Sunday, April 29, 2012

The Loss of Dentistry

So I wrote that last post because of a scenario I experienced a few months ago....

Owner brings her dog in for a swelling under the eye.  As soon as I look at the dog's mouth, I realize it's most likely a carnassial tooth root abscess.  I discussed this with the owner, and also informed her that the rest of the dog's mouth is in really bad shape and he needs multiple tooth extractions.  I also told her that the dog needs to have the mouth radiographed (xrays) because sometimes what we think is a simple abscess can actually be something a lot worse, like cancer.  (two of my most recent carnassial tooth extractions actually ended up being sarcoma in the mouth, not just an abscessed tooth - had I not done xrays before pulling the teeth, we would not have known that)

Owner said this to me:  "Oh no, I only brought him here for you to diagnose him.  I'll be taking him to the low cost facility because they are soooo much cheaper than you.  We will only come here for the real problems." 

WTF?

I was flabbergasted, insulted and angry.

I told her the reason it was so cheap there was because I did such a better job than they do.  It didn't matter.  She just wanted "cheap."   Okay, I get that.    You have 3 kids and 5 dogs.  Maybe you should look at that.  However,  I digress....

But let me do a comparison for the difference between what would occur at my place vs. what will occur at the low cost place.

The removal of a carnassial tooth involves splitting the tooth and pulling out 3 roots.  It involves equipment that can cost $5000.  We also do what's called a mucosal flap with the gum tissue so that we can then close the open socket/defect.  The animal is much more comfortable after surgery and heals so much better.  We also do nerve blocks so that when the pet wakes up, they aren't feeling the pain of that extraction.

We would take dental xrays of the mouth so that we can see the roots of the rest of the teeth, and make recommendations on what else might be abscessing and needing removal.  We also look for things like...  cancer.

All of our anesthesia patients, especially those having dental work, are intubated (have a breathing tube) and have an IV catheter in place and are on IV fluids.  This is for safety and their comfort.

The only ones who do dentistry in my hospital are myself and my registered, licensed techs.  And let me add - that is per my state's LAW.  Unlicensed techs are NOT supposed to be doing dentals.  Period.

Now let me tell you what will happen at the low cost place:  they don't even have RVTs.  They don't have dental xray.  They do not intubate the dentals (there is no breathing tube inserted into the trachea) and they definitely do not place IV catheters or administer IV fluids.   They yank teeth without splitting them, they do NOT do mucosal flapping and I'm pretty sure that local nerve blocks aren't even in their vocabulary.  I can only imagine how many tooth roots are left in those sockets.  How would they know?   They don't use dental xray.

I know of a low cost vet who doesn't use a high speed drill.  He used a pair of pliers to "break" a tooth so he could get it out.  I wish I was making this up, but I am not. 

That's not how I do things.

So what is this client getting?  A very, very poor service, yet she thinks that I'm ripping her off because I charge more for what I do at my practice.  Hmmpf. 

She then had the nerve to ask me for an estimate, so she could compare it to the low cost place.  I refused.  I mean, why should I bother wasting my tech's time working up an estimate for this woman?  I politely asked her to leave.

She deserves the medical care she gets.  And when she does come back to me for something like...  a major abdominal surgery, it's gonna cost twice as much because I now have to make up for the loss of my dentistry services - another bread and butter income - to the low cost facility.

It is a vicious cycle, American Public.  Please hear our cries and believe us when we say we aren't doing it because we want to gouge you;  most of us really do want to provide quality care.  But if you can't support us on the little stuff, then don't expect us to be around when the big stuff comes up.

You will get what you pay for, in the end.





23 comments:

  1. Wonder who she will get to fix the Ornonasal fistula when it happens... There is a Vet in my area who will beat any estimate people take in but they also don't realize the quality of care their animals are getting is much lower.. Even when you explain it they look at you like you have two heads and say but they are cheaper.

