Multiple pet appointment leads to loss of customer focus

10a.m. Saturday morning

Diane angles over to Dr. Henry Hammond who is busy writing up the resultsof an abscess surgery he has just performed on "Goliath" Newmana 3-year-old tomcat that the Newmans will never neuter.

Diane starts to explain the litany of problems that he presently mustattend to in the large exam room. Waiting in that room are John and BetsyBainbridge and their four pets. Dr. Hammond is not surprised to learn thatmultiple issues are to be discussed. Henry, overweight by at least 80 poundsfrom the snacks ingested to allay the stress he encounters on a daily basis,lumbers off to address the situation.

Dr. Hammond opens the door and lying on the floor is Jamie, a 10-year-old,105-pound Malamute. He is not surprised to see three cat carriers stackedchest high in the corner of the room. Upon entering the room, a cacophonyof spitting sounds emerges from the carriers. Jamie, thankfully, is a pictureof happiness. Unfortunately, Jamie is not a picture of health.

On the card charts the technician has enumerated both requested servicesand a parade of old and new problems to check for each pet. Dr. Hammondexamines the card charts for each pet and attempts to collate each of theanimals' previous problems in his mind. Each card has to be turned thisway and that. Some of the cards are tattered on the corners where multiplestaples have lived and died.

Even though the cards are manipulated like a Rubik's cube, they are determinedto keep most of their secrets.

Dr. Henry Hammond finally starts to look at the bewildering raft of questionsthat Diane has written in various places on the exam cards.

Each pet has been in multiple times for multiple problems and, therefore,each pet is taking a large array of pills and medicaments.

10:15 a.m.

He finally looks up and says, "Well, do you want to start withJamie?" That seemed the best place to start, as Jamie is the mostaffable of the group before him.

Betsy Bainbridge is the spokesperson for the family on trips to the vet.She starts by announcing that Jamie hasn't eaten for five days and reallynever got over the itching that she brought him in for last summer. Shewould also like for Jamie to have a thorough exam and to especially checkhis hips for 'hip dylepsia'. Diane peeks in the door and says that thereare two more clients waiting in the other exam rooms.

Betsy helps Dr. Hammond hoist Jamie onto the exam table while a trioof staccato spitting catacoustics reverberates briefly from the corner ofthe room.

Although Jamie is here primarily for his skin problem, Betsy asks ifJamie could get his shots and have his teeth cleaned while he is here. Shereminds him that he has been after her for several months to do just that.Dr. Hammond gulps almost imperceptibly and opens the door slightly and callsout to Diane. He changes his mind and slips out the door.

"Diane, I need you to get an X-ray ready for Jamie and also we needall his vaccinations prepared," Dr. Hammond implored. Diane agreesbut reminds him that two more rooms were waiting.

10:30 a.m.

Betsy watches as Dr. Hammond re-enters. She says that she forgot to tellDiane but notes that Jamie has been developing tumors on his chest and seemsto be losing control of his bowels during the day. Dr. Hammond adds thisto the growing list of problems.

He is eager to begin his exam but Betsy wants to talk about organic foodsfor elderly dogs and something she read in "Dog Fancy" magazinelast month about natural arthritis cures. The last part about arthritisis somewhat muffled as he listens through his stethoscope to both Jamie'sheart and Betsy's unending monologue. Doc, somewhat distracted, completesa cursory exam.

Henry notices that John sits placidly in the corner reading a book. Hemakes no offer to help as Betsy and Dr. Hammond groan to half slide/halfdrop Jamie to the floor in preparation for an X-ray.

10:40 a.m.

Diane and Dr. Hammond try desperately to get Jamie to lay on his backfor the X-ray. Jamie is a friendly dog but the prospect of being on hisback is so disorienting that he screams loudly bringing Betsy to the examinationdoorway in tears.

Dr. Hammond, against his better judgment calls for help from anywherein the hospital but only gets Betsy. She is distressed to see her dog flailingon the X-ray table and points out that he is being hurt. After several falsestarts, an X-ray is finally taken in violation of only a few safety precautions.

Immediately after the X-ray is taken, Jamie scrambles off the X-ray tableleaving behind a healthy sample of hair and urine.

A moisture trail tags along as he trots back to the exam room with Betsyin close pursuit.

11:05 a.m.

Dr. Hammond slips into another exam room to find "Wilber" Black(an iguana with 'attitude') that has swollen limbs. Doc sees another X-raycoming. A quick glance suggests metabolic bone disease and a 20-minute diatribeconcerning the pathophysiology of this condition in lizards. Wilbur is the10:15 a.m."work-in." Diane is soon busy preparing for anotherX-ray.

11:15 a.m.

Jennie, the receptionist, catches Doc between rooms and says that thelady with the dog in the third exam room is somewhat upset. She has beenin the exam room for 45 minutes and needs to get to a soccer game at 11:30.

Just then Diane shows Henry the long list of prescriptions that Betsywould like filled before she leaves today. Diane also says she needs him to order that special cat food for her sister's cat in Milwaukee.

Henry notices that his body is talking to him again. Once more he realizesthat he is getting that subtle message from his coronary arteries.

Multiple animal syndrome

No pediatrician in his or her right mind would book four children withmultiple problems into a 15-minute examination slot. Yet veterinarians everyday and every hour are faced with this very situation. The problem is oneof focus. Juggling with too many balls leads to only one thing-a veterinarian"dropping the ball."

