The Wagging Tail

Several weeks ago, I showed up early at the hospital on my “day off” for some paperwork.

I first noticed that the rest of the hospital also seemed to be closed when operating hours had already started. All of the exam room doors were closed, lights were off, no one was at the front desk and a pile of trash in front of the counter.

I was a little upset. I imagined clients, both potential and current, walking the other way so I went about picking up trash, opening exam rooms and turning on the lights. My receptionist walked out of the treatment room a moment later and greeted me enthusiastically while helping me finish opening everything up. She also explained that a team member had called in sick, which was why she had to go in the back to help secure a Pet and could not set up shop right away. She assured me she had only been gone for a few moments.

Before I left the store, I gathered the team to discuss the situation in order to avoid this from happening in the future. We discussed how my team did not prioritize the hospital’s appearance with the rest of their duties, and while much of the reason was that the team was distracted with other morning tasks, we all knew that we could do better.

We discussed the importance of first impressions, consistency, friendliness and overall exceptional service. Everyone understood that we needed to put certain protocols in place to prevent this from happening in the future. Amongst other things, we decided that, as a team, we should walk around the counter to make sure the hospital front looks clean. Because whether we’re seeing a new or an established client, saying “I’m so sorry about the mess” with an excuse just doesn’t cut it. While an established client might still continue to come to our hospital because we have solidified a positive first impression and they know that this situation is not typical, a new client’s first impression would most definitely be a negative one.

As I departed my hospital a few minutes later, I felt much better. Not only did I make sure to prevent a problem that is easy to fix, but I effectively communicated the needs of my hospital to the rest of the team. While I had not expected the need to communicate something that I thought was so simple to the rest of my team, I took this as a good learning opportunity on interacting with my team as well as stressing the importance of first impressions to clients.

Want your paraprofessionals to be the best they can be? A good technician, receptionist or office manager is extremely valuable. Where can you get one, or how can you develop one? The latter question is more important.

Everyone has great worth and infinite potential, so growth depends only on desire, will, circumstances, and education. As a leader, you have little control over desire or will, but you have some influence over circumstance and education. Education should be part of the culture at your hospital. Having a library of accessible books, manuals, and references is the most basic sign that your hospital encourages learning. Ensure that there are charts, pictures, handbooks, and technician’s manuals in easily accessible places. Everyone should come to work with the expectation that they will learn something new every day. As a leader, try to take yourself to as many formal education events as possible. When you come back, share what you’ve learned with your team members.

Banfield, the Pet Hospital streamlines and facilitates training through the online Banfield Learning Center modules. These are of extraordinary benefit in providing education to team members. I make it a point to ensure my team has the time to take advantage of this training.

Many veterinary practices encourage technicians to attend Continuing Education (CE). Is this a possibility in your hospital? Several PetNurses subscribe to veterinary technician magazines and associations. Litter your break room or coat area with these publications. Similarly, there are online technician’s courses available through accredited sites. I recommend the VetMedTeam, or those provided by Colorado State University, the Ohio State University or Tufts University. Given the benefits of continued education, you might even consider reimbursing your paraprofessionals for the cost of one of these classes.

When all is said and done, all the training in the world will not replace good hiring, recruiting and placement practices. In order to practice the best quality medicine, hire those who take their job seriously, especially those who have experience or who have acquired formal training (such as a relevant undergraduate degree or a veterinary technician’s degree). This will provide better patient care and a more effective hospital overall.

Don’t be afraid to think outside the box. I once heard about a veterinarian who insisted upon hiring elementary school teachers to be veterinary receptionists or office managers. He reasoned that elementary school teachers are not only compassionate people, but that their communication skills are superb and they are accustomed to a workplace in which emotions run high and chaos is commonplace. Sound like a medical facility?

In an interview, try to identify a person’s worldview, personality traits and how they handle themselves in order to know how they might work under pressure or how they might respond to an angry client, a crashing patient, a lobby full of sick patients or a kennel area full of howling dogs. A lot of us enter our dream job only to discover we are not very well suited to it. Make a point to hire people with experience in the veterinary field, who are also open-minded and flexible.

