Life skills become invaluable when entering practice

You have graduated; you have passed the boards, and you have finallyfound a practice that is a great fit. The owner is very excited about havingyou start your career at the practice too. Now, you must walk through thedoor of that practice, and make your first impression as a "new"team member.

You know in your heart that you are expected to be a leader in case management,yet you also need to be a follower of the practice's standards of care,and contribute to the continuity of care of patients you have never seen,owned by clients you have never met, and with a staff who probably has manymore years of practical experience than you. What are you going to do?

What-cha-goin'-ta-do?

Hopefully, you have been directed into a Toastmasters or Dale Carnegiecourse during your last year of school. If you have developed/learned communicationskills, life will be far easier in your new work environment. Maybe youhave read Crucial Conversations (by Patterson, et al) and have a skill setfor leading participative facilitated discussions. Then you may have beenone of those "gunners" who only studied for tests, and left thelife skills ride during your school years. Regardless, the first 90 daysin a practice have many similarities, and the savvy "new doctor"will address the new environment using a sane and progressive integrationsystem.

Pre-day one

Make an agreement with your employer that you get 30 days of non-productivetime to learn their system and strengths. (You may get involved in somewellness cases, but please resist trying to jump in with both feet.) Usethe "short list" offered below for the first month to "negotiate"your initial orientation and primary care development time. Some may believethey "know it all," but experience has shown the listed itemsare usually very practice specific, so make yourself valuable by becominga student of the practice systems and expectations.

Day one

Dress like a practice doctor (practice standards, be careful of beinga sparkling clothes horse or a street person dress-down), ensure your hygieneis smell-worthy, and put a smile on your face. When being introduced tothe practice team, don't be cute, be sincere. Learn people's names, andassociate names with practice skill areas or areas of personal pride.

As applicable, get personal copies of mission statement, vision, corevalues, practice philosophy, employee manual and other baseline documents;read and learn them.

Week one

Ensure you get a practice rotation established so you can spend time(at least one full shift) in each practice zone learning what they do andhow they do it. Ask questions about what they want you to do in the coursea patient episode, solicit from "womb to tomb" alternatives andexpectations.

Month one

Become a fixture in the treatment room. Do not try to change or challengeanything until you learn the "how" and "why" of thecurrent operations. Continue being a great student this month by askingquestions and learning how they want things done. Ask the staff to "helpyou learn the practice methods" for:

• Maintaining staff harmony (usually a core value).
• Review staff training protocols and programs.
• Pre-emptive Pain Scoring program(s) and protocols.
• Inpatient Pain Scoring program(s) and protocols.
• White Board use (use of Treatment Room Flow Sheet).
• Bathing - you learn best by doing it - use Hydro-surge or equivalent.
• Hospital ward monitoring systems and cage card use.
• Determining hospitalization levels
• Respecting nursing rounds
• How inpatient nurse schedules inpatient doctor(s) (staying in time).
• Operating the laboratory equipment
• Setting up fecals
• Outside lab form completion terminology/protocols.
• CBC procedures
• UA procedures
• Staining slides
• Cytology procedures
• Catheterization (be a holder and watch first).
• Learn risk assessment scoring required for all admissions.
• IV therapy
• Radiology positioning
• Radiograph processing
• Telemedicine capabilities/agreements
• Ultrasound/endoscope protocol(s) as applicable.
• In-house ECG procedures
• Hospitalization protocols
• Nutritional grading of inpatients
• Body condition scoring for outpatients
• Learn dental grading (four levels)
• Dental prophy (Grade 1+ and Grade 2+ dentals).
• Oral surgery (Grade 3+ and Grade 4+ dentals).
• Surgical pack preparation
• Pre-surgical patient surveillance standards
• Pre-anesthesia techniques and protocols
• Patient induction protocols
• Patient anesthetic monitoring expectations.
• Start doing spays and neuters
• Gain surgery speed and techniques using practice resources.
• Scrub in and assist in other surgeries
• Recovery procedures
• Patient discharge instructions
• Understanding of travel (circle) sheet and category use.
• Planning the next contact (Recheck, Recall, Remind = 3Rs = 100 percent).
• When treatment room is slow, shadow outpatient doctor(s).
• Understand the Outpatient Nurse (OPN) asymmetry exam.
• Accept the documentation shorthand expectations.
• Become confident; use the term "need" instead of "recommend".
• Respect the S-O-A-P (H-E-A-P) formats of the practice.
• Review the "Assessment" to "Problem List" techniques.
• Understand importance of admit or discharge decision after 10 minutes of doctor's consultation.
• Work outpatient for wellness cases on a Saturday morning.
• Understand practice's competency and productivity standards.
• Develop an agreement for seeing new clients with wellness patients.
• Seek constructive feedback from the employer on a weekly basis.

