This new resource offers veterinary professionals and students an opportunity to earn RACE-approved CE credit via a series of informative online webinars.

dvm360 launches online CE center amid pandemic

Registration is now open for the first virtual Fetch dvm360 conference, which combines three of our exclusive annual live events: Fetch Baltimore, Hospital Design 360 and Fetch Kansas City.

Registration for Fetch dvm360 virtual conference is open

This exciting event is ideal both for recent graduates and veterinary professionals looking for new opportunities.

dvm360 hosts second virtual recruitment event

For many people, personal and professional life goals are intertwined, and this is certainly true for current and future veterinary practice owners. Reaching your personal goals often depends on having some level of financial freedom, which is only achieved when you reach your professional goals. If your goals include early retirement complete with travel and other luxuries (boats, vacation homes, etc.), then your professional goals will likely be more audacious than if you envision a more modest lifestyle and a later retirement.

The first step in helping improve your overall financial success is to decide (or update) what you want to achieve in your life and create a list of specific goals to get you there. Only once you consider the bigger picture can you begin to refine the details. One of these “details” for many veterinarians is practice ownership.

The definition of personal financial success is different for everyone. Some people have an arbitrary number or scenario in mind that they believe they will achieve if they “grind” their way to the top. But working hard and blindly reaching for the stars may not be as successful as implementing a defined and disciplined approach to investing and saving.

Many people either have no budget or have a budget that is not strict enough for them to improve their finances substantially. The fact is that realizing financial success will likely involve time, effort, discipline, and sacrifice. If you are willing to make tough decisions and take the time to plan the framework for your personal financial growth, then all that is left to do is execute your plans and begin to see the results.

One way to determine where to make cuts in spending is to categorize your goals as needs, wants, or wishes. This allows you to see what you can do now and what will have to wait, giving you a broader understanding of what you are able to accomplish and when.

One of the best ways to create a disciplined budget is the “50/30/20” rule. This method dictates how much of your after-tax earnings you can allot for three types of spending:

50% is spent on your essential fixed costs and (e.g., rent/mortgage, groceries, utilities).

30% goes toward your wants (dining out and other discretionary spending).

20% flows right into savings/investing and paying down bad debt (credit cards, high-interest loans, etc.). 

To make a real difference in your financial habits and bottom line, this 20% number is the “magic sauce.” If your spending is allocated correctly, you should reach your desired position in due time.

The value of a practice is realized by an owner when the practice is sold. Understanding what drives practice value and how to improve it is critical. There are two primary markets in veterinary medicine today in which a practice can be sold. The first is the historical market, which is when a practice is sold from one veterinarian to another. The second is the corporate market, which is when a practice is sold from a veterinarian to a corporate entity that owns numerous practices (and may or may not be owned by other veterinarians).

The amount buyers in each market are willing to pay varies, but the practice’s profitability is almost always the most important determinant of practice value. Whether you are 2 years or 30 years away from selling your practice, this is a critical metric to understand, yet most owners don’t know what that number is for their practice. Improving profitability not only will increase your practice’s value at the time of sale, it also will increase your cash flow during ownership.

Determining your practice’s profitability

Calculating the true operating profits of a practice is not a simple task. None of the standard financial or management reports a practice usually gets include this figure. Neither the taxable income from the tax return nor the net income from the profit and loss statement represents true profitability.

The operating profit is the difference between the operating revenue and the expenses a practice incurs. Operating revenue and expenses include only those items normally and necessarily seen in day-to-day practice operations, such as fees for professional services, and drug and medical supply expenses. These items should be listed at fair market value.

For ease of comparison with other practices, a hospital’s profit margin is generally stated as a percentage, which is calculated as practice profits divided by gross revenue. However, some items must be calculated differently to determine operating profit versus taxable income or net income. These include practice owner payments, facility and equipment rent (if these items are owned by the practice owner and leased to the practice), services provided by family members to the practice, depreciation, interest on debt, and perks. The resulting percentage is the true operating profit of the practice, and it is important to compare this percentage with other investments you have and with that of other practices. An operating profit of 20% or higher is considered superior, 12% to 13% is average, and less than 6% is poor.

