The 2015 AAEP Convention offered multiple sessions on business, with topics to fit every practitioner’s level of interest and experience. The overall theme for the business sessions was “strategy.” Here are some of the topics addressed during the convention. This coverage is brought to you by Zoetis.
The Art and Science of Resiliency
In response to the growing concern about wellness issues among veterinarians, the keynote speaker of the 61st annual convention was Dr. Daniel J. Siegel. A nationally renowned neuropsychiatrist, Siegel spoke on “The Art and Science of Resiliency.” Siegel indicated that everything he shared with the audience had been studied by scientific means and published in refereed journals.
Siegel explained, “Many fields have explored the nature of mental life from psychology to psychiatry, literature to linguistics. Yet no common ‘framework’ where each of these important perspectives can be honored and integrated with one another has been created in which a person seeking their collective wisdom can find answers to some basic questions, such as, ‘What is the purpose of life?’, ‘Why are we here?’, ‘How do we know things?’, ‘What is the mind?’, ‘What makes a mind healthy or unwell?’ And, perhaps most importantly, ‘What is the connection among the mind, the brain and our relationships with one another?’ ”
He emphasized that our mental lives are profoundly relational. The interactions we have with one another shape our mental world. Yet neuroscientists know the mind is shaped by the neural firing patterns in the brain. So how can we reconcile this dichotomy that the mind is both chemically and relationally reactive? Siegel suggested that interpersonal neurobiology is a way of thinking across this apparent conceptual divide. Understanding interpersonal neurobiology can aid in the personal and professional application of this approach to developing a healthy mind, an integrated brain and empathic relationships.
Siegel described a study utilizing a well-established “Burnout Profile” at the Mayo Clinic in 2015, where 54% of the physicians were found to be suffering from compassion fatigue. In the veterinary field, the CDC study published in February 2015 indicated that veterinarians suffer from mental distress at a significantly higher level than the general population, and that 1 in 6 veterinarians has considered suicide at one time or another since graduation. Siegel discussed the “Caring-Killing Paradox” that exists in veterinary medicine, where euthanasia is a necessary, important, but under-taught service. It is a stressor unique to veterinarians and might contribute to their distress, in his opinion.
The expression of empathy from a physician has been shown to increase positive outcomes in patients through stronger immune function, according to Siegel. He explained that it is possible to reach out to someone in psychic pain and change the outcome. The science behind this occurs at the chromosomal level. He said that inside the nucleus of a cell, our genes are arranged along the twisted, double-stranded molecules of DNA of our chromosomes. At the ends of the chromosomes are stretches of non-gene-containing DNA called telomeres, which protect our genetic data from damage and make it possible for cells to divide. When chromosomes are replicated during cell division, a stretch of the telomere is left unreplicated, making the telomere a bit shorter with each division. The key to inhibiting the process of telomere shortening involves an enzyme called telomerase. Stress and aging negatively affect telomeres, and without them, mutations are more frequent.
Siegel explained that epigenetic regulators (methyl groups and histones) sit on the DNA and affect when genes are expressed. Epigenetic regulators allow an organism to respond to environmental effects through changes in gene expression. Through this means, “mind changes” can affect clinical outcomes.
Siegel reminded the audience that, “Not everything that can be measured is meaningful, and not everything meaningful can be measured.” Through conscious as well as nonconscious information processing, the mind regulates the energy and flow of information that takes place in the body and in relations with others. Because we are all relational creatures, the mind does not reside in the brain, but is both “embodied and relational,” he said.
In order to achieve resilience, Siegel recommended educating the mind to create integration, with integration defined as differentiated, but linked. Thus one could honor differences while retaining flexibility and compassion. He described two banks of a river, one bank called "chaos" and the other "rigidity." These river banks enclose the harmony of the river’s flow, which is flexible, adaptable, coherent, energized and stable. In order to be resilient, one must differentiate, as follows: Coming upon the scene of a car accident, do not imagine if you were in a car accident; instead imagine what it is like for the person that is in the car accident. Mirror neurons cause you to soak in the suffering of your patients and clients. Differentiating will help you cope.
