Latest / The Derm Vet Podcast / 210. Veterinary Dermatology in Mexico -- what's the same and what's different?

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210. Veterinary Dermatology in Mexico -- what's the same and what's different? · The Derm Vet Podcast

• 0:00
  One of my favorite things about the podcast is inviting my friends to be on it.
• 0:04
  I love just to see the differences in specialties or even between dermatologists and how they practice.
• 0:10
  So today's a really fun different episode.
• 0:13
  I got to invite my friend Galia Scheinberg on and she is a board certified small animal veterinarian that specializes in dermatology in Mexico City. So she is a diplomat of the Latin American College of Veterinary Dermatology which has really been blossoming and expanding. So I invited her on just to talk about the Latin American College. Some of the differences in how we practice maybe between different countries so me being the United States and Galia being in Mexico.
• 0:42
  Just talking about the differences in our education, how the Latin American College has really been expanding its reach and having a true residency program. But then also some of the differences day to day and how we communicate with clients you'll see some of the differences she experiences being a veterinarian in Mexico compared to my experience practicing the United States.
• 1:03
  It's a really fun episode really opens your eyes into this big world and how different all of our countries can be but a lot of similarities can exist too and how we handle clients. So I really hope you enjoyed this episode of the podcast. Well welcome everyone to another episode of the Durinvet podcast. I am extremely excited. One as you know, I have wanted to get back to interview type episodes which are some of my favorites and no better way to kind of kick off some more interview type episodes and having one of my dear friends, Dr. Galia Scheinberg on. We have seen each other a lot of conferences. Galia does a lot of speaking, educating and I'm just very excited to have her on because she is well first of all fun but second of all very passionate as I am about teaching. So I'm excited to have her on and one thing we're going to talk about that's really interesting is the differences in how we practice because I obviously practice here in the United States and then Galia is in Mexico. So we're going to talk about some of the differences we see between countries and having different people from different countries spend time with us and you know, trying to learn from learn or each other because it's not all about where we're at like the world is a big place so we need to know kind of power practicing. So Galia thank you so much for coming on especially after a long day in the clinic. I know you rush to do this and I really appreciate it.
• 2:22
  I'm so excited to be here. Thank you for the invitation. I've been listening to your podcast and watching you develop this community and I think it's so much fun and I love to be part of it.
• 2:36
  Well wonderful. Well we're so happy to have you. Let's kind of just kick off you know pulling back the curtain a little bit. So tell me a bit about just you know I can kind of give you shadow my experiences becoming a diplomat of the American College. Give us just some insight about your training you know from you know university all the way up into your diplomacy kind of tell me what that looks like for you. Well for us becoming their metologists let's say it was a winding road. It was a different road because residences are not well they were not established in Latin America up till now.
• 3:14
  We're just we're gonna talk about that. We're just stopping a program. But for many of us in Latin America that we've been practicing many years we sort of started liking their mythology and then it started growing from there. So I studied veterinary medicine in UMAM that's the National University of Mexico City which was at the time like the place to study veterinary medicine but in Mexico there's actually a lot of veterinary universities. So it is widely available to study veterinary medicine in Mexico. Maybe it's less competitive than it is in the United States. I know that right now it's very hard to get into veterinary medicine. And afterwards I did an internship in a residency program in the same university. So when I finished that internship and residency program it was just like internal medicine and surgery training. So it was after five years of university of veterinary university I did two years of internship and residency. So it was seven years of at school and you end up in your event and you start practicing and you don't know anything really. And I don't know if it happened to you when you started practicing but it's it's a little bit scary. And then super scary.
• 4:34
  But it's like I'm supposed to to give medications to dogs right now so it was hard. And I was lucky because I started working in a specialty hospital. It was a granny hospital and it was the first sort of real hospital in Mexico City. My dear friend, Jesus Paredes was the the the the one who generated this hospital. Sadly he passed away about two years ago. But his memory lives on in this wonderful hospital where a lot of specialists developed there and I think that the profession grew a lot from there. So I knew that I did not like surgery and this was a very surgical oriented hospital. So I ended up dealing a lot with internal medicine but I really liked immune mediated diseases.