This all may sound a little daunting, but there are resources available to help. If you work with a veterinary financial adviser, this person should be able to calculate your profitability. 

 also offers resources to help guide you through this calculation process.


Converting profitability into practice value

Once the profitability figure is determined for a veterinary hospital, that number must be converted into the practice value via an appropriate capitalization rate (or cap rate). In practical terms, the cap rate is the required rate of return an investor needs in order to be persuaded to make an investment. There is no one correct rate for all situations—the rate is determined by the market and will vary depending on both external factors (e.g., the state of the economy) and internal factors (e.g., the level and quality of the company’s earnings, the amount of competition in the area). The rate is a reflection of the risks associated with owning and managing a veterinary practice, and continuing to generate the current level of profits. The inverse of the cap rate is a multiple; for example, if the cap rate is 20%, the multiple is 5 and the formula used to derive practice value is as follows:

Annual earnings × Multiple = Practice value

To increase practice value, the management team needs to either increase profitability or decrease the risk associated with owning the practice (i.e., the risk associated with maintaining the practice’s current profitability).

A lack of profitability stems from revenues that are too low, expenses that are too high, or a combination of the two. Profitability can be improved in many ways, from increased marketing to better inventory control to improved team productivity.

A wide range of factors affects the risk related to owning a veterinary practice, including client demographics, the state of the facility, the quality of the management team, and the range of services offered, among others.

Increasing practice value involves three steps:

Understand where the practice is doing well and where it needs improvement.

Working with a financial advisor or practice consultant may help not only in gaining a greater understanding of the issues that impact profitability but also in identifying and implementing solutions.

Synergy between practice and personal financial goals

It is very possible to have a thriving business and a personal financial state that has ample room for improvement and vice versa—the two are not mutually exclusive. Having a well-organized personal financial life can impact how your practice is run, and a well-run practice sets the stage for a fruitful personal financial future. The common dominator between these two aspects of financial fitness is planning.

Dr. Felsted has spent the past 20 years working as a financial and operational consultant to veterinary practices and the animal health industry. She served as CEO of the National Commission on Veterinary Economic Issues for 3 years. Dr. Felsted is active in multiple veterinary organizations, has written extensively, and speaks regularly at national and international veterinary meetings. She owns 

PantheraT Veterinary Management Consulting

Miles Saunders owns and operates MNS Wealth Management LLC in Westport, CT. He can be reached at 

Westport Office: 55 Greens Farms Road, Suite 1 Westport, CT 06880 – Phone: 203-571-2312 www.mnswealthmanagement.com Registered representative offering securities and advisory services through Cetera Advisor Networks LLC (doing insurance business in CA as CFGAN Insurance Agency LLC), member FINRA/SIPC, a Broker-Dealer and a Registered Investment Advisor. Cetera is under separate ownership from any other named entity. For a comprehensive review of your personal situation, always consult with a tax or legal advisor. Neither Cetera Advisor Networks LLC nor any of its representatives may give legal or tax advice. All investing involves risk, including the possible loss of principal. There is no assurance that any investment strategy will be successful. Asset allocation is an investment strategy that will not guarantee a profit or protect you from loss.

Articles

For veterinary practice owners, professional and personal goals and growth go hand in hand. Success is achieved through time, effort, discipline, and sacrifice—and a little professional guidance.


Make it happen: Personal and practice financial growth for veterinarians

Urinary tract infections (UTIs) are commonly seen in veterinary practice. While treatment in certain patient populations is straightforward, UTIs can become challenging to manage when there are concurrent complicating factors.

With a typical UTI, a queen (of the appropriate age) or bitch urinates small amounts frequently, seems uncomfortable (often in general, but specifically while urinating), and there appears to be blood in the urine. While a culture is still recommended in these cases (due to the rising prevalence of resistant microbes in the environment), a potentiated penicillin (e.g., amoxicillin) is a good empiric choice as it concentrates in the urine. A sulfa antibiotic is another good option. Other antibiotics (e.g., enrofloxacin, nitrofurantoin) should be reserved for recurrent cases. As always, sample collection via cystocentesis is preferred.

