SPEAKER_01: 0:00

Welcome to another episode of Beyond the Clinic, powered by vet specialists from the 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 more about. I know we don't want this to happen, but it does happen. So when cases get complicated, how do primary care veterinarians and the boarded veterinary specialists who are helping them keep all of it straight? 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. Okay, so we're going to start it all with an example. Was there ever a time, Dr. Tokiwa, when you had to closely manage the back and forth on a tough case? Of course, you know, I don't want to ruin the surprise, but it turns out in some cases, this is an always happens every time kind of situation.

SPEAKER_00: 1:30

Can I change it around to say that collaborating with one specialist is continual with me, my cardiology friend. It is important that before I put any pet under anesthesia that I know is a known heart condition, I need, his name's Ryan Keegan. I need Keegan clearance. And so we make sure that There is definitely a consult with him or a follow-up based on previous results that he can sit there. And he knows coming in that he's not only doing a regular cardiology exam, he is doing it for the purposes of anesthesia. And, you know, he's got this beautiful sprinter van that he's got his system in there. Um, he pulls up if it's too hot or too cold, he comes and does them in the clinic. But at the end, he comes in, we shoot the shit. He gives me all the cases. We talk about things and it's like, can we do this anesthesia on this cat? you know, yeah, go for it. Just avoid this, this and this. Or, you know, we have this one case where he goes, listen, you need atropine on board. So those I think are leading to the viability of the cases. I have very few issues under anesthesia, if any.

SPEAKER_01: 2:34

That's because of the volume of that kind of touch, because you're like, if there's any heart stuff heading into anesthesia, I immediately go to the specialist and pull him in.

SPEAKER_00: 2:42

Yeah. You know, and it's important because I need that There are nuances in cardiology that we don't know about. And so I'm always in the back of my mind, especially with cats, is those situations where pets have issues under anesthesia. And I always ask the question, was there a cardiac workup prior to that? You know, is there a reason why for senior pets, we're talking about cardiac workouts before anything. So I think that it's, it's hugely important on a regular basis. And I think it, it leads to a lot of situations. And again, with social media, you're seeing all these situations. My pet was put on anesthesia and they passed away. And I'm thinking, okay, how could we, I don't want to be reactive to that. I want to be proactive to that and make sure that doesn't happen.

SPEAKER_01: 3:22

What about one? So if we're talking about cancer cases or we're talking about, uh, derm cases, or, I mean, you even mentioned Cushing's once the thing is relatively managed or under control, it rolls back to you. So how does that now the Cushing's cases, if they're not going to that specialist all the time for it now, whatever the maintenance stuff is, or whatever the maintenance stuff for the skin issue is now with you, how do you manage that back and forth

SPEAKER_00: 3:46

with the specialist? So any sort of diagnostics I do, I send to the specialist.

SPEAKER_01: 3:50

Okay.

SPEAKER_00: 3:51

Because I know there's going to be a time where they're going to have to see that pet again and they have a continuum with the case. So it's almost like

SPEAKER_01: 3:58

you're seeing them on your diagnostics after that point.

SPEAKER_00: 4:01

Yeah. Why not? Because what if they see something that I missed, right? What if they see something I missed? Or again, if the pet has to be seen by them, they go, oh yeah, yeah. You know, Mike just did blood work like two weeks ago and he got this. This is what we're going to do. So today what we'll do is we'll see if there's any changes or we're good or whatever. I think it's really important to do that.

SPEAKER_01: 4:20

Do you ever dream of a place, it sounds like not, because it sounds like an ideal situation, but do you ever think about what it would be like to be in a place with no specialists and how your kind of practice would shift significantly if you didn't have access to this stuff? And you think about it and it's like, oh, it sounds like a nightmare. Well, isn't that what ChatGTP's for? ChatGTP, can't that stand in for all the medical specialists?

SPEAKER_00: 4:43

I'd be crapping my pants. I kid you not. I think that this world exists. so that there is a GP and a specialist. I don't care what medical profession you're in. I think the world exists. And if we're talking best patient care, you know, what really hit me was that cardiology study. There are a lot of my colleagues who can manage a cardiology case and they talk about Pima Bendon and blah, blah, blah. But when you look at that study that shows the combined effort of a cardiologist with the GP led to longer survival times, That really, that has stuck. That has created a permanent memory chain in my mind. And I think that applies to so many different things. My limitations are what I can do up here and what my equipment is and what my capabilities are. But there's a limit. I think that pets will live longer, healthier lives with both of us working together.

