Fantastic. So, first of all, thank you very much, everybody who's here. I'm Sylvia.

I'll be your chair for today for the whole of the stream, and, yeah, just a big thank you on behalf of the webinar vet and WikiVett for joining us. And of course, thank you to our event sponsors. So, just a few tips before we start with the first session.

If you're listening on, listening live, it's better if you're listening on tablet, laptop or desktop, not on your phone because you won't get the best quality. All of the webinars today will be recorded, so they'll be all available for 12 months, after today, and we'll have 6 live webinars and there's also another 6, pre-recorded student sessions, so make sure you go check those out as well. And don't forget to visit our goodie bag.

There's lots of great prizes there. And there there should be a link in the chat box for you to yeah, go there and then if you have any questions, just pop them into the Q&A box, and we'll be asking all of them after the, after each presentation. And it would be great if after the, after the stream you could please fill out our post event survey.

That would be really helpful. Fantastic. So, without further ado, we have our first speaker, Lucy.

Welcome, Lucy. I'll just give you a quick intro and then I'll hand over to you, OK? So, Lucy has been a purely farm animal vet.

She's, completed an internship with West Point Farm vets, after which she moved and worked at Eel Farm vets. And she's then also completed a a farm animal residency at the RVC and has gained her European diploma in bovine health management and she's now helping finally your rotation teachings and also mentoring new graduates. So thank you very much for coming and chatting to us today.

So I'll just hand over to you and yeah, we can start with our 1st 1st webinar. Great, thanks very much for that introduction, Sylvia, and welcome to everyone. I'm talking today on surviving your first weekend on call as a farmer.

So I just thought, Sylvia's giving me a bit of an introduction there, but I thought I'd just, a little bit more information. So, I studied at the Royal Bat College the whole way through, like we all do, did a fair bit of kind of farm bits in the first few years, very much went in keen on farm, but inevitably sort of. Wavered a bit in that time, wasn't quite sure what I wanted to do.

I spent a year out doing an integration at UCL. I just wasn't ready to leave London. And then throughout my clinical years of mixed practise, that was mostly just because that's where, that's where I could get placements.

But I did do two weeks in Australia, which is where these pictures are from, just pure farm animal and that really convinced me that that's what I, I wanted to do. The RBC you can track, on rotation, so we did some farm and also some pathology, . And some extras.

We didn't really have als when I was at uni, so we couldn't get involved in that, but did lots of kind of. ABS stuff and, tennis on the side. So in 2014, I graduated from the RBC, my farm experience had therefore been kind of rotation-based, mixed practise.

I'm, I'm not from a farm background to start with, but I applied to, farm internships because I just thought it's a great place to start. And I was lucky enough to get a job offer from my first, interview. So I spent a year at West Point in the internship.

These are my intern, intern crew, and they were really great for kind of helping us get through the year, so, . Yeah, kind of that support from each other was just really needed. After that, I stayed at West Point for, for a little bit longer, before moving on to Endall.

During my time at Endle, they've moved from, part of the Excel that group, so an independent to, corporate. It's been quite interesting, being kind of there for that and seeing what, what changes there are to support and within the new grad sphere as well. .

Also while I end, I went back to the RBC and started a farm residency, which I finished last summer, passed, passed in the autumn. So, I'm now a European specialist in, castle betting. But despite that day to day, I'm seeing all manner of farm animals still.

So yesterday I just saw cattle, but this week I've seen goats, sheep, and cows, and an alpaca. So very much still, still covering everything. As Sylvia said, I'm doing some teaching of the RBC rotation.

So for any of you that have been through, you'll recognise Jane and Sally in that awesome picture. For those of you, who are RBC students and still coming through, you know, that's, that's our team. So we look forward to seeing you there.

I have recently taken on a new role, so learning education and development within CVS. So, I'm kind of involved in trying to set up a bit of a wider new grad programme within, across the UK. And I'm a new graduate, buddy, we call them.

So I have 2 2nd year graduates and I have a 1st year grad starting in a couple of weeks. So, despite having now been out for 6 years, I am, I'm still very involved in, in new graduates, and I think you never really forget those first few weeks in practise. See, one of the things we discussed very early on is, your vet vehicle.

So what you might need clinically. These are some thoughts on what you need from, a variety of farm vets it's not just, not just what's coming out of my brain. And so the main thing is that you know where the stuff is in your vehicle.

This is a picture of my old van, it has racing in it, so it's great because you can kind of put some bits and certain drawers, you know where it is, . The key things that people suggested that you need would be, waterproofs. So you can just about see there one of these bigger boxes has got all my waterproofs in, and they're all clean.

And then you can't quite see in this picture, but, we also have a washing line with more waterproofs on. The ones in bold are the ones that were kind of picked up multiple times by, by our vets, that I asked, so. And the key ones are head torch.

You will always get called to things in the middle of the night. Farms will not have bothered, to re put lights into their barn if the lights have gone, and tracks their headlights are great, but they never are in quite the right place when you need them. So, .

A head torch is, is a really good, good one to have. And investing early and a good head torch. It might sound a bit boring, but something like getting a head torch for a graduation present, means you'll get a really good head torch and you'll be ready to go for that first, that first nighttime call.

And holders and ropes, farm ropes are notoriously dodgy, and, and being able to get a hold on an animal just makes them hopefully a bit safer. And again, farm halters probably are falling apart or holding a gate together, so have your own, have a variety of different lengths of rope and different thicknesses of holters. I'm A fluid pump, so a way to get stomach fluids into this is a stomach pump.

Into a sick animal, I just have a cow one, but, you know, if you think you're gonna be in a small ruminant work, then your practise would have a variety of sizes on that. And certainly it's a really easy way to treat an animal. So food pumps are good.

Lube, you just can't have enough leave. More lube is, is the answer to basically all your problems. So, if in doubt, put some more bottles of lube into the vehicle and you'll be grand.

And sterile surgery kits and scalpel blades. And that's one that basically, any time you use a kit, you put another one in. As a new grad, you're not gonna be doing surgery by yourself.

And so it's easy to You know, just use your more experienced, your support vets and stuff, but I would say really important early on to start using your own, your own bits and bobs because then you'll work out what's working. If you happen to not have any of this, you'll still have your mentor on hand to sort you out. But it means that, yeah, you're responsible for your own, your own stuff.

Scalpel blades are also important. My one of my colleagues in my first job ended up having to make his incision with a the razor blade that he normally would use to, cut into the cow, or to, to clip the cow. So he, you know, ended up having to do that, which obviously is.

Not ideal. So, some basic, basic bits there. And then, sedation is, is your friend.

So we can get quite scared about sedating things, but, it makes everything safer for both you and the animals, so. Is the way forward. There's a variety of other things on that list, some more obvious than others, some of it actually being quite pessimistic, so they were saying things like cheese wire for, ostomies, euthanasia medication, good clamps when things start bleeding, .

But I think probably one of the main things to note on this is that no one has said antibiotics are a key clinical essential. Yeah, you're gonna have them in your, in your, van or your car, but they're not, they're not the be all and end all, . Yeah, that's some basics.

This is my van from another angle, see it's maybe some slight mayhem going on, I use carving ropes to hold everything up at home and have plenty of spare water down, down the sides, . And I even have a coat rack because part of your key non-clinical essentials would be plenty of spare clothes and warm hats. Yes, you'll start in the summer, but it's amazing how cold it can get at night up on the hills somewhere on a farm.

. So these were our top tips from, from the vets that I asked. So they said, have keys that you can grab them somewhere quickly in the middle of the night. Nothing worse than trying to get out of the house at 2 in the morning and, not knowing how you're gonna even drive to the farm.

Snacks, chocolate, a cup to have coffee in, some sort of good music to keep you awake, and motivated on the rage, and be on the road for a lot of hours. Some sort of medicine cheat sheets, your practise might make these for you. I ended up writing one on the side of my, on, on the back door of my van, so when I opened it up, I had it there, .

A diary That way that when you get the call, you can quickly write it right who you're going to in, and then afterwards you can write down your farmer name, the farm that you're at, and a brief call summary, and then it means that if they then phone back, you've got that reference somewhere, you know, if you're having a really busy weekend, you'll forget Mr. Smith from Mr. Blogs.

So that is gonna make you look a lot more professional and make you feel more comfortable with what you're dealing with. A positive mental attitude, it's got to be a good one. And deep breaths.

So they're your kind of your non-clinical essentials. My van, this van is by no means a perfect setup, but it's worked for me for a while, and, and you're just, you know, you'll get used to working out what works for you. So these are some more examples.

The picture on the left is my first, my first. Car, and that was an estate car. You see, actually I probably had a lot less kit in that than I did in the van, .

I got away with it, so that's probably a good thing, but yeah. Think about what you need. Think about what you need to access easier as well.

So here you can see, the drawer that's open is syringes and needles. The drawer below that was my, medications, and then behind that drawer was the stuff that I didn't use as regularly, . So, you know, what do you need access to easily and regularly?

This room in the middle is my surgery box. It's, pretty much immediately post doing the surgery. So again, it's not the most beautiful thing.

I didn't want to organise my everything out and have you think, oh, it always looks like that. But spare su suture material, we're farm investing here, so yes, we're still on catch up, . Surgery kits in the middle.

There's, some custom wool, an entire box of scalpel blades. Yeah, Blue spray, obviously the other essential of the farm, but, so plenty, plenty there. And if you sort things into boxes, then it means when you know you're doing a surgery, you can just take out that surgery box and provided that you've spent a couple of minutes organising it after a call or at the end of the day.

You know that everything that you're gonna need for that surgery is in that box. Yes, you might have to put in your local anaesthetic or your pain relief or your antibiotic. But you know that there's enough syringes in there, there's needles that you're gonna need, and there's all the kit that you actually need to do the surgery itself.

So you might want to put some clippers in there as well. Clippers are definitely another essential clippers and head torch, best graduation presents ever. So, yeah, that, that would be my kind of big bit of advice would be.

Having a surgery kit and then if you go back to this one, this green box here is my reproduction box, so I'm doing a fertility visit. Everything I need is in there, so fertility, drugs, se applicator, lube, and, and my gloves, so. You know, lots of boxes, more boxes are your friend.

This is an example of a truck, so . For trucks, your big problem comes that your tailgate kind of blocks your ability to get to things, and if you are 5'3 like me, you're gonna struggle to get in the side, reach around things. So, there are companies that will make, provide things to make it easier.

For example, Gearmate do these draws, . And practises will pay for things like that. So if you are lucky enough to get a truck in your first job, then tell me where you're working and I'll come join you.

But, also. Yeah, they should be making it as easy as possible. You're going into this vehicle multiple times a day, and the last thing you need is to be getting a bad back just simply from getting, kind of getting hold of those drugs before you've even got started.

So, this is my kind of my drug, drug draw, and kind of in terms of central farm vet medications, fluids are important. Large bags of hypertonic for, the toxic cows, glycol for ketones and oral fluid sachets so that you can pop those in your fluid pump, . In terms of anaesthetics and non-steroidal, so we're gonna have adrenicine.

I have 4 bottles of non-steroidals in there and 3 of steroids, so, you know, I like my pain relief. Sedation, if you're using ketamine, then that needs to be kept securely, and ideally just picked up from the practise. And you're gonna have a way of euthanizing things as well.

In terms of carvings, sanburol and oxytocin are there, so this is, I think they are in the far end of this drawer. For the slightly more weird and wonderfuls, B1 is pretty important at certain times of the year, and I see enough mangy alpacas that, I always carry next to a parasite aside with me as well now. And then only then would I bother coming to the antibiotics.

So intramammary is pretty key, some sort of long acting amoxicillin, maybe a amoxic TMPS. And Moxyt, and that should that would see you through most things, . Yeah.

So, we're just going to put up a poll now, just to get an idea of what's worrying you most about being on call. So, I think you just need to scroll, you can scroll down to see, there's one option that's just not visible. Well, scroll down, and if you just take a moment to, .

Try and work out what on that, what that pole is maybe the thing that worries you most about being on call. So, are you worried about missing, missing a call because you're gonna sleep, sleep through the call, or are you worried about the phone not working, getting lost on the way to farms if you're somewhere new, maybe that's kind of gonna be a scary thing. What about how you're gonna cope with no sleep or food.

Maybe worried about the kind of the outcomes of your, of your calls. So, what it all goes wrong when a patient dies. What about running out of, of kits, of fuel, that the farmer doesn't think you know what you're doing, or call where you genuinely where you don't know what to do, not having anyone to call for help, or multiple calls all coming in at once.

So hopefully you've all had a chance to have an answer to that now, so we'll have a look at the results. Great. So, We're not worried about getting lost, that's always good.

So the kind of the ones that come out on top for worries are the farmer thinking you don't know what you're doing. And not having anyone to call for help, which I think are both pretty valid concerns early on, . Yeah, early on.

So that's really interesting. It's great to know kind of what you guys are are worrying about. So, we'll just close that poll and, we'll move on to some top tips from, the farmers.

Yeah. So, first of all, who are you gonna call? So completely, we're worried about not knowing who to call.

The first thing I'd say is these are some really useful resources to have in your phone or written down in that diary that you're going to write down your farmer information. So the Neuro Compendium, there's an app, and I still reference it probably at least once a week to check doses or things like that. The APHA if you're a farmer, people phone you about all sorts of weird and wonderfuls, but also.

We're all terrified about things like finding, a native verbal disease, have the APH here number in the phone, and that will reassure you that you won't need it. And then Bet life and BDS for if, if you're struggling or if things are going wrong, we see. So you get, you get your call, we have an answering service.

So our call comes from an answering service. So the first thing that you need to do is phone the farmer. The answering service might tell you that it's definitely a visit, but they've got the wrong bit of information.

So, phone the farmer before you set off. To make sure that he doesn't want you and B to know what you're dealing with, so get a bit of a basic history, . And then it means that you can then find someone else on the way there and talk to what you think you might think you might be facing.

Also, it's a good chance to just check that if you've got a postcode, it's the right postcode. Give the farmer an ETA so that, you know, they're not standing staring at the cow for half an hour waiting for you to arrive. Just reassure them, gives you a chance to introduce them before you get to the farm.

And yeah, reassures you and them. Always call your backup, so you're never gonna be your first weekend on call. Probably feel your first few months on call, you're never gonna be alone.

And I very much reiterate to all our new grabs that I want to know where they're going, even if it is just for 6 ft down the road. I want to know where they are. I can have a chat with them on the way there so they can talk to me about what they're gonna do.

And if we think it's something that's gonna need me to join, either I'll go with them straight away, or we'll say, OK, well, you have a look at it for a quarter of an hour, and then I'll join you afterwards. If your backup hasn't gone to the pool with you, then give them a bell on your way home. It's just, it's just good for security to know that you're, you're safe, you're, off the farm, and let them know when you got home as well.

Like I said, we do a lot of driving, I'm a bit in the middle of the night. In the middle of the night you're backup may just appreciate a text to let them know that you've got home rather than phoning them at 3 a.m., but they want to know and they care.

And if they have joined you, I would still give them a bell on the way home just to discuss how it went, . And like I say, you're never gonna be alone. Your mentor might be different to your backup, so your mentor might might only work part time or might not do weekends on call.

So they'll still be available to talk to you, but they might just not be available in the middle of the night, for example. But if you've had a bad experience at a call, then I would chat to them as soon as possible, the next day. And finally, make the most of your friends, use WhatsApp groups, .

Friends generally, that are friends that are doing farm work, they're ideal. One of, colleagues from mine in Sylvia's year found anthrax in his first like 6 weeks, 6 months in practise, and sent a photo of that to the WhatsApp group being like, guys, Is this anthrax? We were like, that's anthrax, so, you know, that was quite a big one, but just having them there to know that you're all kind of in it together is, is helpful.

And if you are lucky enough to be in some sort of new grad programme, then colleagues on your new grad programme, you'll probably have a WhatsApp group to talk things through there. And again, it's just a proof you're all kind of in it together. And sometimes you might just need, need a bit of a event after a call, give them a bell on the way home, get out of your system before you get through the door.

So these are some top tips, again from farmers and farmers. So first of all, just reiterating what I said, your backup would expect you to ring for help. And all the rest of these crates are very similar on that front, so.

You, you need to call. If you need to call, then you need to call. Don't be afraid to call.

Even experienced vets, we have two vets on call, every weekend for my team. And if I get a really difficult calving or I think I'm gonna have a Caesar from hell. Yes, I had to remind myself to do it, but I will probably phone my, my other vet uncle, and we'll do it together.

