What are the most controversial aspects of clinical care?

RE: What are the most controversial aspects of clinical care?

cairncross — Mon, 17 Jul 2023 07:14:59 GMT

In last few weeks we have had non clients contact us ooh having been quoted 3500 for pyometra and 1200 and 1500 for 2 separate cases requiring enucleation following traumatic eye injury. another case where client quoted just over 200 for small lump removal at Christmas was put off by client on affordability grounds when they made enquiry in early June quote had increased to 1200. Practise under new management and off record conversation with staff member confirmed policy now was effectively dont want the have nots.

look at some of the ratings agency company's reviews of the vet companies in UK , suddenly refinancing debt has become massively more expensive , interest rates in uk ,uk economy stagnant veterinary is in the end disgressionary spending debt restructuring is now huge and not the almost free money it was when practises were being purchased and speculated on. Costs are essentially wages and meds, altering margin requires fee hike and consolidation,

RE: What are the most controversial aspects of clinical care?

Martin Hamilton — Mon, 17 Jul 2023 02:38:46 GMT

[quote userid="9239" url="~/f/clinical-questions/30713/what-are-the-most-controversial-aspects-of-clinical-care/241936#241936"]Should insurance pay 7000 for a TPLO? Please don't take this as referral bashing, I am grateful to all the super intelligent people manning those places and for all their help in the past. But how will this affect those who can only afford now basic insurance (lets say up to 4000) because the premiums are so high? With 4000 pounds they can have little help from a referral practice but they will basically subsidy those who are already wealthier and bought the 15000 policy. [/quote]

A little off topic, but I find this comment very interesting. For many years I have commented here and there about the UK job market competing with overseas as higher wages could be found elsewhere, and many told me that a UK client would never pay more than £50 for a consult and therefore wages would remain stagnant. 18 months later and it seems from Dinu's comment that UK fees have skyrocketted, and the TPLO example estimate seems much much higher than here in Canada at least (about £3500 here for a TPLO, has gone up by maybe £500 in the last couple of years, sounds like it's up to £7000 from about £3000 a couple of years ago in the UK?). Seems far above inflation.

Has there been a similar increase in fees in general practice?

Have vet wages also doubled (or is this exclusively in referral practice only)? Have practice owners or corporations absorbed most of this additional income?

Have clients come up with more funds that everyone on here was claiming didn't exist a couple of years ago? Or is this a case of a K-shaped recovery where the have nots can no longer afford any care and those that have are slurging even more on their animals?

Genuine questions as I haven't practiced in the UK for about 6 years now. And a lot has happened politically and with the pandemic since then.

I'll admit our fees in Eastern Canada have risen too but they seem much more modest (and in line with inflation, which I suppose is also lower here, apples and oranges). Emergency fees are probably the only significant increase above inflation whcih have been introduced in an attempt to counter abuse of the emergency services and reduce workload/burden on staff ($50 triage fee by a vet tech/nurse paid even if you don't see the vet, but reimbursed from the $290 consult fee if you''re seen out of hours - prior to 2020 used to be free triage and $150 emergency consult).

RE: What are the most controversial aspects of clinical care?

Alistair Graham-Evans — Sun, 16 Jul 2023 10:33:22 GMT

There’s definitely a problem! But there have always been problems. I don’t think it is as simple as corporate or independent businesses. On reflection there was no such thing as the good old days- some things are now better and others worse - different times have different challenges.

In recent appraisals and general chats I discovered that 4 out of the other 10 vets in the clinic were seriously considering doing something other than veterinary work in the past. They moved jobs. 2 of our vets are new graduates so that’s 50% that we’re going to leave the profession.

I am happy to report that they are all now very happy with their work ( confirmed with an anonymous survey) and enjoy being in the profession As an employer you have to work bloody hard to water the grass to make it green and sometimes accept less than maximal profit to provide for a stable happy team.

