The Wagging Tail

I work in a practice group that employs many different veterinarians with different backgrounds.  I graduated from school in 1998, another veterinarian graduated in 2008 and a relief vet we use is working on becoming board-certified in internal medicine.  With each new person we hire, I find that we all get to share a lot of information.  We each learn from each other. 

I’m likely to have insights on dealing with difficult clients, exam room etiquette, hospital policies, exotic medicine and some of those unusual cases that I’ve worked up over the last 10 to 12 years.  Brand new graduates are likely to have insights on new technology or new medications.  They have recently worked with the leaders in the field and their classroom notes are likely to be a great resource on current protocols.  We have a doctor that loves orthopedic surgery.   With each new addition to the team I get excited about what new things we might all learn. 

I try not to think of it in terms of “How can I learn to tolerate a new associate?” or “How can I learn to get along with the younger generation?”  I try to always think “How can we benefit each other?  What experiences have I had that I can share and what new ideas and procedures have they seen that they can share?” 

When I was a new graduate I found myself frustrated with the “old” policies of the “old” vet that I worked for, so now I actively try not to be that “old” vet.  If one of my younger colleagues asks me about carrying a new medicine or trying a new therapy, I always look at that as a way to potentially improve the practice and not as questioning the current practice.  By reading lots of journals and attending lots of continuing education meetings, even “old” vets are able to stay current and get as excited by new developments as do the new grads.

Oral disease affects 68% of cats and 78% of dogs over the age of three years.  Because it’s a common disease with a big potential impact on the Pet-family bond, the BARK  team has spent a lot of time researching periodontal disease over the last year.  We’ve examined the prevalence and risk factors for diagnosis as well as learned more about how often Pets are receiving dental prophylaxis and therapy in Banfield hospitals. Risk factors for periodontal disease include increasing age and small breed (Toy Poodle, Yorkshire Terrier, Maltese, Pomeranian, Shetland Sheepdog, Cavalier King Charles Spaniel, Papillion, Standard Poodle, Dachshund, and Havanese). Additionally, we’ve learned that canine periodontal disease is associated with certain cardiovascular diseases (cardiomyopathy and endocarditis).

Despite the fact that strategies for prevention of periodontal disease are fairly straightforward, Pets still suffer from the disease.  The most effective strategy is multi-faceted and includes teeth brushing at home, feeding of dental diets or treats, and dental prophylaxis performed by the veterinarian. However, client compliance with brushing is low and we’ve found that there’s a big gap between the number of Pets diagnosed with periodontal disease and those that actually receive dental prophylaxis. That gap can be as large as about 2/3 of all cats or dogs diagnosed with periodontal disease.

Why, despite the prevalence and impact of periodontal disease, are preventive strategies not fully implemented for Pets?  Why are the behaviors that people have adopted around their own twice yearly dental care not standard for our Pets?  Do Pets (especially cats) hide the pain that they may experience from periodontal disease from us?

As veterinarians do we recommend dental therapy less often than we should?  Are there factors like anesthetic risk or cost of therapy that affect your discussion of the diagnosis or treatment with clients? What factors influence your recommendations? What factors affect your clients’ compliance?

We’d love to hear what you think!

Further reading:

• BARK’s White Paper on periodontal disease

Walking into an emotionally charged, stressful situation, especially one you are not prepared for, is not something anyone would volunteer to do, even if your communication-style is up there with the likes of Dr. Phil.  And yet, that is exactly what vets deal with when they close the exam room door and are face-to-face with an upset, sometimes, angry client. Being a vet means dealing with the pain of others who love their Pet; it goes with the territory. Day after day, clients enter your practice feeling distraught because their companion and friend is suffering, or dying, or both.  Their worry and sadness causes pain, and unfortunately, when humans hurt, they don’t always handle their feelings in the most productive way.  We tend to lash out, and it’s usually at the one who deserves it the least. In this case, you.

When someone is addressing you with an aggressive tone, it’s difficult to keep your emotions contained and not fire back in some way.  In fact, after a full day of seeing patients and trying to fit it all in, it’s easy, almost understandable, to retort with a knee-jerk response that stings in return…which we know is never a good idea.  At best, a tête-à-tête with a valued client will leave you feeling bad and, at worst, cause you to lose business. 

Veterinary schools offer helpful information on how to deal with worried, grieving clients, but once you’re out and running a practice of your own, you may find yourself focusing more and more on the physical needs of your patients and less and less on the emotional needs of your clients.

