Life skills turn priceless in practice

You have graduated; you passed the boards, and you have finally found a practice that is a great fit. The owner is excited about having you start your career at the practice, too. Now you must walk through the door of that practice and make your first impression as a new team member.

You know in your heart that you are expected to be a leader in case management, yet you also need to be a follower of the practice's standards of care and contribute to the continuity of care of patients you have never seen, owned by clients you have never met, and with a staff who probably has many more years of practical experience than you. What are you going to do?

Hopefully, you have been directed into a Toastmasters or Dale Carnegie course during your last year of school. If you have developed/learned communication skills, life will be far easier in your new work environment. Maybe you have read "Crucial Conversations" (by Patterson, et al) and have a skill set for leading participative facilitated discussions. Then you might have been one of those gunners who only studied for tests and left the life-skills ride during your school years. Regardless, the first 90 days in a practice have many similarities, and the savvy new doctor will address the new environment using a sane and progressive integration system.

Before you begin

Make an agreement with your employer that you get 30 days of non-productive time to learn the practice's system and strengths. You might get involved in some wellness cases, but please resist trying to jump in with both feet. Use the short list offered below for the first month to negotiate your initial orientation and primary care development time. Some believe they know it all, but experience has shown the listed items usually are very practice specific, so make yourself valuable by becoming a student of the practice systems and expectations.

Day one

Dress like a practice doctor, ensure your hygiene is smell-worthy and put a smile on your face. When being introduced to the practice team, don't be cute; be sincere. Learn staff and associate names and with practice skill areas or areas of personal pride.

As applicable, get personal copies of mission statement, vision, core values, the practice's philosophy, employee manual and other baseline documents. Learn them.

Week one

Ensure you get a practice rotation established so you can spend time (at least one full shift) in each practice zone learning what they do, and how they do it. Ask questions about what they want you to do in the course of a patient episode, solicit from womb-to-tomb alternatives and expectations.

Month one

Become a fixture in the treatment room. Do not try to change or challenge anything until you learn the how and why of current operations. Continue being a great student this month by asking questions and learning how they want things done. Ask the staff to "help you learn the practice methods" for:

• Maintaining staff harmony (usually a core value)

• Reviewing staff training protocols and programs

• Preemptive pain scoring programs and protocols

• Inpatient pain scoring programs and protocols

• White board use (treatment room flow sheet)

• Bathing — you learn best by doing it.

• Hospital ward monitoring systems and cage card use

• Determining hospitalization levels

• Respecting nursing rounds

• How inpatient nurses schedule inpatient doctors

• Operating the laboratory equipment

• Setting up fecals

• Outside lab form completion terminology/protocols for CBC procedures, UA procedures, staining slides, etc.

• Cytology procedures

• Catheterization (watch first)

• Learn risk assessment scoring required for all admissions.

• IV therapy

• Radiology positioning

• Radiograph processing

• Telemedicine capabilities/agreements

• Ultrasound/endoscope protocol(s) as applicable

• In-house ECG procedures

• Hospitalization protocols

• Nutritional grading of inpatients

• Body condition scoring for outpatients

• Learn dental grading (four levels).

• Dental prophy (grade 1+ and grade 2+ dentals)

• Oral surgery (grade 3+ and grade 4+ dentals)

• Surgical pack preparation

• Pre-surgical patient surveillance standards

• Pre-anesthesia techniques and protocols

• Patient induction protocols

• Patient anesthetic monitoring expectations

• Start doing spays and neuters.

• Gain surgery speed and techniques using practice resources.

• Scrub in and assist in other surgeries

• Recovery procedures.

• Patient discharge instructions

• Understanding of travel sheet and category use.

• Planning the next contact (recheck, recall, remind 100 percent)

• When treatment room is slow, shadow outpatient doctor(s).

• Understand the outpatient nurse (OPN) asymmetry exam.

• Accept the documentation shorthand expectations.

• Become confident; use "need" instead of "recommend".

• Respect the S-O-A-P (H-E-A-P) formats of the practice.

• Review the "assessment" to "problem list" techniques.

• Understand importance of admit or discharge decision after 10 minutes of doctor's consultation.

• Work outpatient for wellness cases on a Saturday morning.

• Understand practice's competency and productivity standards.

• Develop an agreement for seeing new clients with wellness patients.

• Seek constructive feedback from the employer on a weekly basis.

Month two

Become an outpatient resource. Continue a dependable surgery schedule for spays and neuters and possibly a few other procedures where you have confidence.

Do not try to change or challenge anything until you learn the "how" and "why" of the current operations. In short, continue being a great student for outpatient procedures this month. Learn the narratives and preferences of the practice, often called the standards of care, and ensure you are meeting the continuity of care expectations of the doctors and staff in your documentation. Ask often for feedback from the medical director/owner on impressions of your team support and contributions to staff harmony. Learn how day-care admissions can improve patient care while providing you an often-needed second opinion. In many companion animal practices, experienced providers have about a 40-percent day admit rate from outpatient cases (e.g., radiographs, ear flushes, full chemistry cases, VetScope cases, etc.)

Attitude counts

The good doctor knows that day admits depend on staff competencies; a great doctor encourages and supports the staff in developing day admit competencies.

Day admit competencies are the result of a well-trained staff that is trusted to do most all of the routine imaging procedures, IV procedures, ear flushes and laboratory samples so results are ready for the doctor's assessment. The terms of employment for new doctors are the same for all other staff members:

• Team fit (maintains and supports practice harmony efforts)

• Competency (dependability for producing expected outcomes)

• Productivity (staying on schedule, speed comes with time)

• Patient advocacy (speaking for what the pet needs)

• Client-centered service (listening and responding to clients' wants)

For staff doctors there are additional terms of employment because they lead a healthcare delivery team:

• Respect (consistency for staff, clients, doctors and self)

• Responsibility (based on strengths, give others meaningful tasks)

• Recognition (individual and specific, in public and often)

• Reliability (accept credit for success and failure — no blaming).

Allow me to share with you the secret triad of client bonding. Commit these to memory and strive for accomplishments with every case:

• Allow no pain.

• Allow no puking, peeing or pooping in the home.

• Tell the client how to feed the animal [never tell a client Nil per Os (NPO) or nothing by mouth].

The emergency and critical care literature tells us that in traditional NPO cases, a 5-ml to 10-ml glucose lavage keeps the gastric flora more viable, thereby enhancing recovery; it concurrently allows the pet steward to feel he or she is doing something. This is similar to the clear broth or clear liquids guidance given to mothers. No intelligent doctor ever tells a mom she cannot feed her child!

Becoming a valuable asset

The new doctor should become productive as soon as possible. It is important that you learn to stay on schedule, as well as schedule personal issues outside the practice day.

The most productive doctors leverage their time by using the staff as critical resources on their healthcare delivery team.

They understand what staff members can do and trust them to do it well. If a staff member does not know how to do a support function, they take the time to coach them to a level of competency where they can be trusted.

Doctors who praise staff members in public and coach in private become respected team members. Doctors who give credit and take blame become respected leaders.

Dr. Catanzaro was the first veterinarian to earn diplomate status in the American College of Healthcare Executives. He has published 10 practice management-related texts in the last four years. Questions can be directed to Veterinary Practice Consultants (Catanzaro & Associates Inc.), 18301 West Colfax Ave., Bldg. R101 Golden, CO 80401; (303) 277-9800; Fax (303) 277-9888; E-mail: cat9800@aol.com or visit the corporate Web site at www.vpc.com.