Vetting together is really fun and something that farm vets don't get to do that much of because we're always out on the road by ourselves, so. Genuinely we enjoy your more experienced team members. Enjoy going and helping you do things.

It's not a mission of failure. The farmer is not going to think that you don't know what you're doing. And actually there's a whole load of stuff that farmers, Probably you're worried that they've seen it a million times before.

And maybe they have, but there's a load of stuff in there that you can do better than they can. So, they don't mind you for the help. If you're really worried that they're going to judge you, tell them you need to go get something else from the car, give your backup a call on the way to the car, .

Or send the farmer off to get a bucket of water or something that's gonna take them a while. Warm water, send them off to get some warm water and that will give you so much time because they probably have to boil a kettle about 3 times to give you enough water. Make sure your phone is ready to go with your colleague's numbers.

And as I said already, check your directions. These are probably our, our big two, so even experienced vet's call for backup, don't apologise to the vet you're phoning or the farmer. Just say this situation will be easier if I have another pair of hands, or someone else just looking at, looking at the situation, and we can then make a decision and treat your animal in the best way possible.

And as long as you're in a supportive practise, you'll not be alone. It can be really scary to be in a practise that, that isn't supporting you and you've just spent 5 years at uni and you don't really know what to do next. And you've been there 5 weeks and you just think it's not for you, but.

I would say probably making the move sooner to somewhere that's more supportive is gonna be better than. I'm staying. So, find supportive practise, talk again, talk to your, your peers about what's good about their practise, about what they noticed on interview and .

That will hopefully reassure you. Other top tips, you will hear your on call phone ring, so don't check it every 5 minutes. Farmers are useless at carving cows, and if you make a Caesar call, your backup will always back you up on that decision.

So. Caesar is never the wrong answer. Make sure you know how to use your carving jack.

If you can't find the vein, don't worry. Sedation is your friend. And sometimes it really is as simple as just a mild mastitis.

I'm Just some more bits so don't rush to each call, know how to dispense drugs. The head torch comes back into play again, and spare clothing, warm clothes, and snacks and food are important as well. And just generally looking after yourself, so eat, sleep, drink, we, and shower occasionally.

As the SGD would say, find your tribe, talk through the difficult things. This, let your colleagues cook you dinner. This was New Year's Day.

Me and Jan, who's sitting opposite me, were on call, and Alfonso very kindly cooked us a lot of food. And when you're not at a cool, eat the food, watch a film, walk the dog, catch up on admin, look after yourself. It's really important.

And looking after yourself is also a question of having some perspective. So will it matter next week, next month, next year? It's easy for me to say that sitting here, and I know in the moment it's difficult, but, yeah, think about that.

So we're gonna talk a bit about the art of triage, but I always I'm good at rambling on about the things they really care about. So, I'm glad I spent more time on the support. But when you're thinking about triaging things, if you have multiple calls coming in, and this wasn't something that you guys were worried about, and then having a systematic approach is gonna be better.

Thinking about the species and what's happening, is it an acute situation? You're gonna prioritise things like bleeding, prolapses and hiplock carvings. Can you send another vet to that call?

And that will help communicate with the clients, tell them what you're dealing with already. They will be sympathetic. They know that their mildly sick cow is not a priority over a calving, and be realistic about what you can achieve.

So clearly the cow in the middle of the screen is a much bigger emergency and it comes with a down cow than the same cow after I treated it, but a cow that sat upright eating and drinking and looking vaguely bright. And so you think about that kind of thing. So we can do another pole quickly.

So, which of the following would you say is most urgent? So you have sheep vaginal prolapse, cow uterine prolapse, lambing, a cut milk vein, a down cow down on its side, or an off colour alpaca. So if you just quickly make a decision on that.

Yeah, so cut milk pain definitely pretty important. Down cow on its side, yeah, important as well, . I'd probably say the you try and pray apps was more important than, than that, but yeah, completely, you make a decision.

And we'll just do it again, but which is least important. So the same set of questions, as a poll, but which one is the least urgent of that. And we'll have a look at what you think for that.

You've already seen the questions, so hopefully. That should be easy enough. The off-color alpaca, yeah, definitely, .

I would say something that's lambing is always going to be an urgent situation. It's still something that's giving birth. Yes, it's a sheep, but it is, you know, those lambs need to come out and you need to get there in a timely manner to make sure that those lambs come out alive and that she, that sheep is healthy.

I'm in a sheep vaginal prolapse, yeah, that is, that's not urgent. I'm So yeah, I would say this is our most to least urgent, so cut milk vein, uterine prolapse. The lambing and the lateral recumbent cow are probably similar, and in terms of the down cow, I'd be recommending things for the farmer to do to make her look better.

So initially sitting her up and keeping her upright will immediately help her. And if he has any kind of calcium, getting some calcium under the skin until I can get there. And cheap vaginal prolapse is least important, and the off-color alpaca would definitely warrant a chat.

Is that an alpaca that's completely down and unable to stand up, or is it wandering around feeling a bit sad, and they're very different situation. The common from emergencies, like we've just discussed there, birthing things is the main one, but we do plenty of other things. So we've got down cows, we've got stitch ups.

This was a shearing injury that someone who blew sprayed, clearly that wasn't going to do the job. This is the same leg after I dealt with it. This is the off colour alpaca that actually had a PCV of 6 and needed a fairly urgent blood transfusion.

So. Communication is key. Thank you all for listening.

I saw that there's maybe a bit happening in the chat, so it'd be interesting to see if there's any questions coming out of that. Thank you very much, Sylvia. So, as Sylvia's so it's been so lovely to introduce me to you all.

I hope you've been enjoying your morning so far, and I thought Lucy's talk was absolutely brilliant and covered a lot of the stuff that, yeah, like me and Sylvia found in our first year, doing our internship. So, Sylvia approached me a couple of months ago and asked me if I could do a talk on communication. So, I sort of thought it tends to be a bit of a, a dry lecture at uni.

So I thought, how could I make this a bit more interesting, hence the name, how to approach the crazy cat lady. Just to try and lighten things up a little bit, because we've all met these people and all, struggle maybe a little bit to understand them. And work out how it's best to, to communicate with them, because at the end of the day, our main priority, with our work is, is to, you know, communicate well with owners so that we can fix animals at the end of the day.

We can't do all the cool stuff like GDB surgery, blood transfusions, orthopaedics, all the stuff that we find really fun, unless we can get the owners on board with the plan that we want to, want to do. It can be the hardest part of being a vet, and I hope that at least something that I say over the next sort of half an hour will help to make this a little bit easier for you. Being able to communicate well will help with your job satisfaction, because you're gonna be able to be less stressed at work and feel like you can do a better job.

So this doesn't. Exclusively applied to Crazy cat ladies, but also Crazy Horse ladies. I'm sure Andy can fill you in on some of those that he's probably had to deal with.

but it's also really important for how you work as a team, and that in itself is really important with how happy you feel at work. They, your team and the people that will have your back when Everything's getting on top of you. It's busy, it's a bit mental.

And especially over the last year where we've all have been having to deal with learning how to change our practise in terms of dealing with the COVID pandemic. So it is really, really, really crucial. OK.

So. Ah, this is me back in my carefree days at the RBC. So, but, but how did I start all of this?

So, I guess when I was younger, I worked at a pub and a riding stables in between, school, I guess. And that in itself, for me, I feel was my starting point for learning how to talk to different people. And, Learning from people's body language, especially when you're teaching them to horse ride, is really important.

So actually, before I did my degree in, the RVC, I did a degree in equine science. And I, in between my 2nd and my 3rd year, I worked as a feed advisor for Deny Horse Feeds. So a lot of that was emailing people, speaking to people on the phone, talking to them about their horses, about what they wanted to.

Achieve about whether they had any health issues, and we needed to consider that in terms of what we were feeding their horses. And just generally building up a rapport with people and promoting the company and promoting a more natural way of feeding as well. So that was, that was brilliant experience.

So, as Sylvia said, graduated from the Royal Vet College in 2015. I can't believe that's nearly 6 years ago. That's gone very, very quickly.

But I feel like, again, a very important thing for me in terms of being able to talk to owners was the fact that I worked in hospitality through vet school. So I worked for pubs. I worked for, a team where we would work at Twickenham and Wembley, with people.

And again, that really, Really made the then transitioning into practise and that first, you know, week or so in practise where you'd have to speak to owners. It took that, it took that stress away. So if there's anything that I can encourage you to do, obviously, it's not really, easy to do face to face at the moment in terms of getting a part-time job in hospitality.

But if you can, I, which would involve speaking to people on the phone or emailing people and. That in itself can be really, really helpful. OK.

So what's the next one? So, yeah, so, as Sylvia said, we did our internship at the Epine Hospital. During an internship, I guess your interaction with owners isn't as great as it is when you're in, in terms of quantity, as, as in sort of practise.

Normally, you're just updating owners rather than taking, so much of the history or deciding on a treatment plan. So after I did, my internship, I kind of felt like I wanted to do a bit more surgery and have a bit of a better work-life balance, hence I moved doing small animals. And the first practise that I was at.

Was incredibly supportive, and had some brilliant vets in terms of their ability to communicate with owners. Very patient, very thorough, and brilliant people to learn from. So, during my time there, I started doing the locum shifts for Vets Now and really enjoyed the emergency side of things.

But again, that's a whole completely different ballpark in terms of how you're communicating with owners because in some of those cases, you do not have time. To go through the whole history. So ask saying to the owners, I'm sorry, we're not gonna have time to go through the whole history.

I need to know X, Y, and Z, so that I can stabilise your animal if you give me consent to, and then we can start from the beginning, . And, and you can feel me on and everything. And as long as you use that sort of sign point to them, that, that you are going to talk about everything, but we don't have time to do that now, then 99% of people are more than happy with that, and they just want you to get their animal fixed.

So, yeah, I got, I got the bug for doing out of hours, and I've been, full time at Winchester for, that'll be 2 years in March, which is quite scary. And during that time, as I said before, we've had to completely change how we communicate with owners because we're having to minimise face to face contact with them, hopefully, as we progress through this year. And, more of the population get vaccinated and we can start to get back to normal, because for me, I know I found it quite difficult in the first place.

I like chatting to people face to face. So then only chatting over the phone or, through other colleagues made everything a lot more difficult. So, but you've got to learn, overcome, and adapt to, to practise.

Oh, that was what I was gonna say. My random picture here is one of my, my favourite things that I find on ultrasound scans. I just thought it was a bit more interesting than a com, communication picture.

If you can see, this is a, liver in a dog. And the, hypoechoic area that you can see is the gallbladder. I hope you can appreciate there's sort of a line around the edge of the gallbladder, which is a sign of, gallbladder wall edoema.

The main two things you find that in is anaphylactic shock or right-sided heart failure. So, it's a pretty, pretty cool thing to find. OK.

So these are our learning objectives. We, hopefully we'll cover through, most of these. But if, if, if I don't, then, you know, it's, there are things, things to work towards, I guess, in terms of where we want to sort of aim to be good at what we do.

But I think the most important thing with this is it's a constant learning process, and nobody's ever perfect with communication. We all have, good days and bad days, and that's fine as long as you can reflect on the bad days and sit down with someone maybe and go, This is how the conversation went. Where did I potentially go wrong?

How can I improve on this? Then that's, you know, that's a brilliant thing to be able to do. So, in terms of forms of communication, everything has very much changed, as I said, due to the pandemic.

So we're not getting as much of a face to face contact with people. So we lose that ability to read people's body language, work out whether we're talking too fast for them, because I think that can be a massive. Issue, for some owners, especially if they're hard of hearing, or if you've got an accent.

I know, my head fat. Jack is a brilliant vet, but he's Polish and he can talk extremely fast, and has quite a strong accent. So, some sometimes I think we have to sort of remind him to, to slow down.

And your tone of voice are really, really important. It's not all about what you say. People in general sort of decide whether they like you or not, apparently within 7 seconds of meeting you.

So I guess the best thing that you can do is be, be friendly, have a happy tone of voice, make them feel like you're paying attention to them. There's nothing worse than for a client than all. Walking into the consult room door and you've immediately turned your back to them and you're staring at the computer, they want to engage with you.

And one of the best things you can do is engage with their animal, because that's why they've come to see you, because they're concerned about their animal. If they've got, you know, a dog with them or a cat with them, I always greet them as well, because that's, that's why they're here to see you. And that really gets people on board with, with liking you.

I guess one of the most difficult things as a new grad as well, I found when I went into practise is that a lot of clients, at the practise I was at had been there for years and they've been used to seeing the main two partners of the practise. So me coming along as a new fresh face that they didn't know. We're like, Oh, well, I wanted to see such and such.

So, you've gotta, you've gotta work hard to win them over. But when you do, it's, it gives you a real sat, you know, feeling of satisfaction. And, yeah, and it, it, that's really, really lovely.

. So in terms of emails and messages on the internet, I think you've got to be really careful. We see the internet and promoting our practises on the internet means that we can reach a much wider audience. But then also, we've got to be careful because some of our clients.

So, you know, in their 80s or 90s, and they don't really use smartphones or the internet. So we've got to be careful not to, miss those people out and make sure that they're, you know, they're not missed out in terms of, in terms of talking to them. So as yeah, as I'm sure you've probably heard people say before, we all love animals and that's one of the reasons why we love doing this job, but we also need to learn to love people as well, or at least learn to communicate with them.

The most important thing that you can possibly do when you're going into each console is to have a plan. So, a lot of the time, we'll have some idea of why the animal's coming in to see us. There might be a little bit of a history from the receptionist or whoever's booked in the appointments.

So you want to have in the back of your head a bit of a, a structure to sort of break down and follow, because that means you're less likely to miss something. So, in terms of learning communication skills, I've covered all of, I think I've covered a few of these before already. So, the best thing that you can do is practise, practise talking to people, practise talking to.

Owners, and you're only gonna get better from, from that. You hopefully you shouldn't get worse. So, and I guess one thing for me, as I said, is watch other vets at work.

It's so important. You pick up on, you pick up on things that they do well and things that they might not do quite so well. And then you sort of develop your own style from, from that.

The other thing is, yeah, it's obviously communicating with your patients. This is my boy, Thunder. He's a rescue husky.

He's, he's quite easy for me to deal with now, but initially, he was not overly easy at being handled. And I think a part of that with communicating with clients and having a good consult is if you can be calm and confident with handling their animals, and that in itself. That communicates to them that you're happy with what you're doing.

And again, that all comes down to practise. I remember when I started in the small animal work and I'm quite happy and confident with handling dogs, but with cats, I just found them to be spiky ninjas. So, You know, learn from, learn from other people in the clinic.

So, other nurses and other vets taught me their sort of tips and tricks for, for cat handling. And, you know, for a crazy cat lady, if you can handle the slightly crazy cat, then they will love you forever. .

So, this is my general structure that I find stick to, when I'm having a, holding a consult. So as I said, welcome the client and patient, acknowledge that they're there. Don't just stand and stare at your computer.

Ask, start them off with asking the most open question you possibly can. So, say, what's been going on with Molly? And then listen.

I know that. I find it difficult to not interrupt people because my brain starts going and I'm starting to think, oh, OK, what's going on with this? It could be this, this, that, working, starting to work through, like, my differential diagnosis list list.

But then you might end up missing something if you're interrupting them. So the way that I help with that is I write what they're telling me down, because then I feel like I've got that right in front of me. It's not gonna go in one ear and out the other.

And I, I, they, it makes me look to them like I'm listening to what they're doing and taking note of, of everything that they're saying, . The other main thing with this as well is you'll find that people will tell, or clients will tell receptionists and nurses and your other support staff, different little bits of history that they might not necessarily remember to tell you. So, again, that's a really important point, is to communicate with your team.

Has Mrs. Such and such, like, said anything to you that I should know of? And And if you're, you know, if you, you work well as a team, you know, get them to take note of what they've said and then feed back to you as soon as they think, oh, that could be important to this case.

It's so, so useful. You know, for dogs that have come in for vomiting, and they might not tell you that they think it could have eaten a sock, but they'll tell the nurse. So go back through what they've told you, to make sure that you're not missing anything.

And it shows them to So shows them that you're trying to understand what's happened, then perform your examination, and get a plan together, . Ask the owner if they, you know, feel like, you know, there's anything going on themselves. A lot, you know, most of, most owners want to be involved in the decision making with their animals.

