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Andy Roark DVM MS

Veterinarian Confession: “I Don’t Brush My Dog’s Teeth”

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Mrs. Griffith sighed as she gently separated her youngest daughter and oldest Labrador Retriever. She stepped between them and over a discarded pacifier to look me directly in the eye. “Really?” she asked. “Do you brush your dog’s teeth every day?”

It was a moment of truth. She didn’t ask me what I recommend. She asked me what I do.

The best thing for her dog’s dental health is a daily tooth brushing with pet-safe enzymatic toothpaste. Unfortunately, the problem with my being a real person — one with a working spouse, young children, two jobs and a few hobbies — is that what I know to be “the best thing” and what I actually do at home are occasionally not the same. Mrs. Griffith had a lot on her plate at home, too, and when she asked me for honesty, my credibility was on the line. I wasn’t going to lie to her, and I’m not going to lie to you either.

I know exactly how dental disease affects pets. I know that the dental tartar you see slowly building up on your pet’s teeth is about 80 percent bacteria and that it damages the gums, the bone beneath and the ligaments that hold teeth in place. This bacteria can gain access to the blood stream and infect vital organs like the heart, lungs and kidneys. I also know that advanced dental disease hurts; it makes pets feel sick. Daily brushing is the best deterrent.

But like 95 percent of pet owners, I don’t regularly brush my dog’s teeth, even though I know it’s the best thing for his health. Still, that doesn’t mean dental health isn’t on my mind. Here’s what I do instead:

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Originally Published by Vetstreet.com.

Manage Veterinary Clients’ Requests for Special Treatment

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Manage Veterinary Clients’ Requests for Special Treatment

Originally Published: DVM NewsMagazine, November 1, 2011

 

 

I drop into my office chair, flip open the puppy’s chart and start frantically writing. I’m 15 minutes late for my next appointment and clenching my teeth. Even my eyelids are tensing with stress. When did I start carrying emotional tension in my face? Is it even possible to do stretches for these muscles?

With no time for a facial yoga session, I glance toward the appointment schedule for the rest of the morning. It’s packed, and it’s not looking like this day is going to end anywhere near our 1 p.m. Saturday closing time.

Before I can rush out the door to meet my next client, the phone lights up. “Dr. Roark, Ms. Nuñez is on the phone, and she says she’ll speak only to you.”

I know what this means. I have crossed paths with Ms. Nuñez before. She’s a loving cat owner but a demanding client and master negotiator. (Takes one to know one: I once talked a limo driver into loaning me his snakeskin boots when a nightclub bouncer took exception to my tennis shoes.) Our conversations feel like they should take place at Camp David.

As I press the flashing button to take the call, I run through the negotiation tactics I know she’ll use against me. Any of these sound familiar?

Get to the decision maker

If a client wants baseless discounts, waived emergency fees or complete circumvention of scheduling protocols, the doctor is whom they ask for. No one else has the authority, or lack of common sense, to make these things happen. So Ms. Nuñez insists on speaking to me directly. She’s off to a solid start.

Create a looming deadline

As soon as I pick up the phone, Ms. Nuñez jumps into the details of her visit to the emergency clinic the previous evening and the impending doom that looms over her cat, Petie.

Petie, it turns out, has had a urethral obstruction and, while he has been catheterized, Ms. Nuñez knows deep in her bones that the cat needs a perineal urethrostomy…right now. She is adamant that re-blockage is imminent and that leaving the patient at the emergency clinic until Monday is simply not an option. She feels surgery must be done immediately—but not at the emergency clinic (or at emergency prices).

Go heavy on flattery

Once she lays out the urgency of the situation, Ms. Nuñez targets my ego. She is certain, she says, that I can help her and do a better job than anyone else. I am, after all, the best veterinarian she’s ever met. (Fortunately, the stress tension in my face prevents my head from expanding noticeably.)

