SPEAKER_00 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 pet owners and veterinarians might want to know a little more about. How to smooth out any difficulties when referrals happen, from primary care veterinarians to specialists, and then back again. Today, I'm talking to high-energy primary care veterinarian and radio host turned podcaster, Dr. Michael Tokiwa, owner of Progressive Veterinary Care in Skillman, New Jersey. We start from the obvious, right at the start, but from the horse's mouth. What leads a primary care veterinarian like Dr. Tokiwa to refer to a board-certified veterinary specialist in the first place?

SPEAKER_01 1:19

Always, first and foremost, through my mind is what are my limitations? What am I not capable of doing and how emergent is this situation? Or I guess for DERM, it's like I'm always thinking if I get a second opinion DERM case, I'm always thinking I got to talk to my DERM guy. I got to talk to my derm guy because those are incredibly, I mean, we talk about this a lot. He gets really frustrated clients all the time and I get it. I mean, we're spending weeks trying to do something. So, but I'm very conscientious of what is the limitation of my scope. And I always pair that with what is best medicine. Like, you know, I could learn how to do cruciate surgeries. I kid you not. I could learn how to do them. And I believe they're training GPs to do TTAs. But TPLO is gold standard. My mobile surgeon is the best surgeon I know. And he does this all the time. And if there's a nuance in a surgery, how am I going to deal with it? So it's easy to address limitations. I do know. Again, with my work with the Collaborative Care Coalition, ACVMA, I do know better outcomes occur with collaboration. And then I also gauge the frustration of the client. It doesn't have to be a DERM case. It could be a frustrational client. So I am there to be the peacemaker as well. If the peacemaker... means, hey, listen, we should get an expert opinion on this. It may be something that, hey, they'll confirm everything that I'm coming up with. But if that's a confirmation and they can pass the baton back to me to treat, that's what I'll do. But I want a person who is in the know to be able to say, yes, this is it. It's equivalent to a young vet coming out of school where they kind of know what's going on. They have an idea, but they don't have that confidence to do it. And then old timers like me go, yeah, you're right. Go for it. That's what I need. I need, yeah, you're right. Go for it from a specialist.

SPEAKER_00 3:09

So when it comes to worrying about, you see something that could develop and you think this could be a more serious thing. How do you figure out where's the point at which you're like, let's try some preventive care from here or let's try before we go to early intervention with the specialist. This could be a very serious thing. We're going to go all the way out. Where's the stuff that gets caught in the gray?

SPEAKER_01 3:30

To me, it's financial. I tell people I'm aggressive diagnostically. I believe my, my heart believes I should see senior pets three times a year. I should be doing cancer screens on anyone, anyone over the age of four. So I'm very aggressive that way. So it'll be a financial decision to determine, you know, or it's a decision from a client who says, listen, it's not money. It's just the way I feel. And this is what I want to do. Okay. As long as you're aware of things, but I would much rather get early intervention on anything because I Pets don't live as long as we want them to. And the biggest thing I hear from pet parents is I wish my pet would live forever. And I tell them, I said, I wish I can help you make your pet live forever. And this is how we can try to do it. I would love early intervention. My dream is to have a general practice. I've got some mobile specialists coming in. I would like every mobile specialty to be available at every general practice so that a client can experience all levels of care. Again, I'm fortunate. I have a mobile boarded surgeon who comes in. I have a mobile boarded cardiologist who comes in. I do have access to mobile internal medicine to come and do ultrasounds. My opso friends are way too busy. My derm friend is incredibly busy. So, you know, otherwise I would have them coming in as well.

SPEAKER_00 4:49

What type of information or records when you've decided now's the time for the handover? What do you decide? What information and records need to go with the client? And what information records do you have to hand off personally through direct communication, whatever? How do you manage that information move?

