Posts Tagged ‘veterinary office visits’

The Elephant in the Middle of the Exam Room

August 1, 2011

My dual career as an author and a practicing veterinarian provides me with a unique vantage point. Not only am I privy to the issues my veterinary colleagues are stewing about, I also receive a plethora of emails from my readers candidly venting about their experiences as consumers of veterinary medicine.  It’s rare that those on both sides of the exam room table are growling about the same issue, but these days this is certainly the case.

See if you can identify the elephant in the exam room based on the following data that has appeared in current veterinary news feeds along with quotes from recent correspondences with my readers:

– The number of pet visits to veterinary hospitals is dramatically decreasing (DVM Newsmagazine, June 2011), and a special session was held at this year’s conference of the American Veterinary Medical Association to explore ways to increase public awareness about the importance of annual checkups for pets.

– “In my opinion, most of the decline in veterinary visits is primarily due to the bad economy. If you are barely scraping by, you are certainly not going to the vet for a very pricey annual exam, especially if your pet seems fine.”

– While pet spending is up, the market isn’t growing fast enough to support the number of new veterinarians entering the veterinary profession. (DVM Newsmagazine, June 2011) Veterinarian supply is growing faster than pet owner demand. (The Bayer Veterinary Care Usage Study 2011)

– “Sadly there are some veterinarians who see hospitalization fees as a revenue stream and do not inform clients that no one will be supervising the pet they recommend be hospitalized. While one tends to like to think of their vet as a kind, caring person and many are, some are more business than heart.”

– Eighty-nine percent of current veterinary school graduates have student debt.  The average student loan debt of students graduating in 2010 from veterinary school was $133,873 (15% have debt in excess of $200,000) and the average starting salary was $48,674. (Veterinary Information Network News Service, January 4, 2011)

– “My question is why most vets feel the need to worry about money instead of worrying about taking care of the pets.”

– Although the number of households in the United States with cats is increasing, the number of feline visits to veterinary hospitals is decreasing. (Banfield Pet Hospital® State of Pet Health 2011 Report)

– “I’d love to take each of my cats in for dental cleaning on a regular basis and I have two cats that desperately need attention now. For me, it’s a matter of costs. Vets continue to increase their charges and there’s no break for multiple pets. Dental disease is a precursor for renal failure in cats and yet it’s so expensive for cleaning – yet alone extracting any teeth. Then blood work is usually advisable to be on the safe side. It’s a small fortune when you leave the vet’s office for ONE pet. Next you’ve got the cost associated with monthly flea control. You have to draw the line somewhere and hope for the best.”

– Fifty-four percent of cat owners and 47% of dog owners report that they would take their pet to the veterinary hospital more often if each visit were less expensive. (The Bayer Veterinary Care Usage Study 2011)

– “I am not saying veterinarians can’t charge a reasonable fee for their services, but most people can’t afford $300+ bills every time they step into a clinic, per pet, per year, and that is for the healthy ones who are coming in for regular yearly checkups and not for other medical concerns that require medications, further diagnostics, overnight stays, dental cleaning, blood work etc.”

– Fifty three percent of clients believe that veterinary clinic costs are usually much higher than expected. (The Bayer Veterinary Care Usage Study 2011)

– “I am sick and tired of the way veterinarians financially take advantage of people who are emotionally upset about their pets.”

– Twenty-four percent of pet owners believe that routine checkups are unnecessary and 36% believe that vaccinations are the main reason to take their overtly healthy pet in for an office visit. (The Bayer Veterinary Care Usage Study 2011)

– “We have a lot of price gouging going on here at local vets. A dental cleaning has gone from $75 to $300 and up at many places. A lot of the clinics are buying high tech equipment and passing overhead costs on us so they really shouldn’t complain when clients come for less visits.”

Have you identified the common thread amongst these comments and statistics?  No doubt in my mind that the “gripe du jour” is the “M word.”  Perhaps it is more accurate to say that the real issue is too little money.

This blog is not intended to create or perpetuate harsh judgments. Please hear me when I say that I know that not every veterinarian or every person who brings their pet to see the vet is thinking primarily about money.  Clearly, however, money matters are on the minds of many, in fact more so than I’ve witnessed throughout my thirty year career.   Never before have I observed colleagues declare bankruptcy.  Never before have I spent so much time in the exam room trying to help folks figure out how to do more with less.

My goal in presenting this information is to create some understanding about what’s going on in the minds of individuals on both sides of the exam room table.  Blame this money mess state of mind on the diseased economy, veterinary competition, or the expense of going to veterinary school.  Whatever the causes, there is an awful lot of emotion tangled up in the financial aspects of providing and receiving veterinary health care these days.