Understand the other party’s priorities

We, as veterinarians, deeply want to help animals. Ms. Nuñez knows that her cat’s health and quality of life are more important to me than money. She is also willing to bet that they’re more important to me than my Saturday afternoon. She uses this knowledge and ends her impressive pitch with, “Doctor, please don’t let my kitty suffer! You’ll save his life, won’t you?”

My mind races as I try to form a response.

She’s made her case so masterfully, I’m almost ready to book the after-hours appointment and risk mutiny by my technicians. But no. Today, I’ll do what makes the most sense for everyone involved, including Petie. I’ve got some negotiating strategies of my own. Here they are:

Recognize the pitch

As soon as a client demands to speak to me and me alone, I go on high alert. This is someone who’s looking to bypass the regular guidelines of the practice.

Control your heart

As her frantic story unfurls, I force my analytic brain to prevail over my warm and fuzzy side. I care about Ms. Nuñez’s cat, but I can’t let that emotion blind me to the consequences of my decision. I must also care about all the other pets who are scheduled to come in, my staff and their time, and my own family.

Understand the other side

Often, we think we know our clients’ priorities, but we rarely know the entire story. I ask Ms. Nuñez why she doesn’t want the surgery done at the E-clinic. She tells me first that it’s because she feels so good about working with me (back to the flattery), and then that the estimate is very pricey. Finally, she tells me she just doesn’t know these people, and she’s scared. Now I really understand where she is coming from.

Slow down

Ms. Nuñez has thrown a lot of information at me at once. None of it has been verified by the veterinarian she saw last night, and all of it is emotionally charged. My next goal is to get off the phone, so I can think clearly and quietly. “Did the emergency clinic fax me your record?” I ask. “I’ll review it as soon as I can and call you back in a few hours.” She nervously agrees to wait, and now I have time to unclench my face and contemplate my options.

Think through the whole scenario

After a few moments of reflection, I am certain that, though I want to help, I won’t be seeing Ms. Nuñez and Petie this afternoon. To do so would make my technicians work well past their scheduled shifts, leave my patient unsupervised after the procedure, and force me to do a solo surgery I am not comfortable with—not to mention strand my wife at home with a young child and infant. Rationally, I just can’t agree to it.

Address concerns, offer options

When I have reviewed the record, I call Ms. Nuñez back. I tell her I want to help, and that her cat’s health is my top priority in making a plan. I answer all her medical questions and then explain that I am not comfortable with the surgery, nor do I have the necessary staff available.

I tell her that I have great confidence in the E-clinic, which helps address her fears about dealing with unfamiliar people. I also tell her that I will support her in either having the surgery there or continuing supportive care until Petie can be transferred to me (and a more experienced surgeon) on Monday.

Step away

I have given Ms. Nuñez all the information she needs to make an educated decision on her pet’s care. I tell her she can think everything over, confer with the emergency doctor, and then let me know how she wants to proceed.

An hour later Ms. Nuñez decides Petie should have the surgery and come home as soon as possible. With my endorsement of the E-clinic, she feels comfortable going forward with the procedure there. She tells me that she will plan to see me when Petie needs his sutures removed.

I have no doubt she will talk me into doing it for free.

Survival Guide to Appointment Pile-Ups

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Originally published: Exceptional Veterinary Team, May 16, 2012

 

It was 11:15 am and my waiting room contained my 10:20 appointment (who had just shown up), my 11:20 wellness examination, an emergency “squinting dog,” and a woman desperate to talk with me about whether I thought her sister’s dog might have Cushing’s disease.

If you’ve ever worked a Saturday in veterinary medicine, you know the feeling—almost as if all the local pets and owners have secretly staged a flash mob performance for that very moment. The slammed schedule is an unavoidable reality in every clinic.

Prolonged client wait time is one of the top reasons clients change veterinarians, and it inversely correlates with veterinarian income.1 This means that the longer clients wait, the less likely they are to return—and the lower their veterinarian’s personal income tends to be. Obviously, the ability to juggle patients (and their owners) is vital to success.

Fortunately, there are steps that lead to better performance when working-up multiple cases simultaneously. Here are 5 tips for more effective movement between exam rooms and decreased wait time without sacrificing quality.