Remember no matter whom you hire, patience, persistence and dedication to learning will make any practice grow.

“Holiday Puppies” are a common present at Hanukah or Christmas. Shelters routinely brace for the surrender of these dogs a few months later. And while dogs are relinquished for a variety of reasons, one of the most preventable is “behavioral issues.” Here are some simple tips you can give to your clients at the first visit with their new puppy that will help mitigate some common behavioral issues, smooth the transition of the new family member and ensure a lasting bond.

Feel free to copy the tips below and distribute to clients:

Contented Confinement: I suggest that every dog should be trained to accept confinement in a portable kennel as early in life as possible. (Prepare her now for boarding or hospitalization later.) For “gone to work” confinement, the ideal setup is a portable kennel connected to, or inside an indoor “exercise pen” with newspaper or fake grass as a toilet. This setup is safe for 8-10 hours at a time and limits the puppy’s access to everything it might do wrong. The best way to introduce the closed kennel is to pair every entry into the kennel with a toy containing a fresh dab of peanut butter. If the puppy cries later, first do a “Needs Analysis” and if elimination, exercise and other needs have been met, it will be necessary to let the pup learn that tantrums don’t work.

Chew Training: A few chew toys inside the kennel during confinement teach the puppy that these are his items to chew. Other times the owner should actively put these chew toys in the puppy’s mouth and praise any chewing. Start with very easily chewed toys such as Greenies and work up to compressed rawhide that has one end soaked in water to soften it up. Booby trap unacceptable targets with mouth wash or underarm anti-perspirant.

Reward Based Elimination Training: Punishing house soiling teaches, “Don’t eliminate when he’s watching!” This approach makes proper training more difficult because the goal is to BE THERE outside to praise correct elimination. When home, begin with confinement in a closed kennel which inhibits elimination. Take the pup out every few hours when awake, and no food or water inside the kennel overnight. If the puppy does not eliminate, just put her back into the kennel and try later. She will learn the way to get freedom, play and other rewards is to eliminate in the right place. Make her urine or feces so valuable she won’t want to waste it indoors. When she routinely asks to go out, she has earned her indoor freedom.

Leash Training: After successful elimination, suggest the owner take the puppy for a walk as reward. This habit of rewarding elimination on the owner’s property reduces the future need to bring baggies on walks. If an outdoor walk isn’t possible, suggest an “indoor walk” i.e. hold the leash INSIDE the house during post elimination play periods. This is a positive leash association, and makes it easy to catch the pup if mouthing something inappropriate, or if about to eliminate again. In the evenings, use the leash to tether the pup next to people to bond, and to prevent sneaking away to trouble.

Following these simple steps will go a long way in making the “Holiday Puppy” a permanent member of the family.

No question about it — these are trying financial times. Fortunately, the stature of the family pet has never been higher, and more than 80 percent of pet owners DO NOT intend to spend less on their four-legged family member in 2009. The American Pet Products Association (APPA) expects pet spending in the U.S. to increase 5 percent this year. In spite of a serious recession, that’s amazing! The APPA predicts the biggest beneficiaries of this year’s growth will be the veterinary care and pet food categories. Dogs and cats must eat, and pet owners have a propensity to bring their pets in for veterinary care.

The ever-present challenge for veterinary professionals is to demonstrate the value delivered. According to a PiperJaffray study of 248 companion animal practices, “While we were impressed with overall growth expectations, we would highlight that nearly 70 percent of the clinics we surveyed believe pet owners are deferring some treatment this year.” The BNResearch PetPoll 2008 concluded that “€¦with household budgets getting tighter due to the economy, clinics can expect more scrutiny and questions related to the cost of veterinary services. If pet owners do not understand the value of the services they are receiving, hospitals are at risk of facing both unsatisfied and lost clients.” Clearly, it’s never been more important to clearly explain the value you deliver.

So, how do you communicate value?

