Use of a Veterinary Clinic’s DEA account

Posted on September 26, 2016 by coverlandfarms

One of the scariest areas of compliance for veterinarians is use of either their or the clinic’s DEA license. There are very few things that can lead to incarceration at a vet clinic. Falling afoul of the Controlled Substance Act is one of them I get the most questions on. Can a veterinarian, with a proper VCP relationship, prescribe a controlled substance that is filled under the clinic’s DEA account, or do I have to have my own license? That’s the question that I was asked at a recent LEAP event in Macon, Georgia.

Off to the source material!  The Practicioner’s Manual, on the DEA’s website, along with the actual controlled substance act, are good places to start. https://www.deadiversion.usdoj.gov/pubs/manuals/pract/pract_manual012508.pdf

The answer, it appears, is that yes, you can use your clinic’s DEA license, if it’s part of the licensed, professional practice of veterinary medicine in Georgia and at that Clinic. You have to track the usage with a very specific record keeping system, and there’s a few other administrative requirements.  Page 16 of the manual has some pretty clear instruction. I copied some of it below for your reference.
“Practitioner’s Use of a Hospital’s DEA Registration Number
Practitioners (e.g., intern, resident, staff physician, mid-level practitioner) who are agents or employees of a hospital or other institution may, when acting in the usual course of business or employment, administer, dispense, or prescribe controlled substances under the registration of the hospital or other institution in which they are employed, provided that:
1.The dispensing, administering, or prescribing is in the usual course of
professional practice
2. Practitioners are authorized to do so by the state in which they practice
3.The hospital or institution has verified that the practitioner is permitted to
dispense, administer or prescribe controlled substances within the state
4.The practitioner acts only within the scope of employment in the hospital or
institution
5.The hospital or institution authorizes the practitioner to dispense or prescribe
under its registration and assigns a specific internal code number for each
practitioner so authorized.”

 

Hopefully this answers the question. Let’s continue to get better together!

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Great LEAP Training Experience in Macon, GA

Posted on September 26, 2016 by coverlandfarms

Yesterday I had a pretty amazing experience providing LEAP training in Macon, Georgia. People showed up 20 -30 minutes early. They had engaging questions. And they were concerned about both their patients and doing their best to comply with the veterinary practice act. I’m so glad I was provided the opportunity to speak and learn from and with them.  Over the next couple weeks, I’m going to post answers to some of their most compelling questions. Questions like:

  1. Do I have to establish the vet-client-patient relationship in order to provide a vaccine?
  2. What type of exam might be required prior to giving a vaccine?
  3. How can a mobile practice be “available for follow-up?”
  4. Is leap training by book or remote learning allowed?
  5. Do I need to check change of ownership documents if a new person brings in a pet that in the records has a different owner listed?

As always, there may have been some other questions they wanted to pose that they’ll send separately to me in a private message. Regardless, the level of engagement was fantastic. It’s one of the reasons I love providing continuing education in Macon.

Next on the speaking schedule is Columbus, GA.  I hope to see some of you there!

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Responding to On-Line Complaints (Part 2)

Posted on September 24, 2016 by coverlandfarms

Ok. I’ve got this deep, dark secret. Please don’t look away, I assure you most of us have this same secret, and it is safe for work. This secret is that I dream that I “win” by responding to on-line complaints. I boldly respond to an on-line complaint. I throw caution to the wind and unfurl the sails of courage. I relate my reasonable positions, refute lies and misstatements, and the on-line community vindicates our practice. Ah… they will throw laurels of ‘likes’ and ‘smileys’ because they’ll see how ridiculous and untrue the on-line complaint is. The poster apologizes and removes their offending opinions. Additional positive reviews will be driven by my madly successful approach. All is well in the land of five stars and 100% positive ratings.

Ok. Get real. That almost never happens. More often my responses  blow up with more negative comments, more people reading what was once a buried, mostly ignored review, and even more frustration for me. People love a good fight or heated argument, particularly if they can watch from the sidelines.

