June 22, 2019

#8: Defining the problem. Prof Jill Maddison

#8: Defining the problem. Prof Jill Maddison
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Professor Jill Maddison is currently Professor of General Practice, Director of Professional Development and Director of the BVetMed course at the Royal Veterinary College in the United Kingdom. She is actively involved in undergraduate teaching and CPD at the RVC in the areas of small animal medicine, clinical problem solving and clinical pharmacology. She has lectured extensively around the world on clinical problem solving, small animal internal medicine and clinical pharmacology. If you’ve ever listened to one of her lectures you’ll know that she is the epitome of clear-minded scientific thinking. And if you haven’t had the privilege of hearing her speak - well, luckily she’ has a book just for you: Jill is senior editor of a book called Clinical Reasoning in Small Animal Practice, a must-read for anyone in practice. She’s also published over 60 refereed papers in veterinary and medical journals and is the senior editor of a previous book, Small Animal Clinical Pharmacology. To keep in touch with the realities of private general practice she consults at a local veterinary practice and at the RVC’s first opinion practice, the Beaumont Sainsbury Animal Hospital. In this episode we talk about clinical vet work for a change: Jill talks about some common mistakes that many vets make when it comes to clinical decision making, and why curiosity and thinking skills are more important than knowledge and facts. Jill gives us her insights about the value of internships and tells us what her favourite textbooks are for everyday practice. Please enjoy - the queen of small animal veterinary medicine - Professor Jill Madison.

Before we get cracking on your medicines podcast what I wanted to share with you or talk to you about was the Unleashed online conference that myself and Hubert heavily involved with and we were organizing.So give me the rundown what it's all about about essentially over the last eight years.
I spent quite a lot of my time developing clinical resources thinking that the more that I am empowered the veterinarian said I was mentoring with can acknowledge the better able and equip they were to cope with Stand the stresses of being an emergency veterinarian that the issue of found was that for some Marian's no matter how much clinical knowledge that I imparted across that was still this level of underlying doubt anxiety.
Just some kind of barrier that there were trying to overcome and I felt like as if I wasn't providing the the information that they needed in a clinical aspect and that's when I realized that actually clinical knowledge plus something else is What actually results in success so what I've done is I've gathered seven of my best friends who have succeeded in different aspects of their careers and and got them together in a online conference format.
So they can share what they've learned Anthony is a behavior expert and expert speaker and he's going to talk about confidence and confidence in the way that you communicate which is an incredible skill and also ring The important in the consult room Shibley is going to talk about self-awareness and how that plays an important role in the way that you communicate and also talks about wealth and how to demonstrate value to clients Brooke is going to talk about social media specifically on Instagram and how she used that to share her message and have impact With Their audience and also how to deal with failure and imposter syndrome Hubert's going to talk about the golden nuggets from the vet volt.
So the key things that the the mentors that we've got on the vet fold of shared and also an aspect on personality.What is your social style and how the social style impacts the way that you communicate and consults and how you can leverage and flex your style.This is an incredibly important skill to understand and can have dramatic impacts on the way that you interact with clients and fellow team members.
Alex is going to talk about the elusive work-life balance.And then also how she connects in the console room.So she'll say her share her.Secrets on how she connects in the consult room.I'm going to talk about Clarity and trying to find Clarity in where you're heading over the next two three four five years because if you know where you're heading then you can make a plan for that.
And then once we understand that we're going to set you down the right path way the Deans going to talk about resilience because we need you guys to swing back and bounce back from adversity.And then Sarah is going to talk about supercharging your impact and influence.
So everyone wants to have an impact.You may not realize the impact you want to have have but we're going to discover that and then how do we get that and maximize your impact on yourself your local team?So your team within your hospital and also the wider community and Beyond so in the show notes would be a link or if you go to our Instagrams, you will find that there will be a link there for the Unleashed online conference and on the website, you will find the speaker pack, but also the tickets which are now available.
You ready to rock and roll?Good evening.Ladies and gentlemen, this is Gerardo Poli. and this sorry one of the best bits of advice I've ever received was to find good mentors and to learn from them trusted people who have already done what you're trying to do.
Now.I've been fortunate throughout my career to have some fantastic mentors to help guide me, but I realized that they'd be hard to find and also hard to commit the time to 1.This is why we've gathered some of the best Minds from the veterinary world and squeeze them for their wisdom so that you don't have to learn the hard way.
With the help of our guests, we flipped the veterinary profession on its back and explore its soft underbelly to find the tips tools and inspiration that you'll need to build the career that you've always wanted.I'm Gerardo Poli.I'm Hubert him strapped and this is the vent valve.If you don't know who Joe Madison is then you're missing out but it's okay because we'll fill you in and this podcast Jill is currently professor of general practice director of professional development and director of The Bachelor of veterinary medicine course at the Royal Veterinary College in the United Kingdom.
She is actively involved in undergraduate teaching and continuing professional development at the Royal Veterinary College in the areas of small arrow medicine clinical problem solving and clinical pharmacology.She has lectured extensively around Well done clinical problem solving small animal internal medicine and clinical pharmacology.
If you've ever listened to one of her lectures, you'll know that she is the epitome of clear-minded scientific thinking and if you haven't had the privilege of hearing a speak well luckily.She has a book just for you.Joel is senior editor of a book called clinical reasoning in Small Animal Practice, which is the best guide to clearer thinking about small animal medicine that you are likely to ever read.
She's also published over 60 refereed papers in Curry and medical journals and is the senior editor of a previous book small animal clinical pharmacology to keep in touch with the realities of private general practice.She consults at a local veterinary practice at the ivc's first opinion practice the Beaumont sainsbury Animal Hospital.
In this episode we talk about clinical vet work for a change Jill talks about some common mistakes that many vets make when it comes to clinical decision-making and why curiosity and thinking skills are more important than knowledge of the facts.You'll give some insights about the value of internships and tells us what her favorite text books are for everyday practice.
Please enjoy the queen of Veterinary small animal medicine Professor Jill Madison.So Jill laughs I've seen over the past 10 years or so since moving to Australia.I've actually seen him speak at a couple of Congress has some as much as much impressed them was a sense of absolute confidence and certainty with what you say.
I've actually joked with colleagues before if you have your clinical clinical disagreement if somebody says, yes, but Jill medicine says this that that is the conversation Back from that one.So instead I must admit when Gerardo said we've got an interview lined up with you as a little bit intimidated felt like I was interviewing Brittany Vivid vision is royalty that there are there I Googled you little bit and and what you've written and what you've done over the years and I realized it's not start vetting royalty.