So you need to, yeah, get them involved and get them on board. But at the same time, you're there to, to be an advocate for the patient. OK.

So, most common consult that you're gonna come across in general practise is your annual health check and booster. And I feel like a lot of the time they get sort of dismissed as a boring appointment and you try and race through them to get to the interesting stuff. But building a rapport and building a relationship with people then is is so crucial because if that animal then does consequently, Become ill, then if they trust you and, you know, trust your advice, then those clients are gonna come to you at the start of a disease process, when hopefully you can get to the bottom of it and fix it, rather than leaving it too late.

And I found One of the most important, the two most important things that I found in practise in terms of what you can do in these consults for improving patient welfare is to make sure that, it's to talk about things like diet, because we know that more and more of our patients, are, are becoming overweight. And also, and one big thing for me was arthritis as well, especially in cats, like something, I think it's something crazy, like 80% of cats by the time they're 11 have some degree of osteoarthritis, but. People aren't great at picking up on the signs of pain, so you have to.

You know, communicate with them well so that they know what to look out for. And people learn in different ways, just standing there and talking at clients doesn't necessarily get across to them, what, You know, You need to really need them to take home and remember from that consult. So sometimes showing them the things.

So if they've got, an overweight dog like this guy was in the top picture, you know, get them to feel their dog and say, you should be able to feel their rips. You should be able to feel their spine. They should have a, a, a tuck up in their waist from the side and above.

And once they can see that, then you can start to work to get these people on board. And then 3 months later, this guy, was looking a lot from her. He had had a bit of a haircut as well, but I can tell you, he was, he was a good 3 kg lighter as well, which was brilliant.

And it was lovely because the owner was like, Oh, he's got so much more energy, and, and so much happier, which is fantastic. Again, if you've got an arthritic patient and you can feel the crappiti in their joints, get the owners to put their hands on that joint and have a feel themselves. And that in itself can make them go, Oh, God, joints, joints shouldn't feel like that.

Give them reading material to go away with. So the international cat care website is brilliant for things like, idiopathic, fe unknown and low urinary tract disease, managing patients with kidney disease, . If people want to look things up on the internet, then it's part of our job to send them in the right direction and give them the right information.

A, so they don't end up doing the wrong thing for their animal, and B, again, so they feel like they're on board with their animal's treatment. Obviously, in day practise and in out of hours work, you've got to manage your time. In day practise, it depends where you're at in terms of, consult slots, but try and, either work with your receptionist, book it, book appointments in for yourself.

If you know that someone's gonna be talking for ages, book yourself a half an hour appointment if you can. And then it feels like they've, they feel like they've got value for, time for their money. So, one of the, one of the million dollar questions that I love.

If it was your dog, what would you do? Be honest with people, because they will appreciate your honesty. Try and give people a bit of an idea as to what way you would go if it was your dog.

You know, that tends to be something that people ask at at euthanasia appointments. If it was your dog, what would you do? And, you don't have to necessarily answer this question directly.

I tend to try and go around it by, sort of saying, Well, if they're having more bad days than good days, and they can't go out to the toilet for to themselves, and they're going off their food, and those things then start to sort of tick certain boxes in their head, and they start to answer that question themselves. So, I guess the other main thing is, well, be confident in yourself. If you're not confident in yourself, these owners will pick up on it straight away, and go, well, if the debt, the vet's not confident, then how can I be in themselves and how can I be confident in them.

So. It's, it's not a static thing. We will have good days and we will have bad days.

But you've got to have some belief in yourself. You got through vet school, you know what you're doing. You've just got to try and put that into practise.

So just be prepared for criticism now and again. Take that on and feed it back into yourself and, and just move forward with it. And decision fatigue is, is a massive thing that we need to.

Be aware of it affects us and it affects our clients as well, so sometimes, If it comes to sort of making tough decisions, there's no, there's never a, it's never a bad thing to give yourself more time for either the owners to mu things over, or for you to think about, you know, different options for your patient. So, when you're making recommendations, . The four main things, I guess, is you need to be clear.

Write things down for them. If you don't, if, you know, and ask them, Do you want me to write it down for you? And sometimes they'll go, Oh, no, no, no.

I'm fine. I've taken that all in. And sometimes they're like, Oh, that's brilliant.

Yes, please. Especially when it comes to things like that you're starting an animal on multiple drugs, like, have a little sort of timetable that you can just click print off and fill in for them. That they love that.

That's absolutely brilliant. It's really easy to do. Mayo is aware that goalposts can change.

If you're saying to people, we might make a different decision about this next time. I just did a really good course on, extreme wounds by the BSAVA with, John Hall. And he said that, you know, every time he's doing a dressing change, he's saying to the, he's like, We might do this next time.

We might do that. We might have to do a repeat surgery. We might have to take this thing a couple of steps back.

And as long as you let people know, then they're prepared. For it if they think that it's all gonna get better in this time frame and then you change that, then that really upsets people. And especially at a time like this where we've had so much uncertainty, I'm definitely finding that people are wanting answers to things straight away.

And you have to let them know we can't know what's gonna go on at this stage. And I can't predict what's gonna happen in the future. Tends to be quite a good line.

They suddenly go, Oh, actually, I'm asking. The vet to, to have a crystal ball, so it's, it's not always feasible. So, in terms of discussing costs, people want to know what they're paying for.

If you can show them an itemised invoice and talk them through the breakdown of the costs of things, then they tend to take that on board a lot better. We need to remember that as a country, we're not used to paying for healthcare. So, for our owners to then come and pay X amount of money for their animals, it always seems like a lot.

But if you can break down, well, this is how much this costs for the consult, for the medication, for the blood tests that we've done. I always find it's better to overestimate than underestimate. If you, if I say a patient's gonna be in for 36 hours with this over the weekend, and it's gonna be 1500 pounds, and I end up, and it ends up being 1000 pounds, well then people think, Oh, that was as much as I thought it was gonna be.

It's always better to overestimate than underestimate and keep people posted on. Where you're at in terms of, in terms of costs as you're going through the weekend, so they've got that in the back of their head, so you don't suddenly go, oh, we've gone from 200 pounds to 1800 pounds cos that's a bit of a scary jump for people. And we're all gonna have difficult clients.

You know, it's, it's part and parcel of our job. I know that in the last couple of weeks, I've had two of the most difficult clients that I've had in my whole career, and it really kinda hit me sideways, especially doing this talk today. But you have to just take on board that you are gonna come across these people, and that's fine.

Best thing you can do with them is be patient and listen, to what their problems are. And, and, you know, accept that it is difficult to deal with, and you need to talk to people about that. You know, talk to your team, talk to your friends, talk through it.

And that really, really helps. I love the fact that, that's now we've got recorded phone lines. So if we have any difficult phone calls and someone else can listen back to that conversation, and then say, Oh, yes, you did really well in handling that, or, OK, maybe next time you can talk about this with them, and that'll help you deal with the whole situation a bit better.

When we were able to have people in the clinic, I, if I was gonna have a difficult conversation, or I thought, oh, maybe this owner would quite like an opinion from another fair, then I'd have someone else come in for that difficult conversation. A, it's great to have someone there as sort of back up for what you're saying. And, and, yeah, B, it's a bit of support as well.

At, on the same note, really don't tolerate people being rude to you. Swearing and, yeah, putting, putting down what we do is just not, you know, we don't have to tolerate that. And if you need to say to people, I can't tolerate that, you know, that language, at the moment, and I need, you know, if they carry on and they don't listen to you, say, OK, we're gonna end this phone call now.

If you can call me back when you've calmed down and we can have a more rational conversation. You're well within your rights to do that. You don't have to have to put up with that.

And yeah, never be afraid to ask for help. So, this lovely little girl was, brought into me last year. She had completely collapsed after, she'd been spayed, was white as a sheet.

So we sort of resuscitated her and got her back on her feet a little bit, and turns out she had a, Bartonella infection before she even went for her spa. So. But I feel like this is the, this is the goal of, of, you know, of having good communication with your clients, is you get to see your patients doing well after, after you fix them, and you get these lovely thank you cards.

I know I keep all my thank you cards, in a little folder upstairs. And when you feel like you've had a really tough day and been struggling to communicate with people, look through those cards and remind yourself that you are really good at your job. And, you know, you've obviously, you know, made people happy because they've taken the time to, to send you cards.

And I guess remember with, with people, it's, it's always a marathon, not a, not a sprint, in terms of, in terms of where we want to get to with improving our communication skills. So, don't put too much pressure on yourself. Ask for help and, you know, be patient with people and be patient with yourself, I guess.

Great, thank you very much, Sylvia, and, thank you for the invitation to, to come and speak. It's excellent event. It's absolutely incredible, the, the, the breadth of speakers and the, and the platform, everything, it's just amazing.

I look forward to exploring it a little bit more, after my presentation. . Just touch on that brief thing about being understood.

I mean, I, I'm, I've grown up in this country. I think I have a tendency to mumble and face masks and not be my friend, I've found, in terms of people understanding, and I think that's, hopefully, once we can, dispense a face mask at some point in the future, that will help. So, I'm looking at the diagnosis and treatment of back pain.

It's quite hard to cover it in quite a short space of time, but I've tried to sort of whittle it down to an approach that is, would be useful, in, in your early days, out in, in practise. The thing is, is that, a great many, of, The horse owners will believe their horse has back pain. It's, it's a difficult thing to prove or disprove in, in many situations.

The kind of things that the horse might be presented for would be the, the rather nebulous term of poor performance, which Of course, that's a lot of people can believe that horse isn't quite performing where they want it to. The tricky thing is all the, the truth has to be, has the horse ever performed where they want it to? Have we seen a reduction in performance or simply is the horse not achieving the heights which the owner believes the horse should, and that could be associated with lameness, gastric ulcers, dental related issues, all sorts of different things.

Bucking . Or problems with transitions into cancer and out of cancer can certainly be related to to back problems. Rearing, loss of a bascule is the shape over the fence.

We want a horse to make a nice, inflexion of the spine. This cold back scenario where horses dip down when they're, initially mounted, but then that is usually resolved easily with just warming them up. It may be sensitive, when brushed or palpated around the back and resistance to girthing.

Now that can also be due to gastric ulcers, etc. And then hanging on one rein, well, of course, that can also be associated with dental abnormalities as well. It is certainly difficult to achieve a secure diagnosis, unlike in, in people, of course, where you simply ask the question, in, in horses, you know, with lameness, it's very easy.

We've got another limb to compare it to. We see asymmetries, but the back, only having one back doesn't make that very easy. And the same is, yeah, as said when we're looking at measuring back movement with the inertia sensors which, Sylvia mentioned.

It would be lovely to have an objective system of quantifying, but we are not really there yet, and it's as much about ruling things out as ruling things in. So I thought I'd show some videos of me palpating a horse, and hopefully these will, will, will, run relatively smoothly. And now here I'm feeling along the dorsal spinous processes here.

I've got these inertia sensors on, that's just for lameness. But I'm literally feeling very gently along the back. Now I say gently because anyone can make a horse flinch, if you press hard enough, especially in the sort of rather ticklish spot along those spinous process.

So I'm literally going along the centre and. You can usually feel the spineless process, especially in a thin horse, and get an idea of what the horse's reaction is. You're reading what is normal for that horse.

That will be different if it's a cob versus a thoroughbred. I then clasp my hands together, little mini workout for me as well. At my age, I need these little ups in the day to sort of keep the, the upper body a bit toned, and this is quite tiring, but you clasp your hands together and rather like bouncing a ball, you sort of time your downward pressure to get the horse literally bouncing.

And you're looking again, is the horse swishing its tail a lot? Is it trying to kick you? Is it just resenting that?

And you might go back and forth, and revisit areas that you think might be uncomfortable. But I'm literally putting downward pressure as they get the timing right so you can bounce it like a ball. Here, I'm using a biro pen, remember to put the lid on.

I've made that mistake once and just draw all the way along this about, it's about sort of 4 inches or so off the spine to one side and the other, and it's an induced ventroflexion and induced dorsiflexion. So it's ventroflexion when they get to this point and then dorsiflexion when you go over the back of the blue teals. And that's the horse cannot help but do that.

And it's not so much the fact the horse does it, it's, it's more about the reaction to it. So the horse may move away from you, try to kick. With its tail, etc.

And and that implies that that movement is uncomfortable sometimes to make. Literally just palpating round. I normally, to be fair, would be looking at the muscles towards me.

I'm just doing this, it's easier to film. But literally just with your fingertips and just palpating these arepas your muscles. You've got longusimus dorsi, just here, I'm also just doing some induced retroflex.

Just literally there in front of the pelvis, and then ticklish horses will do it more just at the back. So if you can't get a horse to do this, don't worry, it's probably a cob, and it'll just stand there looking at you and you'll look like a bit of a wally trying to press it and make it do things. Don't worry that simply some horses will do this more effectively than others.

But when you palpate the muscles, you're looking for trigger points. So you're looking for the muscles to be sort of quiver under your fingers. And of course, any signs of tension or pain on, on palpation.

This, again, we start looking at horses that start to sort of show these are these quivers you see here, these, these trigger points, we're seeing the muscles spasms, and that indicates a certain amount of discomfort. You see the horse is somewhat distracted, it's got its ears back, OK, in, in a certain area. It's not so bad working backwards.

It's, it's literally in these sort of T sort of 15 to 18 region under the the back of the saddle. This is another horse I went to a clinic to operate on, and again, you know, you can see it sort of fidgeting around, lots of swishing of its tail, going to sort of . That to try and kick me as well.

I it's just about drop out this horse, and I just think a park pain just in that sort of region again around about the T15, 180, it's trying to move away from me, anything it can to try and lots of swishing tail, anything it can to try and sort of say, get off that hurts a little bit. And then this horse here, again, this is one that was a show jumper that was showing a reduction in performance, and it really looks like I must be palpating really hard to get a big horse like this to practically sink down underneath me. And I promise you I am not palpating hard.

That's not what I'm in the business of. OK? Just stop these videos trying to get a little bit smoother, but, You know, this was a horse that had started becoming very painful and was having a difficulty maintaining cancer on the left brain, and it's jumping performance is somewhat reduced.

But it is a it's a bit jumping the video, but this horse is sinking down whenever I get to this lumber region that came, which is quite, quite marked. And this horse ended up having . Caudal thoracic, and cranial lumbar region pain.

You see just what a reaction, that is. Another thing we would look at is the horse when they're, when they're cantering, and this is, I've tried to put together this video to to make it to really clarify what I mean. This is a horse with quite reduced hind limb separation during canter.

You want basically when the horse puts its leg down, to, to take a bigger stroke. And then suddenly it becomes disunited. It's now landing inside hind leg first.

So the shorter they get the strides, the closer they are to bunny hopping and the closer they become to becoming disunited. You see, it switches and then becomes disunited. It's united at the moment, just in a second, it's gonna switch there, it's switched.

So what's out and look at these quite interesting to see what happens in slow motion. This also is coming around, it's taking this landing outside hind leg first. What happens just in a second next slide, I think.

Next one, sorry. That Seems to be no rhyme or reason why it decides to put that inside hind leg down first, probably because it's aching, it feels a bit painful and and as a consequence. It decides to think I need to put the other leg down first.

This does it again there. OK, let's just follow this round again. Outside hind leg going round and landing first, and then it just switches.

It seems to be somewhat effortless and seamless, but this is the kind of thing you'll see in horses with back pain or indeed sacreac pain, and you know it's something which really the horse should is probably doing to try and alleviate discomfort in that region. It can be associated with lameness, of course you must always chase a lameness if you . If you have that, present, i.e.

A lameness present, but, if you haven't, then that's the kind of thing you might see with, with back pain. So impinging spinous processes are probably the most common thing that we associate with back pain, otherwise known as kissing spines. But it's important to recognise that there's a lot of forces out there which will have impinging spinous processes, and appear not to be painful, which is obscure.

Because, you know, it's hard to believe why would some be painful, some not, but it certainly seems to be the case. Now, in racehors, it has a huge prevalence in postmortem specimens, euthanas for reasons, not associated with back pain. About 92%, or even up to 100% in some studies, of resources have evidence of impinging spinous processes radiographically and then subsequently at postmortem.

It is not present in foals, but it seem to be born with it, so it does seem to be a product of the domestication and a product of riding and the way horses are actually trained and ridden day to day. Certainly, X-rays do obviously allow diagnosis relatively straightforward. The nucleus intigraphy is another way.