    ReplyDelete
  2. I thought I'd been around a little and knew a few things, but I'm starting to feel stupid. It's just never occurred to me to shop for vet prices. When I got a dog, I finally settled on a vet that I was SURE was taking good care of him. Since then, it has never occurred to me to comparison shop, because I love my dog and I want him around forever. As long as I think I'm getting that good care, I'm gonna pay him what he asks for. Another of my dogs had to have emergency surgery at our excellent late-night emergency vet clinic at about 3AM one Christmas morning (he liked to eat things that wouldn't fit through the plumbing). The cost of the surgery, pre- and post-op care, boarding, etc., etc., was $2K. I was flabbergasted at that figure. For saving that dog's life, I wouldn't have hesitated at twice that much. But now I'm feeling stupid. Just think of how much money I've wasted on all that excellent vet care, when I could've gone cheap. Not to mention all the money I could've save on dog food and toys and stuff when the dog was dead.

    ReplyDelete
    Replies
    1. Your sarcasm rocks. I would love to have you as a client at an EC.... I would call you when people abused their animals and acted like douche bags and threatened me.

      Delete
    2. You absolutely don't have to tolerate threats - at least not the physical kind. Please call 911 if you have someone in your clinic that you don't want there and who won't leave and/or is threatening you. Nobody, and I mean nobody, threatens my vets.

      Delete
    3. Your high cost justifications are B.S. There is no need in many cases, for a full mouth set of x-rays. You are charging for services that are not required.The cost of extracting one carnessial pre-molar for example; varies from vet to vet by as much as $1600.00. Justify that!

      Delete
  3. Ahh, I love my vet. He is open, honest and I never leave feeling fleeced. OC you made me laugh.

    ReplyDelete
  4. I completely sympathize. We have a deal with the local shelter where they give a voucher for a free office visit at our clinic at the time of adoption. One client was bold enough to tell us outright that he was only here for the free exam and wanted to go some place cheaper for everything else. While I did vindictively remove all of the free samples from his new puppy pack before he got it, I was still careful to otherwise treat him with the same enthusiasm as any other new client. I enjoyed his obvious embarrassment as I smiled warmly and answered all of his questions, obviously treating him with more courtesy than he knew he deserved. "Well, you know, it's just that my wife already made the appointment with the other vet and gee..."

    We also get a bunch of clients who only come to us for the "real problems", but half the time, once they see how we handle a "real problem", they decide they'd rather just keep coming to us because they trust us more. You can't win them all, but after seeing the difference, many clients recognize that the better hospital *is* the better value.

    So why not give the woman an estimate? You went to the trouble to explain to her all the things you were going to do that would be better than the low cost clinic. Why not let her take an estimate home and think about it? She might still go to the cheaper place but turning her out on her nose doesn't do anything but absolutely guarantee her pet is going to get substandard care and that she'll continue to be ignorant of the difference.

    ReplyDelete
  5. Because she already pulled this one me once. My estimate ended up at the low cost place and we got skewered. I won't fall for it again. It was not worth it to me to pay my tech to work up an estimate for someone who has insulted me and refused my advice. She also got mad because I wouldn't just Rx some antibiotics. So in this case, No Way would I spend one more second of my or my tech's time providing care or services to her. I take that time now for my good clients who I know care, who haven't fooled me once in the past. I can't fix stupid.

    ReplyDelete
    Replies
    1. Wow, that's really unprofessional of the other clinic. Sounds like a bad situation all around. It's very frustrating but very true that you can't fix stupid (on the owner's part or the other clinic's part).

      Delete
    2. Unprofessional on the vet's part also. Your there to help the dog. If she can't afford your prices she can't afford it. No reason to feel insulted. It isn't personal to you.

