April 7, 2025

#140: Science vs Profit: Navigating Medicine, Money, and Morals. With Dr Brennen McKenzie

#140: Science vs Profit: Navigating Medicine, Money, and Morals. With Dr Brennen McKenzie

We take on one of the most requested and sensitive topics among veterinary professionals: the tension between clinical care and the financial pressures of practice. Joined by Dr. Brennen McKenzie—known as the SkeptVet—an advocate for evidence-based medicine and a practicing small animal vet with over two decades of experience, they explore the often uncomfortable intersection of profit, ethics, and good clinical decision-making.
Brennen shares personal stories from his career, from early experiences in business-driven practices to working in a large, ethically-minded hospital. Together, Hubert and Brennen dissect concepts like spectrum of care, overdiagnosis, cognitive biases in decision-making, and how corporate ownership models are shifting practice culture.
They also discuss why critical thinking, clear client communication, and evidence-supported approaches are essential to maintaining both professional integrity and client trust. The conversation delves into the real-world challenges practitioners face daily—like discussing costs with owners and balancing gold standard care with practical solutions—and offers thoughtful strategies for navigating these with confidence and compassion.
This episode is an essential listen for any veterinary professional wrestling with the realities of modern practice, ethical dilemmas, or simply seeking to align good medicine with a sustainable career.

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Season 1

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Have you ever felt pressured, as a vet, to do more 'stuff' - diagnostics, procedures, and sell more, even when you can’t quite see the clinical justification for it?

In this episode we welcome Dr. Brennen McKenzie-veterinarian, researcher, creator of the SkeptVet blog, author of Placebos for Pets? The Truth About Alternative Medicine in Animals, and all-round lover of science-based thinking. And who better to help us draw the line between solid science and revenue-driven decision making than someone who is known for their scepticism? Dr. McKenzie brings real-world wisdom and refreshing honesty to the debate. Together we explore the often-unspoken pressures of profit-driven care, commission-based pay, and what happens when business incentives conflict with good science. Brennen shares lessons from two decades in practice  on how to use Spectrum of care reasoning to make clinical decisions that respect science, client resources, and the needs of your employer.

A must-listen for any vet who’s ever questioned the system—and their place in it.

Find out more about Brennen's current work in longevity at loyal.com.

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Episode Topics and Timestamps

08:11 The Shift to Profit Driven Veterinary Practice

09:46 A Guide to Evidence-Based Decision Making

12:00 Client Communication and Financial Constraints

17:31 Spectrum of Care: A New Approach

32:15 Overdiagnosis and Screening: A Critical Look

39:09 Cognitive Psychology in Veterinary Decision Making

42:45 The Power of Checklists in Medical Practice

43:18 Balancing Autonomy and Systematic Decision Making

45:52 Clinical Audits: Improving Practice Through Data

48:36 Intuitive vs. Algorithmic Thinking in Veterinary Medicine

51:37 The Pitfalls of Anecdotal Evidence in Veterinary Practice

01:07:40 Communicating with Clients About Unproven Therapies

01:18:17 Pass Along Question and The One Bit of Advice

Profit vs. Science in Veterinary Medicine: Where’s the Line?

 

Drawing on the information in the sources, the line between profit and science in veterinary medicine is a complex and often blurry one, creating a tension that is inherent in the business model of modern veterinary practice. Most veterinary businesses operate for profit, where revenue is driven by the number of patients seen and the amount billed per patient. This can lead to feelings of pressure to perform more procedures, blood tests, and X-rays, even when the clinical justification isn't entirely clear.
Dr. Brennen Mackenzie, a practicing vet known for his skeptical, science-based approach, highlights that veterinary medicine has always been a business. However, the increasing consolidation of practices by large corporations may be making these tensions more apparent. He recounts his early experience in a privately-owned practice where making the client happy, rather than necessarily practising evidence-based medicine, seemed to be the primary driver of success. In contrast, he found a better fit in a larger, veterinarian-owned practice that prioritised high-quality care, believing that good medicine is good business, and where veterinarians were paid on salary rather than commission. This model allowed him to recommend what he felt was right for the patient without the direct pressure of financial incentives.
The pressure to increase revenue can manifest in various ways, sometimes as direct pressure from the company to bill more, or sometimes as a practitioner's internal feeling of needing to generate income to sustain the business and their own livelihood. This can lead to what is described as a "do you want fries with that" approach, where additional services are offered without clear medical necessity, creating an "icky" feeling for practitioners who want to prioritise sensible science and the patient's best interests.
Dr. Mackenzie distinguishes this tension from the idea of a "mythical notion of a gold standard", which suggests that the most intensive and expensive care is always the best. He introduces the concept of the "spectrum of care", which recognises that there is a range of appropriate treatment options for a pet's problem, not a single ideal solution. This spectrum ranges from the most invasive and expensive to less so, but importantly, it is not a spectrum from high to low quality care. The decision of where on this spectrum to land should take into account scientific evidence, caregiver burden, financial resources, clinician competency, and patient factors.
One of the significant challenges in navigating this spectrum is client communication, particularly around financial constraints. Veterinarians often feel uncomfortable discussing costs and may make assumptions about what clients can afford, sometimes leading them to opt for minimal treatment without a proper discussion of alternatives. Dr. Mackenzie emphasises the importance of open and direct communication with clients, explaining the thought process, the available possibilities, and the pros and cons of different approaches, rather than guessing their financial limitations.
Evidence-based decision-making plays a crucial role in drawing the line between good medicine and over-servicing. Dr. Mackenzie stresses the need to be skeptical of "screening testing" or "just casting a broad net just in case" in the absence of clinical signs, arguing that this can lead to overdiagnosis, unnecessary follow-up, and financial burden for clients. He also cautions against the over-reliance on anecdotal evidence and intuition without considering scientific studies. While experienced clinicians develop intuition, it's important to balance this with algorithmic thinking and to be aware of cognitive biases that can lead to errors in judgment.
To improve decision-making, Dr. Mackenzie suggests utilising external decision support tools such as clinical practice guidelines and systematic reviews. He also highlights the value of clinical audits within a practice to gather data and inform clinical practices, particularly in less clearly defined cases like acute gastrointestinal issues.
Ultimately, finding the line between profit and science requires intellectual humility, a commitment to evidence-based practice, open communication with clients, and a focus on providing acceptable solutions within the spectrum of care, rather than solely pursuing a potentially unattainable "gold standard". Dr. Mackenzie suggests that a business model centred on solving the client's and patient's problems effectively will lead to financial success without compromising ethical considerations. He also advises practitioners to be mindful of their well-being and to seek environments where they feel they can practice good medicine without undue pressure to prioritise profit over patient care.