It's more like a bitch deep superhero.Question is where you bought a superhero like Superman or or did it happen later in life more like Spider-Man with that like with a radioactive spider bites question.
I don't know.I'm supposed to say I've always been very bossy.So I was I was school kept my primary school and at my senior schools guys, but I don't know.So when so when you always a very committed driven driven sort of a person or is it did is it something?
Happened as you as you developed in life.No, I think I was probably fairly committed and driven.Yeah, I don't know.I don't know what by they talk about some things and people as they progressed through the careers and they have a lot of successful people.
They have this bias and they call the bias for Action.You do you feel that like as you're going through high school as you're going through University like you saw things and you wanted to contribute you see took action as opposed to the kind of Just the things and then let other people do yeah.
Yeah, so I always got involved with things so well in class Captain being School Captain being on the Su the student, you know Council for school, although that that experience putting any involvement in University politics because that was a kind of remember what the details are now, but barely some fairly sort of difficult things happen, and I thought I don't want to get involved again.
Although I think I was I think I was one of my year reps.At University but then being involved with Association.So get involved with the sav a was my first step is I'm going to be in purse at a Sav a conference years ago guy and just as a delegate and and seeing the committee and stuff and I thought I really like I really like what they're doing and I like what they're doing for smile and all practice which the Ada wasn't doing at that stage and I thought I'd really like to be part of that.
So that's where it kind of that's where I did a lot of my leadership development was through initially through the a SATA a lottery a Saudi a years that I was also on the a board.Yeah, so I guess I just am not one of those people who Minds about something and then doesn't do anything about it.
I just to recap you studied weight in Sydney the correct.Where did you grow up?We Friday from City.And and then how did how did it happen back then?Why wait?How did how did that the journey happen?
So I always liked that I was like writing so I didn't start vet.I started animal behavior or Behavioral Science at Macquarie and my father was a doctor and I knew I didn't want to do medicine or whatever reason that I think his Fighters by kind of went to the behavioral side of it.
And then when I was at Macquarie, it was okay, but This was this was an arrogant but there was one assignment that I did when you know, I was not at all on top of my game.In fact was probably well figure by all sorts of things at the time and it got this amazing Mark and I thought to myself.
This is a I need to be more challenged than this.This is this is to not to easy.It was just right.I need more challenge than this and then I honestly can't remember then.Applied for it but I literally can't remember what the thought process was.
I know my father got me to meet with a friend of his who was professor of anatomy bitter Anatomy Rick's by the field, which is just wonderful man.And the idea was that I would have lunch with Rex and Rex will talk me out of being a vet which equals to work with corrections passionate passionate vet.
So yeah, so that's that's how I go into vet.But I went into it thinking having no experience of it.What I think I've been to that one thinking I was going to be an equine bit that I was sort of all about horses.
Just didn't work out that way.But yeah, you going to horse practice wasn't legal.No, I started vet and that was kind of why I thought I was doing it and then about in third year.I got really sort of enthused about Native wildlife and went tagging kangaroos at it to the burrow and then but as soon as I walked into the spinal clinic at Sid and David medicine and probably has a medicine then that was it.
That was that's what I wanted to do.So then I had a very Just for quite some time that what I wanted to be was an academic small animal clinician medicine condition was that from a like a like a love of knowledge and a lot of learning or and I just I mean it just it just clicked for me, you know surgery didn't click for me at all.
And I hated anatomy and I could never remember anything and then the medicine stuff.I just it just clicked and I liked it and it made sense.Sense, and I didn't have to really study it very hard because I just remembered it.
I really I love that.I really liked in final year because we had we had to prove with his final year.I really liked a really light very very practice because it was so it was scientific and evidence-based and you know it whereas I didn't like if I'm practice which was more kind of fire engine e stuff and things like that doesn't really go off it.
Suppose something really know anything about it.I mean idea team.It's all you know so practice and it was fine.I had a fine time, but I wanted that evidence base in the problem solving and the we had very good mentors.I had very good mentors in Spa.And I understand what he's saying about kind of just things just make sense when you get down enough and you know enough about the underlying disease process than the manager makes sense.
Yeah, you know, I keep saying to everybody, you know, if you know, you've had two fears then you can work most things out and that's what I quite liked and I just I think I was mentored really well and had had really sort of good mentors who were inspiring and were They were teaching medicine in a way that was different from anywhere else.
Right now realize different from anywhere else and it just it just work for me.So this was it Sidney.Well while you were doing your your degrees different in a way because it was is that sort of shape the way because you were walking clinical reasoning was a reason to live in a way back and then I was gone but a story.
Yeah, so so when I was when I was in 4th year one of my mentors he had sabbatical and he had worked with Senator Hunter who was teaching neurology from a very logical neuroanatomical that makes sense type way and he came back and said to the other medicine clinic has only 2 bits and lectures those days to the LMS and make sure David Watson there must be a way that we can use this kind of approach and other body systems and David said yeah, and so David taught particularly gi gi gi from a problem-based way, which was the start of what and so then I I was taught that way as a student.
I then because I did an internship there.It was reinforced in when I did my residency.I reinforced it and it just evolved over time.To be more explicit and I think a little bit more practical because I think David was wonderful in in what he knew but he's very detailed and he he tended to make it a little bit inaccessible that you in sort of general practice.
It was a bit too very detailed and a bit too.You need to know all of these differentials for the problems and so put people off so, I guess what does manage to Move it into something that's a bit more accessible and usable and and you could do but that you know, they very much, you know, mentored me that you if you're understanding pacifist and you're going to it makes everything a lot easier.
That's it is like I'm not a specialist, but I'm on my members and for a masters and a lot of with was passed their fears and when you go through it at the start if you don't really appreciate how important is to understand your how disease occurs and You kind of get lost into into why you treat me as you can learn treatment Pathways.
And yes, they can and diagnose a pathway through the pathways but then you don't really understand why it is things doesn't really complete the circle.Yeah, you know, you just don't remember it it sort of is if you know, you know, I mean, I remember when I was studying for my fellowship and I thought was well study plan here and I thought well, what I'll do is I'll start with the body system or like the least which was kind of escort.
And it's a study that foot right?Well I need to do path of his gourd and the Hawaiians consensus.That's really that's what you do that and that's why you do that and that's why you do that.You know, this is what the body is trying to do silly old body.It's doing the wrong thing, you know, you're trying to sort of stop this dismiss and then it sort of made a whole other things.
