Ethical business, good veterinary medicine

The balance between making a good living from veterinary medicine and being a good practitioner is not as difficult as some members of the profession or the public think, but it does require a mind shift for some of us. What is a fair mark-up on products? How do we choose one product over another? What is our relationship with the veterinary industry – is it actually a form of corruption? What is the best way to compete with other practices? Where do we draw the line and not perform procedures beyond our experience and training?

These are just some of the difficult questions that need to be asked – and there are more. To contemplate these really deeply may bring each vet – employee or practice owner – to some interesting conclusions. Ultimately, we are all individuals and have our own views on what is appropriate and necessary in our practice lives.

It is my experience, however, that many vets do not ask deep, difficult questions and are not entirely self-aware or brutally honest enough with themselves. As the market becomes more difficult, filled with competitors, and clients become more demanding, we have to shift our paradigm or be left behind. After all, a practice that is not growing at above-inflation rate, is either dead or dying.

Some of the advice given may already be self-evident to the reader, or already in place. It is not my intention to offend, or preach, but rather to provoke introspection; to give detailed examples that provide concrete and beneficial starting points for improved profit; and give starting points for intra- and inter-practice conversations. Some may just plainly not be applicable to each and every practice.

Money – that oldest of vices

Money is necessary but not evil. It’s difficult to deal with issues on money when in a compassionate profession. One way to deal with money is to separate the vet from the fees. Wherever possible, have other staff (reception, practice manager) discuss money issues and take payment from owners. This means you must have taken the trouble to prepare estimates for a variety of the more common situations and procedures. This is a lengthy, hard exercise that only needs doing once fortunately.

A computerised system is helpful for this, but even if you don’t have one, try to consider the actual costs of procedures. Do you know what it costs you to get a dog into theatre? What does it really cost you to perform a blood smear? And if an assistant vet or nurse makes the smear? Is having an in-house haematology machine necessary? Does it pay itself?

Start with an understanding of costs – which your accountant or practice manager should be able to give you. For each room, consider it as a cost centre. For example, if your X-ray room is 3 x 2 metres, your hospital is 150m2, what is your bond repayment + building insurance + electricity + water + and so forth, per m2? It might give you a figure of, say, R150/m2 x 6m2 = R900. Then the repayments on your X-ray machine and its insurance need to be added – say R5,000 pm. Remember that it takes a vet nurse (@R18,000 pm / 220 hours pm / 60 mins/hr = R1,36 per minute) and a handler assisting her  (@R7,000 pm etc. = R0.53 p/min) (= R1.89 pm total) 15 minutes to take 2 views. Thus add R28 to your costs of R6.70 for 2 rads. All in all, the more you use the machine, the easier it is to pay off – now one might realise it’s a good earner.

Bad medicine = lazy medicine = recipe for trouble

Now consider the ethical side of radiographs, as an example. How many vets take only one view? Or a “catogram” (same exposure factors for thorax and abdomen). How is this bad practice and bad medicine?

Firstly, there is a reason we use different exposure factors for the thorax and abdomen – the abdominal organs require shades of contrast to distinguish them – this requires a long exposure at low kV. However a slow radiograph allows for blurring of the (moving) thoracic cage, thus hiding detail. One view only? How will you see a soft tissue mass adjacent to the heart, if we only have a lateral view? Vets need to consider the consequences of this kind of laziness: if you miss a bronchopneumonia à the patient doesn’t respond to shotgun therapy because it was too short à the patient is taken to another vet who takes 2 – 3 good views. The client never returns, and badmouths your practice.

Good riddance you say?

Consider this: every pet is worth R100,000 (cat) – R150,000 (dog) to a practice, over its lifespan.  A pet owner with 2 dogs and a cat, who stays with your practice for 30 years, and has replacement pets – say 5 over that time – is thus worth about R1,200,000 to you. Each client that leaves, tells about 12 people of their negative experience. That’s potentially R15 million down the drain, all because a vet though he knew better than the radiologists who taught him to always take orthogonal views. This is one way in which I translate what I was taught, into practical, business implications.

I am constantly surprised how bad some of my referral radiographs are. I ask myself how the vet could diagnose, say, a bronchial pattern, when I can barely see the lung field. Am I that bad a vet I ask myself? Very often, clients have not seen the radiograph and when another vet is forced – by medical necessities – to redo them, the difference is evident to any layperson. The bad blood that is created is really unnecessary – improve our technique or machine. Digital machines are not necessarily better than film, if the patient’s girth is not measured, and settings made accordingly. Some of the best radiographs I receive come from two non-digital practices in KZN. Some of the worst come from practices with digital machines who charge more for these “Rorschach file-dividers” than my specialist practice!

Another example is the latest proliferation of cheap microchips, which are being used by the public and breeders. When you implant a microchip, it’s your reputation you are playing with.  Have you asked yourself what happens if the pet you chipped is lost? If picked up, and scanned by a colleague/SPCA, then is there a database that is easily accessible? I challenge you, personally, to try access such a database yourself, and check the customer service. Do it on a Sunday evening, just as a frightened pet owner would need and expect you to. I am concerned that we vets penny-pinch for the wrong reasons. You cannot play with your reputation, you have only one.

