This week on the podcast…
This week on the Uncharted Podcast, Dr. Andy Roark and practice management geek Stephanie Goss are in the mailbag to take on a question from a practice owner. One of their managers is disagreeing with one of the associate veterinarians and there are some hurt feelings and upset on both sides. There also happen to be good points from both the manager and the doctor involved in this instance and this practice owner needs some help keeping the peace! Let's get into this…
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Episode Transcript
Stephanie Goss:
Hey everybody, I am Stephanie Goss, and this is another episode of the Uncharted Podcast. This week on the podcast, we are tackling an issue that Andy and I had a really good time talking through. We have a friend who is a practice owner and they are struggling with their practice manager, having some disagreements with some of the doctors over some of the decisions that they're making on the floor.
There are good points on both sides of this situation and argument, and this practice owner needs help figuring out how to keep the peace. This was a fun one. Let's get into it.
Meg:
And now the Uncharted podcast.
Andy Roark:
Hey, and we are back. It's me, Dr. Andy Roark and the one and only Stephanie. Before you accuse me, take a look at yourself, Goss. Oh man.
Stephanie Goss:
How's it going, Andy Roark?
Andy Roark:
Oh, it's good. It's good. I took my daughter to a 5K fun run on Saturday, and our friend Tyler Grogan, had signed us up to go. And so I was like, “Okay, Tyler's going and some of the other people in the Uncharted team are going. And I was like, I'm, I'm going to go as well.” And I was going to take Hannah, who's my 11-year-old, and it would be sort of her first cross country. She's never ran more than maybe two miles I think, something like that.
So my expectation was we were going to get there and we were just going to kind of run-walk, and it was about being together. So we would do that. And so we go to this 5K, and it's put on by the local animal shelter. And so there are dogs everywhere because they were like, “Bring your dogs.” And I'm like, “I like dogs, I love dogs, I love dogs, I love pet owners.”
Stephanie Goss:
This will be fun.
Andy Roark:
This will be great. And then I got there. And I was like, “This a terrible idea.” It's a terrible idea to bring together literally hundreds of people with the objective of running 3.2 miles and then be like, ‘Bring your dogs.'” And so there we are. And they're like, “Thank God they didn't have a starting line.” But a couple things came into my mind.
Every time I go to a place where there's people and dogs, I am reminded of how pet owners tell themselves stories about their dogs and just hold onto those stories despite all evidence.
Stephanie Goss:
Sure.
Andy Roark:
There was the dog having a full on panic attack, and people were like, “Look at him. He loves coming to things like this.” And I'm like, “That dog, his eyes, bulging out of head just trembling full body shakes, nails dug into the ground.” And they're like, “He's such a social dog.”
And I'm like, “He's too scared to move. What are you doing?” Before they started, they were like, “If you plan to run fast, come to this end of the group.” And all these people just moved down there with their chihuahuas on leashes. And I'm like, “What? This lady with an English bulldog?” And I'm just like, again, the stories that they tell themselves about their pets is amazing to me. So anyway, so they all do it and finally they're like, “They don't have a starting gun, thank God.” But they're like, ‘Ready, set, go.'” And hundreds of people take off running at the same time. And as you can imagine, it's pandemonium. And there's this woman with this big pit bull running up out of ahead of me and Hannah. And the pit bull is morbidly obese. It's a BCS 11 of nine, and then it runs about a hundred yards.
And then stop. It's like, I'm done and just sits down and the lady runs right into it. She goes down.
Stephanie Goss:
Oh no.
Andy Roark:
And the people behind her go down and then all the dogs around them are like, what are you guys doing? And they come pulling over and now these leashes are pulled out like trip wires.
Stephanie Goss:
Oh no.
Andy Roark:
And there's like retractable leashes everywhere. It's everything that's completely horrible that you can ima … It all happened. And I was like, “Hannah, we're going over.” And we lept over. Did not stop to help. Just so you know, I'm kind of like lady, you know thy self, know thy dog. And you didn't. And so I get it. She was in the middle of hundreds of other people. And again, it's a race. I told myself that stopping would have caused more problems.
Stephanie Goss:
So you were also telling yourself stories in your head.
Andy Roark:
Exactly right. Survival stories, Stephanie Goss. Stories about-
Stephanie Goss:
Someone else is going to help that woman. It's fine.
Andy Roark:
She was shielded by the dog, really it was like-
Stephanie Goss:
I'm sure there's another vet in the crowd who could have made sure the dog was okay.
