Saturday, May 31, 2014

What's best practice? Insights from the AVA conference, days 3&4

Brush tail Bettong
Another pic of the brush-tail bettong at the conference...just because its a whole lot cuter than photos of people speaking behind lecterns. 
Blogging a five-day conference turns out to be a huge challenge when you are attending it at the same time. So we’ve been a little slow – mostly because we’ve been busy attending every possible breakfast session, lunchtime lecture, plenary, special-interest-group dinner and mini-lecture possible. And still we missed a few! (There were eight concurrent streams and over 200 sessions to choose from during the week).

For me there were two stand-out sessions in the last two days that I’d like to single out.

Martin Whiting discussed business and veterinary clinical autonomy. He noted, particularly with reference to the UK but it is also happening in Australia, the growth of veterinary practice franchises or chains. There are of course big benefits of standardising veterinary care – centralised services, bulk-buying and cost-savings for clients, sharing of high-value, short-life products such as blood products between practices, standardised employee training and education, centralised after hours services, better working conditions and so forth.

But there are some very clear disadvantages, depending on the way these are run. What happens when you are treating a patient and the standard operating protocol dictates that you need to work it up in a particular way and you disagree? What if bulk purchased medicines or foods are not the optimal treatment in a particular case? Some practices incentivise vets to sell particular products, or force veterinarians to refer to a particular service. Many pay on a commission-basis or give bonuses for invoicing over certain thresholds. These business practices have serious consequences for vets and patients.

Commission-based remuneration in health care can lead to abuse and generate distrust between the client and clinician. Clients may be unsure if the recommendation is being made for commercial reasons or in the best interests of their pet. Individual veterinarians must always abide by the professional code of conduct, which trumps private practice policy in the event of a disciplinary hearing. Dr Whiting made some excellent observations and the presentation generated a lot of discussion. This potential conflict between practice protocols and clinical autonomy has huge ethical implications and is something that the profession needs to address.

Dr Ilana Mendels from VetPrac won a prize for visiting the AVA's Wellness Stand. Ilana is always well coordinated but note that her glasses, lanyard and shirt are totally coordinated with the prize. Seriously, do us mere mortals stand a chance?
Meantime when it comes to communicating costs in veterinary care, Ontario Veterinary College’s AssociateProfessor Jason Coe had some fascinating data to share. A lot of veterinarians feel awkward talking about money. Some perceived it made them look like they were money-focused, some felt that their job was just to worry about the animal and let reception discuss costs with clients. Dr Coe has done some great work. The upshot is that upfront communication about costs improves clinical outcomes.

When he asked how many vets enjoyed talking to clients about money, 45 per cent disagreed and 28 per cent strongly disagreed. That’s a pretty clear majority.

But time and again, studies have shown that client satisfaction is increased when the client understands the costs involved and why these are incurred.

Vets get a bit defensive. In a study Dr Coe ran, he found that vets often justified costs in terms of their investment in time, overheads, the skillset required etc.

What the clients wanted to know was what the costs meant in terms of their pet. For example, this operation will give Rusty X chance of cure or 6 months additional survival, relieve pain and allow you to manage him without medication…etc. The time taken, the equipment needed etc. weren’t so relevant.

Veterinarians said they felt undervalued or guilty when talking about money which made them a bit gun shy. But pet owners felt that a failure to discuss costs upfront could lead to clients being over-extended financially. One point of discussion was the client who comes in and says “costs are irrelevant”.

This actually means different things to different people and often these clients challenge the bill when they finally see it. So it is important to discuss costs even if the client says that costs do not matter. Knowing what to expect does matter.

In one overseas study, almost 50 per cent of veterinary clients left the consult room without an idea of what costs they would be up for. In another study by Coe, Adams and Bonnett (JAVMA 2009 234:1418-1424) of 200 veterinary consults, only 29 per cent of visits included a discussion of costs, and 25 per cent of vets never initiated cost discussions.

Dr Coe discussed the different ways that veterinarians might initiate cost discussions in an emotionally charged environment. The use of empathy ranked very highly. Interestingly in an Australian study by McArthur and Fitzgerald AVJ 2013:91:374-380), veterinarians expressed empathy in only 41 per cent of consults – and 73 per cent of those occasions involved directing empathy at the animal. Which is fine – except only the empathy statements directed at the client had any impact on client satisfaction.

Dr Coe talked about the use of partnership statements and “I wish…” statements to express our concerns in a way that is meaningful to clients (for further info see Hardee, Platt & Kasper J Gen Intern Med 2005, 20:666-669). You can think empathic and helpful thoughts all you like, but if you don’t express these to the client they won’t have an impact on client satisfaction. 

And client satisfaction is a variable that has a huge impact on client uptake of recommendations and therefore clinical outcomes. We know why we are making a recommendation, but as a profession we need to improve our communication. The client wants to know why we are making this recommendation to Phil, or Rory, or Cliff (insert favourite pet name here).

However you feel about money, Dr Coe’s data showed overwhelmingly that upfront discussions about costs were helpful to clients, allowed them to plan better and improved their relationship with the veterinary team.