Similar false economies are:

  • Reusing syringes
  • Combining multiple medications in one syringe with no attention to their compatibilities
  • Reusing drip sets
  • Not using proper, R2.50 injection ports (which could be marked up), but rather placing the jelco stopper back in the syringe
  • Not wearing quality, sterile gloves, masks (above the nose!) and caps during surgery. These billable items are things we take for granted when WE or our families undergo surgery – but “it’s just an animal” in our “theatre”. Even butchers wear caps in their abattoirs.
  • Taking one radiograph of two areas
  • Using fishing line instead of swaged-on, individually packaged suture material
  • Reusing surgical sets between animals. Again, put yourself in the patient’s position.

And so much more

Patient expectations and value

On the last topic, I want you to contemplate on what your patients MEAN to you and what your sense of obligation is to them.  I see that for many pets, their vets see them as animate objects, an endless procession of tasks, not a living, sentient, feeling creature with a sense of its own mortality, fears and family attachments (a little more on this at the end).

Every patient is presented to you, the vet, by an owner who usually cares, sometimes deeply (sometimes pathologically), for that pet. Both pet and owner have an expectation of you delivering the OPTIMAL OUTCOME or advice that patient could receive. There are not different standards of care and obligation in different areas.

Our obligation and responsibility to the client includes:

  • Always doing a thorough physical evaluation and history, including for a vaccination
    • How else can we affix our sacrosanct signature to a vaccination certificate if we cannot expect that the patient will respond to the vaccine optimally (which requires a health check)?
  • Always giving the client some clear options to choose between.
    • Avoid medical jargon. People don’t think you are smarter – they hide their ignorance, only to resent you later for making them feel stupid
  • Doing a systematic investigation of their pet’s problem
    • Doing bowel biopsies without first checking for intestinal parasites; or not sending samples for histopathology; or palpating a lump and not performing an FNA – this is not a systematic, iterative approach to a patient’s health problems.
  • Embarking properly and completely on best-practice medicine and surgery up to but no further than the limits of your experience, training, equipment and staff.
    • Understanding what the strengths of your practice are, allows you to concentrate on these, and develop a clientele dedicated to you. Moving beyond this puts your reputation and patient at risk.
      • For example performing echocardiography for all but the most basic of diagnoses, in general practice. Firstly, this requires an US machine capable of CW Doppler to perform properly – an extra R100,000 generally. Can this really be regained if the practice does 1 or 2 complete echos a week (at best?) compared to a specialist doing them daily, or several times daily? The training required to perform and interpret echocardiograms, and then integrate them with treatment choices and prognostication, involves several hundred scans done in a short period, under supervision.
      • Would you accept your local (medical) general practitioner performing echocardiography on you or a member of your family?
    • Educating the client about the disease, organs affected, options, needs of the patient, and, where appropriate, the necessity for referral or alternative treatments, is vital in maintaining good compliance with your treatment plans and builds consensus on the way forward. Clients like to be included in the decisions, and to know you have a way forward, even if that is to ask for help by referring or seeking a second opinion.
    • Compliance is everything in treatment. Give written discharge instructions; book time for discharges; give feedback to queries by email, not telephone.
      • Email enquiries can be handled when YOU have time, is quicker and unequivocal – dosages are in writing, your information is clearly conveyed, images can be pasted into email. Telephone messages leave too much open to memory (often fallible or selective) or interpretation (which differs even between colleagues educated in the same class at the same uni – so what chance does a client have?)
      • Compliance with instructions should also, where appropriate, be linked to consequences for noncompliance.
        • For example, a written discharge for a dog having undergone a cruciate repair op – “If Fluffy is not kept restrained as per instructions, and does not attend follow-up physiotherapy, full mobility or even complete breakdown of the repair may occur. Such complications will not be seen as a failure of the primary surgery, but the unsupervised aftercare; therefore please follow our instructions closely, to achieve the desired outcome. Contact us with any questions”. I am surprised that many practices do not give written discharge instructions AND keep a record that they have been given to the client.
        • Another important study showed that when a medication was given once daily, client compliance was 80% (and I bet you thought it was 100%, right?). When the same medication was given in divided doses, compliance can drop to 40%. So consider a medication like ursodeoxycholic acid, used for certain inflammatory liver complaints. It can be given at 5mg/kg q12h or 10mg/kgq24h. As the vet, you have diagnosed a liver condition for which UDCA is the treatment of choice. You want the patient to recover because (a) you care about your patient (b) your reputation may ride on whether it recovers or not and (c) the client’s actions are out of your control, so making things as simple as possible for them improves their relationship with you for future cases. If a vet gets a name as a heavy doser who overloads patients and their owners with complex drug schedules, clients may be more reluctant to seek ANY veterinary care from such a person. So in the example given, I usually try once-daily dosing. There is no evidence that it is inferior. Know your drugs by reading data sheets or consulting an expert. Human cephalexin capsules are given q8h, veterinary products can be given q12-24h! A cheap medicine, not given or given inadequately, is more expensive in every sense of the word, than a pricey but achievable treatment regimen.
      • Give medication for clearly-defined reasons, just as you would for any surgery. No-one would do a cruciate “in case the dog has torn it” – yet I see vets giving multiple, painful, SC injections to pets, for 4 – 7 suppositions, but no actual diagnoses:
        • Vit K for clotting (this doesn’t work for platelet-derived coagulopathies, which cause petechiae – a common mistake)
        • NSAID (“it’s got a temperature”)
        • Vit BCo (when did this ever help anything but an outright case of kwashiorkor or beri-beri – and when did a vet last see these?)
        • Some steroid (for the appetite, and “membrane stabilising properties”) – did the vet forget that NSAID+CCS = Stomach ulcer?)
        • Metoclopramide (but why if a vet-licenced, more effective, safer antiemetic exists in Cerenia – and once daily as well?)
        • And a shot of long-acting antibiotic
          • On this last item, I have a simple philosophy: if the animal has documentable evidence of infection (fever, swelling, pain, discharge/neutrophilia+/-monocytosis, etc.) but is going home, give the medication orally. It works as quickly as systemic therapy, without the pain. If it needs hospitalisation, the medication must go IV, not SC, especially if dehydrated. SC injections of antibiotic are only useful for intractable animals, or where there is poor compliance (real or anticipated).