And let me tell you a little known truth… Veterinary practices are at a severe disadvantage in on-line discussions about clients and patients. Client confidentiality rules, public opinion, and a lack of information or interest in what goes on behind the scenes at a clinic, all conspire to tie our hands in responding.  Our vets could be disciplined or lose their veterinary license for social media missteps, even falling afoul of unprofessional conduct standards.

Yes, we can get in trouble for social media posts and review responses. There are reasons I don’t share information on the patient or procedure on-line. Some states, like Florida, New Jersey and California, have express confidentiality rules about disclosing patient/procedural information. Some  states are more vague and instead have truthfulness and non-deception standards, such as Georgia’s rule 700-8-1 (a) “A licensee or registrant shall not make any false, misleading or deceptive communication….”

Even the ethics on posting information from a patient record is questionable. The AVMA’s ethical code states “The information within veterinary medical records is confidential. It must not be released except as required or allowed by law, or by consent of the owner of the patient.”  This isn’t a universal standard, but there is one thing I do know… sharing a treatment record on a complaint forum is likely to get a whole bunch of pet owners bothered about their record confidentiality. So ethically, and in some states legally it I shouldn’t do it; and from a business perspective it’s likely to cause more harm than good to my clinic and the veterinary practice in general.

But in the event that you absolutely have to respond, particularly after you’ve failed to resolve it by communicating directly, there are some ways to do it that will reduce the chances that you risk your livelihood and business. Just set your expectations low and have a clear goal.

My goal when I respond is to convey that “our hospital heard the concern and tried to improve because of it.” That’s it. I don’t need to win the court of complaint forums, I just have to look like I care. The more someone posts, the more unhinged they look, even if it’s reasonable. Think about it, how many long public exchanges have you read in forums and complaint sites where you thought “wow, those people are both so reasonable, I’d love to have them spend time with me….” That’s not what I think. I generally think ‘these two people are idiots, take it somewhere else, please!”

And once I have a goal, I determine what I *can* share, and what I should share. The two are rarely the same. I’ll explain what I do, and when it’s a can vs. a should.

What we can say is very different than what we should say. Veterinary medicine is not pretty, it’s not perfect, but its needed and usually appreciated. I encourage our staff to respond by talking about how we care and are concerned for the pet. Then we talk about how saddened we are for their bad experience, what we are willing to do to help them, and how their feedback has helped us to become a better clinic.  This is just about all I recommend you should do.

I don’t share information on the patient or procedures. Some states, like Florida, New Jersey and California, have express confidentiality rules about disclosing patient/procedural information. Some are vague and merely have truthfulness and non-deception standards, such as Georgia’s rule 700-8-1 (a) “A licensee or registrant shall not make any false, misleading or deceptive communication….”  The AVMA’s ethical code states “The information within veterinary medical records is confidential. It must not be released except as required or allowed by law, or by consent of the owner of the patient.”  There isn’t a universal standard, but there is one thing I do know… sharing a treatment record on a complaint forum is likely to get a whole bunch of pet owners bothered about their record confidentiality. So ethically, and in some states legally it I shouldn’t do it; and it’s likely to cause more harm than good to my clinic.

Is there an obligation of Confidentiality once they post something? Yes and no. Generally they’ve made the information public. But if I dispute something as untrue, I am in effect providing additional confidential information to the public. For example, if they say our clinic didn’t x-ray the leg of their cat, then by my responding “that’s right, because we were treating for a blocked tom, not for leg issues…” it might feel satisfying, but I’ve breached client confidentiality rules.  The best thing to do is just let them know you don’t discuss patient treatment on public forums, but would be happy to discuss or provide a copy of the treatment records to the client. That’s all I need to say. A person reading that will at least know that we keep things confidential and have good records on the medicine we perform. It may bring less satisfaction that embarassing the client by exposing their falsehoods, but my goal isn’t to embarass former clients, it’s to manage our practice well and perform good medicine. And while that brings some lost opportunities, our clients can be comfortable in knowing that we won’t engage in negative public spats with any client.

I can share commercial details, ie..if the charges were the topic of the complaint, I can talk about that. Not about the related medical procedure, but about whether the charges were fair, accurate, or the same as for other clients. Ican even mention if we forgave or discounted some of the charges.