1. Abandon Multitasking

Often, it feels like the quickest way to get things done is to work on two things at once. For example, it is tempting to have a technician review the signalment for the next case while writing in the preceding patient’s chart. However, science tells us that if you need to accomplish multiple things within a short span of time, it’s better to focus on the component tasks sequentially than to do so simultaneously.

When it comes to paying attention, the brain simply doesn’t multitask. Attempting to take in two sources of information at once means that pieces of both are ignored.2 In addition, studies have shown that people who are interrupted take about 50% longer to finish a task and make up to 50% more errors.3,4

True, some of us are more adept at toggling between tasks than others, and moving between familiar tasks is certainly easier.2 Ultimately, however, multitasking is not a shortcut. Discard it and embrace the “one at a time” approach to catch up faster.

2. Structure Your Appointments

Keeping the intricacies of multiple cases and conversations straight in your mind is tricky. Apparently, so is remembering complex food and drink orders for a dozen restaurant patrons. In a 2008 Behavioural Neurologyarticle, Buenos Aires traditional waiters who had memorized all orders shared an interesting technique for keeping information from multiple sources straight. They thought of patrons’ orders in terms of courses, with each meal having a defined and well-known structure (ie, drinks, then appetizers, then salads, etc). Once the meal pattern was defined and memorized, the waiters could organize information quickly and easily by using the courses as an informational scaffold.5

In the same way, you can structure appointments into segments by mentally compartmentalizing case information (see Creating a Mental “Menu” below). This allows you to move between examination rooms and address segments of different cases sequentially—and more effectively.

3. Fill in the Gaps

Good veterinarians are also good technicians. This doesn’t mean veterinarians should take on technician tasks all the time, but doctors should not be shy about jumping in to help when technical work is required to move backed-up appointments forward. At the same time, don’t micromanage your staff and let them utilize all of their skills to assist you.

4. Don’t Forget the Drop-off Option

As the saying goes, “When you’re up to your neck in alligators, it’s hard to remember you came to drain the swamp.” Look for opportunities to suggest that a client could leave a pet for a few hours. The owner may prefer to relax at home or get a bite to eat instead of waiting. By offering to turn a scheduled appointment into a drop-off, it is possible to turn a complex appointment into a flexible one—while also preventing client irritation.

5. Exercise Regularly

Exercise is highly beneficial to your ability to successfully juggle cases, and not just because it gives you the stamina to dash between exam rooms all day. People who exercise regularly can expect to have greater long-term memory, problem-solving abilities, and attention spans, as well as decreased anxiety. They also show greater capacities for improvising based on previously learned information, thinking abstractly, and reasoning quickly.3,6 All these skills increase effectiveness when faced with different problems (and pet owners) in rapid succession. Even a small amount of exercise will help reap mental rewards: 30 minutes of aerobic exercise 2 to 3 times per week has worked in laboratory studies. Mental benefits appear in as little as 4 months.3,7

Creating a Mental “Menu”

A typical appointment can be organized into 4 menu “courses”:

Interview. Patient history, signalment, body weight, and temperature are recorded. This section can be carried out by trained technicians using a standardized hospital protocol. Veterinarians do not need to be present.

Physical examination. The veterinarian reviews the history and continues the interview while conducting (and explaining) the physical examination.

Diagnostics and treatment. Once the physical examination is concluded, treatments (eg, ear cleanings, bandaging, medication, etc) and/or diagnostics are performed. While the veterinarian may be needed for diagnostic interpretation, many diagnostic and treatment procedures can be carried out by technicians. Doctors are thus able to move to another case during this phase.

Results, summary, and discharge instructions. Following diagnostic and treatment steps, the owner must be updated and given clear instructions. Be sure to summarize all diagnostics, findings, and treatments performed to ensure client understanding and compliance going forward. This is an excellent way to emphasize the value of the services you performed. At this time, your portion of the appointment is concluded or further diagnostics or treatments are undertaken (return to Diagnostics and treatment).

