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

Join us for the Vet Vault's own conference in the snow: ⁠⁠Vets On Tour Wānaka⁠⁠, New Zealand, 10-15 August 2025!

 

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.
Have you ever felt pressured as a vet to do more procedures, run more bloods, do more X-rays, even when you can't quite see the clinical justification for this?You're not alone.In fact, it's one of the most common topic requests that we get here at the Vet Vault.But it's not super surprising because the reality is that most of us work in for profit vet businesses and the profit of a vet business is determined by how many patients you can see and how much you bill for each of these patients.
That tension that is created between the work we want to do and the money is kind of baked into the business model of modern veterinary science.But where is the line between good medicine and overservicing science versus profit?I'm Hubert Hemstra and you are listening to The Vet Vault where we like to occasionally kick the hornet's nest.
And in this episode we are covering ourselves in honey and smacking that hornet's nest like a pinata by taking on that question.Our guest is Doctor Brennan McKenzie, who is a practicing vet with over 2 decades in small animal general practice.But beyond his clinical work, Brennan is known as the Skip vet, as in skeptical, thanks to a large body of research and writing on the topic of science based veterinary medicine, including his Skip Vet website and his book Placebos for Pets.
The Truth about Alternative Medicine in Animals.And who better to help us find that line between solid science and revenue driven decision making than someone who is known for their skepticism?In this conversation, we are going deep on the messy intersection of good medicine, blind budgets, and business pressures.
Brendan shares lessons from 2 decades in practice on how to make clinical decisions that respect science, client resources, and the needs of your employer.One of my favorite bits in this chat was talking about the biases that commonly trip us up in our thinking around this topic.And of course, I couldn't chat to Brendan without asking him to put on his skeptics hat to tell us what he thinks the most common and outdated treatments are that we cling to as a profession despite evidence to the contrary.
Let's get into it with Doctor Brendan McKenzie.Welcome to the Vet vault, finally.Thank you.I'm happy to be here.
I've been a a fan of your work and your writing and I think you're thinking for some time.So you've been on my list of podcast guests for a very, very long time.But I finally found the topic that I, it's weird.It's not really what you write about it, but I'll explain why I wanted you for this topic about money, let's say profit versus science.
So I, I've recently over the last couple of months or so, a couple of 6-6 months or so, I've had quite a few listeners reach out and say, and I definitely see this on social vet platforms as well.That stress, that tension that a lot of practitioners feel between either a, a direct pressure from the company to bill more or sometimes a perceived thing to go.
And I'm like, I understand this is a business.I need to charge, I need to put the money through the till to pay my wage basically.Or sometimes it'll be something like a Commission system or something like that, where your income is directly linked to how much you bill versus I want to practice sensible science.
I want to be a sensible practitioner.I want to do the right thing by the patient.I feel icky taking the do you want rise with that approach versus just let me just do the right thing for my patient.And the reason I thought of you because I was trying to think, who can I speak to about this?
And then the reason I thought about you is because you are the evidence based guy, right?You're the science guy.Let's see, what does the evidence say?What is the right thing to do?And put everything else aside, You're the skeptical guy as well.So I imagine you'd be skeptical of any.Do you want fries with that approach?And you're still a practitioner.
So I, I wanted to know, does Brandon ever struggle with this?Has he in his career has been an issue and how can we fix it?Well, I will say that I don't think it's a new thing in veterinary medicine.Veterinary medicine has always been a business and the model for a long time has been small privately owned practices with a handful of veterinarians.
And we are now seeing, I think a moment, certainly here in the US and probably in other places as well, where large corporations are buying a lot of those practices and consolidating them.And the business is becoming bigger.And I think in some ways that makes us more mindful of the tensions that you refer to, but I'm not sure it necessarily makes them worse.
So I'll give you a just a quick sort of summary of my experience in the profession.And, and I don't know how representative that is, but I started working at a small privately owned practice with a single owner who I feel was very good at the business and not especially interested in the medicine.
He was also sort of mayor of our town and is a charming man.And, and he would do things to make clients very happy that I often felt weren't evidence based or consistent with good quality medicine.And he built a very successful business doing that.He, you know, from my job interview, he picked me up in his Porsche and took me to the Country Club for lunch.
He wanted to make a point that as an entrepreneur he was very successful and he was also a generation older than I am.And I think that was more what veterinary medicine was at one point.It was, it was as much about being a small business person as it was about being a doctor in a lot of ways.
However, my generation and those that have come after me, I think are a little less interested in that, a little less interested in the entrepreneurship aspect of it.I certainly have no such interests whatsoever.I couldn't sell water in the desert.So.So I don't feel like that's my skill set at all.
I just want to show up, do the best I can for my patients and my clients and also take home a paycheck so that I can, you know, send my daughter to college and, and live my life.So my early experience was that with that was definitely one in which the model was do whatever makes the client happy and that's how you succeed as a business and the medicine comes second.
And that didn't sit well with my temperament or personality.So I only worked there for a brief time a couple of years and and moved on to a practice which I think was quite unusual.Also started as a small independent business, but by the time I worked there it was owned by a group of about 6 veterinarians and we had something like 12 doctors and 50 support staff working there.
So quite a large practice, all general practitioners, but a 24 hour, 7 day a week full service practice.And there was definitely an emphasis on high quality care, doing as much as you possibly could for the pet within the limitation set by the owner.
If you wanted to learn a scale, if you wanted to take on chemotherapy or ultrasound or endoscopy, you went ahead and learned that in practice page, you'd learn how to do that because the model there was if we solve people's problems, we'll be successful as a business and good medicine is good business.And we were all paid on salary, not on Commission because the owner was very clear that he felt a Commission based system was an inappropriate incentive and that was not how he wanted to work.
And at our peak, we had 30 doctors and 150 support staff and we all made a good living and we all got to do really interesting stuff.And we had a reputation in the community as a place where you went to have hard problems solved.We were open hospital clients could be with their pets all the time, anywhere.
So it was really about if you do what's right for the patient and what's right for the client, you will make money, you will be successful.And I think that that it, it manifested that we were a very successful business.So that's the model that suited my style and my personality best.
I could honestly, genuinely say to people, what you choose to do has nothing to do with how I get paid.And I'm recommending to you what feels like the right thing for you and for your pet.And I think that authenticity also made me very successful at convincing people to do things.
I think people were were able to sense that and to feel a confidence that allowed them to make choices that did end up often spending a lot of money and making us a successful business.So I think that that was a solution to that tension that that I found very appealing.Now, eventually the owners of that business had to retire and they had to sell a giant practice with, you know, 30 veterinarians.
And that's a very expensive proposition.And ultimately that ended up passing through some private equity and, and ultimately to one of the large corporate owners.And that changing culture wasn't necessarily what everybody wanted when and quite a few of our doctors moved on to other things.
I actually went to working part time and, and work now in a research company as well as as a clinician, partly because after, you know, 20 years of practice, you also are looking for new challenges, but also because that environment was different.Most of the new doctors now are paid on Commission, that's they're offered the opportunity to be on salary, but not at a salary that's a living wage where we live.
So essentially the offer is there, but it's not serious.I'm lucky in that I've been there long enough that I'm sort of grandfathered into a salary that I can live with.And so I would probably make more money if I switch to a Commission based model.But again, it's not a an incentive I agree with.
So I do think there's a tension, and I think how it plays out is connected with the larger model of how we structure veterinary medicine and how practices are owned and run and with the culture.Now, we may talk about this later.I think that's a little bit different from the tension between what is good medicine and what is profitable on a single client basis.
I think sometimes there's this mythical notion of a gold standard that says that the most intensive and aggressive and expensive care is always the best care, and I think that's also a mistake, but that's a slightly different issue.I have to interrupt this episode here with an opinion.A great way to get better at evidence based decision making is to get yourself more familiar with evidence, right?
It really does get a lot easier when you know your stuff, and here at the Red Vault we have several ways of helping you with that.Obviously there's the Clinical Podcast, 2 short but insightful episodes per week with more than 600 older episodes in the vault.We'll help you with small but consistent movements towards more confident decisions and better patient outcomes.
I recently saw one of my favorite endorsements for the Clinical Podcast ever.There was a discussion on a Big Red network about the most useful CPD options out there and one person replied the vet fault should be compulsory.Thank you so much for that.I promised it wasn't me who wrote that comment.
