The writing on the wall

Talk is cheap because supply exceeds demand

~Author Unknown

Mirror Lake Animal Hospital: 8:45 a.m.

Dr. Kenny Long mulled over the chart long and hard. More study time passed. He scratched his head.

"What is this chicken scatchin' here that Jenny Adams wrote down on the O'Henry chart?" he questioned in a resonant baritone that leaked into adjacent rooms.

Anne Britton heard his plea from the other side of the hospital and came to the rescue. She started talking to Dr. Long from the storage area and broadcast her words over the heads of several staff members that were shuffling back and forth between exam rooms.

"The O'Henry's brought Sam in last night after you left for the day," Anne exclaimed in a loud voice over the baying din of an insistent Beagle hound in Anne's vicinity.

"What? Say what?" Kenny asked as he looked up in the general direction of an admixture of baying and human voicings.

Her words trailed off into a decrescendo as she neared the area where Dr. Long stood. She repeated herself.

"The O'Henry's brought Sam in last night and Dr. Adams wanted you to look at him this morning."

"I really can't see what she wants me to do. It seems she examined him and found a mild fever and gave him an injection of an antibiotic. There is a lot of scribbling here I don't understand that doesn't seem to relate," Ken intoned.

"She was talking last night about blood tests and X-rays and maybe sending out a culture. Our blood machine was down for cleaning last night, I think, and I really don't know why she didn't do the X-ray last night."

There was a pregnant pause. Dr. Jenny Adams had left on vacation early this morning.

Anne cleared her throat.

"Carol says that Mrs. O'Henry wants you to call her when you are done with whatever you are supposed to be doing with Sam."

"Did you or Carol get a phone number?" he asked dryly.

"I am not sure. I didn't take the call." Anne quickly puckered her lips and moved her eyes like an old Grandfather clock. The ploy didn't seem to lighten the atmosphere for Dr. Long, so she sighed and quickly moved to a phantom task a few feet away. She peeked again at Dr. Long and found him drawing a very large breath.

Just then, Brittany, a short, yet wiry, technician, called from an exam room regaling Dr. Long to appear front and center for the next client. Dr. Long slumped a bit, then stiffened and pulled at his tie—another large toke of atmosphere was drawn. Then, Kenny had one last perusal of the O'Henry chart looking for a current phone number. He found three places on the chart where the phone number had been crossed out. He tossed the chart in the general direction of Anne and proceeded to the exam room.

Cheryl and Barry Franklin sat expectantly in the corner. Felix a weather-beaten feline with one eye and about six remaining teeth was hiding under the sink. Cheryl and Barry offered no assistance as Kenny fished the oily cat from the corner.

"Felix was double ugly but friendly enough—at least he had been according the last chart entry inserted by Dr. Charles Boone about eight years ago. The ink on the previous visit was beginning to fade. Dr. Boone no longer worked at Mirror Lake Animal Hospital.

On this visit, Felix was obviously very ill. A notation on the chart stated that this cat was diagnosed as FIV positive at the last visit.

A quick examination of the south end revealed that Felix had never been altered. This was likely the only healthy territory remaining. Felix' ears were smeared with dirt and were a sick yellow that most veterinarians could identify in a dimly lit room with their eyes nearly closed. An oral examination revealed a carbon copy hue on the hard palate. Felix's cheeks and head were battle thickened and full of scar tissue.

"Your pet is very sick," he said, stating the obvious for a starting point.

"Did Dr. Boone mention that Felix should be neutered and kept indoors to reduce the chance of the spread of the FIV virus? Did he talk to you about the consequences of territorial fighting and the consequences of this disease in the end?

No response.

Dr. Long's mind was running a mile per minute and the room disappeared. "This pet is sick—is this the time to go into the epidemiological issues? Can they understand any of this at this point? After all, this cat has lived eight more years and is alive in spite of the life this cat has been living."

"Can you do anything for him Doc?"

The response leaked into Kenny's brain—the trite phrase brought him back from dreamland.

A checklist suddenly appeared in Dr. Long's head, and he started a long permutation of possible scenarios for the client. Blood tests, X-rays, biopsies, ultrasounds and cultures suddenly danced in the air like so many lollipops. Dr. Long was proud of his reasoned approach. He then started to reach in his pocket for a pen and some paper.

A throat cleared.

"Can you just give him a shot, Doc?"

The second hackneyed salvo jerked Kenny to reality. What followed was predictable. The client would either dissect each move that Kenny made based on dollars or the client would be mostly unresponsive. Either way, when the client was safely out of the exam room, he likely was going to blast the receptionist concerning a variety of infractions and indignations heaped upon their poor animal and themselves.

Kenny rested on the back wall of the exam room and sweat dripped from his left ear. He was hoping to disappear into the surroundings.

Carol rushed to the back swinging her head back and forth looking for Dr. Long.

Anne became a statue—she looked at Carol and moved her eyes slowly and imperceptibly in the direction of Kenny not wanting to reveal her treachery to the boss.