So so you it from from uni straight into an internship at Sydney.So is it correct or yes, I did an internship the first year I was out.Coming down for three or four weeks and then I did an internship at Sydney for you through the different disciplines.
And then I was in practice in Sydney for 18 months my residency, which is Canada.You need to Canada.That's that's quite a journey and then back to Australia again and then and then to the UK after that does that Following you correctly.
Yeah, I cannot just raelia to I was thinking about doing my PhD the states and I was going to do I was thinking about doing a combined clean path residence in PhD at Davis and then I decided that I really wanted to I didn't want to be an expat which is very ironic because I'm so that's when I went back and then was there I guess.
Well, I went back in. 84 83 84 anybody for end of 83 and then do my PhD and then we sort of had various positions there ended up here, but that's a whole nother story.
Would you mentioned they wouldn't we were discussing is a pretty long process and like was that what did you have an endpoint in mind?Is that what you want you want because you talked about you wanted to be an academic in medicine and See that's similar to what students alike.
They want to be a veterinarian but then they're in there and immersed in that it's almost like they're at the foothills of Mount Everest and it's who hard to get to and like that whole looking up can be so overwhelming as like a how did you tackle that because that's years of process.
Yeah.Well, first of all, you have to accept it is like people who say I really want to be a specialist, but I don't have the time or whatever.He doesn't you know, it's the same today.It's the same process.
I think what's interesting is that that's what drove me and yet if I look back at my career.I've only actually spent three to four years as a full-time academic clinician in the specialty hospital because because what I realized was it kind of in a way it wasn't wasn't enough in a lot.
So I don't know it's sort of I just got to the point the saying, you know, maybe it was a hundred percent clinical commitment and you weren't given time of clinics.It was a denial when I think about us sort of decisions.I made I'm not exactly sure what they were.
I really thought out but except that my passion is still academic medicine and I love medicine, but now Like to translate it, I guess more I'm much more interested in translating it and making it accessible in general practice that I end the fancy stuff that happens, but used to be, you know, I used to love the fancy stuff that happened but I was always much more interested in the problem solving the diagnostic dilemma.
Not the treatment for less and lose interest.Once I made the diagnosis along that what I can do in the first 12 hours.Yeah, then someone else That's exactly how I feel about it.I as you say it's like a mystery that you get to solve and what you sell.
Did you get?Okay now it's pouring out bugger off because he's a video maybe maybe this is where you're at now, it's you coming back for that one patient and that's exciting.
But then maybe the biggest impact you can have now is actually helping people. will be students process and they give you can do that for 300 students a year, but through resources do that for thousands of students year in a systematic kind of matter which helps break down the challenges that are faced with diagnosing disease and passed training that process for them is that now teaching thing came because when so I really always really enjoyed working with students in the clinic.
So when I was a resident, I really enjoyed it.I think I probably recognized that the way I thought which is why I've been taught the problem-solving stuff worked really well as a scaffold for teaching but where it started really was through the what was called then postgraduate Foundation is now called the center for education and Sydney and so when when they started their distance education program Doraemon asked me to do one on problem-solving so I've been doing that for a very long time and that's where through all sorts of all sorts of reasons and Roots.
It really got honed because had to create this course which is distance education course running over a whole year with lots of resources.No alignment.Then this is 25 years ago.Dad had this sort of vision.
So it was very new to be doing it and he and his vision that the tutors needed real educational support to be able to change what they're doing because it's one thing to stand up lecture that now you've got all this material that's always going to be Reading and how to make it engaging so he in engages a Consultants a woman called Julia Atkin who was her area is education.
She was married to have it which is kind of serendipitous.But her area was education particularly primary school stuff and we worked with her for years and she was my greatest learning mentor and because the way she had she done her PhD on different ways that Students weren't chemistry either from a essentially from a problem-solving version versus a traditional version.
So what I was doing with my course, she really got and so we worked really well together, which is amazing for everybody actually everyone ever all of the tutors and there's the program for figure.So that's where I got.Well, I got a number of things one was I've got an amazing education training which I had gotten loving at Sydney as a lecturer.
The second was that it absolutely totally reinforced to me how needed it was and how valuable it was and what a change you could make for people.So when I did it I can remember the very first year I did it and I put it all together and I was convinced that it needed to be this problem based approach to the clinical signs of the knowledge stuff about intricacies of disease was just not part of it really people could Look that up, but this was about structure and but there are lots of people who didn't agree thought it's too simple and and I'm so obviously I am convinced done.
Right?And then the first assignment Canyon was from this woman in Melbourne, and it was brilliant like it was he had written her case assessments and they were absolutely amazing and I can remember sitting there going I have got this completely well, I've got this completely wrong.
People don't need me at all.Anyway, she was the best I've ever had - became very apparent that it was needed.So and so the years of doing that absolutely convinced me as the course is always sold out - and people committed all of this money to do it huge amount of time and effort and got out of the person people would tell me that I had you know the course of fate of them from leaving.
Practice night something so I became I was so convinced.It was right that that sort of drove me for but that's where I that's where it got really honed.It also became what I call my virtual practice because the participants not all of them but most of them were right up cases and I can use them and I know they've been sold in general practice.
So he might teaching I can give a case and say this has been solved a general practice.It hasn't been.During the federal Center is been sold in general practice.So you can do you can do sort of so is that is all of this culminated in your book in the clinic clinical reasoning in small animal practice.
Is that book?Is that the capitulation of everything we're talking about here?Yeah, I mean, so what it's so essentially that bought some additions from some other contributors in areas that I want, you know as strong about that book.
Came out of the notes that I wrote and store for the education course.So it's a distillation of distance education course actually has more copious notes and more things about drinking and drugs and things like that, but it's a distillation of that's where it came from.
So it's a bit like the therapeutic.I've got so clinical pharmacology swung from ecology, which is my other book that came from the notes.I wrote for the You can see when I became a lecturer and then Senior lecturer in clinical pharmacology.So I wrote all this lecture notes and here's them and I gave lectures and I went along as well put together and I think it started I did a little book for the CDE therapeutic update or something in one of the books of pieces and so from that remember, this is the little things you come out a little bit.
But it's been it's been a really slow burn in lots of ways because there are not so much now.My my analogy is that the more sophisticated Society is about smile more practice the more they actually recognize that the thinking skills are needed.