RE: What are the most controversial aspects of clinical care?

cairncross — Sun, 16 Jul 2023 04:29:07 GMT

2.5 hours of intense consults interspersed with breaks to contact owners (consults) and study for more advanced intense veterinary does not seem overly attractive especially if nurses are taking away all the routines which actually give brain a bit of down time. These more relaxed consults are also often the more repeat ones where there is the ability to develope a bit of a relationship with client . Nurses taking away the more relaxed procedures where there is less owner stress and less jepardy makes the day more intense .

Recently we are having periods once or twice a week where consult blocks are running to nearly 3 hours too long quality definitely fades at the end if cases have been complex or owners intense . Some form of downtime and time away from dealing with the public is needed at this point . Go and walk your dog talk to your horse staff stable available and even some "mundane kennel work at this point is good at this point. .

Yesterday client who lost his elderly dog ain what was a difficult and frustrating case , returned with his new pup fo vaccs . This gets us to re establish a relationship and association in happy circumstances , bit of a silly fuss over new pup does nobody anything but good , mundane chat about the journey to collect it is a few minutes of relaxation . Getting to see the client back is reassurance that even though previous case didn't have happy ending client appreciated our efforts . If nurses take up these cases not only is our work more intense but the client relationship has a different balence

RE: What are the most controversial aspects of clinical care?

Alasdair Hotston Moore — Sat, 15 Jul 2023 12:58:46 GMT

you speak a lot of sense, although perhaps you're an outlier in terms of optomism!

RE: What are the most controversial aspects of clinical care?

Rob Loxley — Sat, 15 Jul 2023 12:18:36 GMT

John Hutchinson disagreed with RE: What are the most controversial aspects of clinical care?

care to expand?

RE: What are the most controversial aspects of clinical care?

Rob Loxley — Fri, 14 Jul 2023 07:35:22 GMT

[quote userid="5012" url="~/f/clinical-questions/30713/what-are-the-most-controversial-aspects-of-clinical-care/241940#241940"]Fast forward 25 or so years; newer grads are now mostly working for a faceless corporation; they don't know who the boss is let alone ever met them; they work ridiculous consulting hours (some I work with at the moment consult 0900-1400 and 1600-1900 full booked, no breaks); work loads are unmanageable; very little if any possibility of having time to get their teeth into an interesting case or discuss cases with colleagues; an uninteresting endless stream of corporate style hamster wheel bilge of vaccinations, anal glands, nails, pointless pet health club checks on healthy animals; flogging anti-parasitics; anything more challenging that a cat spay is referred elsewhere. [/quote]

I'm sure this picture is prevalent but not everywhere and it's not the case in my corporate-owned practice: Consulting blocks mostly 2-2.5hrs; plenty of time between to work up cases, read up (maybe do some study for your Cert that we're funding), contact owners etc; typical vet finishes are 1x1400, 1x1700 and 3x1900 (but if you want to work differently, let's discuss); boss (me) in the practice every day (barring holiday/cpd etc); 2nd vaccs, anal glands, nails, wellpet and postop checks etc seen by our nurses; we do in house cruciates, patellas, fracture, more complicated soft tissue surgery, BOAS cases also in house (to be fair our local corporate visiting AP surgeon comes and does the BOAS with us).

RE: What are the most controversial aspects of clinical care?

cairncross — Thu, 13 Jul 2023 23:33:43 GMT

i think this shows the problem is not work life balance is the problem its how work has become , trying to solve the problem with more time off is very obviously a vicious circle.

below to Michael you reply that getting time off for holidays etc isnt so easy in an urban busy SA practise. genuinely thought that this would be easier there , thought statistics show average hours worked were lower and no ooh rota had to be accomodated and holidays would be same but easier to organise? Not disputing the job may be more pressure in many other ways .

RE: What are the most controversial aspects of clinical care?

Clive Ansell — Thu, 13 Jul 2023 21:43:43 GMT

[quote userid="3169" url="~/f/clinical-questions/30713/what-are-the-most-controversial-aspects-of-clinical-care/241939#241939"]

I'm not sure they can't be worked around. I have a 1 year old and a 2 year old. I've not missed a doctors, health visitor or hospital appointment for them yet. Put at least one of them to bed every night (on average). Had a weekend in Copenhagen, 5 days in Ibiza and a week in Jersey with them so far this year. I was off today at the Yorkshire show*. I've booked next Wednesday off to have a day at a local theme park as they are doing a special toddlers day.

