The problem is not whether veterinary practices will survive in competition with other business entities, but whether any veterinary practice will survive at all in the face of social change.

The practice of veterinary medicine is an art and a science. We have heard that from the very beginning, and some still believe that is true. The reality is that veterinary medicine is both a profession and a business, and unless we change ourselves, the profession and the practice of veterinary medicine balance on a very sharp-edged sword. We can go either way, or be split down the middle.

Everyone thinks of changing the world, but no one thinks of changing themselves. - Leo Tolstoy

This profession we love started out as a production-based service. Even in the military, the Veterinary Corps was started due to an embalmed-beef scandal, during the Spanish American War. The first military veterinarians came from the enlisted ranks, the noncommissioned officers, who were the troop farriers. The veterinarians in the "real world" travel from farm to farm, tending to the critters, a lá James Herriott. (For the youngsters out there, he was the Animal Planet of the 1960s and 1970s, but came in book form.)

This created the habit of single-column doctor scheduling, something we still do today, as the computer programmers do not seem to know how to adapt their software.

Things do not change, we do! - Henry David Thoreau

Then in the 1930s, some of these veterinary road warriors decided that it might be nice to bring the smaller critters inside their practice facility. They built "exam rooms" in the barn, or a small building next to their barn. But a funny thing happened after they did. The physicians had one-door consultation rooms, and the dentists had one-door dental suites, but our forefathers built two doors on their exam room, one on either side. Maybe it was because they were used to working at the stock chute.

"Run 'em in one end, close the head catch, treat the critter, and let 'em loose." "Powder River -- Let the buck!"

Perhaps it was a result of the help they had, which was actually no one. Well, there was that one dude or dudette in the milk lab running samples and surveillance testing, but if Doc needed that person, he had to yell, "Tell that technician that I need help!" Gee, maybe that's where the term "veterinary technician" came from, you think?

When you do everything yourself, and as an ambulatory veterinarian you are used to the drugs being behind you in the Bowie box, why not put a door on the back of the "exam room" and have the drugs right there? Sure sounds like good logic for the ambulatory veterinarian. Wouldn't want to confuse the usual flow! As we think about it, that ambulatory veterinarian has always had to worry about pennies-per-hundred-weight (cwt), as well as the feed store prices for drugs. So, he discounted his prices. Guess we need to carry that habit forward too.

One doctor, one room, one patient, and one column in the appointment log, when Doc was not out on the road doing farm calls, he might be in for the small animals, who need some form of veterinary care. Can't be that urgent. They are just disposable farm dogs and barn cats. Such were the earliest days. Doctor-centered service and veterinary linear thinking was born, and discounts continued. And believe it or not, it is still alive and well today in many veterinary practices.

Habit, if not resisted, soon becomes necessity. - St. Augustine

Our profession now had this large-animal veterinarian also working on small animals. So, in the late 1930s, the American Animal Hospital Association (AAHA) came to life, and started to translate "quality of care" issues into facility issues that were being ignored. Thus, the AAHA Hospital Standards were born out of necessity.

It is interesting to note here that many of these "facility standards" were extrapolated from human healthcare, such as:

 Aseptic procedures. Remember, these were the same veterinarians who even today hang piglets upside down on two wall hooks and neuter them without anesthesia.

 Single-use surgical suite. This from guys who still do standing left flank C-sections on cows in the barn.

 No cross-contamination between patients. Yeah, sure. Ever see a milk lot?

 And they even expected medical records that were legible.

Again, this last item has not yet made its way into some veterinary practices, though in 1990, the AAHA Standards, Section 1, "Medical Records", was revised and drove an additional fifteen to twenty percent net in those companion animal practices that actually embraced the better documentation. Then the 2003 AAHA Standards for Accreditation expanded the "expectations" from three standards to eight hundred fifty standards, mostly in actual quality of team-based healthcare delivery.

It is amazing that less than fourteen percent of the practices in North America actively subscribe to the AAHA Standards for Accreditation, while every human hospital in America subscribes to the Joint Commission for the Accreditation of Healthcare Organization (JCAHO). Oh, that's right, The JCAHO standards are mandated by government and are tied to third-party payments from the government. Gee, I wonder if there is a link between public awareness of substandard healthcare practices, or facilities, and government interdiction for the public's welfare?

Maybe, if we do not police ourselves, the community will ask the government to do it for us. Nah, that would mean they would be controlling our medical waste, the elimination of our dipping solutions, and even our personal selection of clinical drugs. Oh, there are the OSHA rules, the Environmental Protection Administration (EPA) rules, the Federal Drug Administration (FDA) rules, the United States Department of Agriculture (USDA) rules, and the Wage and Labor Board. But those are exceptions, right? Not hardly, my friends. They are the result of accountable people keeping their heads in the sand, and the community, as in "government for the people", making demands for safety and welfare issues.

