I graduated from veterinary school 20 years ago. From the beginning of my career the care I delivered was directly related to what the client was willing and able to pay. At the vet clinic, you usually pay up front, and most people don’t have insurance, so money is often in the forefront of the conversation of how to manage a patient.
My first job was at a mixed animal practice in rural Minnesota. Local economics and the fact that animals were raised for the purpose of food or product meant that available dollars per animal were often small.
Return on investment was evaluated daily. Does it make sense to treat this cow’s pneumonia when last year’s milk production from her was low? Would it make more financial sense to “ship her”? Food-producing farmers must and do think of animals in a cost-versus-benefit equation.
This dogma applied not only to animals raised for profit but also to the companion animals that lived on the farm. Often I would see a dog (rarely a cat) that was sick and I had $50 or less of the client’s money to spend in the best way possible to help the farm dog. When faced with a limited spending budget, the veterinarian must make a choice about whether or not to do diagnostic tests to determine the cause of the pet’s illness or try treatments.
There is a treatment that most rural veterinarians know about called the “strawberry milkshake.” Veterinarians aren’t taught about this treatment in school. In school we are taught to approach a patient in steps. First, you examine the patient and make a list of symptoms; next, you perform the necessary tests to obtain your diagnosis; and, finally, you treat the patient. The strawberry milkshake is an injection that has a steroid, an antibiotic and a deworming medication all in one. (The antibiotic was pink, hence the name of the injection). This panacea injection allowed you to avoid the first and second steps and go straight to the third, with relatively good success since most illnesses will get better with one of the three treatments.
At my first job, the cost of companion animal care was low because clients understood we were just going to “try something.” If the strawberry milkshake couldn’t cure him, then there had to be something really bad ailing the dog.
Over time I realized that being a farm veterinarian wasn’t for me, so my husband and I moved to the suburbs of the Twin Cities and I got a job at a corporate-owned veterinary clinic.
I was met with a culture difference right away. The colloquial country style I had adopted didn’t go over well with my new clientele. For example, crap now needed to be called feces. Another difference was that clients wanted tests performed on their dog. At the new clinic I was at, we had equipment to check blood pressure and a machine to run complete blood cell counts. I got to be
a detective again!
Although not as stark, costs were still a concern for the clients that came to my corporate veterinary office. My new clients didn’t just want a treatment and to hope for the best; they wanted a diagnosis, but they still needed to keep within a certain budget. At this clinic, the business model kept individual client costs lower by making it up in volume.
At the time I left my corporate job, a new scheduling model was being used called “cluster appointments.” Cluster appointments worked like this: I saw a patient at 9 a.m., 9:05 a.m. and 9:10 a.m. Then I had 15 minutes to work up those three patients before the next set arrived at 9:30 a.m., 9:35 a.m. and 9:40 a.m. This happened for an hour at the start of the morning, followed by six patients for surgery from 10 a.m.–2 p.m. and then cluster appointments again until we closed at 7 p.m. The cluster appointments were for sick pet visits. Clients whose pets needed an annual exam did not meet with the veterinarian; instead the patients were dropped off. We had two shifts of annual exams, morning and afternoon, and I saw those patients in between my other appointments and surgeries.
The tipping point for me at my corporate job came the day I saw almost 40 patients. The volume model provided the client with access to diagnostic tests and more sophisticated medications, but each pet only got a small part of my attention each day. At the clinic I currently work at, the average veterinarian sees 14 patients a day.
Three categories make up the bulk of the cost of veterinary medicine: medications, diagnostic tests and veterinary team labor. These three items together comprise about 85% of the cost of each veterinary invoice. After those big three, other ancillary costs include rent, utilities, office supplies, credit card fees and all of the other infrastructure costs that go with operating a business.
Veterinarians are notoriously frugal people. We get mad when the office staff splurge on Post-its. We ask clients to donate towels so we don’t have to buy them. Wall art is often product posters that sales reps give us.
Veterinarians spend a lot of time trying to cut costs on the little things to make veterinary visits more affordable, but the truth is that the three big expenses are what clients feel the hardest, and one of those three things needs to be sacrificed in order for an invoice to change significantly.
So what is fair for the patient, client and veterinarian? What should be given up when costs become a concern?
All veterinarians spend a lot of time thinking about this. The only answer for me is to have frank conversations with each client I see. I want my clients to tell me what they value and what their budget is. We can work through different options when I know a person’s limitations. The times my clients get mad at me are when we don’t talk about this. Either the client doesn’t tell me about their own personal needs, or I make assumptions about what they would want.
Over time I have learned that the talking-through part is the most valuable thing I can provide my clients, and this listening and discussing takes time. As a young veterinarian, when faced with the challenge of where to apply a client’s money, I felt pressure to discount my exam fees so more money could be spent in the categories of tests and treatments. I try not to do this as much anymore because although it may provide some temporary relief for the situation at hand, over time this gets to be fatiguing and I have seen many colleagues burn out from feeling like they need to sacrifice themselves for each patient.
It’s not fair that patient care comes down to money. That is the unavoidable truth. We can talk about it though. Your veterinarian wants to talk about it. Your veterinarian wants you to understand your choices and options. At the end of the day, veterinarians feel like we are truly helping when we can sit beside our clients and work through the problems and options together. When we are successful with this, that is true compassion.
Dr. Teresa Hershey is a veterinarian at Westgate Pet Clinic in Linden Hills. Email pet questions to firstname.lastname@example.org.