7 and 1/2 Minutes.

RE: 7 and 1/2 Minutes.

Anthony Todd — Wed, 24 Mar 2021 19:45:24 GMT

Certainly the old days weren't anywhere near the best days now, treatments, knowledge, progress, everything has got better but and as usual, to describe one or two cases where further tests were performed doesn't really show the number of "tests" that showed nothing.

Anyway this is a thread that I and some others that have tried but will never win whatever evidence or parameter is put forward and most vets seem to take any comment or suggestion as personal criticism which I have never intended.

So I'm gone.

RE: 7 and 1/2 Minutes.

Joyce Whitehead — Tue, 23 Mar 2021 21:47:22 GMT

Anthony, how much time do you spend in a veterinary practice nowadays? I’m guessing little, maybe taking your own pets? So where do you get this idea that we take bloods/X-ray/scan every single patient for no good reason? As this seems to be what you are implying. As Lucy says, we still know what we are doing as much as you did. I did a lot of consulting today, some routine, some sick animals, some lame animals. I took samples from 3. One mass in the area of the thyroid, fna to see if it is thyroid or something insignificant. One skin mass that might be a mast cell tumour. And one old cat that was suffering from recurrent vomiting (seen by a colleague last week, symptomatic treatment given, no better). I took bloods as the owner was concerned he might have renal issues. He didn’t, owner is reassured by normal bloods, we will discuss further treatment now we know that.

Please consider that the old days weren’t always the best days. I remember a lot of them.

RE: 7 and 1/2 Minutes.

Lucy Fleming — Tue, 23 Mar 2021 20:04:47 GMT

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/29735/7-and-1-2-minutes/229410#229410"]But, that's my point, made again and again, they are![/quote]

They really aren't. Maybe the odd one, based on a clinical suspicion of something more significant (eg bunny hopping or a "swaggery" gait suspicious of possible hip dysplasia - and even then it probably won't be "booked in" - just the possibility raised with the owner and maybe the pros and cons discussed). The vast majority will be treated, rested, make an unremarkable recovery, and never be discussed on a forum.

I know you don't mean it that way, but by continuing to always bang this particular drum, you're insinuating that the clinical skills of your colleagues still working today are somehow all weaker than yours (and your peers). Frankly, however unintentional, that's a bit rude.

RE: 7 and 1/2 Minutes.

Gillian Mostyn — Tue, 23 Mar 2021 18:13:24 GMT

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/29735/7-and-1-2-minutes/229410#229410"] I'll strat highlighting them when they occur again........[/quote]

OK.

RE: 7 and 1/2 Minutes.

Anthony Todd — Tue, 23 Mar 2021 17:51:43 GMT

[quote userid="2457" url="~/001/nonclinical/f/life-in-practice-discussions/29735/7-and-1-2-minutes/229406#229406"]Won't be booked for rads on first presentation...[/quote]

But, that's my point, made again and again, they are!!

I'll start highlighting them when they occur again........

RE: 7 and 1/2 Minutes.

Gillian Mostyn — Tue, 23 Mar 2021 16:02:37 GMT

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/29735/7-and-1-2-minutes/229405#229405"]But a lame boisterous pup, nothing on physical???[/quote]

Won't be booked for rads on first presentation...

RE: 7 and 1/2 Minutes.

Anthony Todd — Tue, 23 Mar 2021 15:52:07 GMT

And that's where experience and "hit rates" come in!

I reckon even i I might just be able to suspect something serious in a dog with a temp etc imported from Romania but, as usual on here, the particular becomes dis-proof of the many.

i'd even go as far as to say any animal "from Romania should be tested for all infectious diseases before even vaccination, and i don't think i'd not find positives, even before they showed any symptoms.

But a lame boisterous pup, nothing on physical???

RE: 7 and 1/2 Minutes.