Andy Roark:
I'm sorry. She didn't need a vet. And the pit bull was fine because she was big and he just laid down. And no one's stepping on that dog, I'll tell you that. That lady is to fend for herself. But that dog was fine.
We got like two miles into the run, and there's this lady sitting on a bench and she's holding this Chihuahua and he's 100% asleep just like nose under her chin, you know what I mean? She's holding him like a baby and his legs are up in the air and we go jogging by, and my daughter and I look at her and she looks at us and she goes, “He's done.” And I'm like, okay, I love it. But she says, “He's done.” That's what I wanted to be. We're two miles into that. I was like, I would like to lay down and just be done, but everyone …
So anyway, it was, again, I loved it. Wonderful time with my daughter. I still love pet owners, I still love pets. I'm just not a hundred percent bought into hundreds of pet owners and pets together doing a thing at the same time.
Stephanie Goss:
Oh, that's fantastic. But it's for charity.
Andy Roark:
Yeah.
Stephanie Goss:
That's a real good cause.
Andy Roark:
Felt very good about supporting. I felt very good about supporting. And it really was fun. And so that was that.
Stephanie Goss:
Oh gosh, Tyler's take on the event was radically different than yours.
Andy Roark:
Oh, well, see, she just walked.
Stephanie Goss:
I don't know that there was ever running in the idea, although I could see Tyler being a runner, but it was like, we'll do this fun thing together as a team and we'll talk and just meet, make our way through and it'll be bonding.
Andy Roark:
I showed up with my itty bitty booty shorts.
Stephanie Goss:
I'm taking off.
Andy Roark:
Yeah, I showed up tan lines-
Stephanie Goss:
“Let's get this done.”
Andy Roark:
Out there so that everybody could say like, “Little tiny runny shorts.” I was doing the quad stretch where I'm holding my ankle and other ankle, and Tyler's like … She was wearing yoga pants and a sweatshirt.
Stephanie Goss:
And I saw the picture, and Steph's got her coffee in her hand and I'm like, “There was never the intention.”
Andy Roark:
I was like, “Are you guys going to put your coffees down before the race starts?” And they just both just looked at me like I was so dumb.
Stephanie Goss:
Oh, it's fantastic.
Andy Roark:
We're wired a little bit differently, Tyler and I.
Stephanie Goss:
Oh man. Well, glad to know that we haven't even started this episode, and we're off the rails.
Andy Roark:
Oh yeah. Well, you asked how I was doing. That's how I'm doing. How are you doing?
Stephanie Goss:
Fair. I am excited about this episode because when I read this episode I was like, “Did I write this in our ideas database and forget that I wrote it?” Because it is a hundred percent a situation that I had in my practice, and it came from someone else. But I think this is going to be one of those episodes that people are like, “Hmm, I think they might be talking about my practice.” So it came to us from a practice owner who was struggling because they have someone on their leadership team who is fighting with some of the doctors.
And so they unpacked what fighting means and it was a really good unpacking, but they kind of framed it with like, “Help. I need help figuring out how to keep the peace on my team.” So there are some disagreements when it comes to the quality of medicine that is being practiced.
And so this practice owner was like, “Look, I set the standards for my practice and I trained my manager to uphold the standards that I decided on.” Fair. And now the practice has grown and there's multiple doctors on the team, so it's grown from a small practice to a bigger practice. And so they were like when an associate doctor wants to do something differently than our standard, this member of the leadership team and one of the managers has somewhat of a spicy approach to disagreeing with the other doctors.
And this practice owner was like, “Look, I get it because on one hand, I appreciate and want them to do their job and I want them to enforce our standards of care. I want them to enforce the protocols. That's what I've asked them to do. And on the other hand, they didn't go to vet school, the doctors went to vet school and the doctors are making decisions in real-time, and I need to figure out a way to make this not be a spicy conflict when it arises and figure out how to manage the situation when a non-DVM leader in the practice disagrees with one or more of the doctors on the medicine side.”
And they were like, “It's a really fine line. I have no idea where to start. Please help.” And I just thought that this one was a fantastic one. It's one that we haven't talked about before. And like I said, my mind immediately went to the treatment room into this situation that happened in my practice, and I was just like, “I could have written this.” So I'm excited to talk about this one.
Andy Roark:
I like this one a lot. This is one of those fun balancing different people type problems that I really enjoy. So yeah, this is good. All right, cool.
