SPEAKER_01: 0:00

Welcome to another episode of Beyond the Clinic, powered by vet specialists from the American College of Veterinary Internal Medicine, ACVIM. ACVIM is the certifying organization for veterinary specialists in six disciplines, cardiology, large animal internal medicine, neurology, nutrition, oncology, and small animal internal medicine. I'm your host, Brendan Howard, and in this episode, we'll be diving into a topic that every pet owner and veterinarian might want to know a little more about. Building a strong referral relationship between primary care veterinarians and board-certified veterinary specialists for what? The betterment of pet health in your area. Today, and for the next few episodes, I'll be talking to high-energy primary care veterinarian and radio host turned podcaster, Dr. Michael Tokiwa, owner of Progressive Veterinary Care in Skillman, New Jersey. In Dr. Tokiwa's neck of the woods, he is swimming in board-certified veterinary specialists and specialty veterinary hospitals, so he's got some firsthand knowledge of how he and his pet-owning clients interact with... learn from, and get the highest quality care from these experts. So that's why he's shocked, shocked to hear something about specialists from a radio show guest recently.

SPEAKER_00: 1:31

So I'm sitting doing my radio show and it's student run. And I'm talking about medically related products and services and all the things we do. And the student literally asked me, you mean there's an eye specialist for a pet?

UNKNOWN: 1:46

Yeah.

SPEAKER_00: 1:46

And that just hit me like a lightning bolt. And I immediately got on the phone and started just cold calling referral practices saying, Hey, do you have any specialists who would like to be on my show? And you know, our vets are introverted, right? So it's like, you rarely get these people, but I got lucky again. I got people on the show and I get to know these people. I get to know the place they're at. And I just started networking and networking and networking. And then I got to know so many specialists at so many different full practices that. I'm in a situation where if I need to refer, I go, I'm going to send you to my friend and I am going to text them right now. It blows my mind. So you're kind of in that

SPEAKER_01: 2:23

mode to gather information and build relationships with them. But you mentioned at the start, you're like, these specialists are just like all these other veterinarians. They're kind of introverted and they don't, they probably don't make a big point of networking with all the vets around them like you did. What can they learn from the steps you did that you used in that process to build these relationships?

SPEAKER_00: 2:42

So my icebreaker for anyone on the show is what I call the vet origin story. How did you get into veterinary medicine? How did you get to do what you're doing now in veterinary medicine or in the pet world? And so I get a life story. One surgeon goes, my mom's got a videotape of me in the 80s at the age of three saying I want to be a veterinarian. So you get these origin stories and they open right up. And the other thing is, is I make it a communication. It's literally like me and you. We're having a discussion. And that's how I preface the show. I said, listen, let's have a discussion. And subject matter is going to be something you're passionate about. or you want that message to get out there. So you are the master of your world and I am merely a traveler and I will interject with questions. And then we develop this sort of rapport within five minutes. So I have a

SPEAKER_01: 3:32

question about that. So I agree, you're brilliantly building these conversations and brilliantly building these connections with people by asking them about themselves. Is that what you're telling? Like if there's a GP out there or a specialist out there, it's like, I wanna build a better relationship with the vet. Does it come from... I want to sit down over coffee with you or I want to go get lunch with you. And then I'm going to ask you your life story. Kind