The hardest cell is to sell this not necessarily into other because there are some examples Asian countries I work with where we really Visionary people in their Association to get the fact that there's no point teaching people about off standards.They don't know how to think better on him door, but there are lots of other areas of the world where what they want is they just want to hear about you know, really fancy stuff and that's what they say is so It said it's really it's interesting because it's now it's really only now the last few years that the dialogue around Veterinary practice has really shifted to say this isn't about what you know, it's about what you do with it and how you apply it.
And so your clinic you making annual professional decision making which is another thing we focus on a lot of other city and have got you know, he's taught by this Channel and her team You know, that's now become accepted that this is what's needed and whereas before it was just all about, you know facts facts facts facts facts and having now on Sunday trying to get that across to happy happy hours and it was absolutely impossible.
I mean that's just had to give electrons to say that doing it in half an hour.It was impossible like just yeah we do right over talking.They're about talking about this and the contents of that cause I listen to the podcast the other day that you did on your on your book, but there's too much to try and talk about in one little podcast as one of the topics.
I'd love to I'd love to encapsulate it for people but I suppose they just need to read the book get the book and read it take to get to the fact what I what I what I asked and I don't know if that's just a sneaky way of asking the same question, but are they They the flip side of what you say how you should do it.
What are the most common mistakes that you see students and and experienced vets make when it comes to clinical reasoning.Well, I think I think I think when you don't have a structure to grab when you need it because I'm not saying you need a little time but know how to grab it when you need it is so the so the mistakes that I see either through referrals or second opinions that I see or through stuff.
I've marked through if it's students are a little bit different because In one way, they haven't developed bad habits just sort of start to sort of trained up.But then how what so they're the problems that they're grasping or struggling with can often be the Senate so One of the things I do in my online course, which is running at the moment is I ask um, that's you know, what is it?
They find frustrating about about difficult medical cases and it's very consistent.It's not being able to see the wood for the trees not knowing what's important.I think probably at least a proportion of cases that you see a second opinions that have gone wrong.Usually they have find the problem properly or they've overlooked something being having what we call confirmation bias really committed.
You I think it's this and only looking for the information that supports that and that refutes it one of the things I think is surprisingly common is a lack of curiosity to find out stuff, you know, it's sort of this idea that you're relying on your memory, even though no unless your medicine specialist.
You shouldn't be walking around knowing every cause of hypocalcemia, but so many vets bones. they either don't have the resources there that they don't even Google probably, you know, I constantly and maybe it's because I did a PhD in the old days where it was no online stuff and you had to go into in that spending areas and you had to go through stuff and you have to reframe your question and then you find other papers, but I'm constantly Amazed by The almost this lack of curiosity or and to have you know, I don't know practices where the textbooks that are.
There are 20 years old there what they have at school and nothing.I was this still nothing that replaces.I'm sorry.There is still nothing that replaces easily having a Nelson akuto injuring yourself there just isn't, you know, you can Google some stuff and you can Google questions that you Can I still think having and I just always amazed and they go, you know, they'll quite new bookmark over.
That's that's 20 years old.That's what you had a vesicles anything.Something's changed.And this is yes, I think falling into tracks following two tracks being convinced about something not defining the problem.Well in the first place getting very distracted by not being able to sort out a problem, you know, multiple problem case Watson.
And then here's another one hobby horses, and it's particularly evident in Australia for an interesting reason in that Australia was I think well ahead of the UK and I don't know about us government.So in having Clinical Pathology services with quite comprehensive advice at the end of the as I used to work for and in Sydney, yeah.
Yeah so dvl what used to be and you know all the rest of it and so they've got good people working for good medicine.People, you know, not a lot to look soldiers medicine people who give advice but what happens then is that then the bits don't look at the numbers and they can't interpret them selves and we've been as sort of time moved on more and more in-house stuff happens.
So there's all the issues about how you make sure qau in how stuff but then they seem to lose the ability to the never looked at the numbers.They only ever looked at the comment of the room.Yeah and And when you lose that ability to be able to assess clean pass or what I say is that in his final medicine.
The one of the absolute key skills is being able to interpret Clinical Psychology, you know, not necessary.But I told you I am told you but I chemistry and that is it's absolutely essential and so there's that and so the common mistakes I see is either ignoring something that's massively change, but it doesn't quite fit what they're thinking.
Well, then tell him this value that's one point above the reference range.Must me, please.I had one last night where it said, you know gamma GT was 15 a reference range was not to live inside have conversations and not really doesn't you know, so there's a sort of there's a mixture of things actually visit me anymore one thing and I think the people the structure helps some of them to you know, stop those traps to remind them and the other overarching one is where people really struggle where I see people really struggle is because they don't know the physiology but I can't do that.
Well G, so then they really Always and so that the area that really challenges everyone particularly Israel.Okay.Okay, that's interesting.So if you said to not defining the problem, do you mean literally listening to the history and then and then barking up the wrong tree?
They chasing the thing that's not important and then they is that intentionally important can be you know, so I mean the classic example you give is that the owner says it's formed.Team that actually it's regurgitating or is that it's constipated.
So not taking that first step to say what so that's part of it, you know animals that have bleeding lesions that have been worked up as being a local Asian when infected but bleeding disorder Define the system thing.
Yeah, it's a mixture mixture.Did you think that you know nothing even if this is a possible thing to answer but it could you give us like a short summary of the process of some people may not be aware of programming.It's like I will get whatever you need that was part of a process we develop problems be trying to find what they love most localizing problem was and but there was a true problem or not.
All the students are involved and then from there like what diagnostic tests to consider too?Best to get that program and then from there generate differential summer between all that yet.But is what would like you distill the process down some more?
Well, I'll tell you what, it's not and I think this probably helps.So what's a very common approach is you know, these days most people know that problem list, although it's surprising when we see when I see people who are reflecting on having done this to do we give advice for any practice which is kind of like the memberships and they reflect in their part of it on what they've learned so many will say, you know, I really learned that creating from this is important, but I think one of the really common thing that happens is that The clinician might say to the students.
So what's your problem is to this case which is ok, which time and then I'll say what are you differentials?And really what that is is its pattern recognition is saying what disorders do I know of that will cause this pattern of clinical science, which is absolutely fine.
Sometimes what's the times as long as it's not at all?And so what the problem based structure is that you asked a couple of really key questions.Ashes before you get to that differential it's just okay.What's the problem list and on that problem list?