SPEAKER_01: 5:37

Are there ever cases you gave examples of when the case comes back and you sending information to them? When you have a case that hands off to a specialist and it's a long term thing, do you have protocols where you go and ping them for information about the case or you just wait for it to roll back? So the animal's gone for this and they're going to take care of this. I don't know how long it's going to take. Do you have things in your protocols to trigger? I need to check in or no, it's handed off to a specialist. They'll come back when they come back.

SPEAKER_00: 6:03

I think yes and no. And most of it is the onus on me. Ideally, we should be checking every three months and stuff. But there are some cases that I'll see and I say, oh, you've been the specialist several times. It's interesting. I think it's important for a lot of the GPs out there that some specialists like to do the blood work that they can see. Other specialists are fine with you doing them. But the client's concept is the specialist is always going to do it. And so I think it's really important to keep that communication up. I think the specialists that I know at least are incredibly open to having you do blood work and everything like that. They're incredibly open about that. And it's always good for you to get hands on the patient to see if there's any changes. I do have a couple of cases that they'll come in and I go, man, I look at all the work done by the specialist and it's like, wow, those are opportunities that I missed as far as knowledge base and as far as just doing. And I kind of feel lost in those cases. So I think it's really important. And again, that's on me for not setting that protocol for that case to be looked at three months.

SPEAKER_01: 7:04

But it is, it does sound like in that case, it really feels like it's the GP's responsibility in those cases. It goes to the specialist. I've handed it on to the specialist. And when the pet shows up, whenever the pet owner comes back into your orbit, I feel like, are you kind of saying if the GP either has the responsibility or feels like they have the responsibility, they need to be the one to request information or find out what went on.

SPEAKER_00: 7:26

Yeah, I think so. Because no matter how busy I get, I'm less busy than a specialist. Okay. That's a terrible way to think about it. Right? Because they're shuffling multiple very similar cases. It's like ask any GP what vaccine cases they have coming in. Right? You know, it's like that. So they're shuffling a lot of critical cases, a lot of cases. They're shuffling so much. Because I speak to one specialist, but a specialist speaks to hundreds of me. So I think the onus is on us, GPs.

SPEAKER_01: 8:01

Have there ever been situations... I think we've kind of been talking about single situations. A pet is sent to the cardiologist or the cardiologist is in to do some work. The pet is sent to the dermatologist. What happens when there are multiple providers? So you have a multi-condition situation where it's going to a cardiologist and a dermatologist or... How do you communicate among multiple doctors? In hospitals, they manage that by we're all at the hospital. So we're all there rotating through the hospital room. You don't get that. This pet's going all over. How do you manage when there's multiple on the same animal?

SPEAKER_00: 8:31

Well, sometimes I try to preempt it. If I know there's two specialties that I know at that place, or if the client wants to go to a specific place, I'll say, okay, go to cardio. You're going to go in through emergency. You'll be shipped to IM or ortho, but get the cardio involved. And so then I know that the sources are going to, then I get one report with everything in it. If it's multiple places, fortunately, it's not simultaneous. So I talk to everyone individually. And if necessary, and I can only think of a few cases I'll do again, I'd like direct community So it's usually a direct text to both individuals. It's also, again, an opportunity for me to actually, if those specialists don't know each other, I've just introduced them. And so I do that as well, just as a part. But I try to keep, it's not necessarily what I call patient confidentiality, but it's like specialty confidentiality. There are things that I will discuss with a specialist that Maybe we're talking about nuances of a client situation. I don't want the client part of that discussion. I think there should be a separation between what I talk to the specialty with and how I talk to the client and what the specialist talks to the client. I think there has to be a lot of separation there. So most of my communication from medically will be with the specialist, which I will then confirm with the client or decipher or translate if needed.

SPEAKER_01: 9:47

If those, I see again, if they're going to a specialty, if they're going to a specialty practice and the multiple specialties that are going to be involved in that pets care are all there, well, they'll all talk to each other. This is not a problem. If you do have those more rare cases where someone's going to a specialty in one place for this and a specialty in another place for this, do you wind up feeling like it is your responsibility? Whose responsibility is it to make sure they know the dog has a thing over there and a dog has a thing over there and a dog has a thing going on with you at the GP?