Whilst I do work more than 40 hours per week, and am currently on 1 in 2 nights on call, I still get a lot of time with my kids.

[/quote]

You're very lucky, you seem to have it well sorted out with all the boxes being ticked and plenty of quality family time.

Would be very different working in an urban busy corporate small animal practice though.

RE: What are the most controversial aspects of clinical care?

Clive Ansell — Thu, 13 Jul 2023 21:33:05 GMT

[quote userid="3169" url="~/f/clinical-questions/30713/what-are-the-most-controversial-aspects-of-clinical-care/241928#241928"] but these days new grads have it better than they ever have[/quote]

I am not so sure that they do?

In my first job, 1996-2001, although we had on call duties of 1 in 3, the working days were easier and less stressful than they are now. Our consulting hours were shorter; 0830 -1100, 0900-1100, 1400-1500, 1700-1900, appointments were 10 minutes, ops almost always finished by 1200, and finish times per week were 1 x 1700, 2 x 1800, 2 x 1900. All 3 vets were permanent and the boss was one of them taking his fair share of the work, and being available and approachable if needed. We almost always had time late morning to chew the fat and discuss interesting or difficult cases. Almost everything was treated in house, with very little being referred. Yes, it was hard work at times, but it was fun, interesting and rewarding.

Fast forward 25 or so years; newer grads are now mostly working for a faceless corporation; they don't know who the boss is let alone ever met them; they work ridiculous consulting hours (some I work with at the moment consult 0900-1400 and 1600-1900 full booked, no breaks); work loads are unmanageable; very little if any possibility of having time to get their teeth into an interesting case or discuss cases with colleagues; an uninteresting endless stream of corporate style hamster wheel bilge of vaccinations, anal glands, nails, pointless pet health club checks on healthy animals; flogging anti-parasitics; anything more challenging that a cat spay is referred elsewhere.

I know which I prefer.

RE: What are the most controversial aspects of clinical care?

Michael Woodhouse — Thu, 13 Jul 2023 21:03:48 GMT

[quote userid="5012" url="~/f/clinical-questions/30713/what-are-the-most-controversial-aspects-of-clinical-care/241938#241938"]That said, to me at least, quality down time relaxing away from work pursuing hobbies and interests is an important part of my life too, and to be able to do that there has to be a finite amount of time I am willing to spend at work. My first job of 60+ hour weeks and 1 in 3 on call in addition did not fit in with that I'm afraid. [/quote]

Whilst I do work more than 40 hours per week, and am currently on 1 in 2 nights on call, I still get a lot of time with my kids.

*I did call in at 6.30am and 6.30pm to AI a cow in an ET protocol, but then I don't really mind, they are good clients and this is more than just a job.

RE: What are the most controversial aspects of clinical care?

Clive Ansell — Thu, 13 Jul 2023 20:53:52 GMT

[quote userid="19228" url="~/f/clinical-questions/30713/what-are-the-most-controversial-aspects-of-clinical-care/241929#241929"]i think the work life balance concept is a terrible idea to promote. we spend a huge percentage of our life working it shouldn't be separate from things we enjoy , it should be one of the things we enjoy most. we need to have variety in life certainly and a break from concentrating on any one thing and rest but not on the attitude that work is terrible its high pressure .[/quote]

I have not thought about in these terms before, but yes I agree you are probably right.

It should not be a situation of work vs non work, or that work is bad and non work is good, given that our work is a large part of our lives and for the most part should be enjoyable and rewarding.

That said, to me at least, quality down time relaxing away from work pursuing hobbies and interests is an important part of my life too, and to be able to do that there has to be a finite amount of time I am willing to spend at work. My first job of 60+ hour weeks and 1 in 3 on call in addition did not fit in with that I'm afraid.

