Dr. Wendy Hauser is the founder of Peak Veterinary Consulting. She writes extensively and speaks frequently about hospital culture, communications, leadership, client relations and operations. She represents the American Animal Hospital Association in the American Veterinary Medical Association’s House of Delegates.Read Articles Written by Wendy Hauser
Few things create as much anxiety for veterinary teams as talking about money with clients. Studies have shown that a client’s economic limitation is the primary factor behind feelings of burnout in veterinarians working at small animal general practices.
A survey I conducted at a work-life integration workshop hosted by the American College of Veterinary Internal Medicine found that 58% of respondents anticipated client objections to treatment recommendations before the conversation even started. Fifty-two percent thought that clients “always” or “usually” asked about less costly treatment alternatives.
When workshop attendees were asked how they felt when clients declined recommendations, asked for cheaper alternatives or demonstrated anxiety about the care protocol, responses ranged from an understanding of the pet owner’s position to guilt, discouragement, disconnection, confliction, frustration, exhaustion and, occasionally, anger.
Why Is It So Stressful?
In private practice, veterinary medicine is a service-based profession, with fees attached for services performed. It is also an industry that depends on clients’ discretionary spending.
A disconnect can arise between pet owners and veterinary teams when clients don’t understand the benefit behind medical recommendations, are financially unable to accept the recommendation or have a philosophical difference of opinion about what is best for their pet.
Negative ramifications occur when a pet owner declines a recommendation. Most obvious are the lack of pet care and the loss of income to the hospital and production-compensated veterinarian.
The hospital-client relationship can suffer if pet owners feel guilty about not adhering to recommended care. These feelings might serve as a barrier to future care or lead the client to go somewhere else for alternative care.
More insidious is the emotional toll on team members when pets fail to receive needed services. Most team members entered the profession to help animals, people or both. The anticipation of declined recommendations creates anxiety, fear and unease, even before the conversation occurs, causing psychological distress. The outcomes of these conversations at times create an inner conflict so great that it compromises the employee’s integrity, creating moral distress.
Understanding Moral Distress
The concept of moral distress originated in nursing in the 1980s. Moral distress refers to a situation where health care professionals know what is morally right, yet due to factors outside of their control, those actions are not taken. In veterinary medicine, this often translates into the inability to provide necessary care for our patients. This might be due to client financial constraints, a shortage of hospital resources such as time, staff, equipment or supplies, and differences in value systems of the owner and the team member. The result is a feeling of being ethically compromised, with an inability to be true to personal core values and beliefs.
Outcomes include feelings of burnout and negative emotions of guilt, frustration, impotence and anger. According to a 2017 article in the American Journal of Nursing, consequences of moral distress include high rates of employee turnover, declines in optimism and teamwork, and challenges in providing appropriate patient care.
In most veterinary studies regarding burnout, the study design has been to survey veterinarians. Rarely is the perspective of the non-veterinarian animal health care team member solicited. The 2017 article, by Dr. Patricia Rodney, stated that in human medicine studies, moral distress affected nurses at higher rates than physicians. It is reasonable to expect that our paraprofessional teams also experience increased rates of moral distress than current veterinary research suggests. Is it any wonder that veterinary medicine is seeing an exodus of talented team members?
The term “moral distress” best describes the initial episode that creates the intrapersonal conflict. After that situation ends, the feelings remain and are best termed “moral residue,” as described in a 2009 Journal of Clinical Ethics article. Moral residue is cumulative and the effect over time is a lowering of the threshold that triggers moral distress, resulting in more powerful emotional responses as a result of ongoing perceived moral threats. These responses are exaggerated when the triggers are similar to prior experiences. Consider the moral residue experienced by one survey respondent when asked about their feelings about declined recommendations: “Exhausted. I feel like arguing this point drains me every day.”
How to Manage Declined Recommendations
While declined recommendations will always exist in veterinary medicine, you can use several tactics to lessen the negative effects when clients say “no.”
1. INVOLVE THE ENTIRE TEAM
Where did the belief originate that veterinarians should not talk about money with clients? Certainly not in veterinary schools, where students are taught to discuss financial concerns with clients and present treatment cost estimates.
In talking with practicing veterinarians and in my more recent experiences as a relief veterinarian, the role of the veterinarian in discussing money has been relegated to non-veterinarian team members. I heard many reasons why this is preferred, among them the ability of the veterinarian to see other patients as team members explain the treatment plan and gain consent. Colleagues indicated that this approach allowed them to appear detached and less of a beneficiary from the financial aspect of the fee for service. Others stated that by “not knowing” what services cost, they avoid making recommendations that would financially benefit themselves, shifting the focus to what truly benefits the patient.
Finally, some veterinarians said they “felt bad” about the cost of care and would discount services or recommend less expensive alternatives, even to the pet’s detriment.
When I asked clients about their experiences and feelings around estimates, the majority indicated that they felt abandoned when the veterinarian transferred the responsibility to a team member, particularly when the estimate represented a treatment plan for an ill or injured animal.
In studies done by Dr. Jason B. Coe, clients expected veterinarians to start conversations about the cost of care. Many veterinarians are uncomfortable with this approach, fearing negative consequences such as a client’s perception that “Veterinarians are in it only for the money” or having to manage client emotions such as frustration, anger and despair. Some veterinarians might feel moral distress when options for care are limited by the prognosis or economic limitations. I believe a component behind the shift in discussing money with clients is veterinarians’ discomfort. It is far easier to delegate this unpleasant task to our paraprofessional teams rather than shoulder a portion of the emotional burden.