SPEAKER_00: 10:14

It's the GP. Okay. It's your job. It's a GP. It is. I think it is. I think we are the, we're the hub. And I think it's been explained several times. We are the hub and the spokes go out to the specialty and the client. Yeah. Because again, I hope I'm completely right. I think specialists have a lot on their plate that they're not going to, unless they happen to, you know, at a social event, they meet the other specialists. Oh yeah. I had this weird cake. Wait a second. I saw that. But I think it's very pertinent for them to know because I, I, You've just opened up a good question. I don't know if one specialist actually communicates like the report or the client will bring that report. It's up to me. It's up to me to do that. That's my onus.

SPEAKER_01: 10:56

How do you approach discussing specialist involvement with clients if they're hesitant or overwhelmed? So they want it. They like you. You've built up that trust bank. They want to be at your practice. Then you say, it's gotten to a point. I really want you to go see somebody. If you can sense they're hesitant, what are some of the things they say make them hesitant? And then how do you kind of work with them?

SPEAKER_00: 11:16

So I do talk about that trust bank story. I do talk about with the clients. I do talk frankly about finances. I do talk about it. I'm fortunate in that my really good clients, whether they are wealthy or not, it's that trust that overcomes any financial. And pet insurance is huge with that. But I do have that. I talk about the relationship I have with that specialist and how good it is. And I also talk about what are the expectations of what you're going to go there. Like if I say, listen, because of timing, You're going to have to go through emergency. So this is what you're going to expect to show. And I'll say, listen, if you're uncertain about what the emergency vet is saying, you call me up. And sometimes I preempt it and I talk to the specialist and say, listen, they're coming through emergency. So they know what to expect. But I also talk about why are we doing this? Why am I recommending that Fluffy go see my friend over here? It's because this is the best medical approach. I do have a lot of scenarios where I'll say, listen, I'm at my limit of what I can offer you, the best next medical step. If this is the way you want to go, because sometimes it is a potential euthanasia discussion. I go, if this is the way you want to go, the best chance for Fluffy is to go see my friend, in which case they're going to do this, this, this. I do preempt them that some of the diagnostics we do may be repeated. They may do further diagnostics. You need to be ready for that. I do preempt them that The discussion can be, listen, I don't want to do that. I always say that you're the person in charge of yes or no decisions. I am recommending the best for you. And this is why we're going to do this. And then, like I say, I'm here. I'm always here, right? If there's any questions, issues, confusion, you reach out to me. If you need me to talk to them, I will. And move forward from there.

SPEAKER_01: 13:09

Does your incredible willingness, you describe, to be there... to be in communication with all the people in all these cases. And then again, you're charitably like, look, I talked to these specialists one-off, these specialists talking to hundreds of GPs all the time and all these clients, they got, they're busier, but you're still busy too. How do you manage all this communication?

SPEAKER_00: 13:30

It's any spare time I get during the, between things I'm texting and doing everything like that. Yeah. I'll do that. You know, as busy as we all are, there's downtime, but, No, I'll do that. I'll do that. Well, sometimes it's at night, but I can type pretty darn fast on a, on a keypad. So I can definitely get things going quickly that way. And again, I don't really get an answer. So if I don't get an answer right away, it's emergent. Then I phone the referral center.

UNKNOWN: 13:56

Okay.

SPEAKER_01: 13:56

For the situations where it's not about the money and it's not about that they don't trust you that this doctor is good, are there any specialties that have people or any conditions that have people immediately nervous in the GP's exam room where they're nervous that now you're suggesting it's going to be this and you have to go see the specialist and that causes everybody to hitch up?

SPEAKER_00: 14:17

Yeah, usually it's like a bleeding disorder. Anything that's emergent. It's funny. Paralysis is pretty easy to get them to go somewhere. Listen, this whole half end isn't working. This is your best bet. Go, right? But I think my thing is if we stabilize a patient and they have that, I can only imagine what it's like to drive two hours somewhere. If I stabilize the patient and I'm worried, and I kid you not, I've had scenarios where it wasn't good at the end. But I remember when I first started working in emergency, a colleague of mine, We couldn't get this dog to stop seizing. So she did everything. It had to do like general anesthesia called the specialist. They guided them through that dog did not make it between. And that's, that's in our time, 45 minute drive did not make it from us to them. And that was, that was tough, but hesitancy usually comes with the unknown, the unknown, as far as where I'm going, the unknown outcome, because I'm prepping them for every scenario and then financial. Those are the things. And it's incredibly high emotions, incredibly high emotions. Well, I had a situation where a pet got so stressed at my practice that I had to, and the client was so stressed that I drove the client and the pet. As in, you just

SPEAKER_01: 15:42

perceive this is an, this will be unsafe for everyone. If I don't walk, if I don't drive them to the place and manage the situation, something bad could happen.

