Try some of these tactics from dentists on the human side to see if you can't make your clients and patients smile. (shutterstock.com)

	Because they start their own small businesses after school and they've got advanced medical degrees, dentists and veterinarians have long been compared together in business. And the cliché has always been that, because they're more money motivated, dentists pick up on better business practices faster than their veterinary brethren.

	Practice manager Brian Conrad, CVPM, still thinks this is true, and he turned to his wife (a dental office manager) to find out what techniques she uses in her day-to-day work that improve revenue and client relations. See what you can learn from a few of the tips he shared in his session at 

	Conrad has heard of 30-to-45-minute morning huddles before doors open at dental practices for the entire team to go over the patients coming that day, their personal preferences, the services expected and potential revenue for those services. At the end of the day, teams reconvene to check actual revenue against expected and see how things compare. With many dental cases, dentists know exactly what's expected with a patient, while veterinarians might feel more in the dark with their cases. But, it's worth taking a swing at an average invoice amount for the average cat or dog, or a case coming with a particular condition, and finding out why pet owners agreed to or turned down products and services. You could learn a lot from this practice.

	These huddles mirror a bit the start of clinical rounds that doctors might remember from school or that take place at larger hospitals, but the focus is on finances, client service and client compliance. There are no rules about how long you need to meet or what you want to cover in your huddle, but would it hurt to build up some regular thinking and accountability as a team surrounding client service? (Hint: probably not.)

	What does a hole in your schedule look like to 

	For dentists, Conrad says a hole in the schedule is a bad thing. In veterinary medicine, he says, some doctors might joke, “A cancellation? I get to go to the bathroom this morning!”

	Which is to say, dentists are wildly proactive about maximizing their time working and helping as many people as possible in a workday (and they probably don't see many exhausting emergencies). They hire full-time schedulers who spend 40 hours a week filling gaps, and Conrad says they earn multiples of their salary in revenue.

	Conrad had a thought experiment: What if you put up a job advertisement for $45,000 for a full-time scheduler to cover your phone and your email systems with the task of filling each day with appointments? Could you earn that money back quickly? (He did not suggest every attendee run out and tell their teams to advertise for the position. Just think about what that would look like!)

	There are many ways client service representatives or automated reminder and email systems might help with filling empty slots, generating more revenue and helping more pets.

, right? Conrad pointed out one statistic that more than 80% of dental practices schedule appointments during visits, while as little as 5% of veterinary practices do.

	Many pet owners will agree to services when they don't understand or agree with the need, pay their invoices at the front desk with a smile, then never show up again. If your rules, your scheduling, your hours and your brand of client service all tell pet owners that you're in charge, not them, you can expect less loyalty all the time, according to Conrad.

	“I want you thinking about your attitude,” Conrad told attendees. “What parts of your business tell clients 

 in charge? Even if they're not in charge of everything, they should feel that way.”

	Dentists give kids toys, offer remotes to personal TVs in exam chairs and try to make experiences as pleasant as possible. It's as small as giving choices, recognizing pet owner preferences and making it easier for them to do business with you. And when you get the inevitable request from a clinic down the road for medical records for a “mutual client” who's in your database, why not have a truly tactful team member reach out to the departing client and ask why and how you can do better for clients in the future? It's not to guilt them back, Conrad says, but to improve how you work with the pet owners who keep your doors open.

Articles

Could dentists teach DVMs a thing or two about business focus, scheduling and client service?

What veterinarians can learn from dentists

When recommending a therapeutic diet, make sure that the client understands why the diet is important and how crucial it is to the health of their pet. (shutterstock.com)Recommending a therapeutic diet can be tricky. Clients might understand what you're saying but then go to the pet store and buy a food that “supports kidney health,” thinking it's the same thing as what you recommended. In a session at 

 in Kansas City, Cailin R. Heinze, MS, VMD, DACVN, talked about the importance of understanding why clients might not be compliant and how to give them a powerful recommendation they're more likely to follow.

	While you've likely faced some resistance to your recommendations in practice before, you might not be aware of the scope. Dr. Heinze cited a client compliance study conducted by AAHA in 2009 that found that only about 21% of clients were compliant with therapeutic diet recommendations.1 Granted, the study is old, but current pet food marketing trends and increased pet owner focus on what they're feeding may have made compliance worse, not better. 

	The reasons clients are noncompliant can vary from resistance to the cost of the diet, to not understanding why the diet is important, to having some problem with ingredients in the diet or distrusting the manufacturers who produce it.

	Dr. Heinze-who is chief academic officer of the Mark Morris Institute, an adjunct faculty member at the Cummings School of Veterinary Medicine at Tufts University, and one of the founders of the 

 pet nutrition blog-says delivering a strong recommendation is important, but often veterinary practitioners use softer phrases like, “Taking the weight off would be good” instead of “You need to help your pet lose weight before she has more complications.”

	Especially in the case of cats with chronic kidney disease, recommendations need to be strong and clear, as diet in these cases is incredibly important, Dr. Heinze says. In a study conducted in 2014 that focused on owners of cats with kidney disease, 51% of respondents reported feeding a kidney diet as “some component” of the diet.2 The percentage of clients who gave their cats a kidney diet as a majority of calories was even lower.

	So how do you make clients more compliant? Dr. Heinze recommends educating the client thoroughly. In the case of kidney disease, the therapeutic diet isn't a short-term treatment but something the cat will need the rest of its life. Not only that, but diet is the main way to treat the condition-the client can think of it like a medication the cat would have to take.

	And when talking about kidney diets, you also have plenty of facts to back up your claims.

	When it comes to therapeutic diets for renal disease, Dr. Heinze says she first likes to give evidence that therapeutic diets can double a cat's lifespan from what it would be without the diet. While she can't guarantee how long the cat will live, Dr. Heinze says this fact is a compelling one for clients.

