In conversation with Professor Rob Foale; what is mentorship and what could I gain through it?
Dr Ellie Duffy
VVS Commercial Manager
Here at VVS we are so proud of the Internal Medicine Mentorship Programme. It is unique and personalised CPD, that is tailored to each mentee’s specific aims, goals & needs through one-to-one sessions and group seminars.
I caught up with Professor Rob Foale, RCVS and European Specialist in Small Animal Internal Medicine, and our fantastic VVS Internal Medicine Mentor, to discuss the Mentorship Programme in more detail.
E: Hi Rob, so I know you have really enjoyed the Mentorship Programme so far, but for those who aren’t quite sure what that involves, can you explain what mentorship is?
R: Mentorship is a process in which an experienced colleague helps, guides and inspires someone or a group of people to learn new skills and develop themselves both personally and/or professionally in specific areas through a series of regular meetings.
I work with our ‘mentees’ in two ways: 1) 1-2-1 mentoring, where I meet with the mentee on a regular basis and we work through the areas, subjects or topics that they wish to improve in. And 2) group mentoring, where our current cohort of mentees meet regularly together in our monthly seminars, and we work together to build knowledge and improve our approach to different topics.
E: So, what is different about mentorship compared to other types of CPD?
R: In traditional CPD, the company and/or lecturer set the topic to be presented and deliver a pre-determined set of key learning objectives, and how much the delegate learns really is up to them. In mentorship however, although the mentor has key skills and knowledge they will endeavour to impart to the mentee(s), the mentee(s) also have the opportunity to tailor their learning and development to areas they really want to develop themselves, thereby creating a personalised learning journey that they are motivated to embrace because they have set the agenda. The 1-2-1 teaching also creates an environment in which it is possible for the mentor to address areas of difficulty for the mentee in a personal and direct manner, thereby significantly enhancing the learning experience and the value of the sessions for the mentee and in turn, improving the degree of learning and development the mentee experiences
E: What are your favorite aspects of the mentorship programme so far?
R: Firstly, I have really enjoyed meeting and getting to know the colleagues on the programme and creating new professional friendships. Secondly, I love seeing colleagues learn, grow and develop their thinking skills, and then go on to apply these skills in their clinical practice within only a couple of months of starting the programme. This has been immensely satisfying and has re-enforced my belief in this process. Lastly, I too have learned new things from each and every one of our mentees, so the transfer of knowledge is very much a two-way process, which is really enjoyable!
E: I can imagine it must be so rewarding to see that process in each person. So, what have you learnt from the mentorship programme?
R: Well firstly, talking to colleagues in first-opinion practice is always a humbling process because the skill set that these colleagues have (but they often fail to recognise!) is incredible and listening to how they approach and manage their day-to-day cases is extremely informative. Secondly, there are clearly trends in ownership (such as the huge growth in raw diet feeding) that are seen much more in first-opinion practice, than we see in Specialist referral centres, so understanding these trends is helping inform my own clinical ideas and practice. Thirdly, more clearly understanding that some of the restrictions or limits we work within are different in first opinion and referral practice (but one is NOT better than the other!). This is really helping me learn and understand new ways of guiding them to be able practice to the very highest possible standards and improve their professional satisfaction.
E: What sort of things might you discuss within a mentorship session?
R: Well, as I have mentioned, every mentee sets their own agenda, so it is really up to the mentee(s). But something I work with every mentee on, no matter the topics, or their experience, is problem-orientated medicine.
One of the cases we discussed in an earlier seminar was a patient called ‘Bella’. Now Bella was a great example for a problem-orientated approach, as with her everything was not quite as it might have appeared, and she showed how this approach can be helpful. So Let’s talk about Bella…
Case Study: Bella
With Professor Rob Foale and Dr Ellie Duffy
Signalment: 6-year-old, female neutered, Samoyed cross.
Presenting history: 6-day history of progressively worsening diarrhoea, started to vomit 3 days ago and now inappetent. Vaccinations all up to date, over the counter flea treatment monthly, last wormed 6 months ago and no travel history.
Clinical exam: Quiet alert responsive, HR 76, RR 28, T 38.5 C, MM pale pink but tacky, cardiopulmonary auscultation unremarkable, appeared uncomfortable on abdominal palpation but no obvious abnormality.
So firstly, for the reader, what are your initial thoughts reading this? How would you approach this case in your clinic?
Within the seminar we discussed what we would do next with Bella, what questions we wanted to ask the owner and other parts of the history that might help our approach. We agreed the first steps were to provide IVFT, as she appeared clinical dehydrated, whilst we composed our problem list and considered our differential diagnoses. A problem list is so important, as you will see.
