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VetInfo Digest January 2006

Table of Contents

Understanding Veterinarians

Dealing with veterinary receptionists effectively

This Month's Note:

I will have been in veterinary practice for 27 years in May of 2006. So perhaps I shouldn' pass on this bit of information but I feel like it is important to consider. In a recent survey of physicians there was a notable difference in meeting the recognized standards of practice among young physicians (less than 5 years in practice) and older physicians (more than 30 years in practice). The younger physicians were much more likely to follow currently recognized standards of practice than the older physicians. This was felt to affect patient outcome significantly with the younger physicians having a greater success rate. To some extent this may be a counter-intuitive finding for many people since experience is also valuable.

I suspect that this information would hold true in veterinary medicine and that the change from pursuing true " of the art" care to lesser practice standards occurs a little earlier in veterinary medicine. Of course, individual veterinarians won' always fit the average profiles but you might consider the length of time a vet has been in practice when choosing a new veterinarian. I didn' include this in the information on veterinarians that I wrote for this month' issue. Perhaps it hit too close to home!

Understanding Your Veterinarian

I think that many of my clients would get better service and would provide better health care for their pets if they had a better understanding of veterinarians and the way that veterinary medicine is practiced. It is obvious that I can't speak for all veterinarians and that there are major differences among veterinarians over many issues ranging from humane practices to business practices to the practice of veterinary medicine itself. Even though what I write won't apply in all circumstances I hope that thinking about the challenges of becoming a veterinarian, running a veterinary practice and dealing with veterinary clients might help you to understand how to deal with your own veterinarian in a way that is more productive for both of you.

Many people seem to believe that veterinarians are simply people who love animals and who decide right out of high school to open a veterinary practice and provide medical and surgical care for pets. It is hard for me to imagine that this misconception continues to exist but a year rarely goes by without someone looking at me from the other side of the exam table and asking "Do you have to go to college to be a vet?" It may be tempting to think that veterinary medicine is somehow less complex than human medicine but it isn't. Veterinarians do need to go to college for several years prior to getting into veterinary school and most veterinary schools require four additional years of schooling.

Veterinarians usually competed hard in school to attain the best possible grades and to exceed the expectations of veterinary school entrance committees so that they had the best possible chance of getting into school. This kind of competitiveness rarely goes away once a specific goal is attained. A lot of this competitiveness was based on the objective nature of the goals. Get good grades. Do well on the veterinary aptitude tests. There were standards to measure success against.

One of the most frustrating things for competitive, or just conscientious, people in veterinary medicine is the lack of objective measurements of success. There is no really good way for any individual veterinarian to know if their success rate in treating patients is above average. No one keeps statistics. There are no competitions like the "Olympics of Veterinary Medicine" or world veterinary championships. There isn't even a central body that tracks statistics well enough to compare individual practice statistics against national averages. Veterinarians just have to try as hard as possible to do a good job without being able to tell for sure if they are achieving that goal. This is a pretty stressful situation for people who got into the profession at the end of a largely objective process involving obtaining good grades, scoring high on evaluation tests, meeting specific goals and generally competing with others to reach measured objectives.

I am not sure how much the stress of working in an environment in which objective measurements of success are rare affects veterinarians. I do think that it is one of the major reasons for practice burn out, though. Enough veterinarians suffer from some degree of stress or burn out that it is worthwhile to watch for signs of this. The hints are often somewhat subtle. Some vets don't pay attention to what their clients are saying. Others think that it is acceptable to just assume a client won't want to explore all possible treatment options and won't mention some of them. Phrases like "this is good enough for now," should worry you if your vet uses them too often.

