And that gives you the awareness of how much more room there is to grow in your practice for utilizing technicians.
And that’s the first place to start. You need to know where you’re at in order to change it.

Dr. Andy Roark:
Yeah. No, I like that assessment. Just doing that, I go, okay. I love the questions as well because they’re concrete examples of things that technicians could do that they often aren’t. And I go, oh, okay. Yes, it is true that my techs could unblock a cat and they generally don’t. But they could and I get it.
So I like that there are specific examples and just the questions themselves open up your mind to how technicians could be utilized. I really like that exercise.

Ken Yagi:
And I also be a little bit cautious and say that unblocking cats, I’m putting it out there. Right? That’s one of the highest end things that technicians could do because it’s a high risk procedure. What if the urethra tears?

Dr. Andy Roark:
Sure, yeah.

Ken Yagi:
And I would definitely consult the Practice Act to make sure that what you’re trying to get technicians to do is definitely legal.

Dr. Andy Roark:
Yeah. Oh, well that’s important. Yeah.

Ken Yagi:
But with that said, there’s so much more that we could be utilizing our technicians for than we do today.

Dr. Andy Roark:
Yeah. No, I do think that’s good, but what I think… So I realize the sample, so let’s stay with this for a second. So we’re talking about unblocking cats. I think you put your finger right on the valid concerns that doctors have where they go, yes, I have technicians who could do this, but I’m the one who’s going to have to make the phone call if we punch through the urethra and now we’ve got real problems.
And it’s not even about saying, I think that someone else is better than me or not as skilled as me, but it’s almost like if I’m the one held responsible and there’s going to be a mistake made, I would like to be the one who makes the mistake because at least I’ll know then that I’m the one who messed up and now I have to deal with the consequences.
So I think that that’s a very valid emotional response that people have. And so that sort of brings me around to, I think there’s nuance here as far as what are we comfortable with? And in my impression, Rome was not built in a day. I think a lot of people expect that the path to tech utilization is a huge leap forward. Or one day we walk in and say, guys, the rules are changing and we lay down all of these things. I just can’t imagine that’s the case.
So let’s start to talk a little bit about what increased utilization actually look like as it takes hold in the practice. Can we do that?

Ken Yagi:
Absolutely. Yeah.

Dr. Andy Roark:
Where’s the push usually come from? Is it usually… I mean just in your experience. We’re talking a hundred percent anecdotally here. Is it usually, is it an owner, manager, up the chain sort of decision? Is this usually doctor driven where the doctors say, I want to let delegate more effectively to technicians? Let’s talk about changing our protocols? Or is it usually technician driven? What have you seen that has actually accomplished results?

Ken Yagi:
It needs to come from all different directions, but I would say that the push from the veterinary technicians and nurses side has existed for a long time. We’ve been saying we’d like to be utilized, and that hasn’t changed things too rapidly.
I think that the practice management is starting to look at it a lot more commonly now, because of the shortage that we have out there. We need to see as many patients or even more patients in a more efficient manner. And so, one of the ways that we can do that is through more efficiently utilizing every single team member, not just the veterinary nurses. So then we need to think about it that way.
And knowing that the path to retention is also to be able to pay these people better. Having a more efficient team that’s able to bring in more revenue through the utilization is seen as partial solution to the shortage that we have today. And so, I think we’re starting to see a lot more of the practice management paying attention to efficiently using the team members while balancing it with some of the concerns that come up, like the one that you mentioned regarding liability issues.

Dr. Andy Roark:
Yeah, that tracks with what I’ve seen. And now that you say that, I go, okay. Yeah, I get it. Well, I think one of the things that I have seen as a recent movement is, I don’t know if it’s driven by corporation of medicine and we suddenly have these outside entities that are very focused on business and operations in a way that… And most independent practices never used to be.
I don’t know if it’s really coming from them. I don’t know if our whole profession is just evolving. I don’t know if it’s a labor shortage that’s really pushed us, but the operational efficiency is a really big deal now across practices. And I’ve talked to a number of people who have voiced frustration to me where they say that we have this plan, we’ve come up with this way of getting things done. We’ve got these systems for delegating effectively to technicians and other paraprofessionals.
We’ve got all these things that we have figured out and the doctors won’t do it. And the doctors, they won’t delegate. They won’t delegate to the technicians, they won’t use them or they don’t want to use this system that we’ve come up with. So I’ve heard that. And again, I’m not in those practices. I don’t know. I don’t like to think that the doctors are probably the most likely obstacle to evolution this way, but it seems to me that they probably are as a doctor because they’re the ones who feel that they’re held responsible when things go wrong.
And so, I think it’s understandable that they would be the most hesitant to say, okay, I’m going to open this up. I’m going to step back from what I’ve done previously. And it’s not just about belief in our own skills, but it is… There’s a liability part to as well where I go, well, my license is the one that’s going to be come after if this goes badly.
Does that resonate with you, Ken, when I say that? Does that feel like what you’ve seen as well? Am I overstating the pushback that doctors tend to give to these initiatives?