This is bone scan, and this is the same horse, this is the back x-rays of that bone scan, and we can see here, uptake here in the sort of mid to. Thoracic spinous processes. And this simply indicates that we've got active bone remodelling, and that we can see is sclerotic regions on the back of T15 here, and a little bit of remodelling even between 14 and 15.

OK? So, bear in mind though that we don't commonly see this condition in dressage horses, but when you consider the way dressage horses are ridden, they are flexing their spine and working very well. This I put in really to to appreciate that even when you do this a lot, you can get it very wrong.

What I've tried to do here is on palpation, is to put the needles in the gaps that I can feel on palpation. And this is to illustrate the point that it is remarkably difficult to actually find the gap simply on palpation alone. Some horses are easier than others, of course, but if they're impinging, there's less of a gap there by definition, and so it's difficult to feel.

So you really must do this under radiographic guidance, so then you can correct them more this kind of region. And what we're seeking to do here is to put local anaesthetic, dispense it around this region just ventral to the site of impingement, bearing in mind the dorsal spinal nerve runs in the interspinous ligament. And we are looking to remove sensation.

What we need, just like a lameness, is a reproducible sign that is blockable, so that might be bucking on the saddle, perhaps being disunited, difficulty counting on countering on one rein or the other, but something you can tangently say, I can see that, and I can block it. A written assessment, after about 15 minutes, ideally, two riders. This was a, an interesting case that, this, it's a teenage boy, who had a very relaxed riding style, really didn't seem to be too bothered by the fact that the horse.

Which is bucking incessantly, but it was only when the horses in Canter, it didn't look particularly comfortable in Trot, but certainly in Canter, whenever he went into Canter, off it would go into this bucking bronco, really, really reproducible. And he did well to stay on this chat. He's got a rather amusing riding style.

Very, very relaxed, like he's in an armchair. But, this is after blocking the back. And you can see what a huge difference that is.

The horse looks more comfortable, the rider's riding like he's in an armchair. But certainly we've managed to change things there. We've managed to improve things.

And if you get that response, then that's great. You can say, well, that's, that's perfect. We know we've got a.

a, a clinically relevant impinging spinus processes, but it, of course, it has to be borne in mind. You are responsible for the safety of both horse and rider, and if a rider falls off during a test that you're doing, then, even with consent, they are not consenting to being injured, and that's a difference legally. So you have to be a little bit careful about how you Approach these situations.

This was a horse, courtesy of Roger Smith, this video, with the saddle on, OK, not, not too bad, really, trotting around. This is, with a weighted saddle, we've got a weighted sur single here, and this was the, what the owner complained of, and you can see it's not, . Looking like the most comfortable horse in the world, to get on.

So it really was the weight in the horse's back, which was significant. And this, this is lead shot bags that are in the pockets of this single. And the idea is to simply make this test safer, OK?

And we then blocked this horse and . But local anaesthetic around sites impinging spinous processes, and, you know, clearly there's a, there's a big difference here in terms of the way the horse is responding. And this is what it looks like just flat, these are pockets, these aren't commercially available, something we homemade ourselves, but, you know, we can, certainly, you know, similar things can be created.

But just bear in mind this is safer, and we have to take that into consideration. So how do you take X-rays of the horse's back? Well, this is the lateral lateral X-rays.

And here we, we normally take about 4 shots with markers on to make sure that we've got, the, we know where we are, so we can then correlate that with our sights and ingons. And we've got, you know, quite. Marked degrees.

Normally the worst impingement will be in the centre, and this is where it first occurred, and then it sort of radiates out to become less as you come outwards. Not to say that these aren't painful. I really think there's a poor correlation between the degree of impingement, and the pain the horse is experiencing.

Do not forget though that even though you may have normal spinous processes or especially if you've got abnormal spinous processes, you will likely or should probably check for articular process joints. So these are the joints at the back, further down, the spinous processes are obviously up high, you can see down here, and they come down and then they form a joint just here. And the most likely affected joints about T16, 17, the call of thoracic region.

But we take it via this 2 degree oblique radiograph. Not easy with some portable machines, it has to be said, although they are getting much, much better. But don't dismiss that a horse doesn't have back pain if you haven't checked for this.

You can check the spinous process is easy enough, but you must check these. You can ultrasound scan these articular process joints, and this is a curvilinear probe, OK, and these are your spinous processes here, and this is your transverse process, and your articular process joint is just here and here. Now it should look like this one, it should look like you can appreciate the joint space, it's like a box, it should look like a nice distinct box.

If you can't appreciate the joint space, or sometimes you'll have, you know, an uneven bony surface just here. Then we assume that this has got some remodelling because we cannot see that joint space down through. And this is easier done in a thoroughbred, no doubt about that.

You know, I find in this, you'll notice this is not a thoroughbred that I'm scanning here, but it is, nevertheless. Trying to just get used to doing this, especially if you think there may be articular process joint osteoarthritis. And this will be evident on X-rays, but there's a, there is an argument for saying that ultrasound is actually more, more sensitive.

So the aims of treatment are to alleviate pain. The horse won't work properly unless it's in, in, in the absence of pain. And this has really come a long way.

We've borrowed it from the human field in terms of generating exercise or exercise being as, as soon as possible. The horse must not be painful, and in trying to improve flexibility. The saddle must be checked as well, that's imperative, and this was a study by Sue Dyson, Greve back in 2014, and some take home messages really, that back dimensions change regularly, especially with work and even after a work session, and this is really important.

That if you're gonna get a back, a saddle checked, it must be checked after the horse has worked. We all know that muscles swell during exercise, and that includes the back muscles. And so, there are, these are certain things which we must take into consideration when we are .

Looking at getting the saddle checked. And even in sport horses, the saddle should check probably every 2 months, but certainly, every year is probably not enough, in your, other horses because of these changes in time, heavier rider as well. And, .

And that's just something to be considering. When it comes to the the working the back, we know there's the bow and string theory, which was proposed by Leo Jeffcott back in 1979, and it's essentially saying that what we have got is the, the bow is the back and the string and all the sort of weight of the abdominal muscles and so forth. OK, and we've got these muscles which are the stabilisation muscles of the back, especially this multifidu muscle which wastes away, certainly in humans and it's been demonstrated in horses as well.

What we're looking to do and we're we're we're addressing back pains, we want to flex the spine, that makes perfect sense because the spinous process is sticking up and we need those spinous processes to separate. So anything that retracts the leg, the forelegs, and protracts the hind legs, things like walking poles, trotting poles, walking up hills, anything that has the head down will rotate those cranial spinous processes forward, so feeding from the ground and also lowering the the the horse's head. These are baited stretches, which are something the physio would, do with the, with the client, and these have been proven to be useful at, improving the core stabilisation muscles, in particular that multiferous muscle as well.

And the clients find these quite fun, you can see them, they get better and better at them, and this is something the client can be doing with the horse, twice a day. When it comes to impinging spinus processes, the treatments, well, we would normally, obviously a robust diagnosis, but we would normally reach for the corticosteroids medication in the first instance and try and get them to exercise out of it. Certainly in the UK we're kind of on our own a little bit in terms of how early we reach for surgical treatment.

On the continent in Europe and in the States, it's far more common for them to exercise out of it or use conservative therapies. Bee may be simply enough, we're trying to get them pain free so that they engage in these exercises. So we may just infiltrate in the same way that we did with local anaesthetics and corticosteroid around the sites of impingement.

Extracorporeal shock wave therapy has been demonstrated. A recent study, 2020 demonstrated that 3 treatments 2 weeks apart over the affected back part of the back, caused pain relief that lasted for 56 days, and that could be useful as well. Certainly useful for competition horses, although you cannot use Shockwave within 7 days of an FBI competition.

There's obviously withdrawal periods, of course, around about 11 days with triston alone. I normally allow a bit longer, around about 2021 days for methyl prednisolone. After medication, you'll box rest them for 48 hours and then into a non-ridden exercise programme.

And this is a standard programme that I would use. It's one that I've sort of come up with based on sort of experience, and it's incremental walking. I want the head to come down, not necessarily a per se.

I like this Equi core, which you can look online, it's a good device. It doesn't have the sort of the, the rope around over the head. Obviously you adjust it according to the horse's ability.

Concurrent medication can be given the horse must be not in pain. This, a registered physiotherapist can help in, in, sort of supervising the exercise programme that can visit more frequently, and help the owner with these exercises with these water, with these carrot stretches. Water treadmill is useful as well, and after 7 weeks commenced ridden exercise.

This is the ideal scenario if you're really trying to address with a more long, medium to long term aim at resolving back pain rather than simply managing it. There are surgical options with impinging spinous processes here. This is the cranial wedge ostectomy, that was described by Ben Jacline at all in from Newmarket equine Hospital.

There is a danger you sort of cut a bit, you know, sort of never ending cut as we, we call it, but essentially your, your remit. Keeping the height of each spinous processes. This is something we wrote up in the RVC and then Paley Brink as well wrote up doing every other spinous process so that you can actually, you can actually separate the incisions doing this.

But this shouldn't be seen as a first resort, but it is effective, 72 to 79% success rates, but there's a longer convalescence. I tend to have them in work actually around about the 8 to 12 week mark, but it is quite a long convalescence. What's risen in popularity now is the interspinous ligament desmotomy.

And this is where we go burrow underneath the supraspinous ligament and cut the interspinous ligament. Probably it's a neurectomy, the dorsal spinal nerve exceeds the frame in here and goes up through the interspinous ligament to innervate this region just here. OK.

Now, by severing the interspinous ligament, we probably sever the the dorsal spinal nerve. Certainly the initial success rates were huge, about 95%. It's minimally invasive, which is quite nice.

And the horses are back being ridden after an exercise programme of six weeks. Three year follow up, showed that about 53% are still in their previous performance, 91% though are still being ridden in some form or another, with about 80% recommending the procedure. And generally speaking, because it's minimally invasive, people quite like this.

We use, I use a special blade now to assuage John sort of scalpel to cut down the interspinous ligaments. So here I'm just burrowing into the from the side about just off the supraspinous ligament. And then I literally cut down, once I found the slot between the spinus processes, OK, and then I cut down to, sever the .

Interspinous ligament there so you can just see the movement in my hand, I'm just severing that ligament. And these sutures are then just, these sites are closed up with a single, single suture. And that works, very nicely.

So in summary, it's really important to ensure all lameness has been addressed. I can't stress that enough. I've focused on back pain, but lameness must be addressed first.

We're well, we're well aware that lameness affects back movement, and so muscular back pain is almost always going to occur secondary to prolonged lameness. Obviously, we talked about palpation, a thorough physical examination as well as mandatory. Diagnostic analgesia if you've got a reproducible clinical sign, and you can do it safely.

Radiographs and ultrasound we've also looked at, are very useful. And really when it comes to treatment, focus on exercise based therapy. It's like I always say to owners like, can you take your horse to the gym, doing horsey Pilates, horsey yoga, and really get them going.

This is not messing around, this is hard work, they have to be engaged in it. Provide pain relief, whether that's in the form of medication, that could be steroid medication directly, or phenylbutasone or both, potentially acupuncture, which we've not talked about, that could be useful, and shockwave I've also mentioned. Surgical options may provide a better long term solution, and there are two options, the spinous process resection, which we looked at, and the interspinous ligament desmotomy.

So, I tried to catch up on a bit of time because we're quite late starting, we've got, I'm not sure if we've got any questions. I'm gonna talk about, embracing uncertainty, and I, I should declare an interest here in that as a, an internal medicine specialist, I make my living through, approaching uncertain problems, and it, gives me a certain buzz. I'm an unashamed enthusiast for, uncertainty and, and, and dealing with uncertain situations, and that's very much what the practise of internal medicine is, is about solving, solving problems and solving mysteries, and if you like, quizzes and puzzles and, really sorting out those mysteries, then, internal medicine is a great, speciality.

As, as Sylvie said, I'm, an internal medicine specialist and head of cardiology at the White Referrals, which is a large multidisciplinary referral centre in Cambridgeshire. Over 100 vets, over 350 staff are a huge, huge hospital, very, very busy. I wasn't always, an internal medicine specialist.

I've been a vet for nearly 25 years and started off as a, a general practitioner in mixed practise, predominantly dairy and beef cattle, actually. Had designs on being a, a cattle vet to begin with, and it's amazing how your career can change. And it starts off with a, a quote from William Osler.

William Osler was a, a Canadian physician and one of the, the founding professors of Johns Hopkins University in Baltimore. And he was famous as well as being an excellent physician for a number of very pithy aphorisms, and, and one of his that I think is very pertinent is that every patient you see is a lesson in much more than the malady from which he suffers. It's very important to remember there's a huge amount of variety and interest in the patients that you'll see, the stories of their, their, their owners or the, the farmers involved with their, with their care.

And you'll get a, a huge amount of satisfaction and interest and thrill out of making those observations related to those, those patients. We're gonna talk about why your profession's an uncertain one, without that being a scary proposition, uncertainty is a good thing. It creates judgement, it creates skill, it creates feelings of well worth and, and interest, and, and, really makes your veterinary profession a very fulfilling one.

We're going to talk a little bit about coping with imperfection and mistakes and and perfectionist tendencies that we might have, and also to emphasise what it is that's important for clients, and also what should be important for us in order for us to have a fulfilling veterinary career. And then we'll, we'll finish talking about a few tips of how to deal with uncertainty. Remember above all that you are going into a profession where it's a small profession, and a very trusted profession and a respected section of society.

And that respect often comes from the consideration that as a veterinary profession, we're a profession of sound judgement, we are trusted to be making decisions, and that's an important part of our professional self identity. As other speakers have said earlier, and you, you had some great talks earlier, giving some very useful hints and tips. Remember that you're not alone in any of this.

It's very unlikely that any situation you're dealing with hasn't been experienced or isn't being experienced at the same time by another vet within your profession somewhere else. We're all in this together, and it's important to, to, to, to, to remember that there's, there's huge sources of support. Your profession, your veterinary profession is an uncertain one.

There's no getting away from that. We are dealing with animals, that's our raison d'tra. We, we, we're going into this to deal with animals, it's what we all wanted to, wanted to do.

Those animals are, are complex. They vary in their personality, temperament, whether they're wanting to take our face off or be, be, be very bidable in their, in their attitude. We're dealing with complex biological systems, which are, are, are infinitely variable and and complex and, and, and interesting and fascinating in their interactions.

We're dealing with human beings. Lucy, quite rightly earlier, was, was showing a very nice quote from Maya Angelou about how people remember how we make them feel. And that's very, very important, and Vicky was, was emphasising the skills of talking to people.

Our profession is about helping people. That's, that's why we're, we're, we're here and through that helping their animals. Our clients are infinitely fascinating.

They have backstories, agendas, other things that are unrelated to the reason for presenting their animal to us, and that's an enormous source of interest, as are our colleagues, and their agendas, wants and desires, and, and, and the, the, the ways in which we work with them. Increasingly, particularly in small animal work, we may be dealing with changing business paradigms. It's increasingly rare for us to be working in a practise that's owned by another veterinary surgeon or to own a practise ourselves.

More commonly now we're dealing with larger corporate entities, and we may feel ourselves pulled in different directions that May not be exactly what are our ideals as as veterinary surgeons by commercial pressures, but those are, are also uncertainties with which we have to deal, as are those of of questions and considerations around ethics and, and care, dealing with variable time courses and, and, and, and emergency work versus routine work, dealing with out of hours calls and some of the uncertainty related to that, which again, you had some great tips. Of, of how you can try and minimise any anxiety associated with that by preparation and being looking out for, for, for those things that can help you in those situations. Compared with other professions that have more perhaps routine hours and a solid career structure may be more predictable, and ours is certainly a much less predictable profession to be going in for, but those same things that make the veterinary profession uncertain.

Also make it much, much more exciting and rewarding, I would say. We're dealing with a, a huge variety of animal types. There is enough variety in the different types of biological system we deal with, to, to keep anyone fascinated and interested, and it's a, it's a hugely rewarding profession to be going into.

Just dealing with clients of different temperaments, sizes, shapes, and demeanors is, is like their pets, an enormously rewarding part of the profession. And, and it's as much as previous speakers have said about dealing with people as it is with, with, with, with, with animals. And you should be thrilled by the prospect of that, not, not anxious about it.

It's a very important part of who we are, as is dealing with your, your colleagues, and if you're lucky enough to, to work in teams of colleagues or interact on a regular basis, you'll find that enormously rewarding. So as veterinary surgeons, we have a professional necessity to show responsibility and leadership in exercising judgement in the absence of certainty. It's essentially what what we're all about.