What are the important problems that are going to be?Mine don't have to cook.I'm going to use am I sure I know what those problems is, you know, is it family's reputation is it from these of seizure, you know, all of that stuff and then usually sometimes Christian little bit what systems involved how so do I have a structural problem of the body system or do I have something outside that voice system where the body system is just Messenger for the clinical sign and that's really important because very often structural problems of the body system like the guard or the nervous system or muscles.
They you have to image them to find out what's going on.Whereas if it's secondary.It tends to be blood test and all that sort of stuff and you know, given the fact that the most common clinical signs we see in practice of vomiting and Diarrhea, it would be the most common in each field then, you know, if you get that right for you get the vomiting and diarrhea, right?
He should have most of it will fly from that if you get into your head, but just because the other of course the other common mistake is for the daughters coffee has got a heart instead of I've got a dog that's costing does that mean it's got primary screwed because these are secondary.
Thank God all this coffee has got a heart murmur.It must be happy.You know, I've got examples because let's say we use this one's for student teaching where the cat comes in its history of current Ginger restaurant eyeless.
That's responds quite well steroids.Normally the only usually know this is the cats having a problem because he stops eating and he starts to lose weight comes in its truest Bureau isn't fine.This time comes in and she notices losing weight, but you're still eating fine.And what the what the Procedure was that he then had all his teeth taken out.
So he comes back and he had his sister taken out and the owner says well, you know is now fine now, but he's still eating and he still goes you make me turns out to have higher authorities.So that's sort of not defining the problem at the beginning because the problem at the beginning was weight loss despite a normal appetite which is very good for weight loss because either can't or won't it and I think one of the things that the students sometimes they I honestly think I sometimes think it can't be this simple.
I think they think I'm tricking them but it's has to be more complicated and it really isn't.Okay.This is going to be cases that don't it doesn't work for it's always the way it's an awful lot of the time and it takes out, you know, one of the things I'm trying to kind of promote at the moment is that given all of the issues around stress in your graduates that you know that Stress that new graduates undergo and their challenges with decision-making practice, you know some of the stress.
Yes, there's all sorts of other issues as well.But some of the stress is is because they they don't have this framework.And so they're faced with this.Oh my god.I've got to remember all the differentials for this right.Now what's going on?I'm trying to say is if you practice this approach it happens with quickly.
And so you can use the rest of the console to worry about stuff.That's always going to be difficult.And you just go and sit and sometimes it doesn't work.Sometimes all the rules.You know, I sometimes the guidelines you give about with Pharmacy coverage no disease in the course, but I'm running at the moment.There's absolutely classic case of a cat that presented there's been a bit off its food and it started vomiting and so you really was definitely vomiting you really can't assess whether its primary or secondary Joe disease and won't include the satisfied.
Everyone said don't know and it turned out to have so when they did Glides it had this massive changes liver enzymes.Resumes up and blah blah blah and I actually but it turned out to have and neoplasm in its duodenum that was blocking its garlic.
So it was an example of primary gum disease created secondary gum disease changes now, that's really unusual to like really unusual for Knox a little bit a case like that which you can explain but a case like that put you off because that's really unusual.
So it's in that I'm not saying actually like it if I could unexpectedly good questions to ask but also gave us classic examples great examples of how to use that as well.
So Very good get caught up on so that that for me can't summarize these bite marks the eyeball.It's lovely the things that I say is if you don't ask the question then had to get the right answer and what I see and I guess when you go back to what you were using for give ER what common mistakes to study and I see this a lot in countries where there's more training has been very very poor or non-existent trying to learn all this stuff on there. very shaky base hits Is that in this book is also happens in Australia is they're very driven to do something without stopping to think and when I talk to ECC people like you guys and you know in a sec you got to do things quickly, but what our assisted people say is look if it's going to die in the first five minutes going to die.
Anyway, so thinking, you know just a little bit about defining that problem in obviously and sometimes you're moving into you're doing your generic.I've got to say this Animals life bit while you're thinking about so what really is going on, you know what's happening, but that that drives to do something without stopping and to give drugs to give something but I see that a lot in countries where their education is really pores that are trying but there's this relationship with the client with a client expects them just to do something, you know, and just give you drugs and you go home.
Stop and think about what's actually happening - example about the exact details because remember the exact details, but sometimes getting messages from people in other countries.No just family the history and the results and things like that and then and then compile that they will also put down all the medications.
It's on.Yes, like what?Do you know be treating ya?And I know that's a lot of things that it's like two different medication summer natural summer, not natural and like then the comes Jack and so sometimes I reply back in.
It's like what diagnostic tests partner?What are you trick where you actually are?Yeah, so I think I think certainly with medicine is that where errors lies in not taking the history property?
There's certainly you know, there's so many times where I'll get a vet who describes a case to me and says this happens in August to it.And I think this seriously doesn't make sense.It doesn't make this can't be right.You know, it just something's missing here.You've missed something.
You know, there's something in the history of Miss something in the physical exam.It just doesn't make sense.But so that history taking this which is where the problem solving approach really Is a framework because it means that you if what you're guiding your guiding principle is I need to Define problems know what they are Define the ones that need to finding and think about what systems involved and how that structure is your history taking so you don't just walk away saying, ah for dogs watching all the dogs got diarrhea or whatever you it makes you get enough information so you can say I'm happy.
It's one thing or G2 absolutely fine for a week, and it's Upon meeting today in this is bright happy it's going to be property overseas.So it's that history taking and if I think of the number of students who have come out of the console come back to me and said the dogs already.
I'm happy.It's forming.That's great.What's up, but I don't know.It's not easy and I'll say when did it stop eating?I don't know but when it stopped eating is hugely important in how you were because it stopped dating a month ago.Then that's a very different deal than if it's You know been vomiting for a week and it stopped eating yesterday and that's the reason why people for him so it's that recognition that and I suppose one of the things that it tries to help is we're all absolutely prone to taking notice of what we think is the most important problem and forgetting about the stuff that's around it.
But the stuff that's around it is often got all the clues about how you assess bands.Some of some of my biggest complaints have also been noticing all the important stuff but they're forgetting about what the owner actually came in full.
So you get those cases where they come in for a skin problem and then you find that find the tumor and you do the surgery to fix it and you're a hero then goes home and it's still itchy and as it but you never stood very scared.
You know what?He will say to the students.Is that what when you say Define the problem one at one way you can interpret that is what is the owner really worried about ya advice that comes under consultation models that you know that the golden three minutes just letting them talk and just finding that.