• 5:24
  And I kind of fell it fell into dermatology and I loved it. And I started just seeing dermatology cases about maybe like 12, 13 years ago only dermatology. And then I started doing trainings outside of Mexico. So I was very fortunate to develop a very wonderful relationship with Craig Griffin who has been my mentor for many years. And I've trained with him and with Wayne mostly in their animal dermatology group. I was very lucky to have visited many times. And then I went to Vienna to do the ESAPS course which is a dermatology oriented course. And a few years ago the world association worked together with some Latin American vets to develop this program where we would create the college in Latin America. And this college was created having to find diplomates to be part of it. So this is something similar to what happened in the US when the college started that they had to grant father people into the diplomacy. And we had to comply with many requirements. It was a five year process. And we had to publish and we had to present and we had to do rotations. And at the end, 17 of us made it. And now we have been able to buy the new exam by the college. Add eight more people. So the college has grown a little bit. It's been a typical road. I'm part of the board for the Latin American college. And we've been working for five years on this.
• 7:14
  And now happily we're starting to have more of a structure.
• 7:19
  Well, that's really interesting. And when I hear kind of everything that you're mentioning, honestly, it sounds like a lot of the stories I heard from a lot of our original mentors, right? So you mentioned like Craig, Griffin and Wayne Rosencrantz. And obviously where you spent a lot of time in the US is where I did my training in the company that I'm still with. But it is really fascinating because that is a very similar story to I listened to some of the really original dermatologists in the US, right? Like a lot of them were internal medicine. We were kind of a a leader college compared to that. And then I honestly hear your story and I'm like, gosh, like, residents, he's hard enough when they're kind of there, right? Like you apply, they're there.
• 7:57
  When you really are developing a college, when you really are kind of going outside of the box for your country or your region, like that is a whole nother level of commitment to travel to other countries just as been time. So just, yeah, really is amazing when I talk to people, you know, within Latin American college of kind of really where they come from, the dedication that it's taken to develop that is is, honestly, really, really amazing. No, so now being kind of more established, what does like getting bored in within the college for Latin American dermatology look like? I know that we've had people within our company who, you know, kind of qualified and had those credentials.
• 8:37
  So what does that look like? Well, it's been a process. So I just, I did fail to mention the Latin American society of veterinary dermatology that originated part of this process and they started back in about 2011. So they did a lot of important work and I don't want to fail to mention them because they steal, they organize Latin American Congress for veterinary dermatology each year.
• 9:06
  They're very active. So I think it is very important to mention them and I don't want to fail to do that.
• 9:11
  And another very hard thing for us was I did this already having kids. So managing, working and going training elsewhere, it was just really difficult, but it was also super satisfying, super fulfilling. I had the support of my husband and a lot of friends in the dermatology world. I've just had such luck with finding such wonderful people that have always been very open to training us, to showing us dermatology when we didn't have opportunities to do it here, locally. So now, after a few years of very difficult work, we did manage to have two exams for people who got stuck in the process because a lot of people didn't have the qualifications to do the fact of diplomacy when this happened, but we didn't want them to stay behind. So now we prepared an exam and they presented an exam two times. And as you mentioned, we did have somebody who did the residency in the US, but she is from Latin America to present the exam and she passed the exam. So happily, she's part of our group now. And I'm very excited about that because we're going to have somebody who was training the US who did a full residency in the US and who is going to be able to also help us move on and continue forming this very important work in the college. So yeah, that's where we are right now and we're about to announce the new residency programs. Oh, so exciting. Yeah, it is, don't you find though I know we're supervised, but don't you find like in general like the dermatology, like so we're about to have a world congress this year, right? In Boston and July. And for those of you who don't know and I don't know if any other colleges do this and I could be wrong, but for a dermatologist every four years like the Olympics of dermatology, every four years, we do what's called