- Dietary – hypersensitivity, intolerance, diet change, poisoning
- Anatomic – foreign body, intussusception
- Metabolic – hypoadrenocorticism, acute pancreatitis
- Neoplasia – small intestine or large intestine, hepatic
- Infectious – parvo, coronavirus, adenovirus, salmonella, campylobacter, E.coli, parasites
- Toxic – food, other sources
- Vascular – mesenteric thrombosis
- Dietary – indiscretion
- Anatomical – intestinal volvulus, intussusception, GDV.
- Metabolic- hypoadrenocorticism, hypokalaemia, hypercalcaemia, diabetic ketoacidosis, acute pancreatitis, acute hepatitis, acute urogenital tract disease, peritonitis, pyometra
- Neoplasia – GI, intestinal, pancreatic, hepatic, peritoneal, urinary tract, CNS
- Infectious – CPV, CDV, FPL, FELV, FIV, coronavirus, salmonella, campylobacter, clostridia, E.coli, protozoa, ascarids, hookworm, whipworm
- Toxic – heavy metals, digoxin, NSAIDS, erythromycin
Looking at Bella’s signalment, history and clinical examination, our major differential diagnosis list was refined down to:
- Acute gastroenterisis
- Intestinal obstruction
- Renal Failure
Now, when we run any tests we want to ask those tests to answer specific questions about our patients. Looking at our major differentials we have our hypotheses of what changes we might see in her blood results, and we are trying to rule in or out some of those things with the tests we choose
|Total protein||53 g/l||55.0-75.0|
|Urea||14.2 mmol/l||2.5 – 6.7|
|Potassium||6.0 mmol/l||3.6 – 5.6|
|WBC||17.4 x 10e9/l||6.0-17.0|
|Neutrophils||10.8 x 10e9/l||3.0-11.5|
|Lymphocytes||5.2 x 10e9/l||1.0 – 4.8|
|Eosinophils||0.6 x 10e9/l||0.1-1.3|
Summary of significant findings:
- Low Na+ and Cl–
- High K+
- Low Na:K ratio
- Elevated urea
- Lymphocytosis in a stressed animal
Based on our problem-orientated medicine approach, we have a young-middle aged female dog with a history, clinical signs and clinical examination findings potentially compatible with hypoadrenocorticism, hyponatraemia, hyperkalaemia and a lymphocytosis, with no stress leucogram.
Our main DDx now is therefore hypoadrenocorticism.
Therefore we know what question we are asking next: Does Bella have Addison’s disease?
An ACTH stimulation test is therefore the most logical next step.
|Pre-ACTH||145 nmol/l||15 – 110|
|Post-ACTH||437 nnol/l||220 – 550|
Bella has a completely normal ACTH stimulation test result! She cannot have Addison’s disease.
This was not what we expected, despite Bella ‘quacking like a duck’ as it were. Therefore, we go back to our problem list and refine our differential diagnoses.
So, here are our differential diagnoses for hyponatraemia and hyperkalaemia
- Severe enteritis (consider bacterial enteritis)
- Trichuris vulpis
- Third space fluid loss
Reviewing our refined differentials, our next step was a faecal parasitology and culture.
Bella’s faecal parasitology identified Trichuris.
So, she in fact had pseudohypoadrenocorticisim – everything was suggesting she had Addison’s, but she actually had severe GI inflammation associated with a Trichuris infection.
You can see this with severe diarrhoea – Salmonella and Whipworm (Trichuris) are classic for this presentation. With severe diarrhoea you see a loss of Na+ and Cl– into the gut, you also see a loss of HCO3 into the gut causing an acidosis. This acidosis then causes hyperkalaemia.
Bella made a complete recovery with IVFT and anthelmintics.
Our conclusions from Bella:
- By adopting a problem-orientated approach, we were able to develop a personalised investigation plan appropriate for this case
- Testing was focused and rational – we had a plan of what to do when we didn’t know what to do!
- Reflection and re-consideration of problem list and consequential DDx is VITAL!
- Accurate diagnosis reached quickly, enabling accurate and rapid treatment.
If you are interested in mentorship with Professor Rob Foale get in touch with the VVS Team on [email protected].
And here are what some of our current mentee’s say:
“The mentorship programme has been so helpful and fun. Rob is a great teacher and mentor; you can speak to him about anything. As a diversifying vet (after 15yrs of equine practice) trying to knock the rust off my small animal skills, the mentorship programme has shown me how to approach difficult cases with confidence.”
Dr Rebecca McConochie MRCVS
“Rob is a fantastic mentor and has boosted my confidence hugely… I would highly recommend the programme – it has given me the tools to practice excellent medicine within a first opinion setting.”
Dr Annabelle Acres MRCVS
Clinical cases can feel overwhelming to deal with in general practice, but VVS’ friendly world-class specialists are on hand to support you and to enable you to bring outstanding clinical care to your patients and reassurance to their owners. Seamless multi-disciplinary support from our internal medicine and oncology team is available to you for patients such as Bella, so you feel supported throughout as the case progresses.
Get in touch to speak to us further about trying this unique service in your practice!