Ken Yagi:
No, I think that it’s definitely true that doctors have the liability on their mind because it is under their supervision that all these things happen. And if something goes wrong with their patients and it goes to the veteran medical board, they are definitely the primary person that’s called up to defend. And so, there’s certainly that worry there.
I’m also going to say though, it’s not everyone that feels that way. I think that there are many doctors that are very pro-utilization and making sure that they can do their job better by having trained individuals that can help them to perform the procedures that they need to perform or that delegate the tasks that they need to delegate.
And I think that’s the key point is that yes, there is a liability, but the liability falls both on the doctor and the licensed professional, the RVTs, LVTs, CVTs that have their own license that they will ultimately need to defend, as well.
And so, at the very highest level, I would say that nobody should be doing anything in the practice that they’re not trained well enough to do. Not an all or nothing thing where we say all of a sudden everyone should be doing a hundred percent of what’s legally possible and let’s just start doing that tomorrow.
And I think getting there by good training and also starting with the maybe smaller things, lower risk items that will be comfortable enough for the team to start allowing the nursing team to be able to do and gradually getting to the point that you have higher end things being done by the entire team would be good.
But there are probably individuals within each of those teams that are very high caliber that won’t be satisfied with the lower level of utilization that you want to retain. And so a more individualized plan on who’s the person to have these tasks appropriately delegated to them and identifying that within the practice would be important.

Dr. Andy Roark:
If you dream of doing team training with your team, getting your people together, getting them on the same page, talking about how you guys work together in your practice, I’d love to help you. You can check out DrAndyRoark.com and check out the store. I have two different team training courses. These are courses for teams to do together to get on the same page and to talk about how you do things. I have my Angry Clients Course and I have my Exam Room Toolkit Course, and they are both available and there, so come out. All right guys, let’s get back into this episode.
So there’s a couple pieces of this I want to unpack. So first I really like your idea of starting with lower stress, lower risk things that people can get on board with and just starting to build the habit of delegating and letting people do more and start to grow in small steps. That totally makes sense to me.
Talk to more about what an individualized plan looks like in practice in a way that doesn’t hack people off. It’s not like, hey, we’re going to let Amanda do this, but we’re not going to let David do it. And go.
So yeah, help me… What kind of messaging is around that? Because it makes sense to me where you say, I do have some people that I think could do it. They’re licensed technicians. And I have some people who are licensed technicians that I’m like, I’m not comfortable doing this, at least to start. What does messaging around that look like where I say, we’re going to try this with one or two people as opposed to, yes, you have your RVT and so now jump in and go for it?

Ken Yagi:
I can definitely see your point in if we individualize it to the point that only a certain people are able to do certain things, then it would create some tension within the team. I think trying to do this more systematic way would be good.
What we’ve done is we’ve put together a path of growth for people. There are different categories of individuals on the nursing team. There’s something called hospital assistants who might have very little clinical experience and they’re coming in and serving as true assistants that don’t do a whole lot of clinical work. So that’s one type of people.
And then we have veterinary assistants who are not licensed but have gained enough practical and clinical experience that they can function at a higher level in the clinics. And then people who have become credentialed from there that are veterinary nurses. We only hire credentialed veterinary technicians to be our veterinary nurses and draw a line there who are also very clinical in nature. They have knowledge of the why behind the things that they do that allows them to determine when their patient’s in trouble, be able to troubleshoot when things go wrong, and they have the knowledge set to be able to do so.
So just as a basic. Then there’s VTSs, too, right? Veterinary technician specialists that have higher experience and knowledge level and they went through a certification process. So let’s just say there’s four different buckets that people fall into. So then hospital assistants can be utilized in this fashion. Veterinary assistants can be utilized in this fashion. Veterinary nurses are utilized in this fashion. VTSs can do the highest end things.
So if we can bucket them into different categories and then assign the types of tasks that each of these people would primarily be able to be utilized in, then you have a starting place to say it’s not just that I like this person and how they do this particular procedure, so I’m going to let them do that. But this person, maybe I don’t have a good enough relationship with, so I’m going to shy away from working with that individual and then creating a very antagonistic feeling.

Dr. Andy Roark:
I like that. And I think that makes a ton of sense. Also likes about the personal development path. I think that that’s like if you want to keep people engaged and talk to them as an individual about where they’re going and start to lay those things down, I think that that’s such a healthy approach in keeping people growing and growing.
So I want to circle back to, there was three pieces I wanted pull out of what you said earlier, and the first was small steps to start. The second one is this individualized plan. And the third part is the skill training that we talked about. And so, I think back to when I graduated from vet school and my skills were pretty darn ephemeral at the time, meaning if I didn’t get into practice and start using those skills, I don’t know that I would’ve had them a few years later. Because we learned a lot in vet school, we learned a lot in vet school, but you don’t get to do a whole lot.
You are sort of didactically learning and learning and writing notes and sort of taking in. But then there’s the getting into practice and getting that repetition. So if I have… Let’s say I have a technician and he went to school and he got his credentials and he’s come into a practice and he didn’t really get to do a lot of the more advanced work for a couple of years.
And now we start to say, now we’ve got some opportunities for you. I want that person to be successful. Can you talk to me a little bit about how you would look at skill training for technicians when I’m actually… We’re actually going to let them do it now.
I feel like we’d been setting them up for failure if we said, “You were trained three years ago. Jump in there and do it.”
Help me bridge that skill gap.