So that is the drip feed method of getting smarter.But then there's the gorge yourself on learning in a five day period interspersed with bursts of pure fun and adrenaline.And our upcoming vets on to a snow conference in Wanaka, New Zealand from the 10th to the 15th of August 2025.By the time you listen to this, our early bird tickets will probably be sold out.
Maybe not.So hurry to vets on Twitter.com to check, but even if our early bid tickets are sold out, full price tickets are still a great value way to get in your CE while also having a lot of fun.In fact, there have been some insinuation from people who've never attended events onto a conference that this is just an excuse for an epic tax deductible snow holiday.
And while I can see where these opinions might stem from, I mean, let's face it, it is an epic tax deductible snow holiday.But if you've ever been to one of these conferences, you'll know that we also take learning very seriously.In fact, our new tagline for Vets on Tour is Serious Science.
Seriously fun.So how do we do this?We pick a handful of world class speakers and we lock them in a hotel with us for four hours a day so we can soak up all of their knowledge and experience.And this year I'll also be doing some live interview slash Q&A sessions as part of the program, which if you've listened to my clinical parts casts, you'll know means that we are going to get deep into all of the nitty gritty, the practical questions, the pitfalls and the pro tips.
We can't wait to see you there.Oh, and thank you to our key supporters, Hillspitt Nutrition and Index.We're going to have a lot more fun thanks to your support.OK, back to Doctor Brennan.So to sort of encapsulate what you said there is the problem exists.
You were lucky that you and I'll be honest, I haven't really worked anywhere where it was a hard push from, from my employers either.Some stuff will will come to.And I've also been a business owner myself.So I am also 100% empathetic.Exactly as you say, the business model is the system we operate within is private business.
It is a for profit business.So ultimately the thing that the system that we operate in wants is profit.There's no way around it.So I, I do understand the, the motivation, but I agree with you.I think we have very similar ethics and I think a lot of people in our profession are like you and me.
We want to show up and do good work and get paid fairly for it.So the problem is, is really the, the business model, which I don't think we're going to fix in this podcast.Well, if Brendan was going to fix the business model of veterinary science to make it better, do you have any off the top of your head ideas?
I do think about this sometimes.How could you do this in a way that removes this built intention?Well, one of the things that I, I think I would say is that the business model that I worked under when we were a privately owned hospital was successful.
And I think it was very much a model centered on do what is right and solve the problem that the client and the patient come to you with in whatever way works most effectively.And people will value that and, and we'll come back to you and we'll recommend you to their friends.
Since the change in ownership at our practice, I feel like there's been an effort to make things a bit more standardized and a bit more conventional.And we were an unusual practice.Like I said, as a General practitioner, no board certification at all.I do echocardiography, abdominal ultrasound, endoscopy, a lot of things which are, you know, considered specialty tasks.
And I have plenty of opinions on how we designate things as right or wrong for a General practitioner to do.Part of the way that we were successful as a business was by being able to offer people whatever they needed in the moment.If the dog comes in and they have to have an emergency surgery and then they have to stay in the ICU and get a blood transfusion and be on a ventilator, we can do all of that right here.
And what has happened now is I think we're we're moving towards more of a traditional day practice model where things that are considered specialty or seriously ill or require intensive technology or developed expertise and some special techniques are often referred.We no longer have an overnight doctor, so things that are unstable need to be sent to another hospital.
And that has reduced our revenue.At the same time, the response to that has been to increase prices, which then makes us charge more for doing less.And that's not a model that appeals to our clients.And I think it's hurt our business.So I think that if I would say that there's an answer, I would say focus on solving people's problems, on meeting their needs, their medical needs, the needs of the caregivers.
And doing so effectively will make you successful financially and will also take away that burden of worrying about whether you're doing the right thing for the right reason or feeling pressured.And it's easy for me to say because I'm an old person and a little crotchety and, and, you know, I tend to be very much of A stickler for doing what I think is the right thing to do and, and not easily moved, you know, out of that position.
And it's harder for people who are newer and younger and maybe more easily pressured by management.But the tension is one that we create for ourselves.The doing good medicine is good business in most cases.You said the the tension we create for ourselves, and I think that's true.I've always struggled a little bit with that problem of talking money.
I know what I want to do.I, I know I want to do these tests.I want to go do a scan of these things, but I I hate having the conversation because it is, it's a lot of money.I understand cerebrally that yes, that's not expensive for a highly specialized procedure like an ultrasound or I get it.
But going into the family with the two small kids who I go, I'm sure you don't have $3000 lying around for the surgery.I, I hate that.And I know a lot of my colleagues hate it as well.So then we do create the tension for ourselves because all I am really, all I want to do is solve the problem and I have the, the skills and the means to do it.
But we've got to talk about that and believe that there's value to it.It sounds like you've never struggled with that or have you like this?Is that something that's developed with experience where you learn to to sell the skills that you have effectively?I think it is something that I absolutely had to learn over time as a new veterinarian.
As I mentioned, I don't have any sales skills whatsoever.And so as a new veterinarian, approaching it as a sales problem was terrifying and and awkward and uncomfortable for me.And I tended to shy away from that and to just focus on what I think is best in this situation.
And I think that that, again, that authenticity made people more comfortable with accepting my recommendations.Where I think initially I had more trouble than I do now was when people would come back to me and say I can't do that.I simply financially can't do that.And I think sometimes I like to say that new veterinarians are often brainwashed by academicians who train them into an idea of what a perfect gold standard care is.
And it's often a very invasive, very technological and very expensive kind of care.And they will sometimes feel as if a client coming back to them and saying, like, I can't do that ultrasound.I can't do that MRI sort of means, OK, then I can't take care of your pet, right?There's a little bit of a throwing up in the hands and sting.
Well, that's all there is.And I think that one of the things that the new concept of spectrum of care is, you know, how we refer to it here in the USI think contextualized care is a term that they use in the UK and I'm not sure about Australia.I think the idea that there are multiple solutions to a pets problem and they have to take into account not only the science and the evidence, but also the caregiver burden, the financial resources available, the competencies and expertise of the clinician.
And we have to be thinking about how do we solve this problem with the tools that we have available and the limitations on that.And I've become much more comfortable over time saying to people, here's what I think would be best for your pet and then responding to their not being able to afford that with, OK, here are some other options.
Here are the pros and cons and risks of those options.How do we work our way towards something that is an acceptable solution, Not substandard care, not an absence of care, but also not economic euthanasia because, you know, the success rate of euthanasia is 0.So, you know, there are plenty of things that we can do that may not be in our heads the gold standard, but that are still effective and and appropriate ways of solving the problem that don't all the way to that point.
And I think that's something that I've come to be more comfortable with as I've decided, yes, in fact, individual practitioners need to make critical evidence based judgements for themselves about the appropriate approach to things and not simply follow the template laid down for us in our training.So I think this is where I wanted you because even that spectrum of care, having that available as option, it can be really challenging.
It's a, it's a really complex thought process in consult for every single consult because it, it is a spectrum.I can, I'm, you know, I work in emergency, a dog comes in with acute vomiting and I can go, I can fully justify doing full bloods and an abdominal ultrasound and, and, and, and I can spend $30,000 on a work app.
And if I'm a good salesman, which I, I'm like you, I'm not, but there are people that are very good salesman and they can convince clients that this is what we need to do because it could be an interception could be found by your dog.You can have cancer.So how far do you go?And as you say, towards that gold standard of care, cover my ass, sort of a type of practice versus on the opposite end of the scale that I think a lot of people and I'm often specifically used to be guilty of.
This is the wallet guarding to assume that, well, I'm scared of the conflict of having the conversation of it's going to cost this much.And then I convinced myself that I'm being really kind because I'm not going to do a bunch of diagnostics.And in the back of my head, I'm like, yeah.A little bit concerned about your dog.
It could actually be XYZ.Maybe we should run some bloods.And again, I'm personally much better at this now, but then I then I go for the the minimum treatment without actually discussing it.That's so that I'm assuming you don't want to spend money on your patients.So that I say, well, let's give it a jab of Serenia and see how we go.And actually that client would have been quite happy to say let's rule out a foreign body or what whatever.
