Good medicine good business: 16 lessons learned from my doctor

My good friend Dr. Rich Pflueger, president of the New Mexico Veterinary Medical Association, said it comes down to two issues: care and kindness.

Let me back up. Three months ago, I endured a riding accident on my horse and thus began a lesson in human medicine.

And while laying in a fetal position for days on end, I had a chance to consider some issues as they relate to veterinary medicine.

In the emergency room, I lay on the floor in the fetal position for 30 minutes before being put into a cubical, where I lay for two hours before a clinician spent about one minute with me. Then, another two hours passed before a dose of morphine arrived.

Two hours later, I was shipped off to radiology to stand for an X-ray. The pain was unbearable, but I stood for the radiograph.

The diagnosis: compression fracture at T6.

Before discharge, the emergency-room clinician refused to contact my primary-care physician because, "He would be of no help."

Sent home after nine hours in the emergency room for bed rest, I lay on the sidewalk (on vicodin) in the fetal position until my ride came along.

Needless to say, it was a sleepless night.

The next morning I headed off to see a neurosurgeon and was put in the hospital for the next five days: The new diagnosis was C5-6 and C6-7 disc herniation.

It was Labor Day weekend; I was stuck in that fetal position for four days with a demerol pump, which, incidentally, failed to break the pain cycle.

On the fifth day, a brief visit by the surgeon included a facet injection, which also failed to blunt the pain.

I went five days without a bowel movement. After the pump was removed, I went two days without my catheter being flushed, the leg pumps to prevent clots lay unpumping for most of the five days.

Then they finally did flush the catheter—clot included. I contemplated whether or not a pulmonary embolism would be a good way to go.

While in Albuquerque, I live at the clinic. I could hardly get to the toilet from by bed. I lost 15 pounds in three weeks.

I mostly laid in bed for three weeks taking percocet, which did not break the pain, but it did tear up my stomach.

Given my growing desperation at my own inability to take care of myself, I called the neurosurgeon's office to schedule an early fourth-week appointment.

"Naw, Doc, you've just been too active, just tough it out, and it will be OK; we will see you next week."

The only place I was at all able to find a little relief was laying on the clinic's cold concrete floor, where I spent the next three days.

Increasingly alarmed and concerned, our clinic office manager, Barb, called the neurosurgeon to let them know they needed to see me today. It worked. It was momentary relief; the pain remained unrelenting.

Consider your patients

That morning at 10:30, I considered the three rules for euthanasia for our patients: unable to care for itself, unable to go about its daily activities and no hope for recovery. Meeting these standards, I felt like I was ready for euthanasia.

The MRI said I was not a surgical candidate, but they could do an epidural the following week.

Our clinic's senior veterinary technician, Debbie, who became my advocate, advised them that I couldn't make it a week in this condition.

After laying in their office for two hours, still not seeing a doctor for three weeks, with only the practitioner assistant assessment, the neurosurgeon's office referred me to a pain-intervention clinic.

Debbie, poured me into the back seat of her car and carried me to the last hope.

Relief in sight?

As I slogged along trying to get to their door, they rushed out to help me, expressed grievous concern for my condition, helped me to and on the treatment table. It was the first time time in three weeks that I felt caring in our healthcare system.

The two doctors and three assistants did a thorough neurological examination (the first real one), took the history, vitals and explained the situation, prognosis, plan and had me sign all the papers.

They changed all of the medications prescribed by the neurosurgeon.

They loaded the spinal area with a local anesthesia, and as they put it—flooded the spine area with triamcinolone.

At 3:30, I arrived home. I slept for the next 18 hours—pain free.

I am writing this column four days after this ordeal. The pain team received a cookie bouquet from me thanking them for their compassionate and competent care.

They gave me hope that there is life after hitting bottom and that with an advocate, one can find those gems in the flawed medical world that know what healthcare is about.

Interestingly, the first emergency-room doctor has not checked in, neither has my primary-care physician or neurosurgeon.

My message is simple: Do not put good people in a flawed business structure.

Let the veterinary profession avoid the steps of the medical profession, and reconsider messages about care and kindness.

1. Greet the patients when coming in the front door.

If they are in trouble, e.g. pain, get them immediate attention.

