Thursday, September 27, 2018

Dr. Goliath Inc.


It may be a cliche to say so, but change is inevitable. In few aspects of life is this as true as it is in the world of work. Every job and every profession is changing, and the pace of that change is accelerating. In veterinary medicine we have seen great technological change and we have seen an enormous change in our understanding of many diseases. We have also seen the profession change from being male dominated to female dominated in a single generation. These changes are evident to most pet owners, but today I want to talk about an equally important change that is occurring behind the scenes. I want to talk to you about the creeping corporate takeover of veterinary medicine.

Practice groups consisting of locally owned hospitals with a few satellite clinics have been around for a long time, and the larger ones may blur the lines with corporate practice, but I'm not talking about them today. What I'm talking about started in 1986 when Veterinary Centers of America (now Veterinary Clinics of America, or VCA) was founded in California and began buying private practices and practice groups across North America one by one. VCA now owns over 800 animal hospitals directly in 43 states and 5 provinces, and it operates another approximately 1000 (!) under it's Banfield brand name, which it acquired in a 2017 merger. VCA is a publicly traded company listed on the NASDAQ stock exchange (under the cloyingly cute stock symbol "woof"). Other corporations include National Veterinary Associates with over 400 clinics and Vet Strategy with close to 100 clinics.

Winnipeg is always the last place for any trend to hit. We were the last to get Starbucks, the last for the microbrewery revolution and we are the last major market to be targeted by corporate veterinary medicine. Up until very recently all the practices in Winnipeg were locally and privately owned. Then two years ago a large corporation began to buy clinics, owning four now and with a rumoured fifth deal in the works.

Change can be good, change can be bad and change can just be change. On the good side corporations bring deep pockets to the profession that make it easier to upgrade to the newest technology and to present sparkling, professionally decorated practices, but with ample respect and affection for my colleagues who now work for corporate, I am going to argue that this particular change is on balance bad for the profession.

The fundamental problem is that large corporations solely exist to make money. Of course small private practices also have to make money, but the difference is that if my clinic has a bad year financially we tell ourselves that it was bad luck, or the weather, or the economy and we'll hope for a better year next year. We only answer to ourselves, not to shareholders or investors. In contrast, if revenue drops in a corporate practice, management from Los Angeles or Toronto or wherever will put pressure on the veterinarians they employ to meet quotas, or else. Some corporations track remarkably specific metrics.  For example, in the US one looks at the number of xrays a veterinarian should take relative to the amount of respiratory disease they see. The corporations do not dictate the management of specific cases - that would actually be illegal - but they will set general benchmarks for numbers of specific tests and procedures and they certainly make specific financial goals clear to their employees. On one hand more tests can be "good medicine" and, as in the above example, it can be hard to argue against precautionary "just in case" xrays for a cough, but on the other hand this does diminish your pet's doctor's freedom to use their professional judgment and make sensible decisions without having to worry about what management is going to say about their numbers at the end of the quarter.

Another problem is vertical integration. Mars Corporation has recently bought a controlling interest in VCA. Mars is massive. It had $33 billion in sales in 2015, and only a fraction of that was chocolate bars. It is now the world's largest provider of pet health products and services. In addition to VCA it owns  Royal Canin food, with their prescription diet line, and a whole series of non-prescription pet food brands, such as Pedigree, Whiskas, Eukanuba, IAMS, Nutro and more. It also owns the largest chain of veterinary specialty and emergency centers, the second largest veterinary laboratory company, one of the largest veterinary ultrasound companies, and the number one canine DNA analysis company. Oh, and a chain of 130 boarding and doggie daycare facilities. All that's missing from their portfolio is a pharmaceutical company. The fear here is that veterinarians will be increasingly required to use only the products and services under the same corporate umbrella rather than picking and choosing from all the options based on their professional judgment of their patient's needs. I mostly love Royal Canin foods, but only mostly. I would not tolerate being told that that is the only prescription diet I can offer my patients.

At the end of the day the important relationship is the one between you and your pet and your veterinarian. Who your veterinarian works for is hopefully not all that relevant most of the time. It's just sad for us within the profession to see the freedom and independence we enjoyed gradually be eroded. And it's sad to think about the coming generations of veterinarians who will have less opportunity to enjoy the sense of pride that comes with owning your own practice and making all your own decisions.

