Thomas E. Catanzaro, DVM, MHA, FACHE, Diplomate American College of Healthcare Executives
(expanding beyond traditional curative & preventive medicine paradigms)
Wellness is not an assumption; it is a dynamic and continual diagnostic quest!
Dr. Tom Cat, CEO, Veterinary Consulting International
The selection of this chapter title is not a new concept; the AVMA initiated the program in 2004 (in conjunction with FDAH sponsorship), taking the message direct to the client (www.npwm.com). Thanks to Dr. Jack Walthers, who was the President of the AVMA at that launch, I was selected to write and present the roll-out program for practices, using the concept of "one dog year is 5-7 people years, so your pet needs to see the veterinarian at least twice a year for life."
At the roll-out in 2004, clients were averaging 1.9 visits a year to their veterinarian, so it was not a big leap of faith. By 2007, the AVMA/FDAH initiative had changed the face of the profession, with clients averaging 3.3 visits a year for their pet. The need to take it direct to the client was clear, by 2007, only half of the American practices had subscribed to the free training kits being offered each year by AVMA/FDAH to support the initiative and the expanding annual message, which came in the following sequence:
Age Chart - one dog year is 5-7 people years
Awareness of Genetic Predispositions
Concerns about Zoonotic Diseases
Insights into Feline Behavior
Pets are at Risk
The Paradigms of Limitations
Without realizing it, most veterinarians have absorbed unknowingly a series of paradigms that came from the early day's production medicine, and that syndrome has been limiting the success of many companion animal practices. The new millennium found that Production Medicine had evolved to embracing herd health and charging for the time of the veterinarian, yet the habits of earlier production medicine were still found in companion animal medicine (ever ask yourself why is it that teaching hospitals still call it 'small animal' medicine and surgery?). Here are a few examples:
Production veterinarians assumed the herd was healthy, due to the producer's expertise and their livelihood depending on that fact. Companion animal owners do not have that expertise, yet "small animal" practitioners have always assumed wellness until a problem is fulminating, while concurrently telling clients animal can effectively mask the signs of disease. Someday we will realize that both cannot exist concurrently, and the sooner that is realized, the better!
Veterinarians only "recommended" care to producers, who had to weigh the economics of the animal product sales with the cost of veterinary care. The word for pediatricians and other healthcare professions has always been "need".
Production medicine was a linear pursuit, with veterinarians driving from farm to farm... it was institutionalized in the computer scheduling programs, and in hospital design. Dentists evolved to multiple dental hygiene staff chairs and about three restorative chairs per dentist, all scheduled concurrently.... physicians have 4 to 5 consult rooms being scheduled concurrently......the multi-tasking approach offered in the Veterinary Success Factor - Team-based Healthcare Delivery, is being copied by most consultants as the "new and improved way" to deliver companion animal medicine and surgery.....
The one-room-one-doctor pick-up truck ('ute' in Australia) paradigm was further entrenched in production habits by using two doors on the consult room, so the veterinarian could do it all - run them in, close both doors, treat the "smallie", open the door, release the client/patient to the front for collections Powder River, Let Them Buck! The physician has only one door to their consult room, because they learned long ago to allow staff to start each appointment, and close each appointment, allowing them to concurrently work multiple consult rooms.
Dentists learned thirty years ago that "less pain" was not a good way to get their patients to return, so they introduced teeth cleaning, using paraprofessional hygienists to extend their practice, bond their clients and expand their income production potential. Veterinarians are still fighting over what nurse/technicians can be allowed to do.
Production medicine was based on pennies per hundred weight, and it carried over to companion animal medicine in anesthesia, hospitalization, and nursing fees (by weight or cage size). It is still unique to charge hospitalization by the workload requirement (e.g., e.o.d. b.i.d., t.i.d., q.i.d., IV, ICU, CCU, etc.), although we have been promoting it as a consulting team for 17 years.
Even the term 'technician' stems from production medicine, when the only assistant the veterinarian had when returning to the barn with a scouring calf was the milk lab tech, and he yelled, "Get that tech out here to help me unload!" In most other English speaking countries, the term is Veterinary Nurse, and it is well respected, unlike the USA. Some State Boards have folded to human healthcare nurses (who have always called medical assistants with 10 weeks training "nurses" when in the doctor's office) and have prohibited the use of the term nurse, although there are still nurse sharks, nurse ants, nurse bees, and nursing moms. Clients respond very favorably to the term nurse, while "technician" must be explained before they trust them as veterinary extenders.
