VMDiva

Recent news out of Australia slammed physicians for instituting late fees for patients who show up more than 10 minutes late to their appointments. Many argue these physicians are implementing a double standard given how far doctors log behind during their appointments. Perhaps this is a double standard but I guarantee one argument you’ll hear from these physicians is the patient’s tardiness contributes to the physician’s tardiness.

I have toyed with the idea of implementing late fees for chronically tardy clients (and we all have them, usually know them by name, and plan accordingly). My practice runs on a busy 15-minute appointment schedule. A client’s 10-minute tardiness can throw off the entire block of appointments. I know a late fee would go over like a lead balloon and so it remains an idea droning in my temples every time a client shows up late on a busy night. It’s my fantasy revenge.

The facts against a late fee remain: Most clients are on-time or early for their appointments. Legitimate excuses happen. You can’t teach common courtesy.

I have found some of the best ways of dealing with tardiness are as follows:

• If owner’s are more than 10 minutes late, have front desk staff politely inform them they will need to wait because the veterinarian is seeing her next appointment. It’s unfair to clients who show up on time to have to wait even longer for their appointment.
• Squash clients who decide to “sneak” that extra pet into their 15-minute appointment. If you simply cannot fit her in without making clients with appointments wait longer, do not do it. If you do have time to look at Little Lucy’s skin condition, use the line “Fortunately I have time to see her tonight without an appointment, but just make sure to have one down the road for when we are booked solid so we make sure to address your needs.” Spin the situation toward looking out for the owner’s best interest and you’ll avoid an awkward moment. You know the saying “If you give a mouse a cookie….” Set the tone for future appointments.
• Veterinarians must practice excellent time management given the frequently unpredictable and sometimes emergency laden appointment schedule. If a two-minute recheck and a sick exam arrive at the same time, see the recheck while the technicians triage the sick patient.
• Apologize and offer a reschedule. Veterinarians run behind, mostly, due to surprise illnesses mentioned at annual examinations, emergencies, and sick patients who require admission. Once we are behind it’s very difficult to catch up and we find ourselves rushing through appointments. Sometimes it’s better to reschedule than make a client sit an hour in the waiting room with a labrador who has chewed through the leash, peed on the wall, and jumped on the counter during the wait.

I’m a follower of the adage ‘do unto clients as…‘ and believe the best business practices start with that idea in mind. However, sometimes in business, the “Golden Rule” mentality doesn’t quite cut it. My wants and needs as a pet owner don’t match the wants and needs of all pet owners. When I read this article by Gladys Edmunds of USA Today, it begged for reposting! It highlights the importance of open communication and proper training with staff.

The diversity of my appointment schedule never ceases to amaze me. From the blissfully smooth to the guilt-inducing no-money client, I fluctuate between joy and stress throughout my day. One hair-pulling situation involves the disabled pet owner of two small fluffy dogs who routinely appoints her caregiver the task of bringing the aging beasts to me for exams. Following the visit, I then call the owner to discuss my findings, diagnosis, and plan. I’m struck with minor annoyance by having to repeat the entire appointment over the phone but can understand the owner’s absence.

The real trouble arose when I realized the owner and caregiver have a palpable distrust of each other. The caregiver revealed the owner doesn’t want her present at the exams. The owner called before an appointment to ask that I not tell the caregiver too much. The caregiver tells me the owner fails to give medications as prescribed and refuses to follow recommendations. The owner assured me she gave the medication and the dog is still no better. I’ve found myself in the middle of a owner/caregiver/dog triangle and needed to find the fastest way to the best outcome for my patients.

I’m tasked with placing the dogs’ health at the forefront while still adhering to the wishes of their owner. Now, I’m no fool and realize owners lie to me about giving medications, diets, and who knows what else on a regular basis. I rarely have foreknowledge of the impending lie. I tend to believe the caregiver’s story  because there is no rational reason for her to lie about the owner lying. The owner, with her impaired faculties, probably believes admitting to her lack of compliance will result in relinquishment of her pets. Despite this, I refused to cut some back-exam-room-deal with the caregiver to reach the treatment plan these dogs need. The owner has exclusive right to chose as long as she adheres to anti-cruelty statutes. So instead, I’ve employed my straight talker tactic.

I asked the owner pointed questions about completing courses of antibiotics and reasons she wished to pursue XYZ courses of action. We spoke candidly about quality of life and her ability to provide adequate medical care to her pets. I built trust and after we had a rapport, I reiterated the importance of all the things we discussed and planned. I cannot control whether she does them or not which is a lesson in patience and understanding only time teaches.