And our patients aren't verbalising what's wrong with them to us. We have to problem solve that, and we are always making decisions in the absence of certainty in order to help and advise our clients, and in turn then to help in the treatment of their pets or sadly to to recognise that situation where euthanasia may be a better option, a more humane option. Our professional identity is vets is bound up in our, our role of helping clients and, and this picture at the top of the screen really, sort of emphasises that, that bond, that three-way, partnership that we have with our clients and with our, with our patient.

And our role is to help those clients in a supportive and collaborative way, and in turn our clients' desire is to give them professional advice. Remember that they are not paying us for time and or for a pill or for an injection. What they are paying us for and what they desire is our expertise and our guidance.

And we give that in a supportive way based on our knowledge and with discussion in a collaborative way with clients. What that isn't, and, and, and there's sometimes a tendency to in avoiding decision making, and increasingly unfortunately, we see some of these weaselly terms creeping into the veterinary profession that have a better place probably in politics than they do in, in veterinary medicine. Of, of deferring responsibility for decision making upon owners.

So it doesn't mean to say that we should be a, a sort of patriarchal, group that tells owners what to do, we should work with them. But conversely, deferment of decision making and saying things like, oh, the, the, the, the gold standard was offered, but the client didn't, didn't take this, which infers that any problems resulting in their fault, not, not ours. Is, is really something that's best left to, to, to politics.

It really doesn't have a great deal of place in in veterinary medicine and is, is really a source of great antagonism. The very profession and our, our identity and our our self-belief as vets is tied up within our professional identity, which may be exemplified by a number of ideals we may, may adhere to and that our clients would wish that we show those of trustworthiness of being professional, of exercising good judgement, of being knowledgeable, of being competent, and, and, and of being confident as well. Now those ideals and our, our professional identity may be stressed by being pulled in different directions.

This is a graphic from a paper by Liz Armage Chan about professional identity formation and how we as vets view ourselves and how that view, that self-view may be threatened somewhat by being pulled in a number of different directions. And part of our, the challenge of working as a vet is to, to, to try and square those different challenges with our professional identity in a way that we don't feel a dissonance between what we feel about ourselves and those pressures placed on us. So we have to exercise judgement, and that's part of our, our day to day activity.

What do we mean by good judgement? Well, essentially, that is taking up a problem, a degree of uncertainty and through the application of our own personal attributes, our knowledge, our experience and our critical problem solving skills to form an opinion, make decisions and help those patients. And I would emphasise you may sort of look at this and say, well, that's great.

I'm, I'm about to graduate. Where, where's my experience from? And you, you'll have come through an amazing educational experience in which you have been taught a great deal.

And although you may not realise it because you've not had that experience yet, the training that you have had is, is going to serve you very well. And relying on that training and using that training to help you problem solve through situations you haven't encountered before is really important. My first call out as a large animal vet was to a account how to use R tor and it was literally my first call out.

And I had no, I never experienced one before and relied wholesale on what we were taught at college, which seemed to me to be a little far-fetched. We put a railway sleeper over this cow, we twisted it the opposite direction to the torsion and and twisted it, and lo and behold, it worked, worked very well, and I was pretty surprised by it. But there was a wholesale relying on, on, on the training that we'd had.

Remember that good judgement relies on accurate identification of problems and applying logical, critical clinical thinking. One of my main clinical interests is in looking at where mistakes get made. And contrary to popular belief, often or more, more usually mistakes don't get made through lack of knowledge.

They're usually through poor judgement and through cognitive error, those, those errors of of judgement during a clinical process, and usually they occur at multiple sites rather than just at one point. So it's usually not something that is based on a single bad decision. But it's important to look at our knowledge and to turn that into understanding, to take responsibility for those decisions.

This is a quote from Mark Twain. It's a nice one of a bit of a circular argument that good judgement comes from experience and experience that comes from poor judgement often. And learning from those decisions that we could make better, or to constantly revisit and review and refine ourselves based on what's gone on before, is an important part of our learning.

There's no doubt that the pressures on veterinary surgeons now are showing a greater degree of dispersion than they did a few years ago. The attitude of pet owners has become more diverse from those pet owners that may have a A more pragmatic approach to their, their pets, who they may view as companions that they love, but they, they, they're pragmatic about their role in their lives and their financial value and, and, and costs, to those owners that may equate their animals with equivalency to human children or to to to have very broad economic facilities to, to, to treat them. Treatment availabilities have certainly changed a great deal when I start off, we, we were sort of basically making a decision between a brown antibiotic and a white antibiotic, and nowadays I spend time sort of in operating theatres performing complex interventional procedures.

Treaty availabilities have become very, very, more diverse and complex, and we have a challenge to consider those, those situations in which each might be better suited. There's no doubt that client resources have become more available, Dr. Google being ubiquitous, and obviously if the internet is an asylum, the the the discussion chat room is group therapy within that asylum, and we, we quite often deal with clients that come in armed with large amounts of information, both good and bad, that they've derived from the internet.

Veterinary knowledge is certainly increasing a great deal, and, and this little graph is just showing the number of biomedical publications over the last few decades, and currently the, the number of publications in the biomedical sphere is, is doubling every 10 years or so, and that rate is going to increase. William Osler, one of his other, other. Great quotes was that he told the medical students at Johns Hopkins, unfortunately, in 10 years' time, you're going to find out that 50% of what you taught, we taught you is actually then considered wrong, and you followed that up by saying, unfortunately, right now, we don't know which 50% that's going to be.

And that's very true of of of the medical spheres. Obviously, media influence plays a plays a part. Back in the day, there was only ever one programme on television about vets.

That was all creatures great and small. Now, of course, there's still all creatures great and small, just in a new iteration, and of course the ubiquitous super vet, and the, the enhanced client expectations that often derived from that. Social accountability is a, is a, a, a, a big one, but it's not a new phenomenon.

It's always been there. It's just changed in terms of platform and availability. So, back in the day, you were always being judged and, and, and gossiped about in the supermarket or the coffee shop.

Nowadays it's all online. The same rules and adages applied to, to, to not really take that too seriously and not engage with it too, too much. If you value your, your sanity, it's not something you should really pay a lot of attention to.

So getting back to certainty and uncertainty, so, so why is, is, is certainty appealing to us? Well, the brain desires certainty because it takes away from cognitive load. If we had to think very carefully about every decision we make in life, we would be paralysed by, by indecision, because we would be having to think so hard.

So certain situations are familiar, they're safe, they're effortless, they're easy. And gives the feeling of being in control. Conversely, if we are dealing with situational uncertainty, we may feel that we are at a loss of control.

We may feel anxious about that loss of control, and that clouds our judgement and impairs our decision making, and that of course feeds into further situational uncertainty. And the way in which we as individuals deal with uncertainty, those situations may be novel or ambiguous or unpredictable. Varies, and our attitude towards uncertainty can at one end of the extreme be manifested as an intolerance of uncertainty, and our motivations may be to seek safety in our judgments, and that may be manifested as behaviours of worrying and planning and checking and avoidance and seeking reassurance and routine.

To those individuals who more embrace uncertainty. Who is a motivation, have the seeking of experience and learning and mastering those areas of uncertainty within their life. And that tends to be manifested as behaviour that's curious and open and willing to tolerate a certain amount of discomfort in the pursuit of learning more.

And at either end of those two spectrums, we may be so worried by uncertainty that we we we we may indeed have a a generalised anxiety disorder. And conversely, there are individuals who lack empathetic interaction with uncertainty so much that they are guilty of hubris and are are showing a great deal of arrogance. And of course, it's normal to feel some anxiety about uncertain situations.

It shows that you care, and if you didn't have anxiety or or some degree of worry about uncertain situations, that would really be a, a sign that, that, that, that perhaps you are suffering from a degree of compassion, fatigue. uncertainty is a manifestation of, of, of, of caring and, and vice versa. So can uncertainty be a good thing?

Well, yes, it, it can, it forces us to make judgments and develop skills. It allows us to be curious and it facilitates learning. And it mandates thoughtful clinical reasoning.

By definition, if we're certain about things, we don't have to apply that much critical thinking. So uncertainty does mandate thoughtful clinical reasoning. And it's interesting.

If things were certain, our life would be very, very dull, and our life as vets would be very dull. And hopefully, you're excited about going into a profession where there is so much to learn, so much, fascination and interest to, to, to, to deal with. I've been doing this for, for nearly 25 years.

I, I love going to work. I, I get, get giddily excited by what's going to happen each day. As vets, we may suffer from a degree of perfectionist tendencies, and, and there's a, a nice summary from which some of this is cribbed, that is, published by the Veterinary defence Society, and they published a series of, of very helpful guidance sheets in the veterinary record, a couple of years ago.

And perfectionist tendencies tend to be those where we as individuals may strive for flawlessness and have excessively high self standards and hold ourselves up to ideals which really are unrealistic. We're, we're, we're human, we're not going to, to reach those. Clinically, that can be manifested as a tendency to try and micromanage situations where really, that's not going to be possible.

And leads to clinicians often being overinterpretive, so often sort of seizing on a a very mildly abnormal laboratory result and, and really weighing undue emphasis on that, is a, is a common feature. And clinicians may tend to focus on minutiae. Perfectionism's been, it's divided into those perfectionist tendencies that are described as adaptive or useful tendencies that can be harnessed.

So we might use that to accept our failures and realise that we're, we're not going to be perfect, but we can do our best and we can learn, and we can stretch ourselves from those mistakes when held up against what we would really like to be. At the other end, we can have maladapted perfectionist tendencies where actually that becomes a paralysis of of being driven by fear of criticism and being excessively self-critical and feeling anxious and having feelings of low self-esteem, because we're really holding ourselves up to an impossible standard to reach, and that may manifest in behaviours. Such as being unable to delegate to other people, or to ask for, for help, because we feel that that that's a sign of weakness.

We may procrastinate, we may catastrophize. So look out for these, these, things from the BDS if you feel that you, that, that, that, that some description, suits you or fits, fits you of being successfully perfectionist. This is a nice quote from Michael Jordan.

It sort of encapsulates the why failure is important in our, in our lives. He says, I've missed more than 9000 shots in my career. I've lost almost 300 games.

26 times I've been trusted to take the game winning shot and missed. I have failed over and over and over again in my life, and that is why I succeed. And remember, you won't always get it right, but your, your best is, is good enough.

Another feature of, of, of vets and other sort of high functioning professionals is that we may feel that we're not worthy. We may suffer from what's often termed imposter syndrome, a feeling of lack of worth, often because we might think that we don't have enough knowledge. It's worth emphasising and bearing in mind and, and maybe a source of comfort.

And to go back to what I mentioned earlier, that most medical mistakes don't occur through lack of knowledge. They usually occur through poor reasoning and mistakes in testing and assessment, and they don't usually occur just because of one bad decision. This picture on the, the right of the screen is what's often referred to as the Swiss cheese model of, of, of hazard and loss, which is common in, in analysis of medical mistakes that usually there has been alignment of several hazardous decisions before a loss will occur.

It's usually not something that that occurs just because of one bad decision, and it's worth remembering that. It's also worth remembering what it is that clients want from their vets. And Richard Melanby a few years back and colleagues did some surveys of clients in first opinion practises around the Southeast of England, and the, the, the, the main five attributes that that owners would consistently report as the things that they were looking for in their vet, was that they were knowledgeable about veterinary medicine.

Well, that seems a fairly self-evident thing. Being good with animals, yes, being compassionate, knowing when to seek advice, and also confidence. And those last two might seem sort of slightly contradictory to to to each other.

Concentrating on the the confidence part. The same investigators in a, in another study looked at client and vet attitudes towards expressions of uncertainty, and Interestingly, the, the results of that threw up was that the vets significantly underestimated the desire of clients to be told about uncertainties they had, and tended to overestimate the impact that any expressions they made of being uncertain would have on the level of confidence that their clients had in them. Whereas actually when the clients were asked, they were more open to having uncertainty discussed with them.

And in fact, in many situations, it enhanced their belief in their vets. But, and this is an important but, it was a profound influence how that uncertainty was expressed. And if you look at this, it's a little bit of a busy slide this, but this is a couple of the the bits from the questionnaire.

And that if clients had uncertainty expressed to them, that actually generally either improved or had little effect on their confidence level in their vet. It's certainly more seldom reduced that confidence level. But the way in which that uncertainty was expressed, expressing that in a positive way and saying, look, I need to find out more about this, rather than just saying, oh, I'm not sure, or I don't know.

Was very, very, telling in how those clients perceived their, their level of confidence in their veterinary surgeon. Now as vets, how does uncertainty make us feel and, and what part does that play in our work derived well-being? And there's an expression of eudaimonia, which is a, actually from Socrates, a, a fulfilling work description that makes us satisfied with our, our, our working life.

Our, our diamond is our, our inner, inner god. And this has been analysed very well in medical professions and particularly in the veterinary profession, that some of the, the, the, the, the features, the three main features of, of good, enjoyable work, are those of self actualization, those things that make us proud and believe in the goodness of what we're doing. And helping others, both people and animals, and having a sense of belonging to a team or to a profession.

And those self-actualization traits of autonomy, of meeting and achieving complex challenges, displaying skill, opportunity to learn and involve, really involve some interaction with uncertain situations and making judgments through that. So how can we deal with uncertainty? Well, going back to those, those tendencies that you might have of, of, of really being intolerant of uncertainty.

Try and focus on those behaviours which you can control and be objective about. So if those behaviours, it's fairly obvious that worry and avoidance, whilst we may feel drawn towards those behaviours, are not going to ever be helpful. Whereas other things like planning and checking, using checklists is a very useful thing.

If you are someone that has a tendency to be intolerant of uncertainty, using checklists can help with that. As can using what's often referred to as a control-based decision model, which is broken down to three bits. First of all, evaluating the situation to reduce uncertainty, and then looking at those internal features and external features of our decision making that we can do something about.

So with the first of those, focus on the problems, to break that down into what those problems are, write it down, make a problem list, look at the objective information, the data, the parameters, the predictability and certainty. Is this dog vomiting or regurgitating? How often is it doing it?

What's it bringing up? Do we know it's that dog? Has the owner actually seen it doing it, or could it be one of the other dogs in the household?

Think about what you can do to increase your level of uncertainty, and in doing that, you then break down and become more objective about those, those uncertain areas. Think about those things, those biases and traits that you might have that you can do something about. Particularly keep an open mind and think flexibly, try and overcome those personal biases, particularly what's called confirmation bias, where you might try and fit the results of any investigation to the the the disease state or problem that you are.

Bias towards in the first place, that that can be dangerous and lead you up the garden path. So be aware of that. Attribution error is is really placing undue weight on changes that may be a fairly minor significance, and it's often a sign that you're not seeing the wood from the trees.

Write or verbalise problems down, actually using a different media to describe problems is a very good way of taking a step back and looking with a, a, a sort of a fresh set of personal eyes at that. Manage your mood and environment. Do you have to make a decision on this here and now, or would it actually be better if you're, if you're running late in a clinic or you're stressed and pushed for time?

Would there be a better time for you to make those decisions? Does it have to be here and now? There are some situations where that will be the case, others where it where it won't.

So be flexible in your thinking. Mike Tyson famously said, everybody has a plan until they get punched in the face. It's a rather crude way of putting it, but be flexible, be prepared to reappraise, re-evaluate, have contingency plans.

You won't get it right first time all the time, so have a contingency. Don't paint yourself into a corner. Have a contingency plan on where you reevaluate, and that's important in dealing with uncertain situations.

So uncertainty is a challenge, but it's an enhancement. It's, it's a really exciting profession, the very profession, because there's so much to be interested about. I was, last weekend, I was, I wasn't on call, and just on a normal weekend, I had a couple of phone calls.

One was from a consultant at a London teaching hospital who'd had a patient bitten allegedly by a A lion owned by a sheikh in the Middle East that was possibly rabid and wanted to to to discuss the incubation period of rabies and large, large cats. Another call from a colleague is a dermatologist who had an animal that has apparently hematohydrosis, which is is sweating of blood, which is a very rare condition in people that has all sorts of religious and psychological connotations, real X-Files stuff. And that's just the sort of interesting thing that happens on, on, on a, to, to, to vets on a regular basis.

Remember, you're not an imposter. Believe in the training you've been through. You've been through a fantastic educational experience and, and, and rely on that, that, that education.