a world congress. So we have like our North American congress, you know, one every year, but then every fourth year it gets replaced. And so usually there's a European meeting and then you I say US North American meaning, but then every four years, they don't have those and we have the world meeting. So that's embossed in this year's event. You love dermatology. I mean, that is the place to be and we have not had it for eight years because of the pandemic. Obviously we were last due in 2020. But I just think of that meeting coming up and all the different people I've met not only in within my area, but, you know, you I'll burn it like other people in other countries, the Asian college. And I'm just like, we are a fun group and we just are really supportive. Like I just really, really, truly believe that when I have gone in, you know, I taught in Thailand last year and I have never felt students more thirsty for knowledge and eager. It's like if you are a nerd that loves Dern, like we are open arms like please come learn to say,ology and allergy management and do all the things because I just feel like we're like a super passionate bunch. Do you find that too? I find that, like really most of the people I've met, they're so open, they're so warm, they want to share all these knowledge and that's something that's just, I don't know, maybe it's special for dermatology, but I think I do find it everywhere. And you mentioned the North American conference that happens every year but the year of the world congress and in Latin America, we also have a Latin American congress that changes location and it's a yearly congress. It does stop the year of the world congress, but there's also a very interesting conference that a lot of your listeners might be interested in and that's the yearly dermatology conference that happens in Mexico. And this is a fabulous conference.
• 13:20
  I think that next year is going to be focused mostly on a topic dermatitis and with really amazing speakers. So this is something that happens every year in a city that's super friendly to, you know, host and to receive people. It's very safe and the food is so amazing.
• 13:39
  Sign me up. I love Mexican food. We should definitely have you there. You would love it.
• 13:47
  Man, I am in. I do think Alberto has tried a couple of times to be fair to get me to speak to some of these conferences, but man, you know how the schedule goes, but man, it is, it is not only on and like it will happen. I promise at some point, but that's really good to know.
• 14:01
  These one in particular, you should really come because it's so much fun and it's such an amazing conference. All the speakers who come are just, you know, over the moon because it's so much fun.
• 14:14
  But yeah, we're so excited about the world conferences this year. We're trying to get everything ready to go. And I'm kind of speaking in the pre-Congress. So I'm a little bit excited and nervous about this. At this said, this is like the Olympic. So it's, it's kind of exciting, right?
• 14:33
  Super exciting. I did see you there and I'm also speaking there. So you and I can huddle together and do a little pep talk for each other because it is very different. It's very different like to teach a derm meeting. Like I love teaching. I do a lot of speaking and so do you and you have a certain comfort level when you're obviously speaking in general, and honestly, I get asked tough questions by general practitioner. So it is not by any form of the imagination that that is easy. Like I get asked, that's why I love speaking is because I love teaching, but then I get asked questions that challenge me, right? Because we don't know everything. But then you just go into like another level when you're just there with a bunch of people who are interested in derm, including a lot of general practitioners that come to these meetings that are very, very good at dermatology. And so you and I can, you know, we'll huddle together and we'll split a drink before. Yeah, but yeah, the part of the thing is not, we don't know everything. And what's great about lecturing is that you get to study by force.
• 15:37
  When you're presenting. So we have to study a lot and it also makes you just a better practitioner because at the end of the day, that's what we do. We see patients every day and we're in the same situation that all the the people that are listening to us who are just working and trying to solve cases every day and get frustrated. And, you know, you suffered with your clients when things are not going well. And I wish we knew everything. We definitely don't, but we do try to learn every day.
• 16:07
  Yes. And I think with that, you also get really comfortable telling clients or even practitioners and you get asked a question, I don't know. Do you get really comfortable with that because, you know, when you start out, and I think this is a really good life lesson for general practitioners, whether you love surgery or anything, it's okay to say I don't know. You can say it in a way that's more confident, right? Like, I don't know. It's a great question. I haven't thought about it that way.