Gillian Mostyn — Tue, 23 Mar 2021 15:35:11 GMT

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/29735/7-and-1-2-minutes/229398#229398"]What about the other 98%?[/quote]

Even if the 'hit rate' is only 2% (it isn't), we've ascertained that in those two cases it was a good idea. The problem, Tony, is that you don't know which case is in the 2% until you've done the test....

RE: 7 and 1/2 Minutes.

vs0u — Tue, 23 Mar 2021 15:28:51 GMT

For a 7.5 minute consult many of these steps are probably skipped. Wiping the table and hand washing, weighing the pet, taking a temperature would only be done if strictly necessary. There didn't used to be very much explanation back then, compared to now - basically you just injected the pet with something and that was that. As Anthony says most of them got better or died regardless, and the ones that didn't hopefully came back, probably to be booked in for an ex lap! Which was probably cheaper than the cost of a basic blood test now! Oh the good old days!

I also think that using a computer makes things slower than writing notes by hand (of course then it would be a one liner "vomiting, see friday" type thing, scrawled on an A7 index card, now you have to add all sorts of clinical findings and note what you have advised and what the client has declined!). When we got computers I noticed it was taking longer to do consults. You often have to spend a while finding the right drug or test whereas you used to just know the price of an injection was £3 regardless of drug or volume, consult was £20, and writing labels by hand was definitely quicker too. I used to do 10 min apts that included writing notes, dispensing meds, taking the money and booking in the next appointment. Nowadays I struggle to keep within 10 minutes even without doing any of the last 3 things. You just can't get away with not telling people what is going on any more. Plus there's more use of estimates as things are so much more expensive. They can be very time consuming.

RE: 7 and 1/2 Minutes.

Anthony Todd — Tue, 23 Mar 2021 14:55:37 GMT

They are both a positive for your hit-rates [and so is Dagmar's] and I certainly would have tested those, or at worst emphasised a definite follow up, but, hey-ho there's 2 [pretty obvious] ones, that challenge the rule as there always are!

What about the other 98%?

RE: 7 and 1/2 Minutes.

Julie Innes — Tue, 23 Mar 2021 13:54:01 GMT

well,I had an odd one yesterday, that I would have missed without further investigation.

Owner complained dog was lame on hind leg last Friday, seen by my colleague, who thought hip was a little sore, but noticed a temperature (39.6). Saw it back today as "wobbly on front legs and seems a little bloated". Nothing much to see, little subdued, temp 39.9! Bloods showed massively high white cell count, and scan showed great big closed pyo! No history of off food/ PU/PD, no discharge, just presented for vague lameness. I was very relieved to have found it, and I'm sure the dog was too!

RE: 7 and 1/2 Minutes.

Dagmar Steele — Tue, 23 Mar 2021 12:42:16 GMT

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/29735/7-and-1-2-minutes/229393#229393"]If we weren't right and the owner thought the response was not perfect they came back...... [not many did, unless told to][/quote]

and the ones not coming back includes the deaths as well as the disappointed customers seeking help elsewhere because your trial treatment didn't help.

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/29735/7-and-1-2-minutes/229393#229393"]Still waitng for "hit rates" on tests ie where the test added anything, apart from "normal "from the particular test.[/quote]

well take yesterdays feverish dog, freshly imported from Romania. After knowing it was distemper which caused the fever and treatment would be very costly with a poor prognosis the owners opted for it to be put down. The test saved the owners a lot of money and the dog lengthy suffering. Had we tried without a test, bc obviously fever could have been caused by other illnesses as well, it would've been more expensive and the outcome would've likely been the same.

RE: 7 and 1/2 Minutes.

Anthony Todd — Tue, 23 Mar 2021 12:27:27 GMT

Not what I am espousing at all.

If you check you will find that usually I suggest that an obvious treatment for an obvious symptom first is often more revealing than a negative test, and some others on here do agree with me.

The "hit rate" would be a good measure of priority and/or necessity.

RE: 7 and 1/2 Minutes.