Month two

Become an outpatient resource and continue a dependable surgery schedulefor spays and neuters, and possibly a few other procedures where you haveconfidence.

Do not try to change or challenge anything until you learn the "how"and "why" of the current operations. In short, continue beinga great student for outpatient procedures this month. Learn the narrativesand preferences of the practice, often called the "standards of care",and ensure you are meeting the "continuity of care" expectationsof the doctors and staff in your documentation. Ask often for feedback fromthe medical director/owner on impressions of your team support and contributionsto staff harmony. Learn how "day care" admissions can improvepatient care, while providing you an often-needed second opinion. In manycompanion animal practices, experienced providers have about a 40 percent"day admit rate" from outpatient cases (e.g., radiographs, earflushes, full chemistry cases, VetScope cases, etc.).

Attitude counts

The good doctor knows that "day admits" depend upon the staffcompetencies; a great doctor encourages and supports the staff in developingday admit competencies.

Day admit competencies means the staff have been trained and are trustedto do most all of the routine imaging procedures, IV procedures, ear flushes,laboratory samples, so results are ready for the doctors assessment. Theterms of employment for new doctors are the same for all other staff members:

• Team fit (maintains and supports practice harmony efforts).
• Competency (dependability for producing expected outcomes).
• Productivity (stay on schedule, speed comes with time).
• Patient advocacy (talk aboout what the pet "needs").
• Client-centered service (listen and respond to their wants).

For a staff doctor, there are additional "terms of employment",since they lead a healthcare delivery team:

• Respect (consistency for staff, clients, doctors and self)
• Responsibility (based on strengths, give others meaningful tasks).
• Recognition (individual and specific, in public and often).
• Reliability (accept credit for success and failure - no blaming).
• Patient advocacy (talk about what the pet "needs").
• Client-centered service (listen and respond to their wants).

Yes, the last two elements were stated twice, because that is how importantthey are. We know that primary care is not at the high end of training atmost veterinary teaching hospitals.

As such, allow me to share with you the secret triad of client bonding;commit these to memory and strive for accomplishment with every case:

• Allow no pain.
• Allow no puking, peeing or pooping in the home.
• Tell the client how to feed the animal (never tell a client NPO).

The emergency and critical literature tells us that in traditional NPOcases, a 5 to 10 ml glucose lavage keeps the gastric flora more viable,thereby enhancing recovery; it concurrently allows the pet steward to feelthey are doing something. This is similar to the clear broth or clear liquidsguidance given to mothers. No intelligent doctor ever tells a mom they cannotfeed their child!

Becoming a valuable asset

The new doctor is supposed to become productive as soon as possible.It is important that you learn to stay on schedule, as well as schedulepersonal issues outside the practice day.

The most productive doctors leverage their time by using the staff ascritical resources on their healthcare delivery team. They understand whatthe staff members can do and trust them to do it well. If a staff memberdoes not know how to do a support function, they take the time to coachthem to a level of competency where they can be trusted.

Doctors who praise staff members in public, and coach in private, becomerespected team members. Doctors who give credit and take blame become respectedleaders.

As you embark on your career, live long and prosper; may the force bewith you.