	She also explains how important phosphorus is to the progression of kidney disease and how keeping those levels low improves the cat's health. She likes to give specific numbers to show how over the counter (OTC) diets can't really compare with therapeutic diets.

	Treatment recommendations from the International Renal Interest Society (IRIS) suggest that for stage 1 and 2 kidney disease, phosphorus levels in the pet's blood should be less than 4.6 g/dl and for stages 3 and 4, levels should be less than 5 and 6 mg/dl, or as low as possible with diet and phosphorus binders. Practically speaking, Dr Heinze generally recommends diets less than 2 g/1000 kcal of phosphorus for stage 1+/-2 and less than 1.25 g/1000 kcal for stages 3 and 4.

	Counter this by showing that OTC diets are, on average, around 3 g/1000 kcal. And if the food meets standards set by the Association of American Feed Control Officials (AAFCO) (which it should as an OTC diet!), that almost guarantees phosphorus levels won't be low enough for later stages of renal disease. The AAFCO standard sets minimum levels of phosphorus at 1.25 g/1000 kcal for adult maintenance and 2 g/1000 kcal for “all life stages” diets. In contrast, therapeutic renal diets for cats range from 0.8 to 1.1 g/1000 kcal.

	This means a cat in early-stage renal disease (IRIS stages 1 and 2) might be able to eat a carefully chosen OTC diet with low enough levels of phosphorus, but for advanced stages, therapeutic diets are the best bet.

	If Dr. Heinze has a client who insists on feeding OTC, she simply tells them what phosphorus levels to look for a diet. When they can't find a food with low enough amounts, they're more willing to accept a therapeutic diet formulated to the correct levels.

	Sometimes clients will say they don't want to feed a diet because they don't think it's any good. Dr. Heinze recommends asking specific questions in these cases to determine what about the diet is causing concern.

	Maybe the client is hesitant about a certain ingredient-like corn. In that case, you can explain that many renal diets contain corn because it's low in phosphorus, sodium and potassium and explain why it's important to keep those levels low for the health of the pet.

	Maybe the concern is the manufacturer. In that case, offer an equivalent diet by a different manufacturer. Often, Dr. Heinze says, if you get to the real problem a client has with a diet, you can either change your recommendation or address their concern.

	Ultimately, she says, don't be soft in your recommendations. Especially when you think a diet is going to be the best way to treat the disease, emphasize just how important it is to the pet's wellbeing. Clients aren't paying for fancy food; they're paying for treatment-the fact that it also feeds their pets is just a side benefit.

	1. American Animal Hospital Association. 

Compliance: Taking Quality Care to the Next Level Executive Summary.

	2. Markovich JE, Freeman LM, Labato MA, Heinze CR. Survey of dietary and medication practices of owners of cats with chronic kidney disease. 

When it comes to nutritionally sensitive conditions such as kidney disease, make sure your client understands just how vital a role diet plays in managing their pets health.

Building a strong recommendation for a veterinary therapeutic diet

If you tell an average pet owner what's best for their pet, they'll do it.

	If you're rolling your eyes, read on. If you believe that statement … well, you probably have been living in an alternate reality.

	The truth is, pet owners don't fail to follow your recommendations because they are bad people or don't love their pets. Here are a few nuggets of wisdom from two veterinary industry pros on how to effectively communicate in order for pet owners to take the best path forward for the health of their pets.

	Repeat this mantra: “I'm not a used car salesman. I'm not a used car salesman.” No matter how much you may want to, you can't run away from sales when you work in a field where your knowledge is what makes the sale. The cardinal rule is, if you believe in what you're selling, you'll be able to sell it. If you don't want to sell products, you have to be open and honest with the people you work with so they don't schedule you for these appointments.

	Many pet owners are against vaccines and medications for fleas and worms because they feel it's unnatural or harmful. When I was a new associate, I would say, “You need to get vaccines and flea and heartworm medications in order to protect your pet.” But I've learned that people don't like being told what to do, and they also don't like feeling that you're trying to upsell them. Here's what I usually tell clients now: “My job is to present you with the facts and make sure you make an informed decision, and you get to decide what to do with that information.” People seem happier that they get to make an educated decision, and I'm happier because I get to educate them.

Give options, but don't abdicate your role

	I have a friend who despises choosing a restaurant. In fact, it's nearly impossible to get her to weigh in on any sort of dinner-related decision. The reason is that she doesn't want to feel accountable if the place we visit is underwhelming. She takes comfort in always being able to say, “Well, it was your choice.” For a friend and a dinner decision, this is fine. But what if everyone approached choices this way?

	Yes, we need to present pet owners with options, but we cannot relinquish our responsibility to guide their decisions. Too often, we say “Well, you could ... ” and then present a multiple-choice scenario with options that may seem perfectly clear to us but are confusing to our clients. We feel good about putting the choice in their hands, but then we wonder why they so often default to the cheapest option. (The one element that's not confusing in all of this? Price. You don't need a medical degree to understand that part.)

	Instead, what if we presented options in the context of making a strong recommendation? For example, we can use statements like, “Based on what we've discussed, the plan I'd recommend is … ” or simply, “To address your concerns, we need to … ” We can use these phrases and still give people options. However, they offer clear direction on how best to move forward and take advantage of our education, training and experience.

	If we are acting ethically, listening to our clients and their needs and practicing a good standard of care, we should be able to give options while also making clear what path we believe will best serve the pet and owner. When we refuse to commit to any recommendation, we abdicate our position as a guide, consultant and doctor. I believe that also means we fail our clients.

Advice on how veterinary professionals can be better at guiding pet owners to take the best action for their pets. 