Managing recurrent UTIs can be complicated, largely because of antibiotic resistance. The first step in treating a recurrence is to rule out or mitigate other causative factors. Imaging for uroliths is important, as these will be a source of recurrence because they release previously protected bacteria back into the bladder.

UTI is significantly less common in male dogs and cats than in females owing to the male anatomy. Urinary tract infections are much less common in toms and treatment reasonably straightforward, but in male dogs the frequency of prostatic involvement complicates treatment. Male dogs should be tested for prostatic involvement via abdominal ultrasound and/or aspiration of the prostate as warranted. If testing does not reveal prostatic involvement, then treating as an uncomplicated UTI is reasonable. There is a risk for recurrence, but current evidence does not support the use of longer courses of antibiotics to prevent this. If the prostate is involved, then a longer course of an antibiotic with better lipid solubility and thereby tissue penetration is recommended. The best evidence we have is for the use of fluoroquinolones for at least a month.

Additionally, assessment of anatomy is important. Search for vulvar or ureteral abnormalities, both of which can contribute to UTI recurrence. In older patients, transitional cell carcinoma may predispose patients to recurrent UTI. Metabolic disease, such as unregulated diabetes or Cushing disease, may also be at play. Without control of these conditions, the risk for recurrence is much higher, and controlling these conditions may end the cycle of recurrence.

Once concomitant factors have been mitigated, culture-based treatment is still the appropriate course of action. A slightly longer course of treatment is recommended for patients with recurrent UTI (5-7 days as opposed to the standard 3-5 days.) Several other preventive measures have been discussed, but few have been proven efficacious.

 No positive effect was found with direct instillation of any substance into the urinary tract (antimicrobial or otherwise). Pulse antibiotic therapy is commonly used, but this practice is controversial as its effect is not fully clear and it may further increase the risk for developing resistance. Administration of probiotics was tested and not found to be particularly efficacious.

One recommendation that has been found to be effective (in humans at least) is administration of cranberry extract.

 There is also a fair amount of anecdotal evidence, in both veterinary and humane medicine, to suggest its utility. The proanthocyanidin in the cranberry inhibits uropathogenic 

 adherence to the urinary epithelium, preventing an infection recurrence.

Another clinical complication of recurrent UTIs is the presence of subclinical bacteria, in which a patient’s urinary sediment is quiescent and there are no clinical signs of cystitis but the urine culture tests positive. There is strong evidence in human medicine that no treatment is warranted in these cases.

 Some exceptions include patients who are set to undergo any procedure in which bacteremia may be induced (e.g., urinary surgery in which hemorrhage may expose the blood stream to urine).

Finally, a more life-threatening complication of UTIs is pyelonephritis. Patients with this condition present with acute onset of systemic signs (e.g., lethargy, anorexia, vomiting) and are found to have new-onset azotemia. Direct diagnosis requires pyelocentesis (aspiration of the renal pelvis), but this is not commonly performed due to difficulty in performing this procedure. In a patient with new-onset azotemia who is clinically ill and has no toxin exposure consistent with the azotemia, pyelonephritis is largely assumed and treatment (antibiotics) is initiated. This assumption is made in large part because pyelonephritis is the most treatable cause of acute kidney injury. (Keep in mind that this patient population completely overlaps with those suffering from leptospirosis, so appropriate testing and staff safeguards are important until this is ruled out.)

On ultrasound, pyelectasia (dilation of the renal pelvis) is suggestive of but not definitive for pyelonephritis. Ultrasound also helps to rule out other causes of acute kidney injury, such as obstructive ureteroliths, neoplasia, or ischemia. Patients with these conditions require hospitalization and varying levels of fluids and other supportive care. Antibiotic selection should be based on culture, but initial empiric treatment is important. Most commonly, a potentiated penicillin (ampicillin-sulbactam) with a fluoroquinolone is recommended. This is both for broad-spectrum coverage as well as good tissue penetration into the renal tissues with the fluoroquinolone. Prognosis in these cases is fair, although there will be some degree of permanent renal compromise that is not predictable at the outset.

