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Future of Veterinary Teaching Hospitals

Future of Veterinary Teaching Hospitals. Mimi Arighi, DVM, MSc, DACVS Director, VTH. Veterinary Teaching Hospital Missions. The unique challenge of the Veterinary Teaching Hospital is to: Remain financially viable while enabling teaching and research,

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Future of Veterinary Teaching Hospitals

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  1. Future of Veterinary Teaching Hospitals Mimi Arighi, DVM, MSc, DACVS Director, VTH

  2. Veterinary Teaching Hospital Missions • The unique challenge of the Veterinary Teaching Hospital is to: • Remain financially viable while • enabling teaching and research, • all the while providing veterinary medical services to the public. Jim Lloyd

  3. History • Internships began in 1950-60’s, residencies in 1960-70’s. • Board certification became the norm for entry level clinical faculty positions in the 1970-80’s • Clinical Departments began to divide responsibilities into academic & hospital, and Hospital Directors began to be hired in the 1980-90’s • Veterinary Colleges became more dependent on hospital income in 1990-2000’s.

  4. Discussion Forums on VTH Issues • AAVMC meeting – March, 2004 • AAVMC Forum at AVMA meeting – July, 2004 • AAVC/AAVMC/NAVCA meeting -March 12, 2005 • AAVC Meeting – Atlanta, April 2005 • AAVC Forum at ACVIM Annual Meeting– June 1, 2005 • AAVMC Meeting – March 11, 2006

  5. Problems Identified • Difficulty in faculty staffing of VTHs due to attraction of private practice • Funding of VTHs – revenue and gifts were probably the best future source of funding since an increase in central core funding was not likely, • Decreasing of state subsidies, and an increase in the competition for cases and faculty

  6. Too much red-tape in university for many specialists • Research, teaching, and service – hard to be good at all three, can be in direct conflict with each other. Some think there is a 4th mission – to teach business aspect of veterinary medicine • Increased reliance on tuition and fees, stagnant VTH revenues in some areas

  7. State revenue as a % of total revenue for vet schools decreased from 55% to 33% • Average # of state-funded faculty positions has been static, some increase in non-state funded positions, at same time as increase in # of students • Decreasing to static applicant pool for vet students, suboptimal distribution of caseload (need more primary cases for teaching, too many tertiary cases)

  8. Perception of faculty – stretched to limit with multiple balls in the air. • Where will next generation of clinical professors come from? • Are we graduating an entry-level veterinarian? • Do off-shore students dilute learning experience for others?

  9. Do all the students get enough hands on experience? • In private practice, a vet earning $65,000 should produce $300,000 in revenue, but the VTH is not a typical practice • Practice owners want from graduates: knowledge, communication skills, people skills, business skills, how to manage workload

  10. Specialists are finding that VTHs have a lack of money, lack of equipment, lack of new space, lack of control over work day, too many goals, long days and weekends, not efficient, poor location, and that they can do teaching in other places • Present faculty can be poor role models for interns and residents – show unhappiness and frustration. • Adequate caseload is not always there in academia for teaching and research needs

  11. The Need to Change • SVMs and VTHs must be willing to change to accommodate the above issues, prioritize missions of clinical program. • Univ. of Minnesota – Tried some new ideas: clinical specialist model and incentive plan; replaced student labor with techs • Results – increased caseload, increased revenue, tenure track faculty could focus more on research, and teaching improved

  12. Potential Solutions for VTH Issues • Balancing the mission – teaching, research, service, and hospital as a business • Balance the mission as dept. not each person • Have enough support staff • Perhaps teach some of DVM curriculum by non-specialists • Money generation should not be prime reason for VTH • 2 services running simultaneously, one for service and one for teaching

  13. Recruitment/retention of Clinical Faculty • Look for donors for new equipment/facilities and to augment faculty salaries • Look to share specialists with private specialty practices • Need to offer part-time or full-time clinical track positions to specialists, but must not be a 2nd class position – need longer term contracts, sabbaticals, voting privileges

  14. Work with University to get more competitive salaries for specialists, signing bonuses • Develop Incentive Plan – part of revenue back to faculty or section of hospital for their use • Develop satellite practice so as to augment money generated and improve secondary type cases • Offer consulting time to faculty

  15. Improve culture in VTH/SVM so are reasons to attract or retain faculty, market academic lifestyle internally so faculty understand and sell the benefits • Augment a resident’s salary if that person will commit for certain number of years as a faculty member • Select residents that want to stay in academia

  16. Maintaining and Enhancing Case load • Develop good relationships with RDVMs, establish a Practitioners Advisory Board • Hire a Referral Coordinator to deal with RDVM issues • Hire a Marketing Manager for VTH- to market to RDVMs and public

  17. Client and RDVM surveys - to point out areas where improvement is needed, like communication • Make clinicians and staff realize they are competing against private specialty practices for caseload, must give better service • Bring in outside consultant to help make VTH more efficient • New faculty need to introduce themselves or be introduced to RDVM population, also give CE seminars

  18. Enhancing Operations of VTH • Work on alleviating bottlenecks in VTH • Hire Development Officer who is assigned directly to VTH • Have treatments of hospitalized cases carried out by technicians, not students – might improve efficiency and let students learn more

  19. VTHs need to hire a Hospital Administrator/Director – MBA, MHA, or similar training. If not a DVM, must report to a DVM (AVMA accreditation rules) • VTHs needs to have a strategic plan, establish benchmarks, have good financial reporting system. • Clinical Track faculty – good move to hire them but who should pay for them? VTH, Clinical depts.?