Pet owners dont ignore your recommendations because they are bad people

Victoria Kotlyarchuk/stock.adobe.comEvery spring I sit down with graduating veterinary students to offer them each a complimentary, no-obligation hour of one-on-one professional and personal financial guidance and advice. Since I started these consultations in 2015, the demand has exploded. I give away nearly 700 hours of advice annually at veterinary schools and over the phone when in-person visits aren't possible.

	Not surprisingly, the more than 800 new grads I've counseled show a wide spectrum of financial literacy. I ask students to rate their own financial literacy on a scale of 1 to 10-1 is Snoopy and 10 is Warren Buffett. The average is 3. It turns out that where they go to school makes a big difference. Some claim they haven't ever been offered a financial lecture; others had access to guest lectures on financial topics throughout their four years. Some have never even heard of using a monthly budget; others had budgets so detailed they'd counted out how many tubes of toothpaste they might go through in a year.

	We cover the financial basics: Do they have a job offer, did they negotiate compensation (they should) and what will their take-home pay be? I'm often surprised at how many veterinarians have divided their gross salary by 12 months, forgetting they need to pay taxes. Others are dumbfounded to learn that the state where they're moving takes out income tax. Roughly one-third have never been taught-by anyone-how to estimate take-home pay (there are many paycheck calculators on the internet).

	We cover the how, why, when and where of saving up emergency cash reserves. Some work during veterinary school and scrape together an impressive level of savings; others are running on fumes. Some eked out a meager existence in school to keep their loans down; others insisted on living alone or supporting a lifestyle they felt “more comfortable with”-without grasping how tough it would be to pay off the excess loans needed to keep that up.

	We consider each and every surplus dollar, if any, for the next six months so that when the student loan grace period ends, hopefully they'll have credit cards paid off or a decent-sized emergency reserve built up. (Those going into internships scarcely have enough for three meals a day, so saving emergency reserves isn't a reality.)

		Some veterinary graduates have credit card debt, but (incredibly) many of them don't seem to understand that this is different debt than their student debt and should be paid off more aggressively than student or car loans. Again, the variance in this knowledge is wide. Some students are aware that credit card debt is bad debt, but they couldn't avoid it, so we plan out how to get rid of it as quickly as possible. Our society is failing our kids if they get all the way through graduate school and don't understand how carrying credit card debt can be an expensive financial mistake.

	Naturally, student debt is the topic most want to discuss: how to manage it, how to choose a repayment program and how practice ownership or marriage can affect those programs. Because I'm not a student loan expert, I refer graduates to experts, but we get the foundational conversation started. Students amass this giant heap of debt yet are given few resources to help them understand it. No two plans can be the same, because financial planning isn't herd health, yet many say they've been told to just pay the minimum and kick as much of their student debt down the road as they can in preparation for loan forgiveness.

	But not everyone should go for loan forgiveness. The choice depends on many other factors that must be considered as well. On the other hand, not everyone should try to pay off their loans, because some balances start so high that it won't be feasible. But there is no rule of thumb, and whether to try to pay off loans will also come from future information that cannot be known at graduation: income, marriage, retirement contributions, spending, burnout, other financial obligations, practice or home ownership, babies, part-time work, personal tolerances, belief systems, savings discipline … I could go on. Student debt repayment is not a “set it and forget it” decision. It needs to be monitored annually, because life evolves and unknowns at the time of graduation emerge over time.

 the plan and taxes will be due on the forgiven balances 20 to 25 years later, how does a veterinarian start saving to pay that tax? A savings account won't keep pace with inflation. Hundreds have told me they were told to start an investment account, but most don't have the first clue how to do it. One possibility would be a taxable nonqualified account, but they need to consider their own financial behavior, market volatility, rebalancing and repositioning holdings and how to mitigate the taxation of such an account. Mistakes are costly, and perhaps these veterinarians should consider the advice they give to clients-to find a professional to help them “diagnose, build a plan and treat” their financial life.

	We are failing our veterinary students if they leave school without a debt management plan specific to them created by a student loan expert collaborating with a trained financial advisor.

	Once the debt conversation has been navigated, we then turn to risk management and insurances. We discuss what to look for, what to look 

 for, what is and isn't necessary, and how hard it is to understand all the fine print. (Insurance policy language is akin to a veterinarian handing a pet owner a copy of 

 and telling them to read up on their dog's Cushing's diagnosis.)

	Many understand how important income protection is (long-term disability insurance), yet others have never once considered protecting their income. Statistics from the Social Security Administration show that one in four people will become disabled for an average time span of 2.5 years. Would it be a problem if income stopped for over two years? Not all policies are equal or have fine print that is highly favorable for doctors, so it's critical that students be taught all of their disability options, as well as the pros and the cons of each.

	If they're married or have kids, we discuss the importance of life insurance. Then we cover deductibles and insurance for cars, homeowners and renters, health, liability and umbrella coverage.   

	Lastly, if we have time or their attention span can accommodate more, we discuss retirement plan options, buying a house, saving for kids' college or preparing to own a practice. I'm shocked at how most don't know what a Roth IRA is or what an employer retirement plan match is.

	After hundreds of hours with these brilliant young doctors, I know for certain they desperately need professional help on a broad range of financial topics. The debt load is too great to simply open the doors and let people out of school with a farewell and a good-luck pat on the back.

	Many believe that becoming a veterinarian is a terrible return on investment; I couldn't disagree more. From work with more than 1,200 new graduates and my other DVM clients, I have a plethora of data to prove that industry naysayers should reconsider. Some associate veterinarians earn annualized incomes of nearly $150,000, starting with a typical base of $90,000; the rest is production. Conversely, I have clients still earning the same $65,000 base they started with. I have many clients who paid off student debt quickly, while others spend any surplus income on the latest shiny toy. Why the differences? Much of it comes down to spending habits or discipline, but often it is a lack of understanding of financial principles because they either they aren't offered financial education in vet school or don't believe financial education will apply to their lives.