Postscript:
Since posting this I have been asked how these corporations have been able to buy clinics. There must be willing sellers. Of course there are. I should explain this and introduce some balance to this story. The large veterinary corporations can offer older veterinarians a relatively straight-forward way to ease into retirement. Moreover, they are able to make these offers very generous. I am fortunate in that I have younger veterinarians working for me who are keen and financially able to buy into the practice, so when my time comes I will be able to sell to them without any trouble. This is not the case in every practice. Sometimes willing buyers are just not that easy to find. Sometimes junior veterinarians prefer to not to take on the responsibilities of ownership and management. Corporate practice therefore fills a previously unmet need and some of my colleagues are grateful for that. And as much as I might personally wish it to be otherwise, veterinary medicine is ultimately not immune to the laws of economics.

Thursday, September 13, 2018

Sneak Peak


The advance review copy arrived today! I'm told that the official public release will be April 23.

Surgery For Dummies


When I came up with the post title I thought it was cute and absurd. The 'For Dummies' series of  books may have a breathtaking range, from ASVAB For Dummies ('Armed Services Vocational Aptitude Battery' - yeah, I have no idea either) to Zoho For Dummies, which is apparently a suite of cloud computing applications, but surely there would be no Surgery For Dummies. Ha ha, right? Well... it turns out that there actually is a Weight Loss Surgery For Dummies book, as well as Cosmetic Surgery For Dummies. One hopes these are written for the patients, not the surgeons.

I decided to stick with Surgery For Dummies, even though it now seems slightly less cute and absurd. My point was to highlight that there is no great mystery to surgery. A lot of surgery is much simpler than you might have thought. For many lay people surgery may seem like the pinnacle of a veterinarian's (or medical doctor's) specialized skill and knowledge, but I'm here to tell you that I could easily teach any of you the basics of the majority of the surgeries we do, and that I could teach you that with lessons that would fit on an index card. A small index card.

Basically most surgery can be boiled down to one of two processes - either you are removing something, or you are repairing something. The latter can be far more complex, but it actually only accounts for less than 10% of surgeries in a general practice. Most of the time you are removing something and that is usually not terribly complex. You could be removing testicles (neuter), ovaries and uterus (spay), a lump, a foreign object, or a stone, to give the most common examples. Here are the steps:

(NB: We are assuming the patient is already appropriately anesthetized.)
1. Use a scalpel to cut a straight line in the best place to find the thing you want to remove. Avoid cutting through blood vessels, but if you have to, tie them off with suture so they don't bleed.
2. Find the thing you want to remove.
3. Identify the blood supply to this thing and tie it off.
4. Remove the thing.
5. Sew up the cut or cuts you made. Depending on how deep the cut was, you may need to sew a few separate layers.

That's it. If you cut-and-paste those five steps, they'll fit on an index card.
If you have to cut into an organ to find the thing, such as a foreign object in the stomach or a stone in the bladder, then step 3 will be slightly different:
3. Cut into the organ containing the thing in the same manner as Step 1.

And the sewing is really just that - sewing. The thread (suture) may be special and we usually tie the knots using instruments, but the knots themselves are often just square knots. It's not hard.

All that being said, there are however two very important additional factors to consider before you dive into this. Ok, three if you count the fact that you need a license. And you should count that.

The first factor is that in order to "find the thing" and "identify the blood supply", and all that stuff, you do need to know the anatomy. Surgery is basically applied anatomy. (And, by the way, medicine is basically applied physiology.) Anatomy may seem complicated, but it's really just a lot of memorization. It helps to have a good visual memory, but it's not essential. And honestly, to perform a spay for example, you don't need to know the anatomy of the brain or the elbow or the lungs - just the abdomen and even there you don't need to know the name and location of every blood vessel running into the liver, you mostly just need to know what's right around the ovaries and uterus. Also, as soon as you start doing it, remembering becomes easier and easier as anatomy is something concrete that you can hold in your hands and see (unlike, say, the names of Prime Ministers you might have been forced to memorize in history).

This leads me directly to the second aspect, which is that it takes practice to become good at this. Duh. But this applies to veterinarians too! Regardless of how thoroughly a vet student has memorized the anatomy and the five points on my index card (or whatever notes they have from their surgery lectures), it will take them a ridiculously long time to perform their first spay. And they will be terrified and they will have to ask questions and get help and they will not be confident. At least one hopes that they will not be confident, as they shouldn't be, not yet. One of my classmates even fainted during their first surgery. Whump - hit the floor. They went on to become a fine surgeon. Eventually. With practice.

So learn the anatomy, keep the index card handy and practice, practice, practice under the supervision of someone who can swoop in should things go sideways, or you pass out. (And get a veterinary license.) And then you too can be a surgeon.