      Delete
  6. I understand you are venting and sharing your personal experience. However, I work at a full service low cost clinic and I found this post a bit insulting. We insist on pre-op bloodwork for all dentals over 7 years old, start those with infected teeth on antibiotics 3 days before dentals, intubate all dentals, put in IV catheters and run fluids for all dentals, make flaps regularly and suture closed any open sockets, and drill all multi-rooted teeth. Only our LVTs or the vets do the dentals (or any anesthesia for that matter). We don't have money for a dental xray but we do have CR and take skull rads of anything suspicious during the dental (we've found 2 osteosarcs this way). We use peri-op pain meds and send more home. We don't have the fanciest of equipment but we try to practice good medicine for our clients. We can't always follow the ideal recommendation but we strive for at least the second or third choice. BTW, we have an income limit for our clients and treat animals that otherwise might never see a vet and all of our patients must be neutered as to not further add to the burden of pet overpopulation. Local vets complain about us taking business away from them all the time but they don't hesitate to send over a difficult client on a very limited income (like the pit bull that's been in dystocia for a week and is septic that we saw last week). You don't like to be lumped into the category of "money-grubbing" vet (although some certainly do exist) so please don't lump all low-income vets into the category of poor medicine. Low-cost doesn't always mean low-quality. We are a small enough profession struggling for society's respect. We shouldn't be cutting each other off at the knees.

    ReplyDelete
    Replies
    1. Courtney, if you are charging what it is that you believe you're worth, go for it. But by and large, the low-cost clinics are not practicing high-quality medicine. I know this because I routinely clean up their messes.

      And we'll just have to agree to disagree: second and third options may give you something to do, and allow the owner to feel good about themselves, but they often leave the patient less-than-adequately treated.

      There is one party cutting the other off at the knees, and it is not the party that shares this poster's philosophy. If you're looking for respect, begin by valuing your own time.

      Delete
    2. Are you telling me that you never perform an amputation when a leg could be fixed with a pin, an ex fix, plate, etc? Amputation is definitely a second or third choice to preserving the leg but it is a perfectly acceptable medical and financial option. Lifelong methimazole (or y/d even) instead of I-131? Perfectly acceptable medical and financial alternative but not first choice. An enucleation over phaco? FHO over hip replacement? Lateral suture over TPLO? Please, private practice vets regularly offer second and third choice options. I offer every option to my clients, I don't judge them because they are at a low cost clinic. Some do go to a specialist for that TPLO surgery but most don't and whether they choose to do a lateral suture with me or they can only afford pain meds and cage rest, the point is, if I wasn't there, that pet wouldn't be getting anything because that family of 4 is living below poverty level. I support small businesses and regularly patronize them whenever possible (and I make a more than adequate salary that allows me to afford such expenditures but thank you for your concern over my financial security) but my conscience demands that I not leave a large population of pets in pain and disease just because they can't afford private practice. And I've seen plenty of private practices that still use 1 surgery pack and cold sterile all day for all of their surgeries, reuse suture through multiple dog neuters, perform guillotine de-claws on cats leaving them with infected digits and missing half their paw pads, and have staff leave suffering, agonal animals in cages overnight because the distressed owner is unable to pay an emergency fee to justify the vet coming in. There are even several stories on this very blog about private practice owners abusing animals in their care. There are vets practicing bad medicine in low-cost clinics and in private practice just as there are vets practicing good quality medicine in private practice and low-cost clinics. I was just trying to point out that slandering all vets at low-cost clinics is not very gracious.

      Delete
    3. Perhaps we should have defined "second and third options" at the outset. You've cited acceptable, good options that meet the standard of care for treating various conditions. Any veterinarian practicing for more than a couple of years can cite a long list of bad treatment choices that do not meet the standard of care that low-cost DVMs provide because they're limited by funds or because they don't know any better, and if you're intellectually honest with yourself, you'll be able to come up with ideas and scenarios that support my position.

      You are correct, there are good vets in low-cost situations, but I submit that veterinarians who respect themselves and value their time are more likely to be veterinarians practicing quality medicine and charging appropriately for their time and service provided.

      Delete
  7. I too found this post mildly insulting. I work a busy walk-in practice that serves many low-income clients whose pets would otherwise receive NO dental care. We also do not have dental radiographs; I am striving to change this. I practice very good dentistry and am skilled at surgical extractions. I treat the lawyer's pet and the student's pet with the same quality of care.

