Wednesday, August 22, 2012

Exceeding Expectations


As a veterinary practice owner, I’m constantly trying to find that happy balance between being a veterinarian, and being a businessman.  If I had my druthers, I would love to just practice veterinary medicine and devote myself 100% to the cats, and not have to worry about hiring and firing and inventory and revenue and  marketing.  But I’m also a control freak and I like to be in charge of my own life, and the only way you can really do this is to be your own boss.

Whenever I read business magazines, they’re always talking about “exceeding your customers expectations” as the key to a successful business.  It’s a phrase that’s been overused to the point where it’s become a groan-inducing cliché.  I always felt that this phrase didn’t apply to veterinary medicine the way it applies to other businesses, like a bank or a restaurant or the air conditioner repair guy.  With veterinary medicine, the expectations are already set very high: you’re expected to be able to diagnose what is wrong with the patient, and then prescribe the appropriate treatment so that the cat hopefully gets better.  Clients don’t come in thinking you’ll have no clue what might be wrong with their cat, and then are pleasantly surprised that you figured it out.  It doesn’t work that way in veterinary medicine.  Usually, the exceeding of the expectations occurs at the front desk, where the receptionist goes out of their way to fit you into a busy schedule, or in the treatment room, where the technician agrees to cut all 50 tablets into quarters to make it easier for the client.  When it comes to the medical part, the expectation, especially at a feline specialty practice, is that you’re the experts.  If you can’t figure it out, then no one can.  It’s a heavy responsibility, but it’s what vets (the motivated ones, anyway) thrive on.

Last week, however, we had two instances where expectations were exceeded, but this time, the expectations happened to be mine, and the exceeders were some members of my staff.  Perhaps it’s cheesy to toot our own horn, but what happened last week was cool, and it’s my blog, so I’m sharing.

The first incident had to do with a four year-old cat named Fig.  This cat came in for a little lethargy and some weight loss.  The weight loss was minor; less than a pound.  My doctor, Victoria Sheheri, did a very thorough examination on the cat, and thought she felt something odd in the abdomen, perhaps a small nodule or mass somewhere.  It was very subtle.  The odds of a cat this young having something worrisome like a tumor is pretty slim, especially with pretty mild, ambiguous signs like lethargy and a tiny bit of weight loss.  This little nodule could easily have been a little piece of poop that she was feeling. But something didn’t feel right to her, and she suggested that Fig undergo an abdominal ultrasound just to make sure it was nothing significant.  Fig’s owner agreed to the procedure.   A few days later, an ultrasound was performed by Dr. Patrick Hopper, an internist who travels from hospital to hospital, performing ultrasound (and/or endoscopy) for clinics in the area.  He, too, performed a very thorough ultrasound, and he located a nodule in the pancreas.  It was about the size of a chick pea.  “Good call”, he said, referring to Dr. Sheheri’s ability to feel this little thing.

In order to figure out what this nodule was, you would typically have to perform surgery to biopsy or remove the nodule, an invasive and expensive procedure.  But I thought the nodule looked pretty discreet and well-circumscribed, and I asked Dr. Hopper if he could insert a needle in there and get a sample for cytology.  He seemed skeptical, but I’ve seen him do this many times before, and I kinda pushed a little for him to try.  He managed, with ultrasound guidance, to place a needle right in the center of this tiny nodule, and then aspirated some material from the nodule into the hub of the needle, and then onto a microscope slide.  He did this three (!) times, and we got six good slides.  We woke Fig up and sent him home a few hours later.  The next day, the cytology report revealed the nodule to be a pancreatic carcinoma.

We reported the results to the owner, who naturally was distraught at the news.  We recommended that she consult with a surgeon to see if this could be removed. She met with Dr. Andrew Kyles, an excellent board-certified surgeon at Blue Pearl Veterinary Partners, and Fig is now scheduled for surgery later this week.
I don’t know if Fig’s owner ever stopped to think about whether we “exceeded her expectations” or not.  Her cat wasn’t quite right, and we figured out why.  This was her expectation, and we met it.  However, MY expectations were GREATLY exceeded. As a practice owner, I would not expect one of my doctors to ever detect such a small nodule during a physical exam.  The nodule was in the body of the pancreas.  It could easily be missed, or felt and dismissed as probably being a little piece of stool.  After all, who would expect a four year old cat to have a pancreatic tumor?  I’m impressed with, and proud of, my doctor.  As an internist, I know how difficult it is to clearly identify a small nodule in the pancreas, and then be able to zero in on it and non-invasively obtain a good-quality sample of it, for analysis.  Again, my expectations were exceeded by the people I hire.   Dr. Kyles, the surgeon scheduled to tackle this mass on Thursday, said the same.  “You guys did a very good work-up”, he said.  High praise from a guy who works for a center whose job is to work-up cases that other vets can’t totally get a grip on.

