Wellness

Dr. Tina Wismer (Senior Director of the ASPCA Animal Poison Control Center) and Dr. Andy Roark discuss the rising rates of Maijuana toxicity in dogs, the cause, and the staples of effective treatment.

LINKS

PRACTICE OWNER SUMMIT: www.unchartedvet.com/pos2021

Uncharted Podcast on iTunes: podcasts.apple.com/us/podcast/the-…st/id1449897688

Charming the Angry Client On-Demand Staff Training: drandyroark.com/on-demand-staff-training/

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

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Tina Wismer, DVM, MS, DABVT, DABT, is the Senior Director of the ASPCA Animal Poison Control Center. She earned her undergraduate degree from Ohio’s University of Findlay and received her DVM from Purdue University. Dr. Wismer worked in both small animal and emergency practice before joining the ASPCA Animal Poison Control Center in 1998. Dr. Wismer is a Diplomate of the American Board of Toxicology and the American Board of Veterinary Toxicology. She is an adjunct instructor at the University of Illinois, a visiting professor at St. Matthews University (Grand Cayman), a consultant for VIN (Veterinary Information Network) and a Master Gardener.

Editor: Dustin Bays
www.baysbrass.com
@Bays4Bays Twitter/Instagram

SHOW TRANSCRIPT

Dr. Andy Roark:

Welcome, welcome, welcome to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. I am back today with my friend, Dr. Tina Wismer. She is the senior director of the ASPCA Animal Poison Control Center. We talk about rising rates of marijuana toxicity. I saw one of these last week. The numbers are up, and that’s tied to legalization of marijuana, and just an increased prevalence in it, in daily life of many people. And we want to run through it, and then get into the staples of therapies. Make sure you’re up to date on everything you need, what to expect, what to tell people if they’re calling and asking about it, and just generally, what do you need to know, in a short little bite sized bundle. That’s what we got. 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 Dr. Tina Wismer, thanks for being here again.

Dr. Tina Wismer:

Thanks for inviting me.

Dr. Andy Roark:

Oh, it’s always my pleasure, I love to have you. You are the senior director of toxicology at ASPCA Animal Poison Control, for those who don’t know. You’ve been a regular guest on The Cone of Shame. I think this is our fourth episode together, out of a hundred, basically. We have a hundred and a couple, so you’re 4% of the podcast history.

Dr. Tina Wismer:

Woo hoo.

Dr. Andy Roark:

Right here.

Dr. Andy Roark:

Well, I wanted to jump on and talk to you today about, I was always looking at trends and what’s common. What are we seeing in the exam rooms today? And that’s what I’d like to bring you in and talk about on the podcast. Let’s talk a bit about legalization of marijuana across the country, and this has sort of been weird state by state creep. But I wanted to talk to you, as it becomes more normalized and legal, and we’vve got CBD dispensaries and things like that. Are we seeing fall outs of that, from a toxin basis, from an emergency medicine basis?

Dr. Tina Wismer:

Certainly. We have seen an increase in marijuana cases, just about every year, since legalization started. And I can tell you like between 2018 and 2020, the number of cases reported to animal poison control has more than doubled.

Dr. Andy Roark:

Okay.

Dr. Tina Wismer:

And we certainly don’t get all of them that are reported. I think part of it has to do with it being legal, and people are more likely to admit it. Yep, my dog got into marijuana. Right, there’s less of a stigma.

Dr. Andy Roark:

Well, let’s unpack that for a second. Do you think that these are new cases, meaning marijuana is more common and they’re more often getting it, or do you think that we’ve always been seeing marijuana toxicity cases, but people just didn’t admit it, and so we were having these kind of veiled conversations or veterinarians were treating unknown toxins. So yeah, help me with that a little bit.

Dr. Tina Wismer:

Sure. I think it’s a little bit of that. I definitely think that it’s more easily available. So as you said, there’s, dispensaries in, I shouldn’t say on every corner, but it seems like driving down the highway with all the billboards, that they’re on every corner.

Dr. Andy Roark:

Yeah.

Dr. Tina Wismer:

And I think that with less stigma, more people are willing to have it out in the open, and also that we’re dealing more with concentrated forms of THC now. A lot of the edibles have very high amounts of THC.

Dr. Andy Roark:

Okay, so let’s talk about that a little bit. It makes sense. Now that there’s dispensaries out in the open, and they’re selling a variety of products, hyper concentrated products, are they common? I mean, what percentage of toxin cases with marijuana do you think we’re seeing, that are this more processed, more potent version?

Dr. Tina Wismer:

So with cats, we’re still seeing a lot of plant material. Cats get into the baggie or cats eat the joints and become symptomatic. Dogs, it’s all about the edibles and especially because a lot of edibles contain chocolate, then we have to think about treating both chocolate and THC toxicosis.

Dr. Andy Roark:

So for those of us who are not in marijuana legal states, can you give us a quick breakdown of edibles, kind of what they are. Are these gummy products, chocolate products, anything that you can imagine? Are there trends and variables? Yeah. If you’re somewhere like South Carolina, it does not have legal marijuana. So yeah. I, I wonder if veterinarians there would be as familiar with the packaging of marijuana as in other states.

Dr. Tina Wismer:

Right? So you still can buy plant material, but you mentioned some of the things. You can get gummies, you can get brownies, you can get chocolate bars. You can get oil, which is a concentrated THC product. You can get wax, which is an even more concentrated THC product, and it does, it looks very waxy. All of these can be either ingested or smoked, and dogs seem to love them.

Dr. Andy Roark:

Well, I’m resisting their urge to drive this conversation more deeply into wax and how it’s used, because that’s not what we’re here for. I’m going to have to do some Googling after we get off the podcast. Okay.

Dr. Tina Wismer:

And one of the issues is that when people buy a brownie, or a chocolate bar, it’s considered to be multi dose. The typical THC dose for people is 10 milligrams, but a lot of these chocolate bars have like 180 milligrams. You’re just supposed to take a bite of it.

Dr. Andy Roark:

That’s terrible. Let’s let me jump in here for a second, that’s awful. The idea that I’m going to take a bite of a chocolate bar and stop, it’s not going to happen, makers of THC products, you need to be more responsible.

Dr. Tina Wismer:

Right, and dogs certainly don’t stop either. Right?

Dr. Andy Roark:

So what me and Labrador retrievers have in common is, we’re not stopping when we get a brownie, like we’re going to, we’re eating. The serving size is how big the pan is, and everybody should be open about that.

Dr. Andy Roark:

Hey guys, I just want to jump in real quick with some housekeeping wanted to let you know what’s going on. The big thing is December 2nd through the 4th in Greenville, South Carolina, in person, the practice owner summit is going on. This is uncharted practice owner summit. It is a gathering of practice owners. It is only open to practice owners. That’s not business owners, that’s practice owners. It is going to be a summit, which means there is going to be some workshops. There are going to be some hands on working groups, and it’s going to be a lot of discussion. It’s going to be a lot of collaborative problem solving and talking about your practice and working on your practice. So if you want to get re-energized, if you want to get re-motivated, if you want to connect with other people who are practice owners, talk about a real benefit.

Dr. Andy Roark:

We talk about knowledge is power and that’s true, but relationships are power as well. And, and the great thing about the uncharted, especially the summits, we really lean into the relationship. So come surround yourself with people who do what you do. Surround yourself with people who understand the struggles that you have, and get re inspired and re-motivated and reinvigorated. Get yourself a new lifeline or two, or three, or five, or twin, or 20 people who are there to help you and support you. That’s what we’re doing. Anyway, link in the show notes. I would love to see you there, registration closes on November the 15th. If you have friends who are practice owners, don’t let them miss out, put this on their radar. Be like, Hey, you need to look at this, it is really going to be awesome, and God, it’s going to feel good to get back together in person and see these smiling faces. Anyway, guys, take care and let’s get back into this episode.

Dr. Tina Wismer:

Our typical marijuana dog presents to you with the triad of classic signs. It is ataxic. It is hyper aesthetic ,and it’s dribbling urine, classic triad. Now we do have other dogs, about 25%, become a little more agitated, instead of lethargic.

Dr. Andy Roark:

Okay.

Dr. Tina Wismer:

But yeah, the classic triad.

Dr. Andy Roark:

It’s still a mixed bag. I’m assuming as far as what type of report you’re going to get from the pet owner. Yeah. So when marijuana’s legal, I’m sure you’re more likely to hear, yes. This is what happened. Are there common cover stories for nonlegal states that’s code for like my dog ate my stash.

Dr. Tina Wismer:

Right, typically its the neighbors threw it over the fence, and we’re like really. As one of my coworkers says, junkies don’t share. So it’s not uncommon that we’ll get, oh, it’s the neighbors marijuana. Okay, that’s fine. I don’t really care.

Dr. Andy Roark:

At this point, I jump in and help the high school kid out. I’m like, look, this happens all the time. Neighbors are always throwing marijuana into other people’s yards, and it just happens every day.

Dr. Tina Wismer:

Yes. Now, one of the weird things that does happen, so I have to mention it, and it’s kind of gross, is that people who do edibles, the metabolites that are passed in the stool are active. So we have dogs that will go to the park, or out hiking, and they eat human stool, and they get marijuana toxicosis.

Dr. Andy Roark:

That’s the case I would get, I would 100% get the hikers who come in with their dogs, stumbling around like I’m-. So like you’re a hiker, I’m sure that your nature interests extend to marijuana. And they would be like, no. I would only find out after the dog had thoroughly licked my face for like 10, that’s when I would make the discovery.

Dr. Tina Wismer:

Nice.

Dr. Andy Roark:

So, okay. Clinical science presentation, what’s my diagnostic workup on this dog?

Dr. Tina Wismer:

So we really don’t have any good diagnostic tools. The over the counter tests, the urine tests, really with dogs give false negatives, because dogs make different metabolites than people do. So typically we treat based on history and clinical signs.

Dr. Andy Roark:

So are you saying those tests are without value, meaning that they’re almost always going to be negative? Or do you mean that when there’s an error, it’s negative?

Dr. Tina Wismer:

They’re almost always negative.

Dr. Andy Roark:

All right.

Dr. Tina Wismer:

The time it can be positive is when they eat human stool, because that’s the metabolite that they’re testing for.

Dr. Andy Roark:

Okay, so that’s a test specifically for that type of ingestion, let’s write that down, you don’t know when you’re going to need that. That’s a pearl that maybe we’re going to need to break out.

Dr. Tina Wismer:

Definitely. So, we used to always joke about treating these guys with Pink Floyd and Doritos, that’s how you treat a [inaudible 00:11:21]. Forget about them in the back, don’t worry about it, but it’s changed with dogs that get into edibles,

Dr. Andy Roark:

Right.

Dr. Tina Wismer:

Because of the huge amount of THC, we can now see some of these dogs becoming severely hypotensive and comatose.

Dr. Andy Roark:

It seems like now, especially with being out in the open, is probably more likely that you can actually get some information about how much was consumed, in a way that you probably couldn’t in the past. Is that true, and how is that useful?