• See patients and clients on-time. Your client’s time is valuable and finite
• Articulate the comprehensive physical exam as conducted
• “Show and Tell” clients what you see, hear and feel
• Spend adequate time with clients, and probe for pet health questions
• Cliché, but true, a picture is worth a thousand words. Show Me!
• Demonstrate the cost of non-compliance:
  • Obesity likely results in osteoarthritis, shortened longevity, expensive NSAIDS and lab tests
  • Periodontal disease only worsens without veterinary intervention. The systemic risks are significant (see Dr. Glickman/Purdue CVM study of 60,000 dogs linking gum disease with heart disease)
  • Heartworm disease, as well as other diseases, is MUCH less expensive to prevent than to treat

Dogs and cats don’t know or care that the economy is weak. Their health care needs remain unchanged. As Dr. Marty Becker has said, “Your job is to be the spokesperson for the pet’s best interest.” Your oath is to protect human and animal health. Be the pet’s advocate, and everybody wins!

It all comes down to this.   The knowledge from four intense years of study, summed up in one terrifying day (seven hours to be exact) of multiple choice examination.  Ready, set, go!

I have wanted to be a veterinarian since I can remember first being asked the question, “What do you want to be when you grow up?” Twenty-something years later, here I am, six months away from graduation; a lifetime of dedication to get here, over $100,000 in debt, and there is one more hurdle to cross before I can finally call myself a doctor — the North American Veterinary Licensing Exam (NAVLE).

This certainly isn’t the first standardized exam that has popped up during my education. College preparation included the ACT and SAT, and vet school admission involved the MCAT and GRE. I have obviously survived them all, so why does the NAVLE seem so intimidating?

For me, the NAVLE is a rite of passage. It is an assessment which marks the transition from student to professional. The usual test anxiety questions pop into my head: “What if I fail? What if I sleep though my alarm? What if I forget my 2 forms of identification?” These all feel normal.  The question that I’ve never dealt with before is: “What will passing this test indicate? Does it mean I am ready to be a doctor?”

It is this question which has inspired me the most to dedicate plenty of time for studying. I see NAVLE preparation not just as a bunch of questions which I would like to answer correctly. I see it more importantly as solidification of the knowledge that I have learned over the past few years, and an opportunity to make sense of and build on that knowledge before I step out into the field to put it to work.

The trick to NAVLE preparation is allowing adequate time for studying, setting realistic goals, and avoiding burnout. I began NAVLE preparation my first year by signing up for the free online Zuku Review question of the day. VetPrep is another internet site that provides practice questions and examination, and I purchased its 6 month preparation course at the beginning of my fourth year. From my past experiences with standardized examinations, I know that my success is not only dependant on how broad my knowledge base is, but also how comfortable I am with the testing format, time constraints, and taking educated guesses. Online practice tests found though Zuku Review, VetPrep and the NBVME site are valuable. Reviewing old class notes and reading board review books has also been helpful. Studying obviously takes time and energy, so I arranged my course schedule to allow for a free block during the month prior to the NAVLE.

As the NAVLE approaches, I find myself comforted by advice from graduates in years past. Study hard, avoid burnout by taking frequent breaks, get plenty of rest and absolutely do not study the night before the exam. Wish me luck!

On one of my very first days in practice, I faced a challenge that no classroom had prepared me for — unfriendly feedback from a colleague who did not extend professional courtesy. I was mentally prepared to face my first surgeries, to recommend and perform diagnostics to treat a myriad of illnesses; I was not prepared for the shock of a nearby veterinarian stating in several instances to mutual clients that I performed unnecessary diagnostics and prescribed the wrong medications. (Since when are blood work and diphenhydramine not recommended for snake bite wounds?) When philosophies of practice differ greatly among two vets, maintaining professionalism can be very difficult. However, professional integrity must be maintained — not only between two general practitioners, but among specialists and referral hospitals — because we fulfill different niches and working together is best for the Pets we treat. Even if your name is being dragged through the mud unfairly and dishonestly, it’s best for our profession — and for the Pets — when we take the high road.

Differences in philosophy of practice are not always so well demarcated, and Pet owners are able to pick up on even your most subtle of facial expressions and word choices. So, it is extremely important to be aware of how you speak about your competition in front of your clients.

