Dr. LaCasse looked up from his microscope as his new colleague, Dr. Stein, walked by with an aged beagle whom Dr. LaCasse knew very well.
“What's the problem with old Ben?” he asked.
“He's got a cough and a slightly distended abdomen,” Dr. Stein replied. “I'm going to do a complete work-up — blood analyses, radiographs of the chest and abdomen, . . . .”
As Dr. Stein rattled off the list of tests she intended to do, Dr. LaCasse thought about Rosalie Bailey, the elderly woman on fixed income who owned the old dog. Before Dr. LaCasse had a chance to ask if Dr. Stein had discussed the cost of this extensive work-up with the owner, his office manager burst into the room.
“Dr. LaCasse, you have to talk to Ms. Bailey,” the office manager implored, after glaring at Dr. Stein. “She's crying, because she's sure she can't afford all those tests that Dr. Stein is going to do, and she wants you to put Ben down instead.”
“What!” a stunned Dr. Stein explodes. “How can she do that? Doesn't she care about the dog?”
Most experienced practitioners could probably finish the preceding scenario in one way or another, because breakdowns in client communication about money are rampant in our profession. Some may side with Dr. LaCasse, recalling incidents in which an employee's unwillingness to discuss the cost of treatment alienated a good client. Others may sympathize with Dr. Stein, questioning how veterinarians can, or why they should, consider cost when talking about the treatment of animals whom, surveys tell us, many owners consider beloved family members. However, although some clients honestly can say that money is no object when it comes to the care of their animals, many do not fall into this category.
Many veterinarians are trained in a system in which the cost of treatment is rarely addressed. During rounds in veterinary school, the clinician and students generate lists of diagnostic tests, or formulate or tweak some state-of-the-art treatment plan, with nary a word about the price of all this. In some institutions, the business office handles all financial matters, further divorcing cost from the veterinarian and the treatment process. Some will even defend this arrangement, saying it frees veterinarians to practise the highest quality medicine.
Unfortunately, for those in private practice, the belief that cost is not a factor can be justified much more easily, only if they can maintain a distance between themselves and their clients, and if they do not depend upon them for their livelihood. However, many times private practitioners work where they do because they want to belong to a particular community, and that means relying on the members of the community to engage their services. If these practitioners fail to address all of the topics regarding the treatment process that concern their clients, the clients may reject their services and, possibly, even them and their families.
Consequently, when Dr. Stein later self-righteously huffs, “If people can't afford to do what needs to be done, they shouldn't own animals!” she misses several points relevant to this discussion. One, while an accountant might support such a statement, it flies in the face of all those studies of the benefits of animal companionship for human health and well-being. Granted, we could dismiss all of them, but is this the kind of public image we want to project? Even if Dr. Stein feels this way, it may not portray the paternalistic image that Dr. LaCasse desires to project after he has worked long and hard to develop his reputation as a professional who cares as much about his clients as he does about their animals.
Two, Dr. Stein's remarks could reflect a fear maintained by some practitioners that, if clients knew the cost of veterinary service, they wouldn't agree to it. Once the service has been provided, these veterinarians maintain, most people will pay. Either they will pay because they truly are grateful for the service or because they're too polite, frightened, or disinterested not to. Does this result in the kind of practitioner-client relationship that will sustain much beyond the most routine veterinary care?
Three, those who resist addressing money-related issues frequently do so because such discussions often require communication skills they lack. Dr. Stein's limited education in communication taught her how to speak to the media, but it did not teach her how to incorporate financial information smoothly into client interactions. Because of this, she naturally prefers to avoid such discussions.
Regardless of the specific reason(s) why practitioners don't like to discuss cost with clients, the bottom line is that most clients want this information up front and will be grateful to those practitioners who provide it. Although it may take some veterinarians a fair amount of effort to get over their discomfort about providing this information, to do so will enhance the treatment process.
“How can telling people the cost enhance treatment?” asks an incredulous Dr. Stein.
This brings us back to Dr. LaCasse. After alienating more than his share of clients with his inability as a new graduate to discuss money, Dr. LaCasse did 2 things. First, he wrote up estimate sheets that covered the costs involved in the most common cases. Then he practised ways of incorporating this information smoothly into his client communication. In his case, his apprehension was so great that, initially, he practised in front of a mirror or imagined such discussions as he drove to and from work. Then he practised on his office staff, then his most accommodating clients. Soon he could say to more emotional clients like Ms. Bailey, “I suspect that Ben has heartworm disease and I'd like to run some tests to confirm this.” He then explained why he thought Ben had this problem, what tests he wanted to run, and the cost of all this. To keep his client firmly in the treatment loop, he concluded his discussion by asking, “How does this sound to you?”
In such a way, Dr. LaCasse learned to seamlessly provide his clients with a nonthreatening opportunity in which to raise any concerns they might have about what he proposed, including its cost.
“But what if clients say they can't afford it?” asks Dr. Stein.
That's always a possibility. However, isn't it better to know this before the treatment process begins rather than to discover it half-way through, or worse, when the client throws a tantrum in front of a waiting room full of people when he or she receives the bill?
Additionally, raising the matter of cost before commencing treatment gives practitioners an opportunity to offer other options, if money is an issue. For example, rather than doing the complete soup-to-nuts work-up, Dr. LaCasse can begin with those diagnostic procedures that will provide the most information at the least cost for those clients on a limited budget, like Ms. Bailey. Sometimes, such miniwork-ups suffice and both animal and client benefit. Other times, the preliminary information gleaned will lead the client to request further tests. In yet another scenario, client questions regarding cost provide veterinarians with the opportunity to discuss the different payment options they make available to their clients.
It goes without saying that the more complex the treatment process, the greater the need for estimates.
“But how can I possibly think, let alone talk, about money when an animal is dying?” asks Dr. Stein.
No one denies that simultaneously addressing these seemingly unrelated issues poses a challenge. When a distraught owner cries, “Do everything you can, Doc!” Dr. Stein immediately wants to focus all of her attention on the animal for 2 reasons: First, she was trained to do this, and second, it frees her from discussing the cost of that “everything,” for which she received little training at all.
However, this approach creates a serious dilemma for practice owners if clients later challenge the cost: Should they insist that clients pay for services, the cost of which was not clearly explained in advance? Or should practice owners absorb that cost rather than risk losing good clients?
Dr. LaCasse created his estimate sheets to reflect the way in which he naturally examines and works up various cases after experiencing such nightmare scenarios. Not only do these forms keep him from overlooking critical points in his examination of the animal under the most stressful conditions, they enable him to quickly calculate the costs involved, which he includes in his discussion of the animal's condition. While, ideally, all employers should provide their new colleagues with such forms, there is nothing to prevent employed practitioners from creating their own if these forms aren't available.
First century Greek philosopher Publilius Syrus reminds us that a good reputation is better than money. For veterinarians in practice, the ability to discuss the cost of treatment with clients in a relaxed, yet meaningful, way can enhance one's reputation as a quality practitioner as much as a lack of this skill can undermine it.