Dr. Tina Wismer:

Yes. So people will tell you, oh, he ate a brownie that was four doses, or they ate a chocolate bar that was 16 doses. So you can at least get an idea of how much did they ingest? Yes, this is going to be a serious problem. Or, if it’s just one human dose, many times you can monitor them at home. If they can walk around, they respond to their name, they can eat, they can stay home, but if they can’t ambulate, they need to come in and see you.

Dr. Andy Roark:

Okay, all right. What kind of timeline are we talking about usually before we’re going to see significant clinical signs?

Dr. Tina Wismer:

Sure, so signs can start within about 30 to 60 minutes after ingestion, and one of the other differences with dogs that get into edibles, is that they can actually be symptomatic for up to three days, post ingestion.

Dr. Andy Roark:

Okay, that seems important for setting expectations.

Dr. Tina Wismer:

It does. Now, if the dog is recovering and it’s able to get up and it’s still just stumbling, then yeah, we can send it home. But the dogs that are comatose, we treat with lipids. So they get the intravenous lipid infusion.

Dr. Andy Roark:

Okay, talk to me more about that. I’ve never given a dog intravenous lipid infusion.

Dr. Tina Wismer:

Sure, so this is a 20% lipid solution that you can use for partial parental nutrition, and it’s been used in toxicology for fat soluble toxins. So THC is highly fat soluble, highly lipid soluble. So the thought is, that the lipids bind the THC so it can’t get to the receptors and the CNS, and then it’s metabolized and removed from the body. Dosing wise, it’s nice because with 20% solution, you can actually give it through a peripheral vein. You can use your cephalic vein. You don’t need a central line.

Dr. Andy Roark:

All right.

Dr. Tina Wismer:

You give an initial bolus, one and a half mills per kilo, followed by a constant rate infusion of 0.25 mills per kilo, per minute, for about 30 to 60 minutes, and then you stop it. You wait for about four to six hours. If the animal is still symptomatic, you draw a blood sample. If it’s like PMIC, you have to wait. But if the serum is clear, then you can go ahead and re dose your lipids.

Dr. Andy Roark:

Okay, given that dogs can show signs for three days, is there a window in which I would give this and not give it? So saying for example, the pet owner is like, hey, I work 12 hour shifts, and I’m pretty sure he ate it the moment I left the house and now it’s been 16 hours. Is there a window where you go, okay this window has closed.

Dr. Tina Wismer:

Yeah. So the dogs that need lipids are the ones that are comatose or hypotensive. If they don’t hit that point within the first 12 to 18 hours, they’re not going to. They’re just going to be sedated and wobbly and we can typically monitor those at home, but yeah, the other ones will come to you pretty quickly. You give them lipids, and then they recover.

Dr. Andy Roark:

Okay, are there any sort of side effects of lipid treatment that we should be aware of? Is this one of those supportive measures that may have its own sort of fall outs?

Dr. Tina Wismer:

It does, right, because as we know nothing we do as benign. With lipids, there is an increased risk of pancreatitis, and we can see some elevated liver values. The biggest risk is if you have given other medications to treat other clinical signs, if those medications are also lipid soluble, it could take them away. So not in this, in marijuana toxicosis typically, we’re not using any other additional medications, but let’s say you had a dog that got into amphetamines, it ate the child’s ADHD medication.

Dr. Andy Roark:

Okay.

Dr. Tina Wismer:

It’s very agitated. You give it acepromazine, calms it down. Well, if we gave lipids to animal, it would scoop up the acepromazine first and we would see our animal become agitated again from the amphetamines.

Dr. Andy Roark:

Gotcha, okay, any interactions that we tend to see with medications we’d use for supportive care of GI symptoms. So let’s say that we’ve got, our chocolate dogs, things like that, and we’re worried about having diarrhea, having vomiting. Are there medications that I might normally reach for, that I don’t want to reach for, if I’m doing lipid therapy?

Dr. Tina Wismer:

So it can inhibit things like serenia, things that are going to act within the CNS, but things that you are given orally, like your proton pump inhibitors or things like that, it has minimal effects.

Dr. Andy Roark:

Is there benefits of inducing vomiting, or things like activated charcoal? Are there places for either of those?

Dr. Tina Wismer:

That’s a great question. So marijuana is actually a antiedemic. You think about people who are undergoing chemotherapy, they use THC to help decrease the nausea. So getting these guys to vomit, can be difficult. If you are going to induce vomiting, we have best effects using something that acts locally like peroxide, apomorphine, and those new ropinirole eye drops to induce vomiting, don’t seem to work. Charcoal, we rarely give it with marijuana, unless it’s a huge dose and we’re worried about signs and we couldn’t induce vomiting.

Dr. Andy Roark:

Gotcha, okay. Well that makes sense. Are there common mistakes that you see practitioners making, that you would warn against?

Dr. Tina Wismer:

I think the thing is that with our supportive care, we need to make sure that these guys stay warm, because they can get quite cold. And if they’re cold, we’re going to see decreased metabolism. So they’ll be with you longer, so keep them warm.

Dr. Andy Roark:

Yeah. That totally makes sense, that’s super helpful. Awesome. Well, Tina, where can people find you and learn more about ASPCA poison control?

Dr. Tina Wismer:

ASPCA.org, and we’ve got articles about treating many different toxins on there, including marijuana.

Dr. Andy Roark:

Thanks again for being here. I really appreciate your time.

Dr. Tina Wismer:

You’re welcome.

Dr. Andy Roark:

And that is our show. That’s what we got for you. I hope it was useful. I hope it was helpful. Guys, it was good to get little refreshers, quick to the point, super useful, knowledge lumps that we can just pop in our mouth on the way to work. It’s a little knowledge lump for you. If I ever have a candy, I’m going to call it a knowledge lump, and how can I fail? I think that’s amazing. Anyway, guys, I’d love to see you, if you’re a practice owner. I’d love to see you in December at our practice owner summit, for uncharted. Remember registration closes on the 15th of November, link in the show notes. Everybody else, I’d love to see you when I get to see you.

Dr. Andy Roark:

I hope life treating you well. And I hope you are-. God, I hope you’re not already hearing Christmas music because I am, the day after Halloween, my radio station I listen to in the morning. When the alarm comes on, it switched to the Christmas station and I just can’t handle it. I hope that you’re not dealing with the stress, but if you are, let’s stick together. We’ll get through this, ultimately one way or another. We’ll survive the holiday music in November trend. So anyway, that’s enough of that. That’s a whole nother podcast. Guys, take care of yourselves. I’ll see you later. Bye.

Dr. Peter Weinstein and Dr. Andy Roark discuss the emotional and physical fatigue of veterinary medicine. The discuss mental and physical preparation for practice, why doctors and staff aren’t building the habits they need, and what can be done to change this. They talk about controlling appointment schedules, setting boundaries and learning to say “no.”

This episode has been sponsored by Pawp. Pawp is a membership that gives you unlimited 24/7 access to vets for chats, video calls, and texts. It’s a great way to avoid those unnecessary clinic vet visits. Check it out now at www.pawp.com and use my code “andyroark” for 25% off the first 3 months before it expires November 7th.

LINKS

Uncharted Practice Owner Summit LIVE: 
unchartedvet.com/uncharted-practi…ner-summit-2021/

Uncharted Podcast on iTunes: podcasts.apple.com/us/podcast/the-…st/id1449897688

Workshop: Communication Foundations w/ Stephanie Goss:
unchartedvet.com/product/communic…ion-foundations/

Workshop: Content Calendars That Will Cure Your Creative Burnout 
unchartedvet.com/product/content-…lendar-planning/

Charming the Angry Client On-Demand Staff Training: drandyroark.com/on-demand-staff-training/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

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

As he was running his practice, he identified the need for increasedbusiness acumen to make his practice successful. Thus, while managing andpracticing full time, he attended University of Redlands to receive his MBA.

As a result of the MBA, he was able to relocate, expand andsell his practice to a corporate consolidator.

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

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

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

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

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

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

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

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

Editor: Dustin Bays
www.baysbrass.com
@Bays4Bays Twitter/Instagram

SHOW TRANSCRIPT

Dr. Andy Roark:

Welcome, welcome, welcome to the Cone of Shame Veterinary Podcast. I’m your host, Dr. Andy Roark. Guys, today, me and my friend, Dr. Peter Weinstein, sit down and we talk about fatigue in medicine. We talk about how medicine is a marathon, but so many of us run it like a daily sprint.

Dr. Andy Roark:

I love now with Dr. Peter Weinstein. He is a mentor and a friend of mine. You may hear some familiarity in this conversation. And that’s authentic. That’s just because I genuinely really enjoy him and I know him well. And so I’m really glad that we just got to talk about this.

Dr. Andy Roark:

We started talking about physical preparation for practice, mental preparation for practice. We talk about the control that we have and the levers that we can pull to make practice more of what we want to be and make it more what’s sustainable. So without further ado, let’s get into this episode.

Kelsey Beth Carpenter:

(singing) This is your show, we’re glad you’re here, we want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:

Welcome to the Cone of Shame Podcast, Dr. Peter Weinstein. Thanks for being here.

Dr. Peter Weinstein:

Dr. Roark, pleasure to always hanging with you. Thank you for the invitation.

Dr. Andy Roark:

Man, you and I go way back. I remember talking to you. You were a mentor to me just in general thought on that business, and especially on speaking and lecturing when I was in vet school. I distinctly remember pep talk and some good advice I got from you on a bus at the AVMA convention when I was about second year of vet student.

Dr. Andy Roark:

You’ve done a lot of things. In all honesty and total candor, you’re one of my favorite people to talk to in the industry. It is because you think outside the box and you have a background. You have an MBA. You have been a practice owner. You have been the president of the Southern California Veterinary Medical Association. You’ve been the president of that partners which is a national consulting agency working inside of vet medicine.

Dr. Andy Roark:

You have been on the chair of the Veterinary Economic Strategy Committee of the AVMA’s Economics Division. You’ve done a ton of things. You have published your book, the E-Myth Veterinary edition, which if people consider themselves to be business book aficionados and you haven’t read the E-Myth coauthored with Peter Weinstein, you are 100% missing out.

Dr. Andy Roark:

So, you have an amazingly diverse and interesting resume. And so, I’m always glad to get to talk to you.

Dr. Peter Weinstein:

Well, you just told me how old I was there, Dr. Roark. Thank you.

Dr. Andy Roark:

I went to veterinary kindergarten and you were there. Feel like you were old when you were there, yeah.

Dr. Peter Weinstein:

Yeah. I joked with you when we last saw you that I have an email from you from 2009 or something like that or 2007. It was way back when that you sent me when you were the president of the VBMA at University of Florida.

Dr. Andy Roark:

2006, yeah.

Dr. Peter Weinstein:

I have evidence that you actually went to vet school.

Dr. Andy Roark:

You and I have gotten to talk a bit recently. It’s been pretty fantastic. As the world has opened up a little bit, I’ve done a couple of trips. So I went out to Western Vet Conference. And then I went out to Denver to do some work with PSIvet. And those were the only two trips that I’ve made. And you’ve been at both of them and we’ve gotten to have dinner at both of them. So you and I have gotten to catch up a lot which has been really phenomenal.