SPEAKER_01 5:07

So with the technology of everything being digital, I think full records should go. I think a lot of specialists, I envy their ability to take a case from not knowing anything to look at all the crap that I've done and filter it down and say, this is what I want to send them everything. I think what will be pertinent is especially emergent cases. Hey, listen, this is the blood work I just ran. These are the rads. This is what I've done. You know, what I try to do is I try to get a catheter in. And if I get OK from the specialist as it start the treatment, I will actually start the treatment and then ship them. So I want them to be prepared. Or if they say, hey, listen, we'd like to run the blood and you just pull it. Got it. I'll do whatever you want to do. But I think sending that medically is fine. I think the discussion is, as we just touched on before. This is my best client. Or there's huge financials, but they want to do, they're willing to come and they want to see what they can do for their pet. I think those are the subtle one-to-one discussions that we need to talk about. I've even said, listen, this person is an emotional wreck or this person, there's something going on with this person and you need to know that. This is my experience. I think it, talk about prepping the team, right? If we knew that, if we knew what was coming in, right? You know, I joke, I say, you know, when I was a relief vet, I'm there and no one could put a cat. I'm at a practice where no one could put a catheter in and they say black cats come. And I said, okay, okay. So I prepped for everything. I had everything out anesthesia machine. The cat had cystitis. It was great. But it's like, you know, I think if we prep for everything that we're, we're, we're ready for it. And it just changed. It changed. Can you imagine? It just changes the whole vibe of that whole case. Yeah. And being grateful from having specialists say, hey, listen, I was grateful that you told me what was going on. And I think that's great because that, again, it creates another, it creates a great story to talk to when you're at a social gathering with these people. And I think it bonds you more and it brings the human element into things. And, you know, because it's all about, it's really not about the patients. It's really not about the medical. It's about the human.

SPEAKER_00 7:15

So you have, it sounds like it's interesting with the streamlined medical records. You don't worry about, I don't need to curate this. I can send this all over and they seem, and you're like, oh, they're impressive. They seem to be able to take this whole record, rip through it or the person who's with them and they digest it so they can figure this all out. So you're not worried about over communication. It sounds like, is it ever bad to over communicate with the specialist?

SPEAKER_01 7:37

I don't think so. Unless I'm taking their time, unless I'm shooting the shit, taking their time, nothing to do with the case. Listen, Mike, I got to go because like, you know, I got 10K. Oh yeah. Okay. Yeah. Okay. Yeah. Things like that. But no, I don't think so. I think that, I think the problem is, is I'm always a big proponent about, Pre-judging, pre-putting a feeling on something. It's no different than pre-judging a client where they have the money to do something. Right,

SPEAKER_00 8:02

so you had a problem with this client and you're worried, well, if I tell them, blah, I had a terrible thing with this client, that that's going to, you're worried you could poison the well and they may have a perfect relationship with this client from

SPEAKER_01 8:11

their perspective. Yeah, I'll do it as politically correct as I can, but I also don't want to, like, even if I go, hey, I think it's this medically, I don't want to do that. I want them to have the fresh eyes because to me, a second opinion or a special opinion is to have fresh eyes. And I can't tell you how many times I'll talk to a specialist and they'll bring up something that I saw was minutia and I'm going, damn, right? You know, it's one of those things. So again, again, take the ego away, be humble about it. They're telling me something that was relevant that I was thinking, because I'm thinking, oh, I'm thinking it's a worst case scenario. This little thing is that price, you know, and then they go, well, and I'm going, but that's how I learned from them.

SPEAKER_00 8:53

Okay. So, and, and sticking to communication and maybe especially records, the dream of everyone's using the same EMR system. Everyone's using the same electronic metal records and they all move smoothly through the human world. That's a pipe dream, long time coming. And in the vet world, it seems to be easier. And it's still, everybody doesn't do the same thing. Are there any particular tools you use working with your specialists to electronic or otherwise you use or any protocols you absolutely follow, like timing or the way the information comes in or the format it's in.