The net interpretation of this “package” or “smorgasbord” of injections is that the vet has no idea what he/she is treating, and is “covering bases” – this sort of defensive medicine is not medicine, it’s no better than what a technician could do. The years of science-based education, with its emphasis on creating a hypothesis, is wasted: (‘could this dog have Cushing’s?), creating a plan (“ACTH stim test or other bloods first?”), carrying it out (“haem & chem profile first, check for cortisol leukogram, raised ALP; and UA, check for proteinuria, poor concentration, maybe a UTI – THEN an ACTH stim test”) and reappraising your results (ok, post ACTH cortisol 650 – pituitary or adrenal – let’s do an US of the abdomen).

If this is the case, we may as well allow the flourishing of facebook sites run by (perhaps) well-meaning, self-aggrandizing nincompoops who advocate petrol and blouseel mouthwash for gingivitis in pets. Perhaps we already do allow this…?

But how to make a living in difficult times, as a vet?

Firstly, respect the profession, its various permutations and capabilities, and the scientific basis of 21st century medicine. USE that massive resource of accumulated knowledge, introspection, and evidence. Shy away from dubious philosophies – even your own – and keep to the well-tried and tested path. That is what the PET would expect, not fanciful philosophies of some eastern hermit, dreamed up on a mountaintop.

Rather than trying to be all things to all people, concentrate on your core skill and capability sets, and perfect them. If I am not learning, I feel dead inside. If a practice is not growing, it is dead. If a vet cannot change what he/she have been doing, when evidence exists for a better tool, that person is a dinosaur, and should retire, right now, no matter their age. Such a person is a danger to patients, and a retarding force for the entire profession. For example, continuing to use cimetidine when evidence (now 4 years old) – exists that shows it is ineffective in changing gastric acid pH in animals – is an example of this. Attending a CPD for the beer, grub and points, but not fundamentally changing what, how and WHY we act, means we lack serious self-introspection and have become petrified into a paradigm that may not be relevant or relate to the constant improvements in our understanding of animal physiology, pathology, pharmacology and human pet-owning psychology.

These new advances create opportunities for the proactive general practitioner to flourish, even in the face of adversity and competition. We flourish when we make people feel good about bringing their pets to us – even when we cannot fix all of their ailments. We flourish because they see we care about their pets, when we take them on as our responsibility, the moment they step through our doorway for the first time, and when they continue to be our responsibility, until the day they pass away – not just for the 10-15 minutes of consultation.

How are you looking after that pet’s welfare when it isn’t in your rooms?

Well, what are the risks it is exposed to?

  • If I am not vaccinating all cats against FeLV, then I am exposing some cats to a significant, incurable disease. The risks of injection-related sarcoma are tiny, and is manageable in many instances with early diagnosis and referral. If 10% of your patients are cats, and you see 5000 patient visits per year, of which 50% are vaccinations, then you vaccinate 250 cats per year.
    • At this level, you will see 1 case of injection site sarcoma, in your 40 year career. How many FeLV cases would a vet like you see?
    • Well, our practice’s figures suggest about 5, per year. That’s 200 in a career. Most interestingly, since our practice routinely vaccinates for FeLV, for the same price that other practices just give the 3-in-1, all these cases are either referrals to our specialists, OR new patients to the GP side – not from our existing patient pool.
    • Digest that, and then think about how that makes a client feel, when they are trying to decide which practice to use, when they move into the neighbourhood. Who is being more proactive about their pet’s health? What about a cat, newly-diagnosed with FeLV – and a client who discovers that not only is a vaccine available, but your practice has offered it to some patients, and not others. That could be a very sticky discussion!
  • Obesity is the leading comorbidity in animals (closely followed by dental disease and in older pets, joint disease). So what are you doing about it? It is VITAL that YOU give clients your opinion on what is appropriate nutrition for a modern domestic animal. Dogs are NOT wolves and their digestion, environment, and metabolism are sufficiently different that human food (scraps, home-cooked) and BARF diets are not appropriate. Bones in particular are a major issue. Their dental benefits are suspect, and dogs do NOT have a magical ability to digest bone any better than, say humans (their gastric pH is just the same and their immunity to pathogens is no better than ours). Make the effort to educate yourself properly on the science.
  • If the vet isn’t telling your client about the risks of bones, who is? Someone with less experience of the trauma that bones (or Salmonella, Toxoplasma, Neospora, Neurocysticerosis, etc.) cause, and/or an axe to grind with vets and/or a narcissistic, poorly-(google)- informed view of a complex biological system?
    • People come to vets for our opinion and knowledge. Use it wisely, give it with consideration, but always do it proactively and definitely. When I am certain, I sound certain. When I am uncertain, I sound certain … but simply state that I do not know all the relevant facts or possess the relevant skills – but I know who does, and it is more important that the patient gets better, than WHO makes it better. People will respect you for that.
    • Do not concentrate on making the clients like you because you ask about their health and family, or because you give them what they think they want (that 3-month itch injection, doc!) – but because you tell them what is best for their pet, based on the latest scientific EVIDENCE, and that will keep their pet out of harm’s way inasmuch as we are humanely able to.