	Graduating students shouldn't feel so hopeless and confused over their financial future on the eve of their graduation that they regret their decision to become veterinarians. And no veterinarian should feel there's nowhere to turn with their financial struggles. As my time allows, I'll continue to offer this complimentary guidance. And in the meantime, I pray that my experience will inspire others in this industry to step in, step up and bring our veterinary colleagues the resources they desperately need to start out on the right financial foot.

Editor's note: The author asked us to run this copy with this article: Financial Advisors do not provide specific tax/legal advice and this information should not be considered as such. You should always consult your tax/legal advisor regarding your own specific tax/legal situation. Darby is a registered representative and investment advisor representative of CRI Securities, LLC and Securian Financial Services, Inc. North Star Consultants, Inc., Insurance Products and Services| CRI Securities, LLC - Securities and Investments | Securian Financial Services, Inc. – Variable Products and Securities | North Star Resource Group offers securities and investment advisory services through CRI Securities, LLC and Securian Financial Services, Inc. Members FINRA/SIPC. | CRI Securities, LLC is affiliated with Securian Financial Services, Inc. and North Star Resource Group. North Star Resource Group is not affiliated with Securian Financial Services, Inc. North Star Resource Group is independently owned and operated. 2701 University Ave, SE | Minneapolis, MN 55414. 2817066/DOFU 11-2019

	Darby Affeldt, DVM, RICP, is a financial advisor to veterinarians and other medical professionals at North Star Resource Group based in Seattle.

The future veterinarians I talk to are sad and scared about their financial future in their new career. With the right planning and financial education, they shouldnt be. Whos going to join me in fighting this fight?

Why are so many veterinary grads financially illiterate?

With regard to the latest wave of organic parasite preventives, 

 speaker Richard Gerhold, DVM, MS, PhD, is skeptical.

“Although they can appear initially to be attractive substitutes for some other medications, unfortunately there's no solid evidence indicating their actual efficacy,” Dr. Gerhold says. “Given that keeping animals healthy also keeps humans healthy, in using those products you potentially seed an environment that could lead to not only an animal disease, but also a human health disease.”

The Companion Animal Parasite Council mentions “natural organic” products in a question in its pet owner FAQ at petsandparasites.org/resources/faqs/:

 I am very concerned about chemicals around my family. Are there natural organic products that I can use to control fleas and ticks?

 While there are some natural products that have a slight repellent activity against fleas, none have been shown to be very effective over the long haul. Eucalyptus oil, cedar chips and other aromatic oils may act as repellents but to have any effect at all they must be used very frequently and must be very fresh. This makes them a bit unpleasant to be around. Diatomaceous earth and Borax powder are very good drying agents and may be helpful in controlling fleas in the yard or even in the carpet. They can be a little messy but do help.

Dr. Gerhold says the only exception is for those managing backyard poultry, where entomologists have seen diatomaceous earth lessen mite infestations.

The website for the Companion Animal Parasite Council is a good place for GPs to send curious pet owners, he says, with its “science-based recommendations.” The veterinarian-facing website is 

Dr. Richard Gerhold works in the Department of Biomedical and Diagnostic Sciences in the College of Veterinary Medicine at the University of Tennessee.

What can general practitioners say for sure about all-natural, organic veterinary parasite preventives? Richard Gerhold, DVM, MS, PhD, says not much.

No solid evidence behind all-natural parasite products

One study found that while venting -- and even responding to venting -- can make the user feel good in the short term, in the long run, it can make you feel worse. (Rawpixel.com / stock.adobe.com)

	We've all seen the news. Suicide rates among veterinarians are as high as 

. We don't have to look far to find news about another heartbreaking death. We feel helpless, but one of the things we do is create support groups online and on social networking sites.

	It seems like a great idea-other likeminded people rallying in support of you. Freud postulated in his writings that getting things off your chest-“catharsis”-is good for you too. This school of thought has long been discredited, but people still think that venting is a good way to deal with stress.

	But is it really? Today, the veterinary profession is swarming with “support sites” all over social media. Veterinary professionals are made to feel like they're doing the “right thing” to be there reading, venting and commenting. We type, “You got this, girl!” and offer “thoughts and prayers.” We tell similar stories, and we all commiserate together. It feels good. It's helping, right? Research show that it might not be. 

	One 2013 study explored the use of venting sites on the internet1. The study found that while venting (and even responding to venting) can make the user feel good in the short term, in the long run, it can make you feel worse. Subjects who vented their anger and stress repeatedly were more likely to experience more anger and express anger in maladaptive ways. A second part of the study showed that merely reading and responding to rants were associated with negative shifts in mood.

		Psychologists' take on venting is nuanced. Read more on the topic 

	Another 2013 study found that especially for women, the need for close attachment and security from others to feel loved and cared about can be linked to an increased risk of depression. We seek this attachment in social networking to feel valued and cared about, but the researchers examined women who spent more time sharing negative experiences and feelings (called “corumination”) and found they were at the greatest risk of clinical depression.2 Having social relations and providing and receiving support can be an adaptive factor, but corumination can be a risk factor for negative mental health.

	So, while our hearts are in the right place when we visit the social media pages and websites to vent, read and show support, we might not be achieving our objective. As is usually the case, finding a balance in what we allow our mind to digest is probably the best choice. Maybe instead of experiencing a stream of negativity, it may be better for your own health to avoid corumination and watch a funny cat video or two.

