With over 70 years of experience and having consulted with nearly 2000 veterinary hospitals in the United States and abroad, this top 10 list has been consistent through the years with some different approaches since the pandemic. Beyond consulting and advising, we teach practice management for veterinary students at Washington State University (Rick) and University of Georgia (Jeff). As a part of the 4th year curriculum, we conduct on-site evaluations for practices where the veterinary students observe appointments, interpret practice and financial data, and make recommendations for improvement to the owners. From these reports, often over 100 pages long and from debrief meetings with owners, we offer the following as our list of the TOP 10challenges we see in practices today. For each issue, we identify the issue, describe common findings, and then suggest some changes that practices can institute to either treat or avoid these issues for their practices.