Effective Communication Strategies for Discussing Costs and Alternative Therapies

Drawing on the conversation with Dr. Brennen Mackenzie, here are some effective communication strategies for discussing costs and alternative therapies with clients in veterinary medicine.
Discussing Costs
It's clear that discussing the financial implications of veterinary care can be a source of tension for both practitioners and clients. Many veterinarians feel uncomfortable with these conversations and may even try to avoid them by making assumptions about what a client can afford. However, Dr. Mackenzie emphasises the importance of open and direct communication regarding costs. Here are some strategies:
  • Initiate the conversation proactively: Don't wait for the client to ask about the price. As you discuss diagnostic and treatment options, weave in the associated costs.
  • Explain your thought process: Clearly articulate why you are recommending certain tests or procedures. When clients understand the medical rationale, they are more likely to appreciate the value and necessity of the associated costs. For example, instead of just saying "I recommend blood work," explain "Based on your pet's symptoms of [specific symptoms], blood work will help us assess their internal organ function and rule out potential underlying causes like [possible conditions]".
  • Present a range of options within the spectrum of care: Recognise that there isn't always a single "gold standard" of care. Explain the different diagnostic and treatment possibilities, ranging from the most intensive to more pragmatic approaches, and outline the pros and cons, including the financial implications, of each. It is crucial to emphasise that this is not a spectrum from high to low quality care, but rather a range of approaches with varying levels of invasiveness and cost.
  • Avoid making assumptions about financial limitations: It is not your role to guess what a client can or cannot afford. Instead, ask them directly about their comfort level and budgetary constraints in a sensitive and empathetic manner. You might say, "To help me tailor the best plan for your pet, could you give me an idea of what your budget is for their care today?"
  • Be clear about payment expectations: Discuss payment options and any deposit requirements upfront to avoid misunderstandings later.
  • Focus on solving their problem effectively: Frame the discussion around how the recommended course of action will address their pet's medical needs and the needs of the caregiver. Dr. Mackenzie suggests that a business model centred on solving the client's and patient's problems effectively will lead to financial success without compromising ethical considerations.
Discussing Alternative Therapies
Clients may come to you with questions or beliefs about various alternative therapies. Effective communication in these situations requires sensitivity and a focus on evidence-based information.
  • Validate their motives and concerns: Begin by acknowledging that the client's interest in alternative therapies likely stems from a desire to do what they believe is best for their pet. Show empathy and understanding for their concerns. You could say, "I understand you're looking for the best possible care for [pet's name], and it's great that you're exploring different options."
  • Listen actively: Give the client the opportunity to explain what they have heard or read about the alternative therapy and what their expectations are. Understanding their source of information and their underlying beliefs is crucial.
  • Share your knowledge in a clear and neutral way: Explain the current scientific understanding of the therapy in question. If there is a lack of evidence supporting its efficacy or safety, explain this clearly but without being dismissive. You might say, "I've also looked into [alternative therapy], and currently, the scientific studies we have don't show strong evidence that it is effective for [condition]. However, we do have good evidence supporting [science-based treatment]."
  • Highlight the importance of evidence-based medicine: Explain that your recommendations are based on scientific research and clinical trials aimed at ensuring the best possible outcomes for your patients. You can contrast this with anecdotal evidence or personal testimonials, which can be misleading. Dr. Mackenzie cautions against excessive trust in our ability to judge causality based on individual experiences.
  • Address misinformation directly but respectfully: If the client's information is based on misinformation, gently correct it, explaining where the misconception might have originated. Avoid being confrontational or judgmental. For example, if a client believes raw food diets are inherently superior and safer, you could say, "I understand that raw food diets are popular, and while they can have some benefits if properly formulated, there are also potential risks of nutritional imbalances and bacterial contamination that we need to consider. The scientific evidence regarding their overall health benefits compared to balanced commercial diets is still evolving."
  • Focus on the potential risks and benefits: When discussing any therapy, including alternative ones, focus on the potential risks and benefits supported by evidence (or lack thereof).
  • Build trust over time: Recognise that changing someone's strongly held beliefs may take time and consistent communication. Building a strong relationship with the client based on trust and open dialogue is key.
By employing these strategies, you can navigate discussions about costs and alternative therapies in a way that respects both scientific principles and your clients' needs and beliefs.

Brennen Mckenzie