A few months ago, I stood with my friend in the exhibition hall at the American Veterinary Medical Association’s annual convention. He gestured toward the enormous displays and eager recruiters hoping to hire veterinarians for the corporations they represent and said, “This is bad for us.” When I asked why he felt that way, he said, “What power can veterinarians possibly have against this much money?”
It’s impossible to ignore the changes happening in veterinary medicine. Never before has there been so much interest and investment in our profession from outside sources. Corporate consolidation, private-equity investment and the growth of online retail are having a visible impact on the veterinary industry. Seeing this, I suspect many veterinarians wonder whether this is how mom-and-pop hardware, toy and sporting goods store owners felt as big-box retailers began to dominate their respective industries.
Today, the public perceives veterinary practices as increasingly capitalistic (as evidenced in recent New York Times articles on the rising cost of care). Veterinarians and their teams have more conversations about hitting revenue targets than ever before. And our employers ask many of us to follow increasingly rigid protocols when delivering care and to be trained on new technologies and systems that improve efficiency, profitability and customer convenience. Frontline caregivers often sense that the implicit goal in these requests is all about delivering shareholder value.
It’s not hard to understand why veterinarians might feel a bit powerless, frustrated, and even afraid. For some, the changes in veterinary medicine can feel like we are on the cusp of having our trade taken away in exchange for a spot in some quasi-medical assembly line. Is that where we are going?
Veterinary Medicine as an Assembly Line
In the early 1900s, Ford Motor Co. built cars by hand. Clients could request custom features, which mechanics would provide. That all stopped in 1913 when Henry Ford introduced the assembly line. By standardizing and systematizing everything possible, Ford was able to generate profits (and provide products) that were previously impossible. Ford famously said customers could have his automobiles in any color they wanted “So long as it was black.”
Similarly, in the 1940s, the McDonald brothers started their first restaurant with various menu items, like every other drive-in restaurant. Then, in the 1950s, the brothers introduced their “Speedee Service System” to increase efficiency and profits. The only menu items that remained were hamburgers, fries and beverages. That is how the McDonald’s we know today was born.
For the business-minded, the lesson from Ford and McDonald’s was clear: Systematized and standardized processes are efficient, scalable and profitable. Veterinary medicine, however, has historically been resistant to becoming overly systematized. We have found value in treating each patient (and client) uniquely, even if the approach didn’t maximize speed or profitability.
Some outside interests looking at our profession see an opportunity to shift veterinary medicine in a more streamlined direction. These investors and business leaders have the potential to grow and generate revenue easily. They have seen it done in industry after industry. All they have to do is turn medicine into an assembly line and veterinarians into line workers.
Veterinary Medicine as Art
“We need to talk about a couple of things,” I began. “I know you are here because of Sam’s urinary tract infection, and she does have one. I’m sorry to say she also has an ear infection. Most concerningly, the lumps along her belly are not normal. I’m worried that she has mammary cancer.”
The woman in front of me let her brave face waver and then regained her composure. She said: “We just moved here from Colorado, so funds are tight. I’m a single mom raising three kids, and I still owe $2,000 for the emergency hysterectomy Sam had a few months ago. I don’t think I can spend more than what we’ve already talked about.”
From a systems and processes perspective, I know what a good workup for this case looks like. The patient should have gotten an ear cytology, ear cleaning, possibly an ear or urine culture, and at least a fine-needle aspiration of the lobular masses along her mammary track. From a business perspective, some practices strongly discourage scripting medications out as opposed to dispensing them directly. This patient, however, got nothing but a prescription for oral antibiotics and a bottle of ear medication.
Yes, we have protocols for approaching lumps, bumps and ear infections. And yes, I understand the value of a solid diagnostic workup. But in this case, based on the dialogue between the pet owner and me about her resources, I supported her decision to decline further diagnostics and treat empirically.
To fulfill our profession’s obligation to society, the clinical judgment of veterinarians must continue to guide our patients’ treatment. It is impossible to systematize something as nuanced and complex as veterinary medicine so that it can be ordered on a touch screen or delivered via an algorithm. Medicine is, after all, about seeing people and pets as precious beings and not as appliances to be repaired or replaced. Also, I don’t believe our staff members do this job to generate the maximum amount of money possible for themselves or others. They do it because they find meaning and fulfillment in being a caregiver.
The Great Battle of Modern Medicine
When I explain the assembly line versus the art of medicine, I’m talking about the great divide many of us see in the modern veterinary hospital: operations versus medicine.
Operations is the part of our practices that focuses on building systems and hitting financial targets. Those wearing the operations hat care a lot about important things like setting prices that meet our budgetary needs, creating work schedules, booking appointments, managing staff and inventory, and paying bills. Even if you despise doing all those tasks, you can’t argue that they are not vital to delivering care over the long term.
On the other hand, medicine is all about clinical judgment and patient care decisions. Those wearing the medicine hat triage incoming cases based on pathology, decide which antibiotics to use, create personalized treatment plans, and make medical recommendations based on the case in front of them. They tend to think more about logistics in terms of getting pets taken care of and less about running a profitable business.
The truth, of course, is that medicine and operations are yin and yang. One can’t exist without the other. However, in my experience, the balance between operations and medicine is different at every practice and changes over time. Historically, medicine has ruled the veterinary profession. The classic veterinarian archetype is that of the business-blind doctor who charges too little, works too much, owns a no-lo practice and does everything for the sake of the animals. For generations, that was how most clinics operated.