Dr. Andy Roark:

One of the things that we talked about that I want to talk about with you some more here, the troops are tired. Over the course of the pandemic, there was a lot of discussion about fatigue in practices. And there’s just wear and tear on our paraprofessionals and our doctors and people generally burning out. And just I’m thinking a lot these days about leading tired teams. I guess that’s the topic I’m really interested in is knowing that people have a lot on their plates that they’re feeling stress and fatigue.

Dr. Andy Roark:

How do we motivate people? And how do we lead people when we can’t necessarily make them promises of sunshine and rainbows? How do we keep them going? And I want to talk with you. The phrase that you said was you said, “Well, veteran medicine is a marathon. And a lot of us are running it like a sprint or like a series of sprints.”

Dr. Andy Roark:

And so, I wanted to pick that conversation back up here and unpack your thoughts a bit more on what’s sustainable.

Dr. Peter Weinstein:

It’s a great discussion and it’s a combination of physical health and mental health that goes into running a marathon. A marathon is not just your ability physically to do 26.2 miles. It’s your ability mentally to go 26.2 miles.

Dr. Peter Weinstein:

In veterinary medicine, we tend to run, run, run, run, run throughout the day and get exhausted. And then we do it again the next day. And we do it again the next day. And we do it again the next day. And we do it again the next day. And we do it again the next day. Sorry, if it was repetitive, the record was skipping.

Dr. Peter Weinstein:

And I think every once in a while, we don’t prepare ourselves physically because it’s a very physically demanding profession. And we definitely don’t prepare ourselves mentally for this long-term situation which is why I think we see attrition in the paraprofessional. And I think we started to see more and more attrition in the professional levels is because we don’t go through the training to run the marathon.

Dr. Peter Weinstein:

And I think the training is taking time to eat correctly. It’s taking time to prepare physically and mentally. It’s also taking time to rest. You can’t run a marathon every day. You have to rest between marathons and build yourself back up. So, that’s why I think that analogy applies very much in veterinary medicine. The question is, how do we create the resources so that teams are preparing for that marathon every day so that they can sustain themselves long term?

Dr. Andy Roark:

Yeah, I agree with that. I came up with the mantra of make it work. That was what I heard was make it work, make it work. And I don’t want to go too far in this. I think people rush to extremes. It’s either make it work every time, “Suck it up,” or it’s, “Don’t ever overexert yourself.” And you go, “Neither of those is true.”

Dr. Andy Roark:

We’ve got a profession that doesn’t necessarily fit straight up business hours. I think that that’s probably baked in. I had a case yesterday when I was in the clinic. And I’d looked at my schedule and I was like, “This all looks really manageable.” And then, a husky that couldn’t stand came in the door.

Dr. Andy Roark:

And they were like, “It’s just acute onset.” It was an eight-year-old husky came in the door and they said, “Hey, can you look at this?” And, of course, I looked and the dog’s gums are just yellow. And it turns out this dog’s got IMHA. And I’m trying to get the dog set up and stabilized, and talk to the owners about what’s possible and get a diagnosis for him and things like that.

Dr. Andy Roark:

And ultimately, things came together. And I got out of the practice not too far after closing time. But it was just one of those things where that’s … there are things that are part of the job I guess is what I’m trying to get to. You can’t just be like, “Oh, I’m done. I’m sorry I don’t know what’s wrong with your dog. See you later.”

Dr. Andy Roark:

There’s always going to be these things that are going to push us a bit. I think to your point, it’s one thing to sprint, it’s another thing to sprint every single day and have a plan to sprint every day for the rest of your career is. Am I accurately summing up your position?

Dr. Peter Weinstein:

Absolutely. Absolutely. And see, we can control our appointment books. And all too often, we let our clients control our appointment books. And all too often, we let our client service teams control our appointment books without a direction.

Dr. Peter Weinstein:

Just as an example. As a single doctor practice, trying to integrate surgeries into outpatient, well, you know what’s going to happen. You’re going to get into the stay at lunchtime and you’re going to drop a stump. Or it’s going to be a pile or something off the wall and all of a sudden, your 2:30 appointment now becomes a 3:30 appointment because what looked to be an easily triaged surgical time now becomes a mess.

Dr. Peter Weinstein:

Well, what if you just had a surgery day and an outpatient day? What if you just did your surgeries in the morning and had a break for lunch and then you went to your outpatient? What about taking control of the way things are so that you have the ability to take a break and maybe take a nap, maybe get some lunch, maybe not have to put in a urinary catheter so you can actually go to the bathroom or wear the pads? I don’t know what you prefer, the pads or catheter.

Dr. Peter Weinstein:

But the concept of suck it up is not relevant in 2021. The concept of balancing your practice, your life and taking care of your team, Simon Sinek’s book after Start with Why was Leaders Eat Last. And it’s all about leaders taking care of their teams.

Dr. Peter Weinstein:

Well, we have to do that as well. And I think we need to be ultrasensitive to the challenges that COVID has presented from a physical standpoint and from a mental standpoint on top of what already existed in terms of challenging inefficiencies within our practice model.

Dr. Andy Roark:

Yeah, I like that a lot. I think one of the things I’ve picked up that I like a lot is that life balance happens three months from now. And what I mean when I say that is I think a lot of us end up bogged down and overwhelmed. And we feel like, “Oh, my God. Clearly, my time is not allocated correctly. I don’t have boundaries and I’m completely overrun. I need to fix this right this second.”

Dr. Andy Roark:

And when I say life balance happens three months from now, what I’m really saying is the systems policies, plans and commitments that we make now are what are going to dictate our life balance three months from now. I think a lot of people feel hopeless because they look at themselves and say, “I don’t know how to make tomorrow better than today.”

Dr. Andy Roark:

And I say, “I don’t know that you can make tomorrow better than today. But you can make February better than November, that’s for sure.” You definitely haven’t had power to make those changes and to start setting some policies that are going to protect you in the future.

Dr. Andy Roark:

So, I don’t know. I’m curious what your thoughts are on that. I think a lot of us think of work-life balance. I think we put too much emphasis on the individual saying, “No, I’m not available for this,” or the individual holding their personal boundaries.

Dr. Andy Roark:

And what I found with personal boundaries, the story that I like a lot is there’s this guy that wrote Deep Work. His name is Cal Newport I think his name is. He wrote this book called Deep Work. And it’s all about the benefit of uninterfered with time. Its head-down work where no one bothers you, you don’t respond to email, you just get work done.

Dr. Andy Roark:

And I deeply believe in that. I think he’s totally right. So apparently, he writes the book. And he goes on the book tour. And again and again, people came up to him and said, “Yeah, this is really great. Why don’t you tell my boss that I’m not going to respond to email for 90 minutes?” And that’s not the end of the world because we get rated on how fast we respond to email.

Dr. Andy Roark:

And Cal realized, like, “Oh, crap, I can talk to the individual.” But ultimately, if the organizational culture doesn’t allow this type of deep work or this type of independent boundary setting, these people are screwed. And that was the origin story of his next book which is The End of Gmail.

Dr. Andy Roark:

But I think about that a lot in vet medicine. I think we preach to veterinarians, “You got to set boundaries. You got to set boundaries.” And there’s truth to that. And you do need to look out for yourself. At the same time. I think the organizational power to set up systems that promote healthy lifestyles is pretty large.

Dr. Peter Weinstein:

This concept of boundaries is something that veterinarians … well, we haven’t always had boundaries. And I think part of what’s happened with COVID has exacerbated that because we haven’t learned how to say no. I think we’ve been afraid to turn down clients because if we don’t let them come in now, they won’t come in later.

Dr. Peter Weinstein:

And what’s happened in many cases is by not saying no, we have actually done damage to existing clients because we’ve seen not prior clients to the detriment of existing clients. So, our unwillingness to say, “No, you can’t get in to see a doctor for six months,” and that’s routine. “You can’t get in to see a veterinarian for six days,” and a panic ensues.

Dr. Peter Weinstein:

So, we have to start to set boundaries within our practice. And we have to start to set boundaries by the vision, mission and values that our practice has. And maybe, just maybe, there are clients that you don’t need to see because they don’t adhere to your vision, mission and values. Your staff needs to know what your vision, mission and values are from that standpoint.

Dr. Peter Weinstein:

I think the boundaries start to come. And it’s not just a fee schedule, it’s a standard of care. It’s the business hours that you’re open. The balance from a life standpoint comes from a balance on a day-to-day standpoint. I love this life balance occurs three months from now. I would challenge everybody who hears this to take their four weeks of paid vacation, six weeks of paid vacation and book them now. Get them on the calendar a year in advance.

Dr. Peter Weinstein:

And that gives you something to look forward to. Because what generally happens is we book vacation in a reactionary fashion, not a proactive fashion.

Dr. Andy Roark:

Yeah, that’s 100% what I learned in my career. After going a couple of years without taking a vacation, I really had to look at that and say, “Well, how was this going to happen?” And it never shapes up. And my schedule never opens up to allow me six weeks from now to have a vacation. It’s just never going to happen.

Dr. Andy Roark:

The only way it happens is in October, November. I look at my calendar for the next year and put those times on there and say, “This is when I’m going.” And it’s either because there are specifically something I want to do and I’m looking at which is ideal or, and this is what I push for, even if you don’t have a place to go, put your vacation on the calendar. Just put it down and go ahead and ask for the days off and get it.

Dr. Andy Roark:

And if it gets pushed around, that’s fine. You can move that week or you can move that long weekend. But at some point, you’re not going to delete it, it needs to get scheduled in. It needs to be a thing. And you need to be out of the clinic. And I think a lot of us just … I don’t know, I think it’s exactly what your point is. I think you make a strong argument.

Dr. Andy Roark:

I think a lot of us have fear that if we’re not there, then our clients are going to go somewhere else. And that’s if you’re the practice owner. If you’re the associate vet, the idea that like, “If I’m not there, then my clients are going to be frustrated because they can’t see me,” or, “They’re going to go see another vet and maybe they’ll like that other associate vet better,” and whatever the catastrophic thoughts we have are.

Dr. Andy Roark:

I do think that we tell ourselves we’re too important to be gone. And we just never get around to putting our days off on the calendar. And then they roll by. Or we’re not compensated in a way that rewards that at all. And I’m not saying it’s wrong.

Dr. Andy Roark:

But I do remember that from me early on with production-based compensation and ProSal and things like that, I took a financial hit to not take vacation. And I thought I’m fine. I am young and energetic and I don’t need to be away. And I don’t want to incur this financial hit. So I’m just going to work through. And we do incentivize people not resting and taking care of themselves that way.

Dr. Peter Weinstein:

Yeah. Well, there’s so many things you just said that I want to jump all over. But we as a profession, we want to be loved, Andy. Listen, dude, I want to love you, man. You’re 3000 miles away and I want to give you a big hug. So as a result, we try to be everything to everybody. And the miniature everything to everybody is the miniature nothing to anybody.

Dr. Peter Weinstein:

We are so weak, become so exhausted trying to be everything to everybody. And I think it’s because we want to be loved. And I blame the vet schools on that one because they spent four years beating the love out of us with all of the forced education and drinking from a firehose. And we leave vet school with cerebral constipation and we didn’t come out of school wanting to be loved.