UTIs are common, but complications are rare. Appropriate urine culture is the bedrock on which treatment should be based, both for best patient outcome and antibiotic stewardship. While not mentioned above, contacting a veterinary microbiologist can also be helpful in guiding antibiotic recommendations.

A board-certified criticalist at Mount Laurel Animal Hospital in Mount Laurel, NJ, Dr. Greenway earned his DVM from Texas A&M University and is a proud member of the American College of Veterinary Emergency and Critical Care. He was truly inspired by his father, a military veteran, who fostered a deep commitment to animals. His professional interests include emergency (polytrauma, severe anemia) and critical care (septic case management).

Dorsch R, Teichmann-Knorrn S, Sjetne Lund H. Urinary tract infection and subclinical bacteriuria in cats: A clinical update. 

. 2019;21(11):1023-1038. doi: 10.1177/1098612X19880435

Sihra N, Goodman A, Zakri R, Sahai A, Malde S. Nonantibiotic prevention and management of recurrent urinary tract infection. 

. 2018;15(12):750-776. doi:10.1038/s41585-018-0106-x

Weese JS, Blondeau J, Booth D, et al. International Society for Companion Animal Infectious Diseases (ISCAID) guidelines for the diagnosis and management of bacterial urinary tract infections in dogs and cats. 

. 2019;5:8-25.doi: 10.1016/j.tvjl.2019.02.008

Here’s what you need to know about treating uncomplicated UTIs and recurrent infections.


How to manage recurrent urinary tract infections 

Telton Animal Hospital is an established suburban veterinary clinic in the Northeast that has served its community for 25 years. When COVID-19 hit, the practice continued to provide patient care while observing the social distancing mandates issued by the governor and recommended by the state veterinary medical association. Curbside visits were cumbersome initially but soon proved to be very efficient. In addition, the use of FaceTime and other telecommunication apps was well accepted by staff and pet owners alike.

When COVID-19 case numbers started to drop in the state, the governor began allowing a phased reopening of various non-essential businesses. Several weeks later, when retail stores had reopened with mask and social distancing requirements, the owners and staff at Telton Animal Hospital remained uncomfortable allowing pet owners into the facility. The clinic sent an email to clients and posted on the practice’s website and social media platforms that curbside pet care would continue for the near future to protect staff.

Continuing curbside care helped boost the morale of an already stressed staff. A staff member testing positive for COVID-19 would hurt the clinic’s ability to function, mandating the need to exclude contact with pet owners until a viable treatment or vaccine becomes available. These proactive steps, the owner reasoned, were the only way to ensure the viability and safety of the practice. Many pet owners understood the continued curbside policy, but many strongly disagreed.

Client complaints ranged from accusations of being unprofessional and unethical to insensitive and selfish. If the governor and state healthcare officials determined that entering a facility with caution was now safe, clients questioned why the practice was continuing to separate pet owners from their pets in their time of need. Several clients asked that their records be sent to a nearby veterinary hospital that was allowing clients to enter with their pets as long as they wore masks.

This was not the reaction the team at Telton Animal Hospital expected. Improved clinic hygiene and safety protocols had kept staff safe thus far, and the owner was not willing to roll the dice; curbside procedures would continue. A knee-jerk response to these disappointed pet owners simply stating that this is “clinic policy” was unacceptable, so every client who objected to the continued restrictions would be contacted personally and given an in-depth explanation of the clinic’s policy. In extreme situations, such as euthanasia and other dire circumstances, clients would be allowed into the clinic provided they were gowned, gloved, and masked. This policy would be reviewed monthly, with staff safety and clinic hygiene being the top priority. Unfortunately, a number of clients remained aggravated and disappointed enough to leave the practice.

This clinic owner felt that “better safe than sorry” was the right way to go. Do you agree with this clinic’s choice? We would like to know. Email us your thoughts at dvm360news@mmhgroup.com.