Ken Yagi:
Yeah, so I think that one of the first places that you need to start is defining what that task really is. And that if it’s as simple as IV catheter replacement, for example, what does that mean? How is it done? Is there a standard that’s set in the practice that people are expected to do it a certain way? Because if one of the reasons why doctors don’t necessarily delegate to a certain technician might be that it’s faster to get it done themselves or get it done right if they do it, in the exact way that they want to see it happen, then we need to be able to communicate some of that to the team members on how a certain thing is being expected to be performed in that part of your practice.
So do you have guidelines? Do you have protocols? That needs to exist first in order to train against. And then the next step is the training part, which can also be somewhat challenging. That if you have a shortage of people and you’re struggling to keep up with the workload that you have, how do you gain the time in order to train these individuals appropriately? And that’s a harder one to tackle.
But having a system first, having standards set, having assistants trained, do you have somebody who’s dedicated to coordinate the training? Have you established a peer-to-peer training type culture within the hospital that allows people who are knowledgeable enough and well-trained enough to do the training, actually do it?
And then the rest of it is people having each other’s backs to find the time to help each other grow and that being a norm.

Dr. Andy Roark:
Yeah, no, that makes sense. It’s basically figure out what done looks like and then make an action step plan to get to done. And that’s super simple advice, but I’ve found it to be true again and again.

Ken Yagi:
And I guess one more thing that I’ll insert with that is, I think there’s maybe a little bit of a tendency for us to, when we set guidelines and protocols or certain ways that things are supposed to be done, being too rigid in it. And that there’s probably things that we want to make sure happens. If it’s a IV catheter example, we want it to be done in a aseptic manner. We want the catheter to stay in that. We want it to be painless as possible for the patient.
And there’s probably things to pay attention to do that, but how exactly do we need to tape the catheter or dictating it to that very micromanaged level is probably not the way to go. And so I just want to make sure that we’re aware that protocol or guidelines doesn’t mean exactly how it needs to be done, because there’s more than one way to get the goals accomplished.
And I think that’s a trap that we fall into sometimes, too, that makes it a unpleasant experience for the people who are learning.

Dr. Andy Roark:
I love that you said that. I have been… I actually am… I’m halfway through writing an article right now on the difference in protocols and context and leading with protocols and context where it’s a balance. So there’s so many people… I love what you said and just, I have a hundred percent worked at places where it was like, this is how many pieces of tape we use and this is how they go.
And I understand because it’s about consistency and quality control. And at the same time, if you hire smart people who are very good at what they do and you take away their agency and their ability to look at the situation and adapt to what is best in this specific case, the ultimate outcome is less than it would be.
I always say don’t hire smart, great, motivated people and then put them into a system that doesn’t let them make any decisions or affect the outcome on the ground.
And the same thing as don’t hire smart people and give them no guidance and then be frustrated when things are all done every different way. It is a balance of that. But I don’t think I’ve ever had anyone say that the hyper-nuanced, anal-retentive way of this tape, pieces of tape, and this is how we did it. I’ve never had anyone push back against that, but it’s always bothered me of what are we doing here really?
I don’t know. I love that nod towards balance. Let me… Last question. Are there any pitfalls that you see with practices that are starting to utilize technicians? How does this blow up and go off the rails and end up just locked back down tighter than it ever was before?
What are the mistakes that get made that really just tank initiatives to empower technicians?

Ken Yagi:
Having a plan on gradually improving utilization is the first point. And I say that because if we try to go from zero to 60 in a snap of a finger to get everyone utilized and we start letting people do all these things and they should just teach each other and just get it out there and put it out there, mistakes are bound to happen.
Mistakes as in something affected patient care. The client complained because they had a poor experience. The doctors got reinforced in the feeling that they should have done it themselves, because look what happened because I delegated this particular task this person.
So I think doing that in a more planned, gradual manner is the first thing that I think about when I think about that. But also being tolerant in understanding that there will be mistakes that will happen when we start letting people do new things and making sure that people understand that as we try to push the boundaries here a little bit, whatever that boundary is for your specific practice, there are going to be unideal situations that will arise.
But the point of that is to, when something like that happens, the important thing to think about as you approach it is not to then say, oh, see, it didn’t work, so now we have to revert. Let’s not let anyone place nasal gastric tubes ever again. Or doctors will always have to do urinary catheters or something like that, and doing a little bit of a knee-jerk reaction to that.
Instead of doing that, you really have to take the time to evaluate, well, what went wrong here? Was the person not trained well enough? Did the doctor not provide good enough instructions? Was it a difficult case that was going to happen with regardless of who was doing it? And just evaluating each of those situations, learning from it, adjusting for the next time, and providing the right guidance that each of these individuals need to do it better the next time, I think, is one thing that I want to make sure that people understand.
That it won’t always go perfectly. We just need to improve it for the next time. And that gradual improvement as you do it more and more is what will get you there.
Can I throw in one more thing?

Dr. Andy Roark:
Yeah, sure.

Ken Yagi:
When we talk about utilization and issues surrounding it, we often point to the doctor is not letting the technicians do this or the practice management isn’t paying attention to utilization enough and creating systems and whatnot.
But I think there’s a third piece to that, and that last piece is that for all the veterinary nurses out there that are wanting to be utilized better, I think we should self-reflect a little bit too to say, are we the type of people that foster good trust that allows people to delegate the task to us?
Do we have the knowledge and skills that allow us to appropriately do this? And are we making sure that we’re not overextending ourselves and putting patients at risk? Do we follow through and deliver when tasks are delegated to us and make sure that it’s done instead of forgetting it or dropping the ball sometimes? Are we treating the doctors respectfully and creating a safe place for them to come back and ask questions about how things were done or clarifications about the things that we’ve done without us getting defensive? Because that could definitely prevent doctors from wanting to delegate further.
And so, it’s always… I guess it’s more than a two-way street in terms of making sure that utilization is something that naturally happens in the hospital. So for all the veterinary technicians and nurses out there, be that person, is a message that I want to send.