How Proactive Care will change your practice

Proactive care means anticipating risks, advising the clients on these risks and the measures needed to avoid them, and then carrying out risk-management strategies.

One critical point – everyone in the practice must agree on this. It’s no good if two vets are vaccinating against FeLV, or advising Hill’s Science Diet, and the third vet in the same practice is advising against FeLV and flogging “el Castro” brand socialist dogfood. Or if the same vet flogs depot steroids, and the other two are trying to do skin workups, and diagnose and manage atopy (and diabetes!)

The ideal situation for your clients and their animals is when your practice understands the risks for pets in this neighbourhood, and then puts in place a simple, clear program to prevent those risks. Let me use our practice as an example.

In our area, the following risks or context apply:

  • Many stray animals turn up with us, and the occurrence of fireworks a few times a year contributes to this even moreso – therefore, we all advocate the use of a good microchip brand with a functioning “owner locator” database.
  • Coronaviral enteritis –we use the DAPPv-CV vaccine for all dogs, and charge the same that other vets charge for the DAPPv. We tell the clients that “we add this, and it only adds R16 to our costs but I don’t have to waste time explaining the risks and then convincing some people to use the vaccine, and not others. We also don’t have to explain why your dog has a preventable disease that might kill it, and may cost R10,000 to fix” – and that’s a verbatim quote. It also simplifies stock keeping – we only need one variant of vaccine. We never see leptospirosis, so we don’t use that. People appreciate that we don’t charge R90 for that R16 vaccine. Same goes for FeLV as mentioned elsewhere.
  • Two townships adjacent to our suburb, with many strays, in the highest-prevalence province for rabies – so we vaccinate all pets, annually, from womb to tomb, against this disease. Don’t want the vaccine annually? Sorry, then this isn’t the practice for you madam. We have a hospital – in fact, a neighbourhood – of sick, young or very old animals who cannot afford to get kennel cough from your brak.
  • My practice is in a lower middle-class income area, with young families and pensioners, so we advocate medical aid – from only one company – to all clients. We record each recommendation on the computer for “I told you so… now do it before this happens again” We give 5% off vaccinations, food, parasite control and lab fees (for senior annual health checks) to encourage them – EVEN if only ONE animal of a menagerie is on medical aid – the value of it will be self-evident to the owner in time, and they can drive that change. Pets on medical aid are rushed to the vet any problem, earlier. This means a better outcome, and a better reputation from a thankful, bonded owner.
  • Only a couple of good pet food brands, no ostrich bones, hard cow hooves or other potential dietary risks in stock. By sticking to one or two manufacturers, a practice can create great product competency and knowledge in the staff, clear testimonial of efficacy, and easy stock takes – which are ESSENTIAL but massive time wasters and resented by everyone. I would not stock an item – like ostrich bones – that are a clear risk to my patients, for fear of creating a condition where I must pay for the repair (or replacement!) of the patient.
  • Tick, flea, worm and parasite control – we have Spirocerca, lots of fleas and tick borne diseases – plus heaps of worms both exotic and local! Thus we advise year-round prevention with one of two products – a spot on and a tablet – for worms (including lupi) and complementary cover against fleas and ticks with either a long-acting collar OR a tablet. This is clear, and simple. Everyone understands it and if our clients are compliant, we don’t have to treat preventable diseases.

Once we have covered this, and we all advocate these steps at reception, in consult and at every annual visit (or biannual for cats 13+, dogs 11+ and giant dogs 9+) to detect or anticipate, prevent and manage problems before they start. Everyone “sings from the same hymn sheet”.

The schizophrenia of veterinary business

As vets, we vastly undervalue ourselves. We undervalue the world-class training we have, the self-investment in our practices and own development, and we use short cuts and sometimes frankly rubbish, nonsensical, second-grade unscientific medicine, for whatever fallacious self-deceptive reasons we can think of. All this achieves is to demean our prestige in the eyes of the public, who, quite frankly, largely see vets in the same category as shambling, worn-collar-and-scuffed-shoes, door-to-door vacuum cleaner salesmen and James Herriot-era witchdoctors. When the vet gives “a mil of euthanase to stimulate the liver enzymes” in a case of biliary; keeps giving depot steroids until a cat is diagnosed as a ketoacidotic diabetic (at another practice); or put a single pin and cerclage wire in a spiral fracture of a tibia, under a generous slathering of plaster of Paris – that person is a witchdoctor.

There is a better way to do things. Unfortunately, it’s difficult when an individual wakes up and wants to increase their level of practice, but charge the same.

In fact, the schizophrenia of consulting versus running practice as a business person is a continual fine line and for me and some colleagues, a source of much soul-searching and ongoing anguish. Mark-ups versus the desire to care for sick animals can be a toxic nidus for psychiatric disorders.

The way I rationalise it is that if 99% of our clients are paying appropriately sized accounts which are fair (to them and our business’s needs) then we can put aside some money – say in a fund – even an interest-earning money market account – which we use to “fund” discounted or charity work. There is no drive to use it all in a year, but if it’s up, it’s up. No more sad cases until next year. All the staff knows that fund’s limits from month to month. Wealthier clients can donate money into the fund if they want to, but it’s not advertised or promoted in that way.

