“Jerry” 15 yr CM DSH - College of Veterinary Medicine

Animal Care and Treatment
Trends and Challenges
in Clinical Practice
Todd R. Tams, DVM, DACVIM
Chief Medical Officer
VCA Antech
Los Angeles, CA
VCA Antech
VCA Animal Hospitals
520 Hospitals in 40 States
 2,250 Doctors
 276 Board Certified
Specialists
 131 Interns
 5 Specialty interns
 63 Residents
 40 university based
Antech Diagnostics Lab
47 Laboratory Sites
 80 Board Certified
Specialists
 Service for 16,000
veterinary hospitals in the
U.S. every day
Dr. Jack Schaefer , Ohio State Class of 1962
Medical Director at VCA Aurora Animal Hospital, Aurora, IL
 2,250 doctors
in VCA Animal
Hospitals
 96 Ohio State
graduates
• Grad year range
1962 – 2010
• 4 current interns
The Human Animal Bond
is . . . . . Alive and Well!!
James and Gypsy
Service Dogs Visiting Hospitals and Nursing Homes
UCLA Medical Center – Coronary Care Unit
We can learn some things from
our animal companions . . . . . .
“Princess Pharoah”
(owned by Nicolete Bertolone, OSU 2009)
Osteosarcma and
amputation March 2010
July 2010 – “She does
EXACTLY the same as
she used to in the park,
and I mean FULL
speed! Only thing
different is going down
the stairs to our
apartment.”
“Difficult decision to
proceed after Dx, now
really glad we went
ahead.”
VCA West L.A. Intern Class 2009-2010
Nicolete Bertolone
OSU 2009
A beloved cat
rescued from the
scene of an
apartment fire, by
Redondo Beach, CA
fire department
personnel
(happy ending . . . .)
Pet Owners’ Appreciation for the Special
Qualities of Veterinarians
February 2010
Dear Dr. Tams:
“I want to bring to your attention the extraordinary care
my dog received from Dr. Jennifer Stafford and Dr.
Katie Frantz, veterinarians at the specialty hospital in
Gaithersburg, MD. While I am sure they give superior
care to all of their patients, the care my dog Maggie
received was unbelievable. I know I will never forget
them and the kindness they showed me.”
Maggie was just a little 6 year schnoodle, but to me she
was my life. I’m handicapped and a widow. We were best friends.
We ate together, slept together and spent every minute possible
together and until 10 days before she died, she never had a sick day.
Maggie
IMHA and IMTP – multiple transfusions
 Sat on floor with my dog in exam room
 Compassionate
 Listened, well, explained everything
 The day after Maggie came home she started
bleeding again and we were in the midst of a
blizzard. I had no way to get her back to the
hospital. How could I possibly help her?
 Both doctors came to my home during a
blizzard, to pick Maggie up for more care when I
was physically unable to get out.
 Your doctors are true heroes in my mind
Residents at VCA Veterinary Referral Associates
in Gaithersburg, MD
Dr. Jenn Stafford
Univ. of Tennessee 2007
Dr. Katie Frantz
Ohio State 2006
Relationship with Pets
2%
2%
19%
36%
Child
Family Member
Friend
Acquaintance
41%
Property
77%
Based to current pet owners: n=1927
QA9
Veterinary Medicine . . . . What a wonderful
profession we get to be a part of!
One of the big concerns in our profession,
in the practice of medicine . . . . . . .
Too often in the exam room we play it too
conservatively, deciding for ourselves
how much a client may be willing to
spend, missing opportunities to take a
more
thorough, sounder medical
Key
Points:
We
must advocate
our patients,
approach,
being for
content
to just since
wait and
they
see, can’t
etc . do
. . .it. for themselves
“Sales” mentality
(high quality medicine)
What was the best professional
advice you ever received?
“As a young clinician, I
tried to steer an elderly
man with what seemed to
be few resources toward
a less expensive, but
suboptimal, treatment
plan. He sensed this and
said to me,”Sonny, don’t
try to put a price on my
pleasure.” Since then, I
have tried to refrain from
prejudging a client
regarding the cost of
services.”
Senior
Wellness
Programs
How many of us would like
in
Practice
our pets to live forever?
“To me, fair friend, you
never can be old,
For as you were when
first your eye I eyed,
Such seems your beauty
still.”