To find fault is easy; to do better may be difficult. - Plutarch

Okay, back to the beginning of our paradigms. So, we had some facility changes in the small animal hospital pipeline before World War II, and we had our land grant colleges turning out veterinarians. In World War II, the veterinarians expanded their food inspection from animal products to all subsistence products. They were already in the right place at the right time as public health officers. An enlisted food inspection group of specialists was born to protect the rations of the soldiers. These soldiers came home and used their GI Bill benefits for education. These were the Americans who had mingled with people from across the country, while they were in combat, an environment that forms friendships and links that live forever. America was shrinking, mental isolation was now almost impossible, and there were shifts in the population densities from agriculture to industry.

 Veterinarians were still charging hospitalization of small animals by the pound, or by the cage size, rather than by the workload requirements. Gee, many are still doing that.

 Practices priced anesthesia based on the injectable dosage, which was pound or kilogram based. Gee, many are still doing that.

 Most did not have the staff or instruments to monitor anesthesia during surgery. Gee, many are still doing that.

 Radiology was by manual restraint. Gee, many are still doing that, except in New York.

 Most practices had a single price for injections, rather than pricing by the drug. Gee, many are still doing that.

 And believe it or not, medical records were used for invoice tracking, so they only contained what was done, not what was needed for the patient's welfare, or the client's response to that need. Gee, many are still doing that.

 Dentistry in those days was restricted to eliminating infected teeth, and prophylactic care was virtually unheard of in small animal practices. Gee, only a few are still at that level of wellness disregard.

Nothing so needs reforming as other people's habits. - Mark Twain

It is hard to believe that in this new millennium, old habits are being retained as good medicine. Last decade, a national consultant published a book of forms, and they had no gas anesthesia on any travel sheet. Do you wonder what his standard of care was in his practice?

On one consultation, I visited a ninety-four-hundred-square-foot practice that was only six years old. There were no sound barriers in the hospital, and worse, even the two-table surgery suite had a wall with a large, open, "window-sized" portal. The room was constantly in multiple use for such activities as clip and prep. Even dentistries were being done, while on the next table a patient's body cavity was open. So, naturally, a need for a cap, mask, or gown was by exception. Staff traffic through surgery was horrendous, plus it was the surgery nurse's computer station location. To make it worse, the owner had just started planning a fourteen-thousand-square-foot, three-story expansion, with a triple-table surgery adjoined to a dentistry suite, which was the portal passage to surgery, with no contamination barriers. There was no surgery prep, because "he had always done it in surgery". And this was a 1990 graduate from Ohio State University, not a third-world country. His wife was also a veterinarian.

These people were not alone in their practices. Please read this true story.

Leadership is the other side of the coin of loneliness, and he who is a leader will always feel alone. When acting alone, you accept everything alone. When acting with a team, share success and fully face failure, as if you were the causative agent, because as a leader, you were! - Dr Tom Cat

Veterinary medicine is at a crossroads. The same crossroads encountered by pharmacists, dentists, and optometrists thirty years ago, when human healthcare started moving into the required employee benefit category. These professionals did not perceive any threat, since no one could replace them. They started talking, within their own professional circles, about how good they were, and how they provided a much needed service to the communities they served. Many of the associations sponsored expensive strategic planning sessions, centered on how to better serve their constituents. Except there were two major flaws in their thinking.

 The first key problem for the associations was that "their constituents" were perceived as the subscribing members of the association, rather than focusing on the consuming public, which kept them alive. They forgot what business they were in, and what kept their members in business.

 The second problem for the associations was that they used their elected officers as the focus groups for strategic planning of the future. Without realizing it, they had selected a cohort group of professionals, who lived by the success they had in the past, not what was needed for the future. They then selected a strategic planning facilitator, who took the key planning objectives from these "professionals", rather than selecting a skilled futurist.

The pharmacists were convinced that they could not be replaced, so the small "mom-and-pop", independently owned, small business, pharmacies did not change. The corporate pharmacies emerged and offered one-stop shopping for most of the home sundries. Then the supermarkets added pharmacies, and the discount stores added pharmacies. The "mom-and-pop", independently owned, small-business, pharmacies disappeared. They could not compete for traffic or economy of scale costs.

The optometrists did not believe they could be replaced by supermarkets or discount stores, nor did they believe corporate consolidators could replace them with cookie-cutter systems. They believed, at the association level of strategic planners, since they were located on the Main Street of town, very convenient to the consumers, who needed them, knew their clients as community members, and even fit the frames for their clients, while ensuring a proper lens, they could not be replaced. The story is known by most. The frames became the consumer draw, moved to the shopping mall, and the optometrist became just a "side service", since they could fit the lens to the frame, while the consumer enjoyed the mall.