Dr. Peter Weinstein:

And that means trying to be everything to everybody. And it doesn’t work. It’s exhausting trying to be everything to everybody. You know it as a speaker and an author. I know it as a speaker and an author. You know it as a veterinarian. I know it as a veterinarian. We need to find those clients that love us and take good care of us which is why I think, speaking personally and I’ve said this in public as well, I think veterinary medicine is the perfect profession for a concierge business.

Dr. Peter Weinstein:

I think we could choose 500 clients charge them 1,000 bucks a year or something like that. And net 50% working part-time and have 500 clients that love us and not 15,000 clients who don’t. Take the top 20% of your clients. Take them off the top. Give them everything that they want at a high level, give them everything they wanted at a high level. And you’ll be happy and they’ll be happy.

Dr. Andy Roark:

I think a part of that comes from, “I think we just need to be loved.” I completely agree with that and then also serving the people who best fit us. But the need to be loved, part of it for me, I think it’s a need to be right. It’s a need to be perfect. It’s the perfectionist tendencies.

Dr. Andy Roark:

And I think that there’s this cruel reality in vet medicine where what gets you to the top of the class in vet school is what tears you down as a veterinarian. So like the getting everything right, getting the perfect score perfection, that is a highly-prized trait in vet school. And then when you get into vet medicine, you realize that it’s a wildly imperfect world and a wildly imperfect system working with wildly imperfect pet owners in wildly imperfect circumstances. And you think, “Oh, perfection is not possible yet I have been pushed to achieve it.”

Dr. Andy Roark:

I think that that’s where people come into the be-all things to all people and they want to be loved. I think a lot of us want to be perfect. And we will lay down to be perfect because that’s how we’ve been trained. And the truth is perfection is it’s impossible in a complex world, but it’s also destructive.

Dr. Peter Weinstein:

Absolutely. I think we’ve had this conversation about veterinary school. I think we’ve had this conversation about veterinary school where we choose adversely choose veterinary students for a profession that doesn’t need as much IQ, but now needs more EQ.

Dr. Peter Weinstein:

And I think that if we were to focus more on a balanced individual with communication skills, some leadership skills and clinical skills, they might be a better contributor long term to the profession and less likely to get burned out than those people who have always been at the top of the class, made it through vet school at the top of the class, only to find out that there is no top of the class when you get out of vet school.

Dr. Peter Weinstein:

And every day, you will be having to deal with mistakes maybe that you made, maybe that somebody that’s part of your team has made. And there is no definition of perfection in veterinary medicine. I don’t think you can define perfection in veterinary medicine.

Dr. Andy Roark:

This episode of the Cone of Shame Veterinary Podcast is brought to you by Pawp. Guys, Pawp is a membership service for pet owners. It gives them unlimited 24/7 access to vets for chats, video calls and texts. Think about the difficulty pet owners have getting in for appointments right now. Think about the fact that we want them to have good advice and have access to licensed veterinarians for support. And we want care to be affordable. Guys, you can have up to six pets on a Pawp account.

Dr. Andy Roark:

Also, in the case of an emergency, Pawp can provide up to $3,000 in financial support for pet owners. Guys, check it out. Learn more about it, pawp.com. If you like the service, you want to try it out, you can use my code. I have a promo code. It’s Andy Roark and it will give you 25% off the first three months. Use it before it expires. This is a limited time code. I hope you’ll take a look.

Dr. Andy Roark:

Hey, guys. I just want to jump in real quick with a couple of announcements over on the Uncharted Veterinary Podcast. Stephanie Goss and I are breaking out one of our Hall of Fame episodes just called Where Do You Find New Hires. I don’t know. It feels like that some people out there are trying to hire people. I don’t know. Maybe that’s crazy talk. I suspect it’s not.

Dr. Andy Roark:

How do you find new hires? And how do you get them into your practice? How do you get the right people on board when it is really hard to hire? That’s what we’re talking about. I’ll put a link in the show notes over the Uncharted Podcast. And you guys can definitely check that out.

Dr. Andy Roark:

On the Uncharted side of the house, we have just finished up our culture conference. It was the biggest virtual conference we’ve ever had, the biggest virtual event we’ve ever had. It was big. And what I’m trying to get at is large, it was large and it’s flipping awesome. It filled my bucket.

Dr. Andy Roark:

You ever done like a program and then you’re like, “Man, I feel energized coming out of that and not let down.” That was the Unchartered Culture Conference last week. And so I am still riding the high of that. So that is in the books. But don’t fear, we have got communications foundations workshop with Stephanie Goss. That is coming up on November 7th, from 4:00 to 6:00 p.m. Eastern, 1:00 to 3:00 p.m. Pacific.

Dr. Andy Roark:

We have got content calendars that will cure your creative burnout. [inaudible 00:23:09], content calendars that will cure your creative burnout. That is with the dynamic duo, Tyler Grogan and vet tech Kelsey Beth Carpenter. So, Kelsey Carpenter and Tyler Grogan who runs social media for Uncharted and Dr. Andy Roark, who were both just wonderfully creative articulate, just amazing just people, are talking about building content calendars that make your life easier.

Dr. Andy Roark:

And so if you’re like, “Man, I don’t know what to post. I’m tired of figuring out what to post. I’m tired figuring out what to send out in emails,” we got you covered. Check that out. That is November 12th. It’s from 2:00 to 3:30 Eastern Time, 11:00 a.m. to 12:30 p.m. Pacific Time. Both of those workshops are free to Uncharted members. They are $99 to the public, you can grab them.

Dr. Andy Roark:

And if you are a practice owner, the first ever in-person practice owner summit is going down December 2nd through the 4th. It is in Greenville, South Carolina. That’s right. What did I say? Yes, it is in Greenville, South Carolina. The magic is back, gang. We are getting back together. This is going to be a smaller event. You can check out registration for more information on COVID protocols but we are doing it.

Dr. Andy Roark:

Practice owners coming together circling up, collaborative learning, working together on their practices, share their experiences. This is going to be such good stuff. And man, it’s going to feel good to be back together with the gang. If you want to be a part of that, head over again to unchartedvet.com. Get signed up. You need to be a member to come, but you can get a membership so you can become a member and then you can head into the Practice Owner Conference. We would love to see you there.

Dr. Andy Roark:

Anyway, guys, that’s enough of that stuff. Even though it’s awesome, we should get back into this episode. So first of all, let’s take this back to the paraprofessionals and say, what are the things you see coming down the pipe that will help make their lives better? What do we do to help paraprofessionals? They don’t have nearly as much control over the race as the vets do.

Dr. Andy Roark:

I have a lot more decision-making power than my technicians do. And so, I feel like vet technicians and front desk staff, to a lesser degree, just get sucked up a lot of time into what’s going on around them. Are there things that we should be doing as practices, as organizations to protect our paraprofessionals?

Dr. Peter Weinstein:

Absolutely. Absolutely. I want to see paraprofessionals owning veterinary hospitals.

Dr. Andy Roark:

Do you really?

Dr. Peter Weinstein:

Oh, yeah. Here’s my perfect business model, Dr. Roark, in 2022. Three veterinarians each working three days a week in a practice owning 20% each, 20% of the practice owned by the manager and 20%, owned by a technician, they all share in the profits. The doctors focus on being the doctors. The management team focuses on getting the work done correctly. And the technicians focus on the animal care and oversight from that standpoint.

Dr. Peter Weinstein:

They have governance at the top because there are three doctors making the decision on the standards of care. The doctors don’t have to worry about the hiring, the firing, the finances and everything else because if they are good doctors, they get to share in the profits. But now, you’ve got a technician with skin in the game who has a voice, you have a manager with skin in the game who has a voice. And I don’t have a problem if you have a client service person who wants to have some skin in the game and has a voice.

Dr. Peter Weinstein:

I think we need to give some ownership to our paraprofessional team so that they feel that they have a voice in building the practice. I think somebody asked me at a meeting not that long ago, what do I think the greatest weakness is in veterinary medicine. Maybe I should ask you that. Let me ask you that question first before I answer it. What do you think is the greatest weakness in the veterinary profession?

Dr. Andy Roark:

So the greatest weakness in the veteran profession I think is … let’s see, this is not an easy question. And it depends on what we mean by weakness. So from a pure business standpoint, the greatest weakness we have is our inability to just say no a lot of the times. So, no other business is there a scenario where the worker desperately wants to do the work like there is in vet medicine.

Dr. Andy Roark:

And I don’t want to change that. But I do think from a business standpoint, the fact that someone brings me their dog with parvo and they don’t have any money and I desperately want to do this work. I think that that makes things challenging from a business standpoint as far as how do we go forward and run a classic business and have boundaries when you desperately want to help?

Dr. Andy Roark:

I think that’s an interesting conflicting problem. So from a business standpoint, it’s a desire not to say no to doing work. I think the other part is probably what I said before of perfectionism as a problem in our profession. It is having sky-high standards in an industry that has just so many conflicting variables and obstacles and no perfect outcomes.

Dr. Peter Weinstein:

So, let me go on with that for a second before I give you my answer.

Dr. Andy Roark:

Okay.

Dr. Peter Weinstein:

In the E-Myth Revisited by Michael Gerber, and to a lesser degree, the E-Myth Veterinarian, Michael talks about entrepreneurs and small business owners wearing three hats, the hat of the technician, the hat of the manager, and the hat of the entrepreneur.

Dr. Peter Weinstein:

The technician is the individual who does the technical work, surgery, putting in catheters, whatever the case may be. The manager gets the work done. And the entrepreneur has a vision for the practice. What you said by the fact that we just can’t say no is putting the technician hat on. Basically, I’m a technician, I want to do the work, I want to do the work, I want to do the work, I want to do the work. And that’s what veterinarians are really good at is being a technician.

Dr. Peter Weinstein:

Perfectionism, you know as an entrepreneur, there is no such thing as perfectionism. And as a manager, your goal is to get people to become perfect. So, to a degree, perfectionism is really technician as well and maybe to a little bit management. So, my feeling in one of the greatest weaknesses in veterinary medicine comes from a lack of true leadership and a lack of true entrepreneurship because I still think that most veterinary practices are just to quote Michael Gerber, “Technicians who had an entrepreneurial seizure.”

Dr. Andy Roark:

Yeah.

Dr. Peter Weinstein:

And so, lack of leadership in a practice because if you’re a real leader and a real entrepreneur, you will come up with a way to deliver the care and the service and take care of your team so that you’re satisfied, the client is satisfied, and the staff is satisfied, and the patient is cared for. That’s what leaders do. Technicians do more work. Leaders find ways to do work easier, better, smoother, faster, happier so that the team is well balanced at all levels.

Dr. Andy Roark:

What do you think about the idea that it’s time to shift how we prioritize our focuses inside the practice? So, I’ve been feeling more and more that it’s time for us to take care of our team first. And trust that the team will take care of the clients. As opposed to what feels like the classic example which is take care of the clients and everything will work out for your business. What are your thoughts on that?

Dr. Peter Weinstein:

We have lived since Noah in a doctor-centric business. Everything is all about the doctor and the doctoring. In 2021, we need to be a team-centered business to delivering client-centered care. And the team has to help build that experience for the client. My envisioning of the practice of the future, and we’re talking about paraprofessionals, is delegating them with the responsibility of better defining that client experience and the patient experience and giving them the leadership role to make those things happen.

