Crisis in the profession?

RE: Crisis in the profession?

Alistair Graham-Evans — Wed, 06 Oct 2021 07:26:56 GMT

[quote userid="6550" url="~/001/nonclinical/f/life-in-practice-discussions/29945/crisis-in-the-profession/233447#233447"] have a holiday booked[/quote]

Enjoy a well-earned break!

RE: Crisis in the profession?

Bob Russell — Tue, 05 Oct 2021 13:45:21 GMT

Time for an update me thinks!

Not going down the five minute bulls+it route. I want my patients to be given proper care and I doubt it will work for either of us vets here.

We are taking on new clients moving to the area. We are doing puppy/kitten vaccinations for patients refused registration elsewhere (we continued puppy vaccinations throughout the dark days of first lockdown because they needed protection).

A few grumblers have been sent bugger off letters but most have accepted the issues we have.

All staff now vaccinated and only one positive test (child brought it home).

We have decided as a practice to continue the no clients in the consulting room for the time being but once we are comfortable that there will be no mass infection event triggered by the return of the kids to school we may allow masked clients into the CR to hold their pets. Not a lot of enthusiasm for this yet!

We have not told people that we are open again on a Saturday and no complaints so far, urgent cases only plus a few puppy vaccinations if we are struggling for time during the week.

I have a holiday booked to show my wife the city I went to college in. Will be a bit sad because I cannot just drop in to friends flats for food and drink!!

RE: Crisis in the profession?

Alistair Graham-Evans — Sun, 03 Oct 2021 22:03:54 GMT

Bob’s original post was about being inundated with work and stressed staff.

If he has 5 minute consultations he will get through the work quicker but his client base will change because the good ones will leave. He will get more clients complaining and his staff will leave. Poor Bob.

If he doesn’t take on more work that he can give quality treatment to then his nice clients will stay. He will get fewer complaints and he is more likely to have a happy team and maybe take on another vet and become more profitable. Happy Bob.

Tony - I can do 5 minute consults and used to do them in open surgery 20 years ago. They were poor quality, not very informative for the client and I missed or ignored or kicked down the road things that were not the presenting complaint. All of us who are working in the present can easily demolish the idea of a 5 minute consultation. Experience and speedy efficiency are great but adaptability and willingness to change and listen to new ideas is important.

RE: Crisis in the profession?

Stephanie Whyte — Sun, 03 Oct 2021 20:56:09 GMT

Wow! Brilliant info, sounds like a great approach.,

RE: Crisis in the profession?

Dalya Livy — Sun, 03 Oct 2021 20:35:24 GMT

This has made for fun reading (and by fun, you may assume that word does not mean what you think it means).

I've done 5min, 10min, 15min and 20min consults. I've done open surgeries. I'm least stressed and most profitable at 20min. Different strokes for different folks - find your own groove and accept that not everyone is like you and different people thrive in different environments. Our personal comfort zone does not make any one of us a worse or a better clinician. Clients will gravitate towards practices that provide the type of service they want and towards vets that have the approach that they want, which will helpfully allow each of us to say "my practice has got it right because our clients love our 5min/20min consults".

I'm very much in the camp of allowing nurses to do more and shelving the vet ego standing in their way. They are smart and capable professionals and using them as glorified cleaners and telephone-answerers is a massive waste of resources.

I've posted this elsewhere but might be worth mentioning here as well. We have been a 1 vet practice for the last 7 years, and have 3 weeks ago become a 2-vet practice. We have purposefully transitioned from a vet-centred to a team-centered approach, and Covid helped immensely with that transition. Meaning that our nurses do as much as they are legally allowed to do - all sorts of nurse consults (usual stuff plus bloods, BP, 6m checks for healthy pet club/seniors, dental consults, weight clinics, behaviour consults, laser, all the monthly librela/cytopoint etc injections, soon will be helping with OA/rehab clinics), and procedures (x-rays, scale/polish, minor procedures under sedation - ear flushes, laser lump removals) and drips/inpatient care. Their consult lists are fully booked 90% of the time.

The vet supervises sedations, does inductions, is available to pop their head into a consult in case they are unsure about something (as that generally only takes a minute). We had 1.5FTE receptionists and 4.5FTE RVNs in a 1 vet practice (2 vets as of recently, and about to hire another RVN and a VCA and 0.5 receptionist). Our clients know the nurses by name, and ask to see them for specific consults. The nurses love the responsibility, the increase in knowledge and skills, and the fact that their jobs are a lot more interesting. We have 20min consults, with 40min for first puppy/kitten, euthanasia, acupuncture, first exotic appointment, second opinion. We have about 1600 active clients (though have not looked recently) and our turnover is at 2 x average for a 1 vet practice with very average prices. Our clients love us, and we definitely attract people who want a lot of time from their vet.

