When concierge care is reserved for pets

I am a family physician. Like most of my colleagues, though, I must sometimes step out of the comfort of my clinical role to take on the role of patient or family caregiver.

Generally, these trips to the other side of the exam table inspire a fair amount of anxiety.

During visits to the doctor, I find myself noticing many details and comparing the quality of care to that in my own practice. I worry about how the doctor will relate to me — will I be viewed as a knowledgeable colleague, or as someone who knows relatively little? Will my background be treated with respect? Will my needs as a patient or caregiver be acknowledged? The uncertainty eases only when the physician wins my trust by showing both competence and caring.

My most recent such experience came via a family member, whom I’ll call Henry.

He had noticed a lump in the skin of his lower abdomen. It was smooth, firm, mobile and ovoid. There was no history of trauma, and it wasn’t bleeding or painful, but he kept noticing it, and over time, it grew.

When it reached more than one-half inch in size, Henry’s primary-care physician, Dr. Tilman, removed it. To everyone’s surprise, the growth turned out to be an exceedingly rare form of cancer.

Dr. Tilman referred Henry to the nearest specialty hospital, two hours’ drive from home. I was to accompany Henry on his visits.

Soon afterwards, Henry made his first trip to the hospital for an appointment with the oncologist, Dr. Ricci. Beforehand, we received detailed instructions on what to expect and what preparations to make; when we arrived, we found that parking for patients was free and convenient.

Dr. Ricci carefully reviewed Henry’s initial history, past history and preventive health measures. She had discussed his pathology findings with several other oncologists and had studied the literature on this rare form of cancer.

She ordered some tests for Henry, and he went to have them. The hospital staff gave me a list of nearby attractions and restaurants so I could explore the area meanwhile.

Later that same day, Henry and I met again with Dr. Ricci for a follow-up visit. She told us that she’d already contacted Dr. Tilman to discuss her recommendations and would send her a detailed consult note and copies of the relevant research literature.

I drove Henry back home, feeling pleased at how easily things had gone.

A week later, having reviewed Henry’s pathology slides again, Dr. Ricci contacted us to go over the different treatment options — their risks and benefits, pros and cons. To save us travel time, she did this by phone.

She recommended a wider re-excision of the original cancer site, and we agreed that this made sense, so she arranged for Henry to consult the hospital’s surgical team. To minimize travel time, the visit was scheduled for the day before the surgery.

The surgical team, Drs. Hendriks and Danner, indicated that they’d spoken to Dr. Ricci and reviewed the treatment options, the pathology slides and the recommended treatment plans. Dr. Danner again reviewed Henry’s full chart, including preventive measures, then examined Henry carefully and admitted him to the hospital overnight.

The surgery took place the following morning. Before and afterwards, I received regular phone updates on Henry’s progress; I could tell how attentively the team was dealing with his needs, and that they appreciated his individual quirks.

When I arrived to take him home, the receptionist said, “You’ve driven a long way to get here. If you’d like a cup of coffee while the resident prepares the discharge instructions, there’s a pot in the waiting room.”

After only a few minutes’ wait Henry and I departed, equipped with complete discharge instructions and follow-up procedures.

Dr. Tilman got a faxed copy of the discharge summary and the follow-up plan. The plan, created by the surgeon and oncologist, empowered her to manage Henry’s care unless complications occurred.

Our final contact with the hospital came five days later, when Dr. Danner called to tell us that the pathology findings on Henry’s excision were negative. He’s considered cured.

What and where is this excellent hospital, which features such smooth communication between specialists, primary-care doctors and patients?

It is the Cornell University Hospital for Animals, in Ithaca, New York. And “Henry” is Humphrey, my three-year-old black-and-white cat.

I had adopted him from the Humane Society six months previously, on the heels of losing two elderly cats to very prolonged illnesses. Humphrey is gregarious and affectionate, and I’d looked forward to several years of worry-free feline companionship, so I found his cancer diagnosis extremely frightening.