Never forget that towns, no matter how large, can retain a bit of the small town syndrome – everyone eventually hears about you through the grapevine. If you are positive and honest, word will travel fast – your actions will be your best referral source. Conversely, if you have the opposite reputation, new client numbers could eventually dwindle. It’s truly amazing how many clients know each other.

Most of the time, speaking positively about my veterinary colleagues makes absolutely perfect sense. However, what about those instances that may not be so obvious? Recently, I saw a client for the first time on a Saturday because her regular veterinarian wasn’t able to fit her in to their schedule. The client was very worried about her Pet because he had a piece of tissue hanging out of his leg! Her regular vet wanted to wait until Monday to see them. Very upset, the client emphatically stated that she would never go back to them. It would have been easy to fall into the trap of agreeing with the owner that her vet should have worked her into their schedule. Even saying something to the fact that you always work in emergencies no matter the day of the week, which may be true, is still straddling the line of professionalism. The fact is you don’t know why that vet was not able to see the Pet. What if they had a rush of emergencies already? Or the staff had the flu? We should always try to be positive about our colleagues. We can sympathize with the client about having to look for an alternative solution. The client is upset with her regular vet now, but she may forgive them, go back to them, and remember how negative you were — and then state she would never go back to you.

I actually look forward to consulting with nearby specialists. Their grasp of the newest medications from pimobendand to gabapentin usually occurs much sooner than my ability to learn about the latest meds. Research into pharmaceuticals as well as better surgical techniques creates such a huge amount of information that no one person could possibly learn it all and still practice full-time general medicine. Conversely, if specialists had to spend time performing preventive care in addition to their area of expertise, they wouldn’t be able to see nearly as many patients who desperately need them. Instead of being competition, referral practices and general practitioners work best in cooperation.

My philosophy of medicine includes providing the best possible care for my patients, and that means cooperating with my small-animal colleagues, local specialists and referral hospitals. It also means that I will respect my colleagues’ reputations in front of my clients (and I hope they’ll do the same for me!). When we show professional integrity, we raise our profession to a higher standard and ensure the best quality of life for the Pets we treat.

In this unfortunate economy, many owners are choosing to lay off valuable staff in an effort to save money and you may be wondering if you should too. And while you never want to be overstaffed — particularly during difficult economic times — you can ill afford to lose experienced and talented staffers now more than ever.

In fact, most practices are understaffed. Ironically and counter intuitively, high-performing veterinary practices actually spend a greater percentage of gross income on staff salaries and wages. This fact is supported by at least three studies:

* Dynamics of a Successful Practice Study (Arthur Andersen)
* The Well-Managed Practice Study (Advanstar/Wutchiett-Tumblin & Associates) (http://www.wellmp.com/PracticeStudy.html)
* KMPG Mega Study (http://www.ncvei.org/kpmg.aspx)

How is this so? Having an adequate number of competent, capable, well-trained staffers allows two important things to happen: Doctors can spend more time with each client and patient and doctors can see more clients and patients in the course of a day.

Compelling evidence from other health care professions also supports keeping your staff. In the 1980’s, optometrists nearly doubled their staff to doctor ratio. The result? Each doctor enjoyed an additional 50% patient visits. The additional staff per doctor created enormous capacity for optometrists.

Dentists with hygienists see 23 more patients each week than those without a hygienist. More food for thought: All human health care professions have roughly double the staff to doctor ratios seen in veterinary medicine, allowing the doctor to see two to three times the number of patients. In fact, the Medical Group Management Association (www.mgma.com) has discovered that mid-level providers produce a 200% return each year. A nurse paid $90,000 is likely to increase practice production by $180,000.

It’s also important to note that employee satisfaction plays a large role in business success. The Harvard Business School Service-Profit Chain (http://hbr.harvardbusiness.org/2008/07/putting-the-service-profit-chain-to-work/ar/1) . pointedly depicts how profit is achieved in a service business:

* Profit results from client retention
* Client retention results from client satisfaction
* Client satisfaction results from outstanding client service
* Outstanding client service results from employee retention
* Employee retention results from employee satisfaction

Before making any layoff decisions, it’s wise to determine how staff layoffs would impact employee satisfaction.