It's not for everyone, just like 5min treat 'em and street 'em is not for everyone, but that is one way to manage the increased workload while actually creating a happy and fulfilled team and great client relationships. That 40min puppy appt? They get to see me for 15min for exam/vaccines/nutrition, then they spend 10min with nurses going over parasite control/grooming/dental care and 15min with the behaviourist. Team-centered, it's not all about vet time.

When we're super busy, we double book in 10min staggers. Nurse 1 gets Hx and bring into room, i do exam, go out to talk to O about findings and plan (at this point nurse 2 gets Hx on next appt), nurse 1 executes plan and discusses follow up with client then gets patient 3's Hx, while I write up notes and examine patient 2 and so on. Similar to the American approach though not quite as intense and only done when we're seriously out of appt slots, but again ensures that all clients get to see the vet for the appropriate parts of the consult AND builds rapport and trust with the whole team not just the vet.

TL:DR: There is no one solution that will fit every practice and fit every vet. Accept the differences rather than insisting on uniformity, and be open to trying different things rather than automatically thinking it won't work.

RE: Crisis in the profession?

bob lehner — Sun, 03 Oct 2021 20:07:16 GMT

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/29945/crisis-in-the-profession/233405#233405"]so not much point in my trying to help.[/quote]

Yeah ! At last the message is getting through to you.....

RE: Crisis in the profession?

Julian Earl — Sun, 03 Oct 2021 20:01:30 GMT

[quote userid="3169" url="~/001/nonclinical/f/life-in-practice-discussions/29945/crisis-in-the-profession/233410#233410"]I disagree with Julian - think nurse consults good for the nurses and good for the practice.[/quote]

Hmm. Okay Michael, It takes all sorts I guess? You are still wriong to disagree though!!

Best wishes, regardless!!

RE: Crisis in the profession?

Michael Woodhouse — Sun, 03 Oct 2021 19:54:12 GMT

[quote userid="8958" url="~/001/nonclinical/f/life-in-practice-discussions/29945/crisis-in-the-profession/233372#233372"]How long were these surgeries Michael? I suspect they are as I had them in mixed practice. Start at 0900 for an hour, maybe an hour and a half whilst the farm calls rolled in. You then had a break in your car as you drove to the first call and if you overan it wasn't too much of an issue.[/quote]

Yes, two 30 min slots to arrive and then see who was there. Some days 3 people, some days 15.

Funny in that when I started one vet would knock it out in an hour most days. Now (appointments, 10 min slots) seem much busier, can take 2 vets 1.5 hours. Putting in a 3rd nurse consult room (thought I said but maybe never posted). I disagree with Julian - think nurse consults good for the nurses and good for the practice.

Whilst I realise I am working in a different world, I dont think anyone finds a few short consulting slots that bad - what can be learnt from that? Currently fully staffed and do own OOH......

(that said we only have 1 set of traffic lights in the entire practice area......)

RE: Crisis in the profession?

Julian Earl — Sun, 03 Oct 2021 19:40:37 GMT

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/29945/crisis-in-the-profession/233407#233407"]Why? Because, they MIGHT want to know why they OUGHT to have the injury fully investigated and then receive an APPROPRIATE for the task? S[/quote]

Sorry Anthony, Isuspect that you know exactly what I mean? They might want to know but we have an obliv=gaytion to explain for what thy are paying and why we are doing whatis necessary. It would not be correct to just carry on ahead doin whateeeeewe felt like doing to THEIR beloved pet without telling thmmwha and why we are doing what we are about to do? !

Appopriate should hve been followed by treatment bethat abs/lancing/ NSAIDs or a combnaton thereof?

hanks again!!

RE: Crisis in the profession?

Julian Earl — Sun, 03 Oct 2021 19:33:24 GMT

enicillin works so much better for CBA,,and I've retreated loads, after a course of broadies!

I don't really gdt this Antony? An abscess needs draining oe way or another ] scalpel or naturally? If allowing for that, when do you use abs? If I see or saw a cat bite wound before abscessation Iwould try to flush throughly as best as possible and probably aminister boad spectrum antibuotics at this stage in an attempt to stop ann abscess orcellulitisdevloping.

After lancing and drainage, flushing to remove any residual debis may i I may ior may not use uiantibiotics dependant upon any ssociated cellulitis around the wound and cavity. But a large encapsulated unruptured abscess without cellulitis is no indication for antibiotics, IMO and IME! These invariably need lancing/draining and flushing..., I do happily administer tanblets to cats for follow-up therapy having demonstrated my failsafe methond of administration to any cat bar the feline psychopath and/or feral!!