• 16:32
  Or, you know, I don't know, but I'm, you know, happy to kind of look into that for you. I actually think that clients really appreciate that. At least, you know, where I am, and I'm going to assume it's the same for you too. I think they appreciate that a lot more than just trying to work, you know, kind of make up some answer that clearly, like, you don't really know what's going on. And as you kind of shift to like that clinical mindset, you mentioned before we have done that there are you have students say from the states or other places of the world who will conspend time with you and learn from you and the clinics, and you've mentioned there's a few things that students will say, oh, that's a bit different than where I practice. What are some of the common things you feel like are a bit different? Say, were you proud to say Mexico compared to where I practice in the states or maybe someone else practicing in a different country? Well, the first thing, and I think you know this, but we don't have technicians. So that is tough. Just starting with that, it makes a huge difference.
• 17:29
  So in Mexico, there's no nurses and no technicians. So what normally happens in hospitals is just veterinarians work at different levels and they kind of develop up and then they train and they do something else, but normally you would just hire a veterinarian to help you. In my case, in my dermatology clinic where we have three doctors, we have one sort of technician, but we basically do all by yourselves. So I think that the interaction with a client is more direct and this has its benefits and it has obviously time, why is it takes you a lot more time and you have to learn to be very efficient because I still only take about 40 minutes for a first time visit. So I have to be on point. I have to be very efficient. But the cool thing is that I do kind of get to interact more with the client. So I learn more details about adjusting the treatment to what they need and what they want to do. And this is something that when you're not interacting as much with your clients, you might miss some of those details. So if we need to clean a near, I mean a regular cleaning, not a video, a doscopy, I will do it generally in front of the clients and a lot of the management that we do, we don't take them to the other room to do, you know, blood draw or things like that, we tend to do that. We the clients, we use the clients to hold their dogs a lot. So that's a lot of things that we just do differently. So that's part of the main difference, I think. Veterinary medicine in Mexico has exploded the same as in the US. So we're facing the same challenges where you have all these clients wanting to get into the the the the consult and you have a long wait list may be not as long, but a wait list. And also we have, we want to hire vets, but they're not enough vets. It's a challenge that you guys are facing and we're facing. And I think this is a global issue after the pandemic, things have gone up and down, but mostly veterinary medicine has grown. And in Mexico, I think that the level of care that patients are getting has increased tremendously. There's a ton of new hospitals.
• 20:00
  All the hospital have these great equipment. So when I started training in the US, I still felt this difference with the level of equipment or maybe the type of clients, but now I think that we're very much on par. There's that cultural difference where there's things that are different.
• 20:20
  Another thing is, for example, clients want to have contact directly with their doctor. So they have to have a text application to text you. So we use in Mexico, what's up for business? So they will text us and we don't have anybody who's in between the doctor and the client, but I try to get away from that and it's impossible. I try to use an email and it's very slow so we don't find that efficient.