Even though the process of getting into veterinary school was competitive, the great majority of my classmates in veterinary school were there for reasons other than simply academic competition. Most of my classmates had a genuine desire to provide compassionate care for animals and this was the real reason they were in veterinary school. As a group we were almost completely unaware of the realities of accomplishing this task, though. For some of my classmates it was literally a shock to discover that maintaining a pet's health often meant causing short term pain or having to overcome resistance to treatment by physical restraint of an unhappy animal. It meant being able to continue to work with animals truly suffering from a medical condition until they were well or until they died. In the instances in which suffering was prolonged by attempts to cure a pet that failed, guilt in having participated in prolonging the suffering had to be dealt with. The fundamental moral issue of whether it is acceptable to kill a pet when a family can not live with behavioral traits is extremely difficult for all veterinarians whether they believe they should or should not intervene. When to stay quiet and let a client decide whether a pet is suffering enough to warrant euthanasia when death is inevitable or whether to try to influence the client to accept that euthanasia is best is a constant ethical conflict for veterinarians. Very few students entering veterinary school have a real awareness of how they feel about the myriad of difficult moral issues they will face as veterinary practitioners.

Some veterinarians work hard to avoid the issues that they have not yet managed to come to grips with, one way or another. There are veterinarians who will not work with an aggressive pet, for instance. Other veterinarians refuse to perform euthanasia under any circumstances. This eliminates the need to make moral choices on a day to day basis but almost certainly results in some animals suffering needlessly. I know veterinarians who will not treat for heartworm disease because they feel that if the pet dies the client will see it as their fault, even though 98% or better of dogs treated for heartworm disease live and their lives improve a great deal. If you find that your veterinarian can not or will not provide care for your pet that you feel is warranted you should consider changing veterinarians. It is surprisingly hard to get some veterinarians to help you pursue advanced care.

The moral issues include an even more difficult challenge, at least on a day to day basis. Veterinary medicine is a private business in most countries. This means that veterinarians must pay attention to the business aspect of running a practice or affiliate themselves with business people who do that for them. If they are not willing to do this it is likely they will not remain in practice very long. One of the very best associates we ever had in our practice left us because she felt that our business practices were not always compassionate enough. She established her own practice and went bankrupt in a little less than three years. It is a noble goal to provide top quality medical care to all pets, regardless of their owner's ability to pay for care, but it is not a goal that is easy to achieve while also managing to stay in practice. Veterinarians have to charge enough for their services to maintain a practice and to meet their personal income needs.

Most veterinarians do feel a heavy obligation to try to make their patient's lives as healthy and as comfortable as possible and it is difficult for most veterinarians to turn away patients who they feel they could help if money were not part of the decision making process. Many of our clients who can not pay for cost intensive procedures imply that it is our fault their pet is not getting the best care, as if we are simply insisting on being paid due to abject greed. This is simply not fair. Veterinarians have the same goals as most people who work for a living. We want to have financial security, to be able to care for our families and to retire comfortably when the time comes. These are not unreasonable goals. If these goals were not obtainable in a profession few people would be willing to enter the profession. I know very few veterinarians who do not willingly provide care for some pets or stray animals every year without being paid but it is not possible to do this for every pet. In order to provide the best possible care for the majority of pets we must make enough money to pay for our buildings, our equipment, continuing education, our staff and our own family needs.

It may not seem like it to many veterinary clients but the issue of business as an aspect of veterinary medicine is probably the single most stressful aspect of providing veterinary care. I know of very few veterinarians who are in practice as a means of making a quick fortune and getting out of the field or even of amassing great wealth over the course of a normal career. Most veterinarians really do balance their needs against the needs of their clients and patients. Sometimes this is done with better skill than other times but it is still a consideration. It is a good feeling when we can afford to help a client care for a pet by contributing our skill or donating the portion of our operating costs to a particular patient- but if we are to remain in business we can not always afford to do these things.

There is another side to the issue of money in veterinary medicine, as well. It is disheartening when clients refuse reasonable, inexpensive care that would improve the quality of life of a pet. It is disheartening when a pet needs specialized care that simply isn't affordable for a particular client, but it is incredibly frustrating when a client can clearly afford to help a pet have a better life and simply refuses to do so. It isn't hard to accept when a client can't afford a $3000 back surgery for a pet with a herniated disc but it is just plain infuriating when a client won't buy $10 worth of furosemide to help a patient with chronic heart failure breathe comfortably.