We must either find a way, or make one! - Hannibal

Then there were the dentists, who responded differently as a group. This was the era of the "painless dentist". Restorative work was their staple. Association meetings were formed to allow vendors to present product to the dentists, while they were trained in restorative dental techniques. The dental associations watched the pharmacists and optometrists, and assessed the public image of the dentists. The curative approach had made jokes about dental pain misadventures, almost as bad as the jokes about attorneys who specialized in capitalizing on human emotional pain. The dental groups responded, became some of the early healthcare futurists, and decided wellness would form a far better image than restorative work, while bringing in the masses at a far greater rate. Tooth whiteness, clean breath, and a pretty smile became the cornerstone of dentists. Wellness added another benefit, since it could be done very economically by the dental office staff, rather than the dentists themselves. Dentists could now work seven to nine chairs concurrently.

There are no bad soldiers under a good General.

Associations can respond as leaders, or they can be managers of tradition. In most cases, managing tradition is less difficult than being leaders of change. It is the weak who urge compromise, never the strong visionary. Our associations are built on the premise of membership, so compromise for the wants of the masses has been far more fiscally successful in the short term. We talk about a teenager's long-term planning as being "after supper", and we laugh. We see a veterinarian's long-term planning as being "after end of shift", and we sigh. When we see the family unit suffer, and about fifty percent end in a split-up, we cry.

If you do not know where you are, it is hard to go anywhere new.
If you do not have a destination defined, any old place will do.

The above ancillary healthcare scenarios should have changed some of the veterinary paradigms, but, for the most part, they have not. Our computer software vendors are still scheduling outpatients in a single-doctor column, because the ambulatory farm veterinarian could only go from one farm to the next. Physicians work four to five consult rooms concurrently, using medical assistants, who need six to nine weeks of basic medical training and who they call "the nurse", to load and take baseline vital signs. Most veterinary practices charge hospitalization by cage size or body weight, rather than the amount of care required for the patient. The cost of veterinary care assessed by pennies-per-hundred-weight (cwt) is of concern to production animal providers, not companion animal veterinarians, who treat "family members". Veterinary teaching hospitals schedule clinician appointments every hour -- yes, only one per hour -- so the specialists are not rushed. They are doing advance referral care, you know. And they do not train the veterinary students to understand that eighty-seven percent of the clients want to be in-and-out in less than twenty minutes when they see their general practitioner. That statistic comes from Pfizer studies of more than thirty-five thousand clients a year for three years in a row.

Veterinary associations are providing phone service, car rental, insurance programs, and a host of other ancillary services to practices, and some are even forming buying co-ops. They cannot compete with Personnel Employment Organizations (PEOs) benefits, or Internet pharmacies, but our associations expect the professional loyalty to balance the equation. The university veterinary teaching hospital is funded by research and staffed by specialists, most of who could not survive in a private general practice. The veterinary educational institutions have become secondary and tertiary veterinary healthcare facilities, specializing in the extreme curative wellness programs. Some veterinary schools have even stated they do not need to teach primary healthcare or wellness care, because students can learn that after they graduate. The last veterinary teaching hospital to be formed had no research element. They were going to focus on using primary care facilities in the geographic region to develop practitioners of veterinary medicine. The AVMA credentialing body decided in their "traditional wisdom" that without research, they could not effectively teach veterinary students. After a brief litigation negotiation, they granted provisional approval.

If you are planning for one year, grow rice.
If you are planning for twenty years, grow trees.
If you are planning for centuries, grow men. - Chinese Proverb

The current turbulent veterinary practice environment has caused associations, and the larger practices, to pursue strategic planning. In the 1980s, human healthcare responded to competition in the same manner, by funding elaborate strategic planning conferences, developing detailed action plans, then observing their best laid plans fail. By the late 1980s, they had found one common flaw. In most cases, no one person had been given the responsibility and authority, as their primary function, to make the strategic plan happen.

At the same time, McDonald's® restaurants developed the strategic assessment and strategic response model. They abandoned cardboard and paper packaging for the faster and more sanitary Styrofoam clamshell containers. The American environmentalists were beside themselves, due to the non-biodegradability of those packages clogging the landfills. McDonald's assessed the consumer's environment, and returned to the cardboard and paper packaging. Their image was applauded and consumers were happy.

To do what you have always done is comfortable, so the true story above should not be a surprise. In fact, I'll repeat the old adage I quoted in Chapter One: "If you always do what you have always done, you are going to get what you have always got (A² = G²)." The other saying that follows is the definition of insanity: "If you do the same thing over and over, and then expect different results on subsequent tries, that is insanity."

The problem is that this concept describes most veterinarians, as they try to achieve the "next level". They have never been to that level, so they repeat the old processes and ingrained methods, trying to use more hours or more staff, or even new associates, thinking that will move them to that next level. Growth occurs, but operationally. They are reaching a "glass ceiling". They can see what they want, but cannot break through that barrier built by paradigms, those habits of unknown origin.