Because it's so and you know it but it's tough, you know, so 10-minute consult side over here, you know 15 if you like it which made my argument is you've got to be even better a clinical reasoning The Specialist.You've got it out.Mmm-hmm.
Yeah, you still you do practice at the moment a couple days a week Jill said right you will have half a day at our first been in practice here are trying to deliver to its and I do one Saturday a month at a local practice.
I used to do every second Monday evening, but it's just important to do and I think that's still challenge you surely by now, you surely you know, everything.What do you still find challenging about breakfast with its clinical and non-clinical?
So eyes always challenge me.I do the programming for London vet show and one of the things I say, which is new territory that is that the way I program it what can what certainly influences my programming is what terrifies me when I'm there morning and something comes in and I think or if I had to do it, you know, so and because I run the CBD unit here and I you know, seeing what works and what doesn't.
People want you know, I'm more and more convinced.It's some positivity.I'm not saying all of it, you know, it's not the only but there's still an awful lot out there of just really wanting to understand the fundamentals of things also to understand advances for sure.
But you know, we've had people come to our cause we run a course pretty much every year on the exploratory laparotomy and we say, you know, this is the Expo You have brought me practical course and it has topics like oh my God.
It's a big fat bitch spay or the evidence for blood whatever so it's really fundamentals of abdominal surgery and it is a most popular surgical course and we have people come to that who've been in practice for 20 years and learn, you know, better techniques about tying off a very pedicles and things like that.
So, I just think when you're in practice, you've got to deal with so many body systems and so many things and Specialists lose sight of the fact that they're only dealing with, you know, one thing you know, and and when you're in practice you're dealing with, you know, I'll see a wound and I'll go gosh is this going to heal is not going to heal.
What would what would make it not heal, you know, so that's kind of where as you know, if I say dog has got diarrhea.It's fine.You know, it's not a problem, but there is stuff.
Yeah, it's funny you say eyes so why my career started in general practice because I wanted to be a dairy and Veterinary that its Moorings where I have loved the idea of cattle just nice to work with really a dairy cattle.
Yeah, Green Hills and so forth and end up becoming smaller practitioner and I do learned a lot of stuff at a certain level.Like I wasn't good at managing any pain is presentations of common diseases.
That's very extroverted.Yeah prefer to place that actually work at now.But what I did do those I tackled a lot of skin ears and eyes and so forth and more of my colleagues who went straight into emergency.
Is terrified of skin eyes?Yeah, it's TV is out.It's like we're doing the skin eyes outside.Yeah, that's six months.She would tackle.It's interesting and you know, I don't think it matters how long you're in practice.
You'll still see stuff that you go.I have never seen this before - no never said before this is My Achilles heel is neurology.Like this is the vestibular disease.I've got that.Yeah.
It's but if you're reasonably comfortable about what goes wrong, you know, localizing your lesion, then you find when I was at a meeting in Sweden a couple weekends ago.One of my colleagues from here was a neurologist was there as well and I was doing some stuff on clinical reasoning and the whole day was more on mine stuff, you know stress and learning and things like that, but he did and I've never listened to his lecture, but he he's got his anus.
To spotless mirror and Soviets and he just gives this really lovely lecture and and holga folk whose the co-editors of the book he developed a structure what she calls the five finger or which is it still defined the problem and system and location, but then the five finger or really helps you in deciding and leaden.
It really makes a whole lot of sense and I think one of the things about neurology is that you get this feeling that you supposed to do this amazingly complicated neurological.But actually, you know what?It's sort of obviously, you know, what's the proprioception like do they have proprioceptive death their desserts, you know, is there any virtualization you can do a bit of reflexes.
I can never remember the cranial nerves.But you know, if I saw that there was something different I've gone walkabout and then it's goes on came along comes another where it is then when is it painful?Is it progressing is it much lysing?Is it is it resolving?
It kind of really helps you narrow it down.
The feeling that you have to do 14 steps of a neurological exam can never remember the planning session.
It's very very valuable.If we think about who I'll let Gerardo deals a lot with with younger younger younger vets or which students and the people we interviewed before there's a major concern.Is that feeling of never know?Everything I never I don't know enough and then to hear you say that this stuff that scares you and it's not it's I think it's a nice message to say to people it is there's always stuff that's going to scare you and even if even if your job better than you won't know everything but it's not as I try to put it in a context that you know, one of the things I say about the problem solving approach that we teach is that I mean left and right brain stuff is kind of ending.
Crepitus couldn't sort of but I still think you've got an emotional side of your brain which can be really activated when you're stressed.Even if you're not normally an emotional topless and see really activating this dress because you're stressed about what you're doing is just about the client and the client stressed how there's a whole lot of emotional flying in that difficult consultation for whatever reason it is.
And if you have a structure that you can say just grab onto that ladder that pulls you into your problem solving.Bring that takes you away from that emotion you go.Okay.Well right in one of the shows fine and show them some day but there's a slider show students the lectures and it's a really lovely need to find out where it's from is it's a staircase somewhere here in the UK to University and then it's got a quote which is Martin Luther King is saying it doesn't matter if you can't see the end as long as you take the first step and it's got it on the staircase and the me.
Being able to say okay, right?Let's just find a problem.That's what do we got, you know cook it in.This is let's just make sure we better from this and grabbing onto that ladder to me is that an analogy for I'm in this soup of stress can grab onto this and kind of pull myself out and then at the same time it helps you communicate with clients so that your be clear about, you know, you know the sort of consultations skill.
You know you get taught about signposting your sign hosting is who right?Well, I'm just going to end it just I think helps with that.Absolutely of the easy yet a ladder.It's like it's a receptor a recent.
Yeah, then it was the dividing line is little by little the thoughts because as you go through that ladder and as you talk and as you kind of reason then things start to solidify, but yeah, it's just it's you know, when you've got Google all the time.
So I saw a dog on Saturday and it's a little cute little Six-month-old Maltese but his head to acute in size of right falling - I hate - that's really quite much rightfully - that really seemed to me through relate to the Schulman.
We're coming from one completely closed in the snow snow is this week and I was thinking to know if you were a labrador, you know, I'd be worried about OCD or something like that.So then I Googled You know what Breeze get OCD.I don't know.And of course for me agrees come up some going.
