Thursday, November 2, 2017

Veterinary Care in the Age of Having it All

I want to tell you a story.

A young veterinarian has been practicing mobile veterinary medicine in a small, close knit community for the past several months. She has been received well, especially as an outsider. The town is so small that there is only one other veterinary practice with two veterinarians in the town. She recently decided to open a brick and mortar practice in order to better serve her clients and expand her business.

The community members have been stopping by regularly to see the progress being made on the new clinic and make small talk. One fine spring day while she’s working on her new reception area, the mailman brings her a letter from a gentleman she had spoken to briefly the day before. Intrigued, she takes a break from working and sits down to read. 

The letter goes something like this. 

Dear Dr., I am so happy that you are going to remain in our small town and be our vet. I thought I would pass along a few words of advice as you open your practice. 


1. Be excellent at your job, and show us that you really love animals. The other vet doesn't know what she is doing. 


2. Most people living here are retired and are on a fixed income. A senior discount would attract clients. 


3. It is important to us that veterinary costs are kept low and are reasonable and fair. The other vet is greedy and clearly only cares about money as she charges way too much. 


4. If you don't plan to be open daily, leave a phone number where you can be reached in times of emergency.


I hope this will help you.Best,
Resident Senior


____


What exactly was the intention of this letter? With what tone do you read the letter? Do you think the requests are "fair and reasonable?" 


To break it down, this is what the letter is requesting (or demanding, depending how you look at it):
- Excellent care and compassion 
- Low cost
- 24/7/365 access to this vet. 

Sounds great, right? This is exactly what you want from your vet, right? While I think the letter was written with good intention, the letter writer is asking for an ideal that is impossible in the current day and age. I am going to try to explain why this combination does not exist.

24/7/365 No one works 24/7. Do you ask your mechanic for his cell phone number so in case your car has a problem at 11 pm you can call and ask him about it? How about getting your kid's teacher's personal number so you can call with homework questions? It is not fair and reasonable to expect your vet to work 7 days a week and answer your phone calls at all hours of the day, and if your vet does do that (as the market in this small town might require because it is too small to support an emergency clinic), then that service will come at a premium. Being on-call creates a terrible quality of life. You are a slave to the phone, feel like you can never go anywhere or do anything because what if there is an emergency. You start hearing your ringtone in your nightmares and feel a sense of dread whenever your phone rings. Not to mention the effects of being “at work” 24/7 have on your family. With the exception of OB-GYNs, even human medicine has largely eliminated on-call because of this. And if you have to be on-call, it must be worth it. So there will be an associated cost. 

Fair and Reasonable Cost Everyone has a different definition of “fair and reasonable” pricing. The truth is that some people will complain even if the exam fee is only $10. But to the vet, fair and reasonable means being able to pay for the cost of maintaining the facility while remaining affordable for clients. Most vets are not greedy. Truly. Yes, there are a variety of types of people in every profession, but most vets really do want to help you for as low cost as possible. I think sometimes pet owners forget that vet practices are in business. They have to charge in order to keep their doors open, and there is no government subsidy like there is for human hospitals. My boss pays the mortgage, electric bill, water bill, payments on the x-ray machine, the blood machines, fixing and replacing instruments as they wear out, paying the lab and the outside services we use, purchasing all the materials and drugs we need to run the practice, then fairly compensate all the staff. Well paid staff work better. They like their jobs more, do their jobs better, and less mistakes are made when people are happy. That translates to better care for your pet. And the cost of care has risen. Excellent, top notch care will cost you more.

Low cost clinics and options are available and serve an important purpose in helping lower income families get preventive care for their animals. The cost of a neuter surgery will be very different between a low cost clinic and a general practice. Low cost clinics are still profitable, but sacrifices must be made in order to cut costs. And those sacrifices are not to the practice owner’s pocket. To the pet owner, the cut costs are invisible. Two pet owners drop their dogs off for surgery, one at a low clost clinic and one at a general practice. The incision will look much the same, the bill will look different. Even though the procedure was the same, things were done differently in order to save costs at the low cost place. Just don’t translate that low cost to mean that your regular vet is OVERCHARGING you. Each is charging appropriately for their services. 