Well, let's start with some head space just to get into this a little bit. The first thing I'm going to say in head space is this is a classic example of what we're fighting about is not what we're fighting about. Absolutely, there is so much baggage here. The first challenge here is to get everyone to understand what we're actually talking about because otherwise they will not. And so we've talked a lot about this.
I tell a story sometimes about forgetting to get a babysitter when I had told my wife I was going to take her out on a date, and my oldest daughter was like 11 and my youngest daughter was eight. And she was like … The night came and we were getting ready to go in an hour or two, and she was like, “Who's the babysitter?” And I was like, “We don't need a babysitter.” And she was like, “Yeah, we do.” And I was like, “No, we don't. Jacqueline is old enough to watch her and Hannah and we can go.”
And Allison was like, “No, she's not.” And I was like, “Pretty sure she is, and I'll Google it and see what I'll see the legal.”
Stephanie Goss:
Shut up.
Andy Roark:
Ah well, there's legality here. There's a legal precedent. And I am going to investigate it and see what it is. And so I googled it. And 11 years old in the state of South Carolina is the answer. And so clearly I won the argument and then we both just agreed that I was right and we went on a lovely date. That's not what happened. We did not finish the argument the way that I had hoped. It escalated, if anything.
Ultimately, this is an example of the fight is not about the fight. The fight was not about how old the children need to be in order to be left alone. The fight was about Andy didn't get a babysitter even though he said he was going to take his wife on a date and now this is a thing and he really dropped the ball, and he hasn't apologized for dropping the ball– he has made excuses instead. And so that's an argument that's not really about the argument. The same thing is here too. When you go to the doctor and say, “You are not upholding the standard of care.” You are saying a lot of things you are saying you did not take acceptable care of the patient, you possibly don't know what you're doing, you are not worthy of being here based on this result.
People get real defensive about those things really fast. There's a lot of stuff about identity, self-worth, your medical knowledge, your values. Are you doing a good enough job, are you walking your talk, all of those sorts of things. There's an ethical component. You are doing something unethical. You were negligent. “When you say you didn't meet the standard of care,” what I hear is you were negligent in your treatment of the patient. And that's not what the person said, but boy, you better believe all of those things, depending on the individual you're talking to, they come right to the top of mind. And so the first thing we've got to do is know that when you go to the doctor and you confront them this way, if you walk right up to them and say, in this case you did this, you're going to get a lot of strings attached to the response you get back.
Stephanie Goss:
Yes. Well, I mean to your point when you were telling us the story at the beginning of the episode, it's about the stories that we tell ourselves in our head. And I think that's from a head space perspective, I agree with you a hundred percent. It's never the conversation or the argument that's about the thing. It's always something else. And the question is it about something else on both people's parts? On one person's part on? You have to figure all of that out. And so I think from a head space perspective, for me, I think part of it is about where we always start, which is part of the talking about having a safe conversation. And when I think about looking at this, one of the questions that I try and ask myself … putting myself in this practice owner's shoes, one of the things that I would hope that I would do would be to ask my manager, “What else could this be about? What could the vet have – are there things you think that the vet could have been thinking about to help assume good intent?”
Because there are things on both sides. The vets are thinking about other things. They are weighing in things that the manager may or may not know about. And to the practice owner's point, they went to vet school, they have a medical degree that proves them perfectly competent to make those decisions. And there is reasoning there and getting curious about what that reasoning is and why it happened is really I think important to assuming good intent.
And on the flip side, getting curious about why the manager is asking questions is also important because to this practice owner's point, the manager's job is to care about the decisions that the doctor's making because they are supposed to be thinking about things like patient safety and client experience and the impact to the practice and staff retention and staff satisfaction, and all of those things. So they have a vested interest as well. And when you have two parties that are both potentially telling themselves stories in their heads, I think where you have to start is with that assuming good intent and asking yourself part of, am I safe to have this conversation for me in problem-solving this, and I know we're not to actions yet.
But is to ask yourself what else could this mean? Why might they have made this decision ahead of the conversation? It's also one of the action steps that I am going to encourage to the manager to ask in the moment, but teach them a healthy way to do it. But it's important for them to ask themselves that question of, why else could they have made that decision?
