Dicks commentary bug
During the past eight weeks, the VIN News Service published a set of commentaries by Michael Dicks and Dr. Melissa Maddux that examine the veterinary profession through the lens of economics. Dicks served from 2013 to 2018 as chief economist at the American Veterinary Medical Association. Maddux, a veterinarian, was an AVMA economics fellow.
After studying the profession in depth, Dicks concluded that its members are at imminent risk of losing control of the profession to outside business forces. To prevent that, he argues that veterinarians, individually and collectively, must overcome inertia and tradition to act urgently in reforming the profession, from the way aspiring veterinarians are educated to how veterinarians are deployed in the workforce; and from how practices are owned and sold to how veterinary services are priced and delivered.
The eight-part series drew hundreds of reader comments, most of them posted on message boards of the Veterinary Information Network, an online community for the profession. Here is a selection.
Letters
[W]e as individual practitioners are usually best suited to decide how to provide our particular services and ... must dig inside ourselves to improve our ability to sustain our profession, not look so much for higher bodies to provide for us, whether by instituting higher published standards, changing vet school admissions, expecting salvation from AVMA or by accepting admonishment from anyone who is not knowledgeable of our particular practices.
My opinion is that our best "fix" is to work on self-improvement to raise our level of trust and respect on a local level. We can cry all we want about societal and political changes that diminish our profitability, but no one will legislate for our individual improvement. It must come from within, as we still have a great profession with fantastic opportunities. I contend any U.S. or Canadian veterinarian has the opportunity to be successful if they truly have the desire and grit to be so.
Dr. Gary Lesamiz
Okanogan, Washington
I do agree that the history of how things used to be done has dramatic effects on how we do things now, even when it doesn't make sense any more. We do it the same way as our predecessors because we don't know any other way. The whole damn profession needs an upgrade from education on up. Actually, a redesign. The question is, are we going to let the corporations define us, or are we going to do it ourselves? I fear I know the answer.
Dr. Meghan Ellis
Sanford, North Carolina
Since graduating vet school in 2015, I realized the profession (from schooling to delivering medicine and communicating with owners) was in bad shape. I hit the most difficulty when coming up with a treatment plan for owners that cannot meet the "standard of care." We have to have lengthy discussions on risk-benefit of certain decisions. And then there are the legal implications as the doctor. It is incredibly muddy waters.
I am thrilled this is being addressed.
A noteworthy example of a visionary approach is the Stanton Foundation's effort to shift the veterinary profession from the concept of "standard of care" to "spectrum of care," and the Access to Veterinary Care Coalition's focus on improving affordability of veterinary care. Spectrum of care refers to offering clients a range of diagnostic or therapeutic options for a patient. Development of the options is guided by many factors, including the veterinarian's knowledge and skill sets, current scientific evidence for safety and efficacy, practice guidelines, cost and — most notably — the owner's goals, values, resources, and willingness and ability to comply.
Dr. Sara Corrigan
U.S. Army
Never thought I would be looking forward to reading articles on this subject, but after 10 years of practice and feeling some qualms about the trajectory of our profession, I'm looking forward to reading this series.
I think that one of the major factors affecting how our profession as a whole operates is the lack of skilled paraprofessionals. Veterinarians need support. We just can't do it all, and nor do I think we should be expected to. Do you think that human MDs would be as productive as they are if, for example, in addition to performing a surgery, they also had to sedate the animal, place the IV catheter, scrub the surgical area, attend to the anesthesia, provide the aftercare, double check that prescription labels are accurate, and then coordinate the physical rehab? Yikes! We do a lot.
I have a friend who left the profession (she was the best RVT ever) to become an RN. She tells me she has more job satisfaction, is actually less stressed, does not bring her work home with her, and she feels respected by her colleagues.
Friends, we are losing or deterring really good people, and I don't necessarily blame them. How do we fix this?
Dr. Leslie Sklena
San Luis Obispo, California
Regarding the statement "Looking at the veterinary profession as my patient, taking a patient history, running numerous diagnostics, reaching a diagnosis and creating a treatment plan, I failed to get the client to accept and implement the treatment."
This is an appropriate and telling analogy. Information is not the main driver for clients to take actions for their pets, nor for people to take action, period. That is why compliance in veterinary and human medicine is so low and resistant to efforts to improve it.