Dr. Peter Weinstein:

We need to create a team-centered health care model where the team has a voice in ultimately making the decisions that support the vision, the mission and the core values that the practice has. If you go to a team right now, what is it, sometime in October and said, “Listen, Christmas is coming up. Christmas is on a Saturday this year. When should we close? What days should we close? When do you want to be with your family?”

Dr. Peter Weinstein:

And you let them have a voice. And you say, “You know what, that’s what we’re going to do.” And maybe, you miss out on a really busy day. But you listened to your team and you let them have a voice and you supported them. They’re going to be there next year. Whereas in another practice that maybe had the staff … maybe they were open Friday, Saturday, Sunday, and whatever the legal holiday they took but they didn’t take anything more than that, maybe that team gets a little bit more burned out. Maybe that team starts to look for a practice that has a better culture that they can work at.

Dr. Peter Weinstein:

I really do think the move from a doctor-centric health care delivery model to a team-centric health care delivery model with responsibilities delegated with decision making shared that ultimately delivers on a client experience and a patient experience.

Dr. Peter Weinstein:

I think we need to start to move away from the classic 1920s sweatshop. Oh, I’m going to get some pushback on that, aren’t I? Somebody is going to be unhappy with that. From the 1920s sweatshop that said, “Hey, I work 60 hours a week, you need to work 60 hours a week, too,” to a, “Hey, I’m going to hire three people to do the work of one-and-a-half. And it’s all fine. We’ll get it all taken care of.”

Dr. Peter Weinstein:

Instead of trying to continue to push square pegs into round holes, let’s just see if we can smooth out some of the edges and get a whole bunch of people fitting into one hole.

Dr. Andy Roark:

Do you feel like we’re starting to see a cultural arms race where practices especially corporate practices … so I think they’re sort of driving this. There’s such competition for labor right now, skilled professionals. It feels to me like we’re seeing big jumps forward in things like work-life balance and holidays and programs to help take care of staff as opposed to just a battle in salaries. I do think salaries are going up.

Dr. Andy Roark:

But I feel like the landscape is getting more competitive about taking care of the staff and making your place a place that people would want to be. Are you seeing that?

Dr. Peter Weinstein:

I’m reading about it. I’m hearing about it. But let’s just say that in 2021, there’s been a lot of bright, shiny objects that people are chasing, classic veterinarian. It’s like squirrel, squirrel, squirrel, squirrel. We’re chasing new bright, shiny objects and culture is the buzzword that many corporations are using. It’s the stickiness, how long they can stand with that culture support. That’s what I want to see.

Dr. Peter Weinstein:

It’s marketing. It’s the new coke. It’s the new Tesla. It’s the new this. But how long can it stay on the market and do that and still be profitable especially when you’re talking about corporations? God, I hope they can stick to it. I hope that we can continue to see improvement in cultures. I hope we can continue to see the ongoing salary escalation that we’re getting. I do think that there’s a great upswing in salaries.

Dr. Peter Weinstein:

I’d love to see a greater upswing in salaries for the paraprofessionals. We need to start paying our paraprofessionals a life salary that they can live in the communities in which they work and, exclamation point, can actually afford to pay for the veterinary care at the hospitals at which they work as well.

Dr. Peter Weinstein:

And to do that, we need to have more profitable practices. They need to be more efficient. They need to be more productive. We need to create veterinary careers for people that we hire and not just jobs. And that basically goes back to some of the things we talked about with the paraprofessionals which is training and giving them the opportunity to grow, giving them the tools and the resources to grow. And giving them the opportunity to be leaders within the practice and have a voice that’s heard.

Dr. Andy Roark:

Yeah. There is some data that’s come out and people are sort of pointing to. And this is not new, but we’re seeing that pet owners are starting to hit near the top of their financial flexibility, meaning it’s unclear how much elasticity there is in pricing, meaning how much vet medicine can continue to increase their prices with pet owners being able and willing to pay for those prices.

Dr. Andy Roark:

When you talk about running healthier practices, do you see some of that coming from increases in prices? Are you seeing more of that coming from efficiency and changes in how we do business? Because I want that, too, I want our paraprofessionals to have living wages. And I want them to be able to afford to have a career and not a job.

Dr. Andy Roark:

I want them to stay with us. I want to see long-term paraprofessionals in our practices. And I’m just thinking about how do we make that happen? And so, when you talk about more financially healthy practice, what does that look like in your mind?

Dr. Peter Weinstein:

I think instead of looking just at revenue and expenses, I think the practice should set, to begin with, a profitability mark. Let’s just say 20% and work backwards. How can we get there? What on the expense side can we control? What on the revenue side can we control so that we get that 20%? Because generally, what happens is we set a growth mark of 10% revenue. And we say we’ll try to keep the expenses the same. So we’ll get a little bit of a push in profitability.

Dr. Peter Weinstein:

But what if we started with a profit margin and reverse engineer that profit margin focusing on paying our people more, maybe keeping our inventory a little bit better under control because as you know, there are three major cost centers that cover 60% or more of your expenses, people at the doctor side, people at the paraprofessional side and cost of goods or products.

Dr. Peter Weinstein:

The cost of goods, you actually can start to make cuts in and still be an effective and efficient practice. The people side is where I’d like to see some of that redirected. So, if we take that 60% and tweak it, maybe drop it a little bit, could your profits be there? And maybe some of that profit gets fed back to the staff. So, people need to be paid appropriately but we need to keep that profit margins.

Dr. Peter Weinstein:

Then we get to the pricing side at the top. Well, let me address one more thing on the expense side. We have large hospitals with not enough doctors that aren’t being utilized to their full capacity. So, for example, if you do boarding and grooming, that boarding is probably working at 30% efficiency over the year. It’s at 100% efficiency over the holidays. But if you average it out over the year, it’s only a 30%. But you’re still paying for that part of the physical plant. Same thing with grooming.

Dr. Peter Weinstein:

So, how can we create greater utilization of our physical plants so we get a greater return on the physical location? I jest that with curbside, what it told us is we don’t need a waiting room. Make the cars the waiting room. Add more exam rooms. Get people from car to exam room back to car. Do we need all of the bells and whistles? The bottom line is there’s a number of areas on the expense side that can be tweaked.

Dr. Peter Weinstein:

If you look at the revenue side, can we continue to have a pharmacy and be cost-competitive with the Chewys and Amazons and Targets and Costcos and Walgreens of the world? Can we figure out whether we want to run a practice that’s based upon a higher quality of clients who spend more but we see less often which would be earns.

Dr. Peter Weinstein:

Or as Mike Dicks when he was with the economics division said, “Earns or turns.” Earns means you make more money per visit. Turns means you see more people at a lower visit cost. I think it’s very hard to be a practice that does both. So, can you decide which practice model you want? Do you want to be the high volume low cost and try to see more people then you have to leverage your staff? Or do you want to see fewer people at a higher cost?

Dr. Peter Weinstein:

I think the way veterinary medicine starts to make more on the revenue side is to leverage technicians in exam rooms, utilizing them to the ultimate abilities that they have, and to what the Practice Act allows them to perform. And to start having a line item where it actually reflects to the clients a charge for technician time in the same way that your dentist has line item that charges for their hygienist’s time.

Dr. Peter Weinstein:

We need to start reflecting the fact that our technicians are generating income for us, thus, they are an asset and not just on the expense side of liability. So, leverage staff to generate income, reward them with having their name on the invoice. Your technician today was Suzy, your receptionist today was Crystal, and start to give a name to the team who are delivering veterinary care as well.

Dr. Peter Weinstein:

So, whether that answered your question or not, it was a pretty roundabout way to say that we can, we just need to look at reimagining our business models so that we’re more effective, more efficient, greater utilization of staff, maybe adding two technicians instead of a doctor to do more. There are only three things that average doctor has to do, diagnose, prescribe and do surgery, and maybe give a rabies shot depending on your state.

Dr. Peter Weinstein:

Anytime they’re not doing one of those, then that doctor’s being inefficient. Everything else can be delegated if you train them how to do it. So, I’m sorry I went off on that one.

Dr. Andy Roark:

No, that’s great. That’s fantastic. Where can people find you online? Where can they read more of your writing? Where can they find the E-Myth Veterinarian?

Dr. Peter Weinstein:

They can find the E-Myth Veterinarian on Amazon, both the audible book. If you’re not tired of hearing me now, you can listen to me on audible. You can get a hard copy of the book. You will see more and more of me in the next few months as we start to launch a new business. Myself and a business partner are going to be launching a new business that’s going to focus on some niche areas.

Dr. Peter Weinstein:

But what I’m looking forward to in my next life is to help create simple solutions for practices for the things that are pain points such as compliance, regulatory issues, OSHA, HR malpractice, all of these things that are just like little gnats or fleas sucking the blood out of you that you can’t find the answer for when you need them. We’re looking forward to building some different resources to help practices get the help that they need when they need it.

Dr. Peter Weinstein:

And so, that’s what I’m looking forward to doing in the years ahead. I want to put the F back in fun in veterinary practices. I really do think we’ve lost the fun. And we all got into this because of the thing, that’s the animals. And we’ve gotten distracted from the animals to the stressors of the people and the finance and everything else.

Dr. Peter Weinstein:

And I think you and I talked about this when we were together more recently. I said, “If we had socialized veterinary medicine and all we had to do is go in and take care of pets and the bills were taken care of and we got paid a fair and equitable salary and our staff members got paid fair and equitable salary and we didn’t have to talk about money, think about how much less stress we would all have in our practices.”

Dr. Peter Weinstein:

I think money, student debt, cost of care are huge … I mean, they’re great white sharks taking bites out of us every day.

Dr. Andy Roark:

I completely agree. I love that you enjoy the profession. And I appreciate all that you do to help support it. Peter, thanks a lot for being here. I’ll put some links down in the show notes to help people find the book. And I look forward to see what you’ve got coming down the pipes.

Dr. Peter Weinstein:

Andy, thanks. Thanks for the opportunity to hang with you today. And anytime you want to come back and throw some feces against the wall and see what sticks, I’m all about throwing feces.

Dr. Andy Roark:

Sounds great. That is it. That was my conversation with Peter Weinstein. I hope you enjoyed it. I hope you got something out of it. I always love talking with Peter. Yeah, this is hopefully one of those thought-stimulating conversations. It definitely gave me something to think about.

Dr. Andy Roark:

If you enjoyed it, do me a favor and write an honest review wherever you get podcasts. That always means the world to me. I really do appreciate it. Yeah, that’s what keeps us going here. It helps people find the show. And tell your friends, hit Share on the episode. Help us get the word out.

Dr. Andy Roark:

Anyway, that’s enough for me. Gang, I hope that you are well. I hope you’re getting fired up for Halloween. Yeah, they’re looking forward to get some candy or giving out some candy or just be a near candy if that’s your thing. Yeah. I hope that that is something that is on your radar. Gang, take care. Be well. I’ll talk to you later on. Bye.

Dr. Joe Arpaia MD discusses his recent article in Today’s Veterinary Business on why we shouldn’t always do our best. Dr. Arpaia talks about the 5 components of stress, the difference in stress vs strain, and the importance of separating unease from difficulty.