Phased and staged openings of cities and towns are based on both scientific healthcare recommendations and, to some degree, political pressures. Veterinary facilities are particularly vulnerable. For many practices, if a single staff member contracts COVID-19 everything will grind to a halt. This is not the case in most business models. For many types of businesses quarantines are instituted for an affected employee and business continues remotely. Veterinary workplaces require staff to work shoulder to shoulder to provide proper pet care. In view of the uniqueness of veterinary practice, I feel curbside care will be with us for quite a while and that our pet patients and their owners will do just fine.

Dr. Rosenberg is director of the Voorhees Veterinary Center in Voorhees, New Jersey. Although many of the scenarios Dr. Rosenberg describes in his column are based on real-life events, the veterinary practices, doctors and employees described are fictional.

As pandemic restrictions ease should veterinary practices get to choose whether they stop or continue curbside care? 

The Dilemma: the curbside care controversy

 scheduled for later this month combines three robust individual conferences (Fetch Baltimore, Fetch Kansas City, and Hospital Design 360), so it’s got something for absolutely everyone on the team. In this episode of the Vet Blast Podcast, Dr. Christman is joined by Jacqueline Whittemore, DVM, PhD, DACVIM (SAIM), who shares a bit about the lectures she will be doing in the conference’s gastroenterology track.

Dr. Whittemore, an associate professor at The University of Tennessee College of Veterinary Medicine, will cover four hot topics: probiotics, chronic hepatopathy in dogs, gallbladder diseases, and hepatic lipidosis.

“I think we’ve got a really great mixture of practical information,” Dr. Whittemore says. “Some of it involves really cutting-edge new research.”

Take a listen as Dr. Whittemore shares some nuggets from her talks and why she is so passionate about GI medicine. The virtual conference is scheduled for August 26 to the 31, so register 

Podcasts

In Episode 5 of The Vet Blast Podcast, Dr. Jacqueline Whittemore discusses the talks she is preparing for the virtual Fetch dvm360 conference later this month.

Episode 5: Highlights from the Fetch dvm360 virtual conference

New legislation and court opinions throughout the country are making what used to be a fairly clear prohibition on contractually specified competing practice instead a confusing puzzle of definitions, case-by-case interpretations, and newly enacted statutes.

In Massachusetts, for example, the enforceability of a noncompetition agreement may depend on whether it was entered into before or during the employment relationship. In Rhode Island, enforceability might hinge on whether the agreement is signed as part of a separation-from-employment deal. In Washington State, whether your noncompete will be upheld might depend on the salary you made when you signed the agreement or your pay rate when your employment terminated.

The increasing complexity around noncompetes creates just as big a challenge for practice owners (including corporations). On one hand, restrictions that are too broad could be struck down as not having a realistic relationship with the “goodwill protection” actually needed by the clinic that drafted it. On the other hand, if a noncompete is created with an insufficient duration or distance (perhaps for the sake of ensuring enforceability), the document offers little protection to the drafter.

Throughout the many years when practitioners’ noncompete terms were relatively certain to be enforceable in most jurisdictions, many drafters ignored or glossed over a potential companion or alternate provision known as a “client nonsolicitation language.”

Post-employment nonsolicitation clauses have existed for a long time. And in the new world of judicial and legislative distaste for noncompetes, these clauses may be moving to the forefront of veterinary employment law.

Simply put, a nonsolicitation agreement (NSA) expressly prohibits a former employee from reaching out to existing clients of their former employer for the purpose of encouraging them to quit that employer and instead come to the employee’s new employer (or a practice the employee might start up or purchase after exiting employment).

NSAs seem ideal at first blush. So why have they not been more widely used in the recent past? And, for that matter, if they weren’t popular before, why are they becoming more widely used nowadays?

A solid, enforceable noncompete still trumps an NSA

In a situation where a veterinary practice enters into an associate noncompetition agreement that is fair, reasonable, and signed in a state that “doesn’t hate” noncompetes, the train to enforcement is quick and fairly obstacle-free:

Obvious violation of the agreement may entitle the practice to an injunction or temporary restraining order. This stops the violator immediately, not a year or more later when the case might reach trial.