	1. Martin RC, Coyier KR, VanSistine LM, Schroeder KL. Anger on the internet: The perceived value of rant-sites. 

Cyberpsychology, Behavior, and Social Networking 

	2. LC Bouchard, Shih JH. Gender differences in stress generation: Examination of interpersonal predictors. 

Journal of Social and Clinical Psychology

Tennessee Tails: Pets and Their People, owns Applebrook Animal Hospital in Ooltewah, Tennessee

. She is a frequent contributor to dvm360.com and other publications, and she was the nation's first Fear Free certified professional.

On the good side, veterinary websites and social media pages devoted to supporting struggling veterinary professionals are a good thing. On the bad side, when it turns to venting, that might be hurting, not helping.

Is venting healthy?

2019 dvm360/VHMA Practice Manager of the Year Jessica Molina, PHR, CVPM, CCFP (Photo courtesy of author)

	Jessica Molina, PHR, CVPM, CCFP, hospital administrator at Lee Veterinary in Atmore, Alabama, has been named 2019 Practice Manager of the Year by dvm360 and the Veterinary Hospital Managers Association (VHMA). Molina wowed two rounds of judges with answers that showed leadership and decision-making, team motivation and management skills, a dedication to lifelong learning, and a demonstrated ability to adapt to change.

	Her work has run the gamut-from hiring associate veterinarians and empowering team leaders, to inspiring her employees with 

a different take on superheroes in the workplace

. Molina says she hopes the win will give her even more opportunities to share with colleagues the insights she's gained from her mentor and her own team members.

		Veterinary professionals have a chance each year to nominate managers for the dvm360/VHMA Practice Manager of the Year at 

. Here are a few comments from people who nominated Molina:

		• “She is the best leader and organizer and leads by example. She's enthusiastic and an extremely hard worker.”

		• “She demonstrates excellent management skills and has the clinic running very smoothly.”

		• “She stood as strong as a lighthouse, taking ever-crushing waves that each day provided, but still led us stray employees back to our path of success and efficiency. I watched her sit with employees individually and help them hone their strengths and identify their weaknesses to make them better team players.”

	“I also hope that winning this award will inspire more individuals who are looking for a career in veterinary medicine to recognize and consider the path of veterinary practice management,” Molina says. “Most of all, winning this award will not only push me to continue learning but to continue to grow. As I say (and firmly believe), you cannot get too complacent-after all, today's great is tomorrow's subpar.

	“I've always had a passion for animals, but people and numbers have always excited me more,” she continues. “The more challenging, the better! It's the ‘aha' moments that come out of both that are my favorite part of being a veterinary practice manager. Both relationships and numbers provide key insight into the practice's overall health.”

	The VHMA and dvm360 have co-organized the dvm360/VHMA Practice Manager of the Year contest since 2014. Christine Shupe, VHMA executive director, says she looks forwards to Molina's contributions in the coming year.

	“We are excited that Jessica is the 2019 Practice Manager of the Year,” Shupe says. “Her performance demonstrates that she has effectively transitioned from being a competent manager to a successful leader … and is committed to personal and professional growth, empowering her staff and effectively addressing the challenges and changes that confront practice managers.”

	The new VHMA president, Michelle Gonzales-Bryant, CVPM, says Molina is a great person to carry the torch for the award, which is about “giving managers a platform to spread ideas that work.”

	“Jessica's track record shows that she is innovative and thoughtful about the issues that managers address personally, with their teams and in the practices,” Gonzales-Bryant says. “She has been remarkably successful, and I am confident that she will have much to offer her colleagues and the industry over the next year."

	Molina's prizes for winning include a free registration to a Fetch dvm360 conference as well as registration and travel expenses to attend two VHMA events in the coming year.

This veterinary hospital administrator impressed judges from dvm360 and the VHMA with her approach to team unity and change in the veterinary industry.

2019 Practice Manager of the Year: Jessica Molina

Mary Lynn Strand / stock.adobe.comVeterinarians have a variety of tools at their disposal to keep puppies and kittens healthy as they grow, and we are well prepared to help our patients as they reach their adult and senior years. What we don't always keep in mind is that caring for a geriatric pet is much different from caring for a younger animal. As pets enter the last life stage, there is much that can be done to keep them comfortable and help their owners deal not only with their fragile family member but also with the personal toll that providing care can take on them.

 co-owner Mary Gardner, DVM-who has dedicated her career to educating other veterinary professionals about end-of-life pet care-about guiding clients during their geriatric pets' final months of life.

dvm360: First things first. How do we distinguish senior and geriatric pets?

 Veterinarians cater to patients in four life stages: the puppy/kitten stage, the adult stage, the senior stage and the geriatric stage. Although we tend to link the senior and geriatric stages together, there are some big differences. A nine-year-old lab that comes in wagging its tail is considered a senior, but we think much differently about a wobbly 12-year-old lab.

	When we think about the age of a pet in the geriatric stage, we have to consider the pet's size as that can determine the category. For example, think of a Great Dane that's 9 years old. That dog may be geriatric, but a smaller dog may not start to be considered geriatric until age 12 or older. In general, we might consider the last 10% to 15% of any pet's lifespan to be the geriatric stage, regardless of the animal's size. A cat's geriatric stage can be considered even later in life.

dvm360: What's so different about older pets?

 Geriatricians in human medicine deal with three major aspects of patient care: polypharmacy, dementia, and helping caregivers help their aged family members. In veterinary medicine, caregiver (client) education is one of the most important aspects of caring for our geriatric patients. In people, the difference between a senior and a geriatric is not their exact age but how fragile they are: A senior is usually thought of as 65. How that person acts or what physical abilities they may have don't come into play-it really is just a number. A person is considered geriatric when they are more susceptible to adverse outcomes and increased health risks-when they are fragile.

dvm360: Why is it so important for veterinary practices to educate their clients about caring for a geriatric pet?