Excellence This request is the only one I feel is reasonable. Like most people drawn to veterinary medicine, I am a Type A perfectionist personality, and I want to offer the very best of care while being compassionate to my clients and patients.  Being compassionate doesn't cost me anything. In fact, being the opposite WILL cost me - it will cost me my clients, business, and reputation. However, gold standard care does have a cost associated with it. In order to offer digital xrays, ultrasound, the safest anesthesia, diagnostics to obtain the correct diagnosis - we the veterinary clinic have to pay. We pay in time spent learning, and we pay for the raw materials. We cannot eat those costs and be profitable.


The cost of care is a complex issue. There are many factors at play, and due to the increasing sophistication of veterinary care, which meets or sometimes exceeds that of human medicine, costs have risen. In veterinary medicine, we are struggling to find a medium between being able to provide gold standard care at a “reasonable” cost for pet owners. We don't want care costs to be so high that we can't treat and fix our patients. Veterinarians 'push' preventative care because preventative care is generally cheaper than fixing things after they happen. For example, heart worm prevention is  approximately $240 per year. Heartworm treatment is a one time cost of $3-5000. Pet insurance will help people cope with these rising costs for sure, but if pet insurance becomes like human insurance, the cost of veterinary care will increase.

Thank you for reading. My intention with this post was to offer some insight into why costs are what they are. I hope you have found this information valuable. 

Thursday, September 28, 2017

Appreciation

There are so many stories that need I need to write, and so little time. Here's one from today.

A client called to tell me she was moving back home to be closer to her family. She first came to our clinic about 9 months ago. A recent stroke survivor, she had some difficulty communicating and with her memory, although I could understand her without any trouble.

Her first time in the clinic, she was looking at her phone to write down her address on the client info sheet, and she couldn't remember her phone number. After helping her search through her phone, I finally just texted myself from her phone so we could get the number and write it in the chart. It was a small thing to me, but she thanked me and apologized for being a 'nuisance.' I told her it really was no trouble. I saw her dog a handful of times and enjoyed every visit.

A few days ago, I learned of an impending backorder on a medication her dog needs. I called her to let her know she may want to acquire a bit of a stockpile, since the medication is essential for her dog's continued health. After 3 or 4 phone calls later, we got it straightened out and I called in a large quantity to her pharmacy.

Today, she called me to let me know she was moving away again.

"I'm not sure if I told you the other day," she said, "but I'm moving back to ___."

I replied, "Oh, thank you for letting me know. It was a pleasure knowing you and let me know if I can help you with anything."

She said, "I want to thank YOU. I want you to know I appreciate YOU. You are the only person I am calling in California with this news. If I ever come back I will be sure to come and see YOU. Thank you for all of your help."

I am so honored that she felt strongly enough about this to call and tell me. It was really wonderful to hear and made my day. I will be sad to see her leave our practice because she is such a nice lady and I like her dog also. But I'm happy she will be moving closer to family. Live long and prosper, E.


Wednesday, March 29, 2017

The Handsomest Cat


On March 14, 2007, a young grey and white cat was found scrounging for food in a McDonald's dumpster. He was picked up and taken to an animal hospital down the road and named "Shamrock Shake," since that was the special treat at McDonald's at the time for St Patrick's Day. He was a stinky intact male tomcat who desperately needed a bath and a neuter.

I worked at an animal clinic that took in stray cats and fed them until they found homes. In the morning all hospitalized animals needed cages cleaned and changed, and new food and water. I never did the strays because I couldn't have pets while still living at my parents home, and I didn't want to fall in love with a kitten I couldn't keep. Until one day.

I walked into the cat ward, and in the first cage was a grey cat who immediately began pawing at me through the bars and rubbing his head all over. I opened it up and he was just as happy. He was handsome. I looked at his cage card and saw it said Shamrock Shake.