Dr. Andy Roark:
Yeah, I love that. It’s definitely a dance that we do together. We want to be trusted and we want to be empowered, and then we need to make sure that we’re able to accomplish the things that we set out to do.
You know what I mean? And trust is cyclical that way of we give trust to someone else and they validate and reward that trust and we continue to spin up. So anyway, I love that point.
Well Ken, where can people find you online? Where can they learn more about you and/or VEG?

Ken Yagi:
I’m on LinkedIn, Instagram, and Facebook, and happy to chat through any of that.

Dr. Andy Roark:
Awesome. Thanks so much for being here.
Hey guys, take care of yourselves, everybody have a great weekend.
And that is our show. That’s what I got for you guys. I hope you enjoyed it. I hope you got something out of it. As always, if you did, share it with your friends, write me an honest review wherever you get your podcast. That always means the world.
Thanks again to Ken for being here. Guys, take care of yourselves. I said at the end of the recording with Ken, like, have a great weekend. It’s Wednesday. I don’t know why I said that. I’m think I’m done with this week.
I’m sure other people know how that feels. And regardless of what day it is, have a great day and a great next two days as if it was a great weekend, even if you’re listening on Monday.
Anyway, that’s all I got. Take care everybody. Bye.

What Happens in a Veterinary Board Complaint?

April 28, 2023 by Andy Roark DVM MS

Dr. Beth Venit, Chief Veterinary Officer at the American Association of Veterinary State Boards, joins the podcast to discuss veterinary board complaints in the United States and Canada. Dr. Venit explains how board complaints are made, processed and communicated to doctors and technicians. She talks about what to expect at State Board hearings, and what practices are most likely to land someone in one of those meetings. Finally, she gives some simple “best practices” to protect your license if you are a veterinarian or technician.

Cone Of Shame Veterinary Podcast · COS – 197 – What Happens In A Veterinary Board Complaint?

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

LINKS

AAVSB Website: https://aavsb.org/

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

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Beth Venit VMD is a graduate from the University of Pennsylvania’s School of Veterinary Medicine, Class of 2007. Throughout the area of Washington, DC, she practiced small animal medicine, both ER and GP, as both a full-time associate and a relief veterinarian for the next 12 years. In that time, she earned her Masters of Public Health from the University of Iowa and became a Diplomate in the American College of Veterinary Preventive Medicine. She then worked at the US Department of State, first as a fellow with the American Association for the Advancement of Science, and then as a full-time project manager focused on training foreign partners on biorisk management and the prevention of bioterrorism. In 2022, she joined the American Association for Veterinary State Boards as their first Chief Veterinary Officer.

In her free time, she enjoys hiking in various parts of the world with her husband (past trips include hiking the Grand Canyon Rim to Rim, the Inca Trail to Machu Picchu, several 14ers in Colorado, and a successful summit of Kilimanjaro), and being lazy on the couch with her pittie mix, Eleanor Woofsevelt and maine coon / tiger mix, The Chairman Meow.

EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome, everybody, to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. I am here with my friend, Dr. Beth Venit, today. She is the Chief Veterinary Officer for the AAVSB. Those are the vet state boards. And we talk all about license defense and what happens when there’s a complaint against your license, whether you are a veterinarian or a credentialed technician. And she runs through it, and she makes it less scary, which is good. That was actually what I wanted. I think there’s a lot of unknowns around what it means to have a complaint against your license. And when I met her, I said, “Would you tell me what really happens? Because I’m not sure I really understand and get it.” And anyway, she walks us through the process, what you can expect, what you should know, and most importantly, how to make sure you don’t have complaints against your license. It sounds like some pretty simple advice that was just really reassuring and good to hear.
So anyway, guys, she’s lovely. I pitched to her my Google review system where, if people haven’t been to my practice, their complaints should not be allowed. Kind of like if you haven’t made a purchase, then Google won’t let you write a review. I think we should do that for our vet state boards, but it does not go anywhere. She does don’t agree, and she tells me why. And so anyway, it’s a good episode. I hope you guys will enjoy it. It’s comfort food. All right, 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. Beth Venit. Thanks for being here.

Dr. Beth Venit:
Hi. Thanks for having me, Andy.

Dr. Andy Roark:
It is my pleasure to have you. You and I met in Orlando this year at one of the little functions, the muckety muck things, and I got to talk with you, and it was wonderful. You were such a wonderful sunshiny spot. It is a great event, but it was really, really wonderful just to bump into you and meet you. You and I were having that thing where we were talking, and I said, “Oh, that’s what you do.” And you said, “Yes.” And I was like, “I have many questions.” And you said, “Oh, ask me anything.” And I thought this is great. I said, “I know exactly some things I want to ask you.” And I think it’d be a great podcast. So for those people who don’t know you, you are the chief veterinary officer with the AAVSB, which is the American Association of Veterinary State Boards. Why don’t you talk a little bit… Oh, and you’re also a veterinarian, and you’re a Penn graduate. So why don’t you talk a little bit about what the AAVSB just does as a high level in the US and Canada and kind of how it comes into the lives of unfortunate veterinarians, many not unfortunate veterinarians. For me, it’s a scary… If you called me, I’d be like oh no. Tell me about the AAVSB.