This episode has been sponsored by Pawp. Pawp is a membership that gives you unlimited 24/7 access to vets for chats, video calls, and texts. It’s a great way to avoid those unnecessary clinic vet visits. Check it out now on www.pawp.com and use my code andyroark for 25% off the first 3 months before it expires October 31.

LINKS

Stop Doing Your Best (Article): todaysveterinarybusiness.com/stop-your-…st-effort/

Ibernetics.com – Cognitive Training to Better Manage Stress:
www.ibernetics.com/

Uncharted Podcast on iTunes: podcasts.apple.com/us/podcast/the-…st/id1449897688

Charming the Angry Client On-Demand Staff Training: drandyroark.com/on-demand-staff-training/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Joseph Arpaia is the husband of Oregon veterinarian Mary Arpaia, DVM. He has been interested in mind-body interactions since he was a child and began meditating over 40 years ago. He received his B.S in Chemistry from the California Institute of Technology and his medical degree from the University of California, Irvine. His medical specialty is psychiatry and he has maintained a solo private practice for over 20 years in Eugene, OR, focusing on treating stress-related conditions.

Editor: Dustin Bays
www.baysbrass.com
@Bays4Bays Twitter/Instagram

SHOW TRANSCRIPT

Dr. Andy Roark:

Welcome, welcome, welcome to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys I am here today with Dr. Joe Arpaia. Dr. Arpaia is a psychiatrist. He’s an MD. He is married to a veterinarian. I picked up on his article, I put a link in the show notes, it is called Stop Doing Your Best. And I thought, “What is this?” And Dr. Arpaia makes a stress related recommendation about maybe why it’s not best to always do our best. And he breaks that down and talk about what that means and how do you balance that and the physiological impacts of stress and how stress and strain work on our bodies and kind of how we can maybe get around that a bit. I thought it was a really useful conversation. It made me think a bit about how I structure my day and what I do with my time. Guys, I hope you’ll enjoy it. Let’s get into this episode.

Dr. Andy Roark:

Welcome, welcome to the show Dr. Joe Arpaia. Thanks for being here.

Dr. Joe Arpaia:

Oh, you’re welcome. Thanks for having me on.

Dr. Andy Roark:

Oh, it’s my pleasure. You are a psychiatrist and your wife is a veterinarian, and I sort of came across your work in Today’s Veterinary Business magazine, where you had written a column just just a month or so ago, well, actually not, this is back earlier in 2021 called Stop Doing Your Best. And I want to get into that in a minute, but your main area of interest is in treating stress and stress related conditions, correct?

Dr. Joe Arpaia:

Yes.

Dr. Andy Roark:

Can we go ahead and start this discussion by talking about stress and how we perceive stress and I guess the interface in stressful jobs and how we respond to them?

Dr. Joe Arpaia:

Sure, sure. That’s a great place to start. So when we think about stress, let’s say I have a stressful job. So I go in and I say, “I’m under a lot of stress.” That’s one way we use the word stress. Then in the moment we might say, “I’m feeling stressed.” And then later on in the day, when we’re exhausted, we might say, “I’m stressed out.” And we’re using the same word stress, but these are subjectively quite different experiences. When we say, “I’m under a lot of stress,” we’re referring to generally the tasks that we have to do or the demands we’re facing compared to the resources we have to deal with them. So if in the morning I go into the office or if the veterinarian goes into the clinic and a couple of staff have called in sick, that’s more stressful in the sense that now there’s all the demands of the day, but the resources are less. So I call that difficulty. You can roughly think of it as the ratio of demands over resources. So when you have fewer resources, then it’s more difficult. And if you have more resources, the difficulty goes down, as long as the demands stay the same, or if demands go up, of course, difficulty goes up unless resources go up to compensate.

Dr. Joe Arpaia:

The other component of stress, when we say “I’m feeling stressed,” usually we’re referring to something different than just the tasks or the demands or the lack of resources. It has to do with our desire to achieve something or our aversion to a particular outcome. We’re trying to avoid something. You might think of desire as wanting something we don’t have. And aversion is something we don’t want. And the combination of those, I call it unease because it’s not an emotion. It’s something even more primal. If I’m just, “Eh, I don’t like this,” that’s aversion and it makes us uneasy and we want to try to fix it. We want to try to make the aversion go away. Or, “Hmm, I’d really like that.” There’s this desire to get whatever that is and until we get it, we’re uneasy. And when we get it, the unease goes down.

Dr. Joe Arpaia:

Now, as we go through the day and we’re dealing with difficulty, dealing with unease, it affects our energy level. So these are all phenomenological. This is phenomenological approach. I’m not saying it’s energy as this neurotransmitter or this chemical in the body. Just how we fee.

Dr. Andy Roark:

Yeah.

Dr. Joe Arpaia:

And so we feel more and more drained. So we go through the day, the first hour, we’re good. The second hour, we’re okay. As time goes on, our reserves go down. So we have these energy reserves and they’re going down. And that’s when we start saying, “I’m stressed out. I’m depleted. My reserves are down.” Between the experience of difficulty and unease and those energy reserves, we’ve got two processes, which I actually think there’s a lot of brain stem activity here. One I’ll call activation, and it’s largely sympathetic activation, but there’s like our body’s hitting the gas. It’s pushing a gas pedal to get energy out of the reserve so we can meet the demands and we can reduce the unease.

Dr. Joe Arpaia:

So we have this stress, which is a combination of demands and difficulty and unease, and we act activate in order to pull energy out of our reserves and we’re able to meet those demands, reduce our unease. And the problem with activation is it drains reserves. So we have this other system, what I call modulation, which is largely parasympathetic activity, which helps us restore our reserves. So we get to rest. And as we rest, our sympathetic activation comes down and we recharge our reserves and we’re back and ready for the next day. And this goes on and on and on, and that’s, you might say, is life. We handle difficulty. We reduce unease. We use energy to do that. And then when we need to rest, we reduce our activation, increase this modulation or parasympathetic system. And we recharge.

Dr. Andy Roark:

Yeah. So it seems like sort of a stress cycle, if you will.

Dr. Joe Arpaia:

Right. And we might say the stress response system. And that’s very effective. I mean, I sometimes joke and say, “It’s worked really well.”

Dr. Andy Roark:

Yeah.

Dr. Joe Arpaia:

When our species started out, we were facing ice sheets a mile thick, there were tigers running around the size of small elephants, and wolves that stood six feet at the shoulder, and all we had were pointed sticks and torches, and we made it. So clearly this system has some benefits to it.

Dr. Andy Roark:

Yeah. So I like that. The unease part, when you sort of mentioned that, it reminds me of sort of this Buddhist concept of thirst, which is kind of our innate wanting, either wanting to fix something or wanting to have something, and it sort of keeps us in a state of discomfort, but it makes a lot of evolutionary sense,. It’s a driver for us to push onward, essentially it’s a driver against complacency, right?

Dr. Joe Arpaia:

Yes, exactly. In fact, i use desire and aversion come from in some mindfulness systems, there’s a level of awareness which you’re paying attention to literally that, your desire or aversion. It’s translated as feeling but the instructions really say it’s not an emotion. It’s the raw, “I want to get.” They sometimes call it grasping, clinging, and the sort of wanting to push away. And it’s a visceral thing, that unease, really, it activates visceral processes. I sometimes joke, and if you have your hand outstretched, and especially if you like cats, and someone puts a little kitten in your hand, there’s this, “Ah.” You want to pet the kitten, there’s this feeling of the body going toward it. And if someone puts let’s say a banana slug in your hand, there’s this, blegh. I mean, it’s not dangerous. We’re not fearful of that banana slug, I mean, most people would want to pull their hand back a bit. That’s aversion and it comes in all sorts of intensities, and the stronger it, the more it motivates us.

Dr. Joe Arpaia:

And you’re exactly right, without desire and aversion, we’d still be sitting in caves. So we need this. And the fact that our brain enjoys doing things that reduce and it tends to learn what reduces desire and what reduces aversion, tends to, “Hey, do that more.” That’s a very powerful learning. That’s how we learn to walk, for instance. Babies don’t think about walking. They start to balance and they get uneasy as they get off balance and their brain does something with their muscles that brings them back on balance. And the unease goes down, the brain goes, “Okay, that worked. Keep doing that.”

Dr. Andy Roark:

Yeah.

Dr. Joe Arpaia:

And we learn to walk, we learn to talk, we learn to ride bicycles, and all sorts of things because whatever reduces unease, the brain tends to learn more of and says, “Do that. That was good.” We get into trouble though, because in a system that’s more complex than learning how to walk, difficulty and unease may not track very well. So when the baby’s learning to walk, or I’m learning to ride a bicycle, the demand is stay balanced. My difficulty is I don’t have the resources to balance yet. So the difficulty’s high. And whenever I do balance, and demands go down, difficulty goes down, and unease goes down at the exact same time, so this learning process works.

Dr. Joe Arpaia:

But let’s say I’ve developed this idea that I need to do a 100% on every task.

Dr. Andy Roark:

Okay.

Dr. Joe Arpaia:

Well, now the difficulty may be, I’ll give you an example. I have patients where, they’re in college and they’re pushing themselves, “I need to get a perfect, I need to get an A.” And I’ll ask them, Well, what are you taking the course for?” “Well, I’m just taking it because I need to graduate.” “Okay, so the grade is really not going to have any effect on your future career. This is just something you’re taking to grad. In fact, you’re taking it past fail?” “Right?” “So all you need to do, the real demand is just get a P, a pass.”

Dr. Andy Roark:

Yeah.

Dr. Joe Arpaia:

But so clearly this desire to get 100 on every single test is overdoing it. You just told me what your difficulty is. Your demand is the demand is get the pass. You don’t need a 100. So there’s clearly this feeling, this desire, to get a 100 or an aversion to not getting a 100. And now this aversion to not getting 100 in this pass-fail course is causing problems in other courses, because there’s too much time being spent on the pass-fail course. And not enough time on the course that is actually important for their career. When the problem is that when they study hard on this pass-fail course, their unease goes down, and their brain goes, “Do more of that. Keep doing that. That’s that’s what you need to do, keep doing it because it feels good.”

Dr. Joe Arpaia:

So even though, you might say, my guess is their prefrontal cortex can say, “Yes, I agree. This is not helpful.” Their mid brain is going, “Yes, it is. This is the survival learning that has brought us through thousands and thousands of years of adversity and keep doing it.”

Dr. Andy Roark:

This feels like the mental wiring for anxiety, of “I’m going to stress out about the future because that will motivate me to do everything that I can to control it.” You know what I mean?

Dr. Joe Arpaia:

Right.

Dr. Andy Roark:

And in some way, I’m going to get rewarded for this anxiety that I feel, and so we train ourself to be anxious. Do you think that that’s similar to how some of us approach doing our best and approaching academics and things like that?