It’s natural to feel a bit angry when someone is hostile towards you, but what you do with your anger can make all the difference in the outcome of your interaction.  Below are two simple, but effective strategies that can help you bridge the communication gap between you and your client.

Pause for the cause

It’s been my experience that by merely slowing down the speed of a verbal exchange, I can actually raise the odds of a more positive outcome.   Just pausing momentarily before I allow myself to respond allows my brain to engage, evaluate and better diagnose the problem. Solving problems doesn’t happen when our emotions are in the driver’s seat.  Allow yourself a moment to process.  Create some space to regroup, rethink and redirect. 

Sometimes, I find it helpful to actually remove myself, physically, from a high-stress situation.  People are accustomed to medical practitioners coming in and out of examining rooms, so excuse yourself from the room, if need be,  take a few deep breathes then go back in with your emotions contained and your head on straight.   Creating a self-imposed “time out” is an effective tool to gaining composure. Increasing your awareness of your emotional thermostat during stressful times will allow you to adjust your internal temperature up or down accordingly and better prepare you to handle any situation.

Objects are larger then they appear

Before you walk into your next appointment, take a moment to remember that the people who come through your door (unless it’s for a routine exam) are there because they are concerned about a potential health problem with their family member.  And, this may not be the only issue they are dealing with.  Job loss, family problems and financial struggles might be swirling around in their head too. 

When clients are agitated, try to look past what is being presented and respond back with a softer demeanor. When you take a bigger picture perspective and strive to understand your clients better, you inevitably neutralize the tone, and consequently, the outcome of the exchange.

(Print and post a copy of these concepts and use the information to discuss “How to Handle High-Stress Situations” at your next staff meeting.)

Do veterinarians practice evidence-based veterinary medicine?  In the human medical profession, evidence-based medicine (EBM) has become established and clinicians have accessible EBM tools to support clinical decision-making. 

What exactly does EBM mean to a practitioner?  EBM is the conscientious and implicit effort to apply current best research evidence to medical decision-making.  EBM should enhance clinical expertise in concert with consideration of patient needs and client circumstances.

For veterinarians, EBM is gaining momentum, but it is not widely employed in clinical practice. In addition to published research evidence, veterinarians still rely heavily upon textbooks, anecdotes, faculty expertise, and peer consultations.  Depending on the clinical question, these may be the only resources to utilize, but they are often inadequate, outdated, and unproductive.   Why has veterinary medicine been slower to adopt the practice of EBM?    Is it because there is less rigorous, controlled research conducted and published in the peer-reviewed literature?  These challenges create a gap between new knowledge and the practice of EBM in veterinary medicine. 

How can the veterinary profession close the knowledge-to-practice gap?  The gap represents a barrier to high quality care for individual patients. Where can veterinarians go to get evidence-based, synthesized information?   Who teaches veterinarians how to incorporate it into clinical settings?  The US Preventative Services Task Force (USPSTF) is well-known for providing physicians with recommendations and guidelines based on research evidence.  According to their website, the USPSTF is “An independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services.”  

Could similar guidelines for preventive care and screening be developed for veterinarians?  These guidelines would support the most efficacious screening for optimal pet care.  The BARK (Banfield Applied Research and Knowledge) team is using Banfield’s large database to generate new knowledge, in addition to critically appraising existing knowledge from a variety of sources, to create preventive care and screening guidelines for the common diseases of middle-aged and senior pets. 

Next month, BARK’s Research Medical Advisor Associate, Patrick Shearer, BVMS, PhD, will talk about periodontal disease.  Please join us, post your comments, and engage in a discussion about what we know about the disease and how as veterinarians we can promote the highest quality evidence-based dental care for the pets that we see.

• Each month thereafter, the BARK team will blog about topics such as:
• EBM and evidence dissemination initiatives in the profession
• Strategies to best apply evidence in clinical settings
• Current and future research initiatives at Banfield

Let us know if you have ideas about questions or topics that are of interest to you, especially in relationship to evidence-based medicine and getting new knowledge to our patients!

Further Reading: Click on the links below for two articles on EBM that recently appeared in the Banfield Journal. The current edition of the Banfield Journal can always be viewed online at www.banfield.net/banfield-journal. 

• Banfield Journal May-June 2009
• Banfield Journal July-Aug 2009

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!