What are your thoughts? Let’s talk about it and in doing so we will be able to kick that big ole’ elephant out of the middle of the exam room!

Best wishes for good health,

Nancy Kay, DVM
Diplomate, American College of Veterinary Internal Medicine
Author of  Speaking for Spot: Be the Advocate Your Dog Needs to Live a Happy, Healthy, Longer Life
Recipient, Leo K. Bustad Companion Animal Veterinarian of the Year Award
Recipient, American Animal Hospital Association Animal Welfare and Humane Ethics Award
Recipient, Dog Writers Association of America Award for Best Blog
Recipient, Eukanuba Canine Health Award
Recipient, AKC Club Publication Excellence Award
Become a Fan of Speaking for Spot on Facebook

Please visit http://www.speakingforspot.com to read excerpts from Speaking for Spot. There you will also find “Advocacy Aids”- helpful health forms you can download and use for your own dog, and a collection of published articles on advocating for your pet’s health. Speaking for Spot is available at Amazon.com, local bookstores, and your favorite online book seller.

Normal Abnormalities

May 23, 2011

A “normal abnormality” is the term I use to describe something that is worthy of note within my patient’s medical record, yet is an anticipated abnormality (given the animal’s age, breed, or circumstances) that is highly unlikely to ever become a significant health issue.  I liken such abnormalities to the brown “liver spots” many people develop on their skin in response to sun exposure and aging.  Here are some examples of commonly encountered “normal abnormalities”:

Lenticular sclerosis:  This is an age-related change that occurs within the lenses of the eyes (dogs and cats). The pupil of the eye is normally black because the lens which is located just behind the pupil is crystal clear.  With age comes some rearrangement of lens fibers resulting in a grayish/whitish rather than normal black appearing pupil. This change is referred to as lenticular sclerosis.  People who notice this are usually concerned that their pet is developing cataracts. Whereas cataracts are opaque and interfere with light transmission to the retina, lenticular sclerosis causes no functional visual impairment. How can you know if your pet’s graying pupils represent cataracts or lenticular sclerosis?  Ask your veterinarian to have a look.

Sebaceous adenomas:  These small, warty appearing skin growths commonly develop in older dogs.  Sebaceous adenomas result from blockage of ducts that normally carry sebum to the skin surface. Smaller dogs are particularly prone- Miniature and Toy Poodles reign supreme when it comes to this age-related change.  Sebaceous adenomas are completely benign and rarely need to be removed unless they are growing or changing significantly (some dogs bite or scratch at these skin growth resulting in bleeding or infection). Removal of sebaceous adenomas may also be warranted if they manage to get in the way of grooming clippers.  Always point out any new lumps or bumps to your veterinarian including those you suspect are sebaceous adenomas.

Lipomas:  These benign fatty tumors develop under the skin in mature dogs (rare in kitties).  They can occur anywhere, but their favorite places to grow are the armpit, the inguinal region (the crease between the upper thigh and the belly wall), and along the body wall.  They are completely benign and need to be removed only if they are growing rapidly or, because of their location, have the potential to impede normal limb motion.  How can you know if a lump you’ve just discovered is a lipoma?  Schedule a visit with your veterinarian.  She will collect some cells using a small needle for evaluation under the microscope. If all that is present are fat cells, the diagnosis is a lipoma.  Every once in awhile these tumors become infiltrative sending tendrils of growth down into deeper tissues.  If your vet feels that your dog’s lipoma falls into this category, surgical removal will be recommended.

Stress induced changes:  No one likes going to the doctor, and our pets are no exception.  Squeezing your kitty into a cat carrier, the car ride, a lively waiting room scene, having a thermometer inserted you know where, the sights, the smells- all of these things can cause stress for your dog or cat!  And when the body is stressed, the body compensates by producing a number of normal physiologic changes such as increases in heart rate, blood pressure, body temperature, and blood sugar measurement.  Your veterinarian will have various tricks up her sleeve to determine whether such changes represent “normal abnormalities” or are indicators of underlying disease.

Should such “normal abnormalities” be ignored?  Not at all.  They should be noted in your pet’s medical record.  Additionally, “watchful waiting” will be recommended because every once in awhile, these abnormalities can morph into something that is deserving of more attention.  For example, a sebaceous adenoma can become infected, a dog with lenticular sclerosis can develop cataracts, and a growing armpit lipoma can begin to hinder normal motion of the front leg. While you are doing your “watchful waiting” count your blessings because, of all the abnormalities you or your veterinarian can find, a “normal abnormality” is the very best kind!

Does your dog or cat have a “normal abnormality”?  Do tell.

