Missed moments in every appointment (Proceedings)

The biggest source of missed income originates in the exam room. Too often we fail to recognize the vital role this service plays in creating value and confidence in our services. Performing a physical examination is a part of nearly every patient interaction in a veterinary hospital. How we perform and communicate our physical examination plays a large role in our compliance with recommended diagnostic and treatment offerings. While every doctor will have his or her own style and routine, it is important that the examination be methodical, efficient and convey thoroughness and compassion to the client while keeping the pet as comfortable as possible. Step-by-step instruction of how to perform a physical examination is found in the staff training DVD "Creating the Veterinary Appointment" (2008 E3 Management Press – www.E3Management.com). If we want to maximize our minimal contact with our clients and patients, we must start by focusing on improving our physical examination skills.

The entrance

I believe the ideal physical examination begins with a warm entrance and greeting of the client and patient by names. I have all of our staff greet by shaking palms and paws. We then sit down and the technician reviews the pertinent medical history she has previously obtained. The doctor then asks any additional questions and we begin the examination.

The physical examination

General condition, ears, eyes, and nares

The technician gently lifts the pet onto the exam table. If the pet is large, we often perform the examination on the floor where a larger dog is often more comfortable.

I start by performing a body condition scoring (BCS) and assessing the pet's general appearance. I make comments regarding the coat, stature, weight and overall state of appearance. I then move to examining the ears, eyes and nares and work my way back, articulating each part of the exam. It is very important that you explain each step and point out any abnormalities as you discover them. I start the examination with the pet facing me to gain better access to the head and neck. It is important that you have a logical examination flow that incorporates natural transition points. Transition points are opportunities to change orientation naturally so you appear coordinated and rehearsed. Without a well-thought plan of execution, your examination may appear haphazard and incomplete. Further, by training a coordinating with your staff, you avoid embarrassing gaffes such as bumping into each other or having to ask them to turn the pet back to you because you failed to complete an aspect of your examination. Whatever your desired flow, you should discuss and role-play it with your staff so that everyone is on-board and understands your methods.

I like to dim the lights as we start the exam by looking into the ears and eyes. This helps me in my examination and also reinforces the seriousness of the examination to the client. Dimming the lights is a natural transition point in that it takes the client from the previous ten or twelve minutes to talking and discussing their pet's medical history to the action of performing the examination. We then create another natural transition point when we turn the room lights on again.

I recommend detailing your findings verbally whenever a client cannot see what you're examining. This serves not only the client but the staff member assisting you as well. When your staff is involved in the examination, they can help you complete the physical examination report. While we use a video-otoscope in diseased ears and nares, for most routine examinations we use traditional otoscopes. Describe the retina, lens, conjunctiva, tympanum, nares and other pertinent structures. This reinforces to the client that you are performing a thorough and complete examination and are capable and competent. I use an ophthalmoscope followed by a halogen penlight to test pupillary light responses. After describing my findings, I use the penlight to illuminate the nares to assess patency, architecture, the presence of any discharge or other abnormalities.

Oral exam

I then bring the room lights back up as I move to the oral exam. Since this is a dramatic step, it also helps me change the level of involvement from the client. I ask the client to get out of their chair and come close to show them any problem areas. I want them to see and smell any periodontal disease. If the teeth look great, I take this opportunity to congratulate them on their efforts. By actively engaging and interacting with clients, you're more likely to impress upon them the seriousness of the condition. If a client remains distanced and uninvolved, it is much easier for them to ignore our recommendations for dentistry. It is imperative to make the connection between oral health and systemic diseases such as endocarditis. Too many clients view dentistry as merely a cosmetic procedure and see no value in keeping their dog's teeth "Hollywood-white." It is our professional obligation to make sure clients understand the relationship between the mouth and general health and well-being. If you note loose teeth, discuss pain. If you see gingivitis, remark about gum recession, tooth root exposure and the potential to adversely affect adjacent teeth. It is important to keep in mind that few clients thoroughly examine their pet's oral cavity at home. Take this opportunity to lift the lip and educate your clients on the dangers of periodontal disease.