Some of our clients seem to resent charges for veterinary services out of sheer ignorance over how the business of veterinary medicine works. The profit at most veterinary hospitals is between 20 and 30% of the total charge, on the average. The profit being the portion that is available to pay the veterinarian above operating expenses. This means that when your veterinarian charges you $200 for a procedure his or her profit from the procedure is usually between $40 and $60. There isn't room for 50% discounts. A 25% discount, which isn't unusual for special situations such as spay or neuter surgery for pets adopted from humane organizations means the veterinarian is giving up his or her salary for the surgery.

While these figures are close to the averages, there are aspects of veterinary medicine that don't conform to them. Veterinarians have traditionally undercharged for the value of their time and overcharged for specific procedures - at least when using these averages as a guideline. Vaccinations have a high profit margin comparatively, for instance. Dispensed medications tend to also have a higher profit margin. This has allowed some companies to exploit these differences from the average to their benefit. It is less expensive to buy vaccinations and many medications from mail-order or Internet pharmacies or pet supply outlets because veterinarians traditionally bundled the cost of their time doing examinations into the fees charged for these items.

The difference isn't due to veterinary greed, though. It is due to business practices that supplemented services with profits obtained from tangible items. Veterinarians found it easier to charge for a vaccination than for the examination that went with it. We found it easier to make a profit from pharmaceuticals that clients could hold in their hands over profits from diagnosing or treating illness where clients may not have been as able to perceive value. While this looks like a poor business practice in retrospect, it probably wasn't a bad model for its time. I suspect that over the next few years veterinarians will be forced to begin to charge adequately for their time and will eventually get out of the pharmaceutical dispensing business entirely but I could be wrong.

There is a phrase that is used in variations by many businesses that goes something like this for veterinary medicine, "We can give you great service, state of the art care and cheap prices --- pick which two you want". You really can't have it all. Try to remember that when you are choosing your veterinarian. There are veterinarians who choose to provide services inexpensively. They can do a good job for the majority of their patients but usually do not provide "state of the art" care for all patients because that can't be done inexpensively. There are veterinarians who feel compelled to provide state of the art care at any cost. They generally have very high prices and serve a much smaller number of patients but provide excellent care for those they do serve. As a veterinary client you have to decide which approach appeals to you. Fortunately, there is often a choice of veterinarians offering a range of services along the spectrum from inexpensive basic care to true state of the art care. You can choose the level that works for you. Just remember that you are making a choice and that it is unreasonable to think that the inexpensive veterinarian can provide advanced care or that the vet who has invested in expensive equipment and who follows very careful diagnostic and treatment protocols can do so inexpensively.

The first step in getting the level of care you want is to think a little about your veterinarian's practice philosophy and to decide if it matches yours. You would be surprised how few people pick their vet by thinking about what they want in a vet, with the possible exception of people seeking the lowest possible cost for pretending to take care of their pets (sorry, bias showing). The majority of people pick their veterinarian based on the proximity of the veterinarian's office to their home. This has held true throughout the time I have been in practice if the results of surveys of veterinary client behavior are true. This isn't a good way to pick the person who is responsible for the care of your pet, regardless of the type of care you really want for your pet.

If your want a "top gun" vet who is aggressive at every level of practice look for a practice with veterinarians who have board certification or participate in the American Animal Hospital Association certification program. Check on the facility's equipment. Practices that are trying to maintain a real cutting edge ability tend to have ultrasound machines, dental X-ray machines and to offer endoscopy. Practices in the middle of spectrum might offer some of these services but not all of them. They may still practice very good medicine by referring patients to facilities that offer these services as necessary. Practices that meet the basics only tend not to offer these capabilities. There is a little less tendency among practices that really try to meet only the very basic needs to refer to specialists. I think this is a combination of extreme cost consciousness and the feeling that the specialist may judge their choice to practice very basic medicine as poor medicine, even though it is clear that these practices are very necessary for people who can not or will not seek advanced veterinary care.