Thanks!

RE: Crisis in the profession?

Anthony Todd — Sun, 03 Oct 2021 19:24:15 GMT

Why? Because, they MIGHT want to know why they OUGHT to have the injury fully investigated and then receive an APPROPRIATE for the task? So That is why. Therefore; they then can understand what is going on! It shows hat you are very consientious anddiligent! This wil sually bond them to you and/or the pactice IME! practice personally,for having been so thorough and diligent??s his not a Good thing ofr all concerned? Especially for the cat? All of this = Job satisfaction and not a crisis!!

RE: Crisis in the profession?

Anthony Todd — Sun, 03 Oct 2021 19:19:05 GMT

[quote userid="19228" url="~/001/nonclinical/f/life-in-practice-discussions/29945/crisis-in-the-profession/233404#233404"]script for amoxyclav.[/quote]

I've said this before, penicillin works so much better for CBA,,and I've retreated loads, after a course of broadies!

RE: Crisis in the profession?

Anthony Todd — Sun, 03 Oct 2021 19:16:58 GMT

I wonder why we had any clients at all............................

I have tried, but you guys won't even, try 5 minute appts, and will just keep claiming "stress" and overwork, so not much point in my trying to help.

RE: Crisis in the profession?

cairncross — Sun, 03 Oct 2021 18:38:22 GMT

Agree with all except it is probably what a medical GP would do, had consult with my 11 year old son just before covid lasted less than 5 min and emerged with script for amoxyclav.

RE: Crisis in the profession?

Julian Earl — Sun, 03 Oct 2021 18:37:07 GMT

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/29945/crisis-in-the-profession/233397#233397"]

Julian Earl said:
If this is all explained to an owner, I would be pushed to do this within a consultation lasting just 5 minutes! Good luck!!

Why explain all this? Clients just actually want the animal sorted. How come dinovets managed 5 minutes, or did the patients not get better without ten minutes of options, remote complications, alternatives, suggestions, and choices?

[/quote]

Why? Because, they might want to know why they ought to have the injury fully investigated and then receive an appropriate bill for the task? So That is why. Therefore; they then can understand what is going on! It shows hat you are very consientious anddiligent! This wil sually bond them to you and/or the pactice IME! practice personally,for having been so thorough and diligent??s his not a Good thing ofr all concerned? Especially for the cat? All of this = Job satisfaction and not a crisis!!

Cheers Anthony!

RE: Crisis in the profession?

Neil Wheadon — Sun, 03 Oct 2021 18:32:40 GMT

I'm pulling out, we're in the same spiral again, logging out

Neil

RE: Crisis in the profession?

Martin Hamilton — Sun, 03 Oct 2021 18:27:07 GMT

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/29945/crisis-in-the-profession/233400#233400"]How can you possibly drag out a CBA for 15 minutes unless you have to, or want to??[/quote]

Physical exam & history taking - 3-5 min

Explaining to owner that CBA most likely diagnosis, bacteria in CBA most often anaerobic meaning once we have lanced and flushed abx are not likely required (unless there is significant surrounding cellulitis) - 1-2 mins

Take cat back, clip, lance and flush copiously, examine for other wounds, puncture into thorax, abdomen, joints etc - 5 mins easily

Write comprehensive notes about all of the above, enter bill and review dispensed medications - 2 mins at least

Discharge cat and answer any remaining questions - 1-2 mins

Honestly, these timings are a bit of a guess but seem pretty reasonable to me. And just giving a CBA a jab of antibiotics and off it goes is pretty poor antibiotic stewardship.

RE: Crisis in the profession?

Anthony Todd — Sun, 03 Oct 2021 18:20:16 GMT

[quote userid="16672" url="~/001/nonclinical/f/life-in-practice-discussions/29945/crisis-in-the-profession/233398#233398"]Client expectations and an inherent lack of trust in vets (or at the very least clients more often than not want to hear your reasoning). They want to be part of a conversation regarding their pets care, not just told what to do (most of the time).[/quote]

Or is that what you think they want [and/or sadly, motiivated by the modern fear of being reported to the RC etc.??

I think most, even dinovets, would give an associated reasoning for their advice.

How can you possibly drag out a CBA for 15 minutes unless you have to, or want to??

RE: Crisis in the profession?

