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.

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!

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.

A few weeks back I highlighted my current case of a 6 year old golden retriever, Goldie Hawn, who I diagnosed with bone cancer in her femur. Her x-rays were pretty convincing for cancer and I performed biopsies. Bone biopsies can result in inconclusive answers a third of the time. Sure enough, the bone biopsies came back as “new periosteal and endosteal growth and proliferation.” In other words, not completely normal but the pathologist could not call it cancer. This is a very frustrating situation for veterinarian and owner alike.

X-rays on 2 different dates showed a progressive lesion. The scenario went as follows: We had a highly suspicious lesion in the distal femur, one I was was convinced was a particularly aggressive form of cancer called osteosarcoma. We could rebiopsy, but the chances of getting a diagnoses were no greater than the first biopsy. We could send Goldie to a specialist who would evaluate her x-rays and most likely recommend biopsies. We could repeat x-rays in a couple of weeks to see if the lesion had progressed. And finally, we could amputate the limb in hopes to catch the cancer early prior to its spread to the lungs.

It was an agonizing decision for both the owner and me. The owner knew waiting on a potential aggressive tumor could mean the difference between life or death. However, without a definitive biopsy there was a very real possibility we would amputate a leg that didn’t have cancer. We walked through the surgery and options at least three times leading up to the decision. I reradiographed the limb one more time, saw even more changes in the femur, and the owner very nervously elected amputation.

The permanency of amputation gives me agita. I thought about the surgery in the weeks leading to it, the night after, and the waiting period for biopsy results. Goldie’s case kept me up multiple nights. My biggest fear was getting back an inconclusive biopsy report and having nothing to show her owner. After a three week wait on pathology results, we got our diagnosis of very early osteosarcoma. I was relieved then saddened with the diagnosis.

This case reminds me medicine is a process that doesn’t have all the answers. As much as we want it to, disease doesn’t always follow the textbook. I frequently tell my clients that just because it looks like a duck doesn’t mean it quacks. Sometimes we’ve gotta put a little faith in our instincts and other times take that educated guess.

This time of year reminds me of the nerve wracking process of job interviews and trying to find my place in the veterinary world after graduation. Most new vet graduates, the 60% or so who choose to become general practitioners immediately following vet school, are knocking on doors in search of the ultimate vet practice. The strained economy makes openings at the best practices hard to come by but a little bit of knowledge can go a long way in guiding a new vet toward a good practice. Of course, the list of things to look for in a practice are also the same things pet owners should look for in a hospital. Pet owners don’t necessarily get the “inside scoop” but simple observations can help them make a decision.

For Vets

Standard procedure for the interview process involves a tour of the practice, a meet and greet with all veterinarians, head technicians, and business managers at the practice, an interview, and lunch/dinner. The last one is actually pretty important. Practices unwilling to “court” their prospective associates are either cheap, too informal, too understaffed, or just lacking in business etiquette.

Know your values and personal standard of care. Have a problem with unsupervised overnight hospitalization? Want to refer complicated cases? Oppose declaws, ear crops, tail docking? You’d better ask what the practice policy is and if you are expected to perform any of these duties.

Do vets share cases or will you need to figure it out on your own? Is there continuity of care? Is your boss willing to mentor you? I remember my very first interview where the owner told me, in more explicit terms, that he hated seeing the term “mentorship” in a cover letter. Red flag. New graduates need a support network.

For Vets and Pet Owners

Looks matter. Are the buildings and grounds well kept? Does an odor smack you in the face when you open the door? Well maintained practices indicate a higher level of dedication and pride in the practice which can translate to quality of medicine practiced. This doesn’t mean the practice needs to have marble countertops and fireplaces. An old home that is well cared for can provide the physical foundation for an excellent practice. People make the practice, not the building.

Keep highly attuned to how you are treated from the second you walk in the door. Do the receptionists make eye contact or welcome you as you come in? Are they friendly? From a vet’s perspective, the receptionist’s are on the front line of the practice. Aside from the veterinarian, they are the face and personality clients will engage with most. Rude or inefficient receptionists can indicate a systemic problem.

Employee churn is a red flag. The constant turnover of employees, both support staff and veterinarians, can indicate a management issue. In my experience, churn happens for a few reasons. First, employees who feel undervalued or under respected are likely to leave. Next, employees making minimum wage need benefits because most cannot afford insurance or routine medical care. Practices that don’t provide benefits will lose employees as their life events dictate. Veterinarians tend to leave positions when the hours stink, the boss is inflexible, and promised changes never come to fruition. Personality conflicts are inevitable and expected. Most times, employees can work through them to get the job done.