Best wishes for good health, 

Nancy Kay, DVM
Diplomate, American College of Veterinary Internal Medicine
Author of  Speaking for Spot: Be the Advocate Your Dog Needs to Live a Happy, Healthy, Longer Life
Recipient, Leo K. Bustad Companion Animal Veterinarian of the Year Award
Recipient, American Animal Hospital Association Animal Welfare and Humane Ethics Award
Recipient, Dog Writers Association of America Award for Best Blog
Recipient, Eukanuba Canine Health Award
Recipient, AKC Club Publication Excellence Award
Become a Fan of Speaking for Spot on Facebook 

Please visit http://www.speakingforspot.com to read excerpts from Speaking for Spot. There you will also find “Advocacy Aids”- helpful health forms you can download and use for your own dog, and a collection of published articles on advocating for your pet’s health. Speaking for Spot is available at Amazon.com, local bookstores, and your favorite online book seller.

Reasonable Expectations VIII: Written Cost Estimates

January 8, 2011

This is the eighth part of an ongoing series describing how people are developing new expectations when it comes to veterinary care for their pets. Parts one through seven can be found at www.speakingforspot.com/blog.

You’ve just taken your best buddy to see your veterinarian because he’s been vomiting for three days and is now beginning to refuse his food. Your vet performs a thorough physical examination with all normal findings, so she recommends blood tests along with X-rays of your dog’s belly.  If these tests don’t provide a diagnosis, she tells you that the next recommended step would be abdominal ultrasound.  Of course you want to proceed with this testing because your dog is a beloved family member and you want him to get better, but do you know how much the recommended diagnostics will cost?  Will you be charged $300, $800,  $1,300? Unless your dog is a “repeat offender” how in the world could you possibly know? Three hundred dollars might be completely within your budget; whereas $1,300 might mean coming up short on your mortgage payment.

Whether you are independently wealthy, barely making ends meet, or somewhere in between, know that it is perfectly reasonable to request a written cost estimate from your veterinarian before services are provided.  Why must you be responsible for asking- shouldn’t your vet automatically offer forth a written cost estimate?  Much to my chagrin, I must tell you that only the minority of vets voluntarily provide written estimates. This was documented by veterinarian/researcher, Dr. Jason Coe and his colleagues. Their research appeared in 2009 within the Journal of the American Veterinary Medical Association.  The article titled, “Prevalence and Nature of Cost Discussions During Clinical Appointments in Companion Animal Practice” documented the following:

• Actual cost is addressed in only 29% of veterinary appointments.
• When cost is discussed, 33% of the time it is the client and not the veterinarian who initiates the discussion.
• Talk related to cost information constitutes a mere 4.3% of the total dialogue time.
• Written cost estimates are discussed during 14% of appointments.
• Written cost estimates are actually prepared and delivered to the client in only 8% of appointments.

Dr. Coe’s research certainly supports the notion that veterinarians are squeamish when it comes to discussing fees for their service.  I must admit it is certainly one of the least favorite parts of my job.  Nonetheless, I consistently provide written cost estimates, particularly if I’ve recommended something other than a single treatment or test, in order to avoid communication snafus and clients who are disgruntled when it comes time to pay their bill. 

Why is a written estimate preferable to a verbal estimate? Written estimates require time and focus. Guaranteed such estimates are far more likely to be accurate than those prepared by the vet using mental math while “on the fly”.  Additionally written estimates avoid uncomfortable conversations such as, “You told me it would be $100, not $300……..” and, “But you never told me you were going to do that……”.   So, please don’t encourage your vet to simply give you a “ballpark estimate” or an estimate “off the top of his or her head.”   I avoid providing such guesstimates at all costs (no pun intended).  Try as I might, I invariably lowball such estimates because of my innate desire to make the cost for my client as reasonable as possible.  And when this happens I end up cutting corners (not a good thing for the patient) and/or having to make uncomfortable phone calls advising clients of added expenses (and I definitely get called into the principal’s office).

It is completely reasonable to receive a written cost estimate before services are provided, but keep in mind, you may need to be the one who initiates this process!  With written estimates everybody wins- communication is so much clearer and there are no surprises when it comes time to collect fees.  Additionally, a written cost estimate provides an itemization for you of everything that is planned for your pooch. Have you received estimates from your veterinarian?  If so have they been delivered verbally or in writing?