Dr. Joe Arpaia:

The world is somewhat uncertain. And so uncertainty raises our unease, and it’s not clear exactly what the demands are. So there’s this motivation. “Well, if I just do everything, then I’m going to get everything covered. I’ll reduce my unease by doing everything I possibly can.” And the problem is we’ve lost sight of the fact that our reserves are finite. We have to have time to recharge, that some of these demands we’re trying to meet are not really demands in the sense that not meeting them won’t have any real effect on our life. And the anxiety is this feedback loop between the unease and then it affects our perception of what the demands really are so we lose perspective and we over activate, so we’re constantly on edge, we’re constantly pushing ourselves. We can’t unhook from the unease and the activation and allow that modulation to take effect. So the person’s off. They go home from the clinic and they’re still, “Oh, yeah. What about this client? Oh, what are they going to post? What if I get a bad review?”

Dr. Andy Roark:

The behaviors that I tend to see are people staying forever at the vet clinic, not going home because not every single I is dotted and every T is crossed and there’s maybe something else that I could do, or I could follow up with this, or I could make more detailed notes of this conversation that I had. And then when they do go home, there’s that, to your point, there’s the rumination on cases, there’s the fear of negative reviews, or something coming in when they’re not there. And I guess my question for you, it sounds like those sort of match this sort of stress type behavior. Is this purely habitual, in your opinion, or is this a genetic component for some of us? How do those things sort out, as far as causation?

Dr. Joe Arpaia:

There certainly seems to be a family tendency. So I take a family history of someone who has this kind of this pattern, which I’ll call an anxiety pattern, there tend to be anxious, but it’s hard to say whether that’s actually in their genes or was imprinted, because if the parents imprint, the parents are modeling this kind of behavior, this kind of approach to the world, this way of relating, we’re mimics. Children pick up on that very quickly. So to me what’s important is that actually the person can un-train themselves. So there’s a lot of, whether it’s genetic or early childhood learning or just practice, the fact is, is that it can be unpracticed, so we can unlearn it.

Dr. Joe Arpaia:

And to do that, what we have to do, the first step is to start really being able to separate unease from difficulty. And that’s one of the things I teach my patients early on is, “Okay, is this about how you feel, or is this about what’s going to happen in the world?” Sometimes the example is, “Okay, is this going to matter in three days and three years and 10 years? What are your real values? What do you want to make important? Not just what feels important in the moment.”

Dr. Joe Arpaia:

So they start to separate, “Okay, I’m uneasy about this. At the same time if I really sit down and think about it, this is not important, or it’s not as important as other things, because other things have a higher priority.”

Dr. Andy Roark:

Yeah. Or you say other things are more important because they’re more actual, they’re more real. A lot of times we wrestle with the fear of the pet owner writing a negative review and they never actually write it and they never had an intention to write it. It’s 100% fictional. Right?

Dr. Joe Arpaia:

Right. Right. Or the person’s, they’re missing out on their family. One of the assignments I’ve done, it’s pretty harsh when someone’s really not distinguishing. I’m like, “So you’ve got kids, so, okay, let’s fast forward for 50 years. At some point you’re going to be dead and your kids are going to be standing around your grave or your headstone or something. What do you want them to be saying?”

Dr. Andy Roark:

Yeah.

Dr. Joe Arpaia:

Do you want them to be saying, “Mom was just such an awesome vet. She never came home. And she spent all her time with her.”

Dr. Andy Roark:

That’s brutal. It’s useful, but, man, that that’s brutal.

Dr. Joe Arpaia:

But I mean, it’s worked for some people when they kept going to this, “Well, no, it’s just, I can’t let go of that.” I mean, in fact, that’s not a Buddhist string, you contemplate your death.

Dr. Andy Roark:

Yeah.

Dr. Joe Arpaia:

And It starts to make you realize, “Wait a minute.” Or some of my patients who had cancer and they come in. One patient, I remember her telling me, she goes, “There was BC and AC, before cancer and after cancer,” because she beat the diagnosis. I would say she was cured. But she said, “My priority list was before I got cancer. Now I know what really matters. And I put my time into what really matters and I’m not getting distracted like I was.”

Dr. Andy Roark:

Yeah. I think that’s a really important life lesson. I can tell you, that’s something I’ve struggled with in my life. And I think I’m probably not alone. For a sort of a perfectionist type personality, sort of a high achieving, goal-oriented person, man, that shift from deciding that hanging out and playing board games with my kids matters in a way that anything I do in the vet clinic doesn’t. That was nonsense to me for a long time. And it’s still hard for me, honestly, when I just look at it, to get my head around that idea of what really matters. I feel like we’re so habituated that academics matter, job performance matters, and like those things are just so reinforced than say going the park with your kids or taking your spouse on a date. That seems like that should be the topping. That should be the last thing that we get to do. We should do that when we’ve done everything else. And it feels like a bassackwards way to live. But man, it’s hammered into me pretty well.

Dr. Joe Arpaia:

Oh, I think people are very well meaning when they do that, parents and teachers and they saying, “Just do your best, do your best, do your best.” I remember a conversation with somebody where she was stressing about this English paper she needed and I’m like, “How are you doing in your English class?” She’d say, “Oh, I’m doing really well.” “This is eighth grade. It’s not going to matter. Why don’t you just put your name on the paper and turn it in.” And she burst into tears and I’m like, “Well, what’s going on.” She says, My parents, everyone, tells me, ‘Do your best.’ My parents tell me ‘Do your best.’ Teachers tell me ‘Do your best.’ And you’re telling me, ‘Don’t do your best.'” And this is really distressing her.

Dr. Joe Arpaia:

And so I pointed out, I said, “If you’re running a 10 mile race, let’s say you’re running a 10K. You’re going to run every kilometer at your best time? You run that first kilometer at your absolutely best one kilometer time and you’ll maybe make it through the second kilometer and then you’re going to be needing a cardiac rehab unit.”

Dr. Andy Roark:

Yeah.

Dr. Joe Arpaia:

“You pace yourself and pacing yourself, when we say pace yourself, it means you’re not doing your best. You’re doing good enough. And the reason you pace yourself is that you have energy to do what’s really important. I mean, if this English paper is really, really something you’re passionate about, yes, do your best on it. If it’s not, do good enough, and then you’ll have the energy to do what you’re really passionate about.”

Dr. Andy Roark:

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Dr. Andy Roark:

Over on the Uncharted Veterinary Podcast this week, Stephanie Goss and I are talking about what do you do when the whole team’s acting badly? What do you do when everybody’s got kind of a crappy attitude and everybody’s just sort of feeling down and nobody’s really being nice to each other, including you? You’re kind of part of the team. How do we turn this thing around? Guys, that’s what we’re talking about. You can get it wherever you get your podcast. I’ll put a link in the show notes to this week’s episode. Check it out. It’s a good one. It’s a super fun one.

Dr. Andy Roark:

Also, if you just can’t even get enough of my co-host Stephanie Goss on the podcast, she’s amazing. She’s fantastic. She is doing a communication foundation workshop on November the 7th from 4:00 to 6:00 PM Eastern time, 1:00 to 3:00 PM Pacific time. It’s a two hour workshop. It is all about taking stress and anxiety out of hard conversations and learning eight key elements that you can take back to your practice to build a team that’s filled with strong, effective communicators. That’s it, that’s the workshop. Two hours, eight keys, hard conversations made a whole lot easier. Do not miss it. This is free to Uncharted members. If you’ve been on the fence and you’re like, “Maybe I should join Uncharted?” Spoiler alert. You should totally join Uncharted. But if you’re not ready to make that jump, it is $99 for the public. So you can absolutely jump in. Just check out the two hours, see what we’re about, see if you like it. I hope that you will. I think you will. It’s pretty good stuff. That is, again, on November the 7th

Dr. Andy Roark:

Guys, that’s enough. Let’s get back into this episode.

Dr. Andy Roark:

The do your best mantra. First of all, I feel like is strongly, positively reinforced early in our lives. Do you agree with that?

Dr. Joe Arpaia:

Yes. Oh yes. That’s why we learn it so thoroughly.

Dr. Andy Roark:

I mean, oh yeah. And especially the valedictorian, coming out of college and heading to vet school. This is someone who has ascribed completely to this mindset and mentality and been rewarded for it again and again. I feel like to some degree, those are often the people who struggle the most when you get into vet medicine where the best outcome is often not the one that you get and it’s not going to be the one that you get. The best outcome involves specialty care and thousands of dollars of treatment and that’s just not going to happen. And what we have always gone to, of do the best, be the best, get the best, I feel like that does us a disservice.

Dr. Joe Arpaia:

And also I think sometimes the outcome is largely, not maybe largely, but to some degree it’s outside of our control. I mean, sometimes I tell people, “Mother Nature’s playing the cards. We’re just trying to load the deck here, but she’s in control of what cards you’re going to get.”

Dr. Andy Roark:

Well, if people buy into this, and I feel like your rationale is pretty strong of we’ve only got so much that we can control, we’ve only got so much energy and time in a day. We need to think about the things that are actually important and you can’t make everybody happy and we can’t do everything to the ultimate perfectionist level. How do you help people start to accept that? If this has been our construct that we’ve lived in our whole lives, and we’ve always said, “I do all the things. I get A’s in everything that I do.” And now this person is looking around and realizing that that’s not happening and they are dropping balls. And I think I’m sure you’ve seen those people, I know I’ve seen those people, who are having that realization, in their 30s and they’re just juggling so many things and they’re really struggling. How do you help people change that world view when it’s so ingrained?

Dr. Joe Arpaia:

Right. So I said the first step is to be able to get them to objectively be able to look at what they’re doing and realizing, “No, I’m managing my unease, but my I’m not managing my demands for the difficulty. I’m spending way too much energy reducing unease and the important tasks and things like that, some of them are not getting done.” The problem that they face though, is that unease tends to hook our attention. And let me give a simple example, I mean, this is a simple example, but I think it captures it. Let’s say there’s a board on the ground. It’s 50 feet long. It’s about two feet wide. It’s nice and thick and your task is walk from one end of the board to the other.

Dr. Andy Roark:

Okay.

Dr. Joe Arpaia:

That’s a very easy task. Now I’m going to take that exact same board, two feet wide, 50 feet long, eight inches thick. It’s a real solid board. I’m going to put it up between two skyscrapers. It’s the same task. It’s a two foot wide board. That’s a very easy task for every average adult. The problem is is when it’s between two skyscrapers, we have this extreme aversion to being in that situation. We might fall. And our attention gets hooked by unease. We look down.

Dr. Andy Roark:

Yeah.

Dr. Joe Arpaia:

And when you look down your body changes. That activation goes up through the roof, your heart’s pounding, and when your activation’s that high, it actually can impair your balance. So now you feel wobbly, you feel lightheaded, and now it’s actually a high difficulty task.

Dr. Andy Roark:

Yeah. I worked commercial construction back in between, right in between high school and college. And I really liked it, but we were building this industrial building and so we did the footers and the concrete work and then scaffolding. And so we’d put up the scaffolding. And I remember being up on the second story of this building and they just had the big steel girders and these guys I worked with would just walk along these girders. And I had myself all looped in and roped in and everything. And I distinctly remember saying to one of those guys, “How do you do this?” And he says, “You just do it.” And I said, “Don’t you worry about falling off of this thing?” And he said, “Look at this beam. I don’t fall off it when it’s on the ground.” And that’s what he said to me. And so when you’re saying this, it’s the exact analogy of the board, because you’re right, this beam is 12 inches wide, it’s a big surface.