• 20:48
  And that's just a lot like things that I have on the top of my mind. But when people have visited from the states, they like it. They just find it kind of surprising, but it's a different way of working, but it still works really nicely. Yeah, I think that's really interesting. I mean, as you said, there's almost pros and cons to everything. I know even for our clinic, we obviously have assistance in technicians and we have client service representatives and I really try to be client centric. So I'm not doing, I'm not texting clients, as you are. But I do try to really ask go and ask, like, can you do this? What does this look like for you? So I try to find that middle ground and not just be like, oh, we're doing this in the sea later. I really do like to involve myself in the team and get to know my clients as part of the reason I love our specialty. But even as we start moving towards email, and at least in our clinic, we don't do a lot of texting even through some of the tools we have, but even getting some doctors within the US as a whole to even accept, it's okay to email. That scares people. I can't even imagine people texting more because I know, like, I'm totally comfortable emailing clients for certain things. There are certain things where I'm like, oh, you know, you're really upset or you're not quite understanding something. Like, we need to have a heart to heart because there's limitations in texting and emails, right? You can't hear tone of voice. Like, there's certain things they need to be really cautious of. But if it's pretty standard questions, like, I'm all about, you know, boundaries, but accessibility, knowing that my clients are, are them are working? They can't always call me exactly when I'm available. I can't always call them exactly when they're available. So I do think there is a hybrid that, you know, I've been trying to adopt compared to maybe some of the clinicians who have practiced it maybe even longer who are really hesitant to, you know, put it in writing quote-unquote because they're nervous about, well, to just things and things of that nature, which is probably a little bit of a reflection of our country, unfortunately. But I've really tried to adopt it for things that are straightforward because I hate playing phone tag with a client if it's something I don't have to. Now, if we look at like diseases, you know, do you feel like in your time in the states of me, I'm going to guess you do a lot of allergies, but do you feel like there's anything that's a bit different? Say, do you tend to see more ectoparasides? Do you feel like you see certain infectious diseases? And of course, this can be very variable even within a country like what I see in Oregon, but we don't have a lot of deep fungal compared to like the southeast. But are there things you feel like are a bit different between either actual diseases you see or medications or topicals that you have compared to say the United States? That's a good question. So I in Mexico City, for those of you who are not familiar, Mexico City is very high up. So we're 7,000 plus feet high, so it's very high. So we don't have a lot of humidity or tropical diseases, so that's not a big concern in Mexico City. But we do see a lot of patients that come from outside of Mexico City to visit us. So sometimes we do see patients that come from the coast, and there's a little bit of Lashmiania in gross. Yeah, yeah, gross. It's not something we see often, but we have to be aware that it's over there. So if they're coming and going from Mexico City to Cancun or Merida, those diseases are there. So we have to be aware of those diseases. We do see a lot of more, I think, active parasites in terms of circopters. It's fun. We like we miss science Gaby's. I will tell you, I love the Isoxazlins, but I find Skabies or Demedict Megawoncy here.
• 24:37
  But it's funny. You know what we get? We only see puppies, like we rarely see puppies, right? We see puppies for my slightest or like, yeah, yeah.
• 25:01
  The funny thing is that so we get excited, but when they're really young, when they're like two, three months old, they're always coming in for Skabies. So as you've seen, there's sometimes bad breeders and puppy meals and those will usually have those issues. So there's like times where we see one after another. So we'll see maybe three or four puppies, young puppies with Skabies. And it's fun because it's a fun diagnosis as you know, you feel like a hero because they're miserable. And you're giving them a treatment that's gonna cure them. And we hope we hope that more cases would be like that. But the truth is that we do we do see a lot of chronic diseases and we have to keep seeing them and managing them and seeing puppies with Skabies is fun. And yeah, Demedicts, we still see like rarely, I think on Saturday, we saw a puppy. I didn't see him, but one of my colleagues did with a really bad case of Demedicts. So sometimes they fall through the cracks, but happily is successlions did make such a huge difference and we still see them less and less and less. But we used to see a lot more of that. Let's see, in terms of topicals, we do have one thing that you guys don't have, which is the quartervans, which is a soft breed. You know about it. And I know that there's a new product that's coming out. I think that you might get it for years. So it's the same, it's the same steroids just for years because we've been using it for years for years. So that's something we have. We rarely get to, you know, brag about products that you guys don't have in the US. But Mexico is kind of fortunate. We do have a lot of products. But as you go to Central America, they have less products available because the markets are smaller. Brazil, I think it's a kind of a different market and the rest of Latin America. They do have some lack of topical products and lack of some medications. And they are a little bit behind of when they're getting those products. But I think it's been changing and they're getting more and more things available. Court Odex, I think is the product that is, I've heard is going to be released, to be honest, I'm not sure if it has been released or not in the United States. But yes, we've heard of it. In Brazil, I know they have it. We don't have it yet. Okay. We're looking, we're looking forward to it. Yes. I am too. For the problem of own dog, honestly.