If communication was at issue, I can talk about the communication; I just avoid discussing any patient record related content. For example, I can discuss if I called them repeatedly, or if an employee was rude to them.  They are likely unhappy or grieving,  and you can discuss the feeling and perception they had, and show compassion for their loss. If it’s a smell or cleanliness, you can talk about your cleaning methods and what emergency came in that day that might have delayed it.

I should apologize and talk about what I’ll do better.  Even if it’s a complaint about the medical procedure. If they say my clinic botched a spay, I can respond that we’re happy to discuss the case, we are sorry for their poor experience/impression of our medical practices, and we have since directed our veterinarians to review the procedure, check on VIN, and research techniques to see if there is anything we can improve for spays in the future. Look, the answer is usually that we did it right. But we can improve, and perhaps with better follow-up and communication we’d find out why the owner thought it was botched.

Every once in a while, we really could do a better job with a procedure. Everyone can. We don’t have millions of dollars of diagnostic and surgical equipment, we don’t hire AVMA diplomats that specialize in each procedure. We don’t have all day to prep a single animal, evaluate, and then perform a single spay. While it’s possible to do that, the financial costs would be astronomical to attempt to achieve the ‘perfect spay.’

Mark Cuban once said “Perfection is the enemy of profitability.” We’d be out of business, and there would be no vets in the area, if the standard of care was perfection, rather than the standards of acceptable and prevailing veterinary medical practice. And keeping that in mind when I respond is important. I don’t have to be 100% right, I just have to recognize where I can improve and that it concerns me that the client didn’t feel they and their pet were better off after coming to our clinic.  If it’s really malpractice, then I should *really* apologize and be prepared to talk to the board, my staff, and my insurance broker.

So I can apologize, and frankly, given that damages are limited to the value of the animal at the time of the procedure, unless there is also a human injury, my admission is not likely to lead to thousands of dollars of potential liability. I don’t want to make this a fear issue, I want to make it a customer experience and clinic quality issue.

I can also truthfully talk about how I tried to resolve it directly. I can wish them well and even recommend some alternative veterinary hospitals. I can tell them you donated their fees to a local rescue foundation (normally better than advertising I refund fees). I can share, broadly, what was going on in the clinic. For example, we had one complaint that we were hurting a person/animal. We had a pot belly pig in treatment that was vocalizing in a way only pet pigs do during treatment. It did sound awful, but the pig was not being harmed in any way. That was easy to explain to the concerned person in the lobby, she even saw the happy, healthy pig leaving later that day.

And I should explain when the poor customer experience was tied to someone else’s critical need and positive experience. We had a puppy come in with maggots, needing immediate medical attention. While we can’t and you shouldn’t share medical details, there’s no doubt our lobby stank for a while afterwards. We explained that we had a very sick animal come in,  and that sickness was what the other clients smelled. That we had all hands on deck to help the animal, and thus we weren’t able to do a lobby cleaning until after the animal was taken care of. That  post generated more compassion, as every pet owner generally wants immediate care in an emergency. Our clients do not want to be told we will delay their urgent treatment until that awful smell in the lobby is cleaned with Odo-ban. And we did do a thorough cleaning later, and invited the client to come by and check it out.

I don’t ask them to remove their review. If they do, great, if they don’t, I’ve responded and that response has a positive value to our clinic’s reputation. Most negative posts have a short shelf life. Reviews from a couple years ago have little bearing on what we do now, and people who pay attention to reviews know that.

If the review is false, then I will file a complaint with the review site for a falsified review. We’ve gotten reviews removed when done by former employees, by reviewers who never received services, or the reviewer confused our clinic with another clinic.

And I only respond once. I can ask them to contact you if they’d like to discuss it more. Engaging in a hotly contested discussion is not in my businesses best interest.

