Roll with the punches

Editors' note: Over the course of a year, Dr. Philip VanVranken, a 33-year veteran of veterinary medicine and owner of Dickman Road Veterinary Clinic in Battle Creek, Mich., acted as a mentor to recent graduate Dr. W. Andrew Rollo, an associate at Gibraltar Veterinary Hospital, a five-doctor, small animal practice in Gibraltar, Mich. The two doctors exchanged regular e-mails discussing pressing industry issues from new grads' biggest worries to living a balanced life. This is the third of four articles that share portions of their conversations.

Learning to anticipate and react to painful blows can take the edge off that uppercut and help you keep your balance in practice. And you know you need to hold it together on that day when you euthanize three pets—and stay collected when clients can't afford or won't pay for the care their pets need. That's part of your job. But it's not easy. Our mentor, Dr. Philip VanVranken, and recent graduate, Dr. W. Andrew Rollo, talk about the challenges and share their insights and strategies.

Dealing with death

Dr. VanVranken:Have you had the "Angel of Death Day" yet? Here's how it starts: You drive to work on a nice sunny day, and walk in the door, and hospital team members tell you that your acute pancreatitis and parvo cases (both of which were doing much better) died during the night.

5 points of enlightenment

You hurriedly call the owners and give them the bad news. Both clients take it badly, and you spend at least 20 minutes on the phone with each person. That puts you behind right away.

You see two new kittens during your first appointment. And 15 minutes later you're informing the owner that both tested positive for feline leukemia. Your day goes on and on like this.

Dr. Rollo: Some days I have to euthanize multiple animals. Most are on their last legs, which makes the situation easier. However, I can't say that I've had the "Angel of Death Day" yet.

During one two-week stretch, I didn't euthanize any animals. When I finally had to, I opened the controlled substances book to record the euthanasia solution I'd use, and I noticed the whole page was filled with a young colleague's initials. For the past two weeks she'd performed all the euthanasias—three to four a day, everyday.

I felt bad that she got stuck with so many bum cases, but I guess it was her turn to draw the short straw. I'm sure my turn will come.

Dr. VanVranken: I once had a full-of-bad-news day that ended with a toenail trim on a 10-year-old, fractious dog. Forty-five minutes later, the client returned with a pale dog. Further examination revealed it had suffered a ruptured splenic tumor. The tumor imploded with the activity surrounding the toenail trim. Now that's a bad day when toenail trims end lives.

Here's the deal: These days happen to all of us. Once in a while, one of the other doctors here will walk around muttering, "Just call me Dr. Death." Look to your colleagues for support; they've been through this. Your next day will likely be better.

Dr. Rollo: When I euthanize an animal, I say a prayer under my breath. I came up with the prayer when we put my childhood dog to sleep. I say it quietly so that I don't offend my clients—that moment is about them and their grief. But I need to feel that I'm sending a sick animal on to a better place. I don't like euthanasia, but with a prayer in mind, I find the process easier to accept.

When I first began working, we would let a pet owner sign the necessary paperwork and leave the pet for euthanasia. I hated coming to work and learning I'd need to put some random cat to sleep.

One day I'd never seen the cat in question before, and it looked healthy. Luckily the owner left her number on the paperwork. I felt obliged to call, and I learned that the cat was urinating outside the litter box. Of course, it could be a behavioral problem. However, the cat hadn't undergone a urinalysis or any other diagnostics to look for an underlying medical reason. And no one talked to the owner about behavior training options.

In the end, the owner approved the diagnostics and the cat went home. But the case was the last straw for me. At our doctor's meeting, I asked if we could meet with all pet owners to learn why they'd chosen to pursue euthanasia. And we changed our approach, which is great.

I try my best, but I can't save every animal. I still struggle to come to terms with that sometimes. But here's something interesting: I got more Christmas cards from clients that I couldn't help. So it's not whether I'm right that matters; it's that I care.

Dr. VanVranken:I applaud you for changing your euthanasia policy. I've seen clients present these patients at least 100 different ways—from extremely emotional to completely apathetic and everything in between. There's no one way to handle it, because each incidence is unique. Still, I've developed some rules of thumb:

1. Never argue with clients who've already made up their minds. They may be weighing more variables than they share with you. For example, they're moving, or the pet is soiling the house, or they want new carpet. You just never know.

2. Explain to clients that cats and dogs seldom die in their sleep. (Clients pray that will happen.) I explain that humans die from strokes and heart attacks; but animals die from organ failure, which can be a long, painful process. Humane euthanasia may be the kindest gift they ever give their pet.