Well.It's malteaser probably isn't but I still think if it happens again under this dogs just feel around like English crazy, but let's just cut you just can't mohel mean I'm particularly what I've never been very good at what breeds get what and because partly I've under a train myself about it because because that can that can really that can trap you in a pattern of so I I've got so far the other way actually so I'm really bad and knowing I mean something it's a please.
Okay, so it's something like that but but I try to train myself a lot to do that, but sometimes that means lets me down so I don't think I like older dogs come through like 12 13 year old dogs come through and they've had a collapse episode at home.
And there and they come through and then and for me it's almost like you know the man, you know, like it's kind of like it's a pattern that sniffling times Edition.Yeah, he members you see boots guy like and he mounted into a differential list, but consider, you know, these are the thing.
It's like you can use some punk pattern matching to help shortcut, but it's not it's as you said, yeah, it's not to get trapped down and this is what it is something else because otherwise as you said before you get stuck, it's not that When you go next you have anything else?
Yeah, so you are doing that which can be to the detriment of the example.We took that yesterday was about you know, the dough through its entire female dollars and well blah blah blah blah blah, of course, you've got a pilot on the list, but if you go a little higher and don't see that anything else and when you can't find that pie over your image, then I know you'll Stop going.
What is that or your sometimes?You take it too far and it goes to surgery and it's normal.So yeah, it's kind of a I think it's a I think it's a safety net in and it was interesting because after that talk yesterday one of one of our students I was talking to him about his experience in the u.s.
He said I really work for me because I saw this dog and it presented and it was vomiting ahead of Donald Payne analyst bourbon snap.He'll I was before but we don't stop there.And with the pancreas was normal and students is if it was really stopped and said but I'm sure it's pancreatitis and the student says I use a problem-solving framework and said well, you know, something's going on Tommy's her solid primary or secondary GI disease.
So let's and make sure that the guts look okay and some other organs, but they seem to thinking was there whereas the vet was kind of.Oh my God, which is also knowledge thing not all dogs have been retires will have any longer.Yes, just so it'll be fate. to say with pattern recognition because it's Gerard says it's handy because it's it can save you time but instead of fat and recognizing and saying okay, I need to go and Prove that it's that to rather change your frame of mind and I'm saying this for myself now to say well the first thing I need to go in to rule out is that so you see you'll see you'll see a classic him abdomen and you go.
Okay the first thing I need to go and rule out not prove this proof is an amendment and then you scan is got yes it is.Okay, or if it's not then you go.Okay.Well, yeah, that's a good one.I'm not really fond as a rule out system, which means you have tended new rules about but absolutely you That difference between I've got the collapse dog.
And that's a German shepherd and his pale.Therefore.Of course I've got a collapsed dog for coming is membranes as an era poor perfusion if it's an emu bleeding or humanizing its German Shepherd.My first thing is that it's bleeding.It's a he my abdomen but I've actually just said it's him lysing or bleeding.
So if I can't find that bleeding and immediately I'm ready to go is a humanizing. but when I do that when I do that Case using turning-point, you know Anonymous voting quite a quite understand either people who will say my first thought was that had whatever and then when you say those people find out how you're going to explain the Molina and a woman will deliver but I've had some people I've had I remember one person or one of course is going but I saw a dog like that and it had he'll ever wake it up.
I know I of course, but this dog deal, I promise you it didn't and it's a fight.To you on the dog, and there's and then I've got another dog that I use again real one which has PPD and is unwell and it's an unneeded female and it's been a while for a few 10 days or so.
It's got a bit of diarrhea and things like that.Anyway, so course for what is it?Is it higher fine?But I have people get really upset with me and say but that dog whoever python ago.Yes, but it didn't, you know, I don't mind.I need to make sure of course, you know, even if the merest whisper of a possibility you want to rule it out because if you miss Italy, but you have to have the backyard because otherwise you then you have the potential to take it too far.
How we going for time till or we don't work I could talk to you all day.Can I ask about books?
Have you got any books that you recommend and they don't have to be clinical even if If it's another book that that really helps you or that you that you recommend people read.But I don't but I would like your opinion on the best clinical books as well as some point of view.
So I'm just doing medicine.So I always have the latest edition of Ettinger and of Nelson Cruz.Oh, so that's why more medicine and I like Nelson akuto because it I just like the way it's laid out.
I find it easy to find things are quite like it is but I like it.Enjoy.Because if I want to read up about a disease, so I tend to within to use it and go I now need to read about ecstasy is just to see things for the whatever it just not as strong on path is it used to be which is a bit of a my joy, it covered covered so that from from it's interesting.
I mean this little books that are read a book called street lights and shadows and that's what it's called and it was about how the decision People make decisions and you know, there's that fast and slow thinking what we're trying to confess.I haven't read and I think there's things about that that I quite liked, but I have to I have a terrible confession to make you met I was asked to write a chapter in a book that was published.
Last year in 2017 coming up on Veterinary Medical Education advisor friend of mine jihyo person and a colleague of hers in the states and he asked me to write a chapter on clinical reasoning we're teaching him breezing and I said I'm going to do this and then I thought I better read the literature because I never read it.
Never been informed by the literature what I do or what we do and so And I've always been haven't really like that educational literature can't really understand some of it and you just find it.I find it quite opaque and difficult to get into so I thought right.
Well, I better now I really need to I can't just say stuff but a reference it and what was what was really interesting was that?I think it was a matter of time but everything I read about just supported what we were doing.But if I'd written literature ten years ago, it probably wouldn't have like it's really evolved to recognizing your processing and a combination of cataract if your light source there's arguments and what's more accurate, but I don't think it's relevant.
So I found it quite good that I was able to find maybe it's confirmation bias and we'll just Studies that sort of supported what we do reasons why what we do because there really isn't anything out there it was that tells you how to adequately analytically reason they just talk about analytical reasoning and say that's what clinicians do when pattern recognition of the work for them or they're faced with something unusual.
You know, there's stuff about how doctors will be talking where they're seeing a common case and as soon as they see something that's not when they stop talking because they're sick.They're you know, they're talking to the students are thinking more.Analytically.The thing that to me we've been able to do is to just provide a bit of a structure about how to enter clear reason because before that all it really was was identify the problems and think about every single differential that goes that problem that just doesn't work.
Well differentials bombing a quite time Hank exactly.Whew?Yeah, I love catamaran.But that's that's all about feminism not about some reason should have to be clinically any books does is that it doesn't have to be clinical.
Who was that?I missed the name Caitlin Moran.She's a right.Okay, okay how to build a girl how to be a woman and she writes in the cellar.Times a column and she's just incredibly funny but really insightful about, you know gender issues and stuff.