William
Shakespeare
Wellness Programs in Practice
It’s All About:
Early Disease Detection (EDD)
KEY POINTS: High Quality Medicine
This
needs toPets
be a major
focus in
the profession,
Keeping
With Their
Families
and in the
now and into the future . . . . just as it is in human medicine
Best of Health for as Long as Possible
Requires education and marketing
ZEUS
12 Yr MC German Shepherd Dog
Hx: no c/s/v/d/pu/pd
appetite and activity wnl
Exam: grossly normal
(pannus both eyes)
Assessment:
happy healthy dog
Plan: Senior Wellness PLUS
(Blood tests, UA, AND
chest and abdom. rads)
ZEUS
Early Disease Detection
Senior Wellness Results
CBC: Normal
Chemistries: Normal
Abdominal US : Normal
ECG: Normal
B/P: 135/75
Tonometry: < 17 OS OD
Chest Radiographs:
ZEUS
12 Yr German Shepherd
Chest Radiographs Taken March 2009
Part of Early Disease Detection Screening
Happy healthy dog
April 2009
Denial ain’t just a
river in Egypt
March 2009
ZEUS
Early Disease Detection
CT Scan:
1. No thoracic lymphadenopathy
2. No other lung lobe involvement
Plan:
Exploratory and lobectomy under same
anesthesia
Surgery went well.
Diagnosis: Pulmonary adenocarcinoma
Zeus continues to do well 17
months after surgery to remove
his lung mass, thanks to
EARLY DETECTION
Feline EARLY DETECTION Study (VCA West L.A.)
165 clinically normal CATS 7 yrs of age and older
Radiographic Abnormalities
Thorax
Bronchial Dz
Cardiomegaly
Metastatic Dz
Pulmonary Mass
Pleural Effusion
16/165
11/165
6/165
5/165
1/165
24%
(10 %)
(7 %)
(4 %)
(3 %)
(<1 %)
Feline EARLY DETECTION Study
Clinically normal CATS 7 yrs of age and older
Radiographic Abnormalities
Abdomen
Bladder/renal/ureteral
Hepatomegaly/mass
Choleliths
Splenomegaly
Gastric FB
Microheptica
Calcified biliary tree
Adrenal mineralization
31%
28/165
9/165
6/165
3/165
2/165
1/165
1/165
1/165
(17 %)
(5 %)
(4 %)
(2 %)
(< 1 %)
(< 1 %)
(< 1 %)
(< 1 %)
Canine EARLY DETECTION Study
Clinically normal DOGS 7 yrs of age and older
Radiographic Abnormalities
Abdomen
Hepatomegaly/Mass
Splenomegaly/Mass
Cystic calculi
Renal Mass
Microhepatica
11/99(11 %)
7/99 (7 %)
3/99 (3 %)
2/99 (2 %)
2/99 (2 %)
25%
Thorax
Primary lung tumor
Megaesophagus
Hilar adenopathy
6/99 (6 %)
1/99 (1 %)
1/99 (1 %)
8%
Future Focus
More collaboration between
universities and large private
sector hospitals in clinical
trials and case studies
What Makes Us Successful?
Most methods used by service businesses to
keep customers won’t work for hospitals
Unlike other service companies, hospitals have
only one way to create loyalty – the patient’s
personal experience
. . . . And for veterinary medicine, this means
BOTH the patient and the patient’s owner
For patients/clients, loyalty comes from
COMPASSION, one of the core values for
veterinary medicine!
The Disney
Approach
to Quality Service
For the Healthcare
Industry
In the Pursuit of Excellence
Today’s
veterinarian must
be technically
skilled but also
compassionate and
an effective
communicator
Key Points:
Enhanced communications training
in veterinary school is essential
Situational training (“street savvy”)
“Society ready veterinarians”
Changing Trends in Veterinary Medicine
Greater demand for advanced care!!!!
 Larger practices
 24 hour care centers
 Intensive care units
 Pain management is a major priority (finally!)
 Many more specialists in private practice sector
 Imaging: DR, ultrasound, endoscopy, CT, MRI
 Cancer diagnostics and treatment
 Advanced surgical techniques
 Among the fastest growing:
Rehab/physical therapy services
Alternative medicine
Minimally invasive
Dr. Ron Bright and Dr. Clarence Rawlings
surgical procedures are
Laparoscopic Assisted Prophylactic Gastropexy
on the rise
Rehab/Physical Therapy is Growing
Newer modalities in recent years
Endoscopy
Ultrasound
Interventional radiology
Advanced dental
procedures
Laser modalities
Acupuncture
Alternative medicine
Chiropractic
Rehab therapy
Kelly Cairns, DVM, DACVIM
OSU trained IM resident
Etc.