• 27:48
  We, I have heard of some differences like I have friends who practice in Canada and then friends who practice in Europe. And I do know there are certain, I mean, it's, it's really interesting, some of the differences in regulations that happen with topicals. So I know in certain countries, they can't have certain percentages of corehexidine. I believe my practice is in Canada. I think that there's some regulations over which products can be combined. I know that even some companies, when they're creating some of these products, they have to be thoughtful of that. So for example, when Siva put out their new duxaline, you know, the previous one had clenvas all in it. And then now this one doesn't it. It's just the O33M and the corehexidine. They have studies showing the corehexidine can be anti yeast, but when that happened, we're like, well, why, why, why did you do that?
• 28:34
  And a lot of it is because of regulations within certain countries, which I think we kind of forget about that it's not as easy for these companies to necessarily say like, oh, well, here's, here's your pee and version. I mean, they do that sometimes, but, you know, there are certain concerns that happen when they're creating these products because of the differences and even topicals for our countries. And when I was talking on a podcast, this can flip podcast, you know, me and Sue Potter said we're talking about some of the differences between even topicals we have available to us over the counter. So she was like, oh, I heard you guys have like backs of trees. And I'm like, well, yeah, that's just triple antibiotic equipment. They don't have that like that is not over the counter in Europe. And here, yeah. And here, I think it's, it's the opposite. So one of the challenges that in Mexico is that clients are able to go to veterinary pharmacies and actually purchase apocryl or I mean, without a prescription. Yeah. So that's that I mean, they end up coming to us at the end because I think that those are wonderful products that we love using, but they can be used when it's not appropriate to use them. And they don't know like the small details when something it's failing, why is it failing or dosages or things like that. Here in Mexico, antibiotics, you do need a prescription, but people manage to get prescriptions.
• 30:05
  So if they really want to purchase an antibiotic, they're able to, they don't go to a human pharmacy.
• 30:11
  And there's normally like a small consultation room where they can go and see a doctor and get a prescription. So it's more lax here. I think that having too much regulation can be hard. And sometimes it can be restricted to veterinarians and having a lack of regulation can also be a challenge. So it goes, it goes both ways. So in terms of topicals, we don't have a lot of restrictions, but registration of the products can be very lengthy and very complicated. But we do have, you know, 4% chlorxidane and things like that. We're not restricted at all. And people are able to buy, you know, the normal triple antibiotic that they can buy over the counter. So those things are different. But we have more challenges where clients who really want to get medications and products, they're able to go around us and get medication directly, even online, like even in Medcador Libre, which is similar to eBay, let's say, they will be able to buy a lot of products and foods are not eliminated by prescription. So anybody can buy a prescription diet, a hydrolyzed diet without a doctor's order. So those are some things. Yeah. It is really interesting, even just talking about, you know, the different student to hear versus that conversation. I almost felt like the rogue person when I was on the European podcast is like, oh, yeah, we have that. And now I feel like we're more conservative once talking, you know, to your country. So it is interesting how wildly different they are.
• 31:46
  Do you feel like the pattern of resistance that you see with some of these bacteria? Because when I practice, when I say practice in Australia, I held one of our clinics there for a few weeks. I was there, I think like two different times, like one time, like two weeks, and this is years ago. But when I was there, like their degree of resistance was so much less than ours. Like it was because there's just there are those restrictions put in place, whereas we do see a pretty high amount of methamethosel in resistance staff and multi-drug resistance to demonis in America. How do you feel like that comparison is in Mexico? You think that we're very similar to the virus. Because remember, one thing is what we're doing. We're trying not to prescribe anti-liatic to them. They're not necessary and we're trying to culture and we're trying to, you know, transmit this information where we really want people to to be conservative with the use of antibiotics. But the reality is that a lot of the resistance doesn't come to necessarily from our practice. It comes from the way humans live in general. So in human medicine, antibiotics are still over prescribed and they're overly used, mostly pediatric medicine. During the pandemic, there was a 65% increase of resistance. And that's measured in the US because so many antibiotics were prescribed during the pandemic because we didn't know how to treat COVID-19. So I think that the drivers, the true drivers of resistance come a lot from human medicine. Obviously, we participate, but we're not the bulk of the antibiotic prescription.