The second incident occurred last Saturday.  We had a cat boarding with us named Cosmo.  He is an elderly cat – three  months shy of his 18th birthday – and he’s been  coming to our hospital for years.  He has a number of illness – inflammatory bowel disease, chronic  renal failure, and occasional unexplained  seizures, previous bout of pancreatitis  – and he’s been negotiating them very impressively.

Cosmo was boarding at our hospital while his owners were out of town.  Cosmo receives several medications daily, and that’s a big reason why many of our clients board their cats with us rather  than have a cat sitter come into their home to care for the cat.  They don’t want to burden the sitter with having to give so many medications.

When Cosmo boards, he gives the technicians a little sass.  He figures he’s been around for almost 18 years; he’s earned  the right to be grumpy.   So he gives a little attitude when you change his litter box.  He gives some ‘tude when you try to give him his meds.   On Saturday,  I  normally have a slew of appointments back to back, straight  through to 1:30.  Surprisingly, my appointments came to an abrupt end at 12:30.  But my technician, Rita, filled in my 12:30 appointment slot with Cosmo.  I asked what was going on.  She told me that this morning, he didn’t give her much grief about being fed and medicated.  She just let her do whatever needed to be done.  She also thought he was maybe breathing a little funny.

I put Cosmo on the scale.  He had lost 3 ounces; nothing significant.  I checked out his breathing.  Rita noticed that his nostrils were flaring a little when he breathed.  I could see his respiratory rate was a little more rapid than normal.  I listened to his heart and lungs, and they sounded fine.  I looked at his eyes.  Uh oh… the whites of his eyes looked yellow.  Jaundice.  His gums were yellow as well.  I felt his abdomen, and his liver felt a little enlarged.

Sometimes when a cat is anemic, they will be jaundiced and they will breathe a little rapidly, due to low levels of oxygen in the blood from the anemia.  So I checked his red cell count. It was normal.  I took an x-ray of his lungs.  The lungs looked fine.  I realized that his rapid breathing was probably due to pain.  The presence of jaundice, a history of a previous bout of pancreatitis, and a breathing pattern suggestive of pain, I suspected Cosmo was having an acute flare-up of his pancreatitis.  I contacted the owners and explained what was going on.  They were due back in town the following day, but they agreed to let us do whatever we felt was necessary to get him through this.  I started him on intravenous fluids and pain medications.  Right at that time, Dr. Sheheri arrived at the hospital.  I work on Saturday from 10 to 2; she works from 2 to 6.  I explained what was going on with Cosmo. She was going to keep a close eye on him throughout the day.

Around 6:00 p.m., Dr. Sheheri called and let me know that Cosmo hadn’t really improved; he actually looked a little worse, and she was concerned about leaving him unattended for the night.  She felt that he needed closer monitoring.  I agreed, and was going to come to the hospital and arrange for his transport to Blue Pearl.  Before I could even offer, Dr. Sheheri said that she could load him up in his carrier and take him there by cab, after getting the green light from the client.   Cosmo arrived at Blue Pearl about 30 minutes later.  They have a highly skilled team of intensive-care doctors, and they looked after him that weekend, until his owner could arrive back in town.

As the practice owner, I was pleased at the way everything was handled logistically.  A boarder became sick while boarding, appropriate treatment and diagnostics were performed, and proper round-the-clock care was arranged for when it was  clear that the patient wasn’t doing  as well as expected.   The part that exceeded my expectations was my technician Rita noticing that something was off with Cosmo.  Saturdays are busy, and she is the only technician on duty that day.  The boarding ward was full, and she had to make sure all the cats were fed and medicated, their bedding changed, and their litter boxes clean, before appointment begin.  A grumpy cat in the boarding ward can slow things down and make the day more difficult.  It would have been easy to say, “wow, Cosmo is being behaved this morning”, and  just clean cage, feed him, and then move on to the next boarder, without thinking about it.  But Rita is not like that.  Rita gets to know every cat who is boarding.  My office is down the hall from the boarding ward.  On weekdays, when I’m in my office and Rita is taking care of the boarders, I can hear her having long detailed conversations with each cat in the ward.  She talks to them. She notices what they like and what they dislike.  She knows it’s stressful for the cats to be away from their family, so she tries to make them as welcome and comfortable as possible.  So rather than just dismiss Cosmo’s lack of “attitude” as just being non-grumpy that day, she KNEW that this was abnormal for him.  And she did something about it.   If a grumpy cat isn’t acting grumpy when you’re trying to clean his cage, that makes  your life easier, and I think most people would just be thankful for this making the day easier, and then go on to the next cage.  But to notice, and to care, and to add him to the appointment schedule was very proactive, and I think this is a pretty clear case of “exceeding their expectations”.

My staff and I spend our time always trying to exceed our clients’ expectations.  Most of the time, I’m sure we do.  Every now and then, perhaps we don’t.  But my staff always exceeds MY expectations, and these are merely two examples.   It makes coming to work an adventure every day.

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