And the reason I thought you were good for it.I've looked at some of the stuff you've written and some of these were long ago, but you did veterinary clinical decision making, cognitive biases, external constraints, and strategies for improvement.So I feel like that is exactly the topic we need to discuss, specifically the strategies for improvement.
And interestingly, I just submitted a chapter for a book that Gary Block, who's an internist here in the US, is putting together on Spectrum of Care.The original concept got some momentum in the US after a classmate of mine, Jason Stahl, who was at the Ohio State, brought together a working group of people to write about sort of the concept of spectrum of care and what it means and, and how it might solve some of our accessibility and affordability problems.
And I was part of that working group.And so I've kind of been addressing this concept in a variety of ways for a long time time.And I think that it does dovetail quite nicely with evidence based medicine.Evidence based medicine is a structured set of practices and tools that ultimately serves the purpose of giving us the most accurate understanding of the situation, the medical situation and the needs of the patient so that we can then work towards a solution.
Standard of care in my mind is similarly A structured set of concepts and tools and techniques that we will then use to integrate that information, that scientific information about the medical situation with all of the other variables with clients capacity, both financial and and logistical and practical and emotional with our own capacity and ability.
I can't offer something that I don't know how to do that isn't available in my area and with what's acceptable to the patient.Because, you know, if you have a terribly fear aggressive dog, weekly sequential chemotherapy is probably not an appropriate treatment, regardless of what the scientific context is.
So we tend, as you and I have, as we go through our career, to stumble towards our own personal idiosyncratic way of integrating all of these things and offering people staged solutions that take into account what they can cope with.
But I think we could do better than than that sort of ad hoc process.I think we could talk about it explicitly.We could maybe formalize it a little bit.We could train students in thinking in this way.And I think that will save a lot of the anxiety and awkwardness and stress that we went through as early career veterinarians in trying to get over that discomfort in talking about the the limitations that finances and that lots of other things put on what we can offer to our clients.
So it is a topic I'm very interested in.And I think it's, it's starting to get some momentum.We're seeing, you know, some community practice options in universities now so that students get a chance to work with a clientele that isn't necessarily a tertiary care.Do absolutely everything, whether it's necessary or not clientele something that's a little more representative of what you'll see in practice.
And I think as always, a big element of the solution to these kinds of dilemmas is effective open communication with clients.As you said, we have to avoid the tendency to guess what people can or will spend on something.And that's not our job to guess.
That's our job to ask and to find out directly from them.And I think that that we lead them through our thought processes.Here is what I think the situation is.Here is what the possibilities are.Here's my sense of how likely each of those possibilities is.
Here's the best way that we get to that answer.What is your level of comfort with the most aggressive and and perhaps most secure way of ruling out all the possibilities that could be there or with a more pragmatic and short term solution to the immediate problem, knowing that we may be leaving some stones unturned?
You know, having those conversations with clients is, is how we get to a solution and that's workable, that's practical.So.Double click on the spectrum of care conversation.So you said you want to integrate that with you use the term standard of care.So just to clarify, standard of care is that a here's the ideal, you know we have for this condition on these scenarios, this is the ideal thing.
So there are a couple of terms that get tossed around and they're all problematic.The standard of care, at least as it's defined in the US, is a is a legal construct.It sort of means the minimum acceptable care that you can provide and not get in trouble for.The gold standard is a mythical concept that people carry in their heads that there is some perfect optimal type of care that applies in general to all patients with a given problem.
You know, the gold standard for a dog who's comes into your emergency vomiting is, you know, CBC, chem, UA, abdominal ultrasound, you know, Cpl. all of these things.But of course, there is no universal gold standard because there's no single universal template patient that's exactly the same every time you see them.
Spectrum of care is the notion that there is a spectrum from the most invasive, intensive and expensive care to less invasive, expensive and intensive care.And it's not a spectrum from high quality to low quality care at all.
And that's a myth that we really need to dig out of people's head.It's a spectrum between how aggressively we do things.And the example of course, is always in the university you tend to do absolutely everything you possibly can.And some of that is for purely teaching purposes, some of that's for research purposes.
And a lot of that, honestly, I think is one of those cognitive biases I wrote about called selection bias.I don't think people at the university realize that the problems they see are the most difficult and intransigent problems that haven't been solved in primary care practice.If those problems are solved in primary care practice, then the tertiary care specialist never get to see them.
So they get this notion in their head that general practitioners fail at treating certain kinds of problems because of course, the only patients they see are the failures, not the successes.So I think that that's one of the things that gets us into this notion that we must do absolutely everything.
In general, what I say is there's very rarely a single right way to handle a particular problem.There are occasionally clearly wrong ways to handle a problem, but even that you have to be a little cautious about assigning.So there's a spectrum of ways to approach particular problems, and what we want to do is maybe think a little more systematically and rationally about how we define that spectrum and how we choose what point on it is appropriate for each patient.
We as individuals, not as a governing body or anything like that.We we as individuals.I mean, I think we as a profession, how does that work?I mean that's that to some extent there's a cultural consensus.There are individual cultures in particular practices.I would like to see the curriculum address it in a more explicit way as we've tried to do with evidence based medicine.
But I think as a community, it would be better if we were all somewhat more aligned on how we think about that.I think part of the problem, as I mentioned, is that we all come to our own individual ad hoc solutions to the problem.And then that can be very frustrating for clients who see multiple veterinarians and get very different approaches because we haven't all agreed on what we think a spectrum of care looks like and how we choose a spot there it's.
Very interesting that the way you talk about training and tertiary institutions for students and I can't trust that without training in I, I qualified in South Africa at the vet school over there.It was a Tishi institution and we had specialists so we were exposed to that.
But the interesting part of that is a the, the vet school in the union, the hospital attached to it, it was in a fairly low socio economic area and they had an outpatients department, but the only people who are allowed to come to outpatients had to be in a certain post code.
So it wasn't open to the whole city.So there are two ways either to live there and then you can come to outpatients, Audis or you were referred to one of the specialists.And that's the the high level stuff.But as a large part of our rotation, our finally, it was a clinical year.We had to work and do consults and outpatients.
The students backed by not a specialist, by a General practitioner who'd sort of babysit you check that you don't stuff up too much.And I think you're right, that did teach us a very different approach that and sometimes I think to to detriment maybe too much to the other side because I my first year of practice was in there and almost all of my clients in first opinion were money tied.
He said.Maybe he has given me that bias of assuming that well, I have to be very careful.But even though education, even within the specialist department, they wanted us to think about each test.So we had, we didn't have a profile.There was no such thing as CP2 cannot health profile blood test.
You were like, OK, here's my patient.This is the clinical science, this is the presenting stuff.And then they'd say, which test do you want to do?And we had to write down, I want to do ALP because I'm worried about XYZ and I want to do that.So you do four or five tests and then you see what it says and then you get a nothing.
Then they go, what's next?What are we doing next?So that's how I think.So I think that's why I personally struggle with the it's a bit unwell, let's just run everything, let's do all the tests and scan to rule out everything else.Yeah.And I think I would like to see the attitudes and approach in the US move more in the direction of what you're describing.
And I think it is beginning to do so with these community medicine practices.One story that I often tell that sort of capsulizes my experience as a vet student.And this was, you know, almost 25 years ago now was I tend to be, as you can tell, kind of a nerd and a fairly academically minded personality.
But I was a career change student in vet school.So I was in my 30s when I went to vet school.My daughter was born halfway through my final clinical training year.I borrowed a very, very large sum of money to go to vet school.So doing an internship, residency and academic career just wasn't an option for me.
I needed to get a job and get paid.But clearly, I have that sort of temperament.And I think that showed in clinics.And I had a internal, a medicine resident come up to me one day and say something along the lines of, well, you know, we were sitting around the residence and talking about you and, you know, you're doing really well with this rotation.
We think you really should do a residency because you're too smart for general practice.And of course, you know, immediately I get a flush of ego.Oh, great, someone thinks I'm smart.And then I got actually offended following that because the implication there was the general practices for people who are not ambitious and not bright.
And that is very much still, I think, a sense that sometimes these students will come away with from their university training that the best and the brightest follow specialty and that you really, you know, don't know anything and shouldn't be doing much except WellCare if you're in general practice.
And I think that has led to some of this trouble with doing too much.I've written a couple of papers on over diagnosis and how to make rational decisions about diagnostic testing.And I think that there is a scientific approach to making those choices and it actually aligns with a more conservative approach more often than you would expect.
