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Multiple pet appointment leads to loss of customer focus


DVM360 MAGAZINE

10a.m. Saturday morning

Diane angles over to Dr. Henry Hammond who is busy writing up the results of an abscess surgery he has just performed on "Goliath" Newman a 3-year-old tomcat that the Newmans will never neuter.

Diane starts to explain the litany of problems that he presently must attend to in the large exam room. Waiting in that room are John and Betsy Bainbridge and their four pets. Dr. Hammond is not surprised to learn that multiple issues are to be discussed. Henry, overweight by at least 80 pounds from the snacks ingested to allay the stress he encounters on a daily basis, lumbers off to address the situation.

Dr. Hammond opens the door and lying on the floor is Jamie, a 10-year-old, 105-pound Malamute. He is not surprised to see three cat carriers stacked chest high in the corner of the room. Upon entering the room, a cacophony of spitting sounds emerges from the carriers. Jamie, thankfully, is a picture of happiness. Unfortunately, Jamie is not a picture of health.

On the card charts the technician has enumerated both requested services and a parade of old and new problems to check for each pet. Dr. Hammond examines the card charts for each pet and attempts to collate each of the animals' previous problems in his mind. Each card has to be turned this way and that. Some of the cards are tattered on the corners where multiple staples have lived and died.

Even though the cards are manipulated like a Rubik's cube, they are determined to keep most of their secrets.

Dr. Henry Hammond finally starts to look at the bewildering raft of questions that Diane has written in various places on the exam cards.

Each pet has been in multiple times for multiple problems and, therefore, each pet is taking a large array of pills and medicaments.

10:15 a.m.

He finally looks up and says, "Well, do you want to start with Jamie?" That seemed the best place to start, as Jamie is the most affable of the group before him.

Betsy Bainbridge is the spokesperson for the family on trips to the vet. She starts by announcing that Jamie hasn't eaten for five days and really never got over the itching that she brought him in for last summer. She would also like for Jamie to have a thorough exam and to especially check his hips for 'hip dylepsia'. Diane peeks in the door and says that there are two more clients waiting in the other exam rooms.

Betsy helps Dr. Hammond hoist Jamie onto the exam table while a trio of staccato spitting catacoustics reverberates briefly from the corner of the room.

Although Jamie is here primarily for his skin problem, Betsy asks if Jamie could get his shots and have his teeth cleaned while he is here. She reminds him that he has been after her for several months to do just that. Dr. Hammond gulps almost imperceptibly and opens the door slightly and calls out to Diane. He changes his mind and slips out the door.

"Diane, I need you to get an X-ray ready for Jamie and also we need all his vaccinations prepared," Dr. Hammond implored. Diane agrees but reminds him that two more rooms were waiting.

10:30 a.m.

Betsy watches as Dr. Hammond re-enters. She says that she forgot to tell Diane but notes that Jamie has been developing tumors on his chest and seems to be losing control of his bowels during the day. Dr. Hammond adds this to the growing list of problems.

He is eager to begin his exam but Betsy wants to talk about organic foods for elderly dogs and something she read in "Dog Fancy" magazine last month about natural arthritis cures. The last part about arthritis is somewhat muffled as he listens through his stethoscope to both Jamie's heart and Betsy's unending monologue. Doc, somewhat distracted, completes a cursory exam.

Henry notices that John sits placidly in the corner reading a book. He makes no offer to help as Betsy and Dr. Hammond groan to half slide/half drop Jamie to the floor in preparation for an X-ray.

10:40 a.m.

Diane and Dr. Hammond try desperately to get Jamie to lay on his back for the X-ray. Jamie is a friendly dog but the prospect of being on his back is so disorienting that he screams loudly bringing Betsy to the examination doorway in tears.

Dr. Hammond, against his better judgment calls for help from anywhere in the hospital but only gets Betsy. She is distressed to see her dog flailing on the X-ray table and points out that he is being hurt. After several false starts, an X-ray is finally taken in violation of only a few safety precautions.

Immediately after the X-ray is taken, Jamie scrambles off the X-ray table leaving behind a healthy sample of hair and urine.

A moisture trail tags along as he trots back to the exam room with Betsy in close pursuit.

11:05 a.m.

Dr. Hammond slips into another exam room to find "Wilber" Black (an iguana with 'attitude') that has swollen limbs. Doc sees another X-ray coming. A quick glance suggests metabolic bone disease and a 20-minute diatribe concerning the pathophysiology of this condition in lizards. Wilbur is the 10:15 a.m."work-in." Diane is soon busy preparing for another X-ray.

11:15 a.m.

Jennie, the receptionist, catches Doc between rooms and says that the lady with the dog in the third exam room is somewhat upset. She has been in the exam room for 45 minutes and needs to get to a soccer game at 11:30.

Just then Diane shows Henry the long list of prescriptions that Betsy would like filled before she leaves today. Diane also says she needs him to order that special cat food for her sister's cat in Milwaukee.

Henry notices that his body is talking to him again. Once more he realizes that he is getting that subtle message from his coronary arteries.

Multiple animal syndrome

No pediatrician in his or her right mind would book four children with multiple problems into a 15-minute examination slot. Yet veterinarians every day and every hour are faced with this very situation. The problem is one of focus. Juggling with too many balls leads to only one thing-a veterinarian "dropping the ball."