RE: What are the most controversial aspects of clinical care?

cairncross — Thu, 13 Jul 2023 16:54:38 GMT

had bit of a debate with student last week on this who has seen mainly high end practise so far and was debating why we dont provide x,y,z that she has seen elsewhere . Costed it out to them , showed what we charge for certain procedure's and how this clearly doesn't add up . Debated what is in the press re some practises not offering spays neuters showed a local affordability study {not for veterinary but general digressionary spending.} tried to explain what all these extras has done for inflation in vet costs whilst our client base has had a drop in available funds . Did my standard boring example of what people might have been expecting to pay for a pyo or FB op when they bought their pup 8 or 9 years ago what it would be now , should they have expected that degree of inflation ? explained if we all only provided x,y,z what about the welfare of those animals which cant therefore get any service

i think the outcome is they would rather work somewhere which provides x,y,z but not have to think who pays for it and certainly not what impact it has on those missing out.

RE: What are the most controversial aspects of clinical care?

Dinu Catilina — Thu, 13 Jul 2023 06:56:32 GMT

[quote userid="3169" url="~/f/clinical-questions/30713/what-are-the-most-controversial-aspects-of-clinical-care/241928#241928"]As I get older and more cynical, I genuinely wonder about the future of the profession. Everyone complaining about WLB, burnout, stress, attrition, pay. I'm not saying we don't have problems, but these days new grads have it better than they ever have, and yet seem more miserable and bitter about it. I suspect it's when this stopped being a profession, a vocation, and just became a job. I think veterinary medicine is a brilliant vocation, but a pretty crap job. [/quote]

I also think like Michael. I also think that many have unrealistic expectations from life in general and not just in our profession.

[quote userid="9179" url="~/f/clinical-questions/30713/what-are-the-most-controversial-aspects-of-clinical-care/241934#241934"] It is just a job. A lot of the profession's errors and problems today have arisen from the 'vet med is life' attitude we all had when we were going into university and especially as new grads.[/quote]

Maybe? Still those who see it as a vocation seem to be happier. Anecdotal of course.

[quote userid="9179" url="~/f/clinical-questions/30713/what-are-the-most-controversial-aspects-of-clinical-care/241934#241934"]Life is far too wide of an experience, and we are apparently intelligent and interesting people (at least some might be!) to be pigeonholed into defining our lives by our work.[/quote]

But how is it different than defining our lives by our hobbies? Or children? Or any other thing? I hear this all the time, you are not your job, see the world, go explore. Why is it better to be defined by your instagram account?

[quote userid="9179" url="~/f/clinical-questions/30713/what-are-the-most-controversial-aspects-of-clinical-care/241934#241934"]hey have housing problems, veiled (and increasingly not so) student debt, future economic woes. In Britain (like it or not, depending on your age I suspect), many young people are incandescent at the state of the UK's future prospects. Most will never be able to buy a house,[/quote]

The UK, even under the current circumstances, still has a fantastic quality of life and life is good, much better than on 90% of the planet. One of our young nurses just bought a house, not married, nurse salary. I also bought my first when I earned 32000/year (yes 8 years ago). It's 100% not difficult for our profession.

[quote userid="9179" url="~/f/clinical-questions/30713/what-are-the-most-controversial-aspects-of-clinical-care/241934#241934"] let alone a clinic[/quote]

They can very cheaply open on, no need to buy it.

[quote userid="9179" url="~/f/clinical-questions/30713/what-are-the-most-controversial-aspects-of-clinical-care/241934#241934"]their exposure to constant negativity merely amplifies these issues[/quote]

I 100% agree with you on this. Everybody talking about downsides and always looking over the fence at other countries/ other professions/ other friends etc. When we are in a profession who even in times economic disparity we are still doing ok. Not great but ok. We are stable. Covid or the Ukrainian war didn't kill our businesses.

For me the controversy is what our standard of care should be. Should we try to do everything for patients? Should we have the human standards? Do we need the new 1000 slice CT? Should we have cardiac surgery worth of 25000 and half of it to go through insurance? Should insurance pay 7000 for a TPLO? Please don't take this as referral bashing, I am grateful to all the super intelligent people manning those places and for all their help in the past. But how will this affect those who can only afford now basic insurance (lets say up to 4000) because the premiums are so high? With 4000 pounds they can have little help from a referral practice but they will basically subsidy those who are already wealthier and bought the 15000 policy.