3. Make sure you really do offer humane euthanasias. I've seen people struggle with cats for 20 minutes to place a catheter. In this case, the patient's last moments aren't particularly pleasant. We use our third feline exam room as a comfort room. We dim the lights, and the client sits in the chair with his or her feline friend while the cat gradually fades away. I sit on a stool on the other side of the exam table, fill out my controlled substance log and chat about the pet's life. Clients appreciate the chance to cradle their cats as they pass. We let them spend as much time as they need to say goodbye to their friend.

4. Act as your client's funeral director. Carry the pet to his or her car, and offer cremation options. Make certain you handle every step with dignity. If we perform an individual cremation at our clinic, we offer clients a brochure that features containers they may purchase—and we place the order, if they wish. When the ashes and urn arrive at our clinic, we place the remains in the vessel—don't expect the client to do it. Send a sympathy card to every client who loses a pet; or, for the very best clients, send a terrarium or flower arrangement in memory of the pet.

Euthanasia is tough; I'm guessing your skill at handling these situations will grow with time. I've stood on both sides of the table; most of us have. It's never easy.

When money is an issue

Dr. Rollo: The worst thing about my job is when money interferes with medicine. This certainly happens every day; owners either don't have the money or don't want to spend it.

I beg owners to let me run one diagnostic test at a time, hoping I'll get lucky and find the answer. I intentionally don't learn the price of any procedure; I don't want the owner to feel that I'm financially driven. I don't envy MDs with their constant fear of litigation, but I'd love to have just one day where every client simply says, "Whatever you say, Doc."

Minimize the stress of euthanasia

Dr. VanVranken: Money certainly interferes with how we approach cases—but hey, that's the challenge. And while it can be difficult to match the medical condition with the right checkbook, if you give clients your "A" effort, you'll keep getting those Christmas cards.

Personally, I really hate to hear veterinarians say, "If they won't do every test or procedure I want, I send them on their way." In other words, if you're wealthy, I'm your doctor; otherwise, hit the road.

Last year, I heard a speaker discuss how she serves only "A" clients. I find it almost elitist. Of course, she can run her practice as she sees fit. But when I got home, I checked the AVMA Directory and found she was educated in a state-supported university. In other words, everyone in her community paid taxes that helped support her education. I think doctors should keep that in mind when dealing with the public.

Here's a little hint: Hospitalize patients that may require expensive treatment overnight—at no charge if you have to. Let the client spend a night without his or her pet. It puts a completely different angle on their plight. They may decide that Sampson is better company than Thomas Jefferson and Ben Franklin.

Pro bono work

Dr. Rollo: Often we can help an animal but owners can't pay for the care. We want to help every animal, but all that care comes from the practice owner's pocket. Where do you draw the line?

Dr. VanVranken:We used to do some free work for the disadvantaged, and it seemed to snowball. Everyone had a hard-luck story, and we got a reputation as an easy mark.

Dr. Philip VanVranken

The first thing we did to correct this was to give the receptionists some guidelines. Then we empowered them to handle everything financial and took some doctors out of the loop. When the doctors made these decisions, we remembered our veterinary oath and made choices that weren't good for the financial stability of the clinic. Our receptionists make more objective decisions.

Next, we decided to offer a "Good Samaritan" discount to clients who presented strays or injured animals that weren't their own. That left the community with the understanding that we're not a charity clinic, but that we truly care about animal welfare.

We always take care of long-time clients, no matter what their financial status is on a particular day. Usually this involves signed promissory notes. At Dickman Road Veterinary Clinic, we extend the privilege of charging to some clients. Abuse it, and you lose it.

Dr. Rollo: We have some dogs and cats up for adoption at our hospital. We fund their stay and veterinary care strictly through donations.

We recently had a beagle puppy with such a bad case of coccidiosis she nearly died. After a week of hospitalization, we were able to bring her back to health. However, we ate the cost.

It was definitely worth it when I saw her going home with a wagging tail. But she's an exception to the rule—there are just too many that need help.

Dr. W. Andrew Rollo

Editors' note: What strategies does your team use to handle euthanasia, financially challenged clients, or pro bono work? Post and share your thoughts with your colleagues under this article at www.vetecon.com.

The bottom line

Three tough things in practice: euthanasias, clients who refuse to pay for care that could save pets, and managing pro bono work. Tips to help:

1. Ask your team how they prefer to handle these issues and why.

2. Try to find a better option. Could you refine your team's approach?

3. Discuss solutions with your co-workers and employer. Never stop looking for the solution that will help pets the most without violating your personal and professional ethics or damaging the practice.