And I haven’t forgotten to document, document, document!

Anyone else out there find themselves in a similar situation? How did you handle it?

It’s internship season which always makes me wonder: Is life after an internship so radically different from spending your first year in private practice? I decided to forgo an internship, mostly for financial and marital reasons. Kudos to my husband who tolerated my indebtedness for four years of vet school. This year’s new veterinary graduates are faced with a decision that has educational, financial, and personal implications: Pursue an internship or full-time employment? About 40% of new veterinarians are entering internships upon graduation, leaving the remainder to *fingers-crossed* find strong mentorship at a private practice. New graduates have the base knowledge needed to develop a list of differential diagnosis but have yet to learn the the art of recognizing nuances of disease in practice, delivering bad news, and having confidence in their abilities.

In an academic setting, influences from specialists and the constant inundation of “ivory tower” medicine can easily persuade students to pursue additional training after graduation. Many of my classmates pursued an internship with knowledge they would never pursue a residency. But why? I argue many new graduates lack confidence in their knowledge and instead find themselves leaning on an internship as a crutch, that stepping stone between student and independent veterinarian. It’s not wrong to feel insecure but it warrants recognition for what it is. I’ve heard many reasons for pursuing an internship from: inexperienced, not ready, want more emergency training, not sure about specialization. Most of these reasons boil down to fear.

I felt fear and, admittedly nausea, on my first day of work as a veterinarian in private practice. I don’t regret my decision to forgo an internship. Within months I felt at home, climbed the steep learning curve, and blossomed into the veterinarian I am today. Interns earn a pittance, work double the hours of a private practitioner, and defer loan payments for one more year all the while accruing interest. I challenge new graduates to honestly explore the reason for pursuit of an internship because that path is wrought with challenges.  If the pursuit is for more education and career advancement – go for it! If it is fear of primary case responsibility and decision making – take the brave step, find a mentor in private practice, and jump!

I’m proud to see my undergraduate alma mater extolling the virtues of canine companionship! The University of Scranton sponsored a pet therapy day prior to final exams. It’s widely known interacting with domestic animals lowers stress and blood pressure. If only Fido took your finals for you….

You certainly don’t think of the veterinary profession as one where performance of duties risks loss of life. Police, fireman, and men and women in our armed forces certainly face the prospect of death daily, but veterinarians rarely need to worry. Sadly, a small animal veterinary colleague died this month after she was struck by a vehicle while attending to two dogs who laid in the road outside her home. The driver fled the scene but has since been arrested and jailed.

Dr. Kathryn Gilpatrick, 37, died assisting her neighbor’s dogs who strayed into the road near Knoxville, Tennessee. We animal lovers put ourselves in harm’s way treating these animals. I know the emotional trauma of seeing pets in the road struck repeatedly by traffic. As a teenager, I stopped in the middle of the night to carry a wayward snapping turtle across a darkened road to ensure its safety with disregard for my own. I’ve even pulled over on the side of the highway to help fearful dogs who’ve found themselves in the middle of traffic. I won’t say these traits are innate but they come pretty close. Veterinarians share the passion to preserve animal life and alleviate suffering. I am sure Dr. Gilpatrick died doing what she loved.

Like Dr. Gilpatrick, I find myself unable to sit idly by during times of crisis. It’s humbling to view the fragility of life and to know the call of duty, however great or small, comes with great implications.

How do you remove dried snot from painted walls without damaging the paint? You can’t. At least that’s my experience with my chronic snotting, snuffling, sneezing, snorking cat. Winston has successfully plastered my walls with copious amounts of mucous with a holding power rivaling the largest tube of gorilla glue. If you have one of these snorkers in your house, there is hope!

I recently attended a veterinary conference lecture that focused on these cats by Cynthia Stubbs, DVM, DACVIM. We all know snot-nosed cats can prove difficult to manage for both veterinarians and pet owners. Once the appropriate diagnostics are performed to rule out some of the more easy to treat issues, many pet owners are faced with the choice of advanced and often expensive diagnostics. While I still strongly recommend performing a vast array of diagnostics to get to the heart of the disease, many times cats suffer from difficult to diagnose rhinitis and sinusitis that can be exacerbated by respiratory infections. There is a probable association between chronic snorkers and chronic infections with herpes and calicivirus. Both herpes and calicivirus attack nasal and upper airway mucosa, causing chronic inflammation that can lead to nasal discharge and destruction of the delicate nasal bones that sit inside the nasal passages. This correlation has lead Dr. Stubbs to pursue both palliative and curative treatments.