In closing, Siegel made some very specific recommendations:
- Create and nurture social networks of support, through personal and professional friendships.
- Honor your family life and your well-being.
- Create a strong self-relationship by writing regularly in a journal, which has been shown to decrease stress, increase immune function and help integrate the brain.
- Remember neuroplasticity: “Where attention goes, neural firing flows.” You can intentionally strengthen the circuits in your brain in differentiation and linkage, which will have profound effects on mood regulation, emotional regulation and relationships.
- Mindful attentiveness equals presence, which equals the activation of neural fibers that are integrative, which makes for better regulation.
The Business News Hour
Lisa Kivett, DVM, MS, DACVIM, Mary Beth Whitcomb, DVM, MBA, ECVDI (LA Associate), and Mike Pownall, DVM, MBA, headed up this popular kick-off to the Business Education sessions at the convention.
First up was a paper published in Pediatrics in August 2015 entitled, “The Impact of Rudeness on Medical Team Performance: a Randomized Trial.” The investigators hypothesized that team-targeted rudeness might underlie performance deficiencies, with individuals exposed to rude behavior being less helpful and cooperative. Their objective was to explore the impact of rudeness on the performance of medical teams.
Twenty-four NICU teams participated in a training simulation involving a preterm infant whose condition acutely deteriorated due to necrotizing enterocolitis. Participants were informed that a foreign expert would observe them. Teams were randomly assigned to either exposure to rudeness (in which the expert’s comments included mildly rude statements completely unrelated to the teams’ performance) or control (neutral comments). The videotaped simulation sessions were evaluated by three independent judges (blinded to team exposure). The study concluded that rudeness (even the mild rudeness experienced here) had adverse consequences on the diagnostic and procedural performance of the NICU team members.
In veterinary industry news, the 2014 Nationwide/Purdue Veterinary Price Index reported in July 2015 that overall veterinary pricing is not keeping pace with the cost of other consumer goods and services. Significantly, the gap between well-care and medical treatments is widening, with medical treatments continuing to decline while pricing for well-care procedures is increasing. Additionally, it was reported that the number of high-volume, nonprofit companion animal veterinary clinics such as Mission Animal Hospital in Eden Prairie, Minnesota, is growing, and that it is probably only a matter of time before we will see this in the equine sector.
The horse racing industry has had its ups and downs in 2015, the team reported. Although American Pharaoh’s Triple Crown victory brought Americans renewed enthusiasm for racing, many states have slashed horse racing support from their budgets, creating a fight for survival in many locations.
New technology was highlighted. It was stated that 35% of seniors are using social media. Facebook has started live video streaming, and a new service called Periscope (owned by Twitter) is available; this is a platform that allows you to video-record and broadcast to anywhere in the world. If you have used Skype, it is a similar experience, but instead of video conferencing with one person, you can stream to the masses.
In human medicine, it was reported that telemedicine is advancing: ICU units’ patient monitoring is now being performed remotely in some hospitals. Increasingly, physicians are utilizing Skype to interact with patients.
However, in veterinary medicine, a Texas veterinarian who offered pet-care advice online lost his fight in late November against state regulators after the U.S. Supreme Court declined to hear his case. The veterinarian argued that a state regulation requiring him to physically examine an animal before practicing telemedicine by offering a professional consultation over the phone or Internet violated his free-speech rights. But the court had ruled earlier that Hines broke Texas law when he answered pet owners’ questions through an “Ask a Vet” link on his website. The Texas Board of Veterinary Medical Examiners suspended his license. The Supreme Court’s decision not to hear Hines’ appeal means the lower court's ruling will stand.
New products are continually available. Highlighted were Parasight, I-Sperm, SlyDial, electronic stethoscopes, GPS dog collars, halters which communicate vital signs, “smart” bandages and CrowdMed.