Finally,  I decide when I no longer care about the review. For me, it’s six months, for you it may be two years. But at some point we need to be able to put that comment to bed and be at peace that I’ve gotten all the value I can from the feedback. And that means I have to stop composing my perfect response to a negative review while driving to work. I doubt anyone can avoid thinking, dwelling upon, turning over, and arguing internally, with every line of a negative review. It’s probably unhealthy to bury that response deep down in any event.  But the action I take can’t be driven by my feelings, or even by the incredible logic. It’s not about winning an on-line argument with a former customer, it’s about running a successful, constantly improving veterinary clinic. It’s about practicing good medicine on the pet family members of so many people. It’s about avoiding burning out with distracting negative situations. And it’s about becoming better together.

 

But rest assured, I still  secretly dream about that perfect blazing response that causes all our negative reviews to be replaced with positive ones…

 

 

 

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Responding to On-Line Complaints (Part 1)

Posted on September 13, 2016 by coverlandfarms

To start with, I don’t think anyone deserves to know my initial thoughts and responses to an on-line complaint. It’s not pretty. It’s not professional. It’s not classy. And it’s rarely safe for work.  But it would feel sooo satisfying to throw good judgement and respect for others to the wind. To just unload all the stress that has built up on a well deserving negative reviewer. But that would likely be disastrous for our reputation.

Let’s start with the self-evident facts. Every clinic and doctor will have negative reviews if they practice long enough. You can’t please everyone all the time. I don’t recommend that you aim for 100% positive reviews.  It’s likely to yield the opposite of what you intend or be an unattainable goal. Most people who see 100% positive reviews are leery that it’s faked, doctored or otherwise untrue. Even e-bay vendors that ship the same thing over and over again rarely get above 99% positive reviews, and they never even see the public face to face.

Not every review is going to be factually accurate or fair. People are grieving over fur family members; they have financial pressures and triggers that you don’t and shouldn’t know about. They are sensitive to smells, other client’s behaviors, impatient for delays (even if caused by emergencies), and often don’t understand some of the medical practices that are required for meeting the standard of care. When customers are unhappy, they are far more likely to post a review than if they are pleased or satisfied with our service.

So what to do?

I set a realistic target, and plan our practice towards it. Four stars or 80% is acceptable, 4.5 or 90% positive is the goal. I throw a virtual party when we get above that level.  And that all starts with my commitment to spend money, time, and training to ensure our staff are making people thrilled. It means that on average, everyone who walks through the door has a better experience than at past clinics, some have the best experience of their life, and we occasionally don’t live up to our standards and have to improve.

I make it a point to have our reception and management monitor our reviews. I have an independent service that sends a copy of all posted reviews to my e-mail.  I DO NOT have my associate doctors or supervising doctors monitor reviews, except in summary form.

Most of us take our work very seriously. Our vets want to provide the best medical care and client experience for everyone who walks in the door. And when our vets vet reads a negative review, they go into a funk. It’s almost like grieving their career choices.  They go through the stages of denial:

Anger- I didn’t do anything wrong! This review is unfair! They’re just crazy!

Depression- why do I do this? Why are my efforts to help unnoticed? Why can’t I just be appreciated?

and finally…Acceptance- ok, there might be something we can improve.

The managers and reception staff gather the facts regarding the client and complaint. I have our most experienced and best customer service team member call the client to understand their feedback. We do what we can to make that particular client’s experience better (or at least repair any damage we unwittingly caused). And that’s not easy.  It’s frustrating to spend time and money on something we’d prefer didn’t happen.

Only after we have a resolution or are at a clear impasse, do provide a summary and feedback for the vets and staff, at the end of a day. It gives all of us distance and time to see what we can glean for improvement.

We don’t ask a review to be removed unless it’s fake or damaging to others. It’s ok for clients to see them, to see how we handle and improve based on the reviews.  We have a review that complained about our large animal service. Good news! We improved by only being a small animal clinic! And we referred the client to a reputable large animal clinic nearby.

We try to see if there’s anything of value in a review. If they say: “it’s dirty”,”reception was rude”, “they did a terrible job and had to have another vet ‘fix’ it”,  or even “they just want money”, it hurts. But there has to be some reason they chose that complaint, rather than “terrible vet practice.” Finding out why they chose a particular thing to complain about is helpful.