Dr. Beth Venit:
So, Andy, at the end of this, I’d love to have you not fear the process so much and actually perhaps have a little bit of appreciation for the state boards and might, I don’t know, dare I say they love them.

Dr. Andy Roark:
I appreciate the state boards. I do. I believe that they’re run by good people who are doing an important service. I just don’t want to hear from them at all, ever.

Dr. Beth Venit:
That’s true. That’s true. That’s true. Well, so let me tell you about AAVSB first. The AAVSB is a 501(c)(3) nonprofit, and we are the bridge between our member jurisdictions in the United States and Canada and the licensees to strengthen the regulatory process. We create programs that make licensure process more efficient and user-friendly, with the ultimate goal of public protection. So we work with our member jurisdictions to provide them expertise and data management solutions, and we work with licensees to give them tools to maintain compliance and manage the requirements of being a licensee. And this applies to both veterinarians and veterinary technicians. And we also work with students. We like to educate them on licensure and the regulatory process, because it is so confusing as a student on what to expect after graduation. So we like to give them ideas about how AAVSB can help them through the life of their license.

Dr. Andy Roark:
Okay. That’s a lot. That sounds like, I call it corporate speak.

Dr. Beth Venit:
It is.

Dr. Andy Roark:
Okay. Tell me, just you and me… Like I’m nine years old. Tell me… I’m a nine-year-old veterinarian. Tell me what the AAVSB does, just in the most simplistic terms. Like efficiency of licensing and things, I’m like, okay, what does that mean?

Dr. Beth Venit:
Well, first of all, congratulations on being a nine-year-old veterinarian.

Dr. Andy Roark:
Thanks. I am very precocious.

Dr. Beth Venit:
A Doogie Howser. So we make it easy to manage the requirements. We simplify the process. We make it easier to manage the requirements for both licensure and regulation so that everybody can forget about those requirements and then do their jobs.

Dr. Andy Roark:
Gotcha. Good. That’s what I like to hear. All right, great. Cool. When we started talking, I was asking you about what it means to have a complaint filed against your license with a vet state board. And so I have seen this a number of times in my career. To me, it’s still kind of this black box process where you get a letter possibly delivered by a raven. It has black smoke when you open the envelope that comes out, and it says, “You have been summoned to defend yourself,” which is not what it says, but that’s what I imagine it saying. And on the day of the event, a carriage drawn by large black stallions pulls up outside your hospital, and you have to get into it, and then you go. And hooded figures weigh judgment upon you and whether or not you get to continue to practice the profession you love or whether you are exiled from the community to live in the wilderness by yourself and forage for food. And that’s kind of how the process is in my mind. And so if it’s different from that, we can just sort of start there and sort of start to unpack what the process, how it is actually different from that and what I might actually expect.

Dr. Beth Venit:
Yeah. And actually, Andy, you have it pretty correct, except you forgot to mention the red burning eyes.

Dr. Andy Roark:
The red burning eyes. Yeah, I blocked this out.

Dr. Beth Venit:
And the letter kind of explodes when you open it. So I think the process is scary. I’m going to a admit, as a practitioner, I was scared about the process. Every day I was scared that something that I would do would get me in front of the board. But I’m here to alleviate some concerns. It is a scary process, but it’s not as bad as you think it is. So the board follows something called due process, just like we do in our court system. And what the due process is is meant to look at the complaint as a whole and see if there’s actually a violation. So the very first step… And everything I’m going to say here has a caveat of in most cases.

Dr. Andy Roark:
Sure.

Dr. Beth Venit:
So in the United States, we have 52 different jurisdictions. And as you can imagine, there’s 52 different ways of doing things, slightly different. So this is a generality.

Dr. Andy Roark:
Sure.

Dr. Beth Venit:
In most cases, so a complaint comes in from member of the public, a coworker, concerned citizen, whatever. It is the board’s job for public protection to review every single complaint. So they have to look at every single complaint that comes in and determine is this jurisdictional? Is this within our jurisdiction? Or is this non-jurisdictional? And non-jurisdictionals are the things that we hate when they get in front of the board. So that includes things like complaints about fees, complaints about wait times, complaints about bedside manner, your business practices, debt collection. All of those are non-jurisdictional, and what that means is with none of those complaints was there actually a violation of a rule or regulation. So those are immediately dismissed in most cases. Okay?

Dr. Andy Roark:
So when you say immediately dismissed, is that like the veterinarian doesn’t hear that they have happened? Or is that We still go through the process, and when we get to that point of, “Hey, Dr. Roark, today’s the day,” and then we look at it and go, oh yeah, “People thought that your T-shirt was too tight and was inappropriate, and that’s why you’re here. And so we threw that out.”

Dr. Beth Venit:
That’s a great question. That’s a great question. So in most cases, most cases, the veterinarian doesn’t know about those complaints. The horses have not been hitched up. The raven has not been summoned, okay?

Dr. Andy Roark:
Okay, good.

Dr. Beth Venit:
So in most cases, but the board still has to review them.

Dr. Andy Roark:
Sure.

Dr. Beth Venit:
So if they look at a complaint and they determine that there is jurisdiction, so there is the potential for a violation, or at least it falls within the rules or regulations of that jurisdiction, then they look at the actual complaint. And they review the complaint, and they say, they may say, “Oh, there hasn’t been a violation here. It’s dismissed.” Okay?

Dr. Andy Roark:
Gotcha.