Imaging for Radiation Treatment Planning
CT scanning ideal modality
•Accurate shape/depth
info
•Physics calculation based
on x-ray absorption
in tissue
MRI also used
•CNS tumors
•Not as accurate dose
calcs as CT due to
distortion/ lack of
electron density
measurements
Radiation Therapy
Siemens Linear
accelerator
Xrays
Electrons
Versatile machine for
different situations
Prowess 3D TPS
3D treatment program
Patient receiving electron therapy
VCA Aurora (Aurora, IL)
Radiation Therapy
Typical caseload
12-18 new radiation
patients start
monthly
150-200 patients
treated yearly
Each patient gets
daily treatments
for 3-4 weeks, or
once weekly
treatments
7-10 patients being
treated every day
Henri with his alligator
buddy after treatment
CyberKnife
Robot Radiosurgery
The only CK
in use in vet
med at this time
(VCA in Yonkers,
NY)
X-ray sources
Manipulator
Linear
accelerator
ROBOTIC DELIVERY
SYSTEM
Treatment
Couch
Image
detectors
Changing Trends in Veterinary Medicine
More graduates are pursuing internship and
training . . . . this is a very good trend
WHY Did You Sign On
To Do An Internship?
To train to become a better doctor
How? More rapid assimilation of
clinical experience with focused,
quality mentorship in a busy
hospital setting. Internship
training helps new grads “piece it
all together’ more quickly.
Focus is on case management skills
AND communications
training/experience
Human vs Veterinary Medicine
In human medicine all
graduates from
medical school do
internship and
residency training
OSU Data
Class size 140 students
Advanced training:
2009 28% of grads
2008 40%
2007 25%
2006 18%
In Veterinary
medicine, advanced
training is optional
 In 2009-10:
 Approx. 2500 veterinary
school grads
 VIRMP: 722 small animal
med/surg internships
listed
 167 university based
 555 private practice
 VIRMP: 48 large animal
internships
Advanced Training After Graduation
There are currently enough internship
programs for approximately 28% of new
graduates
VERY IMPORTANT (Key Issue)
There is more oversight now, fewer
“cheap labor” internships (these need to
be shut down until standards are
improved by an accrediting process . . . .
a need for the future)
2010 Interns - Schools Represented in VCA Programs
(131 interns, 17 programs)
Colorado State
UC Davis
Illinois
Ross
Tufts
Western
Florida
Michigan State
Wisconsin
Cornell
Iowa State
Pennsylvania
Auburn
Kansas State
Ohio State
13
11
10
9
8
8
7
7
7
5
5
5
4
4
4
Georgia
Minnesota
Tennessee
Washington State
Atlantic
Lousiana State
Missouri
Oklahoma State
Oregon State
Glasgow
Ontario
Purdue
Romania
St. George’s
Texas A&M
Tuskeegee
VA-MD
3
3
3
3
2
2
2
2
2
1
1
1
1
1
1
1
1
VCA Intern Orientation in New York 6-16-10
for our interns based in Massachusetts, Connecticut,
NYC, Maryland, Delaware
1 OSU Grad
Steph Grenert, VCA Newark, DE
VCA Intern Orientation 2010
Sonia Kuhn – Ohio State 2010
VCA Veterinary Specialty Center of Seattle
Good interns are interested,
excited learners.
“Teach me more . . . . “
Opportunities for Interns
 Excellent internship training experience – in the
quality programs equivalent to 2-3+ years of
clinical experience . . . . And the establishment
of many good habits that should last through a
career
 Post internship
 GP positions post internship (where a
majority of intern grads go)
 Specialty internships
 Strengthen resume for residency
application
 Residency programs
What were your goals in doing an internship?
Exit interview comments from interns June 2010 class:
“I wanted to feel more comfortable working through
problem lists and making smart decisions in regards
to the best plan of action in working up cases. I also
wanted to learn “all the things they don’t teach you in
school” and to be able to advise clients more
confidently on things like prognosis, complications,
and varying treatment protocols. I am much more
comfortable now in my clinical proficiency.”
What were your goals in doing an internship?
Exit interview comments from interns June 2010 class:
1. To learn to think on my feet
2. To be able to handle anything that walks through the
door
3. Be thorough yet efficient when handling a large
amount of cases
4. Become excellent in my communication skills with
clients as well as colleagues and support staff
5. To gain confidence in handling complex medical cases
and in performing surgeries that are routinely done in
general practice
6. To gain skill and experience in diagnostic procedures
such as ultrasounds, bone marrow biopsies, FNA, and
CSF taps
What were your goals in doing an internship?
Exit interview comments from interns June 2010 class:
(continued . . . .)
“I feel I have met most of my goals this year.
Specifically, I have learned to think on my feet
while seeing emergency cases. Also, I no longer
dread what might come through the door as I have
learned to approach cases in a systematic manner
and keep my cool in intense situations.