I think sometimes the do everything is a habit acquired in academia or a way of treating our own anxiety rather than a scientifically legitimate approach to diagnosis.Can you tell me more about that article?Are there principles, takeaways that somebody listening to this and I'll put a link to it if you'll share it with me in the show notes.
But what's the outcome of that?You say it's do more is not always the answer, but how do we get better at that type of thinking to pick a level of where do we land on our standard of not a standard of care, how much we do?There are two sort of soapbox issues that I have that I like to rant about on the street corner.
I love soapboxes.Soapboxes are my favorite topics for the podcast, so go.One is the concept of overdiagnosis and screening.So screening is diagnostic testing directed at patients who have no clinical symptoms.So our clinical index of suspicion for disease is quite low.
And if you take a population of animals who have no clinical symptoms, the prevalence of disease in that population is pretty low.It's not 0 occult disease exists, but it's pretty low.And there is often a sense that because the prevalence of disease is not zero, we should test everybody for everything because we if we don't, we're going to miss some cases of things, right?
And that was widely held in human medicine for quite a long time.And then we tripped across some problems with it.You may be familiar with the prostate specific antigen, or PSA test, which is a blood test that is associated with the risk of prostate cancer in men.And that was widely recommended as a universal screening for men over an arbitrary age for many, many years.
And after collecting A decade's worth of data, we discovered that the vast majority of the diagnosis made by that method were indolent cancers that were never going to be clinically significant.And that, in fact, we harmed far more people by doing biopsies and follow up testing and the sheer anxiety of telling them they might have cancer.
Then we helped by identifying actionable cancers earlier.So the recommendations were scaled back to do less of that testing unless there's a clinical index of suspicion that suggests that there might be a real problem.Similar changes in mammography screening guidelines for people for breast cancer.
So what we've discovered with enough data is that haphazardly testing everybody for everything leads to a lot of incidental diagnosis that are not clinically meaningful.But we do a lot of harm and we spend a lot of money following those up now in Ventonite medicine.
We're never going to have that quality of data.We're not going to have 10,000 dogs that have all had, you know, a senior profile run every year from six onward to know how many of them we've saved and how many of them we've harmed with unnecessary diagnostics.We have a little bit of data We used to tell everybody, well, when the dog comes in with their splenic mass bleeding, there's 2/3 of those are cancer and 2/3 of those are hermandiosarcoma.
And so if we found a splenic mass incidentally on ultrasound looking for something else, we might give them those same statistics and send them to surgery for that.Turns out the tiny, tiny minority of those tumors are actually malignant if they're found incidentally and they're not bleeding.
So that more aggressive approach is not appropriate.It took us a while to stumble across that data.And I think in general, we're not going to have the kind of quality of data that we have in human medicine.But I will say we need to be very, very careful about looking for problems in patients that don't give us some indication that a problem exists.
So screening testing or just casting a broad net just in case, which is really what we're doing to treat our own anxiety, is not a good strategy and probably not an appropriate way to approach diagnostic testing.The problem is, and I'm almost nervous to say this, but it's a very good business strategy.
And that's why we, I feel like in many practices and many groups, that's why we do it.It's fries with your burger you covered for your vaccination or your health check and go, do you want to run a health screen?Yeah, cool.And then you stuck with it.Then you're like, oh, should I found something abnormal now I was supposed to do with it.
Well, and I think, I think it's a good question whether it's a good business strategy or not.It seems like it would be in the short term because it generates revenue.But I think it also, I mean, I, I see plenty of clients online talking about how vets are just in it for the money and they're just trying to RIP me off with these unnecessary tests.
I think it creates an impression of the profession that may not be in the long run a good business strategy.And I think as you said, most of us are really interested in doing what's right for our patients.And, and I think we're more likely to run unnecessary tests because we're afraid of missing something than because it makes us money.
But you're right, the incentives can be set up inappropriately and I think we have to be very wary of that.I love that answer.And I've had that feeling increasingly over the past 10-15 years of my career where they, and maybe it's just because of social media that we see it more.
And there's, you know, people gathered around in groups and speak openly and we read it and we're like, oh shit, people don't like vets anymore.But I do worry about that erosion of trust because of this very business minded model and push more.Do you want again that we that in the long run it is a really bad strategy because people then become worried when I then recommend the test that I really want to do.
Is there that little seed of doubt and my client said of going 0.He's just doing that because he wants to charge you like that genuinely this time, you know, it's the boy cried wolf.Don't really I really want to do this test.I know the previous 20 times when you ran bloods it showed nothing, but now I want to do it.So I, I love that answer to say be very mindful of and how much we abuse our clients while it's and what does it actually cost us in the long run.
Again, it's not to say that that I'm dogmatically opposed to screening testing.I think that in in human medicine, there are a set of guidelines for when screening testing is appropriate.And they include things like a reasonably accurate test, a reasonable suspicion of the disease existing in the population you're testing, an effective response to the test result.
You know, you don't go out and test people for something that you have no treatment for because there would be no purpose to that, things like that.So I just think that that sometimes we need to think a little more rationally and systematically and God forbid statistically about our testing strategies.Which is not easy.
Easier said than done, because it's not always intuitive.You have to take time and think about it.You have to.It's not a blanket rule.And I think very often as busy practitioners, we just want to be told what to do or have one decision made for us to say patient type A, this is what we do, that's the protocol.
Whereas what you're saying offered requires stopping and thinking.Does that make sense in this patient?And sometimes we just don't have the the time.Or, and, and as you said, you know, if you're required in your training to explain why you want to do each test you want to do, I think you get in the habit of thinking a little bit more about the meaning of each of those things.
And I think that's probably a better strategy.You're absolutely right.Humans love heuristics, right?We love shortcuts that make our lives easier, but sometimes shortcuts lead us to the wrong answer.And I think that that we want to encourage critical thought as much as we can in the profession.
I think when we say that medicine is, you know, an art as much as it is a science, we're not so much talking about determining what causes a disease or determining whether a therapy works.Those are really the province of science.What we're talking about is how we use this tool between our ears to make decisions.
And I always like to say I don't think that anyone should graduate with a veterinary degree who hasn't had a course in cognitive psychology and in the philosophy and history of science, because both of those things teach us about how the mental processes behind our decisions work.And if you don't understand how the tool works, you're not going to use it effectively.
Can you talk more on that?Is it simple enough to highlight some of the I love the the cognitive psychology bit.What do we need to know about a decision making that's happening in the background that we might not be aware of?Unfortunately, our brains are brilliant instruments for drawing conclusions from limited data, which is the environment in which our ancestors evolved.
But those conclusions are faster than they are accurate, and when we have alternative options like science or like a diagnostic decision tree or something a little more formal, those often get us to the correct answer more consistently and more reliably.
And so being aware of our own limitations is the first step in accepting the help we need to do a better job.We aren't going to accept the tools of evidence based medicine if we think that our clinical experience is adequate and probative.The analogy that I'll use is I read a book which I highly recommend called Don't Believe Everything You Think by Thomas Kita, and it's a quick survey of sort of common cognitive errors.
And one of the things that that struck me really quite dramatically when I read that was the unreliability of our memory, that we imagine that we remember things like video cameras, but really we're making up stories based on a very sketchy bits of information left in our brains.
And the stories are remade every time we remember them to be consistent with our current understanding of the world and ourselves.And that sounds all interesting and abstract and theoretical.But as a practical matter, I don't fight with my wife nearly as much about our disparate memories of events that we shared, because I know that we're probably both wrong.
And I don't have to defend my version of events because it's probably not accurate and neither is hers.And so I think there's practical value in understanding and accepting our own cognitive limitations.So how do we make that practical for the practitioner?What are the limitations that we might not be aware of?
So for example, you you say that we're often a decision making is faster, but not always right.And then the reason I'm digging down this is, is it might to some extent be a solution for the veterinarians who who maybe struggle a little bit with justifying.And unfortunately, this does happen.
But I have my annual meeting with my manager or my 6 monthly meeting.And they say your KPIs, your turnover is really drastically lower than everybody else.We're not pushing you to sell muddy wormers or run Wellness screens.But everybody else is up here and here down here and you not doing the necessary diagnostics and we worry that it's maybe your standard of care.