• 33:23
  So I think it's kind of similar. We do culture a lot and we do find resistance, but a lot of the cases we see as the ones you see have been treated by many that's maybe previously. So those are kind of a special niche of patients. I don't know if you agree about that. Yeah, I mean, that's why we all say how important cytology is, right? Because you do want to reserve those antibiotics for when it's necessary. And we don't want to forget about really good topicals because a lot of these superficial pyrodermas can be managed topically. There's lots of caveats to that, but a lot of them can be. And I can forget about that. But also, when we, one of my soap boxes is if it smells like yeast, looks like yeast, smells like corn chips, it doesn't mean it is. And the reason we're so passionate about that is because we've all seen those cases that time and time again, you know, either been put on antifungals, which are not benign medications or antimicrobials when it wasn't appropriate.
• 34:21
  And a lot of that is that one health thinking and, you know, especially me currently having a son as many people who listen to podcasts know about it, we've, you know, compromised. There is a lot of limitations of what, you know, he can handle and be on and things like that. So it gives you a different perspective of how one health is not just this fancy term. It really does have a meaning to it.
• 34:40
  It's so important. We've been championing it so much for many years. And we have a statistic in our clinic about 85% of the pyodermacases, even generalized and severe, we treat with topical therapy and we're mostly successful. And this comes from, you know, having these conversations with clients where we are touching on one health and changing the minds of our clients where they really think that an antibiotic would make things faster. And the reality is that we know that it doesn't happen necessarily. So we've been pretty successful if we have the right topicals to treat our patients.
• 35:23
  And that's been really successful. And kind of bouncing out that my last question for you. This has been awesome. The last question for you and when you talk about like topicals and having that conversation is communication. So client communication, obviously you guys have a bit of a different way of managing that. Not having, you know, a lot of ours is of course us communicating but also training our technicians and our CSRs and our assistants to really kind of drive on that message and you doing a bulk of that word but going to that client communication. So having to explain to your client how you could manage it topically and why you don't necessarily need that, you know, suffolexin prescription. What are some of the challenges you feel like you face whether the same or different than I would face in practicing dermatology in Mexico when you talk about client communication? I think in that sense, I think it's similar. I haven't felt a huge difference between our clients and the ones in the US. Maybe the way we communicate culturally is a little bit different. I think there's this closeness that comes, you know, if you are seeing a patient with a topic dermatitis and you're seeing them every few months and it's a long term relationship, obviously you get to know them and you get to develop this close relationship and I know actually that you are a proponent of good client communications and you can treat a dog successfully and a topic patient, a long term patient if you don't have successful communications. That's a fact in the US, in Mexico or anywhere else that we can't avoid that thing. But what I do is I do have a lot of information that I either send them links, send them electronic messages with information. I feel like people like to read on their cell phone and if I give them a paper handout, they will not read it and they will lose it and forget about it. So we do use visuals. We have videos that put on the consult room while we're doing something else where we're trying to provide that information in various ways and more when it's something that we really want to take home the message, right? So if we want them to come back for an appointment, we talk about that, but we don't have enough time and that's the same situation that you have. So instead of using technicians, we have handouts, we have videos and we have links to different websites or information that save us a little bit of time, save me a little bit from the repetition of everyday consult because there is some of that also, but I do think that every patient and every client combination is different. So every client needs a little bit of a different type of communication. Sometimes it's something that's more scientific and sometimes it's going to be something that's really basic, but I think that that's pretty much the same with your clients. We just have to be very efficient. That's all. Yeah, and I think you touch on a lot of points of anybody can help with their efficiency, right? Like we do probably set aside more time as dermatologists compared to the general practitioner would, which completely makes sense if we have that type of client who's going to be referred to us, or either, you know, non-neasy case or a client who needs more that kind of communication, I totally respect that that would be different than maybe what a general practitioner would do. But we kind of have to change how we practice with every single client as well, no matter what country you're in in a way to be efficient or things like, "Derm intake forms to help guide your conversation," right? Like if I look at a Derm intake form in two minutes, you know, I'm going to have a way to get a lot more information quicker and then guide our conversation. We actually are in the room together more poignantly because, you know, we don't have clients that go on and on. You don't have clients that hate filling out those forms, they-- Oh, I'm sure that some of them do. I've had clients like, we try to send it a lot of time so they can do it on their own, right? But some people don't or forget or get lost. And I've like, I've heard like, couples arguing in the exam, like exam room, like, "No, it's not this is that. No, it wasn't this is that." But I do find it just, at least for me, it makes it so I can walk in and kind of direct our conversation a bit better. I am in my Technicians School test to this and this is a lot of surprise you. I am by nature a more chatty person. I do like really want to get to know my clients in, you know, in an efficient way. So it does help me to guide that a little bit more.