Strategies for increasing profits without losing clients

In everything, you need to consider that your clientele is being subjected to the same income pressures as you. For this reason, any price increases need to be carefully considered. If a practice is not profitable, it will close. If it has massive turnover but high costs, it will collapse. If it doesn’t have enough cash to meet creditors, it is possibly paying inappropriately (e.g. too soon, or in the wrong order) or spending too much on the wrong things.

Remember – when a hospital buys that R200,000 ultrasound machine, the bank will not be understanding of a quiet month. The hospital will have to make the R5,000 repayment every month, come hell or high water, for five years. If you are charging R500 for a scan, this means 10 scans a month, charged out (no freebies), which means one every other day. Sounds easy to achieve, but the learning curve is high, and if you get frustrated with your own inability to make diagnoses with US, it will create resentment and fear of the technology, which means you will sabotage your own need to use the machine, and avoid its use. This is human nature, and doesn’t just apply to US machines, but also to orthopaedics, glucometers, microscopes, computers, smart phones….. the list goes on.

Alternately, if an individual is aware of his own own inability to translate mere possession of a device, into usable diagnoses, this can create a feeling of shame which then comes out as not charging appropriately. In this instance, it is better to use the services of a travelling specialist radiologist or a specialist facility as an “outpatient” imaging service. This way you have none of the costs, and all the information. You also have another R5,000 in the bank to fund your drug wholesaler bills, or annual SAVC fee, or a replacement needleholder or pin cutter.

So how to make money off what you have?

Firstly, understand the costs – as I have discussed above.

Secondly, know what the industry norms are for mark-ups.

  • Endo- and ectoparasiticides – 40 – 50%
  • Toys and treats – 40 – 50%
  • OTC medications (shampoos, digestive pastes, chondroprotectants, oral hygiene) – 50%
  • Prescription medications – 75 – 100%
  • Injectable medications – 100 – 200% (see below)
  • In-house laboratory tests (on consumables) – 25 – 40%

In terms of injectables, consider how you charge these out. For example, in my old practice we would charge the drug plus an injection fee for IV (into a preplaced IV port) of R70, plus an ampicillin 250mg vial R5.71, marked up 150% to R14.28 = R84.  The problem was that afternoon staff would repeat the injection but forget the injection fee, particularly on weekends and when half a vial was used q12h.

Always make things easier for staff by automating and simplifying functions!!!

AVIMARK (and probably most practice management programs) can automatically add an IV or IM/SC fee. All it took was me spending half an hour batch-coding injections into these two classes, and assigning a cost. Suddenly, the same injection fee was never forgotten and profit went up R14,000 per annum. This is not ripping people off – it’s a young nurses’ monthly salary, paid, for doing what she was employed to do – treat patients!

In addition, there are some injectables which are given once-off before transitioning to oral meds (or admission for more intensive care). There is nothing inherently wrong with increasing the mark-up on these. Take for example an injectable like Synulox. No-one should be using this repeatedly except in specific circumstances (e.g. a cat with an abscess that cannot be pilled – we’ve all had those!). In this instance, there is often some wastage from the bottle – that your practice must absorb – unless the mark-up takes this into account. Secondly, if one reduces the mark-up on the tablets from the standard oral meds mark-up of 100% to 75%, then it can make these excellent but slightly pricey meds more affordable. At the same time, if a client is paying R75 for the injection fee, and the drug costs R2.90 per ml, no one is going to complain if, instead of marking up 100% (=R75 + 2 x R2.90 = R80.80) you mark up 500% (R2.90 + 500% = R17.40 + R75 = R92.90). It’s only R11 more but it means that a relatively cheap component becomes very profitable, while the pricier component – the tabs – become more affordable. You only prosper from the shift in profit generators, but the client sees a smaller overall bill. The practice’s costs are lower, you have done everything correctly and ethically. The animal is benefitting from a better medication that its owner could afford.

When giving multiple injections, it is only right to use a sliding scale. This is how to use your practice management software to do this:

In addition, notice the prescription fee. In AVIMARK, this is a “P” code added to any medication from S4 upwards that is dispensed to a client (e.g. Cerenia tabs, Pexion tabs, Ulsanic liquid etc.) This covers:

  • The cost of bottles, packets, labels, label printers (pricey but worth it – they keep everything legal without you writing it all);
  • The salary cost of the staff making up the meds – time is money, as is expertise;
  • The cost of building and maintain a pharmacy – fridge, shelves, thermometers, safe, formulary books, subscriptions to MIMS; and
  • Offsets wastage and shrinkage costs

If meds are returned, note – do not refund this fee! You can’t give back time!

I recently visited a friend’s practice in KZN and helped his nurse set up a R30 prescription fee (tapering with additional scripts, as shown).

He dispenses about 40 scripts per day. Say ½ x 1st and ½ x 2nd = 20 x R30 + 20 x R25 = R1,100 per day x 220 work days per month x 12 = R290,400 extra per year.