I just I just really like it because she doesn't take herself too seriously, but she's really serious, but she's very very funny.Well, it's not like it's awesome to share that because 90% of people with disabilities.Thank you for that one right in Toronto.
Anything else one other one last question.Ali and then we can ask those other questions the shorter ones but I always get asked Should students go spend some time to practice.Should I go straight into what they choose to do based on what they see and love or should it go to a rotating internship like yeah.
Okay, so which I think in the circumstances line because at that time was a mixture of General a And we felt that these are lots of us have things done.
And I also at the same time but I would strongly recommend that nobody goes straight into an internship.We won't our well that's very unfair.So here we now will not take our smaller in terms of Greater physical there for two or three is the equine per Farm ones member and I think it depends because I think it kind of my sense is that I'm not experience my senses that the internship is more of a kind of here's another year to get you structured and if they're interns like that, but I just think to get the most out of an intern shit what you what I always say is you want to get some of that just basic stuff under control you want to be able to get a vein you won't be able to put in a catheter you want to be able to move that want to be able to you know, how to talk to clients, you know, just get that stuff and then while You're doing your internship.
You've got the more capacity to learn the stuff that you're there for your internship error.Our interns here kind of run hour after hour service.So it is important that they have some smarts on board and some confidence about being able to do that.
But even so I think and then I also think longer term that that not having been in general practice ever.Makes you not as good as Specialists because it makes you not aware of the challenges that you face in general practice.
And I think it makes you you might be a reading specialist and you might you know your experience in small animal practice and in general practice, then really informs a better understanding of what everyone's out there facing and I think one of the things we're Specialists can become a bit arrogant or whatever is to avoid.
How did this happen?How did it get to be like that?Why not enough now that by the time the animal gets to the specialist all sorts of things change.Yes, sometimes there's been it's gone terribly wrong, but often things have really changed some things become a lot more obvious, you know, the clients behave very differently with the specialist and they did with the with a general practitioner.
They allow for they come with a different mindset, you know, there's a whole lot of things so I think having that experience in general practice and from the point of view of if If I'm looking at for people who are going to either teach our students or lecture the general practitioners, I want them to understand those challenges.
So when I remember Vette show, you know, I say to the lecturers you might be a top of your fuel but I don't want to hear about that.I don't want you to tell me what cool stuff you do because that's not really of Interest.What I want is you to be able to use your experience and your knowledge to help practitioners do the very best.
Best job they can do in the practice and that doesn't mean just referring to you so much.Most challenging lecturers a ton of it show have been those who stood up and said so beyond this tiny bit.It's all really complicated.You should prefer and then that's not real.It's can't do any other stuff as I could that's the best answer to that question.
It is an excuse and it's just like Jewels lectures always oats decisive is that you listen to what I said at the beginning You walk out of that lecture, you know exactly what you need to do.We don't believe wrap up with with the one with the word question.
So you're at a Congress and you've got all the world's veteran a new graduates in a room when you've got two to three minutes to give them one bit of advice.What would you tell them?Ha ha ha ha should have warned you it this way.Well, it's what I'd probably what I always put so for our for our yearbook here over finally is we're just going to find find Define the problem.
Honestly, honestly truly knowing I know it's an if you define a problem so might the analogy that I give is that if someone brings you up your friend Rings you up with your partner and grew up or whatever and they're crying on the end of the phone.
I'm crying, please don't lie.The first thing you ask is.What's the problem?So if you can Define the problem everything for even if you don't even go into defying the system things is to define the problem and Define the problem would be so if I had to destroy minutes I'd say listen, listen, listen active listening and as the guide to that what you're aiming to do is to as the start is to define the problem be the animals problem or the clients problem.
Or both so she really good business advice to the amount of times where you're tackling some kind of fire and you have this idea about what the problem is, but it's go with something completely different.I like that was really good.
That's great.That's a great spot to end.All right.Thank you so much Ellen.I'm honored there was really lovely.I think that can be very very useful for a lot of people.Thank you so much.Thank you for inviting me.
Thank you again to Joe.What a legend now.Let's see what we what we can apply I have to say and this is just a thought that struck a chord with me personally, but I like what Jill said about not doing something because it seems too hard and that maybe that means that you don't really want to do it for a very long time.
I wrestled with the idea of specializing because it seemed like the sensible next step in my career, but I always had a hundred excuses why it's not a good time to do it and to be honest it just You hide and to hear Joel say that just brought home to me what I'd probably realized a long time ago.
I clearly don't really want to specialize.Otherwise, I would have started a long time ago and it's actually quite a released to say that you know, I don't really want to do that thing.I can let go of that idea.Is there anything that you struggling with that?Maybe you just don't want to do Jill talks about defining the problem and how to do this you need to ask and then you need to listen then listen and listen, but many of us don't know how to actively lose actively listen.
So here's a quick guide to active listening in case you haven't heard this elsewhere.There are at least five kinds of listening when we talk about active conscious listening.So the first listening to disagree this involves identifying words phrases, An idea is that you use to disagree with the other person you're listening to clearly not helpful listen respond or record.
This seems on the surface near very helpful form of lips listening.However, it diverts our attention to our own thoughts experiences and stored memories finding a helpful question or suggestion might seem appropriate but what often happens is that the clients thinking progresses as they talk making Our intended intervention obsolete before it is even voiced.
So also note that taking notes as the clients speak is also - distracting for both you and the client listening to understand now we're getting there here you focus on intent.What is the person trying to stay and why what avert and hidden implications are there fourth.
We have listening to help the other person understand this goes a step further in that it shifts your Meself to the client here.We help the client become more aware of their own thinking processes and the meaning that they attached the words and phrases including the emotional responses that are affecting their behaviors and decisions.
Finally listening without intent the same Sue's simply to support the other person in the conversation that they need or want to have with themselves with minimal intervention.This is not necessarily appropriate in a Nicole or consult setting but it's still a good goal to aim for with relationships with your colleagues or in some areas of your personal life.
So here's what we need to do for the next week when you are in a conversation be aware of how you were listening.Where do you fall between levels of listening from one to five and then try to aim for the next level up?And that's it for this episode.
If you liked it, we'd like a five-star review on the iTunes Store or if there's something else you'd like us to talk about get in touch hit us up and then on Instagram or click on the link on the episode to find out how to get in touch now get out there and go smash it.

Prof Jill Maddison