When I was young, some kids would call me carrot top.  Why carrot top rather than four eyes, moron, or something else hurtful? It’s because my blazing red hair was the most obvious trait. If a client complains about your techs, congratulations! Whatever issues your reception had are not noticed, because your biggest obvious area for that client was your techs. There’s value in knowing what’s most obvious, even if there’s little wrong with it. What I’m suggesting is that vets look more at the why of a complaint first, rather than the ‘what.’

Our likely response is to gather our staff and go over the interactions. What was most noticeable? Could we have been rude? Was there a miscommunication we can avoid in the future? Do we need more Odoban in cleaning the lobby?  Did we offer options for charges and care?  Did we follow-up?  Even if our behavior is perfect, understanding why a client chose a particular thing to complain about can be helpful.

I’m not saying that every complaint has to be addressed. We’d drive ourselves crazy fixing everything. We’d also go broke, because the perfect experience is costly, and our clients won’t pay for latte machines, vets on standby for them, and free childcare facilities during visits. Make no mistake, you need to closely watch how much you spend on client experience above the goals you’ve set.

I am recommending that you should choose the level of feedback you feel comfortable with and work to ensure that you customer experience matches that. You should budget and track the time and money you spend on improving client experiences as well.

And when you feel depressed by negative feedback, reflect on your last emergency room visits. No matter how good an emergency room staff and management are, they will get negative feedback on a constant basis. That’s likely because the combination of stress, lack of knowledge, and urgency create an environment where negative feedback and opinions breed. God bless emergency clinic veterinarians for what they deal with each night and weekend.

If you want some additional advice, I recommend”Thanks for the Feedback” by Douglas Stone and Sheila Heen. This book greatly improved my ability to give and receive feedback with others. I am still pretty horrible at it, but at least a couple days afterwards  I am able to focus on what was of value in on-line reviews and other potentially poor ways to communicate valuable feedback. Here’s the link if you’re interested. Thanks for the Feedback.

My next post will be on how and when to respond directly to an on-line complaint. I’ll also cover what you are legally allowed to put in that post. Client Confidentiality rules will be explained in scary, but simple detail.

And now, I need to cool down from our clinic’s last review.

Until next time, let’s get better together.

 

 

 

 

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Using Text Messaging as part of your Veterinary Practice

Posted on September 2, 2016 by coverlandfarms

Let’s face it, if you’re under 40 in mind, spirit, or body,  you probably dread voicemail and calls. I’d rather just get a quick text and read it when I feel I have a spare moment. Voicemail has become so exhausting that my current voicemail message starts with “I don’t accept voicemail unless you are a family member, medical provider, or law enforcement…please text me instead.” I admit it’s gotten mixed reviews.  But text messaging is a part of our society right now, and veterinarians should use it appropriately while understanding legal requirements around it.  I’ll go through the legal hows below, and then let you know how we’re using texting at our clinic.

The AVMA model Veterinary Practice act has several sections, including patient confidentiality in Section 19 that expressly mention electronic authorization or waiver.        ( https://www.avma.org/KB/Policies/Pages/Model-Veterinary-Practice-Act.aspx ). The Georgia Veterinary Practice Act has similar references to electronic records and consents in several places.  It’s a sound position that an e-mail, text, or (gasp) fax, can act as client consent. Technically, a voicemail is an electronic storage of a voice, and is also an electronic consent.  Further bolstering  this is the now venerable Electronic Signatures and Records in Commerce Act of 2000, signed into law by President Clinton, that allows electronic signatures and records to have the same status as in person or paper records. Almost every state has an a version of this in addition to the federal law.

That was all very wordy, but what it means is that vet practices can accept consent for procedures, payments, boarding, and other routine communication with an electronic, rather than paper trail.  It also means that you can use texts as part of your patient and client records.  Many texting applications allow you to “capture” a set of texting, and then send it as an image to another person. This is a good way to capture client consent and put it as an attachment in your record(s). Some practices just put a line in the record that says “texted on x day, client consented, [client consent quote].”  You’ll have to determine the right amount of detail. For our clinic I recommend you at least capture the question and the consent.