For Pet Owners

Remember small mistakes will happen and cut the staff a little slack. If your medication isn’t refilled on time or a phone call isn’t returned in a timely manner, remember it isn’t personal. However, repeated errors, confusion, and inaccurate charges are a sign the practice is inefficient.

Basic observation skills and a little probbing can ensure both veterinarian and pet owner find a practice suited to their needs.

I began formal training today for the 10-mile Broad Street Run (Philadelphia) with my new found Team in Training friends at The Leukemia & Lymphoma Society. I ran 2 miles today in horizontal snow working up to my May 2nd 10-miler. I’m not going to lie, it was miserable to have snot dripping from my nose and my lungs scorched from the cold. And did I mention I hate running? But I did it. Let me tell you why.

Over a year ago I met a vibrant sassy 27 year old named Shanna when she began working at my hospital. She was diagnosed with uterine cancer at 16 and underwent chemotherapy. I learned she unexpectedly became pregnant at age 21. She went into preterm labor at six months gestation from complications from her cancer. Six months later, despite the NICU’s best efforts, he died.  She then had a hysterectomy and partial ovariectomy. As if that was not enough grief for one person to bear, flash forward six years and she found herself afflicted with malignant tumors in her remaining ovary. Another surgery and series of body scans cleared her of cancer. She was doing well until about 4 months ago, when she found a painful lump in her breast. Multiple visits to doctors and multiple breast surgeries revealed severe mastitis secondary to Stage 3 Lymphoma in both axillas. This is a crushing blow to everyone who knows her as we anticipate more chemotherapy and surgeries.

Shanna brings join, humor, and life to people around her. In her 4th battle with cancer, she has remained positive and hopeful. She’s still working as she rapidly approaches her surgery date for a single mastectomy and lymph node removal. She’s the reason I committed to running and raising money for The Leukemia and Lymphoma Society. If Shanna can come to work every day with a smile on her face, I can certainly run 10 miles and raise money for this great foundation.

I need your help on multiple levels. First, I need fundraising ideas! If any of you have a practical idea for fundraising, please let me know! I have boxes of candy bars and sweet treats to sell at the office. I am thinking about selling homemade dog biscuits. What else?

More important is the focus on raising funds to benefit cancer patients, for research, and to provide a network of understanding and support for people with blood cancers. If any of you know of a blood cancer victim and feel compelled to donate to LLS, please visit My LLS Site to make a donation! My personal goal is $1000 by race day but I would be proud to surpass that!

Discussions on a colleague’s blog stoked my agitation about rude exam room etiquette.  If you’re a cell phone user, screamer, or lousy parent, this blog post is for you. Most people understand how to behave in any professional appointment. When I go to the doctor’s office, I sit quietly in the waiting room and then in the exam room,  stay courteous, and express my health concerns. I wouldn’t even think about wandering the hallways or yakking on my cell phone. Here are some examples of how not to behave at the vet’s office:

Don’t Arrive Late and Then Act Angry When You’re Bumped to the End of the Line

Most veterinary practices operate on 15, 20, or 30 minute appointment schedules. Your 10-15 minute tardiness can drastically affect the flow of appointments when the schedule is full. Try to arrive early. If you know you’re running late, call the hospital. If you arrive late, be prepared to wait. It’s not fair for clients who arrived on time to wait past their appointment time due to your tardiness.

Stay Off the Cell Phone

Cell phone etiquette is generally terrible every where we go. I enter a public arena and often hear a loud one-sided conversation. That doesn’t belong in an exam room. If you are caught on your cell as the veterinarian walks into the room, promptly end the call. If you don’t, your veterinarian may just walk out on you. I’ve done it.

Don’t Take Your Pet For a Walk During the Appointment

This seems like common sense. If you are in an exam room waiting for the vet, don’t leave. On numerous occasions I have walked into an empty room. I would rather have Fluffy urinate or defecate on my floor (what, you think that’s the first time it’s ever happened?) than walk into an empty exam room. See scheduling crunch listed above.