Lucy Fleming — Tue, 23 Mar 2021 12:10:07 GMT

Anthony, we're still waiting for you to accept that not every single case seen gets "a test". A large number of them will be managed based on initial presentation/ clinical suspicion/ call it what you will. I'm not sure if you get this idea from the cases discussed on here, but by the very nature of the forum it tends to be the odd cases, the frustrating cases, the cases where things aren't that obvious from first presentation that people will post on a forum. I understand the point you are trying to make, but you constantly espousing that every single case should be managed with a treatment determined from a physical examination alone gets tiresome.

RE: 7 and 1/2 Minutes.

Anthony Todd — Tue, 23 Mar 2021 10:48:41 GMT

[last, forlorn] try]

If we weren't right and the owner thought the response was not perfect they came back...... [not many did, unless told to]

Still waitng for "hit rates" on tests ie where the test added anything, apart from "normal "from the particular test.

Surely they can't all be just reassurringly NAD??

RE: 7 and 1/2 Minutes.

Dinu Catilina — Mon, 22 Mar 2021 08:42:37 GMT

[quote userid="7269" url="~/001/nonclinical/f/life-in-practice-discussions/29735/7-and-1-2-minutes/229316#229316"]We used to be on 10 minute appointments and I could keep up pretty well (worked in some very busy practices early in my career and had to speed up). We swapped to 15 minutes at the start of lockdown when we first stopped clients coming in, and definitely won’t go back, it gives you time to chat to the client about all options.[/quote]

We had 15 minutes appointments before Covid and are now on 20 minutes with gaps between appointments so no one is ever fully booked.

I worked in 10 minutes appt with double booking sometimes and things were done in a day but I wouldn't want to be there again. I find clients to appreciate the longer appointments, the working day is more pleasant, we have time to know our clients and not just jab and go. We are not expensive and not the cheapest. The business has excellent profit margins and staff is paid well.

I changed recently to a private dentist and what a massive difference compared to my previous one. Everyone is calmed, no running, no rushing, things explained well and again, no rushing. I like it. I suspect our clients like this as well.

Maybe this is where telemedicine has a role. Arrange in 5 minutes the obvious things to have 20 minutes for the not so obvious.

RE: 7 and 1/2 Minutes.

Anthony Todd — Sun, 21 Mar 2021 23:22:14 GMT

We used to base "wages" on what each vet did but with an essential difference in that we paid more for items that were "good practice" ie worming, chipping dentals etc etc rather than on money having done that and having dentals going home on 2 weeks of Ceporex...

.Didn't make a blind bit of difference! Some vets hated dentals, some didn't like microchipping and one vet loved dentals and did 20 times as many per 100 contacts as others....

We also had vets who deferred things they didn't like and others who followed up all their cases through time of and rotas etc. [usually the best vets too]

RE: 7 and 1/2 Minutes.

Gillian Mostyn — Sat, 20 Mar 2021 06:02:00 GMT

[quote userid="7811" url="~/001/nonclinical/f/life-in-practice-discussions/29735/7-and-1-2-minutes/229304#229304"] We never run over, and most things are seen on time. We also pick up the slack and help each other while consulting, if someone has a tough case and I have a stitches out![/quote]

I have been surprised, as a locum, that this isn't actually commonplace anymore. It seems more common to have your own list and not help out anyone else, even if they're running behind through no fault of their own. It's not universal, but is certainly a thing. I find it quite sad.

RE: 7 and 1/2 Minutes.

Dagmar Steele — Fri, 19 Mar 2021 21:48:33 GMT

Just this morning I had a client come in with an apparently healthy Pomeranian they bought last summer. He had a list from his wife to go through and he was supposed to talk about the food, how much exercise, how to groom properly, how to clear tear stains, what to do about the retained teeth,wether to neuter or not, and lots more things I’ve already forgotten about. I am proud to say I jammed all of this in 15 minutes, but only because I can be quite firm if people want to elaborate on every nook and cranny. They paid 2800.- for the creature and they’ll continue to insist on spending as much money they can on him. Even with the 15 minutes they had they called back later because they weren’t satisfied and had more questions to ask. While Tricky Woo was a curiosum back in the day these people are getting more common by the day.