Dublin in F-Ward at WVMC

Later he had his neuter surgery. A knot slipped and he hemorrhaged little. NBD. Then when he was healed, I gave him a bath. He just sat there letting me bathe him, and stared off into the distance like his life was over. But it had just begun.

He was put on the adoption board as a young, active, 9 month old cat. He was taken home and returned twice, once because he was a gift and the receiver did not want a cat, and once because he was too old and they wanted a younger kitten.  After the second time, I couldn't bear to let him be rejected again. I added him to my account and changed his cage card. "Shamrock Shake" would have to go though. I enlisted help from my teammates. We decided to stick to the Irish theme. One of the assistants suggested Clover. Too demure. How about Dublin? Yes.

My fiancé was soon returning home from Oregon so we could attend his cousin's wedding in April. I called him and told him that before he left, he should go out and procure a litter box, litter and cat food because he would be returning with a cat.

"But I don't want a cat." He said.

I said, "Well it's not up for discussion. You'll learn to love him." And...

Two days after arriving at his new home 2800 miles away from that dumpster, he was sleeping on my pillow next to my future husband. He has been my husbands favorite cat since then.

On my pillow

Later that Spring I received my acceptance letter to vet school. When I brought Bella out two months later, he accepted her immediately and they became so close, I had to leave them together in Oregon when I went to school.





As they aged and became more mature, my husband started calling him Fatman, even though he really wasn't that fat.  We also referred to him as Handsome Man, Little Buddy, and Bud-bud. We really only started calling him Dublin again once my daughter could talk, since we didn't want to teach her it was ok to call furries or people fat.

He was super sweet, never hissed or tried to bite or scratch anyone. He was cautious, preferring to hide first and ask questions later if someone knocked on the door. He was always the last to come out and meet people. He was intensely playful, and would jump in for a game any time. He chased the laser pointer with a sniper's focus. He attacked toy mice with a frenzy worthy of Nat Geo. He trotted around with his tail ramrod straight up in the air, except that time Bella did something to him and it was down for a few days. He never ate wet food but he did have a penchant for Chinese.

Catnip was a favorite
He never sat on our laps unless forced but he was always near us and wanting to be scratched. He loved to be furminated but pretended he hated it.  He had a substrate preference for soft, fluffy towels and would ball them up and urinate on them whenever he had the chance. This actually worked out well because it trained my husband to not leave towels on the floor. He loved watching birds and laying in the sun. He wanted to go outside so we got him a harness and let him go out occasionally. I even had plans to build him an outdoor cat enclosure so he could go outside and breathe the air.

Dublin in the Sun

When Sophie arrived on scene, she started bullying him. He backed down even though he was easily twice her size. He accepted Alice without anything except curiosity. He even warmed up to my daughter and eventually let her pet him and stroke his tail, and he would rub against her. He loved to have his whiskers scratched.

On the porch in Portland


He began losing weight 6 months ago. He had a long standing heart condition that was controlled with medication and practically non-existent. Every test I ran came back normal. I posted his case on VIN and in Facebook groups for vets. I asked colleagues for ideas. I thought it might be intercat stress and tried everything I could think of to reduce stress in the house, but my stress increased and was sustained as he continued to lose. Eventually I started him on mild treatment for GI disease presuming that's what it was since no other cause could be found. Still nothing worked and he finally went in for endoscopic biopsies. I was substantially worried to leave him, but I had a previously booked girls trip starting the day after his biopsies were taken.

The day after I left, he had a saddle thrombus and my poor husband had to take his favorite cat to be euthanized without me.



I am so heartbroken. I wasn't there for him when he needed me most, I wasn't there for my husband or daughter to ease the pain of this. I couldn't have predicted this or done anything to fix it, but I still feel like I failed him as a vet and mother. I could have sought more help, taken him to the cardiologist, did more investigating, something.