There are a lot of solutions out there. Google Voice, 2SMS, AT&T Business texting, Line2, etc….  You can also just ‘old school’ it and have a clinic cellphone or tablet with a separate number. We use Google Voice, because it can be accessed by reception and the back. It also allows our managers to see it off site, and to look through records of past texts. Most products have this same functionality, this isn’t an endorsement as much as letting you know what we use. I will say that Google makes theirs easy enough that our reception learned it quickly.

But just because something is legal, doesn’t mean it is appropriate to do. It’s legal to sing my conversations to everyone using only Adelle lyrics. It probably would destroy most of my personal and professional relationships. And by extension, it’s not the best idea to use texting in all situations. Your professional and business judgement should be used here.

Some of the things we use texting for:

  • Setting up meetings with Employees
  • Supply requests
  • Notifying a client that the patient has successfully come out of surgery
  • Notifying a client that they have an appointment the next day
  • Notifying a client that their pet is available for pickup from boarding (or dry from a bath)
  • Notifying a client that their dog food/prescription/supplies have come in
  • Notifying a client of a billing issue
  • Asking for consent for something already discussed
  • Asking them to call for an unexpected complication
  • Finding available times for an appointment
  • Notifying an offsite doctor a client has come in and wants to see them.
  • Letting a referring doctor know the outcome of a procedure.

This isn’t a complete list by any means, but the consistent theme is that we aren’t discussing new items by text, only things we have already covered in person. This really limits confusion or frustration.

Make certain you have clear written guidelines on how to use the text line in your clinic. It should include who can text, when you text, and what things you text about.  I’d recommend that your reception or clinic manager review the texts each day to make certain you are communicating in a way that is positive and helpful for your clients and clinic. I don’t think reviewing every text before it is sent is helpful, assuming you have competent staff that you trust. Just keep some monitoring to adjust messaging and tone as you develop a texting presence.

Some clinics  post their text numbers on their websites and advertising. I’m not a fan of this, primarily because a lot of time is wasted on price comparison. Texting is easily misread, so using it to resolve conflict or as a feedback line has lead to some ugly, public disputes with vet clinics. Some owners abuse the texting to try to get a consultation or information without seeing a vet, which is not good for the patient or the public. (See my blog on physical exams- There’s no relief from physical exams.)

My bit of advice is that everything you text can  and probably will be copied and posted on blogs, forums, social media, or reviews. You have little to no rights of confidentiality in these texts. So anything sensitive, or that could be misinterpreted, is likely to cause you and your clinic untold concern. It may even give the veterinary community as a whole a bad name. And it will likely live on for years after the event, even if it’s just a misunderstanding.

Texting can have a lot of positive commercial and customer satisfaction benefits for your clinic if used appropriately. You just need to decide how you want to use it, and make sure your staff understands the boundaries.

 

 

 

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When does a vet need to perform a physical exam? What if another vet in my practice already performed an exam?

Posted on August 28, 2016 by coverlandfarms

It’s a common question I get at Law and Ethics education seminars, from small animal vets.  The idea that one veterinarian can rely upon another vet’s exam in order to create the veterinary – owner- patient relationship. Normally it’s phrased like “If my relief vet sees a patient while I am gone, can’t I look at the notes and then prescribe a medication?” or “If one doctor does an exam, and then I look at the labs, why can’t I provide a diagnosis to the client?” And I get the underlying concern, that we all want to leverage the multi-doctor practice advantage, or use the relief vet to the fullest. And many vets don’t want to ask a client to come back into the same practice again, since they’ve already seen a different veterinarian recently.  But waiving the requirement to establish a vet-owner-patient relationship through physical exam of the patient…it’s just not a good idea.

In Georgia, the Veterinary Medical Board thought this item was so important, they updated the practice act to clarify what’s needed to practice medicine on a patient.

In 700-8 -01, of the Georgia Code,  in relevant portions states  “An appropriate veterinarian/client/patient relationship will exist when…the veterinarian is personally acquainted with the keeping and care of the animal(s) by virtue of an examination of the animal by the veterinarian within the last twelve (12) months….A veterinarian/client/patient relationship cannot be established solely by telephone, computer or other electronic means.