The team cited an article posted November 2, 2015, on the Business Insider website that listed the 27 jobs most damaging to your health. Veterinary medicine was #4. Statistics were also shared about cyberbullying, with 20% of vets experiencing this in 2015, usually from a former client or employee on Facebook.
As always, the whirlwind 60 minutes through news pertinent to the business of veterinary medicine was informative, interesting and thought-provoking.
AVMA Economic Report on Equine Medicine
Michael Dicks, PhD, Director of the AVMA Veterinary Economics Division, gave an hour-long presentation on the state of the macro and micro economies affecting those in equine practice. To begin, Dicks gave a macroeconomic forecast. He said that the biggest impact on a veterinary practice’s performance is the economy, as discretionary income drives most veterinary service purchases. He recommended regularly accessing the technical report of the Leading Economic Index at www.conferenceboard and monitoring the graph for a downturn, which gives about 18 months of forewarning of a recession. The Conference Board is a non-profit, global independent business membership and research association working in the public interest.
Dicks predicted that a short shallow recession would occur in the next 8-18 months, possibly in June of 2017. He expects the GDP (Gross Domestic Product) to increase for the next 8-20 months, and recommends that practice owners put aside cash in expectation of the coming recession. The GDP is one of the primary indicators used to gauge the health of a country’s economy. It represents the total dollar value of all goods and services produced over a specific time period; you can think of it as the size of the economy.
Dicks believes a full recovery of our country’s economy from the Great Recession will take many years, as 11% of the workforce is underemployed or unemployed. This is in part because Baby Boomers are retiring early and Millennials are joining the workforce later than previous generations, he said.
Moving on to the veterinary industry, Dicks shared data from the AVMA’s ongoing economic studies. The equine veterinary market is quite diversified; practices perform highly varied work, even within the equine field. Of the sum of applicants to veterinary school, 37.5% indicate an interest in equine practice at the time of application, yet only 2% of new veterinarians enter equine practice after graduation. This might be because entry-level salaries are much lower than those in companion animal practices. Of the 30 new veterinarians reporting that they accepted associate positions (not internships) in equine practice in the latest AVMA employment survey, the mean salary was $45,000. This study showed a 5% increase in salaries in 2014, and a 10% increase in the number of available equine positions in 2015. Internships are frequently chosen by graduating veterinarians interested in equine practice, and the numbers have remained stable. There were 107 graduates choosing equine internships in 2009, down from 148 in 2012 and 144 in 2015, Dicks noted.
Although it was reported after the 2014 AVMA Second Economic Summit that the net present value of the veterinary degree for an equine practitioner was (-)$500,000 with a break-even age of greater than 65 years of age, Dicks reported new, more positive findings that used different estimates for lifetime earnings, discount rate and BS (Bachelors of Science) degree earnings. The economists use the discounted value of the lifetime earnings minus the lifetime earnings for a BS degree, the cost of the veterinary degree and the income not received during the four years of veterinary college attendance to calculate the net present value.
With respect to the lifetime earnings, these change as the starting salary increases. The economists also changed the earning path estimate for the DVM/VMD degree by doing an economic analysis of veterinary incomes for both men and women rather than using a generally accepted earnings path. In addition, the discount rate used in 2015 better reflected new veterinarians’ time value preference (the value of today’s $100 in the future) and used a published lifetime earnings path for BS recipients.
Dicks noted that starting salaries increased by 5% and that a $2,000 increase in starting salary would essentially offset $50,000 in debt. These new assumptions yielded a (+)$200,000 net present value for female equine veterinarians and (+)$80,000 for male equine veterinarians. The reason for the discrepancy between the genders is that females in the general population working full-time generally make only 79 cents for every dollar earned by men, a gender wage gap of 21%. By contrast, women in the equine veterinary profession, although they typically earn less than men, have a smaller wage gap. Thus a career in equine veterinary medicine is financially more beneficial to females than males, compared to a career following a BS degree.