 Better medicine, better nutrition and a stronger human-animal bond mean that veterinary practices today see more geriatric pets than ever. Data intelligence company VetSuccess worked with me to determine general practice demographics, and we found that only 5% of pets in the average clinic's database are in the puppy/kitten life stage. About 30% are adults, 15% are seniors and a whopping 48% are in the geriatric stage.

	Similarly, the AVMA reported in 2007 that 30% of patients in an average veterinary practice are 6 to 10 years old and another 15% are over age 10. That's about 45% of your client base that's considered senior and geriatric.

	If you apply those numbers to your practice, that's a lot of missed opportunity to help your patients and clients while generating additional revenue for your business. Yet we tend to concentrate our marketing efforts toward owners of puppies/kittens and adult pets. This is understandable as those pets have greater lifetime value to a practice. But pets that are in the geriatric stage are the ones that could benefit the most from seeing their veterinarian. So, keep in touch with those clients with senior and geriatric pets!

dvm360: Are most practices doing this now?

 Sadly, many aren't getting the chance. In the same VetSuccess study, 77% of cats over age 12 hadn't been seen by their veterinarian within the 18 months preceding a euthanasia. And the numbers are only slightly better for dogs: 69% of dogs 10 years and older hadn't been seen by their veterinarian within the 18 months preceding a euthanasia.  

dvm360: OK, so can you give us your best advice on how practices should concentrate their efforts?

 A home visit can be massively helpful when assisting a family with a plan to manage their geriatric pet. But for many veterinarians, that's just not feasible. Instead, ask families to bring in videos and pictures of the home environment to help you look for trouble spots, identify areas of opportunity or confirm that the family is doing a great job with their pet. It's also helpful to ask clients to fill out a questionnaire like 

 that gauges their perception of the pet's physical and mental status.

	Mobility is the most common ailment we manage at Lap of Love, particularly with the larger breeds (but it does affect cats as well). In more than half of the homes I enter, the main living area is covered in tile flooring with no areas of traction. I call this the “ice rink of struggle” for dogs with mobility issues. You'd be amazed at what a simple “runway” of yoga mats or bathmats can do for a dog. Harnesses that can be worn at all times are also a great help. For tips on helpful products for managing pet mobility, click 

	Safety is paramount with these grey-muzzle pets. Think about stairs-even one or two can cause a tragic tumble. Consider pools or lakes, or areas where the pet could get into trouble. Also be wary of young children, who may not understand the concept of a pet in pain, dealing with decreased vision, etc.

dvm360: But you feel strongly that these owners need care, too.

 It wasn't until I dealt with the struggles of caring for my own geriatric pet that I fully appreciated the toll it placed on me. We love our pets, and we'll do what we need to do for them, but it's hard both physically and emotionally. We also have the burden of deciding the appropriate time for euthanasia. That in itself is a heart-wrenching decision and pet owners need our guidance.

dvm360: You wrote an article for dvm360.com two years ago about caregiver burden among pet owners. Can you tell us about that?

 Yes, it was a cross-sectional observational study and the first to examine the 

. The investigators measured the mental health of individuals caring for a chronically or terminally ill pet by monitoring the owners' levels of depression, stress and anxiety, as well as their quality of life.

	The study results showed a greater level of caregiver burden and stress in the group caring for a sick pet; these individuals also had greater perceived stress levels and symptoms of depression and anxiety, as well as lower quality of life scores. These results aligned closely with those found in caregivers of human family members.

dvm360: What are the symptoms of pet caregiver burnout?

: Symptoms of caregiver burnout-regardless of whether a pet or a person is being cared for-include withdrawal from friends, family and other loved ones; loss of interest in activities previously enjoyed; feeling blue, irritable, hopeless and helpless; changes in appetite, weight or both; changes in sleep patterns; feelings of wanting to hurt yourself or the pet/person for whom you are caring; emotional and physical exhaustion; and getting sick more often.

	We need to empathize with our clients' feeling of burden and find ways to support them through things like education, respite care and helping them find ways to manage their pet. 

	Dr. Gardner is a co-founder of Lap of Love Veterinary Hospice, a network of veterinarians around the country whose goal is to empower every owner to care for their geriatric pets. She is also co-editor and contributing author of the textbook 

Treatment and Care of the Geriatric Veterinary Patient

Dr. Mary Gardner believes that golden-age pets offer veterinary practices a golden opportunity to provide better care for their patients and more support for their patients families. 

The home stretch: Practical care for geriatric pets  and their owners

It's likely that for every dental procedure performed in your veterinary clinic, there are scores of canine and feline patients still in desperate need of dental care. How do you emphasize the urgent needs of these pets in ways their caretakers understand?

	GPs in veterinary practice, you're in luck! Kendall Taney, DVM, DAVDC, FAVD, of the Center for Veterinary Dentistry & Oral Surgery in Gaithersburg, Maryland, is here for you. At this week's Fetch dvm360 conference in San Diego, she offered brilliant, action-oriented tips you can start implementing right away.

	Dr. Taney's first tip: Involve the owner in each step. Start with an awake oral examination during the initial visit. “Explain your initial findings with periodontal disease charts and tooth models,” she said. “Say to clients, ‘We only see 40% of the tooth with our eyes.'”

	Next, provide a treatment plan with a range of costs. Make 

 that the plan can (and likely will) change. “I used to get in trouble when I'd say, ‘Oh, this doesn't look too bad!' And then I'd take X-rays,” Dr. Taney said. “Don't make my mistake.”

		You've probably heard some variation of, “You removed two of Muffy's teeth? How will she ever eat again?” And inside your head you're thinking, “Well, Karen, she has 42 teeth. She will manage 

.” You'd never say that out loud, but what you 

 say matters greatly-because extractions can be shocking for pet owners!