Is there something there to help somebody to say, well, maybe I'm making those snap decisions?How do we make that practice?Yeah.I mean, I think, again, the first step is, is the intellectual humility to realize that the human brain is not very good at doing what we're asking it to do.The model that we've trained people in is what's called the just in case model, where you shove every known fact in the universe into your head and you keep it there for the duration of your career, just in case you need one of those facts at some point with a given patient.
But the brain doesn't work very well.What we really need is a knowledge model that structures our thinking so that we can identify what information we need at the moment and then go get that information from a resource that's better at storing data than our brain.And I think that one of the tools that I think is really useful in that is external decision support tools.
So things like clinical practice guidelines or expert consensus guidelines and systematic reviews, what we call the synthetic literature, where somebody has sat down and looked at the existing evidence and and appraised it critically and come up with a bottom line for what it says.
Or another example that's commonly used a tool.Gawanda, as a physician who's written a lot about this as the concept of the checklist, we don't expect airline pilots to remember every single button in their cockpit.So we give them a tool to use when there's a problem to help them make decisions in a more systematic way.
And I have surgical safety checklists in my practice.I've created checklists for dealing with rattlesnake and venomation and sepsis and a whole bunch of common presentations that are complicated and difficult so that we can be consistent and systematic and evidence based in our decision making.
Now that does involve giving up a little bit of our autonomy and we hate that.We want to, we want to make all the decisions for ourselves, right?And it does sometimes fail because of course, there are cases where your individual patient doesn't fit the standard and it needs something that's a little bit different from what's in the standard guideline.
But I think those cases are more rare than we think.I think we use that as an excuse for wanting to be autonomous and make our own decisions.So I encourage people to be aware of the tools that exist.There are tremendous number of resources out there that can help support the decisions that you make and not expect to be an expert in everything and to have it all in your head at all times.
Now, when you come to that situation where you feel like your boss is pressuring you to do things that you're not doing for financial reasons, I think you'll be in a better position to argue that, you know, it's quite clear according to the CVIM guideline for mitral valve disease that this test is not necessary once I've diagnosed them as stage CI, don't need to re echo them every six months.
That adds no useful information.I think you're in a better position if you have the possession of those facts and those kinds of scientific consensus guideline documents to say this is appropriate medicine and we need to talk about how else we generate value rather than than simply doing more things.
I personally find the the cases that are easier to make decisions on are the ones that are sicker.So you mentioned mitral valve disease, clear external guidelines.I know if I hear a murmur and I can go look at what's, what's the newest study say, what are my steps?
That's fine.And I have no problem recommending that.I'm like, here's the here's the problem.It's well defined.Or the animal that comes in vomiting for three days, it's super dehydrated.The algorithm goes tick, tick, tick, tick.I have the boxes to tick and with the owner can pay for it.Great simple discussion.The ones that are much, much harder are the little bit unwell or as I said, the acute gastrointestinal, an emergency.
I feel like about 80% of what we see is just gastrointestinal disease, vomiting, diarrhea.Do I need to pull the trigger on the whole diagnostic work up?Is it over servicing or is it a is a jab of an anti medic?Go home.And I struggle with those ones a lot more.And I feel, and there are new ones, because the dog that's vomited twice can have a fatal disease, but it can be the start of a sodium crisis or it ate a rotten piece of chicken and it's going to be just fine in the morning.
Obviously the the less clearly defined a problem is the more room there is for for personal judgement and the harder it is to make those decisions.Here's something that I think we could do more of in practice that would help us in situations like this, and that is clinical audit.This is a concept where you look at your particular patient population in your hospital and you have a question like that that you need an answer to, and you go about trying to collect some information to answer that question, not for the purposes of publication, but simply for the purposes of informing you about what's happening in your own practice.
So the example for our practice was someone came back from a conference having been told you should not close the linea with Monocryl because it takes too long for the linear to heal and the suture dissolves too quickly and you'll get more dehiscences, more complications.You should use PDS instead.And our doctors were pretty much evenly divided between PDS and Monocryl for totally arbitrary reasons, personal preference.
And so some people were like, absolutely, we should stop using Monocryl.And other people were like, no, no, I hate, I hate PDS.So what we did is we made a little sheet.And ideally you do this in a computer, but sometimes our computer systems are stupid.So we made a little piece of paper and for a year we simply checked off a series of boxes for every routine spay and neuter surgery that we did, which talked a little bit about, you know, the, the signal to the patient, the procedure and the suture and the technique and a few other things.
And then about 3 months or so, one month and three months, I think after each surgery, we had a nurse call and just say, how's everything going?Any issues, any problems, write that down.And at the end of the year, we had about 800 cases and we went back through and we could say there was no difference in terms of complication rates between the two suture materials, except perhaps more suture reactions with the PDS.
And I was in the PDS camp and I had to give up and realize I was wrong and probably it was fine to use the other sutures.So I think you can do simple things like that.You can take all the dogs that come in and get what I call a gastrotini, right?Subcu fluids, some kind of antiemetic, maybe some kind of gastro protectant.
And you can keep track of them and do a little follow up and find out what percentage of those had another problem that you didn't detect or what percentage didn't.And that won't tell you what to do in every single case, but it'll give you at least a little reassurance that, you know, most of these cases are really going to be fine.
Or actually I'm missing a fair number of things.I should probably be more aggressive about my work up.I think there are simple things you can do like that to help inform your clinical practice.Never going to make it perfect, never going to be omniscient, but just to help you understand a little better what's happening in your particular part of the world.
That's so cool.I really like that you can do it retrospectively because again, it's still evidence based.I read through some of that article, your article on veteran clinical decision making and you talk about maybe we'll look into that.But the intuitive decision making, am I understanding that you said it's not a great science?
Don't use your intuition.Use what?I was talking about was Daniel Kahneman's idea about type 1 and type 2 thinking.So type 1 thinking tends to be what one of these is, tends to be very instinctual and automatic and experience based and very rapid.The other is more formal and more algorithmic.
So an experienced clinician like you would look at a patient that came in with vomiting and say, well, it's a happy young Labrador and it's bouncing off the walls and it eats stuff all the time and, and you know, it doesn't look sick to me.So I'm going to treat it conservatively.A new graduate might come through and go, here's my list of differential diagnosis.
Here are the tests I need for each of these.Here's what you know.They're going to be much more structured and formalistic in their thinking because they don't have that sense of clinical intuition.Those are two different ways of approaching the problem and they have their strengths and weaknesses, right?The intuitive experience based approach is much quicker.
It's very good at dealing with common things that you see a lot and that behave in the usual way, but it's also not very good at dealing with unusual things, things you don't have a lot of experience with, things that don't follow the rules and behave in the usual way.Whereas the algorithmic thinking is a lot less likely to miss the unusual or the uncommon, but it's a lot slower.
It tends to lead to more expensive interventions.And, you know, it has its downside as well.So it's not that 1 is better than the other, it's that we need to find a balance between the two.And what we normally do is rely way too much on our instinct and our feelings, because that's just how the human brain works.
Yeah, and I read that little bit and, and and that is me to a large degree.And the scenario that you described is exactly what happens in our practice because I've been doing it for 25 years.I'm embarrassed even saying it.But when my patient walks through the door, I have a pretty strong feeling about how much I need to do to you.
But exactly the stuff I can see, the way you walk, it's intuition.I just have a gut feel like, yeah, you don't seem that sick to me.And I'm always mindful.I'm worried that I'm going to miss something.But my counter argument is, no, I'm still using evidence.There's a feeling, but then I'm like, well, let me double check.I could feel your abdomen.
There's no pain.I can't feel a foreign body.I imagine if you had something terrible going on, you'd be painful.Maybe you'd be parorexic.So clinically, I can't find anything wrong I could justify.I can say offer you a piece of chicken.If you're eating chicken, you're probably not obstructed.And I go, it's in Jewish, but it's also evidence.
Now I don't necessarily follow it up with and let's run some bloods and do an ultrasound, which exactly as you say, many of my younger colleagues will say they they want to do that because what if it is an inception and they've missed it?And it very well may be more appropriate for a less experienced veterinarian to be more aggressive about diagnostics because they haven't developed that intuition yet.
They don't always know if the patient is really sick or not.So, yeah, I think that that that's part of the the art of it all is balancing the two.Now, I'll turn it around and say the other side of that, though, is that we use our experiences to justify things.Even when the evidence comes along to show that we were wrong, we have a very hard time believing that.