SPEAKER_00: 15:51

Yeah. And she was, here's the funny part of the story. So she owned a Tesla and she asked me, can you drive, can you drive a Tesla? I said, well, I've never driven one, but she goes, no, you're not. I had to drive my car. I had to get my Honda. So I tell everyone, Oh, opportunity to drive a Tesla. Oh, didn't get the opportunity, but no, I pulled right up in front. Thank God. I mean, I, we, we called ahead. They were expecting us. And I sat in the waiting room with her till the dog was stabilized. Then I went back. I got a call. The criticalist was there. Phenomenal, beautiful person. I've known her my entire practicing career and walked her through it. And the dog's fine now. But, yeah, that was interesting. And it's funny because I'm not even thinking. I go, what's the best case scenario? This is what I got to do. My manager goes, you know, no one would do that. You know, I don't care. The doctor, too. I said, I just want to drive that Tesla. I just want to drive that Tesla. I get to do that. No, it's one of those things. But, yeah. That happened like a year and a half ago.

SPEAKER_01: 16:52

Does anybody freak out about the C word? So there are things that dogs get, like paralysis, just like you said, everybody can see it. It's a major thing. Either we're talking euthanasia or we have to go now to a neurologist or we have to go to a surgeon to find out what's going on here. Are there other conditions like cancer where people immediately have the wrong impression about whether this is an achievable outcome or not achievable outcome, or the word in human medicine is so freaky, it freaks them out.

SPEAKER_00: 17:21

So there's three things about cancer. Number one, if we're talking about a splenic bleed, I talked about the statistics that this could possibly not be cancer. You've got a percentage chance. And if you want to give your pet a chance, go get the splenectomy done, see what's going on. The other concern is personal experience they've either had with themselves, a family member, a friend with chemotherapy. They are deathly scared about it. So then I talk about, hey, this is chemo in pets. I always say, I say, listen, if I get cancer, they're going to create a protocol for me. And it's either going to make me or break me. But I'm going to go through this. I said, you are in the driver's seat. I want you to talk to an oncologist because they are in the know about what to do. They get the latest therapies. They can give you specific statistics. But you can say, hey, I want to do everything. I want to do nothing or anywhere in between. That's what gives you that power. And I'll give an analogy. I go, a lot of times I don't know a pet's under chemo unless I see a shaved arm where the catheter goes. And even today, I mean, sometimes you don't see the shaved arm, right? And we don't see the radiation burns anymore with all the great radiation, specific radiation therapies. So I tell them that. And so I try to ease their mind that way. But yeah, I think it's one of those things. But like I said, like backs are easy. It's like your dog can't walk. You want your dog to walk? Go here. It's like, okay, gone. Right. You know, it's, it's, but I think that the thing they can't see physically happening in front of them is, is problematic, but yeah, but they do the C word scares everybody. Yeah. Um, but I think it's how you discuss it and what the potentials are. And, and I think putting them in that driver's seat or giving them, you know, cancer is one of those things that you feel powerless. Yeah. But if, when I tell them you are in the driver's seat for this, you have a team behind, you're going to offer you the best medicine and you can choose which way you want to go. Cause I have some clients go, listen, I don't want to do anything. And if, if it's something that I go, listen, this will make a world of difference. If you do, I will say that. But if it's like, Hey, you know, the chances are not great, but I'll, I'll try to convince them. I've even had a client talk to oncologist without their pet just to have the statistics, um, to, to go through that. But I always, you know, you always, Always, again, recommend the best, let them decide what they want to do.

SPEAKER_01: 19:39

What have you learned from working alongside specialists that's helped you to be a better primary care GP vet?