“There’s only so much I can do!”  How many times have you wrestled with the feeling that you didn’t accomplish enough?   At the end of the day, you think about the patients and clients you interacted with, reflecting on whether or not you did everything you could to measure-up to your standard.  Your mind then shifts to a conversation you had with a team member that morning, and you question the way you handled the exchange. 

Dealing with sick animals, bereaved clients, newly hired team members, managing the practice and trying to be the family person you want to be is a tall bill.  Being a veterinarian is rewarding and yet, absolutely taxing – physically and emotionally at times.  You love, and are devoted to, your family and your job, but the demands of both get to you, maybe more often than you’d like to admit, even to yourself.

Renee Rucinsky, DVM, DABVP, and contributing writer for dvm360.com, refers to the feeling of emotional overload in her article, Compassion Fatigue. What is compassion fatigue?  We know that compassion is about feeling for others while fatigue is related to a lack of energy. Dr. Rucinsky believes that compassion fatigue is a state of complete exhaustion that leaves a person feeling physically and mentally overwhelmed.

No doubt, we’ve all experienced extreme stress at times, but veterinarians are more likely to suffer from compassion fatigue for a number of reasons: 1) the profession inherently calls upon vets to deal with many intense emotions on a daily basis 2) vets are innately caring people which means they feel for others on a very deep level, and 3) vets tend to be perfectionists, which causes them to expect too much from themselves. 

What can you do to combat compassion fatigue? First, know the symptoms. In Dr. Rucinsky’s article, her list includes, “excessive complaining, isolation, compulsive behaviors (excessive spending, eating or other addictions), poor sleep habits, poor hygiene, apathy, difficulty concentrating, recurrent infections or chronic aches and pains.” Using a few of Dr. Rucinsky’s techniques as a guide in fighting compassion fatigue, start by saying “No” to stepping out of the exam room to answer that non-emergency client call, and reduce your stress by empowering your team to handle any issues that arise.

There are steps you can take to change things – and that might even include seeking professional help. We all know what’s good for us. Dr. Rucinsky touches upon the usual such as regular exercise (taking a brisk walk during your lunch hour), making healthy food choices (brown bagging it instead of heading for fast food), surrounding yourself with positive people (the vet tech who’s always willing to jump in and help wherever needed), for example.

If you start from within, you can consciously change your attitude – and that’s a good first step to a better outlook on life that will ultimately help you combat compassion fatigue.

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.

Most of us came to this profession as a calling, not as a result of a measured analytical decision process. Veterinary professionals share a sincere, idealistic, and passionate desire to give back by helping Pets and families.  We are excited by the opportunity to participate in that magic bond between Pets and their Pet parents.  It turns out that our choice of profession was not only a sound emotional decision, but also a good rational choice given today’s uncertain and changing economy.

Since 1972, the U.S. economy has suffered through six major recessions.  Through the previous five the overall gross domestic product (GDP) shrank while the veterinary profession grew.  The current sixth recession is once again proving to be kind to our profession.  According to Fritz Wood CPA, CFP and noted veterinary accountant, eighty percent of small animal veterinary practices are continuing to grow despite the current economic climate.

The Pet care industry (of which veterinary medicine makes up the lion’s share) accounted for $23 billion in 2008.  This is projected to grow to $34 billion by 2013.  Currently the second fastest growing segment of consumer spending is Pet care (second only to consumer electronics).

The Bureau of Labor Statistics reports Certified Veterinary Technician as the second fastest growing profession and Veterinarian as the ninth fastest growing profession.  New graduate veterinarians and technicians continue to entertain multiple job offers.

Veterinarians continue to be ranked as one of the most admired professions. In fact, Money Magazine (November 2009) just listed veterinarian as one of the top 25 “Best Jobs” in America. Veterinarians were ranked as an “A” in benefiting society and scored near the top of all careers in job security, personal satisfaction and future growth. 

And it just keeps getting better!  The bond between Pets and families continues to grow stronger.  Technology is allowing us to do things we couldn’t even imagine a generation ago, and a huge number of Pets remain in need of quality veterinary care.

The economy will rise and fall, recessions will come and go, but the bond between Pets and families continues to grow, and the need for great veterinary care is stronger than ever.  There has never been a better time to be a veterinary professional!