Some of the consequences:

* Incomplete examinations.

* Insufficient and sloppy record keeping.

* Inadequate patient planning. and case management.

* Overlooked charges.

* Overlooked and under-treated problems.

* Higher risk of pharmaceutical and biological mistakes and mix-ups.

* Veterinary care appears disorganized to the client.

Etiology

For many clients it is natural that they are going to want to cram asmuch veterinary care into one visit as possible.

This is obvious since bringing animals to the vet can be time consumingand problematic at best. Unfortunately, it leads to a bad situation allaround for the pet, the doctor and the staff.

Veterinary hospitals have become part urgent care facilities, part full-servicepharmacy and part pet grocery store. We seem to have embraced this philosophyof practice without reacting to its consequences. While most professionsare procedure-oriented and book patients months in advance, veterinary hospitals,even with strict appointment policies, take in a large percentage of patientson the day the client requests service.

Some of this is because in most areas of the country the clients havea number of readily available choices. In other words, it is a buyer's market.

Veterinarians and the staff who work for them are generally very agreeablepeople and want to please and serve the public. In other words, we wantto be liked and avoid conflict whenever possible. Therefore we have shortmemories when it comes to problems inherent with managing the patient flowin the exam room.

Taking back the exam room

Dividing the patients

When a client requests a visit, the front desk should always pull andexamine both the physical patient record and the computer record.

It can be overwhelming to supervise a family of pets that is in the doubledigits. Organizing a chart with more than four or five pets is demandingfor a veterinary hospital. Add to that the additional reports and lab resultsthat accompany the record and it can become daunting.

The physical record: if you are still using small cardboard records foreach client or patient you should consider the larger 8x11 folders. Theseallow you to put all the pertinent records and laboratory and referral sheetsin one place. The 8x11 progress notes allow for much better organizationof information.

Clients with many pets should have multiple charts, otherwise there willbe chart chaos. It helps to give a pet with many problems a chart by themselves.

Dividing the time

Your patients deserve your undivided attention. Whenever possible yourfront desk should try to encourage individual appointments for each patient.When a client asks about bringing another animal, try first to make a separateappointment for that pet. If the client insists, limit it to only one morepet for the sake of the pet.

There are only so many 'irons' that can be in the fire. Clients who insiston multiple animals per visit should be given the first appointment of themorning (never on Saturday) and told that they may have to leave the petsfor the day in order for the doctor to complete all the procedures. Theseclients must leave a full checklist of requested services.

As a veterinarian, it is wise to make additional procedural appointmentsover a period of time. Dentists make a living dividing visits per tooth-sometimesover many months.

Animal doctors haven't learned this valuable lesson. Veterinarians oftentry to do X-rays, dentals, vaccinations and full workup all within a 15minute examination-sometimes on several pets. Patients with acute illnessshould be hospitalized. Trying to address acute illness dictates a goodhistory and examination and hospitalization. Trying to hybridize an officecall with a makeshift semi-hospitalization using a 45-minute treatment sessionfor a sick pet and then out-the-door with antibiotics is poor medicine atbest.

Stretching the twine

We can see that Dr. Hammond is reacting to a client's requests in a knee-jerkfashion and has created an environment that he cannot control.

Control begins with the front desk. Although not often possible, it helpsto have a seasoned veteran in the front to try to evaluate client motivesand help direct traffic. Sometimes the practice of veterinary medicine islike a large ball of twine presented all at once.

In 15 minutes we can investigate this ball of twine superficially butthere is no time to unwind and fully investigate it. Our goal is to 'stretchthe twine' of procedures into sections that can be addressed in an organizedway. This will mean dividing patient problems into 'treatment units' overa period of time without losing track of the whole patient.

Stretching out the procedural twine should occur in two ways-immediatehospitalization for acute situations and planning for future procedure appointments.

Immediate hospitalization: Much time and staff efficiency is lost tryingto do too much in the exam room to the patient.

If a situation cannot be easily managed within your normal allotted timeslot, it should be kept in the clinic to properly workup and manage thecase. This allows for maximum efficiency of the staff and doctor. It alsoallows the doctor to concentrate on the management of medical and surgicalmatters. Once the case is properly managed the patient can be released.The explanations and 'what-ifs' can now more easily be assessed. This willbe much more straightforward to the client. Many clients need reassurancesbefore they will agree to a hospital release of their pet-especially newclients. Nonetheless, it is the patients' and hospital's best interest forthe veterinarian to focus on the patient and then on client understanding.

Future procedure appointments: This can be thought of as staging. Themost common example presented to veterinarians is the issue of a dog presentedfor vaccinations that has some form of active allergy. Although vaccinatinga dog and pumping it full of steroids may or may not present a danger tothe pet, it certainly cannot be considered good medical practice.

Delay the least necessary items (the vaccines) and use them as a carrotto bring the animal back to assess the response to steroids. Although someveterinarians feel they must do everything now or risk losing the incomefrom procedures if the client has a change of mind, this is rarely the case.Radiology and elective surgeries, for instance, should be scheduled as futureappointments.

Are you an exam room cowboy or cowgirl? Do you need to complete yourpatients' needs in one big wad of monumental effort? If you are, you arewasting everybody's time and money-especially your own.