• 39:55
  But then to your point, like having things like the handles and the resources because I know that even if I try to read that client and know if I can go more in depth or I can't go more in depth, I can sometimes misjudge that and all of a sudden I get the deer and the headlights look and I'm like,"Oh, we didn't really absorb that." And so sometimes I need to go home think about it or the spouse asked them what happened the appointment and they're like, "I don't really know." So I think like handouts videos, links like all that stuff is wonderful just to help. I'm sure that this has happened to you, but we changed the way we practice like year by year. I look back on what I was doing maybe three, four years ago and the way I'm working now and you learn to adjust and to be more connected to your clients and you just get better at it maybe with time because you try and fail and then you adjust again. But yeah, sometimes you have this wonderful conversation where you think you got everything in and the client didn't get it and then you have to find another way to communicate. So that happens to us obviously all the time the same. We should always be adjusting and changing and learning and shifting.
• 41:02
  Like Arles, that's kind of boring. Like I don't want to go, you know, the next 23 years, however long I practice like maybe not 30 years. I don't want to go the next 25 years. I do want to retire at one point.
• 41:12
  I was on the changing, you know, like how boring to be like, "Oh, I'll just do everything exactly the same way like for the next like 20, 25 years." So I think that's a really good point, a really good point to end on and also just a really good point to in general sense kind of pick up when you are practicing in a really client-facing industry like we are. And with that, I just want to say thank you so much for being on the Durambat podcast. It's been so awesome to have you here. I know the hard thing for us is like we could just go on for hours and this is usually what happens when we see other conferences. But you know, your friendship means a lot how much you are passionate about teaching.
• 41:50
  I love to see what the Latin American College is doing. I think it's awesome. You know, the Latin American College, the Asian College has really been gaining some steam. They've been really adding to their diplomats too, which is awesome. And I just think it's great. Like, you know, dermatology is not individual to where we are. It's worldwide. So it's super important to have these avenues and that's the whole point of the spot it has is to kind of reach everybody who maybe doesn't have accessibility as easily. So Dr. Shayan Burguis, I want to say thank you so much for being on today.
• 42:23
  Thank you, Ashley. And have a great rest of your day. And thank you for the invitation.
• 42:30
  Of course, thank you. Well, thank you so much, Galia, for being on the podcast. As you can see, she's so passionate. I just love hearing her insight, how she practices some of the similarities and differences that we have between her countries. I just find it really fascinating and we can always just learn from the different ways people practice medicine. You know, we always want to be expanding, not only our knowledge, but how we communicate with clients. We always want to be evolving. So thank you so much, Dr. Shayan Burguis for being on the podcast as always, especially as we get in a more interviewed episodes. It would just mean the world if you could rate the podcast, hopefully a good rating, but it just expands the reach and gets more people listening to the podcast. And if you ever have ideas of things you'd want to consider as far as podcasts, topics or guests, please feel free to reach out, specifically on Instagram at the Derm vet so that I can continue to get content that helps you with with your dermatology practice.
• 43:28
  You