One final note: I recommend that you point out and briefly touch on an abnormal finding during the course of the examination. I recommend that you reserve the more detailed discussion for the time after your examination when you review pertinent findings. Additionally, you can also have a trained staff member give more detailed information on conditions such as periodontal disease after you exit the appointment.

Lymph nodes and skin

With the pet still facing me, I then feel all of the lymph nodes, all the while explaining what I'm doing and why. I start with the submandibular and work my way caudally. I create a natural transition point for turning the pet away from me as I palpate the inguinal and popliteal lymph nodes. The assistant turns the pet and I palpate these caudal lymph nodes. I next verify if the client had observed any new lumps or bumps as I run my hands along the pet's body. I make sure to emphasize to the client to closely monitor the areas of the lymph nodes for any swellings as I feel the body. Any masses are noted and measured and we generally take a digital photograph of any sizable or suspicious masses to be included in the pet's electronic medical record. If there are any new masses we strongly advise the client to have a fine needle aspiration performed and submitted to the laboratory for histopathological review.

Thoracic cavity, abdomen and hindquarters

I then auscult the chest. I like to close my eyes to demonstrate my attentiveness and also as a signal to the client that it's time for quiet. I usually say to the pet and client that I'm going to feel their pulse as I listen to the heart. Again, this provides me with valuable information regarding pulse strength and quality and further enforces to the client that their pet is receiving a complete and thorough exam. After I auscult each quadrant of the thorax, I open my eyes and describe what I heard and then move to palpating the abdomen. I start in the cranial abdomen palpating the kidney(s), liver, spleen and bladder. I pay close attention the any structures that I feel are enlarged or abnormal in any respect. It is very important that you explain what you're doing and why, especially when you are engaging in seemingly incomprehensible actions. I make it a point to describe what I'm feeling as I probe the abdomen. I also comment to the patient and client if there is any tenseness or apprehension as I palpate the abdomen. Some pets are more accepting of this procedure than others. If a pet is nervous or fearful, I must take great strides to calm both the patient as well as the client. If a client perceives that I am being rough or in any way less than gentle with their pet, I risk forever damaging my reputation and kind and compassionate. Often all that is required to allay even the most challenging fears is communication.

Once I've completed palpating the abdomen, I lift the tail to evaluate the rectum and hindquarters. While this is arguably the least glamorous part of the physical examination, it is critical that we are thorough. This includes the anal region. There may be an emerging perianal adenocarcinoma that will go unnoticed until the groomer sees it in two months.

Musculoskeletal system

The final step in my physical examination is the evaluation of the joints, limbs and paws. With the pet still facing away from me, I lift up and examine the rear paws and begin flexing and extending the joints as I progress toward the hips. Any withdrawal or tenseness is noted. I repeat the same for the front limbs. I end by putting the head through a normal range of motion by extending and flexing the neck up, down and side-to-side.

Reviewing the examination

Once I've completed my exam, we replace the pet on the floor or in the carrier and I resume sitting on my stool. I pull close to the client, generally about 36 to 42 inches away and at a 45-dgree angle to the client. I review my findings and outline a course of action. This is the time to discuss more fully the importance of weight reduction and oral care. I have found that by introducing a problem area during the examination and then reviewing it more formally after the examination is complete, the client is much more receptive. It sends a clear message to the client when you take additional time and effort to revisit a particular area of interest concerning their pet's health. It also improves your communication when you're properly seated and without the distraction that a pet on the exam table may create. This discussion also reminds the assistant of topics you want them to enforce in the patient discharge. During this time the technician is filling out the physical examination report and taking notes or entering charges.

Once I've completed my review and outlined a plan, I ask the client if they have any questions and tell them we'll be right back after we read any lab test such as fecal parasite evaluation or heartworm tests, finish their paperwork or get any recommended items. It's important to maintain an open body posture at this time, facing the client as you prepare to leave. If you turn to the side or begin approaching the door, you're sending a signal that you're ready to leave. Before I exit the room, I make sure to shake palms and paws. I exit the room leaving the assistant or technician to tell the client what we're doing and then they also leave the exam room.