(Now before I continue, I should not that there is an exception for herd/food animals.  I’m not going to talk about that here though. This blog is related primarily to our typical small animal vet.)

Basically, you have to have seen the animal in the last twelve months to perform veterinary medicine for that patient. And some veterinarians seem to blow this out of proportion, that it somehow defeats the whole purpose of using a relief vet or of establishing a multi-vet practice.

The key here is to focus on what you can and should do.  If you’ve seen the animal before, in the last 12 months, then if a relief vet covers for that existing owner and patient for the weekend, performing an exam,  you still have an independent vet/owner/patient relationship. Just because another vet looked at the animal, it doesn’t remove your relationship unless the client no longer agrees to follow your direction for the care of the animal. So in this case, we’d look at the records, recall what we know of the animal, and proceed. The requirement for an exam is still once per 12 months. There were be circumstances when you’ll want a recheck or for the animal to come in, but the limit is 12 months.

This covers 80% of the cases in our clinic, and should for most other small animal veterinarians as well. But here are the more uncommon scenarios:

  1. It’s an existing owner/patient you haven’t seen in the last year.  If that’s the case, then make certain your associate, relief vet, reception, assistants… i.e. somebody, warns the client that if they only see the relief vet for an exam, they may have to come back in for an exam and recheck before another vet can see them. This is to establish the vet-owner-patient relationship, and to ensure that owners and patients get the best medicine, rather than just diagnosis by phone or reading.
  2. It’s a new client, that the other vets in the practice or only the relief vet has seen. In this case, the obligation is clear. Before a vet intervenes with a patient that another vet has taken the time to examine and treat, make certain you have established the vet-owner- patient relationship. An under most state veterinary practice acts, one element of establishing this relationship is the physical exam of the patient.

Look, I get that it’s a hassle, and that clients are unhappy at the prospect of what they see as a duplicate exam. But the practice of veterinary medicine is regulated in order to protect the public. And in most cases, the standards for the practice of veterinary medicine are there for a good reason.

I recall a telemedicine call with a human doctor when I had pain in my side, and they thought it might be kidney stones. The symptoms were all there. But when I came in, it turned out that I had shingles, and a simple physical exam confirmed it.  The exam provided additional information that helped provide a proper diagnosis. The number of times people have called in with incomplete or incorrect information about pet “emergencies” that we were able to correct with a physical exam are too numerous to count. Vets are the professionals, and generally have more experience and expertise to be able to correctly identify physical symptoms than pet owners.

This is better for everyone, including the owner, who may grumble about the time, hassle, and expense of another exam, but will file a complaint for malpractice in a heartbeat if you miss something because you didn’t do an exam. I have heard, more than once, the question from angry or grieving clients “why didn’t you (vet) see that?” Without the physical exam, or a knowledge of the animal from a physical exam in the past 12 months, you’ve got very little to defend yourself with.

But there is something that makes this a little easier, with proper planning and communication. And that’s the fact that one vet (at least) has established a vet-owner-patient relationship.

If the vet that saw the animal has left follow-up instructions, such as refills or contingent additional treatment instructions…. following those instructions does not create the need for a new vet-owner-patient relationship for another vet. And if something changes, you can call the vet with the relationship for additional guidance, if it’s appropriate for indirect supervision. Why? Because they, the first vet,  *still has* the vet-owner-patient relationship for another 11+ months after the exam. They can still practice appropriate veterinary medicine in relation to their patient.

For example, if Lydia is a relief vet, and prescribes an antibiotic for a dog at your clinic, with two refills set for the next two months.  The refill is still at the direction of the veterinarian that performed the exam, diagnosis, and has the vet-owner-patient relationship.  If the owner calls in for the refill, you don’t need another exam to fill that order. If Lydia also instructed that ‘if dog is painful, then the client can call in and we can provide an anti-inflammatory without a refill. ‘ Again, this is still Lydia, the vet with the existing relationship, and the rules are the same as you use.. ie.. appropriately  indirect supervision for treatment or care of the dog. The fact that a vet is performing indirect supervision while another vet is in the clinic is not material in this case.