The hospital’s entire team of veterinary professionals showed phenomenal skill, thought and dedication in their care for Humphrey — and for me. As a physician, I was extremely impressed; as Humphrey’s family caregiver, I was tremendously relieved and grateful.

I found it deeply reassuring that the hospital scheduled consultations so that we could have closure with each one. There were no long delays in the diagnosis and treatment process; only a short time elapsed between the caregivers’ recommending and getting approval for Humphrey’s tests, administering the tests and responding to the results.

By scheduling Humphrey’s exam and follow-up visit for the same day, by clearly communicating a follow-up plan for his primary veterinarian and by giving a phone consultation, Humphrey’s caregivers acted in the spirit of a patient-centered medical home.

For this, I will be forever grateful. But my gratitude is tinged with sadness, because very often the efficient, patient-centered care Humphrey received is not available to human patients who face similar illnesses.

Most people’s medical insurance will not reimburse medical providers for two visits on a single day; nor can you obtain ultrasounds or CT scans on the same day as a consultation. Delay is often the norm, not the exception.

Recently, for instance, a patient of mine who has lung cancer waited nine agonizing days before her insurer approved her CT scan; her work-up spanned three weeks and five separate appointments at the tertiary-care center. And for a human patient, a consultation like my phone conversation with Dr. Ricci would typically require another office visit.

My experience with Humphrey’s caregivers showed me that veterinary medicine and human medicine, although very different branches of healing, hold similar values and priorities — the importance of efficient, patient-focused care; clear, timely communication between team members; the need to show kindness to the patient’s whole family.

I cherish this knowledge.

And I wonder: what if we could set up the human healthcare system so that the communication, competence and kindness that made Humphrey’s care so special — that made it so humane – were not only valued but also reimbursed?

Deborah Pierce is a family physician. This piece was originally published in Pulse — voices from the heart of medicine, and is reprinted with permission. 

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  • John C. Key MD

    Maybe this excellent veterinary care was market-driven; perhaps it was just compassionate common sense. Whichever it was, it can clearly be seen that it would have been impossible, or far less likely, with government and insurance companies calling the shots.

  • JennaSM

    These veterinarians were fortunate to have a motivated client with the ability to pay. This is only rarely the case in veterinary medicine.

    Did the author pay for those compassionate, humane telephone consultations? Maybe, because Cornell is a tertiary care center, but it’s common for veterinarians to provide this service without additional reimbursement. BTW, what was the total cost (consultations, surgery, treatment)? Veterinary oncologists are well-paid compared to general practitioners, it’s true, but they receive chump change compared to the salaries of their human equivalents.

    Overall, the average veterinarian is willing to do more for patients for much less money than the average physicians is. Why is that?

    • fatherhash

      could be several factors…but right off the bat, i’d see some differences in the malpractice liabilities and average length of training(residency). i assume school costs about the same.

      i think human medicine has overly inflated prices due to overgrowth of admin costs….doubt there as much admin burdens in veterinary medicine(or dental specialties).

      • LastoftheZucchiniFlowers

        I suspect this wonderful service had a bit to do with lot to do with Dr. Pierce’s ability to provide cash up front for her pet’s care? I too, have gladly paid for my dogs’s emergency in the middle of the night. There is no 3rd party payer to get in the way and my vet is a dedicated, happy lady with very good staff who are caring animal lovers. I understand there are only a handful of Vet Schools in the US (my vet graduated from Prince Edward Island). I have always been interested in the fact that out of all the military services, only the Army has active duty vets who staff the equine division (cassion and mounted units). For the rest of the military animals, civilian (civil service vets) provide care. My kid LOVED playing ‘Zoo Vet’ when she was a little girl….and while some of us dearly love our pets and would do anything for them, others treat their ‘pets’ abominably as any headline will show. The answer lies in the fact that anyone who loves a pet will do whatever it takes……….as we would for a beloved child. Glad Dr. Pierce’s cat did so well. Pets have ZERO secondary gain and do not malinger; so when they start to feel better, we know it right away! Sort of like little kids!