My little buddy, I am so sorry for the pain you went through. I am so sorry I wasn't there to support you in your last moments. I am so sorry for bringing three bitchy cats into your life and letting them boss you around. I will forever treasure your sweet gentle spirit and I hope you can forgive me. I hope you are running free and chasing birds like you always wanted. I hope I will see you again someday. I love you--love, mommy

The Handsomest Man


-----
Other Blogs featuring Dublin:
Professional Courtesy and Pay-it Forward
Mirrored Cats
Three Bad Cats

Tuesday, February 28, 2017

YES it fucking hurts and other idiocy

Lately I feel like I am defending everything I say in the exam room. I have to compete with Dr. Google constantly. I don't just have to explain things. I have to actually convince owners that I know what I am talking about. (If I really don't know what I am talking about, I will tell them I don't and we will discuss where to find someone who does. That's called referral).

For example. A client came in with a clearly limping cat and said the cat got out a few days ago and came back limping. It hasn't gotten better, so she brought the cat in for an exam.

Many times, limping cat appointments are unrewarding because the adrenaline of the vet visit masks pain and so the cat often will not show any limp or pain during it's exam. This time though, anybody could have seen that the cat was favoring it's left front leg.

I recommended radiographing the leg and some pain medication to take home, assuming no bones were broken. The owner agreed that this was a reasonable plan. But, once my receptionist went in with my estimate for exam, radiographs, and pain management, the owner flipped out, said the cat is not in pain "He's just limping" and took him home without any treatment.

Well, when was the last time you hurt your foot? Pulled a muscle? Did you limp around, screaming in pain constantly for days after you stubbed your toe? NO!

It is a common misconception (I'm not sure why, honestly) that if an animal is not crying out, it is not in pain. Animals have an instinct to hide pain and illness for many reasons including self preservation. Most animals WILL NOT continuously cry out in pain from minor or even major injuries. If a cat or dog is screaming in pain constantly, obviously that warrants immediate attention. However, silent pain is there and deserves equal respect and attention.

Animals do not limp just because it's fun. You or I don't hop down the street on one leg just for the hell of it. They limp because they cannot bear to put their full weight on that limb.

I recently broke some bones and dislocated a rib. I didn't cry when it happened, but have been in pretty constant pain since. But I am still sitting here quietly writing this blog on my lunch break where I am back at work full time, driving, and doing all my regular activities without screaming in pain constantly.

So therefore, yes, it fucking hurts.

Ultimately I think this comes down to ---- duh-duh-na-nah! Money. She probably didn't have the money or didn't want to have the money for the recommended plan, but instead of asking if we could just try pain meds first, she decided to get angry and leave with nothing, except her painful cat.


Sunday, December 4, 2016

Glimpse

This is going to sound like a whiny post, but it really is a plea.

I really try to do my job well. Mostly because, it is not really a job to me. Veterinary medicine is a vocation. Most of us vets heard a call at some point in our lives. I was 10 years old, I read a book and I just knew. You work at a job, but you live a vocation.

I take "work' home with me. Constantly. I don't know a vet who doesn't. I agonize over my cases. As I drive my long commute home, some of the thoughts that wander through my mind are these. "Did I make all of the best, most up to date recommendations for that GI cat? Did I miss anything? Oh, I forgot to tell that dog's owner to watch out for this other symptom! I hope he'll be okay until I can call her tomorrow. Did I come across ok in that tense emergency? How can I communicate more effectively about the importance of treating ear infections? I need to remember to check and see if that diabetic patient scheduled an appointment."

Then, when I get home and have put my kid to bed and made and ate dinner, I'll go and do just a little more digging on that one tough case and see if I can find any other nuggets of information that could get us closer to a diagnosis. That night, as I get ready for bed I'll be thinking of my surgery from earlier that day and wondering how restful she's feeling, and if I sent enough pain meds home. I might dream about some of my patients or clients as I sleep. On my day off I will check bloodwork online and call or email the owners if it can't wait until the next day.

The next day I'll draft up a client information handout to better explain a complicated disease. I will turn every page of every veterinary journal and magazine I receive because I don't want to miss a single small bit of info that may help my patients. I'll spend an hour on the phone calling pharmacies, specialists, and labs to get the best medicine for the best price for my clients.

And I'll see countless appointments, and then begin a whole new cycle of wondering and thinking.