Pick a practice that offers the level of care that you seek. In the long run this works a lot better than picking a veterinarian and trying to change his or her practice philosophy by complaining when you have to go elsewhere for testing if the practice keeps prices low by not investing in advanced equipment. It also works better than complaining when you choose a truly state of the art practice and have to pay more than your neighbor who goes to a vet who is more comfortable offering basic care. You're usually just annoying your vet and the staff rather than making a difference in their philosophy when you complain either way. If you choose your vet by driving distance you just aren't thinking hard enough about the value to you of your pet's health care.

Working With Veterinary Receptionists

It is surprising to me how many of my clients fail to understand that they should treat my receptionist with respect. Clients who would not dream of snapping at me will often snap at my receptionist. Perhaps they don't think about the fact that my receptionist schedules my day and is the key to being able to speak to me, as well. On the other hand, there are times when my receptionist fails to recognize the importance of a pet's condition and puts off a client whose pet truly does have an urgent need to be seen because a client is afraid to be assertive. I have a good receptionist so this isn't a common problem but it frequently could be resolved if people just knew what to say in an emergency.

The first thing to think about is the best way to describe the situation so that it will be taken seriously. "My cat is sick," is not enough information if the cat is vomiting blood, for instance. There are a few things that almost every veterinary receptionist learns to recognize as an emergency situation. The short list at our practice includes difficulty breathing, ongoing blood loss (with the exception of small amount of blood in the stool or urine), paralysis, traumatic eye injuries, pets who have been hit by cars even when they seem normal, seizures longer than 5 minutes in duration and acute severe pain. If your pet has one of these problems make sure that is understood.

This isn't just a problem in veterinary medicine so I'm going to use an example from my past that helps to illustrate how bad this situation can get. I called my daughter's pediatrician's office when she was two months of age. The conversation went something like this, "Dr. Summers saw my daughter yesterday and diagnosed mycoplasmal pneumonia but today her lips and eyelids are blue and I am worried that she will die today if she is not seen." I thought that was pretty direct and stated my worry clearly. The receptionist replied, "Dr. Summers is booked all afternoon and your daughter is scheduled for recheck tomorrow, I'm sure it can wait until then." This is a judgment call that a receptionist should not make. Therefore, I asked her to check with Dr. Summers. She said that he was busy and she wasn't going to disturb him. Taking a different tack, I said to her, "Dr. Summers is the pediatrician on call at the emergency room, so what I'm really asking you is whether he would rather see my daughter there or in his office." To which she replied, "I'm sure he'd rather see her at the emergency room." Which is what he did, roughly thirty minutes later, when the physician from the emergency room called and asked him to see a patient on an emergency basis. Fortunately, my daughter lived but it took several days of intensive care to assure that.

There are three things to note from this story. First, it really is important to state why you are very worried as specifically as possible. Second, when it is obvious that the receptionist isn't going to respond to your concern it is necessary to ask to speak with the veterinarian. This doesn't always work. When it doesn't you need to have an alternative plan. Do not ever hesitate to follow your gut instinct when you believe you have an emergency and the receptionist isn't being helpful. One tactic that sometimes helps is to ask the receptionist who your vet recommends taking patients to when they can't be seen at his or her office. This shows that you feel a real urgency to have your pet seen by someone and often a receptionist will try harder to fit you in if you are willing to go elsewhere if necessary. If you feel strongly that you must see your regular veterinarian, just show up there with your pet and explain that you really do believe it is an emergency. This will almost always work but it will create friction with the receptionist if you make a habit of it. If that doesn't work because your veterinarian really is swamped with prior emergencies be prepared to leave immediately to find a veterinarian who can see your pet on an emergency basis. You must be prepared to take this step if necessary.

You will have much better luck getting help from the receptionist if you have been nice to him or her in the past. If you aren't the warm and friendly type that is OK, just make sure that you treat the receptionist with the same respect you treat the veterinarian.