You could simply let long waits become a habit at your practice. You could also keep staff members late to handle backed-up appointments. However, since labor costs are the greatest expense most clinics incur and clients exhibit a clear trend for switching veterinarians when waits become too long, it seems unwise to ignore the costs of that pattern. Practicing ways to work up multiple cases more efficiently saves not only your sanity but also your business. And a healthy business means more healthy patients. | EVT

I’m a Veterinary Hypocrite; Are You One Too?

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Originally Published: DVM Newsmagazine, May 1, 2012

 

Click here or the link above to view the article.

 

 

I’m a Veterinary Hypocrite, And You Probably Are Too

 

Special Sauce

Between the crab cake course and the chocolate mousse finale at a recent CE dinner I attended, I heard an orthopedist across the table utter the word “steroids.” I looked up immediately (and not just because I was out of crab cakes). As a “new-school” veterinarian brought up in the age of NSAIDs, the subject of steroids in orthopedic cases always gets my attention.

 

The orthopedist related how, as a resident years ago, he balked at using steroids. His team now uses them with such frequency that the drugs have earned a nickname: the “special sauce.” I saw looks of horror flash across the faces of most veterinarians under the age of 35, and nods of approval from our most senior colleagues. The orthopedist went on to discuss how and when steroids enter his treatment plans.

 

As I listened to his experience with the “special sauce” and observed the reactions around the table, I felt my brow furrow critically – and then I stopped myself. I reflected on how many times I have judged other veterinarians for their chosen course of action. I also thought about how many times – just like the orthopedist talking to us – I’ve said, “I’ll never do [X]…” and then done just that.

 

I thought back to the first time I used steroids in a limping dog. It hadn’t been my choice. The practice owner had come into the exam room with me, because the client was a longtime friend of his. He guided the conversation to a steroid injection, and the owner decided that’s what he wanted.

 

As I gave the injection, I felt like one of those subjects in psychology research instructed to press a button that will shock some poor test subject in another room. On more than one occasion, I had mentally (and even verbally) ripped doctors who had chosen this treatment. Yet, here I was, committing the very Vetalog sin I’d derided others for so many times.

 

I am relieved to report that the patient survived the injection and stopped limping after about 10 minutes. The client was thrilled, and the lameness did not recur. My boss slapped me on the back and said, “I told you so.”

 

Since then, while I have not used them with nearly enough frequency to qualify as a “steroid jockey,” I have employed steroids from time to time when a situation dictated the need.

 

But you know what else I’ve done? I have rolled my eyes at the medical records of others who have done the same.

 

 

Veterinary Hypocrisy

 

Thus is the nature of veterinary hypocrisy. We do what we have to do in the circumstances we are faced with. We then conveniently forget all we have done and pass judgment on our peers when their similar cases appear before us. We often do this with minimal knowledge of the circumstances the other practitioner was facing.

 

I remember working an emergency shift a few years ago when a patient presented from a referral hospital. Shortly after arrival, the patient began to show signs that her condition might be deteriorating. My colleague asked the owner if we could investigate by repeating some of the diagnostics that her referring veterinarian had done previously. The owner agreed.

 

The next morning, the referring veterinarian called in a rage. He believed that we had implied to the client that his tests “weren’t good enough.” I don’t know if he ever believed our version of the story, but I remember feeling insulted and telling our team that we would be sure never to treat other veterinarians the way he did.

 

Two years later: I arrived at work to a swarm of agitated technicians. They informed me that a client I had referred to a specialty hospital for an abdominal ultrasound had called and was angry. They said the specialty practice wanted to charge him emergency fees and admit his pet for care prior to performing the ultrasound. They also (rather easily, I admit) planted the idea in my mind that my client, who trusted me, was being gouged by the people I had recommended. I was furious. I called the referral hospital and let the attending veterinarian know that I would not stand for this!