SPEAKER_00: 3:54

of. So it's ironic because I went to a talk by Prina gave this talk and I was invited. I don't know why. I really like my rep. So maybe he liked me. We went to the talk and I brought my new associate and I'm sitting there and I don't know anyone there. Typically, I don't know anyone where I go. I ended up knowing one person, but I just started circling the room. I would sit down beside someone and And I go, hi, how's it going? And I introduced myself. And believe it or not, I'm an introvert who, well, people say I'm extroverted, but I feel like I'm an introvert who forces myself to be an extrovert. And I force myself to, as I think many vets do in the exam room, they are forcing themselves to be an extrovert. They really don't like dealing with people. So I, I just put myself in challenging situations. So I'll go and I'll sit beside someone. I don't know. And I'll just literally, as I tell my, I tell my manager, I'm just going to go shoot the shit with that person. Right. As I go over there. And so I introduced myself, I just asked them questions and then I let whatever keywords come out of them. I just follow that line going down and I get to know them. And my associate said to my manager, they were watching me because he He just talks to anyone. But it's not like I want to go in there and do that. I want to be like every vet. I want to go in there and sit down in a corner by myself and do it. So I think it's very important to face your fears, to do that hard thing and make that connection because that connection will become a lifeline. If we're going to take this from a referral to GP issue or concept, that little relationship becomes a humongous lifeline. I can't tell you how many times I text my friends what I consider a fairly mundane specialty question. And to them, it is mundane, but to me, it's, you know, the book of God comes in and all these words come out. And so I find that these lifelines are phenomenal. And the other thing I found, which has to do with everything in vet med, I used to think we were two degrees of separation from every vet in the world. The more people, the more vets I meet, we are one degree of separation. Every vet I meet knows a vet I know. Every time. I tell the young ones, I said, you know, it's who you know. Well, now you're making me think. Let me go back to my childhood. So my dad, I had all these uncles. One uncle owned a appliance store, TV store, Uncle Yash. Uncle Stan ran an SO in Canada, Exxon station in the States. And he did all of our car maintenance repairs. My dad also knew painters, everything, Uncle Sam, Uncle whatever. I had all these uncles. And I never realized the importance of that until as an owner. It's who you know, right? And so my network doesn't just exist with vets. It exists with anything. And so I always offer that. Anyone I meet, I say, listen, if you need someone in any way, shape, or form, I may know them. I'm talking financial people to vet people I meet. You know, it's everything. I think it's all about networking because that is how life will be better for you. You will have those connections. You will have all those resources available to you.

SPEAKER_01: 7:00

This stretching yourself is like, look, I'm an introvert. I get it. I want to sit back and just deal with the pet. I want to do the science. I want to do the medicine. I don't want to have to go to that meeting where I don't know anyone and go around the room, but I will. I'll push myself. Maybe somebody's done that. So maybe somebody's thinking about us and they're thinking, I do know specialists in my area or know specialists online that I can reach out and just... Again, break the ice with them. Ask them a question or like, would you tell me more about this? Could I get some time? And veterinarians, as you know, will be often very free with their time to talk to you about stuff if they have time. What about the ongoing communication? So you break the ice, you establish these kind of meaningful but small relationships. Like they're not your best friends. They're your colleagues and you know them. How do you maintain the connection with these people when it comes to cases and maintain the connection with these people? You met somebody a year ago and you want to ping them again. How does that work?

SPEAKER_00: 7:50

I always feel the direct approach is best. So what I'll do is I'll actually call the referral center and I will say, I understand so-and-so may be busy. Do they have a voicemail? Okay. And nine times out of 10, I do have one that doesn't have a voicemail. I understand why she is phenomenal. She's been in the industry forever and she's probably in a day. So she didn't have a voicemail, but I got her text number, so it's okay. So I will leave a voicemail message. That's how I break the ice that way. And I want. it to be very relaxed. Hey, you know, it's Mike DeHua. We met a year ago, you know, and then that connection will be made. And I say, listen, I would love it if I could send so-and-so to you. You know, this is what's going on. Or I have a question about a case. And as you said, vets are very giving, very giving of their time. But I find that that Voicemail enables them to, they'll hear it and listen to it when they have the opportunity. Even the people I do know well, I do not like taking them out of the exam room process. I would say, listen, I know they're really busy. So my second best approach is texting. I text because again, if they're free, I'll get a text response immediately. If not, I fully understand. I usually get a text response several hours later, worst case scenario the next day. If it's emergent, I've already sent the pet and I'm just letting them know, listen, heads up, sending so-and-so, blah, blah, blah, records will be sent, everything like that. But I do find that in today's social media world, and again, I think it's really important for young vets to break that fear and have a direct communication.

SPEAKER_01: 9:22

even though they like to just make it look, I know the person's we'll send it professional. We'll send the case over, but you, yeah. Having some one-on-one, even though you don't want to do it, it's not your favorite thing.

SPEAKER_00: 9:32

It's a good thing. And I do, I do think that, you know, because there's nuances in a communication and there's things you can say, like text will not say, Hey, listen, this, this pet is their baby. So I can say this pet is their baby. What does that mean? Right. But I go, listen, This is their baby. And then I'll add things like, you know, no kids or this pet belonged to their late husband, their late wife. This is incredibly important. And so I get those nuances through.