Show up for appointments or call early enough that the appointment can be rescheduled if you just can't make it for some reason. This is particularly important on days that a veterinary clinic has reduced hours, as often happens on Saturdays and holidays. If you miss several appointments it is pretty likely that you will have trouble getting appointments at times when a missed appointment is likely to cause your veterinarian to inconvenience another client. The odds of getting an appointment on a short day go down dramatically with each appointment you miss. Most of the time missing an appointment for health maintenance procedures isn't going to cause a practice major problems but when several people miss in one day it can be frustrating.

Try never to miss an appointment for a major procedure, such as a surgery or teeth cleaning procedure. You'd be surprised how many people fail to bring pets for surgery appointments at our practice. This causes major scheduling glitches and sometimes can cause a practice to turn down a legitimate emergency or an urgent but time consuming surgery such as a fractured leg, unnecessarily. It really can be harmful to someone else's pet to miss a surgery appointment. My receptionist has petitioned me to tell a client they were no longer welcome at our practice over missed surgical appointments that caused her to turn away other pets when more than one appointment had been missed.

Don't make jokes about the cost of care, especially ones that include phrases like "paying for the vet's children to go to college", "paying for a wing of the hospital" or "this costs more than my care". These are things the receptionist has heard before. If the receptionist is loyal to the practice, as most are, it may make him or her angry. Even if this doesn't happen it is tiresome to field repetitive complaints. You might be surprised how much a receptionist appreciates people who simply pay without comment.

This might not be a problem in the city but it isn't a good idea to ask the veterinary receptionist for an appointment when she's in the grocery store or at the bank. Very few receptionists memorize the appointment book daily and even those that can have no way of knowing if someone else has already scheduled an appointment for a space that was open.

You don't have to give the receptionist every detail of what is wrong with your pet. Try to summarize. The receptionist can't make use of the detailed information because he is forbidden by law from making a diagnosis or providing treatment advice, except for nonmedical things like grooming. Give enough information to help the receptionist schedule the proper amount of time and save the details for the vet. The receptionist just wants to schedule the day so that it runs efficiently so make sure you mention all the things you hope to get done during the office visit. A pet scheduled for a toe nail clip might not be in a time slot adequate for a complete physical exam and vaccinations, for instance. If your pet requires special care, such as sedation prior to examination or if you want to be sure a specific technician or veterinarian takes care of your pet tell the receptionist. Be reasonable if this means scheduling the appointment at the practice's convenience rather than yours, though.

A veterinary receptionist can't give tell you what is wrong with your pet or make treatment recommendations legally. The receptionist is not being evasive when she refuses to tell you the whether your pet has tapeworms or kennel cough even though she may strongly suspect these things. Many times receptionists are experienced enough to know from symptoms the most likely diagnosis but there are always other possibilities. The veterinarian is the proper person to complete the diagnostic process. You may want a simple over the phone diagnosis and there are times when I am sure it seems reasonable to expect one but that's just not something a veterinary receptionist is authorized to provide.

Give the receptionists a break and let them do their real job, scheduling the veterinarian's day and handling some of the business aspects of the practice. When you really feel your pet needs to be seen on an urgent basis explain why that is necessary calmly and clearly. If they really can't fit you in, ask them to help you find an alternative veterinarian rather than wasting time arguing with them. The point is to get the help your pet needs as efficiently as possible in an emergency. You might be surprised how fast a receptionist can go from being very defensive to very helpful when it becomes clear that you really do have the best interests of your pet at heart and aren't just trying to make his or her day miserable.

Veterinary receptionists almost always chose their jobs because they genuinely like helping pet owners care for their pets. If you have the same goal they will usually go out of their way to help you achieve it. Especially if you recognize that they are an important part of the health care process, not just a roadblock on the way to seeing the vet.

It's a Team Effort

Perhaps the single most important thing to keep in mind about working with a veterinary practice to obtain the best possible care for your pet is that it is a team effort. You are part of that team. When you work well with all the other members of the team your pet has the best chance to receive the care he or she needs and deserves. Make sure you' working with a team that recognizes your importance, too.

Thanks for your Support!

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The opinions expressed in this newsletter are those of Michael Richards, DVM., author.