RE: 7 and 1/2 Minutes.

Joyce Whitehead — Fri, 19 Mar 2021 18:48:03 GMT

I’m adding on here as I clicked disagree on George’s post and wanted to say why. I think I would agree that of course clients want their beloved pet getting better, but so many of them nowadays know that we can do further diagnostics. And often specifically ask about bloods/ultrasound/X-rays etc. Now I don’t always do them of course, I will discuss the pros and cons, and often will just advise a repeat examination in a few days, but clients are so much better informed now than they were when I was a new graduate.
Even if we do give an injection and ask for them to come back the client wants to know what you’ve given and why in most cases. They don’t blindly accept what the vet says these days, rightly so IMO. Possibly this is partly due to tv vets and seeing what goes on and what is possible?

We used to be on 10 minute appointments and I could keep up pretty well (worked in some very busy practices early in my career and had to speed up). We swapped to 15 minutes at the start of lockdown when we first stopped clients coming in, and definitely won’t go back, it gives you time to chat to the client about all options.

RE: 7 and 1/2 Minutes.

Lucy Fleming — Fri, 19 Mar 2021 18:00:00 GMT

[quote userid="2122" url="~/001/nonclinical/f/life-in-practice-discussions/29735/7-and-1-2-minutes/229239#229239"]The only thing - the ONLY thing a client expects is that their dearly beloved pet will be restored to full functionality having seen the vet, and so the more promptly this is restored the better.[/quote]

I think this is absolutely spot on with regard to consultation time - I find that many clients appear to have little to no idea that they've been designated any time slot, and expect to be in the consult room for as long as it takes for either the pet to be diagnosed and fixed, or for a plan to be made to reach a diagnosis and thereafter fix it. Some prefer to be in and out in a flash, some are extremely difficult to shift no matter how many times you repeat your end-of-consult spiel or how long you spend standing with your hand on the door handle ready to usher them out.

Whether "client expectations" overall are a myth created solely by vets, I'm not quite as sure. I think some/many clients just want to be given a single answer, and preferably a treatment then and there, and in many cases this can be provided (with the above "if no better etc" proviso). Others either may be dissatisfied with that approach at the time, or may prove to be dissatisfied with that approach if the case doesn't go quite according to plan. Some cases simply don't have an obvious answer at first presentation, or the treatment for one possible diagnosis may be actively harmful if you got that diagnosis wrong and in fact a different condition caused the clinical signs.

I'm not a big fan of defensive medicine, but having properly explained things to the client is certainly helpful should a case go south and the client find themselves dissatisfied with the outcome....

Client expectations aside, I find the appointments where a little extra time is most valuable, are the booster appointments - particularly in older pets. That's where you get the chance to address the problems the owner hasn't actually brought them in for - the festering teeth, the crippling arthritis, the gross obesity, the elderly cat that's lost 25% of its bodyweight since you've last seen it... since the owners often don't perceive any problem (but most of us would agree they are detrimental to the pet's QOL) it can take a little longer to get them on board with addressing the problem, rather than simply disappearing into the ether to "think about it" or "cut back on his treats". I find I'm often more likely to get a sick pet in and out of the consult room promptly than a middle aged booster jab.

RE: 7 and 1/2 Minutes.

Lucy Fleming — Fri, 19 Mar 2021 17:33:53 GMT

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/29735/7-and-1-2-minutes/229266#229266"]

A jaundiced cat would get a blood for sure, a lame dog with a sore hip on manipulation would not. A lame dog with reflex deficits would, but, in fact. what difference to the dog or the owner would the bony or disc change visible on Xray make?