		“I've had clients burst into tears just seeing the level of disease present in their dog's mouth,” says Dr. Taney. A big help to facilitate better communication with clients? Before-and-after photographs. Don't dismiss these valuable tools.

	Be firm in your explanation of anesthetic protocol, knowing that every client will feel better knowing what to expect for their pet's procedure. “Everyone has a story of how their neighbor's cousin's dog died under anesthesia-it's always because of a dental procedure, too,” says Dr. Taney. All together now: 

I will not let clients' fears about anesthesia preclude this pet from getting dental care

. Believe in your ability to help the client overcome these fears.

	Dr. Taney's No. 1 most important tip is to double-check-and then triple-check-that you have a phone number where the client can absolutely, unequivocally, 

 be reached. Ask, ask again and ask once more just in case. Not only is unauthorized tooth extraction a top reason for malpractice complaints in veterinary practice, but this insistence will reinforce your dedication to the quality of care the anesthetized pet will receive.

	Another tip to help ease anesthesia fears revolves around instructions at discharge. Make sure pet owners understand that a pet's behavior after anesthetization can be jarring. Yes, moaning, crying and whining might be scary to witness, but these are normal post-anesthesia side effects. The pet can also experience bleeding and pain, and clients will appreciate a heads-up to keep the pet away from nice carpet and furniture. Advise clients to watch their pet carefully after the dental procedure. And make sure clients know what constitutes an emergency and who to call with questions.

		Bottom line, best advice to convince an owner to do a dental procedure? Here are a few ideas from conference attendees ….

		• Dogs have bad breath, sure. And you can certainly give the example of a person not brushing their own teeth to help illustrate the point. But why not take it one step further? Ask the client to think of how she would look if she only brushed her hair once a year. Pretty crazy, right? Now, have her apply that kind of thinking to her dog's mouth. If she's only brushing those teeth once a year, imagine what's going on in there!

		• After an initial exam, offer the client a 10% discount on the full dental procedure that must be used within 30 days. Create urgency and help mitigate worries about cost.

	Keep your clients happy by calling that evening and the next day to check on the pet, Dr. Taney advises. Be available for their questions so you can intervene early if complications arise. This thoroughness helps show pet owners the value of your service, even with a higher bill, Dr. Taney said.

	Dr. Taney's last tip: Always take post-extraction radiographs. Always. These images document that the entire tooth has been removed. They prove to the owner that you did what you said you were going to do. “Which, of course you did,” said Dr. Taney. “But don't let your pet owners unintentionally reinforce this idea that vets ‘swindle' in any way.” The radiographs are proof of your beautiful work. Don't skip them, for the health of the patient, for your client's satisfaction and your peace of mind. 

	Kendall Taney, DVM, DAVDC, FAVD, is a partner at the Center for Veterinary Dentistry and Oral Surgery in Gaithersburg, Maryland. She earned her DVM from Virginia Tech and completed general and surgical internships before completing a dentistry residency. Her special interests include maxillofacial reconstruction and oral oncologic surgery.

Keep pet owners informed through the entire dental examination and extraction process, soothe fears about anesthesia, make jargon-free correlations and address cost concerns with advice from Kendall Taney, DVM, DAVDC, FAVD. 

7 veterinary dentistry tips for general practitioners

Veterinarians are being bombarded these days by questions, requests, lofty claims, unrealistic expectations and patchy scientific information about cannabidiol (CBD) products for pets. Public demand is outpacing the research as clients increasingly gain access to these products and, on the advice of a neighbor or internet article, begin using them on Max and Maizy. It's a bit of a free-for-all.

	Scientific input from reliable sources is simultaneously vague and overwhelming, largely because this is uncharted territory. Researchers are still investigating the endocannabinoid and phytocannabinoid systems in people and animals, along with the phytopharmacology of the cannabinoids themselves. All of this needs to be unraveled before the veterinary profession has clarity, and while the unraveling is happening, demand is growing faster. Existing research gets a spotty summarization in most veterinary lectures on CBD-for one, there's never enough time to explain it all, and two, the story is not complete.

	Even so, research data is not what most veterinarians want to hear. They want to know about clinical usage. Unfortunately, the data is not yet translatable into reliable clinical information for all the claims made. While over 23,000 scientific papers on cannabinoids in humans, lab animals and companion animals in 24 different species have been published, the jury is still out on exactly what CBD products are effective for and what they are not.

	Plus, despite a relatively good therapeutic safety index, they can cause harm, so caution is necessary. If they do cause problems, and veterinarians have been involved in recommending them, they can be held legally responsible for the outcome, and this includes both civil and criminal liability.

	Legal and regulatory issues aside (because those change almost daily-and you should definitely stay in touch with veterinary legal experts in your state for specifics), what exactly do we know about the science and clinical value of CBD so far?

	Several experts spoke at a recent 2019 Fetch dvm360 conference about their experience and knowledge of CBD, including some case-based information on its use in veterinary medicine. Robert Silver, DVM, MS, CVA, chief medical officer for Rx Vitamins and a practicing small animal veterinarian in Colorado, is seeing some trends and passed along what he recommends so far. Stephen Cital, RVT, RLAT, SRA, VCCS, CVPP, VTS-LAM, co-founder of the Veterinary Cannabis Academy and director of education and development for ElleVet Sciences, added his expertise as well.

	Prior to recent studies, the generally accepted therapeutic dose range for CBD in animals has been 0.1 to 0.5 mg/kg twice daily, but you can go as high as 5 mg/kg twice daily, according to Dr. Silver and Cital. A Cornell study shows that dosing as high as 8 mg/kg is safe,1 but this is not very cost-effective or practical, says Cital, who notes that dosing has been updated to 0.1 to 2 mg/kg twice daily based on now-available canine and feline data.

	Also, these experts say, not all patients will respond the same to standardized dosing. It is speculated that animals may need to have an endogenous “deficiency” in the endocannabinoid system to respond to these products.