Dr. Beth Venit:
They may look at the complaint and say, “You know what? We can’t tell from the complaint if there’s actually been a violation.” So then what they’ll do is they’ll gather more information, they’ll assign an investigator from the state board, and they’ll research the complaint. And that includes looking at the medical records, looking at a statement from the licensee, looking at a statement from the complainant, if that was available. So they’ll look at all of that information. From there, and usually at this point, the licensee knows that there’s a complaint, because they’re [inaudible 00:10:53] a statement.

Dr. Andy Roark:
Yeah, I would imagine when they start looking at medical records-

Dr. Beth Venit:
Right. [inaudible 00:10:56] You’re going to know something’s up.

Dr. Andy Roark:
[inaudible 00:10:57] your hand. Yeah.

Dr. Beth Venit:
So from there, there may be a potential for something called a consent order. And what a consent order is is an agreement between the investigating member of the board and the licensee. And the consent order usually is, “Hey, I realize that I was deficient in my medical record-keeping. I agree to a fine and this education, the X number of CE hours, to help me improve my medical record-keeping,” or, “Hey, you’re right, I did not keep up to date with my CE. I’m going to pay fine and have to make up the CE and do extra CE on top of it.” So consent order is basically, usually it’s a one-time offense. It’s a minor offense, and you work with the member of the board and the licensee to present this option to the rest of the board, and they have the decision to accept or reject it. Okay?
Now, if in the information gathering process they determine that there is a major violation, or if the board rejects the consent order, then we’ll go into a hearing. And that’s the nightmare situation that we all worry about and we fear. And this is where the licensee is called in front of the board. There might be a judge involved. There are lawyers involved. There might be a subject matter expert. So they will have the hearing like Law & Order. A CE’s hearing’s probably less dramatic with less dramatic music. And there will be a decision based on all of that. Again, was there a violation? Or was there not a violation? And then from that violation, they’ll determine what the proper course of action is. So it could be still education and paying a fee or a fine. And in very rare cases, there’s a suspension of license or the license is revoked. So things that may get you a violation for the board, because I talked about the things that are non-jurisdictional. So let’s talk about things that may be a violation of the board’s rules or regs.

Dr. Andy Roark:
Okay.

Dr. Beth Venit:
Would include things like negligence, substandard care, malpractice, unprofessional conduct, illegal activity, drug diversion. All of those are actively bad things.

Dr. Andy Roark:
Like really obviously bad things. Yeah.

Dr. Beth Venit:
Obviously bad things, but it also can include controlled drug errors, so if you’re doing something wonky with your [inaudible 00:13:47] license or another person’s CE license and you’re not aware that you’re doing something wrong, or you just don’t know how to do it correctly or you don’t know how to store your controlled drugs correctly. So that’s a violation. CE deficiencies are a violation, and medical record-keeping is a violation. Also, in some jurisdictions impairment, so chemical impairment could be a violation as well.

Dr. Beth Venit:
Sure.

Dr. Andy Roark:
So what percentage… And I know this differs wildly between states, but what percentage of complaints actually end up going to a hearing? Are we talking about 10%? Are we talking about 50%? We’re talking about 1%. Kind of what percentage of complaints… If I get a thing that says, “Hey, there’s been a complaint. We’re going to investigate,” what’s the probability that that’s going to end up in hearing? Just kind of big picture.

Dr. Beth Venit:
Yeah. It’s a low percent. I can’t say exact percents because it varies by the year and by the jurisdiction-

Dr. Andy Roark:
Of course.

Dr. Beth Venit:
But it is a low percent. And part of that is because the public doesn’t understand due process. So a lot of the complaints, the large portion of them are non-jurisdictional. So you have to think about that whole process, but it is a very small number that actually make it all the way through.

Dr. Andy Roark:
Okay. So yeah, it’s funny about the public not understanding due process. When you and I met, I had my own idea, and I was like, “You know how if you write a one star rug review on Google, but you haven’t actually been a customer of the business, Google will just remove that review?”

Dr. Beth Venit:
Yeah.

Dr. Andy Roark:
“Because it stops people from showing up on the internet and bashing you?”

Dr. Beth Venit:
Yeah.

Dr. Andy Roark:
I was like, “I think the state board should have that policy,” which means if you have not actually been to the clinic, you are not allowed to file a board complaint. And you did not agree with that and told me that that was not how it’s done. Can you touch on that, on the reason why that’s the case?

Dr. Beth Venit:
Well, it’s part of the process. I don’t know if that’s exactly what I would say now. It’s part of the due process for the board to investigate whether or not this complaint is reasonable or not.

Dr. Andy Roark:
Gotcha.

Dr. Beth Venit:
So if a complaint is anonymous, they have no way of verifying if the person complaining ever had experience, right?

Dr. Andy Roark:
Gotcha.

Dr. Beth Venit:
But I do want to emphasize there is due process. So in complete opposition to Google or Yelp reviews or Yahoo, whatever, there is somebody and a multiple number of people who are reviewing the complaint for is this worthwhile? Does this make sense? And personally, for me, if I was a veterinarian, I would much prefer a complaint to go to the state board than to have it end up on social media or Google or Yelp.

Dr. Andy Roark:
Oh, that’s interesting. Yeah, I have to process that a little bit. I see where you’re coming from, because it’ll be handled. You’ll get a fair hearing, which is not the case on-

Dr. Beth Venit:
It’s not the-

Dr. Andy Roark:
On the social medias. Yeah, I see that.