Of course, information is important. We use it to shape decisions and behavior. However the primary driver, the determinant of how we ultimately make decisions and behave, is emotion. ... Facts and figures will not change behavior, of our clients or ourselves. ...
How will pet owners who are struggling with debt (just like many veterinarians) and living paycheck to paycheck, feel about paying more than a thousand dollars for an ovariohysterectomy, or several hundred for a routine wellness visit, for that matter?
Those who will succeed in veterinary medicine will be, I believe, those who adapt to the profound shift in the delivery of veterinary medicine that is already in motion. It’s not just about money, either. We are in the process of moving from a "closed system," in which we own the information and the choices available to the animal owner, to a more open system, in which access to information and a variety of services is widespread. It's already happening, and the momentum for more choice in veterinary care will only grow.
Pet owners want to feel empowered and confident that they are making the right decisions. They also want to feel financially secure. Their decisions may not be ones with which we always agree, but more and more pet owners want to feel ownership, or at least partnership, in these decisions.
Those of us who fear and resist this change will not like the outcome, whereas those that become active participants in new ways of delivering veterinary care to animal owners will thrive.
Dr. Michael J. Murray
Oro Valley, Arizona
Regarding the concept that veterinary education is outdated, too expensive and in need of redesign:
I'm a small animal vet. I'm trained in large animal, equine, pocket pets, birds, pigs, small ruminants — and I don't use any of it. A month ago, I was driving and I saw a down horse. My mind debated pulling over and seeing if I could help, and I thought, "I'm not insured on equines, and I don't remember anything about them," so I kept driving.
I could [have] cut out so much of my curriculum because I knew that I had no interest in [the] above. I'm literally paying down a hundred thousand [dollars] plus interest for something that I will never use. I understand the argument "you may not know when you get in there, and a lot of vets change their track" but yeah, let them change it and make them pay more. Not me.
If you want to look at changing something and changing it quick, easy, and usefully, change that. Change the "all creatures great and small" way we're educated. ...
We don't get business education in vet school; at least, I didn't. I became an owner at 29 and I knew nothing about business. I'm expanding my practice this year and I would love it if there was a real place or consultant that I could bounce ideas off and would jump into what I'm doing and help with pricing, staffing, etc. Without quality people running around, we are just minnows waiting to be eaten by corporate sharks. They know the business and they will direct us on what to do, and sadly, some of us just jump into the whale's mouth because we know no other way.
Dr. Matthew Pike
Schenectady, New York
I think part of the problem on cost is that large academic institutions and specialty hospitals are constantly trying to "one up" each other in a competitive market with pretty buildings, new equipment and new toys. One way we might lower costs is by playing nice in the sandbox so that not everyone is duplicating the same equipment and we agree to refer smartly and collaboratively, figuring out how to maximize caseload in certain institutions and then figuring out how to move students around with special interests to just see a lot of caseload in one place.
Dr. Beth Davidow
Seattle, Washington
While the curricula have been tinkered at many schools, we still transmit didactic information primarily through stand-up lectures. Sure, we have PowerPoint and everyone is on her laptop during lecture, but it's still pretty much the same as when Socrates was teaching.
Some of my best students (from my teaching days) skipped lectures, watched the video of it or listened to the recording of it, read the slides (faster than actually presented), and did so in a "binging" fashion — all of a given module in one meal, rather than in little interrupted chunks. Those students did very well on exams.
I realize in a clinical education, there is a necessary and labor-intensive need for hands-on laboratory and senior clinical instruction, but roughly three years of the DVM/VMD training is didactic, and the lack of innovation is notable. I also appreciate the pain of curricula change — the picture in any dictionary next to the word "inertia" is a university curriculum committee.
Instead of innovation, administration/facilities/faculty continue to expand their number at a much greater rate than class size expansion would dictate, and the tuition costs rise at two to four times the rate of inflation. There is no downward price pressure at all on the higher education (including vet med) market; it is a bubble of giant proportions. It is a remarkable exception to the general improvement in efficiency seen in most other businesses (manufacturing, service-based businesses, logistics). It takes vastly more resource to confer a degree today than it did 30 years ago.
The education piece is insoluble so long as buyers pay the asked price for the degree; only when class seats go unfilled will there be any thought to improving the efficiency of the education system.
Dr. Michael Moyer
Bensalem, Pennsylvania
None of Dr. Dicks's "fixes" are going to work until the federal government decides to cap graduate lending. That is a political hot-potato issue which no one wants to touch. We go on discussing online courses/species specific educations/cutting down undergraduate years and on and on, and ignore the elephant in the room.