SPEAKER_01 9:24

No, and I agree with you. I think that format is impossible. I think format is impossible. This is one moment where I wish there was a monopoly on format. Right. I wish Steve Jobs allowed the operating system to go and Apple owned everything. I would love that. But the biggest tool, the best tool I ever have is this guy right here. This is my best tool. I think that is my tool because that enables me to communicate immediately, directly with the specialist. I make it clear to the team. I say, listen, guys, we need to send the records. They're usually on it. When I go, I'm going to go talk to Fluffy's mom because I'm shipping them here. They're usually on it. They're on it. They get things going. And again, a frustration or breakdown is that communication is lost sometimes. We don't get referral reports sometimes. A lot of it gets lost in the ether. So I do. And I know I'm really bad at saying this. I want a monopoly on records and data.

SPEAKER_00 10:21

You're offering. You're like, I just want someone to take over. I know maybe it's not economically appropriate or at the best decision, but boy, it would just make things so much easier if everybody just used one thing. So this is talking about... When to refer, you know you want to refer, you hand off the information correctly, you give some personal information so there's an emotional understanding, a communication understanding of where this pet owner is. Have you ever had, where do you hesitate to refer? You mentioned sometimes, okay, someone says they'll just say it right out. Like, I think this should go to the dermatologist and somebody might just say straight out, I don't have money. I can't possibly do that. So maybe one reason is money. What are other reasons that you hesitate to refer to And there's some pressure from somebody else or you think, oh, this isn't right.

SPEAKER_01 11:05

That's a tough question. I think COVID really delayed me on immediate referral because clients weren't willing to wait eight to 12 hours. And so it was like, what can I do in the meantime? But I did have this discussion list, try to go into emergency and do it. Or I would call ahead saying, this is urgent. Don't worry about triaging. This has to go through. But my first job ever as a vet, I worked for an individual who blatantly said, He hired like three of us at the time. We were a five to 10 doctor practice. I can't remember how many total. And he said, if I can't fix it here, he didn't believe in referral. If I can't fix it here, no one can. And so that really instilled in me a strong desire to connect and refer. Oh,

SPEAKER_00 11:50

because even out of school, you're like, uh, I don't think that's the right path, man. No.

SPEAKER_01 11:55

So it opens up a general point. I always tell young grads, I say, listen, you come out. I don't care what school you went to. We get a great education. You come out with this upfront, modern knowledge about veterinary medicine. And if you happen to get your first job at a school, a practice that practices old medicine, you are actually going to take on that sort of practice. And you have to be conscientious of that. I had a young fellow come by. He's been out three years now. He's working at an old school practice down the street. And second opinion came in. I'm looking at the workup. He's old school. He is old school on his workup. And so I tell the young ones, you always have to, it's tough though, but I get it. Like I didn't get along with my first boss. I was probably the most biggest proponent, but I still couldn't, change that process. So, you know, advice to give young vets is have that communication. And if that's not working out for you, to me, that's a culture difference and you may need to make a change, but it really instilled in me the necessity to look at specialty as a viable option rather than a fight. And, and along those lines too, you get I'm open to second opinions through GPs. I can't tell you how many GPs you go up to me and go, hi, how's it going? And they're like this, the shields up and they're like this. I remember meeting a GP at a community event and I'm, I, I wanted to get them on my show and I go over and I'm talking to them. I got like the shield came up and until I broke the ice again by saying, Hey, listen, I just want you on my show. Is

SPEAKER_00 13:24

it, what's, what is the defensiveness that people build up over the years that makes them, that makes them put that shield up and like, I don't know if I want to, who are you? Yeah. Are you

