Dr. Thomas Catanzaro provides a detailed outline of the essential elements for developing nutritional counseling for your patients.
For years, companion animal practices have thought things like: grooming has no net; nutritional sales has minimal net; we are professionals and do not "sell." These types of functions were even considered "unethical" a decade ago. The times have changed and the companion animal veterinary profession has polarized into two camps: change and capitalize upon the new opportunities or maintain what we have always done, and "this, too, shall pass." The latter thought has caused practices to decrease their liquidity.
Before we start, let me state that I am not a believer in sales for the sake of sales, and I am even less enamored with sales for the sake of a higher ACT (average client transaction)! I believe in training healthcare providers to talk about "needs" and then allowing the room to fall silent while the client thinks then speaks; in letting the client buy, and in providing them two "yeses". Effective healthcare marketing is a triple-alignment process:
Marketing is the ability to believe in what you do and let others know that it is worthwhile.
The secret of client bonding has long been a trial and error process, yet we can teach the new graduate the basics in a very short three-part message:
NEVER allow pain;
NEVER allow vomitng;
ALWAYS tell them what they CAN feed their pet!
The veterinary school usually teaches the student "do not feed" as a treatment modality, but the Veterinary Emergency & Critical Care Society (VECCS) has shared studies that show even an NPO animal recovers faster when they have had an oral glucose drip (5 to 10 cc a time, multiple times a day) to keep the stomach flora active. What both institutions have not stressed, but is obvious to the experienced practitioner, is that the client who is allowed or even directed to feed their animal is a much happier person; feeding is a maternal instinct which we must respect. Happy clients stay bonded to their attending veterinarian and will usually return as expected.
The veterinarian needs to set the stage for introducing nutritional wellness as a component of the overall preventive care approach to clients. This responsibility can then be turned over to a trained staff member who acts as the nutritional advisor within the practice.
I have always believed that nutrition is a contemporary healthcare concern; animals require food. In our consulting service, we have shown repeatedly that while doctors cannot make much profit when they spend their time "selling dog food," when they prescribe diets, monitor nutrition wellness, and establish nursing surveillance programs for each case, better animal health and wellness occur. Wellness is a popular term for our clients in their own healthcare and nutritional counseling and is well accepted for people. Nutritional wellness is a media industry in itself. The phrase nutritional wellness brings mental images into our client's mind that makes our marketing efforts easier. The sad thing to note is research shows that while most companion animal practices have started 30 percent or more of their patients on some form of quality diet, less than 7 percent of the patients stay on for an entire year; we are not doing our job as patient advocates when these many animals are allowed to "fall off" a quality nutritional program.
There are those who have started to sell maintenance nutritional products, and there are those who have recently stopped selling maintenance diets because of the lack of space, low margins or competition from outlets from outside the veterinary profession. The use of the nursing and paraprofessional staff as patient advocates, monitoring patient changes over time by rechecks and recalls, allows client/patient return visits to the practice at greatly reduced costs to the client (without doctor consultation charges being assessed), and still allows doctor referral when the situation dictates. Regardless of the decision, there is one important "profit center" concept to understand when using staff as veterinary extenders: your practice overhead is a fixed cost whenever you consider adding any new line item.
For years, we considered square footage and other apportionment methods to determine profitability of a service or product, but in the new millennium that thought pattern is outmoded. In the cost benefit analysis, if the service or product replaces something else, the values of each must be assessed and compared (expense to cost ratios by line item, rather than percentages of gross income). If the new line item or service only replaces idle time ("coffee time"), there is no overhead expense. You would pay the overhead expenses with or without the new product line or service. This is the category in which I usually find pet food and nutritional counseling. It is a spare time activity within a practice, best done by a caring staff, not displacing anything else.
Rule of thumb #1. Complete medical records are internal communication devices for continuity of care! Sequential body weights, with body scores, should be a consistent element of every healthcare documentation program, just as TPR data and baseline laboratory screens are. Many practices have a "weigh every animal" program, but do not take it the next step to body scoring.
In this era of veterinary diversification, marketing of nutritional products has become a concern in many practices. The current rule of thumb is that when the income from pet food exceeds three percent of gross, it should become a separate expense element and be managed as its own profit center. The standard markup on pet food makes volume a tracking concern if the lower net is combined into the drug and medical supply account. To see it as a profit center, rather than just a client service, it needs to be tracked separately, and the real dollar income must be compared to the real dollar expense; transfer of the product(s), transfer between activities (TBA) for the bookkeeping, from resale to wholesale is equally as critical when products are used for nursing, boarding, or staff discount sales.
The rule of thumb that prices are often set by our competitors has waned. The new "rule of thumb" is that, "Prices are controlled by the most efficient agency known: the consumer" (Fortune Magazine). This is especially true when competing in the nutritional market, since the pet or feed stores carry similar products and the manufacturer's marketing effort is aimed at the product user and not the outlet. Some practices have added "holistic food" or "natural products" to their nutritional line, in an effort to differentiate their nutritional services; this is an effective alternative only if the staff is specifically trained and believes in the product line.
The rule of thumb that a veterinarian is worth in excess of $220 per hour in the examination room or over $330 per hour for surgical suite time makes nutritional counseling by the veterinarian a low-payoff activity, if nutritional counseling replaces professional healthcare. If it replaces coffee time, it is not a comparison issue. The wages a practice usually pays the paraprofessional staff make their nutritional counseling efforts a higher payoff practice activity; some practices have started to pay their nutritional counselors a portion of the net from sales, as when they exceed 30 percent net income.