SPEAKER_01: 10:02

So stuff that doesn't show up in the, yeah, stuff that doesn't show up in the medical record, this is about the stuff you gathered by listening, watching their body language and listening to them talk and ask them questions in the

SPEAKER_00: 10:11

exam. And even like, hey, this is my best client. Like I have this client. She's my best client. I literally tell them, well, now all my clients colleagues, they know she's my best client because she's their best client too. I mean, she will do anything. I'll listen. I'm sending, you know, I'm sending mini. She's my best client. And so I think they get a sense of relief because if someone sends their best client, I trust them enough that their best client means they're a good person. Best client is all around cares everything. incredibly listens to your recommendations. And as a result of that, yes, they do end up spending a lot of time at your practice, which then leads to more revenue. But man, it's like, if they're my best client, I will do anything for them. And I want the best for them. That's why I'm sending them to you.

SPEAKER_01: 10:53

So you already know the people. You've made contact with them. You've talked to them through the years. You've sent people to them. Can you think of a time where the fact that you had a good relationship at the get-go made a difference in the outcome?

SPEAKER_00: 11:04

Yeah, well, actually, here's the irony of it. I didn't know them well. I didn't know the client well. I knew the referral well. Second opinion, Cushing's case. Told dog had Cushing's, started Cushing's med, crashed. We repeated the blood work. We are in the gray zone. We have no clue what's going on. And Cushing's disease by itself is a gray zone disease in my mind. So I call up my go-to internal medicine friend. Pete, listen, man, I don't know what's going on. I don't know these people very well. They seem really nice. They really love their dog. They are frustrated. They are frustrated. And, you know, I'm literally the middle person because I'm thrown into this scenario. I guess I'm the new guy on the block, right? Here's the novice, right? Throw them in. Like, oh, yeah, okay, okay. Don't really have a lot of records from before. Know what's going on, kind of. Am I lost? And I send them to Pete. And so again, Pete's got the best bedside manner. He's a genius, lovable guy. All the reports back from clients are, I love him. I said, I do too. That's why I said them. And he got to the bottom of this. And so now it becomes a shared case. The beauty about knowing people, so getting back to making those connections and networks is I get a response that day directly from the specialist telling me what's happening or what's going on. And that is huge because then I'm fully aware of what's going on. Again, you get a report. And in a lot of cases, you don't get the report same day. Takes me a while to write it up. And words don't tell me anything on paper, but talking to an individual does. And then I can go, okay, now I am confident that I could totally talk to the client and go from there. Yeah. So that's, that's a case that is, so we are not treating this dog for Cushing's. That's what I can tell you right now. And the clients are incredibly happy. It's a monitoring situation, but it's something that was beyond my scope because I agree with their first vet. I would have said, I think we should treat for Cushing's, but it's a case where the specialist has that knowledge, that experience that they're saying, listen, these are these rare cases that we get, and this is what we do.

SPEAKER_01: 13:11

I think you're also in the very beginning of that, saying, I'm the new kid on the block. Look, I'm brand new to this. This case dropped in. I don't have the previous stuff. I don't know what's going on. I'm not an expert on this. This is going to be tough. So also admitting, you had kind of self-awareness admitting vulnerability. It can also be hard. A GP who's trying to be a master of their clinical practice, at their veterinary practice, you can always feel a little uncomfortable. insecure about the massive knowledge that the niche specialists have about their stuff. And I think there's an ease to look, if I can't do it, I punt it off. But then I don't necessarily think about how that feels to me or whatever, kind of like, they don't think about what the emotional play is when you kick somebody to a referral, because they, people do get upset about these relationships, the referrals don't come back, they whatever happens, how do you manage that the emotions around that?