The internship allowed for interns to have primary
case management on receiving rotations, and that
was invaluable.”
VCA Intern Skills Set List
To help ensure comprehensive training and experience
VCA Intern Directors April 2010
A very dedicated group of mentors
FOR DISCUSSION
 What is the prevailing level of direction
from OSU clinical faculty about
recommending internships for students?
 Strongly recommend for qualified
students? (Do one!)
 Limited recommendation, more
lukewarm? (Don’t push too hard)
 Direct more toward university programs
vs. private practice internships?
 Is it financially “worth it” for veterinary
school graduates to do an internship?
Mentoring/Training Are
Extremely Important for New Grads
Continuing Education Programs
A University’s Role
 University CE programs continue to be a very
important source of post-graduate education
for veterinarians – a key responsibility of
veterinary colleges (even though it is no
longer required by AVMA for accreditation)
 University-based lecture/lab courses are
among the best anywhere
 OSU has developed a renowned series of
CE programs in recent years . . . . This
should be continued
 Future: more on-line courses in the portfolio
Frequently heard quotes from general practitioners
“As I look back, I wish I had done an
internship”
“I’ve been in practice 20+ years and I am
bored. Really looking for something new to
get me excited again.”
“The technology of today is incredible, I wish I
could go back and start over again.”
A big reason why post graduate CE continues to be
so important – especially lecture/lab type courses
More CE hours should be required for relicensure
For Discussion
How can we better prepare students for
clinical practice and today’s demands?
For students who do not pursue an
internship, are there ways we can get them
additional post-graduate training in their first
6-12 months after graduation?
 Communications, client situations
 Reviewing key medical/surgical skills
 On-line CE from universities?
 Courses to help teach employers how to
better mentor new grads?
Looking Ahead…
Today
61
Looking Ahead…. CHALLENGES
Declining patient volumes/traffic
Economy
Veterinary medicine is recession
resistant but not recession proof
Pricing at the hospital level – getting it
right (historically too low; but there is a
limit on what the market can bear)
Pet insurance – only 3-5% of pet owners
purchase coverage; will be beneficial
when more purchase policies
Local competition
Morale
Looking Ahead…. CHALLENGES
Expanding product distribution
channels (flea and tick treatments,
preventive meds, products are
available through many channels)
Many practices need to change focus
 less vaccinations, product sales
 need to redirect primary focus:
increase wellness (ED),
diagnostics, new services for
clients
Alliances
Challenges in the Profession
Technician shortages . . . . Everywhere
 More states are limiting what non-certified
technicians can do
 It is incumbent on practices that hope to
effectively compete to have certified
technicians on staff
 improved efficiency
 better client service
 better quality of care (allow your techs to
make a difference – some docs don’t know
how to do this!!!!)
 improved profitability for the practice
Looking Ahead…
The Plan for Now
Managing in challenging times
Pursuit
Improved service and value
of
NEW services!!!!
Excellence
Control costs
Increase productivity
Improve client compliance on “the
basics” (recall AAHA study 2002-03)
Focus on training
Communicate with our clients &
market place
Service, service, service . . . .
Expand Marketing Programs
What Veterinarians Think About the Internet
 88 percent say the Internet
gives greater access to the
latest science and research.
 64 percent say it makes
practice and work more
efficient.
 61 percent say it helps provide
greater care for animals by
informing on medical matters
ranging from their veterinary
association to animal
genetics.
 43 percent say they use it for
client communication.
 32 percent say it makes their
practice more profitable.
 69 percent say their practice
has a website.
 22 percent send e-mail
reminders.
 18 percent send electronic
newsletters.
The Future
Where Are We Going????
There continue to be many opportunities
for veterinarians, but there are many
issues we must consider:
 Ways and preferences of the millenial
generation
 Shorter hours, want weekends off, no
holiday hours
 More are seeking part-time hours
 Difficult to balance with high debt load at
graduation
Personal Challenges
(these critical issues have been there awhile, most
likely, but we have increased awareness now)
Psychological issues:
*Depression
*Anxiety
*Post traumatic stress disorder
*Suicide or suicide ideation
*Eating disorders
*Lack of ability to work with others
*Personal crisis
*Family/relationship issues
Substance abuse
Sexual identity issues
Generational Shifts
Previous generations:
 Higher level of
confidence, but not
as competent
 Much more willing
to try new things,
had to . . . . In
practice, probably
doing things we
shouldn’t have done
 Limited referral
options
Current generation:
 Higher level of
competency, but lower
confidence, especially
in surgery
 Issues with teaching
style for surgery in
veterinary schools?