As hard as it is to believe, there are practices that forbid the receptionist from leaving their stations to greet patients.

2. Check boxes on duties to perform.

The medical record should have check-off boxes for each duty. If one wants the catheter flushed twice a day, then there must be two circles or check boxes to indicate that such duties have been performed. If one wants to know the status of eliminations, then there must be a place for this data to be addressed in the medical record.

There can be no excuse for failing to attend to the catheter or leg pumps.

While the medical profession has these neat scanners to assure pharmacy accuracy, such technology now must be applied to basic nursing duties.

3 Make sure to follow-up on everything with an active telephone call.

Assume that a certain percent of things, no matter how good or competent we might be, will have adverse outcomes—not malpractice mind you, adverse outcomes.

4. Make sure each patient goes home with individualized written home instructions.

Such instructions must address diet, exercise, water, medication, general information about the diagnosis and what to expect and maybe most important, when the follow-up appointment is needed. Give them the appointment before they leave.

Hastily verbalized instructions just cannot be remembered, and the written format assures that each issue is addressed.

5. Give praise to the staff, clients and those who support the veterinary practice's mission.

The thing that we do for our clients that has been most appreciated is sending a bouquet of treats or flowers.

When a client is in the hospital, is bedridden, has an accident or another personal setback, we send them a cookie bouquet with a message like "Cookies are good medicine."

6. One must listen, listen, listen.

The motto to live with is simple: "When in doubt, check it out."

When a client calls with a concern, there are always two options: coast along with the current home care, or, consider that things might not be coming along as expected.

When in doubt, get that patient in to re-evaluate the situation.

7. Remember competency counts.

It is not good enough to be compassionate. To assure competency, read one hour per day or seven hours per week to stay within the confines of competent veterinary medical care.

8. Fess up.

Be open to the reality that little things happen, like plugged catheters. Correct it, and stand with it.

9. Malpractice also happens. Prevent it.

Malpractice is "improper or careless treatment."

The current level of accountability in the veterinary and medical profession only finds abrasive personalities sued, not always malpractice situations.

We diligently must seek to stamp-out practices that could lead to medical mistakes within our practices.

10. Follow your patients even when referred to a specialist.

Veterinary specialists have become very good at sending referral letters to the primary-care clinician, and this trend must continue, but more follow-up is needed. The primary-care clinician must contact the client at appropriate times following the referral.

11. Tend to staff needs, such as health insurance.

Healthcare and the insurance trauma in this country shall not be solved in our lifetime (mine anyway). So, it is my opinion that small businesses must come forward to help solve this national issue with coverage.

Start by begging AVMA health-insurance trusts to resume coverage for support staff.

These folks could not afford to continue to contribute to our clinic's mission without healthcare coverage.

The economic strength of the profession has reached a point where we adjust fees and budgets to provide this essential element of employer responsibility.

Clearly, the key members of my staff—some have been here for 25 to 30 years—could not afford to be with our clinic without healthcare coverage. As members of my staff have been treated for dental problems, hip replacement, breast cancer and now one is headed to brain surgery.

12. Sit down when assessing patients.

Clients listen and patients are more relaxed when we sit to gather data. And more pertinent data is then forthcoming.

13. Pray for balance with incentive programs.

Human healthcare clearly has documented that healthcare is influenced by incentive. Do not put good people into a flawed environment.

Check to see that a clinic's incentive and compensation programs reward excellence in healthcare, not just a larger volume of care.

14. Do a complete exam.

Not one time in three months has any one of the assorted professions looked at taking a comprehensive history on me. Let's learn from the mistake; look at retinas and ears; listen to the heart, lungs, and check the urogenital system. (A-Exam, F-Physical Examination Format as presented in

Management For Results.)

15. Listen to colleagues.

Each of us has unique professional experiences and lessons we can teach each other. Let's learn from each other.

16. Live up to the image.

Learn from your critics and appreciate your fans. As professionals, we can create enemies. There are always those clients who believe the next veterinarian down the road is a little "goofy".

Finally ...

I know that from time to time I have failed to follow these 16 Rules, but I clearly shall redouble my efforts henceforth.