SPEAKER_01 13:34

going to steal my client? Okay. Right. Are you going to steal my client? My patient? Am I good enough? I think along with a lot of veterinary medicine is there's an insecure, a lot of vets are insecure. They're not comfortable with their knowledge base. And so it, and they take things. We are so emotional. We take things so personally, which means I wasn't good enough to solve this case. And I think that they're there. Then they reverse it. I'm good enough to solve this case. And I'm like, I'm not good enough and I'm okay with that, right? I've got a learning experience here to do. I tell people, I literally tell people I'm not the greatest vet because I'm going to learn every day and I'm going to build from it. And I've met tons of clinicians that are way more brilliant than I could ever dream of being. So I have no problem being where I am. So I'll take my strengths, which is networking. That's

SPEAKER_00 14:25

my strength. It is the tough part. You mentioned the triangle of care with the pet owner in one spot, the specialist in one spot, the GP in the other. And the communication or feelings can get rough in any direction on that thing. I mean, somebody may go to a specialist and then be frustrated with their GP or somebody may go to the specialist and be frustrated with the specialist and be angry with the GP. And then the GP may not get along with the client. And then the client may not get... It's just big feelings. People got big feelings. You

SPEAKER_01 14:52

bring up another thought. One of the biggest hurdles I get is talking to a client about the specialty who they don't know. And a friend of mine, he's a criticalist. He said, listen, you as a GP, you have this emotional bank and your bank is like full. He goes, they come in to see me. They have a zero balance in bank account and I'm handing them an estimate for thousands of dollars. They just met me 15 minutes ago and I'm handing them an estimate for thousands of dollars. So what I take to that is I go, I'm sending you to my friend. They are phenomenal. I trust them with my life. I will

SPEAKER_00 15:28

take my pet. It's important to you. You vouch for the specialist in communication with them and say, you can trust them because you can trust me.

SPEAKER_01 15:36

Yep. It's equivalent to, what would you do if this was your pet? Right? So I say, listen, I would take my pet and I do take my pets to these guys, right? This is who I would take to. I trust them, you know, and the other thing I'll say is I defer to their, they go, well, what should a client go? Well, so-and-so said to do this. What should I do? I said, listen, they're the specialist. I'm going to defer to what they recommend. I am not equipped to make that decision. And then if it is something that is questionable, which is, I don't think I've ever, I think it's more like, should we really do this? Cause I have no experience, but if there is something questionable, I am, On the phone, I'm talking to them. Listen, like, is this okay if I do this? Stuff like that. So I think there's nothing better than building that trust bank, filling that trust bank. Then, you know, my role here is to promote animal health well-being. So I'm going to promote the people who do that because I want the best for my patients.

SPEAKER_00 16:30

Is there ever, you know, as you talked about, you talked about triangulating between husband and wife, multiple owners of a pet is more of a problem than triangulating information with the specialist and their team. It's much smoother. The information, you're going to provide information to the specialist. The specialist is going to provide information to you. When you refer, what information do you ask the pet owner? Pet owner, you're going to be responsible for sharing this information. Is there any response? Like, do you ever find out that like the pet owner was supposed to explain this to the pet owner already knew this when they left, but then when they got there, they act like they didn't know it. Does that, do you ever run into

SPEAKER_01 17:08

that? I do, but only, I think it's emotional. I think they are so stressed emotionally that, you know, and I'm cognizant about whatever I'm talking to them in the room, I'm cognizant that taken in less than 20% of it. And so again, I think that's important for me to reach out to the specialist and fill them in. So hopefully there is no gap. And anything there is, again, I'm in a good relationship with them. So they'll call me up and say something. But it's not as bad as a pet parent not telling your team something and you walk in the room and they tell you something completely different. It's not as bad as that. I think it's more like they don't remember. They'll have a snippet of, oh, yeah, Dr. T said this. but I don't really remember or I don't understand what he meant. And so I'm fully cognizant about that. And the same way, the specialist said this. I love it when they said, the specialist said this, and I go, there's no way the specialist said that, right? Like, that's like, no, that's not something I'll compliment. And again, it makes a great opportunity to have a laugh, have a good time, get to the bottom of things and do things right.