Some of the consequences:

* Incomplete examinations.

* Insufficient and sloppy record keeping.

* Inadequate patient planning. and case management.

* Overlooked charges.

* Overlooked and under-treated problems.

* Higher risk of pharmaceutical and biological mistakes and mix-ups.

* Veterinary care appears disorganized to the client.

Etiology

For many clients it is natural that they are going to want to cram as much veterinary care into one visit as possible.

This is obvious since bringing animals to the vet can be time consuming and problematic at best. Unfortunately, it leads to a bad situation all around for the pet, the doctor and the staff.

Veterinary hospitals have become part urgent care facilities, part full-service pharmacy and part pet grocery store. We seem to have embraced this philosophy of practice without reacting to its consequences. While most professions are procedure-oriented and book patients months in advance, veterinary hospitals, even with strict appointment policies, take in a large percentage of patients on the day the client requests service.

Some of this is because in most areas of the country the clients have a number of readily available choices. In other words, it is a buyer's market.

Veterinarians and the staff who work for them are generally very agreeable people and want to please and serve the public. In other words, we want to be liked and avoid conflict whenever possible. Therefore we have short memories when it comes to problems inherent with managing the patient flow in the exam room.

Taking back the exam room

Dividing the patients

When a client requests a visit, the front desk should always pull and examine both the physical patient record and the computer record.

It can be overwhelming to supervise a family of pets that is in the double digits. Organizing a chart with more than four or five pets is demanding for a veterinary hospital. Add to that the additional reports and lab results that accompany the record and it can become daunting.

The physical record: if you are still using small cardboard records for each client or patient you should consider the larger 8x11 folders. These allow you to put all the pertinent records and laboratory and referral sheets in one place. The 8x11 progress notes allow for much better organization of information.

Clients with many pets should have multiple charts, otherwise there will be chart chaos. It helps to give a pet with many problems a chart by themselves.

Dividing the time

Your patients deserve your undivided attention. Whenever possible your front desk should try to encourage individual appointments for each patient. When a client asks about bringing another animal, try first to make a separate appointment for that pet. If the client insists, limit it to only one more pet for the sake of the pet.

There are only so many 'irons' that can be in the fire. Clients who insist on multiple animals per visit should be given the first appointment of the morning (never on Saturday) and told that they may have to leave the pets for the day in order for the doctor to complete all the procedures. These clients must leave a full checklist of requested services.

As a veterinarian, it is wise to make additional procedural appointments over a period of time. Dentists make a living dividing visits per tooth-sometimes over many months.

Animal doctors haven't learned this valuable lesson. Veterinarians often try to do X-rays, dentals, vaccinations and full workup all within a 15 minute examination-sometimes on several pets. Patients with acute illness should be hospitalized. Trying to address acute illness dictates a good history and examination and hospitalization. Trying to hybridize an office call with a makeshift semi-hospitalization using a 45-minute treatment session for a sick pet and then out-the-door with antibiotics is poor medicine at best.

Stretching the twine

We can see that Dr. Hammond is reacting to a client's requests in a knee-jerk fashion and has created an environment that he cannot control.

Control begins with the front desk. Although not often possible, it helps to have a seasoned veteran in the front to try to evaluate client motives and help direct traffic. Sometimes the practice of veterinary medicine is like a large ball of twine presented all at once.

In 15 minutes we can investigate this ball of twine superficially but there is no time to unwind and fully investigate it. Our goal is to 'stretch the twine' of procedures into sections that can be addressed in an organized way. This will mean dividing patient problems into 'treatment units' over a period of time without losing track of the whole patient.

Stretching out the procedural twine should occur in two ways-immediate hospitalization for acute situations and planning for future procedure appointments.

Immediate hospitalization: Much time and staff efficiency is lost trying to do too much in the exam room to the patient.

If a situation cannot be easily managed within your normal allotted time slot, it should be kept in the clinic to properly workup and manage the case. This allows for maximum efficiency of the staff and doctor. It also allows the doctor to concentrate on the management of medical and surgical matters. Once the case is properly managed the patient can be released. The explanations and 'what-ifs' can now more easily be assessed. This will be much more straightforward to the client. Many clients need reassurances before they will agree to a hospital release of their pet-especially new clients. Nonetheless, it is the patients' and hospital's best interest for the veterinarian to focus on the patient and then on client understanding.

Future procedure appointments: This can be thought of as staging. The most common example presented to veterinarians is the issue of a dog presented for vaccinations that has some form of active allergy. Although vaccinating a dog and pumping it full of steroids may or may not present a danger to the pet, it certainly cannot be considered good medical practice.

Delay the least necessary items (the vaccines) and use them as a carrot to bring the animal back to assess the response to steroids. Although some veterinarians feel they must do everything now or risk losing the income from procedures if the client has a change of mind, this is rarely the case. Radiology and elective surgeries, for instance, should be scheduled as future appointments.

Are you an exam room cowboy or cowgirl? Do you need to complete your patients' needs in one big wad of monumental effort? If you are, you are wasting everybody's time and money-especially your own.

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Source: DVM360 MAGAZINE,
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