The last rule of thumb is the medical basis of this discussion. Is nutrition important to health? Does every animal deserve to be on a nutritionally complete and balanced diet? Is digestibility also a concern? Would you prefer a pet owner to receive information concerning nutritional wellness and products from your practice instead of the local pet shop or feed store? Do you want your practice to integrate nutritional concerns into the veterinary healthcare delivery plan? Are you capable of training the practice staff to be nutritional advisors who can assist clients in their patient advocacy? If most of the answers are yes, the rule of thumb is, "Provide it or lose it."
The client must believe in what a veterinary healthcare provider tells them. To be professional and believable, the provider must sincerely and medically endorse whatever they are saying. The marketing of pet food without believing in the product usually results in the practice effort becoming a cost center rather than a profit center. The professional training of a practice staff, as well as ourselves, includes the mental attitude adjustments required to develop nutritional counseling as a needed service as well as a profit center. Ask yourself; does everyone feed quality diets to their own animals? In one Illinois practice, when the doctors were asked what they fed to their own animals, only two of the six were feeding premium diets. We made a pact; everyone would feed only "practice available" diets for 90 days (even if they had to be sold at cost to the staff). At the end of the 90 days, retail nutritional product sales had increased by 19 percent. The team saw the difference, believed in the products, and had naturally started to share their belief in nutritional quality with the clients.
Discuss with your staff why certain diets are indicated, why Iams, ProPlan or Waltham, or whatever you stock, is available in your practice, and why you professionally feel certain animals need specific dietary management. Get the staff to believe in what you believe. More important, at the end of each month, ask each paraprofessional the following four questions:
These questions are designed to empower the veterinary nutritional advisor, based on the training completed outside or inside the practice. They are designed to show the practice's confidence in the capability of the staff member to follow "their own clients" and delegate the client counseling to a cost-effective level within the practice. The questions used are in concert with the values of most paraprofessionals, client service and a caring approach to wellness. They center on factors for which the staff member has complete accountability. If revenue dollars are brought into the equation, excuses are possible (OTC sales, size of purchases, cross sales, etc.). This would be detrimental to measuring personal success. In cases of tracking client access, the paraprofessional can be proud of the service provided. In healthcare delivery, it has been shown that staff pride is perceived by the client as quality. Caring and belief in the value-based quality received causes the client bonding. The bonding is what causes return trade (and increased liquidity).
Each client has specific hot buttons, those things that really spark an interest or keep their attention. The receptionist, the technician and the veterinarian need to become a team in writing those key personal elements in some specific area of the medical record. This allows more effective communication with the client since analogies can be drawn.
The marathon runner will usually understand the need for stamina, the nurse will understand the need for a balanced nutritional program, or a parent will generally understand the need for an owner to provide a nutritionally complete diet for animals under their care. Inversely, the overweight client will generally not respond favorably to statements about a fat pet, but may respond to a comment about the need for higher fiber and extended life spans. The client who likes to feed table scraps and rebels when we recommend stopping will often respond to the wellness need when we point out that the nutritional consultation can balance the diet to a point where a few specific table scraps are okay during the transition to a better lifestyle and fitness state for the pet.
The public perception of nutritional wellness is formed by many factors, most of which are out of the veterinarian's control. The local media intensity of human nutritional center advertising programs will pre-sensitize the client. The family standards for balanced or complete diets will affect the perception of importance of diet for the pet. The amount of junk food consumed in the client's daily lifestyle will affect the importance of a controlled diet in their pet's life. The veterinary practice staff cannot affect these environmental factors to any significant degree.
The total patient advocacy program of your practice style will allow nutritional counseling to be seen as a farce or as a sincere concern. How you approach the healthcare needs of the pet from the first visit will often set the stage for nutritional counseling. Balanced client education in the areas of vaccinations, internal and external parasite screens, pre-anesthesia laboratory testing, documented physical examinations, dental hygiene exams and similar routine healthcare concerns make the use of nutritional counseling seem normal.
The veterinarian must set the stage for the need, but does not have to conduct the nutritional counseling. A well-trained nurse technician or client relations receptionist can act as the nutritional advisor (an extension of the veterinarians) within the practice. Veterinary extenders are needed in every practice. Those are the people or things that allow the veterinarians to stay in the examination room or surgical suite and earn theincome that they were trained to earn.
One examination room can often be set up for routine use by the trained staff, with certificates of training and other credentials hanging for the clients to read. The display of these "glory walls" should not be restricted to only the veterinarians on staff. This lends an important credibility and recognition to our support staff. To a veterinary extender who serves as a nutritional counselor, the scale is an important instrument, and should reflect a professional approach to monitoring weight loss or gain.
The routine follow-up weighing of animals on nutritional programs is expected and can easily be programmed for a veterinary extender to monitor, to include the recall reminders if the pet fails to appear for monitoring. The fact that the nutritional counselor monitors the weigh-ins does not require that the recall be done by that trained person. Any member of the staff can be trained to make "Doctor and I" recalls.
It has been said that "Service is adding people to the product." Profit is adding any net income to some action, void, or habit which had none. Marketing nutritional wellness fits these definitions exceptionally well, especially when we consider using the internally trained veterinary extender as our practice methodology to make it happen.