So it really bugs me when people think vets "do it for the money." Yeah right. I do all of the above work unpaid while filling every other obligation I have as a wife, mother, friend, daughter, sister, neighbor, board member, horse owner, and working (and getting paid for) full time. I do all of the above to make myself a better veterinarian, to learn as much as I can to better assist my clients and take even better care of my patients. I do it because I want to.

So please, just appreciate your vet. That's all I ask.



Saturday, September 24, 2016

QOTD 2

Client: He is totally fine with his belly being touched. He just needs to be distracted by food or someone petting his head or a stuffed clown.

.....

Technician asks of a rather overweight male cat: Is he neutered?
Client: Yeah, but I think they grew back a little bit.

.....

Technician: Is she on any medications?
Client: Just the medication of love!

.....

Client: We finally figured out what breed she is.
Me: Oh?
Client: Yeah, she's a (insert rare dog breed here).
Me: Oh, but you got her at the shelter, huh?
Client: Yeah. They didn't know either.

.....

A good samaritan brought in a stray but clearly well loved dog she had found. We scanned the dog and it had a chip, and we called the owners and they were overjoyed we had him. They came from the next city over to pick him up. My technician brought him out to the lobby for the tearful reunion. Then, the man took the leash off, gave it back to my nurse, and started walking out the door with the dog off leash. I said, "Hey, that is a busy road, you probably ought to leash him."

Mr. Doesn't have a clear grasp on the situation at hand: "Oh no, don't worry he's super trained."


Thursday, September 8, 2016

Overcharging Folks on a Fixed Income

I just saw an older woman who brought in her little dog for some issues. Some diarrhea, and some allergies. I mentioned it needed a dental cleaning, but that we would focus on resolving the current issues first and do the dental at a later date.

She then said to me, "Well, I am on a pension and it's fixed but I understand it needs to be done and I will do it, I just don't know when. But everybody knows vets overcharge people, well, people like me who don't have limitless funds."

Excuse me? Yes, my absolute sole purpose in life is to overcharge veterans and retired folks. On purpose. Then, I skip gleefully down to the bank in the moonlight with my overflowing riches.

I told her that she could likely find a cheaper dental elsewhere, but it would not be the same dental. Then she told me she didn't think the cheaper price I quoted her off-hand was a bargain either, and I said "Well, you're entitled to think whatever you like, but we charge appropriately for our services and you can take them or leave them."

Just as with any other field, various providers will charge differently for similar items. Usually they are on a spectrum of similarity, with most being about the same price and a few outliers in either direction.

The difference is, people seem to think that veterinary care should cost pennies or be free. Or my favorite, that we "sell things to people that they don't need."

No, that's what retailers do. Those constant ads for leasing a new car, or for buying that new iPhone, or for those shoes that are on sale this weekend only, those ads are selling you things that you don't need. You may WANT them, and if you want them you will spend money on them, even if it is money you don't necessarily have, but you don't NEED them.

But when your vet tells you that your pet NEEDS flea prevention, because there are fleas crawling all over your pet and that means they are in your house and potentially carrying bacteria such as Yersinia or Bartonella or tapeworms or Mycoplasma, it is because your pet actually needs to be free of these pests for their own comfort and safety and yours. Not because we are trying to make a buck. Most vets will honestly tell you you can now get flea control over the counter (it won't work as well as prescription and there are some that are safe and sadly many that are not), but just get something. Anything is better than nothing.

(Most) Veterinarians are not rich. This has been discussed elsewhere many times. No vet ever went into debt over 200k and alienated their family and friends because they are never around "for the money." We do it for one reason, because we are driven. We wake up early to go in and see the pet we stayed up late worrying about over night; we discount things that we can get away with so the pet can have what it needs even if the owner can't afford it; we squeeze in one more urgent appointment at the end of the night because the owner sounds desperate, even though we were already supposed to be off; we see the technician's pets and make phone calls to pet owners through our entire lunch; and we do these things because we care about the animals. Their health and well-being is our bottom line. And that's all.