Let that sink in…. profit, ethical, process- and profession-appropriate, per year. Input cost = 0

Other tips for ethical profit increase:

  • Add +2% to the mark-up of your 50 most common medications sold or procedure fees charged
    • This is a function on AVIMARK which added R9,000 profit pa to my practice. You can only do this kind of thing once.
  • Segregate acute drugs and chronic drug mark-ups separately
    • Patients on long-term NSAIDs should have biannual blood and urine tests. This additional cost, as medically necessary as it is, may be forgone by many clients. Rather take the mark-up on chronic medications e.g. the larger bottles of Metacam (100 – 180ml), down to 50 – 70% from the industry-standard 100% that you use for the smaller 10/32ml bottles. Inform the client that you have a reduced mark-up on these products, to facilitate their safe long-term use by enabling the client to have the monitoring tests. You don’t have to discuss the actual mark-up, just the policy. People will remember and appreciate this.
  • Give 5% off vaccinations, lab tests for senior pets, and parasite control, for clients whose animals are on medical aid (even if not all are on).
  • Advocate and facilitate proactive medical care e.g. prophylactic Advocate or Milbemax, monthly, for spirocercosis – by reducing the mark-up you use for these products.
  • Have a practice policy formulated by everyone, and promoted by everyone, for parasite control and disease prevention by vaccination, deworming, ectoparasite control and medical aid; it helps when you all speak from the same protocol.
  • Loyalty schemes should be based around purchases of bulk items – like free 7kg bags with purchase of 5 x 12kg bags of food – not 2kg bags!

Generics Vs Originator Products

We know that the MCC and other regulatory provisions ensure generics are meant to be effective as originator products. With respect, I, however, am not a great fan of them, from a business point of view. For a simple reason – they reduce the net profit of a practice, making it harder to survive and prosper. Let’s use an example of two equivalent products, call them O and G.

If you are going to convince a client their pet needs treatment X (being the active compound), and they agree, then they have agreed. Don’t muddy the waters by putting the decision of O vs G in their hands – they will only ever make the cheapest choice and, in so doing, force your practice further from solvency, meaning you have to make additional work out of thin air – or overcharge another client, in order to maintain the same net profit. Let’s say tablet O is R9.50 a tab, and G (same active, “X”) is R4.50. You mark both up 75% = O becomes R16.65 (profit R7.13) and G becomes R7.88 (profit R3.38). The difference is R6.72. So every time you sell 10 of active “X”, you are throwing R67.20 profit away. If you get O/G in boxes of 100 tabs, and like us, sell a box a month, you are throwing away R8,064 net profit a year. Good luck finding that elsewhere. That means using that generic has essentially cost the average, 1.5 small animal practice 0.27% of its annual growth. That equates to having to suddenly find a month’s salary for a receptionist, 1-2 month’s salary for a handler, or trying to make it up by selling another 72 x 12kg bags of a premium dog food – over what you were doing already.

Taking a more philosophical approach – a company that originates new products sits and thinks about the medical needs of the animal population and the medical profession. They get teams of original thinkers and innovators together to create new products – a 5 – 15 year process involving hundreds of people – chemists, toxicologists, vets, production managers, marketers, and so forth – they pay for trials, and they discard 99% of the work (and money) invested. They market, support and educate us on their products. When we have an issue with a product, there is a vast army of support for us and our clients, and a huge array of company technical literature and expertise. The company is about making money – aren’t most of us at some level – but they are primarily focussed on developing new drugs for our use. They are problem solvers.

Generic producers are simply imitating a known formula and are therefore focussed around production and marketing. There is little or no problem-solving or ingenuity focussed around their products. The waters are a bit muddied when some companies produce a generic of an active but the rest of their products are originals, or vice versa – you must make up your own mind what will work for you, in your practice.

In general, however, if profit is a driver for some of your business decisions, then generics are bad for business, in my humble opinion. In a welfare organisation, or for individual patients, they may be life-saving. It all depends on the context. You should know yours.

The ethics of expectations regarding levels of medical care

[Acknowledgement: This is extensively paraphrased and contextualised to veterinary practice, from Chapters 73, 79 & 80 of the 6th edition of Holland and Frei’s Cancer Medicine.]

Most patients and society in general, would like to think that the entire team of doctors, nurses, and specialists are cooperatively involved in solving their medical problems. Clients have little awareness of turf battles, professional egos, personal animosities, or medical fads, but if they knew of their existence, they would have little tolerance for them. Vets of all disciplines and health professionals who interact with them are human beings, not unemotional automatons. Happily, the energies they squander in picayune or counterproductive activities are small compared to their constructive, positive efforts to seek improved (not just new) approaches to veterinary medical and surgical problems.

The keystone for a successful interdisciplinary management team is attitude: humility, tolerance, adaptability, and appreciation for alternative approaches. None of us is so skilled that he or she can be as expert in every discipline as a highly competent exponent of that particular specialty. No one is omniscient. We are, and must be, interdependent, so it is important to work with individuals who are trustworthy and friendly. More failures of interdisciplinary management teams seem to occur because of personality conflicts than because of intellectual disagreements. In the heat of confrontational oratory, emotional preferences may win out over reasoned accord. Resorting to the literature should shed more light on a problem, not more heat. A selective literature survey can often be construed to support either side of an acrimonious dispute. Facts trump opinions.

In actual clinical practice, decisions are often implemented by the primary vet or specialist who first encounters the patient. A much better way is to work with trusted colleagues and consultants whose opinions, where appropriate, are solicited before the first irreversible step is taken. Actions already taken can seldom be undone. A formal patient conference (never really possible or necessary for every patient) serves the purpose of institutionalizing a forum for discussion, thereby diminishing the impact of bias and prior anecdotal experience. A conference serves the additional function of allowing vets of several disciplines, viewpoints and skill levels to recognize individuals of other disciplines whose opinions and consultations appear to be the most learned and whose personalities are compatible.

A referral or pre-referral conference occasionally alters the primary vet’s opinions and plans and, thus, the therapeutic approach for a specific patient. A conference may surface unfamiliar data, with references, that can change the course. The most important contribution of a conference, however, is the establishment of dialogue between vets and owners.