Dr. Micaela Shaughnessy
Alexandria, Virginia
Responding to the installment "The market for veterinary services: cracks in the foundation," in which the authors talk about "upside-down pricing of products and services":
I'm very happy to see Michael Dicks take on the challenges to the profession, and directly engage veterinarians! I hope these conversations will yield changes to the profession that can help sustain the profession, rather than destroy it. I am often offended that the "solutions" of reducing the cost of education, or altering markups are posed at all. All professions face the cost of education, and anyone who sells any product faces competition and a changing model for distribution of products to the end-user. These are not unique challenges to veterinary medicine. Somehow, other professions have risen above those challenges with higher compensation for their services, sufficient to cover the cost of education and the cost of being in business, even if that means fewer product sales or lower markups on products.
Dr. Jake Zaidel
Malta, New York
Regarding the statements "The takeover of veterinary practices by non-veterinary owners who are motivated chiefly or solely by profit" and "These issues have persisted since at least the year 2000, yet there has been no profession-wide effort to address them":
This is the point that bothers me the most. The big banks that support practice consolidation can certainly offer unbeatable prices to buy out established private practices, but could that be because we as general practitioners underestimate the future value of those independent practices?
I fear that I will spend the rest of my career working for someone else; making a fraction of the potential wealth an owner can achieve; and depending only on a IRA/401K to survive after retirement.
There are other ways our industry could unite without giving up ownership to non-veterinarians. Why do we not see more franchise groups in our field? A network of independently owned and operated franchise clinics may be able to compete with the corporate groups.
Believe me, I feel the debt-to-income crunch every month. But obviously, our industry has enough future potential to make the banks and corporations ready to fight over us. Instead of selling out to the highest bidder, maybe we should reinvest in our own future and keep ownership options alive.
Dr. Andrew Tesh
Houston, Texas
Regarding the statement "Unfortunately, strict adherence to the highest standard of care that medicine can provide ironically may serve to widen the gap between animal health care needs and the treatments to fulfill them":
This, I think, is the biggest problem in veterinary medicine right now. We cannot wish our clients into having more money than they do. We do ourselves a great disservice by pricing a significant amount of the population out of adequate care. We do ourselves an even greater disservice when we try to make these clients feel bad about not having money. This discourages them from seeking veterinary care period, resulting in all-out emergencies and the tragedy of offering euthanasia for free because the client cannot afford $5,000 for treatment for something preventable....and perhaps all because we priced the basic services out of their range. Is this what we are becoming?
Dr. Lois Lassiter
Conyers, Georgia
Responding to the installment "Practice consolidation demystified":
I see some Blue Ocean opportunities for veterinarians to feed where the sharks aren't feeding. ... Corporations are mostly ignoring ... smaller practices. … I would encourage veterinarians to evaluate opportunities within their geographic area. The first step is a simple telephone call to those colleagues that each of us has known for years. Rather than seeing these smaller practices disappear, their owners should consider doing a small roll-up or merging into a larger practice. Not only do these increase practice value, they also help decrease risks associated with temporary understaffing, can lower cost of goods sold and greatly decrease stresses associated with practice management and human resources.
Dr. Jose Pla
Rutherford, New Jersey
One way some veterinarians have been able to fund clinics, or even their own homes, was other veterinarians that know them privately loaned them money, and I wonder if an investment group of veterinarians could set up a fund and invest in independent hospitals. Maybe not now with all this Monopoly money flying around, but in a few years when the inevitable pullback happens.
Dr. Dani Weber
San Mateo, California
Regarding the statement that "Understanding that the boards [of large corporations] have a responsibility to maximize return on investment, the main question for practitioners is: To what extent will this impact veterinary medical service guidelines and veterinarians’ freedom to make the best health-care decisions for their patients?":
[G]reat point. When you are in control, you are in control. When you work for a nameless, soulless corporation, they tell you what to do. Yuck!
Although there are economies of scale and efficiencies large groups have, they also have an overarching corporate structure they need to support. CEOs, boards, and investors all need a constant stream of money that you don't have to even think about when you own your own clinic. And the more they pay, the more they are going to need in return. This gap ... between what you need as an independent owner and what they need is huge!