SPEAKER_00: 14:00

Well, it's interesting. So I think a lot of it has to do with years of experience. So you come out of vet school, you think you know, and when you don't know, man, is that an ego hit? You got to break that ego. You have to be able to say, I do not know, but I will help you find out. And when we're at the stage as a GP and we do not know, that is a specialist, right? Because there is someone, I'm dealing with a medical case. I don't care what it is, opto, ortho, neuro, I am. I am dealing with a medical case that I don't know. But guess what? There is a specialist who probably does know. And so you have to be able to just say, I don't know. I think it's equivalent to... I was talking to... Two students who want to be vets. I said, listen, if you screw up, you have to own up to that client. The number one reason why you get sent to the board and there's a complaint is you stop communication and I see that these young vets get like this. I didn't do anything wrong. You have to talk about it and you have to own up and everything. So I take that sort of mindset and I take it towards referral. You know, part of the reason why would one refer when it reaches limits that are beyond my scope? And I will literally tell them, I go, I can do this much. I can do a lot. I'm a jack of all trades. I can do a lot. And it's why I got into veterinary medicine because I can be the surgeon. I can be the skin specialist to a point. I can be the ophthalmologist to a point. I can do so many different things. That's why I love it. The jack of all trades. But to a point, there's a point where you need specialty input. There's someone trained to do that. It's their bread and butter. It's their, you know, 24 hours, seven days a week type thing. It's something out of my scope.

SPEAKER_01: 15:44

How often do you have to draw on relationships you've built with people outside your geographic region? How often do you wind up ever having to send someone farther away? Like the only place I know to get this done is two and a half hours away.

SPEAKER_00: 15:56

So being honestly and transparent.

SPEAKER_01: 15:58

I'm going to hate

SPEAKER_00: 15:59

you. Everyone's going to hate you.

SPEAKER_01: 16:00

Anybody in a rural area is going to

SPEAKER_00: 16:02

hate you. Yeah, there's a couple of things I've said. But getting along those lines, so I understand it. And getting to know people, my work with the ACVIM is... There is one specialist in this entire region. And so I think that is key to actually introducing yourself to that specialist. And it is also key in the... I'm blown away when I said they're giving. The amount of times these specialists in these sort of situations give of their time for... telehealth, telemedicine, just, um, advice, you know, it comes down to the point where should the pet be referred or not? They're literally saying you could probably do this and I will guide you through it. Um, and I think that is amazing, but yeah, I'm, I'm that spoiled entitled vet kid who just goes, go, go here. And it's like, yeah, you know, it's, yeah, I'm, I'm very, they're just down

SPEAKER_01: 16:52

the road. They're not,

SPEAKER_00: 16:53

Oh my God. Yeah, so when I started practicing, it was one of the first radioactive iodide treatment for cats. I think I've got three or four around me. That's insane, right? It's insane. Yeah, it is. It's really bad because here's part of my protocol. I'll talk to the client. I'll say, where have you gone before? Was it a good experience? And where do you live? Those are the criteria I talk to them about. And so I could literally find a referral center close to them If they've had a bad experience, then I can find the next closest referral center to them. And so I'm very spoiled that way.

SPEAKER_01: 17:31

A lot about you and like, oh, the weight on the GP. The GP has to meet the specialist. The GP breaks the ice. The GP keeps the relationship up, ask questions. What things do you look for in specialists that make you want to work with specialist A versus specialist B when it comes to collaboration, talking?

SPEAKER_00: 17:49

So it's a given they are geniuses. I don't know specialists who's not a master of their craft. So I immediately eliminate what they know. But what I look at is, are you a good person? Do you communicate well? So I think I've been in this long enough that I can determine if they're communicating well. And I don't care really how they communicate medical terminology to me. I want to know how they're going to talk to that client. But it's just being a good person. And you can find out, I mean, my radar about nice people is pretty sharp. And so I can find out pretty quickly if this person's a good person or not. And then I also rely on the feedback I get from the clients, but that's what I look for is, are you a good person? You're a master of your craft, but can you talk to a client at their level? Because you are dealing with a very serious medical situation that they're, they don't know anything about. I don't know hardly anything about it. What am I expecting a pet parent to know about it? And then the, Along with that, what goes along with being a good person is they're very, very open-minded. They're very aware of that sort of tension that can exist between GP and referral. I mean, I've worked for enough guys who would say they're never going to bring that case back. You have to change your mindset about that too as an owner. You have to say we're working together because I know that working together leads to better medical outcomes. And a lot of times what I talked about young owners is about, I said, believe it or not, better medical outcome and working together actually leads to better revenue for you as a hospital. So you're getting a win-win situation, but they're very open-minded about that. And they're just very humble. They teach, like, I feel so dumb talking to specialists because they'll say something, you know, like what, you know, give me anal glands, man. I'm called the anal gland King. I can feel and tell you anything about anal glands. But that's about the extent of my specialty. But I can talk to these specialists and they'll say things like that I know is probably something they say a zillion times a day to someone. But I'm like, oh, my God, I didn't know that. So I learn so much from these guys.