Your Appointment is Not the Time to Start Disciplining Your Pet

Most pets, when confronted with the unfamiliar and sometimes terrifying prospect of their veterinary visit, will act uncharacteristically anxious, fearful, or aggressive. Vets expect this. I dread owners, who I sense haven’t invested much time in training the pet, that resort to screaming and correcting the dog in a volume loud enough the dogs in the waiting room obey the commands. On the other hand, I also loathe the owner who finds the pet’s biting, scratching, and fearful behavior hilarious. Don’t laugh and think it’s cute when your pet bites at my staff. Bites and scratches are serious threats to well-being.

Your Appointment is the Time to Start Disciplining Your Children

Children should never handle instruments in the exam room. They are expensive and not designed for little hands to bang and drop on the floor. It’s happened to me. Don’t allow your children to pinch, poke, or otherwise agitate the veterinarian. That’s happened to me as well. And it’s always a good idea to keep your kids away from Fido’s face during the exam and vaccinations. You cannot always anticipate fearful behavior and bites may ensue.

I hate on-call. I loathe, detest, and lament on-call. Every time I have that ringing beast in my possession my stomach churns when it sings it melodic tune. Most small animal general practitioners would agree on-call just plain stinks. Calls during dinner, holidays, and the middle of the night coupled with the constant threat of changing plans and interruptions give on-call its much deserved bad reputation. No one likes a leash. Shifting trends in veterinary medicine are making on-call obsolete, though its archaic status is not uniform across the veterinary world yet.

Many new practitioners look for positions with limited or no on-call. It’s very difficult to balance home and work when works comes home and calls you in the middle of the night. The new generation of veterinary medicine recognizes the need to better balance work and life which has culminated in less hours, more vacation, and flexible schedules. Requirements to see patients on emergency add long and irregular hours to an already stressful, tiring job.

A majority of the push to eliminate or limit on-call is probably traceable to the changing demographic and ideals of the newly female-dominated workforce. Women must exercise caution when meeting a client alone in the middle of the night for an emergency. Ketamine, among other drugs, has increasing street value and veterinary hospital robberies are not uncommon. Additionally, phone calls and travel throughout the night do not provide a family friendly schedule and mothers of young children may find it impossible. Employers have noticed and many have begun advertising positions with no on-call in the banner.

On-call is more than an inconvenience for veterinarians forced to hastily jump from bed.  If not executed properly, the on-call vet can find herself providing sub-par care overnight or on the weekend. On-call compensates for a closed office and closed offices rarely provide 24-hr care. While leaving an unsupervised but stable animal in the hospital overnight may be okay in some circumstances, sick and unstable animals typically require more extensive monitoring, medications, and treatments. I am in the camp of “If it’s sick enough for you to call me at 3am, it’s sick enough to warrant 24-hr care.”

If a veterinarian offers to see a pet at an owner’s regular hospital on an emergency basis, it’s important the owner know what types of services the vet can provide. Without support staff, usually simple tasks like drawing blood or taking an x-ray can prove challenging. Having owners help retrain their pets is dangerous and a potential legal nightmare.  Will the vet or a technician stay at the hospital that night to observe the animal? Most times the answer is no. Many pet owners may find more comprehensive care at an emergency hospital, and given the rising cost of GP’s emergency fees, the price difference probably won’t amount to much.

Many stalwart veterinarians insist they are providing a service to their clients. In rural areas where the nearest emergency center is miles away, I can see that point. But the majority of people live in or around cities where overnight and 24-hr hospitals abound. Those hospitals are equipped with multiple technicians, multiple veterinarians, and the ability to care for a sick pet quickly and efficiently. I challenge those stalwarts to examine if they are looking out for the animal’s best interest or their bottom line.

Admittedly, I stopped reading books for pleasure during college and had a long dry spell until I resolved to pick up the slack several years ago. My attention span is embarrassingly limited so a book really needs to peak my interest for me to even pick it up. I’m a sucker for stories narrated by emotive animals (can anyone say anthropomorphism) but I’m particularly vulnerable for insightful ones. Such was the case with The Art of Racing in the Rain.

Enzo, a lovable aging dog, tells the story of his owner’s balancing act between his desire to race cars and his commitment to his struggling family. His comedic and painfully accurate assessments of human personalities keep you laughing and cringing at the same time. He also offers a poignant perspective on his own impending death.

Laughter, anger, love, hope, introspection: It all made me fall in love with Enzo.  This book will leave you wondering what your own dog is thinking.

Highly recommended.