It is definitely beginning to look and feel like fall.  The air is crisper, the leaves are beginning to turn, store shelves are lined with holiday decorations, and most importantly in my world, it is time to start visiting veterinary colleges to speak with students about gaining hands-on experience that will enable them to ease their way into the veterinary profession.  This fall will be my eighth consecutive year of having the privilege of speaking with those of you who are the future of veterinary medicine.  While the dynamics of veterinary medicine have changed over the course of those years, it is clear that the common themes that are on the minds of veterinary students have stayed generally consistent.

Two common topics present themselves when I am speaking with students.  Students are looking to find a summer job that will enable them to work side by side with a veterinary team where they will gain real-world experience in an environment that is conducive to learning practical knowledge, and they want to ensure that they are working in a hospital that will be similar to the type of medicine they want to practice once they join the profession.  I encourage these students to find an opportunity that will allow them to function not just as a technician, but one to work directly under the mentorship of an experienced veterinarian.  During clinical rotations at school, the student is exposed to many complex cases, but not necessarily the typical caseload of general small-animal practice. Externships give the student an opportunity to work more closely with a mentor doctor while experiencing the caseload of a typical practice. A good summer job or externship should allow students to focus on perfecting physical exam skills, develop client communication skills, learn and understand the proper use of diagnostic tools, and work as part of a team.

As I am speaking with today’s students, I encourage them to think of summer jobs and externships as an extended interview and I ask them to create a checklist of items that are important to them when looking at working in a hospital either while in school or upon graduation.  I believe there are some universal issues students should consider.  First and foremost, the student should determine if the practice encourages a mentoring and learning environment.  Secondly, the student should ensure that the hospital practices the type of medicine that they would want to practice as a veterinarian.  Additionally, the student should know that the practice has a healthy and supportive management structure.  Lastly, the student should determine if this is a practice they would want to join after graduation.  Important things to look for include opportunities for professional and personal growth, a focus on healthy work-life balance, advanced career tracks, and a fair compensation plan that rewards them for their contributions.

Selecting a first job out of veterinary school is most likely the hardest and most important decision a student makes their entire career.  It can be the determing factor in the type of veterinarian they will become.  Participating in a summer job or externship program will enable the student to have a head start when looking for the practice that is the perfect fit.

When dealing with clients, each of us brings our personal experience and background to the exam room.  My most successful classmates were those who could adjust their mannerisms, word choice and overall style of communication to fit the client’s comfort level, rather than expecting the clients to somehow adjust their level of understanding. 

I am very much of an introvert at heart, and early on I had to force myself to look up, smile, make eye contact, etc.  If the clients understand the message that we’re trying to communicate, then we’re more likely to be successful at providing high quality medical care to our patients and feel rewarded by having clients who understand and appreciate us. 

By practicing three methods – courtesy, concern and active listening, I dramatically increase my success when dealing with clients. 

Common courtesy begins as soon as the client enters our facility.  We acknowledge the client with a smile and eye contact.  If we’re busy helping other clients, we let them know that we’re aware of them and will get to them as soon as we can.  When possible, we try to call clients by their name, address their Pets, ask about their family, etc.  Every client is a VIP client. 

Showing genuine concern for a client makes them more likely to trust my recommendations.  In the exam room, I always try to relate a quick personal story to my clients to let them know that I can identify with them.  If they have a boxer, I let them know that I have two boxer puppies right now “and boy do they keep me busy!”  If they have a cat with diabetes I tell them about my cat Jon Tom who lived to the ripe old age of 22 – who by the way, also happened to have diabetes.  It really helps to build a bond when they know that I’ve been in their shoes.  It only takes a minute or two to make this connection, but this connection can last for years.

Actively listening can prevent the misunderstandings that often lead to client complaints. Active listening involves observing body language, facial expressions and tone of voice.  To ensure that I understand the client, I repeat what they’ve said.  For example, “Fluffy has been vomiting once a day for the last week, is that correct?” When I address the client, I speak slowly and clearly in terms that they can understand.

I recently saw a Pet on recheck whose owners went to “their regular vet” for an ear infection, walked out the door with a full set of vaccinations, heartworm prevention, flea prevention and home dental care – but their Pet still had an ear infection.  To avoid these kinds of misunderstandings, I always end each visit with, “Is there anything else you wanted me to check on the physical exam?”  or “Is there anything else that you wanted to talk about?”  I remind them to call us if they think of anything else when they get home.
Effective client communication is a learned skill, but one that I know is extremely important to the success of my practice.  I remind myself each day to be courteous, find a common connection, and really listen to my clients. After all, practice makes perfect.