RE: What are the most controversial aspects of clinical care?

cairncross — Thu, 13 Jul 2023 06:24:16 GMT

The basic sacrifices to buy a house or clinic haven't changed , you needed to work long hours and not spend much on anything else .

In the past you could work long hours and enjoy it get a sense of achievement . The pressures and stress now are greater owner expectation regulation, protocols targets appraisals. It's a continually regimented existence. Fun and enjoyment now has to be sought elsewhere.This promotion of work life balance is accelerating the retention problem not solving it everyone discovers they want to spend less and less time working and sacrifice things like property to work less and enjoy life more .

We need to make the job enjoyable again make people not notice it's work remove some of the pressures and boredoms.

RE: What are the most controversial aspects of clinical care?

Chris Milligan — Wed, 12 Jul 2023 15:55:48 GMT

[quote userid="3169" url="~/f/clinical-questions/30713/what-are-the-most-controversial-aspects-of-clinical-care/241928#241928"]Everyone complaining about WLB, burnout, stress, attrition, pay. I'm not saying we don't have problems, but these days new grads have it better than they ever have, and yet seem more miserable and bitter about it. I suspect it's when this stopped being a profession, a vocation, and just became a job.[/quote]

I agree with this, but two points I would make;

1. It is just a job. A lot of the profession's errors and problems today have arisen from the 'vet med is life' attitude we all had when we were going into university and especially as new grads. Life is far too wide of an experience, and we are apparently intelligent and interesting people (at least some might be!) to be pigeonholed into defining our lives by our work.

2. New graduates today aren't just facing the issues you mention there. They have housing problems, veiled (and increasingly not so) student debt, future economic woes. In Britain (like it or not, depending on your age I suspect), many young people are incandescent at the state of the UK's future prospects. Most will never be able to buy a house, let alone a clinic, and their exposure to constant negativity merely amplifies these issues. So, yes, they're facing all the things you mentioned, but they have a lot of somewhat new background issues in the rest of their lives. For clarity I'm not in this demographic ;)

RE: What are the most controversial aspects of clinical care?

cairncross — Wed, 12 Jul 2023 08:25:55 GMT

last line is it

RE: What are the most controversial aspects of clinical care?

cairncross — Wed, 12 Jul 2023 08:10:34 GMT

comprehensive response , all said in it is very true and reflects absolutely the situation/reality we are working with. Can definitely report that clients phoning independents for ooh has escalated significantly agin recently, have ranted on this previously but now sometimes have change of attitude people regularly now being quoted 3-5 k for care which would have reasonably been expected to cost 2-3 hundred when they took the animal on as pup. not suggesting the 3-5k is a rip off it may well be good value for money if cost of provision of that level of care is considered.

1 slight disagreement, don't agree that we are all martyrs certainly not altruistic ones. i think the work life balance concept is a terrible idea to promote. we spend a huge percentage of our life working it shouldn't be separate from things we enjoy , it should be one of the things we enjoy most. we need to have variety in life certainly and a break from concentrating on any one thing and rest but not on the attitude that work is terrible its high pressure . it is of course these things the fear of the black cloud you mention , the difference in attitude of clients and society today from 20 30 years ago. Trying to fix this by fencing off work as the bad bit and having ever more balence or fun away from it to compensate is an ever decreasing circle to failure, and is playing out in the retention crisis in staff not willing to work ooh to the rush to ever more limited and narrow provision, which doesnt actually deliver for the population of people and animals under our charter.

largely you have the solution to, the responsibility is the clients , the black cloud actually i think often does reflect reality it just doesnt come across as such or takes time to do so.

RE: What are the most controversial aspects of clinical care?

Michael Woodhouse — Tue, 11 Jul 2023 23:21:26 GMT

[quote userid="19228" url="~/f/clinical-questions/30713/what-are-the-most-controversial-aspects-of-clinical-care/241921#241921"]the premiss for having 24 7 requirement surely is an entirely good one so i dont think it should be removed .[/quote]

I completely agree, but I also agree with Clive's assessment that the system is broken beyond repair and I don't see a workable solution.