You will be gaining knowledge through lifelong learning, and remember that mistakes usually don't occur through a lack of knowledge. They're usually through a series of, of poor decisions. And you should be reassured of that and don't feel like an impostor, you're not, you deserve to be doing what you're doing.

Remember that clients aren't just OK with you expressing uncertainty, that can actually enhance the level of confidence with you, if it's expressed in the right way. So clients are more than OK with with expressions of uncertainty, but that should be allied to showing you care and you want to find out, and you're going to do your best. I'd go back to that quote that that Lucy put up earlier, that clients remember how you made them, them feel, not necessarily what the minutiae of what you said.

Remember those things that will make your working life enjoyable. Enjoy the variety. The non-routine is always an opportunity to stretch and enhance yourself.

It might might be a little bit uncomfortable at the time, but a week, a month, a year later, you'll remember the, the, the positives, not the, not the, the, the discomfort, the short term discomfort at the time. And it's worth, while remembering that displaying skill and judgement enhance your self-worth. We've touched on some strategies to help cope with uncertainty, but remember to reflect and talk and learn from, from any errors.

And don't be too hard on yourself. Remember that, that as vets, we probably all have a degree of perfectionist tendencies, but it is something that can be damaging. And I finish with another quote from William Osler there, which he said, To each one of you, the practise of medicine will be very much as you make it to want to worry, a care, a perpetual annoyance to another, and hopefully all of you, a daily joy and a life with as much happiness and usefulness as can well fall to the lot of man.

You will find it a really exciting and thrilling and enjoyable profession, if you look out for that excitement and and enhance it and embrace the uncertainty in what you're doing, because it will make your working life very, very fulfilling. OK, so the topic we've got for today is to talk about behavioural medicine and the question of what makes it a day one skill for veterinary students. So I want to start off just by putting, behavioural medicine within the context of the topic of healthcare.

And so, if we think about healthcare, there's a triad to the way in which we approach healthcare, whether that's of human animals or of non-human animals as we deal with. And that triad has three equally important components. So, we have physical health, emotion, cognitive health and emotional health.

So 3 equally important components, which are interrelated with each other. And that's illustrated a little bit here by this photo, these photographs, because what I've done is I've selected, we've just got dogs on here. We'll look at cats as well as we go through this presentation.

But with dogs, examples here, if you look at the photo at the top right, Obviously used to illustrate physical health, but you can see from the facial expression of this dog that it also has an emotional response to being in the veterinary practise context. You've got some, furrowing here, some tension across the head, a little bit of staring here. And you've also got a cognitive experience, because this dog is learning what from being in that environment and could be potentially building up.

Negative emotional connections. Here, we've got a dog engaging in fly ball, this little jack, and you can see again, there's cognition involved here, and that's what I used it to illustrate, because it's learned to engage in fly ball in this way. But we can also see that there's an emotional component to this activity as well.

In fact, frustration is very strong in these animals who are, engaging. In fly ball. And it's one of the ways in which they get them to go faster and to be more intense in wanting to gain access to that ball.

But there's also a potential, if we look at the way this animal is hitting that plate repeatedly during this activity, there could be physical health complications or implications from engaging in this activity on a regular basis in terms of joints and musculature. And then we have the example that I chose for illustrating emotional health, where we can see, again, the facial expression, ear position, this whale eye here, associated with a protective emotional bias in this dog. But we can also see that there is some cognition.

So it's learning about the person behind the camera. And this dog may also present with, physical health issues, things like intermittent diarrhoea, for example. So all of these things are interrelated to one another, and healthcare involves all three components, your physical, your cognitive, and your emotional health.

So, what is behavioural medicine in a veterinary context? Well, basically, it's a discipline of veterinary science, which recognises this triad in non-human animals, promotes equal consideration of both physical, emotional, and cognitive health, and works to optimise all those parts of the triad so that animals have the most optimal welfare when they are living in a domestic human dictated environment. And so when you think about veterinary behavioural medicine, you might think primarily about the diagnosis and treatment of emotional illness.

And we'll see there are some restrictions to how much that is carried out within a general practise context. But what behavioural medicine is, is far broader than that, and it also involves this identification of links between emotional and physical health. And that is the aspect that really does make it a day one skill.

So let's have a look at what the barriers are to thinking about practising behavioural medicine in general veterinary practise. Some practises don't have a behavioural medicine service, and one of the reasons why they might not feel that it is part of their, remit. I think one of the big problems with behavioural medicine is that people are worried about the knowledge that they need in order to work in this field.

Knowledge about natural behaviour, for example, of the species that we deal with, primarily dogs and cats, but also other species as well. They might be concerned about whether they understand enough about cognition, about learning. And that is important in behavioural medicine, because it's about understanding how behavioural behaviours develop.

And some of the treatment programmes involve cognition and learning and changing associations. But certainly, all of behavioural medicine is not rooted in the, learning theory aspects. We also have concerns whether we know enough about human psychology.

We certainly know that when we look at specific individual behavioural problems, that there may be a strong component associated with the family dynamics or the social environment that the animal's living in. And an understanding of human psychology is important. So I think that knowledge is certainly something that people are concerned about, worried about whether also they know enough about psychopharmacology.

Are they going to be able to understand using medications that are related to changing emotional bias and changing neurotransmitters that affect that? The other thing people are concerned about, I think, is experience. So we get very familiar with certain aspects of veterinary practise quite quickly once we qualify.

So you do a lot of, certain types of interactions. So you start to be able to quite. Rapidly diagnose certain conditions that you see on a regular basis.

But with behavioural medicine, I think people are worried about not having experience with specific individual cases and therefore, feeling that they're not getting experienced in behavioural medicine. And then one of the biggest arguments is that it's too time consuming. Well, if we think about the time-consuming component, certainly, dealing with individual cases is time consuming.

There's the whole part of the history taking, and then the diagnosis. There's also the need to implement a treatment plan, and then also to, give enough an appropriate follow-up support. And that can take a lot of time.

But that doesn't mean that this is not a day one skill of the general veterinary practitioner. Because, although fully investigating a behavioural presentation takes a long time, and for that actual part of behavioural medicine, you may want to refer to a veterinary behaviourist, certainly if you have one locally to you, or with the new arrangements during COVID-19, there's. More availability of online remote access to that sort of help.

You may also want to get support from adequately and appropriately qualified non-veterinary behaviourists who can be extremely helpful, but do be careful when you get out there into general practise, that you look for someone with appropriate qualifications. Look for the initials CCAB, the cert. By clinical animal behaviourists, roll through ASAB and look on the website of the association, the, Animal behaviour and Training Council, the AEBTC, because they hold a register as well of people with recognised qualifications or members of recognised, organisations.

So it is important to get help from the right place. But even if you are going to get help for those individual cases from outside of your practise, the actual con contribution of behavioural medicine to general practise is really significant. So behavioural practise is part of.

Veterinary practise. Vets and nurses on a daily basis consider behavioural factors, often without realising it. And I hope I'm gonna just illustrate the ways in which behavioural medicine is part of everyday general practise, as we talk today.

And also being aware of emotional and cognitive as well as physical health is also a necessity in terms of optimising the way in which we do our job. So, I wanted to, very quickly, cause we've not got long today, just look at 5 potential reasons why behavioural medicine is a day one skill. So let's start off with behavioural change being commonly reported by caregivers.

So, just some examples of the sorts of behavioural changes that are reported, and that can be indicative not only of physical health issues, but also emotional compromise. So, for example, changes in appetite. When we have animals presented with a change of appetite, of course we're gonna think of gastrointestinal diseases, things like pancreatic disease.

But also consider the fact that reactions to food may also be influenced by levels of fear anxiety. Desire seeking is the motivation that drives us to eat. But if fear, anxiety, the protective emotional bias is higher, then these animals may be reluctant to eat, maybe due to social tension in the household, or it may be due to other forms of fear, anxiety triggers such as sounds in the environment.

We may get the reporting of changes in exercise tolerance, and of course we will think about cardiac and respiratory disease and the potential of course for pain to be involved in that. But also from an emotional perspective, animals suffering from high levels of fear, anxiety with what's called a negative emotional or protective emotional bias may also be reluctant to go for walks. They may walk only in certain environments, or they may walk for short distances and then show a need to go back home.

Also, we may get reports of onsets of more unusual behaviours. Those unusual behaviours might lead us to think about neurology, or leading us to think about pain as well. But we can also get compulsion behaviours, so things like tail chasing or shadow staring, which are associated with, again, a protective emotional bias of fear, anxiety, and also coupled with frustration, which leads to these behaviours being done in a repetitive fashion.

So it's important to also consider the animal's emotional health. Other changes that are indicative of either compromised physical or emotional health might include alterations in social interaction or play. These may occur through physical problems such as pain.

We also might see alterations in social interaction. When we have got the onset of endocrine disorders. But fear anxiety as well may also be something to consider, as well as frustration if they're not able to engage in social play or desire seeking motivated behaviours and become frustrated by that.

An onset of confrontational interactions can also have medical causes, pain, and endocrine disorders, but also, we might get hormonal changes, things like false pregnancies, and fear, anxiety and frustration are differentials. So that's one way in which there's an interplay with a day one skill. The other one is where we have this interplay between physical and emotional health.

So these are inextricably linked in both directions. We have a lot of information about this in human medicine, where the presence of physical disease affects mental health, and where having mental health issues is a risk factor for developing physical disease. In a similar way with our non-human animals, we need to consider that physical health conditions impact on their emotional health.

For example, if we have a patient with sensory compromise, they may become disorientated and increased in anxiety, and therefore show behavioural signs. If we have cognitive dysfunction, where there's a decrease in functioning of the ability to, function in a social environment, we get, we may again get increased anxiety, where cognitive dysfunction is a neurological condition with anatomical changes in the central nervous system, but leads to behavioural presentation. We may also get things like polyphagia, where we then get frustration of desire seeking, if they're polyphagic for a medical reason, they may start to show behavioural change, which is what the client notices because they're frustrated.

We also, when we have kittens and puppies who are poorly with physical health in those first few weeks of life, that can compromise their socialisation, their introduction to the world, particularly into a domestic world where people predominate. And that can lead to compromised development, in terms of emotions, compromised learning through socialisation and through non non-social environmental learning. And then lead to increased problems of fear, anxiety, or the potential for panic grief, where panic grief is the emotional reaction to being unable to access your caregiver.

So if you have increased nurturing care because of caring for a young puppy or kitten when they're physically ill, that can then influence their emotional development and make them more prone to problems related to panic grief later. We also have the potential for gut illness, gut dysbiosis, for example, to affect behaviour and emotion because of the high levels of serotonergic production within the gut. If we have alterations in that serotonergic action, then we can get an increase, in fear or anxiety because of depleted levels of serotonin, and therefore a direct effect on emotions and behaviour through a physical illness.

Emotional health also impacts on physical health. So I said it's a two-way street. And so we know that chronic negative emotional bias, so where we have an individual who has high levels of the protective emotions, fear, anxiety, pain, frustration, panic grief, those emotions, if they are predominant, particularly over a long period of time, then there will be a physiological response to that, emotional state.

And that physiological response can then have an effect on the physical body. For example, we can have an effect on mucosal integrity. That can affect various systems within the body.

We can have presentations of disease related to bladder compromise, things like feline idiopathic cystitis. Or we may have gastrointestinal effects, things like irritable bowel syndrome, and, presentations of changes in faecal consistency. We can also have skin changes associated with physiological stress, as well as oral health conditions.

So changes to the integrity of oral mucosa and problems of gingivitis and things, those sorts of diseases. Particularly in cats, and if any of you have ever, vetted in at a cat show, you might know that it's quite common to have high levels of, oral health conditions in some of these cats related to the levels of, pardon me, physiological stress, maybe related to long car travel to get to the cat show, for example. The other thing that can happen when we're in a physiologically stressed state as a result of emotional compromise that it has an impact on our immune system and the same for our patients.

So we may have presentations of diseases such as cat flu. And it may be familiar as well with the term kennel cough for the infectious disease of dogs, but, of course, it's not only related to kennels, it has that name because of the fact that it's been recognised that being in a novel environment, or such as a kennels, where there are higher levels of, physiological stress because the animal is more anxious. May be more frustrated through confinement, which is not normal compared to their normal everyday life, that that can lead to that physiological stress impacting on their immune system.

Obviously, in the case of kennel cough, combined with being in an environment where there's a potential for an increased load of the infectious agent because of the close proximity of other dogs. But outbreaks of cat flu are common, of course, in Qataris and in rescue centres, but also in multi-cat households. We can have problems of chronic stress, chronic emotional challenge because of living in a suboptimal social environment.

If we don't understand the Necessity to create safe environments for each of the, social groups in that household, and then we can get outbreaks of immune, related diseases, infectious diseases, maybe things like cat flu, FIV, FELV, etc. Also, we have to think about the fact that there's a potential for emotional health to impact on pain perception. Pain is perceived and processed within the brain.

There is a common pathway between the anxiety and emotional pathways and those of pain, because pain is an emotional experience as well as a physical one. And so, we also have the potential for enhanced. Perception of pain, increased significance of pain to individuals who have compromised emotional health.

So we that may be manifested to us in a general practise setting with cases such as illustrated here with the cavalier King Charles Spaniel, with syringomyelia chiari malformation. But there are also, of course, other examples. Feline or a facial pain syndrome is another condition, which is a neurological condition associated with discomfort and pain, with the trigeminal nerve being involved.

But in situations where cats are emotionally compromised, we may see an onset of those physical signs, and they will be presented in a general practise setting. Another very common area where there is an interplay between emotional health and physical health is in the area of weight management. Primarily, we think about obesity, and certainly, if we have animals who are consuming food in a compromised emotional situation, then that will lead to a higher level of sympathetic activity during consumption and an increased tendency to lay down glycogen storage deposits.

But we also have the potential that emotional compromise can impact as well, leading to hyperexia, and maybe even to a situation of anorexia, which may be presented to you within the veterinary practise. And of course, in order to get full resolution of that problem, you're then going to need to think about the emotional health of your patient as well as their physical signs. Other ways in which emotional compromise can lead to problems in terms of physical health is when the behavioural responses to those emotions impact on physical health.

So, some examples of that might be responses to fear anxiety. If the response to that fear or anxiety is avoidance, leading to things like bolting, those animals may be at increased risk of things like road traffic accidents. Or if they engage in repulsion responses, they may get engaged with altercations with members of their own species, as illustrated here, with a cat wound from a cat fight.

They may get themselves into situations in dogs where they are more prone to get. Physical injury if they start using repulsion responses to fear anxiety. So if we don't resolve the emotional component, the fear anxiety that led to those behavioural responses, we're going to limit our success in dealing with the physical disease.

Desire seeking can also lead to an impact on physical health when it is, misplaced or when it leads to ingestion of things like toxins or foreign bodies. And also, if we have frustration, so frustration is the emotion that occurs when you cannot achieve an expected outcome. If animals are placed in situations where they become frustrated, so, for example, if they have a desire-seeking motivation for, for a social company and they are not able to achieve that, they may become frustrated, and they may become injured.

This is a, for example, a claw being torn out in a dog that's put in a crate because of a separation problem, and then becomes frustrated by that confinement, and then has a clawed injury that would be brought again to you in a general practise setting. And then in social tension cases, particularly, we think about multi-cat households, if that social tension is leading to compromise of their access to their resources because of not being able to go past another cat or being worried about the other cat being present, then we may get problems such as, Obesity, hyperexia, as we've already thought about. We also might get restriction of access to water with the implications for feline patients in terms of renal disease, or limiting their access to litter trays and problems of urinary retention, increased possibility of urinary tract infections, for example.

So we can see that this interplay happens between physical and emotional health in a way that highlights the importance of understanding emotion as a day one skill in general practise. The 4th way in which we can have an interplay is where compromised emotional health adversely affects your ability to perform your clinical examination or your diagnostic tests. So, for example, if an animal has a protective emotional bias, they come to the veterinary practise feeling, those emotions of fear, anxiety, and also potentially pain.

That may lead to what we term repulsion behavioural responses, where they aim to get rid of the perceived threat, and that of course can make clinical examination challenging, and it can also mean that even if we do a clinical examination, our outcome from that, our information may not be reliable. We also need to think about the fact that caregivers may actually be reluctant to bring their pet in the first place for a veterinary visit, if they perceive a problematic behavioural reaction. And that may not only be being repelling in behaviour, but may also be those animals who use avoidance.