Dr. Beth Venit:
And the problem with social media is that everything kind of snowballs and goes downhill, and it never ends. If it’s on Facebook, if it’s on Twitter or TikTok or whatever the kids use these days, it never ends. But the process with the board, once you get to the decision, it’s over. And if they find there’s no violation, then there’s no public record. So if there’s no violation done, then nobody knows that anything happened, right?

Dr. Andy Roark:
Okay. That makes sense to me. Talk to me a little bit about the similarities and differences between the states. So you said there’s 52… You pulled a face. There’s 52 different ways to do things. I guess what I’m looking for here is just like are there areas that are wildly different? I guess this is my own curiosity.

Dr. Beth Venit:
Oh gosh.

Dr. Andy Roark:
Are there certain things that you go, well, this is an issue on which states seem to vary widely? I guess, in my mind, the more mundane things, probably some people say it takes two weeks, and some people say it makes six weeks, or kind of basic things like that. But I’m just curious if there are topics or areas where you say some states are very aggressive in this way, and some states are not so much. I’m just interested in what those topics or those areas of divergence would be.

Dr. Beth Venit:
The areas of divergence are endless. So the thing that is similar is public protection. The way that they go about that is different from every jurisdiction. Due process is similar between one jurisdiction and another, but there’s going to be minor differences. The makeup of the board and how that office operates varies from jurisdiction to jurisdiction. Sometimes in some of the larger states, they have staff members and staff members and staff members. And in other jurisdictions where it’s smaller, it might just be the executive director or the ED. There’s usually the ED. There’s usually some sort of legal representative. It could be someone who is directly on that staff, or it could be the attorney general or the assistant attorney general. And there’s always board members, and the board members are veterinarians and veterinary technicians if they license veterinary technicians. And then there’s always a public member, a member of the public who’s just Joe Schmo, says, “I want to be on the vet board,” and they get appointed.

Dr. Andy Roark:
Like, “Yeah, I have Thursdays free. I’ll be on the board.” Yeah, I get it.

Dr. Beth Venit:
Well, you could be on the board, Andy. It’s a volunteer position, and most boards, they love their veterinarians because you provide subject matter expertise, and you help with this complaint process. So if this is something that keeps you awake at night, you could volunteer.

Dr. Andy Roark:
Okay, I’ll be on the board. Well, it’s always good to know what my options are, but yeah, all right, I like it. So, no, that totally makes sense. And that does make it a bit less scary. I like that. What are the sort of general suspension and revocation of licenses? When we talked about it, you were saying it’s really rare to get-

Dr. Beth Venit:
It is rare.

Dr. Andy Roark:
To this point. So can you color in the lines a little bit of what… Oh, actually, I guess how about this? Let’s start to look together at how cases kind of break down that generally show up for the AAVSB. So if you had to put them into categories, just big categories of what shows up, where complaints come from, could you do a pie graph for me as kind of like this type of complaint tends to be about 30%. And I know you don’t have numbers in front of you or anything like that, and I know they’d be sloppy categories, but are there big categories that come in? And kind of how does that break down? And then of those categories, where do we see suspensions or revocations, things like that?

Dr. Beth Venit:
Yeah. Again, revocations, extremely rare. I think a board is more likely to suspend and try to remediate than to revoke, okay? The biggest category is failures in communication and medical record-keeping. So that is something, because everything else is kind of active wrongdoing. You’re selling drugs, you’re performing malpractice, you’re doing illegal activities through your veterinary office. So the very most common thing is failures in communication and medical record-keeping. And if you think about it from why does this happen, if you think about it, who would be submitting the complaint, it’s a member of the public. So what does the public care about? They care about communication. So for anybody listening, if you’re saying how can I avoid a complaint to the board, I would give you couple different answers. And this will help with the majority of cases. First of all, don’t do anything illegal.

Dr. Andy Roark:
Yep. Good starting point.

Dr. Beth Venit:
Good starting point. General rule of thumb for life, don’t do anything illegal. So putting on my AAVSB hat, I would say, first of all, very first thing you should do if you don’t want to have a complaint against you for the board, know your jurisdiction’s practice act. Know your jurisdiction’s regulations, because they vary, especially if you’re new to that state or that jurisdiction. Read the regulations. I know it is not the most thrilling information you can get out there. It’s not a Tom Clancy novel, but you should read them and understand them, okay? So that’s the first thing. The second thing is stay up to date on your CE. CE violations or failure to complete your CE is so common, and it is something that you can do very easily. And then the third important thing would be your medical record-keeping and then your controlled drugs. So handle those correctly. All right? Now, if I took off my AAVSB hat and put on my Beth hat, I would tell you the key is good communication with your client and compassion towards your client.

Dr. Andy Roark:
Gotcha.

Dr. Beth Venit:
And those are two things that are going to keep the client and you as a partner and not as them wanting to file a complaint against you.

Dr. Andy Roark:
Gotcha. No, that totally makes sense. I’ll be honest here and say I probably read the state regulations for South Carolina when I applied to get licensed in the state of South Carolina 10 plus years ago. Is there a portal where it’s like, “Here’s all of the state regulations”? Or is it just a go through your licensing body where you say this is where I have to keep up my CE? So in South Carolina, it’s like that LLRC something body and all that. I know all the regulatory stuff is there. Is there another place to go and find those things? Or do you just individually seek it out in your state? And then when we say read the regulations, what exactly should I hunt down to be the most efficient where I go, okay, I got what I need to get?