Dr. Stubbs suggested one such treatment involves giving affected cats intranasal bivalent vaccinations against herpes and calicivirus. The intranasal delivery is purported to increase local mucosal immunity and therefore decrease the inflammation in the nose. Dr. Stubbs reported some cats needed only the vaccine on an every 3-6 month basis for near complete relief. The off-label use of the vaccine does not confer any immunity to panleukopenia, so Dr. Stubbs recommended also giving the traditional subcutaneous trivalent FVRCP vaccine. In addition, Dr. Stubbs bravely uses the anti-inflammatory antibiotic doxycycline along with the NSAID piroxicam to provide additional symptomatic support. Word to the wise: Non-liquid forms of doxycycline are known to cause esophageal stricture in cats and piroxicam should not be used in cats with kidney disease.

I am planning on trialing the intranasal vaccine in my own snorker. We’ve tried multiple antibiotics – no small feat given Winston is a perceptive, neurotic, inflammatory bowel disease cat. Nothing has alleviated his six years of nasal congestion. I will certainly follow-up in future postings.

Diagnostics Performed in Nasal Discharge in Cats

• Complete physical exam
• Complete bloodwork, urinalysis, Felv/FIV testing, +/- coagulation testing
• Blood pressures, particularly if nasal discharge is hemorrhagic
• Nasal cytology, culture, and biopsy
• Viral detection tests
• X-rays, CT scans, Rhinoscopy
• Nasal Flushes

Common Diagnoses In Nasal Discharge in Cats

• Dental disease – very common
• Rhinitis/Sinusitis – very common
• Nasal foreign bodies
• Cancer
• Nasopharyngeal Polyps
• Infection: Bacterial, Viral, Fungal, Parasites – common either as primary or secondary diseases
• Trauma
• Hypertension or bleeding disorders

The focus on client/patient care should comprise the majority of focus for the staff at a veterinary hospital. The same is true for the practice owner, but with one caveat. If a practice owner desires the best care for her clients, she must provide the best care for her employees. In an effort to focus solely on client care, employee relations can get tossed by the wayside.

Many employees go through motions day to day without an understanding of why and how their tasks improve patient care. What type of message does it send to employees? If you repeatedly send the message of dispensibility, you cannot cultivate loyal employees. Loyal employees are the key to practice success. Attitudes toward their boss and work, for right or wrong, affect the very behavior the employees bring to the table. If a boss has not earned employees’ trust and respect (that’s right bosses, you’ve got the earn it),  they are more likely to under perform.

Practice owners struggling with income need not worry. Not every “perk” requires significant monetary investment. I am no subscriber to kumbaya-type community builders. I seek realistic solutions. Some simple (and not so simple) steps can cultivate a culture of practice loyalty and pride that will transfer down to where it matters most – the client.

Be Kind and Approachable

All staff members deserve respect no matter what level of education or proficiency. Kindness and interest in staff members personal lives speaks volumes. Get to know a little bit about them and do something to remind them you listened.  Acts of kindness are as simple as assessing personal comfort. I often ask technicians if the table height is appropriate for them during an exam because too many times I see the short staffer on her tiptoes restraining a struggling dog.

Never forget to compliment a job well done.

Pay ‘em what they’re worth

This is usually more pay than what many technicians and receptionists currently receive. One of the surefire ways to make staff feel under-appreciated is to pay less than the average salary for the geographic area. Performance review based pay raises help ensure incentive to maximal performance.

Training and Follow-Through

New employees, especially those less familiar with the ins and outs of a veterinary practice, are typically overwhelmed. Climbing through mountains of medical jargon, procedures, and policies make them cringe. Training is essential. Follow-up meetings are also essential. New employees need regular reviews of their progress and mile markers. This is their chance to talk about what they want to improve upon and also brings any gap in training to the forefront. The time and effort put into training and following up with new employees speaks volumes for commitment to employee happiness.