One alternative to this quandary would be for veterinarians to delegate the discussion of preventive and elective procedures to the paraprofessional team but maintain the responsibility of discussing more involved treatment plans for sick or injured animals. In his research, Dr. Coe found that when veterinarians discussed the cost and treatment options with clients, both sides better understood each other’s perspectives and formed a partnership benefiting the pet. As he stated, these cost discussions must include an explanation “in the context of the pet’s health and well-being and taking into consideration the unique beliefs and values” of the pet owner.
2. REFRAME HOW YOU MAKE RECOMMENDATIONS
When a recommendation is declined, we often assume that client finances are behind the decision. Studies have found that cost is rarely the reason; rather, clients don’t understand the recommendation’s value to their pet. Dr. Coe found that veterinarians discuss recommendations in material terms, such as the need for specialized training or equipment and additional staff or time. His study showed that clients wanted to know how adhering to the recommendation would benefit the pet.
I never met a client who didn’t want the best for a beloved pet. We need to help clients understand that while every service comes at a price, declining a service can affect a pet’s current and future health.
When making recommendations to clients, explain the why behind the recommendation:
- What information could be learned from the recommendation?
- How would that information help guide additional care?
- How would it benefit the family-pet bond?
3. TALK EARLY ABOUT THE COSTS OF PET OWNERSHIP
Dr. Coe’s studies found that both new and experienced pet owners wanted a proactive discussion about anticipated health costs. Clients who had owned previous pets wanted to be informed about new costs, as they knew what to expect with preventive care. New pet owners are often unfamiliar with the costs and expect cost transparency on all services. According to his research, cost discussions should always be presented in terms of educating clients “as to the purpose and value of their recommendations in a manner that includes consideration of what is important and meaningful to each client.”
- Educate clients early about the costs of pet ownership. These do not need to be in-depth, lengthy conversations. At a puppy or kitten visit, the conversation would sound like: “Mrs. Smith, congratulations again on Sammy, your beautiful new family member. As you are a new puppy owner, we think it is important to set some expectations around the lifetime cost of care for Sammy. This first year will be a little more expensive because you will have the series of puppy visits for examinations and vaccinations as well as the cost of Sammy’s surgery to neuter him. As Sammy reaches adulthood, costs level out and then increase as he becomes a senior dog and needs more frequent visits. As he reaches each of these stages, we will discuss what to expect.”
- Create clear pathways for patient care. At the conclusion of each visit, clearly communicate when the pet’s next visit should occur and explain what services will be due at that time. Schedule the examinations prior to the client leaving the hospital: “Mrs. Smith, now that Sammy is 6 years old, we would like to begin to see him twice yearly. By performing semiannual examinations and diagnostics, we can be proactive and detect health problems early. We have found that this approach helps our patients live longer, better quality lives. Because this is important for Sammy’s health, we will ask you to schedule a placeholder appointment before you leave today. What questions do you have for me?”
4. TALK ABOUT PROACTIVELY MANAGING EXPENSES
As I mentioned, client economic limitations create stressors for the health care team and clients, resulting in a lack of care. In some situations, these financial hurdles can be overcome by having proactive conversations with clients regarding strategies for providing care. Take the time to educate clients about the benefits of wellness plans and pet insurance.
You can say: “Mrs. Smith, we recognize that pet ownership can be expensive. Many of our clients have been helped by preemptively planning for these costs. At ABC Animal Hospital, we offer a wellness plan that includes all the preventive care services Sammy will need to help keep him healthy. Because we can’t predict the cost of illness and accidents, we also recommend pet insurance. We never want the cost of care to be a barrier to caring for Sammy. It pays to plan ahead.”
5. MANAGE MORAL DISTRESS
We can help our teams develop moral resilience, which Dr. Rushton defined as “the capacity of an individual to sustain or restore [her or his] integrity in response to moral complexity, confusion, distress, or setbacks.”
- Practices should cultivate an environment of ethical practice by identifying situations that could compromise employee ethics. Also, create guidelines for preventing situations that could contribute to moral distress. As a hospital owner, I worked with my team to list procedures we would not perform, such as convenience euthanasia, late-term spays, debarking, ear cropping, tail docking and dewclaw removal. Our guidelines for feline declaws allowed veterinarians who had ethical objections to opt out.
- Conversations about moral dilemmas and training in recognizing ethical challenges should be incorporated into staff meetings. Reach out to local human hospitals to explore what resources they have that could be used to help educate your team about moral distress and build moral resilience.
- Create a safe environment for the discussion of ethically challenging dilemmas.
- Employees who feel moral distress should discuss it with other involved parties.
Talking about the cost of veterinary services with clients is unavoidable. Teach your teams that money discussions are not taboo; clients understand that costs are associated with the care veterinarians provide.
Many studies have revealed that clients desire proactive financial discussions so that they can be better prepared to care for their pets. By teaching team members to effectively have these early discussions, the financial narrative changes from one of hopelessness to one where we can partner with pet owners to find solutions.
Dr. Wendy Hauser is the founder of Peak Veterinary Consulting. She represents the American Animal Hospital Association in the American Veterinary Medical Association’s House of Delegates.