Ultimately, avoiding layoffs and keeping your practice fully-staffed should positively impact your practice. You’ll be able to spend more time seeing clients while your staff continues to provide outstanding client service.

Does anyone remember the story of how penicillin was discovered? Alexander Fleming was discarding some contaminated Petri dishes in his lab and he observed that a plate culture of Staphylococcus had been contaminated by a blue-green mold and that colonies of bacteria adjacent to the mold were being dissolved. Curious, Alexander Fleming grew the mold in a pure culture and found that it produced a substance that killed a number of disease-causing bacteria. Naming the substance penicillin, Dr. Fleming in 1929 published the results of his investigations, noting that his discovery “might” have therapeutic value if it could be produced in quantity. Wow, pretty neat stuff when you consider he could have just said, “Hmmm,” and thrown them away.

So you are at work, and you have lots of appointments scheduled, drop off patients and procedures. A few are having routine survey radiographs taken. Many are having fecal exams and blood work. You take a look at a blood smear slide, everything looks o.k. What’s that little spot there? Probably nothing and we move on. Could we have missed something new? Have many of us have been seeing the same thing and disregarding it as an artifact?

There are discoveries waiting to be found everywhere. Whether it be a new drug, a disease or some as of yet unknown species of parasite, we will never find it if we don’t let ourselves be open to discovery. A mindset of “opportunity vs. monotony” can change the way we see each day and how we practice veterinary medicine.

So many of us can get into a rut that leads to professional burn out. How can we keep our practice exciting? Try not to look at each day as a day full of the “routine” vaccination appointments or the “typical” surgery. Look at each case for its unique nature and not its sameness to the rest. An attitude of discovery and opportunity can change our entire perspective in veterinary medicine.

Just when we think everything is “known under the sun,” someone finds a whole new animal species or family of bacteria, even in impossible places like boiling geysers — that discovery lead to the polymerase chain reaction! Try to find the opportunity in each day, in each case and you may be shocked at what you find.

Each summer of veterinary school, I made it a point to work within the veterinary field. I knew it was important for me to become intimately involved in small animal veterinary medicine for the clinical experience in the “real world.”For me, that meant working within a small animal facility because I knew that is what I wanted to do when I graduated. That has always been the vision of myself as a veterinarian.

My first summer, I worked in Ft. Walton Beach, FL, at Reed Pet Hospital. Dr. “Rog” (Roger) was a recent grad with his practice attached to his father’s practice. In other words, a built-in clientele!

I was Dr. Rog’s first and ONLY employee that summer. I played receptionist, vet assistant, kennel help and administrative assistant. I ordered his supplies, made appointments, called clients and assisted during surgery and all in-house appointments. Though this was after my first year of vet school, I learned to connect-the-dots of what I had learned so far! Seeing the anatomy in a live Pet during a spay was pretty cool. Seeing disease connected to that very small pituitary gland (that I could never find during anatomy tests) made it all real. Dr. Rog took great delight in me being his student and explaining everything to me in detail. I know now that was the perfect first summer job!

After my second year of vet school, I worked in Fontana, CA. Mainly because the Olympics were being held in LA that year and it was an easy way to convince my parents I should go. I stayed with friends and quickly found a job between two vet hospitals with one owner. That summer, I was actually the voice and words for a veterinarian new to the U.S. His English was still developing. When clients did not understand him, he would motion with his hand, “You tell, you tell.” I quickly learned to be his interpreter and tell clients what he wanted to do with the Pet, what tests he wanted to run and why. This was perfect since second year we began to learn pathophysiology of diseases in clinics. All those viruses, bacteria and disease processes were still fresh in my mind. And because of this, I was able to help this doctor with his patients. At the other hospital, the veterinarian was well into his golden years. But I learned by watching how to do a really efficient spay. He could do them in his sleep. I often think he did. He didn’t pause at everything that bled nor freaked out if the Pet was in heat. He methodically went about the surgeries. I learned by watching him how to keep cool in these situations. And I took a page from his book: “If something is bleeding in there, go find it. It’s not an infinite galaxy, just the insides of a dog or cat.”