This impacts on the future approach to similar clinical problems. Finances, medical aid (or not) and travel limitations undeniably intrude on this concept, however. This may limit referrals to certain pet owners. This is also a reality of the pressures of economic constraints to spend less time with and on each patient for general practitioners who are volume-driven, unlike specialists.

A second veterinarian, often a specialist, whose encounter with the patient occurs after the first vet has already changed the disease and its clinicopathological footsteps and the patient itself, may rightly point out a better approach for the future. A specialist can better know and eventually better treat a patient who has been seen before definitive primary treatment rather than after. Using an example from my own field, a surgical specialist (and the patient) would be ill-treated if a patient were prepared for surgery by chemotherapy or radiation therapy without the surgeon having been given the opportunity to examine the tumour and the patient beforehand. In diseases where radiotherapy and chemotherapy both play a role, joint planning (including with the referring GP) is mandatory.

In the absence of absolute medical truths, there is much room for diverse opinions. Interdisciplinary veterinary medicine implies that each discipline performs a complementary function. The best analogy is to a symphony: each instrument is played harmoniously on the same score, rather than all on the same note, or each to a different tune. And as in a symphony’s output of music, interdisciplinary veterinary practice requires belief in the probability that better outcomes will result, thus validating the extra commitment in time.

When discussing procedures or medical diagnoses, explanations should be as simple as possible. The standard for determining which risks to disclose varies from one jurisdiction to another. As a general rule, complications that are common should be disclosed regardless of severity, and risks that are serious or irreversible should be disclosed regardless of frequency e.g. arrhythmias occurring within 48 hours of splenectomy or GDV, requiring round-the-clock ECG monitoring by qualified staff (NOT animal handlers!)

 

In considering whether to advise or pursue a course of treatment or surgery (or euthanasia) in a patient, consider that advances in medical science have given patients real chances to recover, sometimes only a small chance, but still a chance, in circumstances that used to be hopeless. When clients take their pet to the doctor with serious illnesses, they expect to have those chances that medical science has provided. When the vet gives inferior options or pursues a lesser course of action, or a course of action for which he and his practice is not trained and equipped, then consequences are compensable by law, and possibly very damaging to one’s reputation. I am constantly surprised by GPs who pursue reckless actions in their patients that they would not permit their own medical practitioners to do to them.

 

This leads me to believe that there is a hierarchy of care that has nothing to do with the client, the patient, or the diagnosis, but rather, the vet’s inner paradigms and preconceptions. Does the vet see the patient as:

  • An object – just another problem to deal with and move on to the next one;
  • A problem – worthy of intellectual effort much like a puzzle, but not with feelings and sensations worthy of taking into account;
  • An animal – a lesser organism deserving medical attention and intervention as dictated by the presenting complaint and reciprocated by medical actions; or
  • A patient – for me, when a pet comes through my door, it is a patient whose only advocate for ideal medical care, is me, the veterinarian, and my team. With the client’s input, I can take stock of the patient’s complete medical needs and advise the client on the best actions, people (at my practice OR elsewhere) and options that would deliver an OPTIMAL OUTCOME FOR THAT PATIENT, IF IT COULD CHOOSE.

It is my firm belief that every patient would choose the best treatment it could get, if that would deliver a better outcome. As an example of this, I am constantly surprised, 4 years into the Atopica/Cortavance era, that so many animals are referred – or even worse, seen as second opinions – for atopy, having only ever had oral or injectable prednisolone. Almost every one of the owners willingly takes the more expensive medication, when it is offered to them, and few go back to their vet if they were second opinions, which is sad.

Conclusion

Every patient is the core of your professional existence, and is a living, breathing, feeling creature with fears and an appreciation for pain and suffering no less than your own. It is your responsibility to give it the best care – either by doing so yourself, or getting other parties to help you do so (labs, specialists, colleagues in your or other practices). Every patient would want the best outcome, with the least risk of side effects, and wants to live just as you want to live. By your learning, effort, attention to detail and compassion, you must deliver this – or being a vet is not for you. When giving that care, do what is needed, according to the training you were privileged to receive and worked so hard to absorb; and charge fairly, but completely, for what you have done. Nothing more, but nothing less.

 

Every practice is, similarly but not equivalently, an organism with needs – cash flow, happy, effective and appropriate staff, equipment, and most importantly, a growing and happy clientele. You must be aware of its needs and every action you take to promote or safeguard its welfare, safeguards the jobs and security of its staff (including you), and the health and satisfaction of the patients and clients it serves. Money, like drugs, electricity or water, is the lifeblood of the practice and must not be ignored at your peril, or over-emphasised in your dealings with staff or clients. But it is an incessant, vital undercurrent to your ability to care for the animals in your neighbourhood. When a veterinarian is an employee, he or she behave like a partner/owner from day 1, and every day – or there is no future for that person in that practice, and they will not ever have the skills to run their own practice, and understand the privation and suffering that goes with that.

 

When managing a patient’s needs, take the time to LISTEN and ask about the medical facts pertaining to the patient, discarding as much of the emotional and distracting overlay from the client. Examine a patient properly and thoroughly, whether for a difficult second opinion or just a vaccination. List, discuss and where possible, attempt to address each and every item both here and now, and also proactively. If you identify risks in the patient’s future e.g. a white puppy headed for skin cancer, or an obese elderly cat headed for arthritis or diabetes, then act now, document your advice, and be clear and concise. Clients respond not to bullying but certainly to direction and passion. Achieve all the patient’s needs where and when you can, or through the agency of another person – vet, specialist, laboratory, consultant – whatever it takes to get that animal right. You are not alone in achieving these goals for your patient.