Best wishes,

Nancy Kay, DVM
Diplomate, American College of Veterinary Internal Medicine
Author of  Speaking for Spot: Be the Advocate Your Dog Needs to Live a Happy, Healthy, Longer Life
Recipient, American Animal Hospital Association 2009 Animal Welfare and Humane Ethics Award
Recipient, 2009 Dog Writers Association of America Award for Best Blog
Recipient, 2009 Eukanuba Canine Health Award
Become a Fan of Speaking for Spot on Facebook 

Please visit http://www.speakingforspot.com to read excerpts from Speaking for Spot. There you will also find “Advocacy Aids”- helpful health forms you can download and use for your own dog, and a collection of published articles on advocating for your pet’s health. Speaking for Spot is available at Amazon.com, local bookstores, and your favorite online book seller.

Reasonable Expectations Part IV: Communicating With Your Vet Via Email

September 27, 2010

This is the fourth part of an ongoing series describing how people are developing new expectations when it comes to veterinary care for their pets. Parts one through three can be found at http://www.speakingforspot.com/blog.

Have you any interest in emailing rather than calling your vet when you have questions? This is certainly a reasonable expectation assuming that your vet is willing to communicate online. Email communication with doctors is not a new concept.  The Kaiser Permanente “My Health Manager” program with an “email my doctor” feature has been wildly successful.  Not only are more and more patients using the program (and Kaiser is promoting it in their marketing ads), a study on more than 30,000 Kaiser Permanente patients with high blood pressure and/or diabetes documented that those who communicated via email with their physicians enjoyed better health outcomes! 

I recently surveyed 120 of my northern California colleagues about email communication with clients and here is what I learned from them:

•58% of the vets who responded are communicating with their clients via email
•62% of those who use email are selective- they do not provide email access to all of their clients
•26% of those using email set “ground rules” with their clients; interestingly, many commented that they strongly feel the need to set email ground rules, but have been too “wimpy” to do so
•Receptionists communicate with clients via email in 37% of the practices polled
•Technicians (nurses) communicate with clients via email in 21% of the practices polled
•95% of the veterinarians who use email reported it to be a mostly positive experience

The veterinarians using email unanimously reported that it is great for simple, non-urgent communications (emphasis on non-urgent). Just imagine every veterinarian’s nightmare- you check your email in the evening and find a message that is eight hours old from a client describing their pet who is struggling to breathe and has blue gums!  Vets using email enjoy the convenience- for many, not only is email less time consuming than telephoning (avoids phone tag), they can respond to emails at their convenience.  I can relate to this- I sometimes don’t finish up with my patients until 8:30 or 9:00 at night at which point I’m worried that it may be too late to return client phone calls. 

Along with the fear of not receiving urgent messages in a timely fashion, here’s what the vets I surveyed told me they do not like about email:

•Clients wanting a diagnosis via email rather than via an office visit
•No simple or easy process for transferring the email communication to the patient’s medical record
•Too time consuming for vets who have remedial word processing skills or feel the need to carefully edit their “written words”
•Clients who take advantage of the system and begin emailing too much and/or too often
•Receipt of “cutesy” emails (photos or stories that are incredibly cute, but only in the mind of the sender)

I happen to be a speed demon when it comes to word processing, and I would love the flexibility of communicating with my clients in the wee hours of the morning or late into the evening.  So why have I not jumped on the email bandwagon?  If you’ve read Speaking for Spot you know that communication between veterinarians and their clients is a topic near and dear to my heart.  So much of what is perceived during communication has to do with body language and voice inflection, neither of which can be perceived via email (unless I begin Skyping with my clients, God forbid!). I worry that, by using email, I will miss out on what’s happening emotionally for my clients. Even with this concern, the results of my survey have motivated me to dip my baby toe into the email whirlpool.  I think I will invite my clients to email me with really simple questions such as, “When am I supposed to bring Lizzie back in to see you?” or “Is it okay to give Radar his heartworm preventative along with the other medications you prescribed?”  Anything more than that, however, and I’ll be jumping back onto the phone in the blink of an eye. 

Do you communicate with your vet or your physician via email?  If so, what has the experience been like for you?

Now here’s wishing you and your four-legged family members abundant good health. 

Nancy Kay, DVM
Diplomate, American College of Veterinary Internal Medicine
Author of  Speaking for Spot: Be the Advocate Your Dog Needs to Live a Happy, Healthy, Longer Life
Recipient, American Animal Hospital Association 2009 Animal Welfare and Humane Ethics Award
Recipient, 2009 Dog Writers Association of America Award for Best Blog
Recipient, 2009 Eukanuba Canine Health Award
Become a Fan of Speaking for Spot on Facebook

Please visit http://www.speakingforspot.com to read excerpts from Speaking for Spot. There you will also find “Advocacy Aids”- helpful health forms you can download and use for your own dog, and a collection of published articles on advocating for your pet’s health. Speaking for Spot is available at Amazon.com, local bookstores, and your favorite online book seller.

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