SPEAKER_00: 19:46

Bedside manner, patience, accepting viewpoints that are out of this world, especially nutrition. Man, can you only imagine the talk about food and diet that a nutritionist has to do? Patients with derm clients, they are frustrated. So my derm friend, the guy is glass. He's glass, so he's really good. But from my perspective is, I'm going into a problematic derm case knowing that it's going to be frustrating for the client. And what can I do to ease that frustration, but I have to acknowledge it. And we have to prep that client that this is a not a short term fix. This is something long term. And just being good. I mean, I'm always humbled by their brilliance. But I'm more humbled by just how nice these specialists are. Yeah, the occasional surgeon can be My shock. So I'm of the generation that when I started practicing, all the surgeons were the same mentality. And then my friend who's the mobile surgeon, I go, dude, why are you nice? No, but I think there's a whole generation of really, really nice people in these specialties. And it's great. It's great to just, I just like hanging with them because it's fun. They're fun people. I think they like coming into the practice because they see everyday mundane things that they don't get to see and stuff like that. But I do drive my surgeon buddy nuts because I'm always filming him and I joke with him. He goes to multiple practices and I laugh because when I go to their website, it's that same photo of him, which he says is his residency photo. So I bug the heck out of him because I always update his photo. I go, Dennis, I'm the only guy who puts an updated photo of you on the site, right? But I'm always filming. He doesn't like to be filmed. He'll look over and go, oh, Mike's filming me again. I go, it's okay. I do that. But again, it's part of that. We're friends, right? So it's great. But it's like, it's great to say my friend is an orthopedic surgeon that's going to take care of your pet. Oh, he did a really good surgery. He did a soft tissue tumor surgery on a dog who this dog is the sole baby of the owner. Okay. He removed him. He did it so well. He took the digit. He took part of the metatarsal, metacarpal, I should say. Things... Out of my league, I couldn't touch that. And he goes, it was puzzling for him. And his closures are phenomenal, right? So it's like, these are things that it just, it solidified to me. I'm so honored to have specialty. I'm so honored to have specialty at my practice doing good.

SPEAKER_01: 22:18

And just, I'm going to let you put this on at the end. So I asked you about you. You've just said some very, very nice things about specialists. Is there anything you think that when you work with specialists long-term, there's something that that specialists lose about the situation or about your experience in general practice, that like, it would be good for the specialist to remember too. So you're like, you learn a lot from them and you're like, it gives me a lot of perspective. Is there one perspective you think sometimes gets lost and that you'll like leak? Do you ever remind somebody about something or massage a conversation in a certain way? Like, remember.

SPEAKER_00: 22:52

Well, it's funny because like, I'm the only GP on some of these boards. Okay. And they'll be talking about what pisses them off.

SPEAKER_01: 22:59

And

SPEAKER_00: 23:00

then I'll say, listen, man, that's something I didn't even know about. I haven't even heard about that until you guys just said it. And I think the general concept is we have to really look at that GP is not a separate silo from specialty, that they're incredibly overlapped. And I think that goes on both sides. I think a lot of specialists are, they'll say how demanding and difficult it is to get a hold of the GP. Sure. And then they'll be saying about that. And I'll say, well, that's actually what the GPs are saying about specialty, right? You know what I mean? It's like, so I'm blown away by some of the things that said, and some of the things that I'll just say to them. I'll say, listen, I never even heard of that. I don't know what you're talking about. Well, it's like, um, I was in the grad student stream before vet school. And I joke that, that grad students do this until they focus so much about one little thing and they're out. And some, in some respects, I look at specialty and Specialty is this. And they lose sight of the big picture. And what I love about being a generalist is I have to see the big picture. Every case, I have to look at the entire thing. I can't just do this. So I know I'm a jack of all trades, master of none. So I have to send it to a master of one, right? And then come back and be jack of all trades, master of none. That's how I look at things like that. But I will agree that the mindset is changing for GPs and specialty, and we're both on the same page about leading to better outcomes using a combination of the two.

SPEAKER_01: 24:37

It's a little creepy. It's like Dr. Tokiwa climbed into my brain, figured out what I wanted at the end of this three episode series interviewing him, and then wrapped it up all with a little bow. Primary care veterinarians and board certified specialists are more and more on the same page about putting the masters of one specialty together with the primary care veterinarian jack of all trades and all of that leading to better outcomes. And for who? The pet owners, sure. The veterinarians, absolutely. But most of all, the pet owners. the pet people, the one living being in every medical case in a veterinary hospital that is important to everyone involved. And that is it for this episode of Beyond the Clinic, powered by Vet Specialist. Big thank you to my guest from this episode and previous ones, 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 love or connect them with your primary care veterinarian. You can find all that at Vet Specialists.