Dicks stated that the NPV is a key performance indicator for the profession, denoting the lifelong value of the DVM degree. The AVMA Economics team will continue to refine it and compare it to other professions, and will have the newly revised estimates and methods in the 2016 AVMA Report on the Market for Veterinarians.
In conclusion, Dicks reported that current excess capacity in equine practice is projected at 12.7%, a very positive development compared to the 23% reported in 2013. He went on to say that in 2013, only 33% of practices were working at full capacity; in 2014, 47% were at full capacity; and in 2015, 45% reported working at full capacity. Income to owners increased accordingly. Equine practitioners can expect continued efforts to provide economic data specific to their small niche in veterinary medicine through the combined efforts of the AAEP and AVMA.
Insights on Business Culture from Zappos
Jon Wolske, culture evangelist for Zappos Insights, presented an extraordinary hour of information about creating a healthy culture. He began by stating that, “If your culture is driving away the best people in your organization, then you are hurting your business every day.” Acknowledging that many businesses consider culture to be a “soft topic” about which they have little interest, Wolske suggested that caring about your practice’s culture can produce decreased burnout among employees, lessen turnover, increase productivity and ramp up profitability. “Culture will ultimately drive employee productivity, customer service, quality and brand strength,” he said.
Wolske defined culture as the common organizational mindset: “Attitudes, feelings, values and behaviors that characterize and inform a group and its members. Your culture and your brand need to make people (your customers and your employees) feel good.”
Millennials, who make up many of today’s employees, want to feel like they are making a difference. In today’s business environment, honesty and integrity are expectations, he said. A company’s values define what it is, and shape the culture. According to Wolske, it is important to define the culture, then commit to it wholeheartedly by living it.
For example, at Zappos, this is a list of core values:
- Deliver “wow” through service. This means you need to exceed expectations, give full attention to anyone who approaches you and listen intently. An example from customer service was a caller who had purchased shoes for a wedding that were too small. The Zappos employee asked where the wedding would be held and shipped replacement shoes to that venue without waiting for the return to be processed.
- Embrace and drive change. This means being open to new ideas, especially from new employees. Never say, “We don’t do it that way here.”
- Create fun and a little weirdness. This means you need to foster relationships and be yourself.
- Be adventurous, creative and open minded. This means that you shouldn’t be afraid of trying new ideas; start small, then grow or kill the ideas, depending on results. Very few true mistakes occur because learning always occurs.
- Pursue growth and learning. This means encouraging everyone to continuously learn and grow in their positions and responsibilities.
- Build open and honest relationships with communication. This means you must foster transparency and honesty. Set expectations, talk honestly about what happened, and stay dedicated to learning and growing. An example from the IT department at Zappos was a sale that was posted with a decimal point in the wrong place. The orders were honored, creating a $16-million loss. The employee kept his job, and new procedures were put in place.
- Build a positive team and family spirit. This means you need to keep in touch with your people on a daily basis. Don’t be so caught up with work that you don’t relate to your team.
- Do more with less.
- Be passionate and determined.
- Be humble.
Wolske cautioned that it is important to hire people that fit the culture of your business. He said, “When the relationship is not beneficial to both parties, it is time to say goodbye.” Referring to customer service, he recommended looking at it as an important investment rather than as a cost. He reported that at Zappos, 40% of customers come through word of mouth, and 75% of the orders are from returning customers. Making a personal, emotional connection in each interaction will make your customers experience “wow,” he promised.
The criteria for great customer service at Zappos include:
- a positive first impression;
- the customer is truly heard;
- customers’ needs are fully met;
- customer experiences “wow”;
- a personal emotional connection is made;
- future assistance is offered.
In closing, Wolske recommended that a company’s interactions with its employees be subject to the same criteria for great service as its interactions with customers.