 

The balance between these arises from making unemotional, well-measured yet compassionate financial decisions; giving clients advice that safeguards their pets and finances (e.g. pet insurance, proactive care, annual health checks and vaccination, avoiding ineffective, unscientific or frivolous medications or surgeries); and being unapologetic for charging for what should be high-standard procedures and medications chosen for non-pecuniary reasons, free of influence by companies or other expediencies. Always do the right thing for the right reasons with the right patient and the right client for the fair, right price, and you will have nothing to fear.

 

Acknowledgements

Drs Craig Mostert BVSc, Nicky Evans BVSc(Hons) and Ms Tammy Gray BA BCompt, gave input into this article.

[1] With acknowledgement to Dr Craig Mostert for this section

 

Questions – Ethical veterinary medicine & business

A Zambelli 2017

  1. A multidisciplinary approach to veterinary medicine fails most often because of:
    1. Differences in medical approaches
    2. A lack of evidence-based decision making by one party
    3. Ego battles between bets
    4. Personality conflicts
    5. Clients being unwilling to be referred

 

  1. The most successful practice policies are those that are:
    1. Developed by a management consultant after investigating your practice
    2. Developed by and agreed to by all involved staff
    3. Described in detail to staff who are trained in their implementation by the boss
    4. Subject to disciplinary action when not followed
    5. Formed by each vet or nurse to suit his/her individual approach

 

  1. Disadvantages of carrying several similar product lines include:
    1. More time taken for stock control
    2. Greater cash flow drain
    3. More shrinkage due to theft going unnoticed
    4. More expiration of stock
    5. All of the above

 

  1. A client purchases an ostrich bone from your practice and this causes a bowel perforation.
    1. You should cover the entire cost of care arising from this sale of a potentially dangerous treat
    2. Caveat emptor – the owner buys it in the full acceptance that there is a risk of harm, and is responsible for the bill
    3. The practice should discount the bill to keep the client loyal, in partial acceptance of culpability
    4. This is an idiosyncratic event, bones are never harmful, the client pays
    5. You do as for (a) and never sell dangerous bones again

 

  1. When choosing a vaccine for your practice, relevant criteria are:
    1. Rewards programs from the manufacturer
    2. Discounts for seasonal or bulk purchases
    3. Rotation to ensure cross-protection
    4. The scientific validity of the vaccine coverage, for your particular area and patients
    5. The availability of cheaper multidose bottles

 

  1. Your primary responsibility as a small animal veterinarian in private practice is:
    1. To offer the patient the best chance at an optimum outcome by advising the client of the scientifically valid, clinically appropriate options, regardless of the implications for your ego or income
    2. Giving the client the option of empirical versus evidence-based medicine
    3. Anticipating what a client can and will spend, and tailoring your approach and advice according to this intuition or your experiences
    4. Fulfil all a pet’s and owner’s anticipated or advised and agreed-to medical and surgical needs, in your practice, regardless of the advisability of referral or second opinion
    5. Make the client like you by asking after their health, and giving them what they ask for.

 

  1. Veterinary medicine which is science-based and evidence-based:
    1. Is an option, similar to complimentary and naturopathic medicine
    2. Is the basis for all analysis and rationality in making patient-centred, evidence-based decisions regarding diagnosis and care
    3. Is the ideal, but restricted to the ivory towers of academia and specialists, who don’t deal with “real, day-to-day” patients and clients
    4. Is inferior to natural and/or alternative medicine
    5. Is a scam based around germ theory, the dominance of big pharma, and kills more patients than it cures

 

  1. An investment by a practice in a new technology and/or skill:
    1. Should be taken by the bosses alone
    2. Will create an opportunity for the development of experience and expertise by a member of staff, that justifies its cost, in time
    3. Must be calculated to cover its entire costs, not just the purchase price, and also take into account realistic estimates of usage
    4. Is an opportunity for a practice to raise its level of expertise such that it relies less on colleagues with pre-existing training and experience in that field, but who are competitors or second-opinion leaders
    5. Should indulge the interests of a staff member who shows a strong interest in it

 

  1. A local pet rescue organisation or the SPCA reaches an agreement with your practice to do bulk sterilisations of rescues for a vastly reduced price. When these patients are spayed:
    1. They are rescues and thus you share surgical kits between animals
    2. The use of sterile gloves, gowns and masks is wasteful and unnecessary because your practice never sees post-op infections anyway
    3. These animals are anonymous and of lesser value that patients owned by your practice, and thus a certain mortality and mobidity (above that normally seen by your facility) is acceptable
    4. We are doing a favour, and thus our practice can choose where to reduce costs by, for example, using fishing line instead of swaged-on needles for suturing
    5. None of (a)-(d) is acceptable; our primary responsibility is to deliver humane, ideal care to our patients regardless of their origin; by agreeing to deliver this service, basic, uniform, minimum standards apply to all animals treated by a hospital or clinic

 

  1. When clients bring their pet to my hospital and in considering the choices I have given them, owners expect from me (the vet):
    1. The best real chance their pet has to recover, that medical science can deliver
    2. To be fully conversant with the latest medical evidence for an advised course of action, or diagnostic test, regardless of past experience
    3. Compassion and empathy with the patient first, pragmatism and assistance with decision-making with the client second, and regard for my own convenience, reward and self-image last
    4. To be able to render any service, or not mention those that I think they will not want, or that I intuitively or experientially decide the animal doesn’t need
    5. All of (a) – (c)

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