Dr. Joseph Frost
Loves Park, Illinois
Regarding labor-supply volatility and workforce scheduling conventions:
The biggest problem with labor supply and demand is that the demand is out there where new graduates don't want to work and live. Many millennials (not all, certainly) want to live near metropolitan areas. I had one that left us because we didn't have a Whole Foods here.
Dr. Mark T. Hayes
Greenville, North Carolina
I am completely able to pay $85,000 for a four-day workweek but not $125,000 like many of the new grads are demanding. And I would gladly pay $125,000 for a four-day workweek if they could produce enough, but the fact is that most can’t, either due to personal work pace or market demand.
Dr. Tracy Walker
Elkins, West Virginia
One thing this discussion fails to include is efficiency of case management. At some point, there have to be some vets who handle the more intensive cases. The elasticity of supply works well in the wellness arena, but on the sick animal side, part-time vets are extremely inefficient.
Dr. Trey Fuller
Anderson, South Carolina
Regarding the call for using data analytics to understand the 'why' behind the biggest challenges facing the veterinary profession:
I'm all for data analysis and analytics. For instance, I'd love to know what the elasticity curve is for veterinary medicine, and in particular to my hospital. (Elasticity measures how the sale of a good or service changes when the price changes) Would I make more money or less if I lowered the office fee? As a single location, I can't afford to run an experiment — if I hypothesize the wrong way, I could lose too much money. A corporation could conceivably do this in neighboring locations.
Animalytix tracks over 8,500 products from 500 manufacturers. They aggregate the data from manufacturers and distributors down to the ZIP code level. In many instances, there is only one veterinary hospital in a given ZIP code. They know more about your hospital's inputs compared to your neighbors than you ever could.
Who is able to purchase access to this data? Can veterinary corporations buy it and choose to build a hospital next to a well-performing one? Can practice aggregators get it and use the information when making an offer to purchase a hospital?
Right now, the piece of data that a company like Animalytix is missing is your selling price for a good or service. They can only get this if you share it with them, or if someone with whom you share data (e.g., your practice management software) shares it with them (hello to terms of service that say your data can be used for other purposes).
I could see this getting ugly quickly.
There's a lot of good that can come from data analytics, but I worry about the risks to an individual business when a private corporation controls the data. This is a job for the AVMA.
Dr. Michael Goldmann
Nanuet, New York
Responding to the installment "Veterinary profession at a critical crossroads," which states, in part, that "From education to employment to clinical practice, many of the profession’s fundamental systems, business models and practices — its customs and culture — no longer meet the needs or expectations of veterinarians, clients or the communities they serve":
These overall problems appear to me to be best solved at a state level. The state level can move faster and implement region-specific problem-solving. The state level can institute species-specific licenses to better suit the regional differences in types of animals, cost of education (decrease number of years needed for license), and testing of licensee's abilities. We could have 50 different experimental models happening to help with national problems.
Dr. Shelley Lenz
Killdeer, North Dakota
Responding to the installment "Fixing the veterinary profession before it's too late":
Challenging times call for intuition and inspiration. ...
1. Why do we more often view our fellow professionals as competitors and not colleagues? I have seen decades of conflict over a spay done down the road for $50 that carried over into the battles at county VMAs and board meetings at local collective emergency clinics. Businesses doing millions in revenue are derailed over a $50.00 grudge (true story).
2. Why does the vet profession not have a national marketing campaign like the dental profession started in the 1990s to overcome the loss [business to treat] dental disease [and] to promote cosmetic care and a vigorous revival of profitability? Would not our ability to increase practice share [improve] if the animal populations not served were brought within the sphere of health care by more educational outreach?
3. Where is the demand that our state and national leadership perform the tasks stated by surveys decades in and out? Most vets do not participate in local and state associations, nor care [about] the outcomes of policy or legislative proposals.The state VMAs do not get much feedback or participation when they reach out. You get out what you put in.
4. What is needed on the ground is not necessarily what is needed in the teaching universities in five to 10 years. While those initiatives are valid, I see little addressing the local issues while seeing much press over evolving issues at the national level. ...
5. Training the new grads to be ready for practice seems to be a bigger challenge than ever. While technology is critical, new grads could truly benefit from some reality preparedness in the realm of clinic financial economics, staff relationships and client communications. ...
These things take sweat equity, but are attainable. Ben Franklin's statement that "We must, indeed, all hang together or, most assuredly, we shall all hang separately" was never more true.
Dr. Robert Clipsham
West Lake Village, California