Letters to dvm360: No easy answers when owner and associate disagree on best course
The March edition of Old School, New School by Dr. Jeremy Campfield, "How to discount associates right out of practice," highlights the tension that production pay brings to a small practice. First, an older practice owner is used to changing fees (right or wrong) and also has years of relationships with their clients and friends. Second, the associate wants to practice the best medicine, because good medicine is also profitable medicine and will not only help the practice's income, but will also increase her income. Third, the clash is obvious—the older owner isn't as concerned about profitability, but his decisions compromise the associate's income.
I have enjoyed working with new graduates and thrive on the energy they bring into my clinic. I always pay a set salary and not production pay because I feel that’s the most fair compensation. As I once heard someone say, "Owners need to step up and have heart-to-hearts with associates if their production is inadequate and not hide behind production pay as a way out of uncomfortable confrontations."
Perhaps the thing I loathe the most about production pay is that young associates are placed in an ethical dilemma case after case, day after day of recommending questionable diagnostics. I don't like the idea of throwing stumbling blocks in front of financially stressed associates.
I’m a female veterinarian with a one-doctor practice. The area is flooded with vets, so it’s competitive.
Not sure where it starts, but Iowa State's veterinary school is "off" a bit. It charges students $300,000 for a degree in veterinary medicine. Those graduates start out earning around $60,000 a year. In 1991, I paid $54,000 for my degree and started out earning $26,000. I worked for a "Dr. Codger" who was extremely cheap, yet he drew clients in and made $1 million a year.
I went out on my own and tried his techniques—no lab work, no tests, just a shot of penicillin and some pills sent home. What was good for him did not work for me. Clients were beginning to want more. The internet provided them with protocols and diagnoses, so I had to adapt to the demands of the public.
This works for some, but there are still people out there who remember the good old days when $50 got you some medicine for Sparky. That same dog would cost them $500 now. My clients now expect to pay $500 and my medicine is better; other pet owners think it’s highway robbery.
People also take advantage of women as they have a nurturing reputation and are expected to feel sorry for someone who has an expensive smart phone but can't pay their vet bill. Older men, who are "supposed" to be doctors, get less crap. These are just the facts.
Who’s right in this scenario? Goodness, it’s hard to know where to start! I believe everybody was a little bit right—and no one 100 percent right. While Dr. Greenskin wants the comfort and support of full diagnostics, not to mention the revenue, Dr. Codger wants to please the client and save the pet. Each feels responsible for and defensive of their philosophy. Either position has merit, but in this case, they are incompatible. Ethically, I don’t believe Dr. Codger should have interfered with his associate’s case without permission; however, on some level Dr. Greenskin was glad of the help.
But primarily I notice that neither doctor considered offering options and letting the client decide which course of action she preferred. I have been an ER vet for 30 years, and critical scenarios with financial constraints are shockingly common. Long ago I realized that my job, in most cases, is not to take the responsibility for decisions away from my clients. My job is to fully examine the patient, discuss my findings and some potential scenarios, tell the clients the logical next step(s) and then offer options. Ideally, I can offer an aggressive plan with diagnostics and the highest estimate and the best odds for success, as well as a conservative approach with symptomatic treatment that is economical and possibly even a middle-of-the-road option. Then the client tells me what she or he wants to (or can) do.
With this approach, the client is involved in the decision-making process; if they opt for the conservative path and it isn’t effective, they are far less likely to be angry. They are less inclined to believe we are all heartless money-grubbers, they understand that money for diagnostics does buy them answers, they don’t feel judged if they simply cannot afford it, and it’s clear whose responsibility this pet’s care truly is.
Obviously there are always those cases (severely dehydrated diabetic, GDV, collapsed old retriever with fluctuant abdomen and white gums) where there is no conservative option that carries much chance of success and the only humane thing to do is euthanasia if the funds aren’t available to be aggressive. However, I don’t believe there is anything intrinsically wrong with putting limited funds toward treatment rather than diagnostics. In Doornail’s case, I would have been willing to offer fluids overnight (at the going price), famotidine and Flagyl, but I would have made sure the client understood that, without diagnostics, we couldn’t say for sure what was going on. If he relapses? Well, we tried. If the owner reaches euthanasia at that point, she knows she tried. I tell clients what I can do, the odds of success and the cost. They decide.
I do always tell owners if I think the pet is truly suffering, but even then it’s their choice what they want to do. Obviously full diagnostics is always great, but, realistically, plenty of clients can’t afford that and I wouldn’t say they all ought to euthanize. I prefer to be able to say exactly what’s going on (e.g. “It’s renal failure, not pancreatitis”) and I often can’t give a valid prognosis without diagnostics, but that doesn’t mean there’s nothing I can do to help make that patient better—which is why I went into this profession.
If you are clear about the level of assurance each option offers and document that on your record, you shouldn’t be at risk for a lawsuit. And by making the client a part of my team so far as decisions go, I don’t own every euthanasia. Of which there are plenty.
I understand that newer graduates are often under a great deal of pressure to keep their production high. However, if the only options a client has is a shocking high estimate or euthanasia, there will be more euthanasias and that’s quite hard on us as well. Even a conservative treatment plan is likely to generate more revenue than euthanasia and the client is almost always grateful to have had a choice. We save a few more lives and feel better about looking in the mirror.
What do you think of production-based pay and clients’ expectations of cheap pet care? Let us know in a comment below or email us at [email protected].