It's funny how we are in a hurry to compare vets earnings with doctor's, but they mostly will do OOH throughout their career (unless a GP or certain other specialities). I think the only way is for us to ALL do our little bit to cover OOH, but how you bring that in, I don't know.

As I get older and more cynical, I genuinely wonder about the future of the profession. Everyone complaining about WLB, burnout, stress, attrition, pay. I'm not saying we don't have problems, but these days new grads have it better than they ever have, and yet seem more miserable and bitter about it. I suspect it's when this stopped being a profession, a vocation, and just became a job. I think veterinary medicine is a brilliant vocation, but a pretty crap job.

RE: What are the most controversial aspects of clinical care?

Clive Ansell — Tue, 11 Jul 2023 20:33:53 GMT

Less of a premiss, more of a pipe dream.

The current situation is not working, and is unworkable and unsustainable in the longer term. At the moment the provison of OOH care seems to be the responsibility of the practice and the profession, whereas it should be full square that of the client or animal owner.

The current model relies on either veterinary surgeons being on call in addition to working demanding full time hours, often paid nothing or next to nothing for it and is view as "part of the job"; or being paid very high rates to work in OOH clinics, more often than not on a locum basis. As the former die hards inevitably retire or die off, and martyrdom becomes confined to the history books, it will rely on the latter as a workforce. Unsustainable.

In actuality, OOH 24/7 care is outside the reach of many people because of costs and distances involved getting to and from OOH clinics, so already we are not providing full 24/7 care anyway. I am seeing several cases a week now where OOH care should have been sought, but has not. Mostly due to costs.

Some smaller independant practices that choose to provide OOH care to their own clients are inundated with OOH calls from non registered clients, and those from other practices that do not wish to go to their designated OOH provider, often many miles away. They want to, and should, be able to tell these folk to take a hike, but feel press ganged into seeing them with the black cloud of an RCVS complaint and investigation hanging over them. There is no clear direction or guidance in this area. Many of these clients have no money and/or no intention of ever paying. My friend works in such a practice, and is getting hacked off with it PDQ.

I have worked in other countries where there is no such 24/7 OOH requirement/commitment/burden, and it seems to work perfectly well. Some practices, particularly larger ones, provide 24/7 care whereas others do not. The responsibility is placed firmly where it should be, with the client, to find OOH care provision. If you want to close the door at 6pm and go home , that's fine, clients have to go elsewhere off their own back. As I say it seems to work.

RE: What are the most controversial aspects of clinical care?

cairncross — Tue, 11 Jul 2023 17:43:27 GMT

the premiss for having 24 7 requirement surely is an entirely good one so i dont think it should be removed .

RE: What are the most controversial aspects of clinical care?

Clive Ansell — Tue, 11 Jul 2023 13:46:01 GMT

I think one of the greatest issues at the moment is out of hours care provision

1. It is becoming/has become unaffordable for many people, which in reality means it is not available.

2. Some OOH clinics have closed, either permanently or temporarily because of staffing issue. People are having to travel greater distances. I was involved with a case recently were clients travelled 44 miles to an OOH clinic.

3. Lack of Vets and RVN's willing to work in OOH care

4. Should the requirement to provide 24/7 care be removed?

RE: What are the most controversial aspects of clinical care?

cairncross — Tue, 11 Jul 2023 02:20:03 GMT

Cheap but financially viable. V expensive but unattainable.

Might not even be much of a debate , treatment A may unquestionably have fewer cons and many more pros than treatment B , but if only 5,10,20%of your client base can afford treatment A is it reasonable to develope your skills and offer your time to that minority .

The most broad spectrum example is OOH care , no doubt a dedicated ooh centre with an awake team who haven't worked the day before and the day after is going to have more clinical/medical pros and fewer cons than a clinic with the day vets providing night cover on rota and no full time over night presence. But if recent surveys show that only 20%of clients can access this and the sites have to consolidate to ever greater population centres to be viable thus adding a geographic discriminator as well as financial ?

After that it's the problem with fruits,

Grapes and cherry eyes