Continue the Education

Veterinarians are not the only ones who need CE. Licensed vet techs are required to complete CE, but many unlicensed technicians and assistants fly under the radar of licensing boards. This staff still requires continuing education for a practice to continue to provide optimal care. Fruitful staff, committed to learning and developing new skills, are invaluable assets to any practice. Fruitful employees who see how their jobs make a difference are more committed to their position and the practice. Many drug representatives offer lunch-and-learn sessions about new medications, common disease processes, and technology updates. Who wouldn’t enjoy a free lunch, some swag, and an education all in one hour? Make the time to educate the staff.

Additionally, the onus is on the veterinarians of the practice to teach technicians skills and medical knowledge. Take every opportunity to instruct. Better education equals better medicine. Period.

Regular Staff Meetings

Including all staff in regular meetings builds a sense of community and togetherness. Staff meetings allow the practice to work through logistical issues between front and back office staff along with clarifying performance expectations. The feeling of inclusiveness goes a long way in creating employee loyalty.

Lighten’ Up

Practices that are all business all of the time are oppressive. Fun, laughter, and a little bit of chatting can go far in keeping employees happy (of course, all things in moderation). An occasional potluck, party, or birthday cake brings the crew together and builds camaraderie and trust, and therefore, increased job contentment.

Above and Beyond

Exceptional practices provide bigger perks like:

• Gym memberships or on-site exercise equipment
• Periodic massage days
• CE stipends for all technicians
• 401k and profit sharing plans for all employees
• Uniform allowance
• Performance-based bonuses
• Practice-wide community service days
• More low-cost perks
• Recession friendly perks

In the age where any Joe can have a blog, website, or informational page, pet owners need to practice extreme caution when gleaning information about their pet’s health. I think most people realize the internet is full of misinformation. That’s why most pet owners who’ve done their research online bring a pile of it to their appointment. I help them sort through the facts and fiction and in due time we come to a conclusion together. While “I read on the internet” can sometimes make my eyes roll, I do enjoy a pet owner who is well informed. I do not, however, enjoy a pet owner who has been handed a bunch of opinions disguised as facts and, despite an education from yours truly, still trusts her online support group more than her veterinarian.

Such was the case I was presented with this week. A senior cat was diagnosed with end stage kidney failure. I was the third veterinarian to see him at our practice and the also the third veterinarian to explain chronic renal failure, treatment options, and quality of life issues. At this stage in my career, I think I have renal failure down pat, but my friend Justine Denial had lessons for me to learn. I walked into my appointment and encountered what I like to refer to as “The Scroll”.

The Scroll is the sheet of paper that has every question, topic, and reference the owner found on infallible sites like Wikipedia, Ms. Kitty Purrfect’s Blog, and Josey Magoo’s facebook page. The Scroll, mind you, is very different from the list of questions many responsible pet owner’s bring to their appointment. The Scroll, on the surface, seems to have been derived from willingness to learn. Explore deeper, however, and I realize it’s a trap. It’s an amalgam of misinformation that challenges the very education I’ve had as a veterinarian.

Ms. Denial informed me she had joined an online renal failure support group and they recommended “slippery elm” supplements for the cat’s constipation. While I am not adverse to herbal therapy, I know nothing about this slippery supplement and let her know I would look into it. I also discussed the constipation issue is due to the chronic state of dehydration and will be something we would battle continually as the cat deteriorates. I was met with a blank stare. I suppose the support group hadn’t told her that. We talked more about quality of life and what to expect as her cat became sicker.  Another blank stare. Hmm, perhaps she wasn’t understanding this is a progressive, always fatal condition? One more try and I realized she just wanted to stick with the scroll.

We charged forward into a headache-inducing discussion about SQ fluid choices because she heard from her support group that the cat should be getting one specific type of fluids. Trying to explain acid-base balance and electrolyte abnormalities to a lay person who didn’t want to hear what I had to say was maddening and a monumental waste of time. I recommended a fluid and we settled on it.

Finally, Ms. Denial rattled off a list of parameters she’d liked checked, including creatinine, potassium, calcium, “anemia”, magnesium, and vitamin B12. When I offered explanations that most of these parameters were included in labwork from several days ago and were normal, she still wanted them checked because her support group said she should have it done. I offered Ms. Denial a renal panel, at the cost of $80, that would allow me to check many of her required values.  “Well, I don’t have THAT kind of money.” I could feel the aneurysm bulging behind my eyes. We finished and I decided I’d rather shove a pencil through my nose than sit through an appointment like that again. Two hours later Ms. Denial called asking to exchange her fluids.

Side Note: Slippery Elm is a safe fiber supplement for cats with questionable efficacy for constipated cats with renal failure.