SPEAKER_01: 19:58

Are there any challenges over your years of practice that you've had in referral partnerships that either caused you to change the way you do things or caused you to look for something differently in people? And how did you get through those problems?

SPEAKER_00: 20:11

It boils down to the knowledge base of the pet parent. And even though the specialist has done their best to explain things and it's in writing, the pet parent just doesn't get it. And so one of the main things I do prior to sending them is I say, listen, I'm kind of like, you know, it's that triangle of care. Or if you want to do the overlapping circles, it doesn't matter. I'm that person in that middle. So my role here is I will act as the go-between. If you have things you don't understand from the specialist, you let me know, and I will get that clarified to you. And I don't want to waste a lot of the specialist time with things. So we'll summarize everything so that any communication from the specialist, I'll be happy to do that. But I'll be, I'll be frank with you. I have more difficulty between husband and wife cases where they don't communicate. And so talk about the triangle of care. I try to get a conference call going, or I literally, I literally talk to one and I phone the other and I literally say, I'm going to tell you exactly what I told your spouse because I want everyone on the same page. I don't have to do that much with the specialist. It's more a translation. I mean, one of our things as veterinarians, we have to translate. I speak regular talk. I do not speak medical talk to my clients. I say poop shoot. But I know that, again, because they're geniuses, specialists, and they'll probably say, you know. They'll probably use anatomical medical terms. And sometimes the clients will go, yeah, yeah, yeah. And they come to me. They go, I don't know what's going on. I'll tell you what. So it's not the specialist. And we could talk a whole show on this. It's hitting emergency. So I did have a new client. I think I saw them once. And the dog actually presented, not with me, later on, had an emergent back pain issue. Husband was home. Wife wasn't. Husband took the dog home. was seen by, and again, this is a whole new world. I think the emergency system has totally changed my take on it. I'm going to be stressed. It's my take on it. We've got a lot of young grads who are not mentored. And so when I get reports back from young grads in emergency, I either see a report that they've gone textbook and done every diagnostic test or they've done bare minimum. And in this case, bare minimum was done. And I happened to talk to the client and I'm listening to, because I didn't understand the report. And they were saying things were declined. And so I know there's a slight language barrier. So I just wanted to get to the bottom of this. So I talked to him. Turns out dog is still in pain. I I'm diagnosing over the phone, uh, this disease dog. I basically tell her to go to specialty the place she first went. She didn't want to go. So she went somewhere else and I didn't know the specialist, but I found out that there was a new neurologist there goes there. Talk about lucky. Neurologist is phenomenal. Does a great workup, does surgery that day. The dog was walking again within three days later. I got the video for that. But here's the kicker. Here's the thing that blew my mind. So I phoned there to thank them for doing this. She not only responded, she gave me her cell number. So we have communicated since then. And I mean, just it's phenomenal. It's the easiest networking I've ever done.

SPEAKER_01: 23:26

Yes, it can be boring to focus on communication for veterinary clinicians who want to solve detailed problems, not just talk about them. And yes, it's easy for pet owners to get distracted by all these medical details, jargon, and fears of prognoses to focus on communication. But that is where part of the magic of satisfaction is going to be. Not just in the sophisticated diagnostics, not just in the highest tech treatment, but making sure every person, specialist, primary care veterinarian and pet owner, most importantly, understand what's going on and why in a complicated medical case. And that's it for this episode of Beyond the Clinic, powered by Vet Specialists. Thanks to our guest, Dr. Michael Tokiwa. If you learned something in this episode, please feel free to share this with other pet owners or veterinarians. And if you want to learn more about veterinary specialists, Find one to help a pet you know or connect them with your primary care veterinarian or colleague. You can find all that at Vet Specialists.