  20. Suggestion is to take charging away from clinicians, put technicians in charge of billing, but get faculty involved in budget process to increase understanding of where revenue dollars are going to. • Or spend less time on student rounds and start admitting cases sooner in the day (earlier than 9:30 or 10:00 am.) • Community Practice Service – good way to get primary care cases

  21. Partner with private specialty practices to hire specialists • Should residents be trained at private specialty practices? Or should it be a joint endeavor with universities? • Specialty colleges have to be careful that too many restrictions for training residents are not placed on specialists/colleges

  22. Next Steps • Help faculty understand the problems and embrace a business plan, create a VTH Task force (AAVMC, AAVC, NAVCA) in 2004 that will work to prepare a “white paper” addressing concerns for future of VTHs – use for local support, consultant backgrounding, and accreditation standards • Develop benchmarks that all VTH’s can complete annually and use to determine efficiency of their model – created Benchmarking Task force for this – AAVMC, AAVC, NAVCA.

  23. Benchmarking Task Force meeting – Aug. 24, 2005 • Task force met in Schaumburg with Howard Rubin, developer of NCVEI benchmarks for private practices. This group started working with him to develop something similar for VTHs that would be more helpful than AAVMC annual info that is collected. • Utilize benchmarking for internal and external comparisons.

  24. VTH Task Force meeting – Oct. 24, 2005 • Task force met in Columbus, Ohio to discuss what to do next • Asked Dr. Hubbell to create a 1 page “white paper” that outlined the problems VTHs are facing • Group discussed the organizing of a conference to discuss the Future of the VTH’s

  25. Dr. Hubbell’s White Paper – Present and Future Problems for VTHs • The vast majority of the advances in veterinary medical care to date have occurred because of the existence of Veterinary Teaching Hospitals. • The convenience and high quality of private specialty practices impacts the caseloads of the VTHs and has the potential to compromise the education of veterinary students and postgraduate veterinarians and the generation of knowledge through clinical investigation.

  26. Dr. Hubbell’s White Paper • The resolution of this crisis will require broad participation and cooperation. New alliances must be formed to foster clinical education and investigation at the professional and post-professional levels. • The profession must be engaged because the solution will involve universities, specialty colleges and practices, private practitioners, veterinary students, and organized veterinary medicine.

  27. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • Invited people from all walks of life – DVMs from private practice, specialists from private practice, specialists from academia, representatives from specialty colleges, NAVCA, AAVC, and AAVMC reps, reps from veterinary organizations like AAHA, AVMA, etc. • We thought it was time to have others discuss problems the VTHs are facing and hear their ideas on possible solutions besides just the academicians.

  28. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • Ms. Susan Baker spoke on managing the expectations of the client • Everyone that meets a client should introduce themselves including receptionists with full name and title, should also address client and pet by name • 1st impression to clients very important • Clients want to be respected

  29. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • Dr. Mary Ann Vande Linde – Veterinary Management Consulting spoke on “Client Expectations for Veterinary Care” • Top reason why a client leaves a vet hospital – indifference or poor attitude of staff or DVMs • Minimal waiting time • Consistent message from one area to another • Want to be treated with respect, clarity, and consistency

  30. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • Want to be communicated with on terms they can understand • Want the exams to be thorough by a DVM and not rushed • All interaction with client must be improved – from reception desk to student to staff and faculty

  31. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • Dr. Colin Burrows, SA Dept. head at Univ. of Florida spoke on “Meeting the Expectations of Referring Vets” • Why RDVMs refer – uncomfortable with case, lack skills or equipment, lack of time, liability, good experience with referral hospital, know specialist, cannot handle diagnosis or emergency

  32. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • Why DVMs don’t refer – Geography (too far), cost, think they can do it all, previous bad experience with referral hospital, poor feedback from clients, don’t personally know specialist

  33. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • What RDVMs expect – knowledge of services being offered, good quick response to 1st phone call, efficient communication from staff, protect relationship between client and RDVM, timely communication during and after animal is referred, do not treat other disorders than what animal has been referred in for, follow-up with RDVM when animal dies or is euthanized.