Proof is easily ascertainable. If the noncompete area is Manhattan and the associate goes to work near Times Square—boom, proof is complete.

The idea of hiring an associate who is burdened by a noncompetition agreement scares potential employers whose offices are within the noncompete radius. They don’t want to find themselves with no veterinarian (if a temporary restraining order is issued) and in the crosshairs of the new potential hire’s old boss, who might initiate a long course of noncompete litigation.

NSAs don’t carry the level of intimidation brandished by noncompetes. An NSA basically says: “Associate, you can work where you like but under no circumstances may you call up our clients or send them letters, texts, or emails suggesting that they come see you at your new spot.” That sounds fairly reasonable and, in fact, legislators look much more favorably on NSAs than on noncompetition agreements.

For example, the Rhode Island Noncompetition Agreement Act, which became effective January 15, 2020, places numerous limitations on noncompetition covenants in that state. However, it specifically 

There are three big drawbacks in enforcing an NSA:

Proving solicitation of clients is not easy. 

Evidence that an NSA has been violated often requires testimony from a client who has been “solicited.” Clearly, no client who leaves the old practice and has their records transferred is going to be willing to testify voluntarily that any solicitation occurred. That leaves the clinic that is trying to prove an NSA violation to identify clients who were solicited but chose to stay put.

The definition of “solicitation” is a moving target. 

Calling a former employer’s clients and recommending they change practices is clearly solicitation, but what if a client calls the departing clinician at home because he heard “through the grapevine” that she was moving to a new practice? Is it solicitation if the new clinic announces the arrival of the new doctor on its website? What if the veterinarian who is moving to a new practice states on her Facebook page that she is leaving her old job? If that is OK, can she also name her new clinic and say she is accepting new patients?

A new employer can take steps to mitigate the impact of an NSA. 

Once the departing DVM begins working at a new hospital, what is there to prevent the new boss from aggressively marketing the services of his or her new hire? The new employer was never a party to the NSA signed by his new associate. Further, nothing prevents an associate who has taken a new job under the cloud of an NSA from asking their new office to prepare a form to be signed by clients that they have come to that hospital to see that new vet entirely of their own volition.

Nonsolicitation law is developing and changing rapidly

The legal status of both noncompetition agreements and NSAs is in constant flux, owing to the strengthening of “right-to-work” advocacy. But just as powerful an influence is the rapidly emerging law of information technology. Competition and solicitation become very hard to define and control through legislation when social media and telemedicine challenge the imagination of even the most skilled drafting attorneys and judges.

The best advice for both private practices and corporate hospital chains looking to protect their client base and goodwill is this: Do 

 let your employment contractual language get stale; review it regularly and make an effort to see how your existing employment documents comport with developing and morphing law.

Christopher J. Allen, DVM, JD is president of the Associates in Veterinary Law P.C., which provides legal and consulting services exclusively to veterinarians. He can be reached via e-mail at info@veterinarylaw.com. Dr. Allen serves on

It’s no mystery that associate veterinarians, in an effort to figure out if their noncompete is enforceable, find themselves trying to solve, well, a mystery.

Understanding the limits of your noncompete agreement

As we all continue to adjust to this "new normal," we will continue to keep you updated with the latest news about the pandemic and our coverage of the veterinary industry.

View the video below for this week's top veterinary headlines:

Dr. Holly Sawyer says one of the best ways for clinicians to get more shut-eye is to 

have a competent, compassionate registered veterinary technician answer your after-hours calls for you

The UC Davis School of Veterinary Medicine has 

named Dr. Michael Ziccardi executive director of the One Health Institute

The veterinary student duo who co-founded the Association of Asian Veterinary Medical Professionals, or AAVMP, in April is 

 on a mission to showcase Asians navigating their way through veterinary medicine 

and to promote diversity and inclusion within the profession.

dvm360 is excited to announce that we be hosting 

on Tuesday, August 4, from 3:00 to 5:30 p.m. EDT.

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dvm360 launches online CE center amid pandemic

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