SPEAKER_00 18:05

You've already offered some advice, but I'm wondering if you bring in new doctors, sometimes you get the brand new people right out of school and they come in and you want to tell them about the right way to make referrals. What rules or protocols do you set up with people who've never referred ever? So they may have come also from school. When you're in school, you have all the specialists right there in the building with you. And then these people get flushed out and they don't wind up at that kind of university facility. practice anymore. Now we're going to have to refer out. I'm not going to get to talk to this doctor. They're not in the other room. What kind of things do you set up for them to make it work?

SPEAKER_01 18:41

Well, it's interesting because I don't set something up from the beginning. I do it case by case. So if there's a case we're working on it and it needs referral, I said, well, I have shared contacts with my associate, at least five specialty contacts. The way it's done is let me talk to Dennis about it. I will text Dennis. He'll give me a response. Then I'll communicate. with my associate cc'd and i go dennis meet emily emily dennis and i saw and then this is where i put the fluff and i go uh dennis meet my new associate emily emily dennis is the best surgeon i know boom and he already i already briefed him on fluffy's case you guys go for it and sometimes they keep that they keep that text going so i get to see it but a lot of times like i go I always end it with, let me know if you need me for anything else, thanks. And then I'll tell Dennis, I go, dude, don't worry about CCing me on anything, right? Do that. But that's how I do it. The other way is, again, I'm very fortunate. Some of these specialists, I'll say, can you come in and lecture to my team? And so one of the specialists I know, she's a pain management specialist, but anesthesiologist by training. I can tell you twofold. So this is a lesson for anyone out there. Bring a specialist on board. My team can do anesthesia at a level that I will compete with any referral center. I got to come in two years in a row for training sessions. Phenomenal. Yes, it's going to cost you as an owner, but the payoff is phenomenal. One of my students who's trained, she's going to vet school this year. She can do anesthesia. I said, you are going to just rock and roll. You're going to laugh at your classmates. They take forever to do something. You're going to have it banged down. So I think it's really worth it. So through that, the specialist is live. And that's when I'll find the introverts start asking questions. I stand back. I let them ask questions. The relationship is established. And that's their go-to person.

SPEAKER_00 20:36

And it starts feeling, again, you also set up a school environment for the people there. Remember school, when we all ask what you're learning? So right, the questions come out, we're talking about the science now. It's not about this case, whatever you're insecure about, however, this case is being handled. No, no, just in general, we're learning. Well, there are doctors that don't ever face to face meet specialists. I mean, there are GPs out there that just don't have any face to face contact with the specialists in their area. Why is my GP person going to go to their practice, have them come, I'm And they have a face-to-face. They put name to face.

SPEAKER_01 21:09

And I've even gone beyond that. So she was a resident at the time. She came and taught my associates how to do dental extractions. Now she's a rocking dentist, right? So I'm helping her. It's on a weekend. So it's such a win-win. I get the training. I see the invaluable nature of the relationship. I see how committed the team is. I get a specialist to help start their training period because they're going to teach people. And we all learn and it's best medicine. It's such a win for taking half a day or day out of your time. It's long-term. I think a lot of things is we have to think long-term. My relationship with the specialist isn't just going to be for one case. It's going to be for every case over the life of the practice or my work or anything like that. And so it's a long-term relationship. I'm not here to treat them and street them. I'm here to develop a connection, have a go-to person, and have the best medicine for my patients.

SPEAKER_00 22:12

So getting the documents from here to there, teams should have that under control. But making sure the back and forth happens between specialist and primary care doctor, so a pet owner and pet get the best care and communication, well, that can use a little finesse. And great doctors learn how to do that communication finessing. And that's it for this episode of Beyond the Clinic, powered by Vet Specialists. Thank you to my guest, Dr. Michael Takiwa. If you learned something in this episode, please feel free, we encourage you to share this with other pet owners or veterinarians that you know. 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, you can find all that at Vet Specialists.