  • EmilyAnon

    I read this article when it was published on the Pulse website. Too bad the title here was rewritten to give away what should have been a surprise ending – that the patient was a cat. Otherwise I enjoyed reading it a second time.

  • http://hautuconsulting.com/ Shane Irving

    Having lived in countries with Universal health care I can confirm this type of care is possible. I have seen it first hand and before moving to the US thought it was the norm….. Little did I know until I joined HealthCorp USA.

  • Anne-Marie

    With far fewer veterinary medicine training programs in the U.S. than medical schools, it’s more competitive to get admitted to a DVM program. And if you’re going to spend your professional life caring for patients who can’t tell you how they feel and sometimes pee on you or try to bite you, you would really need a passion for veterinary medicine above and beyond the financial rewards, yes?

    Not that physicians don’t deserve to be well compensated for what they do, but they seem to have more of an expectation/entitlement about salary than most veterinarians do. Maybe it’s a product of the training process; maybe there’s some self-selection at work… who knows?

    • fatherhash

      although i’m not gonna argue about the “entitlement” attitude of physicians, i do not agree that that is why they are paid more. pediatricians also spend their “professional life caring for patients who can’t tell you how they feel and sometimes pee on you or try to bite you.”
      but they aren’t paid relatively well in medicine either.

      veterinary medicine(like most of dentistry) is still market driven. if there aren’t enough(low supply) and the demand(likely problem) is there, they will likely charge(and make) more.

  • fatherhash

    for malpractice, it’s not just about the cost of insurance, but also about the risk. if a neurosurgeon has a greater chance of getting sued and losing big compared to a PCP, it would make sense for them to make more net income(even after deducting for insurance premiums).

  • PCPMD

    Probably because the market (demand) for veterinary care is relatively small, and likely saturated. According to the American Veterinary medical society, there are 98,900 active veterinarians. By their own admission, this is likely an overestimate, as approx 18% are nearing retirement, and not working full time. Yet they acknowledge a 12% excess in the national supply of veterinarians, and by their own admission, this excess is driving down wages and increasing unemployment in the field.

    http://news.vin.com/VINNews.aspx?articleId=26940

    https://www.avma.org/KB/Resources/Reports/Documents/Veterinarian-Workforce-Final-Report-LowRes.pdf

    http://news.vin.com/VINNews.aspx?articleId=18590

    By comparison, there is a national shortage of all physicians, and especially primary care physicians. There is increasing demand and increasing complexity of care (and therefore, increasing liability). Yet there has been a steady DECREASE in compensation for physicians over the last decade (adjusted for inflation) while other professionals have seen a steady rise in their inflation-adjust income.

    Why?

    http://www.nytimes.com/2006/06/22/business/22doctors.html?pagewanted=print&_r=0

    http://www.kevinmd.com/blog/2012/09/doctors-complain-history-physician-income.html

    http://www.medicalnewstoday.com/articles/262033.php

    • LastoftheZucchiniFlowers

      PCP – interesting. I wonder if some of this is regional? My vet’s office is constantly busy (she and her partner) and have Saturday hours. There are four animal ‘hospitals’ with another one scheduled to open soon on our thin strip of land in the Chesapeake. Many two legged patients have told me they’d rather have local EMS drive them to the ‘critter hospital’ where they’re CERTAIN they’d fare much better than at our local hospital, otherwise known as ‘God’s Waiting Room’. Perhaps the field is tightly controlled, aka CPA’s who mostly fail their exam first and second time up (lest THAT field become glutted by accountants not up the CPA standards)!

  • JennaSM

    Veterinarians earn smaller salaries is because the prices they charge are what the market will bear, and those prices influence the salaries they are paid. Why highly educated, intelligent people who could have been successful in other, more lucrative careers – including human medicine – are willing to accept those salaries is a separate issue.

    What physicians do not want to accept is that the market will no longer bear what they would like to charge, or even what they are currently receiving. The money isn’t there.