Dr. Beth Venit:
Well, I don’t know about efficiency because I’m still learning that myself, but I can tell you if you go to our website, aavsb.org, we have a link to all of the jurisdictions, and from there you can find your practice acts and your regulations. So-

Dr. Andy Roark:
Perfect.

Dr. Beth Venit:
That’s an easy way. But I will tell you also, as public agencies, everything is public knowledge. So you should be able to go to your board’s website, and you should be able to access the regulations, the practice act, any guidance documents. All of that would be on the website, and it is public knowledge.

Dr. Andy Roark:
Gotcha. Okay. All right. Sweet. I will link that in the show notes so everyone can find it for sure. But yeah, that totally makes sense. All right, this sounds very doable. I’m going to need to draw this podcast to a close so I can go check my CE hours and make sure… I think the licensing period is closing up here before long, and I’m like I know I’m good, but now I feel compelled to go and look one more time just to make sure that I’m still good. So I am going to do that. It’s good to hear that suspension and revocation is rare. I like to hear that. Is there a ceremony for that? I imagine in the old war movies when the soldiers would have the stripes ripped off their shoulder, is there something like that? Or do you just get another raven-delivered letter, no ceremony?

Dr. Beth Venit:
I wish I could tell you, Andy. I don’t know.

Dr. Andy Roark:
Okay. Well, it’s probably a secret ceremony, I suspect, that’s-

Dr. Beth Venit:
It might be.

Dr. Andy Roark:
Probably held at midnight, and that’s why you’re not there. So I’m going to still hold onto that, that it’s a secret ceremony at midnight, and that’s why Beth hasn’t been invited. And anyway, so let’s hope that we never find out if that’s true or not. Guys, thanks so much for being here. Dr. Beth Venit, thank you so much for your time and expertise. Are there any final resources, links, words of wisdom, anything that you want to put out for people before you go?

Dr. Beth Venit:
Yeah, happy to. So if you go to our website, aavsb.org, like I said, you can see the board links to the websites and the statutes, but then you can also check out some of our programs that we have for licensees. So we have our RACEtrack program so you can track your CE and stay in compliance. We have our VAULT program and VAULT Premium, which is the secret weapon for anyone who wants to transfer from one jurisdiction to another. If you’re moving, definitely check it out. And then we also have links for our VTNE program, or a test for technicians who want to become credentialed. And then we have a PAVE Vets and PAVE Veterinary Technician program for foreign-trained veterinarians and veterinary technicians who want to work in the United States. So you could check those out as well.

Dr. Andy Roark:
That’s fantastic. Thanks again for being here.

Dr. Beth Venit:
Yeah.

Dr. Andy Roark:
All right, everybody, take care of yourselves. Have a wonderful rest of your day.

Dr. Beth Venit:
Thanks, Andy.

Dr. Andy Roark:
And that is our show. That’s what I got. Guys, I put some links to the aavsb.org down in the show notes. Thanks a lot for being here. Thanks for Beth coming in and talking with me. She’s amazing. But, guys, take care of yourselves. Write up your records. Do you CE. Communicate with your clients. Those are my takeaways. And I’m going to go check and make sure I have all my CE done for this year. All right, take care, everybody. I’ll see you later.

Do You Dine Out For The Food, Or The Experience?

April 28, 2023 by Andy Roark DVM MS

When you go to a restaurant, what do you really want? Do you want amazing food, or do you want an amazing experience? For most of us, we are looking for the latter.

At first blush, eating out seems to be all about the food. It’s not hard to think of fine dining and imagine the inordinate importance of the chef in specific and the cook staff in general. After all, aren’t they doing the thing we actually came for?

I once took a group of people out for steaks at a swanky place here in Greenville, SC. I knew it would be expensive but I really wanted to impress these people and show them a good time. Well, the food was excellent… when it arrived 2 hours after our reservation time. The waiter was nice, but completely clueless about why things were so slow and delivered no information until it was dragged out of him by my hangry guests.

The food was excellent. I’m never going back.

Over the last 50 years, we’ve experienced a shift in the evolution of veterinary medicine from being about the doctor to being about the team. You can still find old-school practices where the doctor is the star and everything is set up to serve him or her. But these practices are dwindling away.

In modern veterinary medicine, the focus is not and should not be entirely on treatment of pets. It should be on the healthcare experience. That goes beyond just excellent care coming from veterinarians and well-leveraged technicians and assistants. It also requires lots of accurate, insightful communication coming from the front desk, CSRs, and receptionists.

A great veterinary experience doesn’t come from medicine. Yes, good medicine is a requirement just like good food is a requirement for a great dining experience, but a great veterinary experience comes primarily from teamwork and communication.

This week is National Veterinary Receptionist Week. It’s a fantastic opportunity to take a moment and think about the experience your practice delivers, and about the role your front desk superstars play in making it happen. If you haven’t recognized “the front” for all they do in a while, maybe slap them a high five today. Maybe mention how important they are to getting pets in and out of our clinics, setting reasonable expectations in the minds of pet owners, and doing the stressful job of collecting payment for services from sometimes-emotional pet owners.

Vet medicine is a team game, and the healthcare experience is far more than just medical treatments. Thank you to all our front desk communicators for educating, informing, comforting, and caring for the clients who put their trust in us. In a profession where emotion matters so much, we could never create the meaningful experiences pets and people deserve without you.

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