So the, one of the favorite arguments I like to have with all of my colleagues is, you know, how often do you prescribe Metronidis ball for acute idiopathic diarrhea in dogs?And we now have a good solid four or five clinical studies which pretty consistently show that it doesn't do anything useful at all.But I, I can tell you that, that most of the clinicians I talked to who've been doing that for many years will say, but they all get better.
So it must work.And that is that kind of thinking that we get into trouble with is that we're not willing to to recognize the limitations of our own observations and experiences.So when I bring up the idea of finding a balance between very rigid sort of algorithm driven thinking and intuition, I'm again I'm back to that intellectual humility because sometimes very difficult for us to accept that we're wrong about something that seems so obviously true.
The confounding factor, again, back to the regional purpose of this conversation, is me versus my younger colleague, my approach with limited evidence and some experience versus the younger one that's going to do all the testing.If I wasn't commissioned, I'd be shooting myself in the foot by not doing an ultrasound.
So then again, there's the advice of going, well, I could justify an ultrasound, it could be.So let me do a $400.00 scan.I would guess though, that you'll see a whole lot more patients a lot more quickly.I don't have any trouble generating as much or more revenue as, you know, the new graduates in our practice, even though I don't get paid that way, they still keep track of those numbers and, and they put up with me largely because of that.
And, and I think as you go through your career, one of the reasons why that's true is you are able to do things that younger people are not able to do, but you're also able to do things more quickly and more efficiently.You know, so, so I, I can do a splenectomy in a foreign body in the time that it takes a new graduate to do a big dog spay on.
Ultimately, I think you're still going to be more economically productive as a, you know, a more experienced and more efficient veterinarian, even if in some cases that leads you to doing less.I think we should focus again, more on what's best for the patient.And it's probably best for people who have less experience to be more careful and more thorough and more thoughtful.
And then over time, you know they can adjust that.So the, the message out there potentially for, for business owners or for the, the bean counters is to make sure that you measure the right KPIs as well.Because, yeah, one of the biggest KPIs that gets measured in practice is average consult fee.
So my average consult fee is probably blessed because I don't do all the things in every consult that I do, but make sure you measure the right outcomes, which I think doesn't always happen, but that's maybe a a systemic thing that has to be adjusted.And a lot of outcomes are very hard to quantify, right?
People come to your practice to see you in a way that they don't come to the practice to see the brand new Doctor that they don't know yet.Because the building of relationships over time is also a big foundation of a successful business in veterinary medicine.And that's harder to quantify with an average client transaction fee.
So I do think you have to be a little cautious about overlooking important things in the interest of metrics.Yeah, it sounds like it's not a simple solution.It sounds like it.It has to be something that the profession has to be very mindful of.How, how do we address this for exactly that reason you mentioned earlier, so we don't betray trust, so we measure the right things.
It can work financially.I don't know that I've got a solution.I don't think we have a solution for the person who is in a job where they are expected to hit certain metrics that are expected to upsell the.I don't know that there's a an answer for them from this conversation.
I mean, I don't know that that there's a perfect way to deal with that.As I say, we've been lucky, you and I in apparently not being in situations where I think we felt a lot of that kind of pressure.And and so I certainly would have empathy for anybody who does.I think as a profession, I think we also have to acknowledge that a lot of us are unhappy with what we're doing.
And there are some pretty serious problems with, you know, well-being and mental health and in our profession.And I don't think a situation in which you are chivvied into doing things that you don't think are the right thing for your patient in the interest of the bottom line are going to make that problem better.
I think they're going to make that problem worse or they're going to attract very different kinds of people to our profession then, you know, have built it.So, yeah, I don't have a perfect answer other than then I always say to people, if you can't do the job that you feel good about, that is satisfying and meaningful to you, that you went through all of that training and all of that effort to learn to do because of the environment you work in.
I hope you have the opportunity and the the drive to look for something else somewhere else because I don't think that's a good fit for you.And, you know, I think that that's important.I knew right away that the practice that I started in wasn't the place for me, and I started doing relief work immediately, and I took about three years to find a place that was the right place for me.
But then I've been at that practice for, you know, 21 years.And so clearly it made a huge difference in my profession to be able to make that chain.And sometimes that may be the answer for some people.Perfect.I think that's a really good answer.Can I ask you, let's prove it quickly to your Just Keep Fed hats on?
I'm not going to go too deep into that, but I loved reading some of your articles and really relevant topics that you discussed.Is it a fair question to say off the top of your head, are there three things that us as veterinarians commonly not all of us do or believe or put up with in that realm of non scientifically backed things that drive you nuts?
I talked about soapboxes earlier.If you had a soapbox about a couple of things in that realm, what are your favorite soapboxes that you could get a message I?Mean there are so many and I have to say that they've become less specific and more conceptual over time.So, so I could certainly pick out a couple of therapies that I'd like to see die.
I'd certainly like to see metronidazole for diarrhea go away.There are a few others, but what I would say is the the bigger problem is excessive trust in our ability to judge causality.You know, I gave the thing to my patient, my patient got better, therefore the thing I gave them was the right thing.
And it works.And that is the underlying conceptual problem behind most of the therapies that we use that don't work.The.In the early days, my blog focused largely on alternative therapies, and that's simply because culturally those tend to be used by people who are more comfortable with that kind of decision making and who are, there's no need to justify things scientifically sometimes in people's minds.
But I think that it's a problem with how the human brain works.And so it applies just as much to, you know, what I would call conventional science based therapies as anything else.So I'd like us to stop thinking that we know that pain medication works because our clients report that they think their pets feel better.
I will say that we used Tramadol for quite a while in veterinary medicine before we got some studies showing that it didn't work.And and there are pretty good reasons why it shouldn't work based physiologically and how it's the precursor drug is turned into the active metabolite in people and cats but not in dogs.
So we had a lot of patients who were under treated or untreated for their pain because we accepted, yeah, he seems like he feels better as a valid answer.We are doing the same thing right now with gabapentin.The American Animal Hospital Association pain control guidelines called gabapentin, the new tramadol, because we're using it without evidence in the same exact sort of way.
I see people sent home with that as their only pain control after spay and neuter surgeries all the time.Totally inappropriate based on current evidence.Might turn out later that it works great, but right now we don't know.So that's a dangerous thing to do.And a lot of the alternative things like acupuncture, it's the same thing.They're justified largely on the basis of we did it and the patient seemed to do OK, and that is taken as proof that it works.
So I think if we could stop doing that, and if we could give more credence to scientific studies when they exist, we will make fewer mistakes and we will, you know, cause less suffering.So that would be the bottom line message.There are plenty of individual therapies I could gripe about, but honestly I think the problem is more in that trust in our anecdotal observations than it is anything else.
I want you to to gripe about individual things because it comes back to what I said earlier.I think a lot of us understand that we should be more skeptical and, and apply critical thinking, but you don't necessarily have the time to go and look at the evidence and review.
Did it actually work?Because we've got some many things to see on a day.So I we kind of want somebody to tell us.Bullshit, not bullshit works, doesn't work.Don't do stop doing that.Do this have clearing guidelines?Because in the meantime, what happens is we believe what the drug company tells us.
They give us their booklet and you go, oh seems good, I'll start using that.I do a talk at continuing education meetings, which I think I used to call it things you know, that ain't so.And it's, I think the most recent iteration of that has been things to stop doing in practice maybe.
And so the most recent version of that that I've given has some of the things we've already talked about on it.It has gabapentin is a primary drug for pain.It has tramadol as a as an oral medication for pain in dogs.It has glucosamine and chondroitin as a therapy for osteoarthritis is that almost certainly doesn't work.
It has metronidazole for idiopathic diarrhea on it.I honestly don't even bother to talk about some things.I mean, if you're still using homeopathy, you have to start over in terms of learning about science because there's just no reason at all to take that seriously.And, and the same is true for a whole bunch of things, you know, that we put in the energy medicine category or you down there have an even bigger problem with the barf diet problem an idea than we do.
The notion that that something is natural, and ergo natural means it's safe and effective and appropriate and optimal, and none of those things are true.You know, uranium and asbestos and cane toad venom are all perfectly natural, but they're not good for you.So just some very basic conceptual problems, and they manifest as particular therapies that we get attached to or that we choose not to use.
