Practice in the Real World - The bouncing client

Sue Swift waited with Charlie. Charlie has been seen at Academy Vet Clinic numerous times, and Sue has had a good relationship with Dr. Swanson in the past.

This time might be different, and Sue was a little apprehensive.

In the other exam room, Dr. Swanson was removing the sutures on another cat. Sue could hear the cat "hiss" through the thin walls.

As Dr. Swanson exited the room, Janet Williams pulled Dr. Swanson aside to inform him that Sue Swift is in the next room and she has various issues to address about Charlie.

Dr. Swanson knew Charlie well and was anxious to see how he was doing. As he inspected the chart, he instinctively knew something was wrong.

"That is what I want to tell you," Janet said in a hushed voice. "Sue is a little upset, and she has always been very nice."

Dr. Ben Swanson carefully looked at the history. He and his associate had been seeing Charlie for the past six to seven weeks for an undermined vomiting and diarrhea problem. They had run blood tests, multiple X-rays and had even done a barium series. They had tried various medications with limited success.

Dr. Swanson suddenly realized that the associate had seen Charlie on the past few occasions, and he had been "out of the loop" regarding Charlie for about three weeks. The associate had even called the university for some help. They had suggested several more tests. The medical record showed three pages of notes about his recent problem.

At the end of all those notes it was written that Charlie had recently been to "Elsewhere Animal Hospital" and had seen Dr. Fred Smothers, one of the "older" doctors on staff there. Today it appeared from the notes that Charlie is now cured. Sue wants some of her money back.

Dr. Swanson begins to sweat. His auto-nomic nervous system is on high alert, and he wondered if the sulfasalazine his own doctor told him to use two years ago will be effective today. Dr. Swanson's cramping and diarrhea return from time to time, especially during stressful episodes with staff or clients. Naturally, he has been using his own medication from the shelf of Academy Animal Clinic pharmacy.

"Hello, Mrs. Swift. It is good to see you and Charlie," he chimed with a sudden dryness in his voice. He nervously moved to pet the animal. Charlie seemed very happy to see the doctor.

"Dr. Swanson, (a moment of hesitation) ... I am very unhappy with your clinic. I have always thought that your facility here was a great place to bring Charlie but Dr. Smothers at the other hospital cured Charlie in no time. I took him there for a second opinion and seemed to know what his problem was right away."

"What did he find out?"

"Oh, he didn't have to take any tests or anything. He just seemed to know after we had talked a while. He said, "Charlie was just under a lot of stress."

Dr. Swanson knew what she was talking about — at least about the stress issue.

"How did he treat the problem?"

Dr. Swanson knew that answer to the question because Fred was known among his colleagues as "Fred Pred" because he liked to use any drug that ended in "sone" as his initial approach to a problem. Dr. Swanson had asked the question anyway.

"He gave some sort of cortisone shot and within 24 hours he was just 'good ole' Charlie again."

At this point, Dr. Swanson knew what was coming next but had always been emotionally unprepared for an answer.

"Dr. Swanson, I really want to continue coming to your office, but I would like to have a refund for the money I have spent on Charlie's problem over the past few months.

Janet had already detailed the money side of the issue, and Dr. Swanson knew that she had spent about $600 or so over the past several weeks.

At this point, Dr. Swanson began the routine in earnest. He had become a pro over the years at massaging and defending the diagnostic approach and the value of rule outs and the disasters he had seen when a full work-up had been performed.

He stated that second opinions were good ideas but this hospital was always careful to guard against the unknown. When he had finished, a full 10 minutes had elapsed and Mrs. Swift had quietly sat through the whole sermon.

"How come Dr. Smothers didn't have to do all that?" she asked.

Dr. Swanson sat mute for a second and could feel a warm gurgly feeling rising from his lower bowels. The air was thick with tension.

"I understand your confusion, but we did what we thought was best," he lamented.

Several uncomfortable seconds elapsed.

"Since these tests were obviously unnecessary, I would at least like a full refund on all of these unnecessary tests," she countered bravely.

"Mrs. Swift we performed all these tests in good faith..."

Mrs. Swift interrupted.

"I think that I will be taking Charlie to Dr. Smothers from now on."

She got up and left the room. Dr. Swanson felt betrayed by the system. He stared at the wall a minute and felt uneasy.

A few minutes later, Janet came to the room looking for the chart. She was met by Charlene the receptionist.

"Where is Mrs. Swift, and where is Dr. Swanson?" Janet asked.

"Mrs. Swift left in a huff," Charlene observed.

Charlene leaned over to speak in a loud but emphatic whisper.

"I think Dr. Swanson is in the bathroom, and he said he might be in there a while!"

Second opinions

It is obviously best if the original veterinarian is somehow involved in the referring process. This is not the case very often. When a client actually asks if you think that a second opinion might be valuable, you have a wonderful chance to increase the bond with your client. On the other hand, if you are defensive, you may plant little seeds doubt.

Unfortunately, many veterinarians see this request as a time to defend their workups and talk about their experiences and wonderful diagnostic abilities.

It is much more helpful to step back and actually tell the client that you would be glad to rethink things over again. Clients like you to tell them that you can see their points of view. This is also a good time (likely a past due time) to talk about referring your patient to a qualified specialist. Proud veterinarians tend to ride the case to the edge of their competencies and then hope for the best. Sometimes they are oblivious to their limitations.

Invariably a frustrated client will eventually seek a second opinion with or without the blessing of the original veterinarian. The clients' level of frustration is often evident at some time in the parade of visits to the practice, and a wise veterinarian can pick up the signals that help direct his or her actions.

It has been my experience that the veterinarian who is fortunate enough to be the second one to assess a chronic problem has a strategic advantage. There is no baggage to justify treatment. Additionally, for some reason the second veterinarian is in a position of seeing the patient from a fresh angle, and the owner may give fresh insight that she was not able to impart to the original doctor. The result? Usually, the second veterinarian has a great deal of success treating a patient.

History

Dr. Swanson likely fell into the trap of not taking a very good history and not re-visiting that history from time to time. Doctors who truly want to do a good job for their patients want to find two things:

• What is wrong with my patient?

• How can I treat or alleviate the problem?

Unfortunately we can sometimes throw tests and medication at the problem trying to please the client and do a good workup, yet not really thinking through the problem. (I have been guilty of this.)

The inevitable will happen. Your client will tire of the routine and seek help elsewhere. Often the veterinarian feels blind-sided. In many cases, the client returns with tales of cure and from all appearances you now have "egg on your face".

The bouncing client

There are, however, many clients who feel it necessary to bounce from veterinarian to veterinarian searching for answers. These clients seem to want to take a poll of the available veterinary pool and decide on the answers, finances and remedies that suite their needs. This, of course, can be disastrous to the patient.

There is virtually nothing you can do about the typical bouncing client. However, the client who bounces to another veterinarian while you "barge on through" some of the difficult or enigmatic cases that they present have a solution: communication.

Talk to your client, and try to listen to the little clues that they will inevitably vocalize including:

"I talked to Joan, and she recommended I should ..."

"I have been on the Internet, and it said that we could ..."

"Do you think we need to talk to ...?"

"Is there anyone locally that I could talk to?"

When the questions get to this point, you should "perk up your ears" and reassess your patient.

Dr. Lane is a graduate of the University of Illinois. He owns and manages two practices in southern Illinois. Dr. Lane completed a master’s degree in agricultural economics in 1996. He is a speaker and author of numerous practice management articles. Dr. Lane also offers a broad range of consulting services and can be reached at david.lane@mchsi.com.