Now the term annual needs to be eliminated from our vocabulary, but it was centered around the early production paradigms of annual vaccines being the veterinarian's ticket back onto a producer's spread. Vaccines now have extended DOI, and the AVMA initiative has made Life Cycle consults expected by clients as an "at least twice a year" occurrence.
Academic training is so centered around secondary and tertiary care for sick and injured animals that our university specialists are failing to understand surveillance medicine, wellness as a diagnostic quest rather than an assumption, and the client's evolution to pet parent (89% of American and British households, 85% of Australians and 75% of New Zealanders consider the pet a family member, or best mate, and the third of those give the pet child status). Yet students are still taught to watch for explosive diarrhea before testing for Giardia, although studies have shown 40-60 percent of all pet store and shelter animals have Giardia, practices can use 'snap test' to screen for this zoonotic protozoan parasite, and clients do not want a soiled carpet.
The days of production practice paradigms limiting companion animal medicine and surgery need to come to a close, and our academic traditions of curative medicine need to be expanded to embrace wellness. The USA kills about 5 million animals a year for behavior problems, while Australia kills about 500,000 a year for behavior problems, yet most Universities fail to train students in the basic behavior skills (crate training, house training, sit, down, stay, heel, etc.) needed to cement the human-animal bond in families. The Association of Veterinary Family Practitioners (AVFP) was founded in 2005 to fill this void, and maybe, eventually, elevate the general practitioner, and quest for wellness as a diagnosis, in the eyes of the academic veterinary profession.
Dr. Clayton McKay, Hill's General Manager in Canada and past AAHA President, said it well, "Tom Cat will be dead and gone for twenty years before we really understand everything he has been saying we need to do as a profession."
The vertically-integrated (usually doctor-centered and directed) veterinary practice model we learned has become outdated, yet no one has decided to euthanize the dying beast and move on -that is what love causes -a resistance to euthanize for our own benefit, not the benefit of the critter.
We were educated at a Veterinary Teaching Hospital (VTH), sacred ground of the academics who are tenured and secure. Most every VTH operates at 40 to 60 percent loss, and no one is willing to admit the model is outdated; therefore our new graduates have no understanding on income to expense relationships.
VTH - a curative medicine environment, with supplemental funds coming in from research on disease, surgery, and cutting-edge diagnostics.
Private Companion Animal Practice - about 20-30 percent curative medicine, and 70-80 percent preventive medicine (vaccines, flea/tick/heartworm, pet population control, and a little dentistry and nutrition), with supplemental funds coming from clients accessing new programs (or higher fees).
The sacred VTH is centered on secondary and tertiary healthcare delivery programs, since the private practices have proliferated around the VTH to handle all the primary care and act as gatekeepers for referral practices. Clients accessing the VTH, or referral practice, have been 'pre-qualified' as to 1) appropriateness, 2) acceptance of higher fees, and 3) endorsed as a favorable next step in meeting the animal's needs. It is therefore unrealistic to expect the VTH to understand wellness surveillance at the primary care level. In fact, when sitting with some of the Veterinary School Deans and Clinical Directors in July 2005, at the curriculum review held at the annual AVMA meeting, not a single Dean or Hospital Director had implemented the AVMA's 2004 initiative on 'Think Twice for Life' (www.npwm.com) and more importantly, most admitted never hearing about it.
If one looks at our education system, and we accept the new AVMA initiative as a replacement for our past paradigms, with pursuit of wellness as a diagnostic finding which can be expected as a reasonable clinical outcome, then there is a chance we can start to horizontally integrate wellness surveillance.
Veterinary medicine does not have enough clout to control the open market, so pricing of products is NOT within our control.
Peter Drucker said in his text, Post-capitalistic Society, "The only thing we have to sell in the new millennium is knowledge, all else will be provided cheaper by third world countries".
Accept that there is appropriate wellness pricing and it is different (more affordable to allow for more often return trade) than curative medicine/surgery pricing.
Most all practices have covertly accepted the preventive medicine aspects as commodity products and services; prices are controlled by the market place and colleagues around town. I say covertly because while we all complain, no one makes the move to change the system. Inversely, practices focus on curative medicine for pricing guidelines, so the pet population control programs are seen as "undercharged". We are the only healthcare profession which is allowed to take perfectly good parts out of perfectly healthy patients, in our spare time (ergo, we call it 'elective' surgery), just in the quest for prolonged wellness (OHE and Castrations - called desex procedures down-under); this is not the acute care required in trauma or emergency surgery. We complain about Internet and Catalog product sources keeping the prices of flea/tick/heartworm preventatives depressed, yet we still fail to understand the other healthcare professions have abandoned drug resale as too low a margin to be retained.