But if something changes, or another vet exercises their professional judgement and provides care that requires their own vet-owner-patient relationship, then all bets are off. A physical exam is needed to create the appropriate relationship and authority to practice veterinary medicine on that animal.

So how do we make this easier for a clinic to operationalize?

  1. First, make sure your assistants, techs, receptionists, and vets, are all aware of the need for physical examination for treatment within the last 12 months by each vet to each patient.
  2. Second, make certain your clinic staff don’t confuse that need for a new exam with following the orders of a vet that already has that relationship.
  3. Third, make sure that they inform clients of the potential for another exam, and see if they want to schedule for a day before or after the relief period, or when a vet with the veterinary-owner-patient relationship is available.
  4. Fourth, work on an agreement, with all vets in a multi-vet practice, as well as relief vets, for how to deal with follow-ups to instructions and diagnosis of patients, where the vet on duty has not performed a physical exam in the last 12 months. Answer these basic questions:

Will you be available for follow-up when you are not at the clinic? What type of instructions are in the notes? Are there any contingent instructions? Did you state in the record when your instructions are no longer valid? Will you inform your clients that they may need a new exam with either a relief or an associate vet at your practice while you are not present? Do you have a general policy on your website on when you’ll ask for an exam?

And if you are an associate, make certain your clinic manager is aware when the requirements for physical exams are required as a part of establishing the vet-owner-patient relationship, in order to practice veterinary medicine in relation to that patient.

With proper communication, particularly by staff and the vet that has the relationship with the client, you can avoid a lot of the complaints and frustrations that clients traditionally experience with what they view as unnecessary extra exams and fees.

By explaining why it’s important for good medicine, and for proper diagnosis and treatment of the patient, you can also provide a better customer and patient experience.

And by doing the things above… you’ll also have included some better vet practices.

 
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Better Vet Practices

Posted on August 28, 2016 by coverlandfarms

Let’s get better together!

If you’re wondering who is writing this blog, but don’t really want to go all the way over to “About”, here’s the short bio that most CLE providers use for me –

Don Riddick is an attorney, practice owner, and former LVT. He’s published numerous articles on veterinary law, and is the former secretary of the Animal Law Section of the Georgia Bar.  Consulting with veterinarians in Georgia, Alabama, and Tennessee, he uses a practical and business focused approach to answering questions on compliance with legal requirements of the veterinary profession, client disputes, and business law. Don’s lighthearted examples from two decades in law and a decade running a practice help the time fly with easily remembered examples, like the 99% wolf/1% dog client, the possum-cat, and the chihuahua divorce. Don’s spare time is spent in the field with his two Italian Spinoni and providing meals for horse riding events.

All of that doesn’t mean my advice is any better or worse than it was before you knew these things. Take it at face value and make your own professional and business judgements. It’s what I do when reading blogs.

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Welcome to Better Vet Practices

Posted on August 28, 2016 by coverlandfarms

LETS GET BETTER TOGETHER.

We’ve all seen it, been a part of it, or even been in charge of it. A veterinary clinic that can’t operate without employee drama, customer complaints, or ever increasing loans. Maybe the clinic you are a part of has been limping along financially, rather than humming. Maybe you’ve gained a reputation for being money focused, for poor medicine, or even had a complaint to your veterinary state board. Whatever your problems, other clinics are also experiencing things that keep them up at night. Whether an associate worried about the practices of the clinic and their job or the practice owner trying to keep it all together, there’s plenty of worry to go around.

This blog isn’t a part of a business. I’m not here to sell you anything. Take, leave it, or discuss it with others. And hopefully you’ll recognize that what works today may not work when the market or regulations change in two years, or ten.

This blog isn’t about the practice of medicine, lord knows my short time as a LVT does not qualify me to comment on that. This blog is about the practices we make around veterinary medicine, whether they are economic, regulatory, ethical, managerial, or customer relations.  Because we all deserve better practices and our clients and patients need better practices in the future.

So welcome to Better Vet Practices, a blog about vet clinics and the way we treat our employees, business issues, customers, and patients. Let’s get better together!

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