"There you are!"

"Dr. Long, Agnes O'Henry was on the phone and she wanted to know when she could pick Sam up and how much it costs. You were in the exam room and..."

Carol stopped and mimicked the Cheshire Cat.

"She's up front right now."

Communication breakdown

The variety of interactions and communication needs within a veterinary hospital seem to be endless. Breakdowns often occur and create havoc and inefficiencies that seem to snowball as the day unfolds. Dr. Long is the victim of yesterday's overheated end of the day frenzy to finish and leave. In this case, a veterinarian who obviously needs to leave on vacation asks others (sometimes a chain of people) within the work environment to communicate needed details of patient care.

Two things are certain:

• The client assumes that perfect communication is going within the hospital.

• Details become fuzzy in direct proportion to the number of people communicating via the grapevine.

The rule here is to write direct and legible notes to the person that will be responsible for your request—in our case continuing veterinary care. This takes effort but saves an enormous amount of time and grief in the long run.

Notes can occur within the record but many times these notes need to be typed into a logical and systematic plan of action, then attached to the chart. If a particular staff member will be working the next day, they should be included in the communication loop for good measure. This person is a compass pointing the doctor in the right direction.

The great unknown, and a lot of blank space

When doctors and staff leave, they take their memories (flawed though they are) with them. Dr. Long inherited a client situation that has lain dormant for eight years—the doctor of record is long gone and had written precious little into the record. The statute of limitations has expired—but not the patient. Felix has lived this period with no veterinary care in spite of a serious disease. These situations can be humbling to veterinarians steeped in the tradition that clients need to take action or there will be heck to pay for the patient.

But the reality is that veterinarians are confronted with clients who darken our doors only under the most dire of circumstances. In our case, what is missing are notations from the previous doctor concerning client attitudes and recommendations made to and declined by the owner.

If nothing is written, a client can make the case that they were never told about the consequences of inaction. They often do, and egg appears on our faces.

We can be a sloppy bunch. Over and over again what appear on veterinary records are abbreviated histories and an array of treatments without clarifications and any real plans of action. Veterinarians can get pretty slipshod when time is short.

Consequently, there is a lot of blank space in a lot of veterinary records across the country. In addition to abysmal communications, this is also simply poor veterinary medicine. Quality care includes great workups, treatment plans and patient management—not just diagnosis and treatment.

A client has no defense against a well-written set of recommendations that document real conversations and client responses. Again this takes effort but will pay dividends, especially for the patient. After all, it is about the patient.

Bottom line: the real upshot of clear record-keeping and communication is a smoother running veterinary hospital.

The written word

Over time very little lasts, except the written word. Buildings, reputations, businesses and even civilizations finally crumble. But the written word—be it Homers' Iliad or the sacred texts of the Bible, persist.

The old saw: "Get it in writing" is sound advice. Veterinary medicine is certainly not immune to this maxim. Unfortunately, a lot of communication materializes as an invisible vapor before us and most of it is forgotten or transmuted in our minds into something the originator did not intend or even say. If this is the case, why aren't we writing all the time? Good point.

Veterinary school ruined my penmanship. I am sure a lot of veterinarians are like me — in a hurry and just don't take the time to communicate properly in writing. I have found that these things help out a lot whether using paper charts or the computer:

• Print instead of writing on the chart. It improves legibility.

• Writing smaller letters increases speed and legibility.

Typing notes to other veterinarians and staff members into the notes section of the computer or typing a note in a word processor.

Typing treatment plans to clients that can be printed and sent home. These notes then can also be cut and pasted back into the computer history, creating both backup and an improved paper trail.

A communication center

Every hospital needs a communication center where scores of little notes and requests can appear before the noses of every working staff member. This, by necessity, needs to be in the middle of the hospital. Nothing fancy here: Post it™ notes and scraps of paper will do. The notes just have to be at eye level. Find a logical place and have all the staff put all the "pig-tail" information that develops into this area. Our communication center is on the bottom ledge of the injectable shelves in the treatment area. I call this the "writing on the wall".

Creating a communication center will also have a major side benefit. Staff will no longer wait in line to speak to the doctor who will likely look at them and perceive only a fraction of what is being said after the staffer walks away.

Bottom line: Write it down and post it where other staff have to see it and go back to your other interrupted tasks.

Are you a good communicator?

If you are spending a lot of time chasing your tail on busy days, you are likely inadvertently participating in broken communication networks that amplify stress in the workplace.

Write it down, take a deep breath, smile and begin to enjoy the day. You deserve it.

"Language is by its very nature a communal thing; that is, it expresses never the exact thing but a compromise — that which is common to you, me and everybody.

-Thomas Earnest Hulme, Speculations, 1923

David Lane is a graduate of the University of Illinois. He owns and manages two practices in southern Illinois. Dr. Lane completed a master's degree in agricultural economics in 1996. He is a speaker and author of numerous practice management articles. Dr. Lane also offers a broad range of consulting services and can be reached at david.lane@mchsi.com.