    I should mention that high prices do not always equal quality services. I took my own dog to an established university clinic for emergency surgery for IVDD; I do not have the expertise to perform this surgery myself, nor the equipment necessary for its diagnosis. I came into the situation expecting to pay top dollar for the very best care, wanting, if possible, a normal dog post-op. Not only was my clinical judgment questioned, but my dog's surgery delayed to the point where he lost deep pain sensation. To this day I am sickened by this; he may as well have been sitting in my clinic on steroids and tramadol for the care he received.

    I guess my point is that if you are a good vet, you're a good vet...regardless of where you work, or what you charge.

    ReplyDelete
  8. Jeannie, I do agree with you, and like The Polite Vet said, yes there are good vets in some low-cost situations. I also find it very interesting that insulting the low cost places always flushes out the vets who start saying, "I'm a good vet in a low cost place and we do a great job!" I'm sure you do, and I know there ARE some really good vets doing some really good things in some really good low cost places. What you WILL notice about my post is that I was not talking about *you*. I was talking about ALL of the low cost facilities in MY area, because yes, they suck ass. They are the representation of low standards of care. So I am not sure why you were insulted. It was not personal, and it was true. Please don't take it so personally.

    If "low cost" is where the profession is going, that's fine too. But the public needs to be made aware of the difference. Hiding behind "we are affordable and they are not" isn't the answer without detailed public awareness on what the differences truly are.

    ReplyDelete
    Replies
    1. I think you're rude and you had a bad attitude towards the lady that obviously could not afford you. Maybe you're prices are to high and you felt guilty when she called you out on it. It isn't like you're a plastic surgeon or anything. Geeze

      Delete
  9. I have a friend that runs a charity low cost place with a sliding scale. They do means testing. He helped start it because, as the vet for the human society, he got tired of euthanizing dogs for things that were relatively easy to fix. He only gives price breaks for those that demonstrate need using the same documents they use for welfare. He is a wonderful vet and compassionate. I sat next to him in class, I worked with him at a few clinics, and I know that he does a wonderful job. And he is one of the best and nicest people I know. But I also know several other "cheap" places that diagnose cats with hypothyroid, vets that cannot recognize seizures due to low blood glucose, vets that believe that pain control is BAD for the patient.

    But the vets that have no financial backer, that have no donated money, that have to pay today's prices for the equipment that will help them having to refer everything, those are the ones that are more likely to go out of business.


    There is an old joke: two patients go to the doctor and are examined. One is sent for an x-ray at another facility, then an orthopedic exam two weeks later, has an MRI 1 week later, and surgery 2 weeks later. The other is examined, radiographed, might have an MRI, but surgery is scheduled for the next day. The first is a human and the second is a dog.

    If we follow the human model, the second patient might have to wait 4 weeks until relief.

    ReplyDelete
  10. I love my vet. Even if I have to pay a little more, I know that she is going to take care of my babies. And if I ever win the lottery, she is second on my list and will have everything her heart ever desired as far as equipment in facilities. That is how much I love my vet. Now I need to go buy a ticket!

    ReplyDelete
  11. Thanks for great information you write it very clean. I am very lucky to get this tips from you.


    Periodontist Branford CT

    ReplyDelete

  12. Dental health is an aspect of overall health and wellness. Many individuals don't realize that an abscess in a tooth, an infected gum line, or an impacted tooth may result not only with fever and pain, but may result in infections traveling to other parts of the body, including the brain. For this reason, individuals are strongly advised to seek the advice of a dentist for dental issues such as loose teeth in an adult, swelling or bleeding gums, or other issues that may affect oral and dental health. Cheap Dental Flap Operations

    ReplyDelete
  13. Nice blogpost and thanks for sharing such useful information about aavadental. If you are interested for the Tooth Extraction then you should visit at best dentist near me .I just try this and its working is awesome.

    ReplyDelete