Women and Success in Ambulatory Practice
Before an almost exclusively female audience, Carol Sabo, DVM, Mary Beth Hamorski, VMD, and Rhonda Rathgeber, DVM, PhD, each gave presentations about their experiences as women in practice, offering strategies that worked best for them in forging success. Common themes emerged from the veterinarian’s approaches: collaboration, managing expectations,
utilizing technology to drive
efficiency and creating clear
All three women stressed the importance of collaborating with their teams. By standardizing shared resources and processes, they maximized flexibility. For instance, by having trucks that are set up and stocked identically, all vehicles are equivalent and can be easily shared among doctors working two-, three-, or four-day weeks. Or if a vehicle is being repaired, no efficiency is lost by a doctor having trouble finding equipment or medications in an unfamiliar rig. In her large practice, Rathgeber determined which services she didn’t care to provide, and provided opportunities for associates in the practice to perform those duties and thus increase their revenue production.
Managing the expectations of clients, staff and partners can be a challenging part of gaining control of practice life for women. Sabo and Hamorski established four-day work weeks for their staff veterinarians and allow as much choice as possible in filling the six workdays of the week. Some female associates choose to work Saturdays, as their husbands can stay home with the children that day. Many mothers who are equine veterinarians enjoy having a weekday off in order to attend school events or doctors’ appointments, and run errands that are hard to accomplish on weekends. Both of these practices share emergency duty equally among their full-time doctors.
With some women practicing part-time or establishing firm limits to their full-time working hours, setting clients’ expectations is particularly important, according to Sabo, Hamorski and Rathgeber.
Collecting extensive client data documenting their wishes during emergencies, including an authorized amount of money to be spent, preferred referral hospital and permission for trainer or agent involvement, has been a key component in Hamorski’s practice. With an organized and detailoriented approach, everyone in the practice can share the information necessary to provide coordinated, team-based care. By communicating in advance about their availability, women veterinarians can prepare their clients for veterinary services that will be provided from time to time by other members of the practice.
Technology can be essential in keeping working time as efficient and as organized as possible. Hamorski’s practice uses a synched Google calendar that is linked to Google maps and scans an extensive group of client forms into each record, so that information is available to each doctor who might service the account. All of these doctors utilize electronic practice management software via laptops in their trucks, and they carefully record re-check appointments, callbacks and other future care.
Using group text messaging allows all on the team to know how the day is progressing, who needs help in completing their work, and what emergencies have come in, said Sabo. While all veterinarians benefit from these efficiencies, women who are trying to carve out family time are especially motivated to utilize all tools at their disposal.
Communication is an essential part of team-based veterinary care, stressed these veterinarians. All medical records must include all communications made between doctors and clients, as well as up-to-date laboratory results. Updates to patient records and invoices should always be completed before a veterinarian leaves at the end of the day. This prevents lost information, miscommunication and missed revenue from forgotten charges.
Sabo’s practice has business-owned cell phones that are kept in the veterinary vehicles to minimize the cell phone “umbilical cord” that often develops between veterinarian and client. She finds that this technique helps set aside time away from the practice that is truly “free” time. Providing continuity of care with excellence requires regular updates and calls about cases between veterinarians.
Strategy: the Foundation for Success
Ky Mortensen, JD, MBA, of Inova Partners, spoke on “What is Strategy?” He said that strategy is an organized plan for getting what you want. It requires that you know your mission (what you do) and your vision (what you want to become), so you can plan steps to achieve your goals.
Mortensen suggested that alignment of your strategic plan with the shared aspirations of the ownership team must be followed by intentional focus in order to achieve the desired outcome.
The wide variety of business presentations at the 2015 AAEP Convention included the results of the 2014 AAEP Listserv Members Survey, how to develop prices for services, and strategies to improve your human resources practices.
Additional coverage from the AAEP Convention's business sessions, brought to you by Zoetis, can be found in the Resources>Downloads section on EquiManagement.com.
Amy Grice, VMD, MBA, was the managing partner of Rhinebeck Equine LLP, a large equine referral practice in New York state, until 2015, when she opened a veterinary business consulting firm. Grice’s areas of special interest are communication, leadership and business strategies. Grice is a member of the AAEP Board of Directors, and she serves on several AAEP committees.