	As far as we know at this time, Dr. Silver says, cats and dogs should be treated the same way.

	The most commonly accepted route of administration at this time is oral, these experts say. Although there are many forms of CBD and routes to choose from (concentrates, topicals, transdermals, vaporizers, nebulizers, suppositories, capsules or tablets, soft chews, powders, biscuits and so on), these are all still being studied in animals. Since bioavailability will be different for different routes, the recommendations for each will be different, and there are no guidelines yet.

	Cital also warns that any transdermal or inhalation route will bypass first-pass metabolism through the liver. So “inhalers or vaporizers may be the new wave, but be very careful using this route,” he says, noting the lack of evidence in companion animals as well.

	Lower doses of CBD are generally adequate for neuropathic pain, but higher dosages are often necessary for conditions causing chronic pain and inflammation such as osteoarthritis (OA), says Dr. Silver. Cital suggests starting with 1 to 2 mg/kg twice daily as support for either form of discomfort and titrating to effect. NSAIDs and cannabinoids can act synergistically, so dual use may lower the necessary dose of either.

	Dr. Silver has been finding 0.5 mg/kg twice daily to be effective, and he reports that other veterinarians also find lower doses to work well for painful patients. “It's worthwhile to start at this lower dose, which may provide a successful outcome, in order to reduce the cost and amount of hemp extract to be administered,” he says. The use of CBD together with opioids may allow a reduction in opioid doses, as CBD indirectly stimulates opioid receptors, producing an opioid-sparing effect, he says.

	Cannabinoids appear to be able to fight cancer, possibly through the induction of cancer cell death, anti-angiogenesis and some anti-metastatic properties, these experts say. Cital reports that an in vitro study looking at three different canine cancer cell lines was just completed by Joseph J. Wakshlag, DVM, PhD, at Cornell University, with results expected out by 2020. Dr. Wakshlag is also working on a quality of life in vivo study.

	While Dr. Silver cautions that many claims surrounding CBD and cancer are, so far, not based in evidence, he also says researchers have discovered the presence of receptors on tumor cells for cannabinoids. He knows of a veterinary oncologist who was treating a lingual mass using non- tetrahydrocannabinol (THC) CBD as a sole treatment (0.5 mg/kg twice daily). Six weeks later the mass was reduced to nearly nothing.

	Another anecdote involved a dog named Olive with an appendicular fibrosarcoma whose owners did not want to amputate. Non-CBD-containing nutraceuticals were used first, with success, for one year, and then the tumor started to grow again. The patient was started on a 1:1 CBD:THC product, and within 90 days the tumor had shrunk dramatically. In another account, a dog with an undifferentiated nasal carcinoma with bone lysis was treated with a non-THC CBD product (0.4 mg/kg twice daily), and the tumor shrunk significantly over six weeks of treatment. The dog was still in remission 14 months later.   

	All humans and animals have been shown to develop tolerance to certain cannabinoids, such as THC, with chronic use, these experts say. This means if you're using them successfully for cancer treatment and then stop, the cancer may recur. If it does, as is the case with some other chemotherapeutic drugs, it has usually developed tolerance to CBD products, according to pet owners and oncologists who've observed this phenomenon anecdotally. It's important to warn clients about this. “If you get a tumor response and stop, it will come back, and it will come back resistant,” Dr. Silver warns.

	It's also speculated that secondhand smoke may create THC tolerance in animals, Dr. Silver said, but further studies are needed.

 considered an anti-seizure drug-it has been reported to actually cause seizures. Therefore, any THC in a CBD product could theoretically make a seizure patient worse, but studies are incomplete. Cital notes that the manufacturer of the FDA-approved CBD medication Epidiolex conducted a 56-week-long study of rats and dogs at high doses of both THC and CBD (roughly 25 mg/kg twice daily) and were unable to induce any seizures in dogs.

	However, Dr. Silver warns, “we are in the infancy of use [of CBD products] adjunctively with epileptic medications.” He describes a Colorado State University study of CBD for refractory epilepsy (2.5 mg/kg twice daily) in which some dogs experienced a 40% reduction in seizures-not a very impressive result, Dr. Silver says.2 A new study at a higher dose (4.5 mg/kg twice daily) is taking place now, but it's too early to draw valuable conclusions. Still, he says, for uncomplicated seizures that aren't frequent or are well-controlled with anti-convulsant drugs, veterinarians and pet owners are finding that 0.5 to 1.0 mg/kg of CBD twice daily can control seizures and, in some cases, allow for reduced doses of anti-epileptic drugs.

	Michelle Carnes, MS, DVM, DACVIM, a veterinary neurologist who gave an update on seizure management at Fetch dvm360 in 2019, does not recommend using CBD products in seizure patients at this time. She says the oral bioavailability of many CBD products is too poor, and CBD is a potent inhibitor of cytochrome P450 with a long half-life in dogs, which could potentially interfere with other medications.

	“There are still no extensive studies in dogs,” she says, describing the same CSU study that found little improvement in canine epilepsy when CBD was used as an adjunctive drug.2 She reports that popular thinking surrounding use of CBD in animals with epilepsy originates from the treatment of seizures with Epidiolex in children with severe, difficult-to-treat forms of epilepsy.

	“This drug is extremely expensive and has now been reclassified as a schedule 5 drug,” Dr. Carnes says. It would not be affordable, or easily available, for veterinary patients at this time, even if it was found to be effective. “That aside, if we take the average human CBD product, using the current recommended dose in humans (5 to 10 mg/kg), and extrapolate this to dogs, the cost would be $444 per month for a 20-kg dog.”

Experts share their experience and expertise on what we know about cannabidiol use in dogs and cats.

Vetted January 2020