Dr. Joe Arpaia:

Right.

Dr. Andy Roark:

To me I can’t get over the, the fact that this is two stories in the air.

Dr. Joe Arpaia:

Right.

Dr. Andy Roark:

But he was like, “I’ve seen you walk on these things on the ground and it’s not a problem.” I think that that’s a great analogy of how our mind makes a situation very different.

Dr. Joe Arpaia:

Yes, yes. And so we have to respect that physiology. That physiology that grabs our attention and draws it in causes us, we may intellectually know, “Oh yes, it’s fine. I mean, I can walk on this,” or, “I should really go home. My kids need me,” but our attention is grabbed by the unease. And there’s actually a physiologic trick to help us unhook.

Dr. Andy Roark:

Okay.

Dr. Joe Arpaia:

And in fact, in the law enforcement work I do, we call this a reset. And I actually learned it in my martial arts training because my instructor, we’d meet over his house and we’d go into the backyard, and we generally worked out at night, so we’d go in the backyard or go over to a park. And then it was heavy contact, no glove sparring. And you’d get very uneasy because you’re going to get-

Dr. Andy Roark:

Yeah.

Dr. Joe Arpaia:

Beat up.

Dr. Andy Roark:

Yeah. Just to restate, you would go to someone’s house at night and fight them in the backyard. And that caused you unease. I get that.

Dr. Joe Arpaia:

Right.

Dr. Andy Roark:

I get that.

Dr. Joe Arpaia:

Especially because he was very, very skilled.

Dr. Andy Roark:

Yeah, he’s a martial arts instructor. That makes it worse.

Dr. Joe Arpaia:

And so what we learned to do is first of all, people do this, they actually do it intuitively, they sigh, they do a long exhale. When we’re tense and we want to, there’s this physiologic release, we’ll do it. We take a breath in, we sigh, and there’s actually research on this. It tends to activate the vagal system. And when someone does it, you often see a bit of a drop in their heart rate for a couple of seconds and we would do this breathing and then we’d ground. Instead of when feeling stressed, you’re feeling uneasy, you feel like a soap bubble. You’re up, your shoulders come up, you feel like you’re up in your head and you’re not really grounded or not connected to the earth. And so we would just make sure our attention was grounded. It’s like, where are you supported? You’re not floating. You’re on your feet or you’re sitting down and you’re seated on the chair. The earth has got you. So you have this long exhale and you ground.

Dr. Joe Arpaia:

And what it does is it helps your attention unhook from what’s grabbing it. So you have this couple of seconds to unhook from the unease and focus on the difficulty. “Wait, what is really going? What’s really important here? And what are the resources I have to deal with this?” Instead of, “I just have to handle this perfectly.” And you reset and then you reorient or refocus and then you choose a response.

Dr. Joe Arpaia:

And what’s nice about the reset is you can do it every few seconds if you have to. I mean, there are times when I’ve got a patient on my mind, someone who’s not doing well, someone I’m worried about, are they going to try to kill themselves? And I’m at home and trying to interact with my family, and my attention, I’ll feel it it’ll go. And I’ll just reset. No, back to the family.

Dr. Andy Roark:

Yeah.

Dr. Joe Arpaia:

I’ve done what I can. The person said they’ve contracted to call me. They said they would be at the next appointment. I can’t do anything more. That’s good enough. Those are my limitations. Back to the family. And then 30 seconds later, I might reset back to the family. Long exhale, ground. “Where am I? What’s going, okay, I’m here. This is where I need to be. This is where my attention is going to be.”

Dr. Joe Arpaia:

And what’s nice is after a few resets, generally my mind says, Okay, okay, okay. I get it. Spend time with family.”

Dr. Andy Roark:

Does it get easier over time? I mean, I go through those processes as well of trying to set these things down and reset. Can this become a learned habit of making it easier to sort of set this unease down? Or is it always a struggle?

Dr. Joe Arpaia:

Well, it seems to be, first of all, my patients tell me that when they’ve practiced, they get better. And so the first step, again, being able to separate difficulty, unease, and really get skill at that, be able to, “No, no, no, wait a minute. I’m just getting caught up in. What feels good? What feels important? What are my priorities? What are my values? What’s going on in the big picture? Okay.” So their mind gets better at doing that. And at first it’s interesting. I’ll ask people, “Okay, is that difficulty or is that unease?” And they’ll go, “Well, that’s difficulty.” And like, “Wait, it’s really more about how you feel, isn’t it?”

Dr. Andy Roark:

Yeah.

Dr. Joe Arpaia:

“Oh. Oh. Okay.” So that’s a mental skill. And that has to become more and more reflexive. If we have to sit down and do a cognitive exercise on a piece of paper, it’s not a reflex. So we have to make the ability to distinguish difficulty and unease more automatic. The reset has to become automatic too. It’s like balancing. If you’re on a bicycle at first you get off balance and you reset, you rebalance. And you don’t notice you’re getting off balance until you’re pretty far off balance and then you have to work really hard to get back over your balance point and sometimes you over correct and go to the other way and then you’re wobbling.

Dr. Joe Arpaia:

When you’re skilled on a bicycle, your brain notices that you’re getting off balance without you even knowing it’s doing that. Your brain says, “I’m getting off balance,” and it re-corrects. So you’re never balanced perfectly over your two tires when you’re riding, you’re always wobbling, but your brain’s gotten so skilled at noticing when it’s off and re-correcting that it looks like you’re just perfectly balanced on the bicycle.

Dr. Joe Arpaia:

So this reset, you have to start getting a sense of, “Okay, what’s my attention on? Oh, I’m getting pulled in.” You do a reset, and the reset, it’s very unobtrusive. It doesn’t have to be this long. It’s just, “Hmm. Okay.” It’s this sense of the exhales a bit longer. I’m grounded. There’s actually a sense of space around me. The world’s not crowding in, client’s not right in my face, the situation I’m dealing with is not right crowding. It’s like, “Oh, I got some space around me and I’ve probably got some time too.” And so make a habit of balancing and resetting, resetting, resetting.

Dr. Joe Arpaia:

There’s actually, we have this heart rate tracing. So the law enforcement work I do, we train first responders, medical first responders, law enforcement first responders, to avoid making mistakes under pressure. And one of the things we teach, the central thing we teach them, we call it reset, refocus, respond. And what’s interesting, I was demoing this and one of the police officers, he was our use of force instructor. And he was pretending to be a psychotic patient and having a psychotic break. And I was going to walk up to him and try to help and then he was going to attack me. And I’m wearing a heart rate monitor, and we can see my heart rate on the screen as I’m walking toward him. And my pulse is starting to go up, it’s shooting up over a 100 because I know it’s going down.

Dr. Joe Arpaia:

And all of a sudden you can see it drops. It drops by 20, 30, beats per minute. And the graph is beat to beat heart rate. So the heart rate’s going up beat by beat up over a 100, 110, 120, and then it suddenly drops, four or five heartbeats it’s dropped, and then it comes up again and then it drops, and then it comes up again and then it drops. and I’m walking toward him and engaging and I’m doing this reset without even knowing I’m doing it. I’m just resetting as I’m walking into the scene. And then he attacks me and my heart rate shoots up to 160, and then we disengage, and then it comes down. And that’s something we see in some of this research we’re doing, they don’t get relaxed, their heart rate doesn’t go from 120 and then go down to 80 or 70 and just stay there, because you need to be activated. You need to have this activation so you can draw energy. You’re awake, you’re alert, you’re tracking things. But you’re also modulating that activation so that you’re able to keep track of what’s important, not to just focused on what’s making you uneasy and then misperceive things and see things that are a threat when they’re not really a threat.

Dr. Joe Arpaia:

I mean, in law enforcement, that’s obvious why you don’t want to do that. But in vet meds too, the client comes in, and they’re uneasy, because maybe they’re nervous about their animal. Maybe they’re nervous about how much it’s going to cost. Maybe they’re nervous because they’re taking time off from work or they have to get to daycare. There’s all sorts of reasons why they could be uneasy. And if we go in and we think they’re uneasy because they’re upset with us, now we’ve misperseen the situation. Now, instead of going, “Whoa, wait a minute, let me check. What’s the client really nervous about or really uneasy about? Or are they that uneasy at all? Maybe they’re just rushed, or maybe they’re tired.”

Dr. Joe Arpaia:

So that ability to reset and then start checking things out. What’s really going on? What’s the real difficulty? Not just, “Oh, I’m nervous about this,” and my brain starts creating a mirage that I then believe and get all involved in and go wrong with not so good results.

Dr. Andy Roark:

That’s really helpful. I think this has been fantastic. I think we’ll leave it here. Let me just ask you, Dr. Joe Arpaia, where can people read your work? Where can they learn more?

Dr. Joe Arpaia:

Well, I have a very disorganized blog at fullcapacityliving.com and I’ve got some people helping me create a more organized site at ibernetics.com, and it’s I-B-E-R-N-E-T-I-C-S, ibernetics. And that’s actually a play on cybernetics. So cybernetics is the communication and control protocols in machines and ibernetics is the communication and control protocols within ourselves. So it’s just a nerdy.

Dr. Andy Roark:

I love it. Awesome. Well, thank you so much. Thanks for being here.

Dr. Joe Arpaia:

Oh, you’re very welcome. Thank you. And keep up your work. It’s really great. And I was looking at some of your other podcasts before this and the stuff you’re doing is so good and so important. Thank you.

Dr. Andy Roark:

Thanks a lot. I really appreciate it.

Dr. Andy Roark:

And that is our episode. That’s what we got for you. I hope you guys enjoy it. I hope you got something out of it. As always the nicest thing you can do is if you did get something out of it, leave us an honest review on iTunes or wherever you get your podcast. It really does mean a lot. We really do appreciate it. Guys, take care of yourselves, be well, talk to you next week. Bye.

This week on the Cone of Shame Veterinary Podcast, Dr. Andy Roark talks with Dr. Tracy Witte about her TWO new journal articles. The first is a commentary on storage of euthanasia solution, and the second is a survey of negative mental health outcomes , workplace and school climate, and identity disclosure for LGBTQ+ veterinary professionals in the US and UK.

LINKS:

A survey of negative mental health outcomes, workplace and school climate, and identity disclosure for lesbian, gay, bisexual, transgender, queer, questioning, and asexual veterinary professionals and students in the United States and United Kingdom –
avmajournals.avma.org/doi/abs/10.246…avma.257.4.417

Suicides and deaths of undetermined intent among veterinary professionals from 2003 through 2014
avmajournals.avma.org/doi/abs/10.246…avma.255.5.595

A guide to fostering an LGBTQ-inclusive workplace: journals.lww.com/nursingmanagemen…WqHO4yQTwzAlGdAQ

Pride VMC: pridevmc.org/

WORKSHOP: Finding Your Voice – How To Speak Persuasively to Groups
Learn more here: unchartedvet.com/finding-your-voice/

The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.

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ABOUT OUR GUEST:

Dr. Tracy Witte is an Associate Professor in the Department of Psychology at Auburn University, as well as a licensed psychologist. Her research is primarily focused on understanding and preventing suicidal behavior, with a line of work investigating suicide and other negative mental health outcomes in veterinarians, other vet professionals, and vet students.