There's a tremendous NSAIDA phobia out there.Part of the reason why we keep using all of these probably ineffective alternative therapies is because so many people are terrified about NSAIDs and we have an incredibly detailed understanding of their risks and benefits and when they can and cannot be used.
And, and I think we deny cats in particular, effective chronic pain control because of an excessive anxiety about NSAIDs that isn't evidence based.So that would be a soapbox in the other direction of things we should be doing more of that we're not doing.I love that.
So how can we be more skeptical in practice starting points just to say, OK, well, I I don't want to be a sucker for these things.Is it just ongoing education or what do we do to get better at it?Be more like Brandon.You know, we've all seen those fancy evidence based pyramids which have, you know, sort of anecdotes at the bottom and all different kinds of complicated study designs in the middle.
And they're way too much trouble and too much work.So I've built an evidence pyramid that I use a lot, which has at the bottom my opinion, which is roughly equivalent to rolling the device and should only be used when there's absolutely nothing better.And then above that, I have expert opinion, which is only marginally better than my opinion.
And then we have the primary literature, which has lots of information in it.But as you pointed out, most of us don't have the time or energy or the skills to wade through it.I mean, I went and did a master's degree in epidemiology just so I could understand the literature so that I could stand on these soapboxes and say these things.
And Even so, half the time I can't tell if the design is correct or the statistics are correct.So that's a great resource, but we're not going to be able to make much use of it most of the time.And then at the very top is what I call the synthetic literature.Those are things like systematic reviews, clinical practice guidelines.RCVS Knowledge has a whole bunch of knowledge summaries.
The Center for Evidence Based Veterinary Medicine at the University of Nottingham has their best bets for vets, which are quick, little critically appraised topic or summaries.There are lots of people out there who are making useful summaries of what we know right now.And I think it's the most time efficient, practical thing for us as general practitioners to do is to rely on those assessments.
You know, if they say we don't know the evidence is equivocal, then you're free to use your personal experience to do whatever makes sense for your patient.There's no problem with that.But if they say the evidence is pretty consistent that X doesn't work, you should get rid of X, whether or not your particular experience suggests it's a good thing.
Something that I'm using increasingly as a way to quickly access and pass through that level of information, the empirical evidence and then the consensus statements and all those things is AI not not relying on cell yet.I don't fully trust it yet, but I don't know if you're doing the same in your work, but I'm creating things for myself where I will dump a few.
And again, I sometimes I'll just ask HDBT as a first line to say, here's my thinking.And it's actually phenomenally good at helping me think through things or discounting things if I go, well, I had a scenario the other day where somebody was showing us a new wind cream that was supposed to be amazing and they wanted us to adopt it, but I've never heard of it.
And some of the signs I looked at, I was like, never heard of it could mean that it's new and I just haven't heard of it.But it sounds weird.And I just gave it to JJ Patel.I said, can you analyze this?Can you tell me what you think about this?And it pulled up articles and it will.And basically it said in the end, now I can't find any justifiable reason why that should work or be better.
So really useful.And I, so for example, I've made myself and I share it with the, the members of the podcast, a consensus statement search bot.So it doesn't use the whole knowledge of the Internet.I've just give it the ACRIM consensus statements that are free and out there and put it all in there as a database.
And there's a search button.And I could say, do you have any information on immunity thrombocytopenia?And then I'll say yes and say, OK, what's the current recommendations for starting those for this?And it's so good at pulling those things out for me.Yeah, that's exactly what we were talking about before, that those are the kind of things that our brains are not especially good at and do slowly, that we need tools to support decision making that do those things better.
I know that those tools are kind of in their infancy and I suspect that they're going to they're going to have to get better before they become reliable as a primary guide for clinical decision making.I asked ChatGPT to tell me something about the skept vet and it gave me all kinds of degrees I don't have.And you know, a lot of hallucination can show up in those things.
But yes, they're absolutely actually a bunch of tools that I play around with and and you know, occasionally they'll pull out an article in, in an obscure journal somewhere that I missed when I was looking through things.And I think in the long run, they're going to be very useful.I think the key is that a resources for veterinarians have to be rapid, cheap and convenient and ideally also accurate.
And right now there's a tension between the two.You know, most of us will go on Vin, for example, here in the US and, and get an opinion from some other vets and that's, you know, rapid and, and convenient, but not necessarily as reliable because it's totally at the whim of whoever you happen to be asking.
So yeah, I think those kind of tools are definitely a big part of the future and, and I'm looking forward to seeing them developed.Yeah.The last piece of this unproven therapy thing is the communication piece with clients.I'm pretty sure that's why you started the Skip.I'm guessing that's what Skip that started because there's something really attractive about these things specifically for our client base.
I spoke to a guy at a conference.They organized online conferences for pet owners, educational conferences and he gave me the numbers and it was really sad.The business model was that get sponsorship for it.So at 3 conferences and then people would pay to have an ad during the during the webinar.
And they started with traditional medicine.You know, not not isn't it's a wrong word.It sounds like tradition, like normal science of science based medicine and attendance was meh.And then they pivoted and they did alternative therapies, holistic medicine, though, whatever you want to call it, basically unproven.
And suddenly everybody wanted to attend, which I was like, that's so sad.Why is that?Why is that?So I suppose my question is you ran an in clinic, a client comes in and asks about raw food, diet.Or again, maybe I'm stepping on toes.
People are wrestling.But anything that that is on your list of soap boxes, how do you talk to them about it in a respectful way?Because it's people come with their, there's a lot of emotion involved in that.How do you guide people and say without saying total bullshit, forget about that.
If you want that sort of stuff, go somewhere else.That's not the right approach.What's your approach to do?Approach it sensitively.Yeah, any effective communication about misinformation has to begin with validating the motives and the concerns of the client, and with making sure that they understand that you share those right.
They've come to you with this idea because they want what's best for their pet because that's important to them.And you have the same goal.You want what's best for your patient.That's why you're there.And so making sure that they understand that you recognize the genuine motivation that they have and that you share it is a necessary first step.
And then talking about in a very clear and direct, but also emotionally neutral way about what you know about that thing that they're interested in and why maybe that's not actually what they want for their pet.So a lot of times people will come in with a a misconception that's based on something they've heard.
And I've spent a ton of time reading on these topics.And so I usually know where they got that from.Yeah, there was that one article which got really widely misreported in the media and didn't actually say what everyone thinks it said.And I've read it and here's what I like about it.
And here's what I don't like about it.Showing them that you've put the time and effort in to understand where those ideas come from and not that you simply dismissed them out of hand because you're closed minded and you've been brainwashed by big Pharma or big Kibble or whatever it is, right?I mean, I think there's an art to the communication of these things.
The other thing I always say to people is you're not going to change the mind of someone whose whole worldview is built around this, and you don't need to.You're going to be much more effective at changing minds when you've built a relationship over time with someone.And so that's something that you don't have immediate control over, but maintaining relationships with clients who don't always agree with your recommendations is a way to gradually earn trust and earn credibility.
So I think there are a lot of elements to it.Science communication is a tricky business and there's no perfect solution, but I think you're absolutely right.Clear, direct, respectful acknowledgement of their concerns and of, of their point of view, and then a presentation of your own and, and what you think in the long run is best for that patient.
And you know, I don't know how much influence I have over every single patient.I certainly know what kind of influence I've had over my colleagues because I've been working with some people for 15 or 20 years, and I've watched their practices change as a result of the gradual wearing away of the Cliff by the ocean that is Brennan's opinions.
And think about it in that sense, right?You're making a a change in a small level every day as part of your practice, and that's all you can hope for.And you won't always get to see that back.I had a, a little wind in that regard the other day, which I wish I could share and it might not work every time, but I, I, I found this works.
So where I work on the East Coast of Australia, we have paralysis tick, which is a devastatingly horrible disease, but we have very effective tick preventatives, The Isaacs Izolins group of drugs.But online there's all the stuff about how dangerous they are.And you know, it's big pharma and it's just the vets trying to make money, trying to sell you these unnecessary things, which is, is very tragic that, that it is the way.
And I had a couple slightly older couple and their little pup was there luckily not too severely I'll but round two of tick paralysis when we see them in emergency for tick paralysis, a large part of the consultation is in future, what are we going to do to prevent this?Because you survive this time, but you might not survive next time.