After third year – what we called the preceptorship summer – I worked in Elk Point, SD. Don’t ask me why. But, thank goodness it was summer time. Why? This was a mixed animal practice. I sure am glad I didn’t have to chase cows, be chased by cows or go pull piglets in subzero weather! The owner of this practice took a student each summer. We were his relief help. He would actually allow me to go on farm calls alone, work the greyhound track as the vet-on-duty and perform surgeries. Ok, this was over 25 years ago and it was in South Dakota. Don’t try this at home! That summer, I learned what it was like to BE the doctor on a case, do the exam on a Pet, advise of the client of potential diagnoses and what needed to be done. I pulled calves and sewed up lacerated horses (another reason I am in small animal medicine). I learned how communication with clients was really the key to being able to care for the Pet or animal. Didn’t really matter how smart you were – they knew you were a doctor (almost) but, could you talk to them? Did they really feel that you cared for their Pet?

Every summer, veterinary students should work within the field of veterinary medicine. There is nothing like those wonder years. Seeing what you have learned in school and making the connection. I learned something from each veterinarian I worked with. The biggest lesson: communication. Second: trust your instincts. Third: I don’t like to be chased by cows.

I remember when I first started practicing veterinary medicine that my mind was full of information—drug names and procedures and protocols, etc.  Early in my career, I was somewhat disappointed to learn that all of those drug names and protocols, anesthesia, equipment, etc. weren’t just sitting there on the shelf waiting for me to grab them and use them.  The doctor that I worked for had his own set of medications and procedures and protocols.  He had his own set of equipment that had worked fine for the last 10 to 15 years and didn’t see any reason why it shouldn’t keep working fine for the next 10 to 15 years.

At that time I didn’t realize that the problem was two-sided.  Yes, I needed to realize that there are multiple ways to do the same thing and that all of those ways might be 100% correct.  But, my employer needed to realize that there are multiple ways to do the same thing and that all of those ways MIGHT NOT be 100% correct.  Over time, things got better as he saw positive outcomes from my clinical cases and I saw positive outcomes from his clinical cases.  Something that helped tremendously was when we would exchange journal articles or attend the same continuing education meeting.  We could compare notes and ideas and come up with new procedures, policies, etc. together.  The secret was developing a life-long commitment to continuing education.

Now that the tables are reversed and I have been in practice for quite some time, I am encountering times when the newer doctors are doing things different and I have to step back and realize that it’s the exact same situation.  Continuing education is the secret to a long and rewarding career with lots of positive clinical outcomes.  Whether you’ve just graduated or have been in practice for many years, continuing education is important. Like human medicine, veterinary medicine is always advancing with new techniques and it is in your best interest to keep up-to-speed. Read scientific journals, industry publications and attend professional meetings, conferences, workshops and seminars. As a matter of fact, according to the American Veterinary Medical Association (www.avma.org), approximately half the states require veterinarians to attend continuing education courses to maintain their licenses.

Although we’re struggling in the U.S. economically, money and time used toward education and certification can be resources well spent. Extra credentials and more knowledge just might mean a higher salary…a new wave of clients with your new specialization…a promotion…who knows where it can take you.

Make it your year to develop yourself professionally. Here are a few websites worth visiting that offer a variety of continuing education courses and other educational opportunities:

• AVMA (http://www.avma.org/education/default.asp)
• Vetlearn (www.vetlearn.com)
• WorldWideLearn(www.worldwidelearn.com/continuing-education/veterinary-ce.htm?s=ypi)
• National Veterinary Education Association (http://www.veterinaryeducation.org/)
• Lifelearn (www.lifelearn.com/c2/2000.html)
• VSPN (www.vspn.org/LIBRARY/WWWDirectory/CE.htm)
• AASVB (www.aavsb.org/RACE/RACEHome.aspx)
• ContinuEd (www.continu-ed.com/ContactInfo.html)
• Veterinary Information Network (www.vin.com)
• International Veterinary Information Service (www.ivis.org)

This is just a start as there are many continuing education options available through colleges and universities. If we’ve left anything out, please let us know.