 

After venting at the attending veterinarian, who swore that she didn’t know why the patient was at the hospital if not for immediate treatment of vomiting, I hung up the phone. I turned to my impromptu anger-support group and asked: “Liz did call and confirm that ultrasound appointment with radiology yesterday, right?” I was met with silence. Oops.

 

Fifteen minutes later, I had the attending veterinarian back on the line. “I just want to apologize,” I started. I went on to grovel, profusely, for quite some time.

 

I had done exactly what I swore I wouldn’t do to others. I had jumped to an inaccurate conclusion about why another doctor had made the choices she did, what her circumstances were, and what she had actually said to the pet owner. I was a hypocrite, and it definitely wasn’t the first time. Or the last, probably.

 

My resume of actions taken after swearing I never would (and harshly judging other veterinarians who did) is extensive. It includes numerous strange concessions to client demands, diagnostic testing waivers, decisions to refer cases, decisions not to refer cases, free-style diet modifications (“Just add some green beans”), etc. Needless to say, it’s not a short list. I’m willing to bet that, if you’ve been in practice a few years, yours probably isn’t short, either.

 

A Plea For Understanding

 

Experience is a profound teacher. Every year, we find ourselves in situations that we wouldn’t have imagined the year before. As they say, you just never know. No one has all the answers. None of us work in a vacuum without the limitations of finances, medical resources, staffing resources, personal experience, or the need for clear communication. Hypocrisy ends when we remember all of that, about others as well as ourselves.

 

We veterinarians strive to do our best to take care of our patients given the circumstances we face in any given moment. While this truth cannot exonerate us from poor decisions we have made (and we’ve all made poor decisions at one time or another), it can help us to improve our profession by making it a more forgiving and less judgmental place. Moreover, think of how many learning opportunities we would miss if we never discovered the exceptions to our long-held assumptions about what is “always” or “never” appropriate.

 

Judgment and hypocrisy are not limited to the veterinary field, and they will never go away. But let’s pledge, as a group of professionals, to minimize that behavior as much as possible. I’ll start with me.

Give Us an Earful: How Do YOU Treat Aural Hematomas?

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Give Us an Earful: How Do YOU Treat Aural Hematomas?

Originally Published: Clinician’s Brief, March 8, 2012

Click here or above to read the complete How Do YOU Treat Aural Hematomas? article.

 

 

Give Us An Earful: How Do YOU Treat Aural Hematomas?

 

“What are you going to do this time?” my technician whispered as we looked into the waiting room. The 4 y.o. MN Bernese Mountain Dog looked back happily, then violently shook his head. The hair on the outside of his right ear was starting to re-grow, as was the fluid-filled pouch on the underside. His owner spotted me peeking around the doorframe as I tried to assess the situation, as well as the attitude of the client who was making his fifth visit in the last 8 weeks. He gave me a pained grin that said, “I like you a lot, but you really need to fix this.”

 

To be honest, I was (and still am) quite fond of this particular dog. However, frustration over this unresolved aural hematoma was threatening to seep into my bedside manner. During this case, I read widely on treatment options, and discussed everything from medical management to ear amputation with the owner. I tried multiple courses of steroids, ran blood work, evaluated clotting times, drained, opened, sedated, anesthetized, quilted, and asked for advice from almost every veterinarian I knew (and some that I didn’t).

 

Ultimately, it was a combination of steroids, quilting, and drains (and possibly prayer) that seemed to do the trick. I used an 6-week tapering course of prednisone with 1cm full-thickness sutures and a ¼-inch fenestrated latex drain, which I removed after 3 weeks. Having gone through this emotionally scarring ordeal, three things now happen whenever I see an aural hematoma. First, I develop a mild eye twitch that my technicians are starting to pick up on. Second, I preemptively warn the owner how frustrating treatment of this condition can be. And finally, I kick myself for not writing down all the great advice I was given on effective treatment of this condition the first time.

 

So today, for the sake of all the veterinarians that are battling (and will battle) this potentially humbling condition, I ask for your help. Please share your best advice for treating aural hematomas in the comment section below. Your words of wisdom may save a young (or not so young) veterinarian a lot of frustration!