So she would have had the talk already about what to do.So the knowledge was there from our side and they had, and that shocked me that they actually had the experience of having their dog treated for tick paralysis, which is costly and dangerous.And still at discharge of that patient.
I, I talked about it again and I could see there was some discomfort between her and the husband.And then I stopped and I said to her, I, I sense that you have some concerns.I'm aware that there's a lot of stuff out there against these things, but do you want to tell me what you've read and tell me what you worried about?
And I think that was really key instead of me just blah, blah, blah, vomiting my information added to say, tell me about what what have you seen?What are you worried about?What are your concerns?And she and it was an immediate OK, yes, I have to confess, I've read this in a way that and then I could go through it.
And again, as you said, I started with, yeah, I've read those things and some of them are really scary, aren't they?They really.I read diminishing in my shit.That's really bad.But here's how I think about it.And I could go through my arguments to say, and even if there's some truth in that stuff, the benefit is so much better.And you know, we went through the whole thing and by the end and she walked to the counter and bought a box of freaking Isaac's Olympic preventative for next time.
So I I feel like that just trying to understand let them talk through what the concerns.I was a was a big shift for her in the way that we interacted about this.Yeah, I think a lot of what I mean apart from the the basic cognitive biases and some of the misconceptions like, you know, natural means safe, apart from all of that, I think a large part of what drives people to alternatives to science based medicine is failures in how medicine is delivered.
And in particularly in the human field, we get to say as veterinarians, we're probably a little better at that so far because we're still a little smaller and a little more personal.But I do think that we need to be mindful of that and listening is an incredibly important part, part of establishing A therapeutic relationship.
And I can give someone credit for doing that effectively, even if what they're offering is not, I think an effective treatment because that's part of the relationship.And we need to have both, right?We need to have a an effective therapeutic relationship and also good science based therapies to offer.
So yeah, I think that was exactly the right tech to take.Right, right.We do have to wrap up time is is not our friend.Let's do that with a couple of wrap up questions.Are you a podcast listener?No, oddly enough I don't commute enough to do that.I, I the last time I listened to podcasts routinely, I I literally had an iPod I wanted like probably second or third generation.
So no, not anymore.Our younger listeners are going what, what?What's with that?What's an iPod?That's how old we are.I showed my iPod to my my 13 year old the other day.Like you, you couldn't understand the lack of touchscreen.
It was like, how the hell does this thing work?OK, so if you're not a listener, then a reader.I'm pretty sure you're a reader.Do you have any standard books that you've read recently that you'd put high on my list that should be next to my bedside table?I mentioned one earlier, I think, you know, if you're looking for a quick introduction to how your brain goes wrong, Don't Believe Everything You Think by Thomas Kita is a really nice a nice one.
It's very accessible.It's much less detailed than some of the bigger ones.If you really get into it and want to go down the rabbit hole, you can read Kahneman's Thinking Fast, Thinking Slow, but I think I think Don't believe Everything You Think is probably a good starting point for most people.Cool the pass along question.
So our previous guest asked what most occupies your mind at the moment?So interestingly, you know, I, as I said, I'm still two days a week in the clinic, but I'm working in this company trying to investigate ways to delay the underlying biology of aging and give dogs longer, healthier lives.
And so I'm very occupied with the biology of aging right now.How does it work?What goes wrong?What are the patterns?What are the potential targets?I just finished a laborious literature review on immunosenescence and inflammation, how the immune system responds to aging.
So yeah, that's that's the topic that has been occupying me pretty intensively for the last couple of years.That's really cool.Are there things obviously you wouldn't be doing it if there weren't things that excited you about that and it's interesting that that you do it because it in my head not understanding enough about it.
I feel like the ante that I want to live forever school of thought.It's at least in human medicine in the in the popular media leans a little bit towards the and scientific and proven stuff.So I love that we've got the skeptics saying, well, let's, let's find the stuff that works in this field are the things that really get you.
There's a tremendous amount of nonsense in the anti aging movement and it's a it's a big impediment to getting the credibility to actually do real science in the space.We're pursuing prescription medications through the FDA regulatory process.So we have that that nice external check to make sure that our science is legitimate and solid.
We're doing a four year clinical study in 1000 dogs to see whether our first product actually delays age-related disease and extends lifespan which is I think the largest clinical drug trial in veterinary medicine ever.So so I, yeah, I'm very excited about it because I too came to it having just heard the nonsense and and there is actually a lot of really interesting science there.
I think the potential is for us to take a more proactive preventive approach to age-related disease.Right now we play whack A mole, we wait for bad things to happen to our patients and then we adjust react to them.And I think that just as we do with infectious disease and with parasites, we could take a more preventive medicine approach to aging.
And, and so I'm just excited to be part of getting that idea across to veterinarians and maybe developing some of the actual tools to do it.Oh, wow.When there's concrete stuff to talk about, that sounds like a topic for the clinical podcast.So I'm going to bookmark that because I immediately want to start asking questions, but we're out of time, so I'll zip it up there.
But so just to anybody who wants to Google that's loyal, is the company you're doing this work for?Yeahloyal.com Loyal is the company.OK, cool.If anybody wants to look for that.All right.Your question for my next guest, not knowing who they're going to be?I don't think it'll come as a surprise given the conversation we've had.
I would say to someone in your space, in your field, in what you do and what you're an expert in, what is the number one misconception or mistake or error that you would like to see go away?I'm in the same soapbox with you with the metronidazole, by the way.
That's my I've done so many podcasts on it and I get stuff out there I still still feel like it doesn't get.All that, it's going to require a generation to pass on and be replaced for that one.All right, great question.
All right, final question, Brendan, you have a couple of minutes to speak to all the veteran new grads of the world.I used to say you're at a conference, but now I'm arrogant and I say you're on the Vet World podcast.So you do have that opportunity.What's your one message for the young vets of the world?
I would normally talk about some of the things we've already talked about, which is, you know, not necessarily trusting your own observations and experience, but I think we've done enough of that.I would say on a personal note, one of the biggest challenges in our profession is that being a veterinarian is all too often your identity rather than your job.
And I was an oddity in that I came to vet school as a career change.I did not dream of doing this as a child.It was something that I discovered along the way that suited my personality and my interests.And I feel like that's protected me from some of the problems that our profession is going through.Because I can go home at the end of the day, you know, and be a husband and be a father and play the mandolin and, you know, do the things that I do that are me as much as what I do for work.
And I see a lot of new veterinarians for whom I think it is still their identity.And I would just encourage people to build things that constitute who you are outside of your profession.Great, great advice.Yeah, if the only pillar keeping the roof up is your career and that doesn't work out, then the roof comes down, doesn't it?
And if you have a terrible day at work, suddenly you're a terrible person.If you make a mistake or you have a case that doesn't go well, it reflects on who you are.And I don't think that that's a healthy way to approach the work.I don't think it benefits our patients, but I think it harms us.So I think, you know, we, we certainly need to have a genuine emotional commitment to what we do, but I think we also need to have other things that support us.
Yeah, Brendan, thank you so much.That that's really insightful.I love the ones that get me thinking a lot about not just the the moment to moment things, but the bigger picture things, how we ran the profession.I'd love all the thinking you do and the fact that you are brave enough to put it out there.
So thank you for doing all of that.And I, I wanted to speed up with your work on longevity.I have an 11 year old Doug who I intend for him to live 25 years.So I need some advice very quickly to get on to it.Well, good luck and and thank you so much for the opportunity.
It's been a great conversation.Before you disappear.I wanted to tell you about my weekly newsletter.I speak to so many interesting people and learn so many new things while making the clinical podcast.
So I thought.I'd create a little summary each week of the stuff that stood out for me.We call it the Vet Vault 321, and it consists of three clinical pills.These are three things that I've taken away from making the clinical podcast episodes, my light bulb moments.Two other things.These could be quotes, links, movies, books, a podcast highlight, maybe even from our own podcast.
Anything that I've come across outside of clinical vetting that I think that you might find interesting.And then one thing to think about, which is usually something that I'm pondering this week and that I'd like you to ponder with me.If you'd like to get these in your inbox each week, then follow the newsletter link in the show description wherever you're listening.
It's free and I'd like to think it's useful.OK, we'll see you next time.

Brennen Mckenzie