    Perhaps human medical schools in search of more PCPs should recruit some hungry veterinarians and give them advanced standing, since the first year of basic classes is virtually identical.

    • Eden Myers

      I know very few of my colleagues who would put up with the regulatory and bureaucratic nightmares of human medical practice for more money, so I’m not sure how many hungry vets would get in that line. Maybe some of the new ones. We are, on the whole, not motivated by money- or we would have been MDs or engineers or lawyers or businessmen to start with. Those of us who are fond of the folding stuff generally find ways to make plenty of it within veterinary medicine- by owning our own practices, writing, consulting, going into industry, adding sideline businesses like boarding, showing, breeding, training, products.

      I think you’re dead on with the observation that we are in a price discovery phase in human medicine. That bubble is bursting, and human med can learn a lot from vet med about providing better care for less money.

  • buzzkillerjsmith

    As you learned, or should have learned, your second year of med school, you have to see the denominator. How many pets in Henry’s situation are not treated or just put down?

    Move along folks. Nothing to see here.

  • Hilary

    As an emergency veterinarian who works at a referral center and deals daily with similar situations as to to what you described, I want to say thank you. I think we can all agree that money, compensation, and legalities have become too big of a factor in all aspects of medicine, and hopefully some day soon we will come full circle and realize that emotional, mental, and physical well being matter the most.

    • LastoftheZucchiniFlowers

      Hilary – I have often wondered about ‘equine’ vets and their incomes? Is it true that these guys are compensated well in excess of what their ‘small animal clinic’ colleagues get? Is it the price of the livestock which drives their fee – or the more obvious, liquid and substantial incomes/cash flows of the horse owners?

      • Alexander Thomson

        Equine practice is actually among the least lucrative specializations in veterinary medicine. Starting salaries for equine vets average around $43k, whereas starting salaries for small animal practitioners average around $69k.

  • Meredith Gould

    You and readers might appreciate my post from 2009, “Given the choice, I’d choose veterinary care.” http://bit.ly/1ckqph8

  • djohnsmd

    Veterinary care tends to be cash-only and does not have to deal with Medicare, Medicaid or other insurance companies. Veterinary care doesn’t have to deal with HIPAA.

  • M Aviles

    Whoa! I don’t think the author’s dilemma was how much money a vet vs MD make. Please, clarify, because all I am hearing is how much better we could do if we were in an unbroken medical system.
    And yes, I am a PCP in Orlando, who is possibly about to open up a micropractice and leave the treadmill-like medicine once and for all. Will it work financially? I hope, but all I want to do is give better ‘unfragmented’ (if there is such a word) patient centered care. Sometimes our pride, anger, frustrations, etc won’t let us hear the real message and what is necessary to change in our field.
    Dr. M.Aviles, M.D.

  • BK Berryman

    A single-payer system wouldn’t be this efficient. I have worked for Indian Health Services, VA, employed physician, active duty military, and private practice. Federal medicine is a bureacracy similar to any other federal program. Private practice and employed positions are handicapped by insurance. Because most veterinary medicine is still cash-only business, the prices have not become outlandish. Divest government-pay and other third-party payers from the market, and you have veterinary medicine prices.
    “Bubba” was our rescue, and he returned the favor by rescuing us. He protected my wife and childeren while I was gone, and drove an intruder from the house. He stood guard against all potential threats to our children. He underwent surgery and chemo for a bone tumor, and chemo again when leukemia reared its ugly head. I took on a third job to pay the expense as I would gladly do it again because …. well, it was worth the expense. Because of my veterinarians and our multitude of pets over the years, my youngest wants to become a veterinarian.
    Sadly, with third-party payers, single-payers, or a combination of the those, the individual is not paying the bill and therefore the relative value is unequally set. Universal pet insurance will change veterinary medicine just as will human medicine. Branded pet insurance will drive up the cost of veterinary medicine the same as it has changed human medicine.

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