I still am waiting for some sort of estimate of the "hit rate" of "tests" ie a test [to include everything which is an aid to diagnosis], or which changes the apparent clinical impression, thus diagnosis and treatment, but none yet...

[/quote]

To put it the other way, Anthony, what proportion of these presentations do you think are having further work up, or what "bloods" exactly do you think they are having?

I just did a quick count on our computer system, of the last 17 non-routine appointments I saw, four had further testing. One had an ultrasound scan to look for pregnancy, one was a phone consult that has been booked in for possible radiographs next week for a non-resolving lameness, one had bloods taken to check parathyroid hormone and ionised calcium (ongoing case) and one was vomiting, lethargic, dehydrated and off his food. He had bloods taken, and was hospitalised on fluids. We suspected GI disease, and confirmed pancreatitis. Arguably didn't change the treatment, but he is an elderly dog with other co-morbidities. Had we found some other cause, such as severe kidney disease, for example (which might present the same way), then his owners probably would have put him to sleep rather than hospitalised and treated him, so I suppose it did change the treatment in that way.

I've been practicing for 13 years, so not a newbie, but not an old hand. I suspect I'm a fairly typical GP in my case approach, so would expect many other vets have similar sort of "rates" of further testing...

RE: 7 and 1/2 Minutes.

Julie Innes — Fri, 19 Mar 2021 14:02:51 GMT

we do blocks of 10 minute appointments, with spaced out "keep free" appointments, and gaps between blocks to catch up/ take blood/ look at bloods/ discuss case with colleagues. If things need working up they are admitted, and our competent RVNs can take blood/ start them on IVFT/ take the xrays 9after we sedate).

i have asked my vets if they would prefer 15 minute consults, but they say they are happy with the way things are. We never run over, and most things are seen on time. We also pick up the slack and help each other while consulting, if someone has a tough case and I have a stitches out!

RE: 7 and 1/2 Minutes.

Julian Earl — Thu, 18 Mar 2021 19:00:16 GMT

[quote userid="2131" url="~/001/nonclinical/f/life-in-practice-discussions/29735/7-and-1-2-minutes/229297#229297"]Oh yes, distemper, tetanus. i'd probably add laminitis in horses. Open pyometra in the bitch, praps not quite instant, but as soon as they say she's drinking a lot, she finished her season then seemed to start again. [/quote]

Yes, thanks Evelyn. Laminitis is a good one, almost a certain diagnosis on sight. Stiff-legged, reluctant to move? Oh yes that looks like Laminitis! Unless it has early tetanus of course!!

Pyometra is another one, after just a few minutes of history taking, plus drips of pus on the floor behind the bitch! Has she just been in season?/ Oh yes, a couple of weeks ago! Okay, got it!!! Well if we now spey her she'll be better within a week! Job- sorted!

RE: 7 and 1/2 Minutes.

Evelyn Barbour-Hill — Thu, 18 Mar 2021 18:33:28 GMT

[quote userid="8958" url="~/001/nonclinical/f/life-in-practice-discussions/29735/7-and-1-2-minutes/229263#229263"]A 5 minute consult works for a single handed 'family' practitioner that knows the client, knows the patient and is in the practice 24/7, but those days are gone, long gone.[/quote]

Ahem. Not quite dead yet.

And it's just that that type of practitioner who does not have five minute appointments but gives each client at each consultation just as long as they need.or want.

Personally, if I had 7.5 minute appointments booked, I'd be running 12.5 minutes late after the first one. Cripes, sometimes the cat carrier's on the table with the door open for five minutes before we take the cat out.

[quote userid="3094" url="~/001/nonclinical/f/life-in-practice-discussions/29735/7-and-1-2-minutes/229226#229226"]So that's a couple of conditions that I feel can be diagnosed provisionally and immediately. What do you all think please??[/quote]

Oh yes, distemper, tetanus. i'd probably add laminitis in horses. Open pyometra in the bitch, praps not quite instant, but as soon as they say she's drinking a lot, she finished her season then seemed to start again.