So the cat who shows distress during the veterinary visit, or the dog as well. Who's reluctant to come into the practise. And therefore, caregivers may delay coming to ask for our assistance, and that can be really problematic in leading to us having a delayed diag diagnosis of physical disease.

And we see that particularly in our feline patients, where they can be quite advanced in physical disease before we actually diagnose it, because we don't see them. We also need to remember that physiological stress at the time of sampling for blood samples, for example, can lead to altered biochemistry. We can have elevated glucose, changes in leukocyte and neutrophil counts, or neutrophil lymphocyte ratios.

We can also have changes in things like creatinine kinase readings. So, when we have an animal who has compromised emotional health, we need to be aware of that if we're going to accurately interpret our lab results. And then finally, I thought about the potential for there to be an impact of our treatment approaches on the emotional health of our patients.

So, when we have patients who are hospitalised, that has not only, a benefit to us in terms of being able to offer better physical treatment, making sure we can monitor their progress and their physical disease, we also need to think about the potential for there to be impact on their emotions. They may feel fear anxiety because of being in a novel location. Of course, there's also within that context, the, the emotion of pain, which is a form of fear anxiety.

We may get panic grief if they are separated from their caregivers and they have a strong, either a strong attachment. To them, so it's a panic grief response. Or they may just be frustrated by lack of access to social contact.

That may be exacerbated if they have anxiety and they need social contact in order to resolve their anxiety, they're more likely to become frustrated by being hospitalised. We also may have the potential for our patients to have emotional impact from advice such as confinement. So if we confine because of surgery or injury, we ask people to keep them restricted within, particularly, an indoor crate, for example.

Need to think about the potential for there to be an emotional impact of that and how we might mitigate that. For example, if it's an elective surgery, we may want to train that animal prior to going into that situation. So they have a positive expectation of being in the crate.

We also might give advice, such as restricted exercise for our canine patients that may involve on lead exercise only. If that dog has a high expectation of social play with other dogs on his walks, generally, we may start to induce, again, frustration for that individual. And we need to be aware of these potentials when we're giving out treatment advice to make sure that we're also giving advice as to how to deal with the potential emotional impact.

And then we might think about the fact that we give advice to clients to administer medication at home. We give them tablets or eardrops, or eye drops, and we expect them to be able to give those to their patients in the home environment, to follow our instructions. But have we asked about the emotional Health of that patient.

If they have problems of fear, anxiety, or if they have a prone, a tendency to become frustrated, we may actually be asking clients to do things that are incredibly difficult to do, and we may need to modify our advice or even our treatment approach. So, behavioural medicine is about welfare. I said at the beginning, it's about optimising all three parts of the health triad to give optimal welfare.

And that is undoubtedly within the remit of the veterinary surgeon, because when we take our oath on entry to the Royal College, we actually say that above all, my constant endeavour will be to ensure the health and welfare of animals committed to my care. And welfare encompasses emotional, cognitive and physical aspects of their health. So behaviour is a veterinary responsibility, and behavioural medicine is a day one skill.

So in conclusion, the general veterinary practise consultation doesn't offer enough time to thoroughly investigate individual behavioural cases. And you may need to either refer those or dedicate specific time. But within the veterinary practise context, there are many opportunities to practise behavioural medicine.

To give preventative behavioural advice and to consider emotional health during the veterinary visit experience itself and during your diagnostic process, whether that is for physical health or for emotional health, or for situations where there's a combination of the two. So, understanding the health triad and this interplay between physical, emotional, and, sorry, cognitive health, a typo there, I apologise. So, physical, emotional and cognitive health is a day one veterinary skill.

It improves our understanding of our patients, and it also improves our understanding of their welfare, whether that's during the veterinary visit or during their experience of a health problem. And it increases our ability to successfully diagnose and treat disease. Thank you.

Thank you so much for having us. We're, we're really glad to be here, aren't we, Danny? Very pleased.

And it's the first talk on these lines this year. We often do 2 or 3 a year at different conferences, especially at the different vet schools. And so it's great to be back doing another one.

What we often do is quite an interactive talk, certainly because of the a subject matter. But this time, we, we, we're a bit tight for time. So we want to impart quite a few sort of thinking points to you, and we're very happy to chat to you afterwards if you, we'll give you our email addresses and contact details if you do want to get in touch for a bit more in-depth discussion.

So the transition from practise to university. It is known to be quite difficult, and some people really do struggle, you know, from being surrounded with all their friends and having, having to sort of learn and pass exams to suddenly making clinical decisions sometimes on their own. But what we hope that you find that at the end of this talk is that much of this transition can be managed by changing your own mindset.

So, although this can sometimes be a stressful, stressful sort of situation. Yeah, the mindset is the difference between you thriving and surviving. And that, as you'll find from this talk, that is actually under your control.

Yeah, so thank you, Sylvia, for that really lovely introduction. Yeah, we just kind of wanted to to state here as well that, you know, all the information that we've harvested in, in this talk is not just from our, our both ourselves as, as being 1011, 12 year graduated vets. It's from our two respective online communities that we both set up to support the profession.

So from the UK side with Veterinary Voices and from the career side, with vets Stego diversity, diversify. So this is very much a crowdsourced advice space, if you like. You know, we're both grads from Liverpool, we're both GPs and very passionate about GP life and how important actually being a GP is, but we've also had diversified twists in our careers, like Sylvia said in One Health, international development, research, marketing.

And I think the reason why we're sharing that is because we both ended up following what we enjoy to carve out our career. And neither of us know where we're headed next, really, but we're very much enjoying the journey. And so don't worry about having to find paths.

We all have wonderful and beautiful squiggly careers. So the first thing we often do when we're giving a talk is ask, what do you think of the top stressor for being a vet? And every talk we do and every online discussion we have, the same answers come up.

And this was actually information that the VDS helped us collect as well. And you can see these, I'll let you read these in your own time, but just briefly, you've got the time pressures, the lack of it, you know people booking, two animals in one appointment or double booking appointments because there's so many people need to be seen. You know, owner expectations, consults late in the day, so you're ready to go home at 6 o'clock or 6:30, and that's when the pyometra turns up, and you can't go home for another 2 hours.

The difficulty of dealing with owners who want you to, treat their animal even though they have no money and can't afford it, or the sad situation where an animal sort of can be treated and, and they, and they can't afford it, you, you have to put it to sleep and help guide the owner through that. You know, team dynamics, how well you get on with the rest of the team, what they like to work with, the sort of support you get working on call, you know, the hours you do, whether you're supported or not on call, paperwork, and just, and the amount of driving sometimes we're doing large animal practise, some people drive, you know, over 100 miles a day between visits. So, What we want to take from this slide is that, you know, these, these stresses are not actually clinical challenges.

A lot of people think when they first graduate, they have to keep studying, you know, what do I revise before my first day on the job. Actually, it's very unlikely the pressures that you are going to face when dealing with your first job. Gonna be a lack of clinical knowledge.

It, it's not, it's more about time management, that self-time management, and the way the practise runs its team and its rota and, and the way it plans out the day. And some of that will be out of your control. So in the year of 2019, 2020, there's 17.9 million working days each year lost to stress, and actually, anxiety and depression and stress are now the number one reason for being signed off work above all physical reasons like back pain or Or other issues.

So stress is the most common long-term cause of, of absence from work. And so when it comes from a health and safety point of view, the biggest risk to you not being at work is, is the way you manage your, your own sort of emotional and, and stress levels. But the good thing is, we know that, so there's a lot you can do to, to, to prevent that.

Yeah, I think that's the whole point is, it's not to depress you. This is actually to say, look, there's so many things on this list that actually we can influence and control as ourselves, or alongside our team as well. So, when you're seeing practise, it's quite interesting if you're on clinical rotations or you're seeing practise on EMS, which vets are the most popular, and you'll find that it, you know, which clients tend to bond to their vets, right?

Which vets are always asked for by the clients. And it tends not to be the ones that have got 2 or 3 PhDs and a diploma and a specialist. It tends to be the ones that can really form a meaningful connection with clients.

Very quickly. And it's all about communication skills, and it's all about building rapport. And building rapport with people is probably the single most important thing you can do as a vet.

And why is that? It's because it builds trust. So you've got a couple of minutes to instil in someone the feeling that they can trust what you say and you care about them, and that the, them and their problem and their issue is the most important thing on your mind at that moment in time.

Yeah. And I think these quotes are are really nice things to remember in life in general, not just at work, you know, people do not remember what you said, but they will remember the way you made them feel. And people don't care how much you know until they know how much you care.

So I think they're just really, really good things to keep in your back pocket. And I think it's also really important to remember when you're in a consulting room, or you're out on a yard, there are always two experts there with you in the room alongside that patient. There is that owner with the lived experience and the perceived problem, and then there's us, the veterinary professionals with that technical.

That technical support and technical advice. And I think it's so important that we do bring together that kind of relationship centred care. And I think Sarah Heath actually really spoke really well about that.

I think behaviour is a really amazing kind of clinical anchor to think about that through that kind of lens of, of relationship centred care. Because I used to think as a young vet that I was there to like, tell, tell, tell, like tell the owners what they need to know, tell them everything I know, tell them how to fix it. But actually, it wasn't until I really started to learn to listen and see the world from other people's perspectives that actually the care I could give was actually enhanced.

And while working at the Brook for an international development er er charity, that really, really got hammered home to me, because who am I as a white, you know, Western woman to come in and impose gold standards. In a place where I haven't yet figured out beliefs, constraints, routine, culture, cash and care. So I just think building rapport is just so, so, so important.

Well, you just come in there, Ebony I I probably should have said that it's these little tiny human moments, isn't it, that really build trust and rapport. And for example, they don't have to take much time at all, but you know if I see a colleague come into the consulting room, I always say, oh, I grew up on a sheep farm. I absolutely love collies.

And that one little phrase that you Said changes the entire tone of the consultation because they know you're a vet when before they walk in the door, but what they didn't know is that you really love collies, and you can, you say that about any sort of meaningful connection you can make with someone, but, you know, this is my favourite breed. I absolutely love golden retrievers. We used to have one of these, you know, that, that kind of phrase takes about 5 seconds and it, and it completely turns a what is quite a clinical formal situation into a real human connection.

Hm. And so, I often speak to to students who are really worried about what they say in the consult room, what do they say on the yard. And actually, I always say to them, right, think about all the jobs you have done before and whilst being at vet school, both paid and unpaid.

And I love this by Neil Connell, one of our previous RCVS presidents, you know, saying the things that he used to do before he became a vet. And I, you know, I did waitressing. I was a barmaid.

I worked in hotels, I ran a travelling kitchen. I worked as an intern in a music television company, loads of weird and wonderful things. And I know that so many of you have also done the same thing.

And the reason why I'm saying this is you already have these amazing skills to listen, build, report and provide customer service because as veterinary professionals on the front line, That is one of the most important things that we do. We are actually, you know, front of house, we are customer service. So often we worry about what to say.

Well, by listening, chunking and checking, feeding back, doing all the things you've done in bar and restaurants, you're actually, you've actually got the core of that skill already within you. It just takes the pressure off when you look at it through that type of lens. So one of the things that you worry about most when you first graduate is that people are going to realise that you don't have a lot of experience and they may feel that you don't have enough knowledge.

And one thing to completely reassure you, if you're standing there and you're examining maybe a dog's eyes in the consultation room in front of the owner and you don't know what's going on. It is absolutely fine to get someone else to come and have a look as well, to give a second opinion or basically tell you what to do. And owners have never once complained about this.

You might think it's showing you up, but once again, it's all to do with how you phrase things. So you don't, you know, look in the dog's eye, maybe if you're an ophthalmoscope, look into it and go. Oh my God, I've never looked in an eye before.

I have absolutely no idea what's going on. That won't instil confidence, but what you can say as you look in the eye and go, now this is really interesting. I've never seen one quite like this before.

You don't have to say I've never looked in an eye before, you say, I've, I've never seen one quite like this before, and I'll tell you what. Richard, in our practise, he, he is really interested in ophthalmology, and I think he'd be very interested in in having a look at this. So I'd like to get his opinion on this.

Owners love it. If their animal has a slightly unusual case, they also love it. If they feel like they're getting 2 for the price of 1, you know, 2, you can even say that as a joke, don't worry, we won't charge you double, you get 2 vets for the price of 1, and they, they always laugh at that.

And I still, at 12 years graduated, regularly get other people to come and have a look at animals for me. And, I have never once had an owner complain about that whatsoever. They've always been delighted.

Mm. Absolutely. And, and Danny, it's, it's right, isn't it, on Veterinary Voices, there was someone, who was kind of 17 years out.

Do you want to just share that quick story? Yes, I mean, it was back when we first set up the group, a few years ago now they, they said that one of the most encouraging things for them were reading the comments. Because they felt that at 17 years graduated, they should know everything by now.

They shouldn't be uncertain. They shouldn't need to keep looking things up or asking for second opinions. They said in just reading all the comments, they realised no one knows everything.

Everyone has to ask for second opinions, and it's normal to be uncertain and make decisions with uncertainty. And that's someone, and she said she's really enjoying her job a lot more now, knowing that it is normal to not know what's going on exactly in many of the cases you see. And thirdly, perfection is the enemy of progress.

Now all of us will have perfectionistic tendencies. We all fit on a sliding scale of those type of tendencies, but it can be absolutely exhausting if we're always operating, thinking and acting at that highest level. So I really like to kind of say to myself and ask myself, what's the end goal?

Is good enough actually good enough? And, and am I going into default perfectionistic tendencies here, or is it necessary? Necessary?

Probably gonna be if I'm doing some surgery. I probably need to pull out some of those that, that, that those tendencies potentially, but I don't need to be doing it for everything that I'm doing in my job, because again, it is exhausting and it's a stick that we often beat ourselves over the head with that we don't need to. So I always just say to myself, what's the aim?

Because I firmly believe now, and it's taken me 11 years, good enough is good enough, and I know that Danny, very much knows that good enough is good enough, and why is that, Danny? Well, this has sort of become my motto, and maybe unintentionally, but I think, you need to have realistic expectations about what you want from your career. From, from a, from a day in practise actually, because there are times where you will get the diagnosis absolutely spot on, the treatment right, and the animal will die anyway.

That's medicine. And that is not a failure. That is you doing everything right and having unfortunately a bad outcome.

There will be times when you do everything perfectly, and the owner will complain. Even though you got the treatment right, even though the animal got better, you've done nothing wrong for whatever reason, the owner will complain. And you have to make sure.

That you're in, at the right state of mind to not see that as an absolute failure, because some people, when they get a complaint, they, they think I can't do this job. They catastrophize it to the point where they think I'm not good enough to do this, you know, I need to quit or I'm I'm, I'm, I'm going home thinking about them. And actually, in, if you put it in perspective, you've probably seen 30 consults that day.

29 people were really happy with the service you provided, with the treatment you gave, you've reassured all those people. One person complained, quite possibly unfairly, and that's the only thing that you're thinking about. So you really have to get to the mindset that good enough is genuinely good enough.

If most people are happy, most of the time, you're doing a very good job. And I think You know, to give yourself the, the right kind of attitude towards being complained against, is that we all know that you will definitely get bitten at some point during your career. You'll definitely get kicked at some point during your career, and you will definitely get complained against.

And if you know a vet who has been kicked, you don't think they're an awful vet. If you know a vet who's been bitten, you don't think they're an awful vet. And if you know a vet who's been complained against, you don't think they're an awful vet, and it's exactly the same for you.

Yeah, absolutely. You know, I just think it's important to, to note that we, we will make mistakes. Danny and I have both made mistakes.

Sylvia has made mistakes. We've all made mistakes. But I want us to think about it through a slightly different lens, because it is very, very, very unlikely.

That when a mistake happens or a near miss happens, that it's just down to you and you have to carry the weight on your shoulders. It's usually a cacophony and a melting pot of lots of different things that might have happened, such as things with the patient, the owner, the communication within the team, perhaps the training or the the equipment you might have had, the working. Conditions, etc.

So I really do urge all of you to check out the VDS VettSafe campaign and tool. And you can see these playing cards here, which are excellent. They're actually a really good way of starting a conversation after there's been a mistake or a near miss within a practise to actually go, OK, do we need to do anything about our equipment?

OK, do we need to do anything about our training here? Because I think it can be so soul destroying to take the weight of that mistake on your shoulders, when, when usually, it's, it's a, it, it, it's a number of errors that come together, that we can all learn from as a team and as an individual. So I just think it's just really, really, really important to remember that.