It is important to keep the amount of time the client spends waiting at this point to a minimum. One to three minutes is about all it takes for the majority of routine examinations. In sick pets, the time spent performing and evaluating laboratory tests will be longer. Be sure to have a plan for dealing with patients that require radiographs, blood tests or more involved discussions.

Technician review of examination findings

Up until this point, the client has had a staff member with them for the entire appointment. I like having a staff member 'velcroed' to the client because I find it is a great way to build trust, ensure that you thoroughly educate and answer a client's questions and create continuity of care within this appointment. It also helps reduce missed charges and increase compliance and follow-up care.

The only time we leave the client alone is when the technician and doctor leave the room to get any additional paperwork or products and complete the written discharge instructions. It is critical that you are aware of the time you leave the client alone in the room. This generally takes us one to five minutes, depending on the complexity of the case.

Once I've finalized my examination report, the technician will return to the exam room and begin the discharge. We are now approximately twenty to twenty-three minutes into the appointment with seven to ten minutes to review the reports and recommendations and bill out the client.

The technician returns to the client and begins reviewing the doctor's report with the client. My strategy is to repeat my recommendations three to five times during the appointment. This offers the most repetition and increases the likelihood a client will take our recommendations seriously and act upon them. Reinforcing a message through a variety of team members will help you improve your compliance with any service or product.

The first opportunity to offer medical advice comes when the technician is obtaining the medical history. For example, if she notes that a pet needs to lose weight, this is a great time to start the discussion of diet and exercise. The next opportunity occurs when I am performing the physical examination. If I observe stage two or three periodontal disease during the exam, I will recommend a dental scaling and polishing. The third chance to offer recommendations happens when I sit down and review my examination findings. The fourth and fifth opportunities take place when the technician goes over our written discharge report and when the receptionist reviews the appointment at billing.

By strategically reinforcing the care a pet needs with the client throughout the appointment, you'll gain increased compliance and that means pets live longer, healthier lives.

Before the assistant enters the room to review the examination report, the first step is to double check the doctor's report. This will help the staff member remember to get all of your charges in and make sure that there aren't any typos or other errors. If there's a problem, your staff should correct it before it reaches the client and causes embarrassment and diminished credibility. Even simple mistakes such as the wrong gender or age on an otherwise flawless report can be enough to create doubt in a client's mind. Everyone, including doctors, makes mistakes and the team can help the doctors look good to clients. Doctors may forget that the patient was prescribed a drug or follow-up care and the technician will catch that mistake and that double-check helps reduce gaps in follow-up care.

The staff member then takes a seat and starts to summarize the written report. The assistant or technician should review the physical examination and comment on the normal findings as well as the abnormal ones. It's important to point out where clients are doing well so any areas that need work don't come across as a reprimand. The staff member takes a highlighter and highlights any test results or abnormal findings and also highlights any treatment or follow-up care instructions. The highlighter helps personalize the report and allows the assistant to focus the client's attention on what the client really needs to do for their pet.

Time

In the real world there is no set time for the amount of time obtaining a medical history, performing a physical examination, reviewing the exam report and billing will take. In general terms we allocate thirty minutes for the entire appointment with a third of the total time allocated to 1) Welcome, medical history and lab samples, 2) Physical examination, and 3) Reviewing the exam and billing. Some pets will require a longer history while others will require fifteen minutes to perform the physical examination. The key is to know your schedule and where are you in the appointment both from a time as well as procedural perspective. Five minutes is a long time if you're staying on topic and discussing what the pet needs. Five minutes is a relatively short period if you're discussing the weather or church and then realize you've neglected the pet's obesity.

While there is no right or wrong way to perform a physical examination, I encourage you to develop a systematic approach that allows you to be as thorough as possible in as short amount of time as practical. Your clients will thank you for being through and compassionate and our patients deserve it. For a training DVD outlining how to perform the perfect appointment, visit www.E3Management.com.