  34. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • RDVMs are our most important clients and we all need to realize that. • Need to perhaps do more marketing to increase our referral base. Florida has done: • RDVM Appreciation Day • Hospital Newsletter • Practice visits to local practices • Local association visits

  35. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • Client and RDVM survey • Hospital Advisory board • Web Site for RDVMs • Hospital Tours for Clients and RDVMs • Press releases • Referral fax covers – news or new clinical studies added to fax cover • Clients advocates - volunteers

  36. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • Educate clinicians on business issues • Remind clinicians of referral protocol and if do not have one, create one (how and when to communicate with RDVMs, what is expected) • Clinician incentive plan • Take clinicians out of the charging business • Toll free number

  37. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • Dr. John Albers from AAHA spoke on “Future of Specialty Practice” • 1996 – 18% of new vet graduates were doing advanced studies (internships/residencies) • 2006 – increased to 33% with most of those wanting to pursue board certification • Why specialty practices will continue to grow? • In survey done, 74% of clients would pay > $500 to treat a serious disease in their pet • 52% would pay > $1000, 15% would pay >$5000

  38. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • 61% of those pet owners that thought of their pet as a member of the family would go to a specialist if their vet recommended it. • Recent graduates have a higher propensity to refer than vets that have been out for awhile • Lenders will lend money to start a specialty practice at a good rate • Manufacturers of expensive equipment offer these practices good rates

  39. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • Dr. David Lee, Hospital Director at Minnesota spoke on the “VTH as a Profit Center” and discussed the use of a professional call center, the use of a referral coordinator, discharge instructions faxed immediately to RDVM, having a Case manager/section, hiring a Hospitalist (a DVM that would help to move cases through the hospital)

  40. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • Dr. Charles MacAllister from Oklahoma State, spoke on Cooperative Arrangements for Training Specialists • 82% of the residency programs are in universities as of 2006 • Need to recruit residents interested in academia as a career. • Plenty of applicants for positions in all specialties except for anesthesia.

  41. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • Oklahoma – growing own faculty by paying other institutions to take them on as an extra resident (pay for their salary and benefits to the institution training them). Must complete a MS degree and work for at least 3 years at Oklahoma vet school after finish residency. Cost of $140,000/resident to home institution for a resident to be trained elsewhere

  42. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • Dr. Ruben Meredith, an ophthalmologist in a huge multi-location private specialty practice spoke on “Ophthalmologist in Private Practice.” • 6 locations presently where have practices and residents, have 12 active residents on board right now and tend to keep most of them on as clinicians after they finish (self-train them) • All schools should do a SWOPT analysis once a year.

  43. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • SWOPT analysis – strengths, weaknesses, opportunities, and problems and threats. • Private Specialty practice (PSP) • Strengths – residency training, large case load, commitment to research, board-certified staff • Multiple centers envisioned. • Weakness – internal communication, staff training, inventory control, employee accountable, communication with clients and RDVMs, lack of uniform operating system, lack of trained techs, inefficient facilities.

  44. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • VTHs • Strengths - Vet students, faculty, bench research facilities, university resources, funding for research • Weaknesses - ability to pay competitive salaries ($200,000 for ophthalmologist), budgetary control, university restrictions, etc.

  45. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • Private Specialty Practice’s (PSP) strengths are our weaknesses – location, salaries, flexibility, budget • PSP’s weaknesses are our strengths – research possibilities, future clinicians (students, interns and residents) • VTHs and PSPs must work together and cooperate, form direct partnerships with PSPs

  46. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • Dr. Richard Valachovic from the American Dental Education Association spoke on the similarities between what the dental profession and the veterinary profession are facing • There are 56 dental schools in the U.S. and there are 400 open faculty positions, the mean age of the faculty is 52 yrs, faculty <30 yrs old make up only 3% of the total faculty, average of 5 vacant positions per dental school, and 10 new schools in the pipeline.

  47. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • Salary discrepancy is the biggest reason for open positions in the dental profession and it is one of the main reasons for the same problem in the veterinary profession. • They have reached out to students in dental schools and also to dentists in private practice to pull them into academia • Academic Dental Careers Fellowship Program – 10 students a year are financially helped if agree to go into academia

  48. Future of VTHs – Conference, Nov. 10-11, 2006, Kansas City • Dental video – many copies sent all over –discuss good points of academic career • Web site information on educational opportunities – a lot of hits on web site • Faculty awards and fellowship opportunities - $100,000/yr • Institute for Teaching and learning in Health Professions created, and Leadership Institute created

  49. The desire to practice specialty veterinary medicine, an activity once limited to teaching faculty positions, can now be fulfilled more lucratively and with fewer additional responsibilities in private settings comparable to the best veterinary teaching hospitals. • In 2006, there were 168 positions in academics that were currently funded but open, and we are projecting a need for >700 clinical specialists in academia over the next 3-8 year. If we continue to deliver 3 out of 4 graduating residents each year to private practice, then we will need to train >2400 diplomates over the next 8 years to meet our academic needs. Our current production rate is 200 diplomates/yr or 1600 over the next 8 years. How will we supply our total needs?

  50. Conclusion • Dr. Robert Marshak wrote in 2005 that there are serious disadvantages to any arrangement for clinical training that is not firmly centered and concentrated in the school's large and small animal hospitals. • If we agree with this statement then we all must work together to preserve our hospitals in whatever way we can. • www.aavmc.org

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