Today, as outside players move into the profession and look to generate a return on their investment, operations seem to be gaining power. Protocols, strategic initiatives and sales metrics are becoming increasingly common in the veterinary landscape. When operations and medicine clash, those on Team Medicine tend to think they are being pushed into the role of salesperson or assembly line worker. Those on Team Operations feel like no one cares about paying the bills, doing their job or avoiding communication headaches. If you haven’t seen this battle between the two teams, I suspect it’s a matter of time.
#NotAllCorporations
I need to pause here and make clear that the clash between medicine and operations is not corporate versus independent practices. I have worked with practice teams worldwide, and I can tell you some corporate groups have done an excellent job of balancing medicine with operations. I can also tell you that some independent practices focus on revenue to a degree that would make many veterinarians I know uncomfortable. The interplay between medicine and operations is universal.
I have found it much more helpful to think of operations and medicine as two sides of a pendulum. Each practice differs in which direction and how far the pendulum swings. None of the swings are permanent.
I’ve seen practices change their focus on medicine or operations based on things like ownership changes, team leadership adjustments, economic changes and strains in practice financials. For example, plenty of independent practice owners have found themselves in hard financial spots and changed their perspective on efficiency, revenue generation and product pricing. Likewise, I’ve seen corporate groups bring in dynamic chief medical officers who pushed the pendulum significantly in a medical direction across the entire organization.
Why the Clash Matters
For those of us who entered the profession because we wanted to fix patients, our future experience as practitioners will be defined by the medicine-operations pendulum. If the pendulum swings radically toward the medical side, we might end up in a profession that puts great weight on individual patients but runs inefficiently, frustrates pet owners, and struggles mightily to compensate staff members and pay off our student loans. If it swings radically toward the operations side (as outside investors might hope), we will experience a profession that prioritizes efficiency and profitability but is inflexible and feels devoid of meaning and purpose.
The obvious hope here is that our profession finds a middle ground. The potential to marry medicine and operations and create an industry that serves pets and clients in new and exciting ways is very real. We can develop a version of medicine that is efficient, profitable and patient-centered. The question should not be, “Are we an assembly line, or are we artists who reject structure and capitalism?” It should be, “How do we combine the art and purpose of healing with systems and protocols that help us meet the needs of our patients, clients, staff members and selves?”
What Power Do Veterinarians Have?
The pendulum between medicine and operations is swinging. Veterinarians are the torchbearers for medicine, clinical judgment and patient care. The power we have today is not about “if” we should engage with the growing influence of operations but “how.”
We cannot just do as we are told by those who don’t understand what happens in exam rooms. Neither can we dig in our heels and refuse to make changes or accommodations for those who want greater efficiency, profitability, and organization. To do so is to set ourselves up to be steamrolled and excluded from the conversation about what our profession will become.
The power veterinarians have is about engaging as active participants in guiding our profession. We must be involved in the decisions our clinics and their owners make about patient care. We must be clear about what is morally and professionally acceptable to us and be willing to consider innovative ways of delivering care.
No one can make veterinarians work at a practice they disagree with. Our power is in our ability to:
- Speak clearly about what is important to us.
- Serve on committees and organizations working to influence how veterinary practice is done.
- Walk away from clinics that run their business in a way that doesn’t live up to our moral standards.
At the same time, we must be collaborative, willing to listen and change how we do things, and generally supportive of the organizations we work for. We must give grace as our profession evolves without taking our hands off the steering wheel. We must be active problem-solvers (and not obstructionists) if we want to end up with an outcome we can live with.
The power veterinarians have today is immense and important. Using it requires us to get involved with the operations side of the business and to think and act outside of the treatment room. We are the voice for our patients, and we have a responsibility to help our profession grow and evolve with the society it serves. We can balance medicine and operations, and I am confident we will.
Let’s coalesce around the paths that can work for us, lest we end up pushed down one that does not.
HOW THINGS USED TO BE
The American Veterinary Medical History Society documents the profession’s evolution. Visit avmhs.org for memoirs, biographies, interviews and presentations ranging from “The History of the Horse Doctor” to “Experiences of a U.S. Army Veterinarian in the Vietnam War.”
HOW TO GET INVOLVED
There has never been a better time to join and support state and national veterinary organizations representing your interests. Here is a small sampling:
- American Veterinary Medical Association: avma.org
- National Association of Veterinary Technicians in America: navta.net
- Veterinary Hospital Managers Association: vhma.org
- Multicultural Veterinary Medical Association: mcvma.org
- Pride Veterinary Medical Community: pridevmc.org
- Student American Veterinary Medical Association: avma.org/SAVMA
- Other groups: bit.ly/4ddg76E
BE A BETTER LEADER
Dr. Andy Roark has partnered with VetFolio to release the Uncharted Leadership Essentials Certificate. The program provides training appropriate for anyone who leads or manages others. The topics covered include setting a team’s vision and values, building trust, achieving team buy-in, delivering feedback, understanding communication styles, setting priorities, delegating effectively and managing time.
Learn more at bit.ly/Uncharted-VetFolio.
STORY ARCHIVE
Veterinarian and award-winning columnist Dr. Andy Roark has contributed to Today’s Veterinary Business since 2017. Among his articles are these:
- “It’s Time for GPs to Define Their Future,” bit.ly/gp-TVB
- “The Art of Kindness in an Imperfect World,” bit.ly/kindness-TVB
- “How to Fare Well When Good Staff Leave,” bit.ly/staff-TVB