Martin Hamilton — Sun, 03 Oct 2021 18:08:32 GMT

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/29945/crisis-in-the-profession/233397#233397"]What has changed?[/quote]

Client expectations and an inherent lack of trust in vets (or at the very least clients more often than not want to hear your reasoning). They want to be part of a conversation regarding their pets care, not just told what to do (most of the time).

RE: Crisis in the profession?

Anthony Todd — Sun, 03 Oct 2021 18:06:31 GMT

[quote userid="3094" url="~/001/nonclinical/f/life-in-practice-discussions/29945/crisis-in-the-profession/233394#233394"]If this is all explained to an owner, I would be pushed to do this within a consultation lasting just 5 minutes! Good luck!![/quote]

Does anyone really think all clients want all this? They certainly didn't express that wish BITD and we didn't seem to have all this angst that seems to pervade the profession now?

Of course some clients did and we did, WHEN ASKED, or when the client gave us the impression.

What has changed?

RE: Crisis in the profession?

Anthony Todd — Sun, 03 Oct 2021 17:59:35 GMT

But why not? What takes 15 minutes? Do you think most clients really need/understand/want to pay for 15 minutes or is it that they are given the obligatory 15 minutes anyway for anything?

RE: Crisis in the profession?

Julian Earl — Sun, 03 Oct 2021 17:50:20 GMT

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/29945/crisis-in-the-profession/233390#233390"]How does a modvet "work-up" a cat bite abscess, and why would anyone need/want/advise/suggest that?[/quote]

Not claining to be a mod-vet at all but work-up? Does this abscess need sedaton for lancing, draining and flushing? Has it penetrated to a vital organ? How old is the cat? Any previous history of of geriatric-related disease sch as renal or hepatic disease before you wade in with sedation or even a full-GA for the further investigation and through flushing? Any joint involvement etd., etc.? How fresh is th bite wound btw?? Half an hour or two weeks? If the former unlikely to be an abscess already, but then more investigation is reqiuired for deeper damage ? So those all require some sort of work-up prior to a potential GA or even just before deep sedation with Domitor or equivalent? If it the cat is not very young at all, are we happy to wade in with NSAIDs before checking renaland hepatic function first ? How many puncture wounds have you identified as well by the way, and where?

If this is all explained to an owner, I would be pushed to do this within a consultation lasting just 5 minutes! Good luck!!

RE: Crisis in the profession?

Stephanie Whyte — Sun, 03 Oct 2021 16:47:11 GMT

Should have said I could not do my job well in less than 15 minutes.typing too fast!

RE: Crisis in the profession?

Anthony Todd — Sun, 03 Oct 2021 16:02:33 GMT

[Paragraphs make my geriatric navigation easier.....!]

But how many consults really need "work-up"?

How does a modvet "work-up" a cat bite abscess, and why would anyone need/want/advise/suggest that?

How many consults can you not diagnose /explain/treat/advise /revisit in how long?? [5minutes??]

I'm not discussing the "whole" consult, but actually satisfying the client and yourself?

I realise that a CBA is simple presentation but how many are not?

RE: Crisis in the profession?

hilary warner — Sun, 03 Oct 2021 15:48:01 GMT

[quote userid="12375" url="~/001/nonclinical/f/life-in-practice-discussions/29945/crisis-in-the-profession/233384#233384"]clients were mostly happy to wait and grateful to be seen[/quote]

I am just thinking and I would say that this is still true on the whole with the number of biscuits and thank you letters received. I don't think there are many jobs where so much is given, I have several shrubs and house plants from grateful clients and other staff members will have other things that they particularly appreciate. Sometimes it is possible to get it wrong and t the complaints start, some are fair and some unreasonable. With regards to being overwhelmed with consults this can occur because there is too much demand but it may also occur because too much is demanded. ie If I wish to be paid for example £100 K per year + NI and pension then I have to be able to fund this with profit that I can make and still be able to pay a sensible salary to the support staff. If the clients in the area can only afford a £30 consult and no work up I will have to see a lot of people, if each client can afford £100 for a consult + work up then I need to see fewer people. In the same way there are very many more cars out there on the road that cost £15K to buy compared to those that cost > £150K to buy. Sadly not everyone can work for RR but that does not mean those working at Ford are less well skilled and it does not always mean those working for RR are paid 10x the salary. It should be less stressful working for Ford as demands on spec are lower but if demands at Ford are the same as RR then there is a mismatch in expectation, of customer, work force and client. 1st opinion vets can be good, very good, even exceptional but they should not have the same expectations on them as referral vets. May be everyone looking to be he best of the best rather than good enough is where so many present pressures lie. (I am competitive but I will not compete if I do not think can win; it is not worth the agro )