Exactly right. And most mistakes when you actually drill down into them, they turn out to be a failure of an entire team or a system. It's very rarely that it's a mistake that you have been made solely on your own.

You're either working in a situation where you're unsupported, or if you're, if you're having to perform surgeries about the right type of support or training. You know, that's not a fault of yours. And a very good book I'd recommend is Atul Gawandi's written a book called Complications, and it talks about these, these complications that arise in medicine and how rarely they are to do with individual error.

And just to highlight that, and I do a lot of work in different practises as a long-term locum sometimes, so I'll sometimes cover maternity leave for a year in one place. And I worked in one practise for a whole year, and for a whole year, I don't think I had a single client complaint, none that I'm aware of anyway. And then the next week, I finished that job and I started a new job, and by the end of the week, I had 6 complaints in that 1st 5 days of working.

Now, I was the same vet, doing the same job with the same skills and the same knowledge and the same approach as I had been the year before, but because of a whole variety of factors, including, you know, the, the, the customer or the client kind of journey. From when the receptionist answers the phone to booking in the appointments to the, I was doing courses, maybe. So, you know, the times that they, they book in, whether you're going to be running late or not, the pricing structure, like, for example, some places have a, a dental price that includes sedation and sometimes it's separate, so they only think it's going to cost one amount, then adds another if you sedate.

All these kind of various things. So it's not worth going into all the details. But if my first My first job had been in that job where I had absolutely no complaints.

I think I was an amazing vet. And if my first job had been in that practise where I had 6 complaints in a week, I think this is not for me. I need to quit this profession.

It's awful. And that just goes to show how much of an impact the practise management team structure and support have on you as being a vet. So number 4, work daily on your resilience, and I must say, I've got a, I've got an interesting or I love hate relationship with the word resilience, but, but I believe it to be the ability to actually bounce forward when curveballs are thrown at us and that come our way.

And this year, this last year has been a lesson for everyone, and, and none more so than vet students in my opinion. But you've actually, in a sense, been forced to develop resilience, right now, because you have dealt with uncertainty, you've dealt with creative ways to learn. You know, all these skills that usually when you graduate, you start to develop them.

And I keep saying the word development them because it is a skill that needs practise, like building your muscles, or anything else. OK? So the fact that you've had almost like a crash course in it.

You might not be thanking it now, but I can guarantee you will be thanking it in the future. So, just, just think about that when you go out into the workforce. And I like to use this tree analogy, you know, we need to develop these skills and develop this, this ability to, to support ourselves, to move us forward, so that when wind comes, we don't bend and break, we can actually bend and flex and move with the times.

But it's not all just about us, is it, Danny? That's true, and what you have to learn to be is responsibly selfish. So there will be times when you have to be able to say no.

Maybe that's to extra nights on call or to, you know, responsibilities or requests from your friends and family. Be really busy, you need to be able to look after yourself and your mental health. And so in a nutshell, it, it's simple, but it's difficult to achieve.

So you need, you need to have enough time to relax. You need to be time to exercise, you need to have time to be able to sleep and eat properly and. You often go through sort of short phases when you can't meet all those things for various reasons at work, but if you're, if it is normal for you not to get enough sleep, normal for you never to finish time to do any exercise whatsoever, never have the energy to even cook something, and any weekend you have off, you're just crashed out and too tired to socialise, you are gonna struggle.

So you need to be responsibly selfish to ensure that your, that work, is, is, works for you, because you cannot look after others. You cannot deliver care to your patients if you do not care for yourself, because that is when you are more likely to make mistakes or struggle to cope with a complaint and, and find that more stressful than it has to be. So, I think it's, I think when, when you, when you, when you're looking for a job.

Have a look at the atmosphere of the practise, the, the team morale, you know, speak to maybe the person who's leaving, see what it's like working there, because what's more important than maybe the, you know, the, the, how new the operating theatres look or what type of equipment they happen to have, or even what the salary is, is whether people have a sense of camaraderie, whether they feel valued, and whether they enjoy going to work, and whether they often finish on time. You won't finish on time every day, but often. And I think if, if your, if your work is really affecting your mental health, no job is worth your health.

No job is worth your mental health at all. And as Ebony has these tree analogies here, and she said, oh, you're not a tree, you can move. So at the moment, there are more jobs than there are vets.

It's an employee's market. So do not stick in a job that is affecting your mental health. And just like me, when I struggled in one practise and did really well in another practise, you'll probably find there's one that suits you much better if you're struggling.

Yeah, absolutely. And so, number 5, the problem is never the problem. The problem is always our attitude to the problem.

We have to remember that how we think about something directly affects how we feel and then therefore our behaviours. I can't control the curveballs. I can't control.

A pandemic coming and sweeping across our globe, but I can control how I choose to react and to respond to it. And I think that's just so important to remember, as we move through life and through work because there will be curveball after curveball after curveball. I'm a freelancer, so I'm, I'm a locum vet, but I'm a freelance educator, and I do other things.

And when the pandemic hit, the first thing that went across all organisations was freelancers, because they needed to save money. They didn't know where work was going to come from. And I panicked.

And I thought, right, that's it. I'm just gonna be, how am I going to get a job, etc. Etc.

And instead of worrying about it and, and playing my violin and being a victim, I actually said, right, When there is challenge, there is opportunity. And I actually went out and I'm, and I contacted companies and vets and, and event organisations that I knew were struggling because they didn't have necessarily the digital acumen that I had. And I've never had a busier year.

So again, by changing my attitude to the problem, I really helped myself. And I know Danny's got a great story about this as well, because he was thinking of giving up doing equine because the long driving can be pretty arduous, can't it, Danny? That's exactly right.

I happened to have one job where we were driving about 200 miles a day, that's sort of little country roads, you know, maybe only seeing 3 horses a day and driving for 7 or 8 hours a day, and I was finding it really depressing, and I then just discovered, I subscribed to Audible, where I could listen to audiobooks and reading was actually one of my passions. And as a vet, I was really struggling to have time to do any reading at all in my own time, whereas it completely changed my attitudes. And now, when I get a call that's an hour away, I'm really pleased because I get to listen to another chapter of a book that I'm really enjoying.

So I'm getting paid at Work to do something I would do as a hobby. And that's an example of something being a genuine problem, and then turning into something that's actually something very pleasurable to me. And, and Ebony and I both had similar situations.

I had to take quite a lot of time off work to look after my dad, who wasn't very well. And it's, it's something I wouldn't have chosen to do. But because I was at home helping look after dad, I ended up to write articles for magazines like New Scientist.

I ended up getting involved in RCBS and standing for council, and it's all things I would never have done if I had just been really busy, snowed under, at work, not having time to think about what else can I do. So what was something I wouldn't have chosen to happen has actually turned into really interesting opportunities, and Ebony's had exactly the same situation. Yeah, yeah, absolutely.

And Danny's gonna just do a very, very quick analogy on this because it makes us laugh and keeps us thinking positively. Yes, so I, I love taking photos of all the animals I see, and one thing you notice when you're in practise is that a Labrador will come in for its vaccine, and it'll be really happy to be there. It'll get a bit of fuss from the receptionist, get a couple of treats, it'll say hello to other people in the waiting will come in.

It often thinks when you're opening the syringe wrapper that, you know, you've got another treat for it, and it sits there wagging his tail, you give him a treat, doesn't notice the vaccine, and he goes out. And then a collie will come in, and you know that they're dragging it in from the car, it ends up urinating all over the waiting room. They have to have a muzzle along, so it's like snappy.

You have to get a nurse in to help restrain it. You won't take a treat, you give it the, you give it the vaccine, that squeals it, gets out of there as quick as possible. And you think that Labrador had a brilliant day, met some new people, had some extra treats, didn't even notice the vaccine actually, and he had a Great time.

If you ask that colleague how is day one, it was the worst day of the year. It was stressful, he's pinned down, his, you know, just, just the most stressful thing that's happened to him that year. And yet both of them had exactly the same thing happen to them.

They both turned up for their annual booster. One had a brilliant day, and one had a terrible day. And we all know people, we all know vets actually, who always seem to have a terrible day.

And other people who always seem to have a funny story at the end of the day. Now, although we do genuinely have some good days and bad days, it's probably unlikely that one person's always having good days, another person's always having bad days. It's likely that they will have pretty similar days on average, and they take home from that day what they want from it.

Yeah. And I like to look at that analogy as well through the analogy of radiators or drains. You're either a radiator and you emit warmth and people want to be around you, or you're draining.

So you can decide which one you would rather be. So, number 6 is seek and serve your support system. This is precisely why Danny and I both started veterinary online support groups with Veterinary Voices and Vets Stayodiversify to provide a support network.

And I know in COVID times, this won't always be like this. But if you're thinking, oh, I wish there was a group for insert what you want, I don't know, vets who kayak, I can guarantee there will be one out there that you can go and find. It doesn't even have to have the word vet in it, you know, go out and find other people like you, or people who are different from you and give you new perspective perspectives, because, we don't have to do this, this journey alone and this career alone.

You know, you, you go from being at uni, usually around lots of friends with big support systems, and you're thrown out into the world that's, you know, that can be quite geographically and mentally isolating. So just do make sure that you seek out those places. If you're in the UK, the BVA Young Vet Network is another great one, and there's a picture of me here volunteering at my local city farm and trying to support and inspire the next generation of vets to come into this awesome family.

But also remember, it's not just about consuming from these communities, it's also about contributing. And when we can contribute, we also feel better. When we can help others, we also feel better.

And every single one of us, whether you're in 1st year, 2nd year, 5th year, 2 years out, 20 years out, all of us have a story, and all of us have experience that can help each other. And you know what? When stuff's not very good, and you're not feeling great, it's actually OK not to be OK, and it's actually really important that you find a safe space to talk about it.

And the more you can do that, the more help you'll get, the more we'll normalise and stigma that's often around, always having to be. Strong and and healthy, and sometimes we, we're not, and that's, that's OK. And actually, I think it's really important to remember.

I've been quite vocal about my mental health journey. When actually I opened up and shared some of the pain that I was having, it allowed other people to do the same. And it also made me more empathetic.

Because I understood, yeah, what, what someone else's pain might be perceived like, and that actually made me a better caregiver, not only to patients, but to clients and my colleagues as well. So I think it's just really, really important to, to seek and serve your support system. And it might come from a, a myriad of different places, but just keep finding a place that you feel that you can fit in and you can contribute.

I think that's right, Ebony, as well, because what we discovered in the pandemic is these online communities really are real communities. And you know, if you've had something amusing happen that day, just share it. It'll make some people laugh.

You'll give them smile that they need. If you've had something bad happen, feel like, if you feel comfortable, share it, because someone else has probably had the same thing happen that day. They'll feel better and you'll feel better knowing you're not the only ones, and you'll get a lot of reassurance from other people.

So this last one, for me, I think as well, it's really important in the job that we do to, to be mindful of these. Beautiful moments that we get every day, and often, you know, the stress and the, the, the time pressures and the other things that are going on in our lives mean that we forget how much good we do and how lucky we are to be sort of working with these animals and owners and helping people all day every day. And for me, one thing that makes a big difference is I take a photo most days of, of things that just make me smile and Otherwise I'd just completely forget.

So this photo of the horse having a cup of tea, he's about 35 years old. He'd had a cup of tea with sugar in it every single morning since the owners had owned him for the last 20 years. And actually we had to put him to sleep, and it was his last cup of tea, and it turned up through sort of discussion with the owners that they'd bought it for their daughter who had actually died of some type of cancer fairly young.

She was only in her 40s, and they still kept this horse, so fairly elderly people because it's their daughter's horse, and and at the same, that week, it was actually the week my dad had died as well, so we sort of had quite a lot to talk about. And that, if I hadn't taken that photo, that memory would just be completely lost to me and just sort of rushing by and sort of life, and you forget, you know, how many beautiful little interactions you have. Whereas there, I can remember the name of the horse.

I remember what the people were like, I remember that story. I remember that was in Somerset. And It just makes you realise how much of an impact you're having and how many meaningful interactions you're having all day every day.

And there's a picture there of our friend called Cal, who was the first, who's a vet, the first person to paddle board from Land's End to John O'Groats to raise awareness for, for, for environmental reasons, for plastic pollution, in particular. And You know, she loves being a vet, but her identity is an environmental campaigner, and her job as a vet, which she enjoys doing, but it makes money, so she can be involved in making these beautiful films and raising awareness on environmental issues, and that is her purpose in life. So her entire identity isn't wound up with being a veterinary surgeon, so that if that feels like it's going wrong, like if your job isn't.

You know, people complained, whatever. It's not a reflection on, on, on you as a person. And I think as well, it's a really good picture of Ebony and Charlotte Dejan, and I know she's sort of a hero of yours, and you always thought you're going to work with sport horses, and because you sort of followed your passions doing other things, you still ended up working with her anyway.

Do you want to sort of feel that. Yeah, I just gonna say, you know, we're such a privileged position to be veterinary professionals. And although I was working as a vet for the Brook charity, I actually signed.

Stepped, because I got really interested in public engagement with the charity and working with our ambassadors and helping to fundraise, and Charlotte Duan was one of our ambassadors at the time. And, and it was just great to be able to connect with her over a common love of animal welfare, be it in this country or abroad. And you just meet the most incredible people on your journey as a vet.

They're not all 3 times gold Olympic medalists, Olympic medal, they're lots. Different people, all of them unique with these incredible stories and passions, and to be around someone like Charlotte Dean with that passion and that talent, and that work ethic. But, you know, you'll just meet so many incredible people.

So much like Danny with taking a photo, remember a memory, I just really like to think that everyone you meet in this profession can lead you to a wonderful story or a wonderful new part of your career, and just to cherish those moments, really. So we hope that some of these little tips and. Hints and suggestions will, you know, help you, think about how you, in a very constructive and proactive way, how you approach challenges and, problems in practise.

We've already got a question here is what we're going to ask you is, you know, is there any suggestion or action that we've, we've made today that, you know, you'll find useful. Someone here has asked you, how do you deal with and protect yourself against client defamation. Many of the times you might have done nothing wrong, and defamation can happen because a client doesn't agree with something you did, that can have a big impact on the future reputation and potential clients.

Yeah, so, well, that is something people worry about. Now, that's not to dismiss, I'm not trying to dismiss this as a concern because it, it can be a concern, but all I would say is it's Very rare when you consider the number of consultations that go every day and every week, that people get to the point where they complain on social media and really go after someone. There's thousands of vets doing thousands of consults every day, and every now and then when a story like this comes up once a year or so, you know, it's, it's that rare.

But it's normally a problem for the practise to deal with. It's, it's rare that they'll be targeting an individual vet, . And once again, this is when you need to have, be sure you're in a practise of a really good support network, where you know your, your managers, your senior vets, the clinical directors, the, the rest of the team are on your side and looking after you.

If you've done nothing wrong, you've got nothing to worry about. You can only do your best and Once again, not trying to trivialise the stress you can feel when someone does make an unfair complaint, because it is very frustrating. I'll be completely honest, I've made mistakes before.

Owners probably should have complained, and they didn't. And so I find that you've got to have a bit of a philosophical attitude and that you win some and lose some. So I've got a way, for want of a better word, without being complained against when I deserved it.

So I get the occasional complaint when I don't deserve it. Well, you know, at least, at least it can't progress to anything serious. Do you have any advice on that you don't, you don't, I think the most important thing is you don't, worry alone.

I think it's really important that you have, like Danny says that support structure, but it's really important that your, your practises have policies in place that can support you. And the VDS are absolutely fantastic at taking you through how to respond and how to react to any of these defamation, claims. So, you know, just make sure there are professionals around you to support you and.

Around you to support you and to talk it through and to just keep good documents of everything you do, so that we, we always go off off fact over feeling. And I think that's just really, really important. Once again, there's the Vet Life charity, which you can phone 24 hours a day if you're feeling stressed about anything, including something like this.

And all the volunteers are vets and vet nurses, so they know what it's like working in the veterinary profession. They'll know where you're coming from. They know what that kind of stress is like.

But, you know, I do have to say, This is not something you should be concerned about when you go into work every day. You know, the, the huge majority of people are phenomenally grateful for everything you do, and it's you'd be very unlucky and unfortunate to be someone who got on the end of one of these situations. It's, it's very unlikely to happen, both statistically and if you, if you're a friendly, nice person, it's, it's hard to complain against someone who is nice to you, isn't it?