 Too quick to refer,
even on fairly basic
surgery, medicine,
derm, ophtho cases
Newer Generational Trends
Accumulation of overall knowledge is much
more comprehensive than in past, but
confidence is lacking
 Longtime university surgeon, working parttime at a Maryland referral practice:
“I was amazed at how simple some of the
referral surgery cases were.”
Newer Generational Trends
 Experienced veterinarian (1990 grad) hired to
serve as medical director of a general practice
in south Florida: Found that young doctors
were referring cases out too early and too
frequently (ear hematomas, cystotomies, etc.)
 Not comfortable
 Don’t have to do it – referral specialists
readily available
 What happens when a client won’t drive?
Someone has to take care of these cases.
 Why aren’t these recent grads applying
themselves more?
For Discussion
Why aren’t these recent grads applying
themselves more?
 “Good” reasons: Concerned for patient, pets
are family members, awaiting better
training to help improve confidence/skills
 “Bad reasons”: Lazy, disinterested, it’s an
inconvenience, might have to stay late, not
good at applying oneself
Goal: Graduate “street savvy,” energized
veterinarians focused on developing
best competency
Private Practice Owner
Recruiting and Retention Challenges
 Location and Practice Conditions
 Larger city vs. small town
 Practice type – small, mixed, large animal
only?
 Number of veterinarians? 24 hour care?
 Lifestyle considerations for younger
veterinarians . . . .
 Physical facility – attractive vs “dated?”
 Medical practice quality? Up to date vs too
much of the “old ways?”
 Can they offer a good mentorship program?
Effect of More Specialists in Private Sector
 Enhanced quality of medical care in the region
 Increased educational opportunities for area
practitioners
 Pet owners pleased . . . . Once they know
specialty care is available in veterinary
medicine
In some areas too many specialists . . . . Some may
turn to doing general practice as well in future
We’ll see more “hybrid” hospitals in the next 10
years (practices that offer both general and
specialty care)
Private Practice Owner
Recruiting and Retention Challenges
 Can they offer a good mentorship program?
 Well organized and positive energy in
mentoring?
 Strong belief in attending CE?
 Practice personality . . . . Fun place to
work? Team? People get along?
 Able to attract intern program grads?
 Concern about some of the newer grads and
work ethic, lifestyle motivation
 Willing to cover emergencies, work some
weekend shifts?
 Overbearing sense of “entitlement?”
Recruiting for Large Animal
Practice Locations
 Begins with the admissions selection process
Must be creative in compensation packages
Loan relief payments in return for a set number
of years of service (3-5)
Programs funded by local communities for
areas with severe shortage of food animal
practitioners?
Desired Qualities in Hiring
Veterinarians:
Team player
Communicates effectively
Desire to continue learning
Business behavior
Confidence
Motivational fit - Coachable
Compassion and empathy
Professional image
Education and experience
77
You make a difference here
Shifting Societal Needs and Changes to Professional Competencies
Assessed by over 100 Veterinary Leaders at First NAVMEC Meeting
(13 February 2010 – LAS VEGAS, NV) One of the most diverse
representations of veterinary organizations ever assembled completed
three days of meetings today to begin a year-long effort to chart the course
for the future of veterinary medical education. The North American
Veterinary Medical Education Consortium, or NAVMEC, was launched by
the American Association of Veterinary Medical Colleges (AAVMC) in 2009
to ensure that veterinary medical education meets the needs of our
changing society. The topic addressed during the first meeting was societal
needs and professional competencies.
“What was most impressive to me was the passion and commitment of
meeting attendees,” said Mary Beth Leininger, DVM. “There is a
determination that the Consortium needs to be a change agent for better
education. Our future depends on it.”
 Veterinary Medical Colleges, AVMA, Accrediting bodies, Natl
Board of Examiners, Specialty Colleges, Industry, VCA,
Banfield, et al
 Chart the course for the future of veterinary medical
education
 Graduating veterinarians lack business acumen,
communication skills, people management, client service
skills to keep the profession healthy into the future
 Median student debt $130,000. Average new grad salary
$64,744
Pricing Accurately for Services
(A longtime problem in the profession)
PRICE becomes
an issue
only in the
absence of VALUE
The “P” Word
Pets
Passion
Performance
. . . . . . PROFITS
Profits Are Good
Reinvesting into the practice to improve:
 Facilities
 State
of the art equipment
 General training for doctors and staff
 Increased continuing education for doctors and staff
 Competitive marketing
 Competitive salaries . . . . Staff retention
 401(k) matching grants
Bottom
Line:
Profits help produce better medicine