Andy Roark:
That is exactly the approach whenever you have these conversations that are not about the conversation, whenever you have these emotionally-loaded things, I would say the little two-pack combo that I would put front and center in head space is exactly what you said, it's assume good intent, first of all. If you go in and say this person failed or you didn't do what you're supposed to do, this thing is already going to go … It's already going to go sideways. It's like right off the bat, this thing is already going to go badly. Just count on it. Assume good intent. Assume the person was acting with noble intentions.
And then the second part is seek first to understand. I'm assuming this person had a good reason for doing what they did. I want to understand what it is so I can understand how it fits into the context of our medical standards. Do we need to make changes to our medical standards? Do we need to make changes to our medical standards or how we talk about them so that in these cases, this is something that it fits into our standards so that … and we can get into it in a second, we're going to start getting into what are the consequences here, what we want to make sure that the team understands what's going on, we want to make sure that the team is able to support you, but they can't support you if they don't understand what's happening.
So all of those are very productive ways to unpack these sorts of things. But I think there's two pieces here. I think number one is when you start to unpack what happened, you better get into a good, healthy, curious, positive head space. And then number two is I would say unpack it and then you need to put all of this aside and you need to talk about what you're going to do in the future. And then you need to have a positive, productive conversation about where are we going in the future. If this turns into the manager arguing with the doctor about a case that happened yesterday, the manager's going to lose, and they should lose because they're not a doctor. They're like, “That's it.” Anyway, I'd say they should lose again, but you get my point. It really does come down to two people, have a clear disagreement about a case, the person who's a professional veterinarian should probably have a stronger leg to stand on.
Stephanie Goss:
Well, and I would say I disagree with that slightly in the sense that I think there have been times where I have had two doctors who disagree on what to do with the case. They're both educated, they both have the veterinary degrees, and they have different opinions or different perspectives. And so I think it's about finding that middle ground to your point about getting curious where you're seeking to understand why are you doing the thing to figure out how are you going to be able to move forward in the future.
It's not about making someone feel right or wrong or you know less than they do because I'll tell you, I've worked with a lot of managers who know a whole lot of things and who will bring about medical concerns that others on the teams may not have brought up. So, I think there's validity there, and it's hard. I get fired up and on my soapbox as a manager who didn't originally come from the medicine side of things when people are like, “Well, you're just a manager, you don't know anything,” and not that's what you said because that's not how I took it at all.
Andy Roark:
No, I didn't want to bring that across. I might need to restate that, but …
Stephanie Goss:
No, that's not how I took it at all. And I think it's important to recognize that we're all telling ourselves some degree of story and filtering it through the lens of our own experience. And so it doesn't matter whether you went to vet school, or didn't go to vet school because you can have two people who even went to the same vet school who have radically different perspectives on how to treat the same case. And so I think it's about that finding that … I'm so glad that you said the seek first to understand because a huge part of that head space is like what are we doing and why are we doing it, are we doing it simply because as the business owner I said we need to have protocols, these are the protocols I set up and you're enforcing them.
Wonderful. I appreciate that so much. I appreciate you doing your job fantastically well. And protocols change. Medicine changes. Medicine is radically different now than it was 20 years ago when I started. We're using different drugs, we're using the same drugs in radically different ways. Things change and things have to be flexible. And so I think getting curious on all three sides of this, because there really are at least three sides here and you brought up a fourth when you talk about the rest of the team, getting curious and asking those questions about, “Why? Tell me more,” is really going to help us get to the heart of how do we tackle this and how do we fix it. And it being future-facing is so important and I'm really glad that you said that.
Andy Roark:
And just to give some color to this because as I say sort of the veterinarian should have the stronger leg to stand on. What I mean, I don't mean, hey, if this person's a vet, then they're right and the other person is wrong and that's all there is to it. I don't buy into that vet worship stuff. And you know that. I think when I say that, I still stand by that as a general rule. And it's a lot of it is because one, yes, there's a difference in medical training, but the bigger part for me is the veterinarian is the one who is in the room. And yes, they're a human being and they're making decisions in the moment on the fly. And I feel like whenever possible, we need to support the person who was in the room making decisions in the moment and who could actually talk to the client and read the situation and see what's going on.
And this is where my point comes from, I'm always a bit wary of someone picking up the medical record two days later and saying, “You clearly did this wrong.” And going in there, I think that that's a recipe for disaster. And so I don't want to overstate that or make it about positions– this person's in the right and this person's not. I just think that when we start to get the benefit of the doubt. I'm a big fan of giving a benefit of doubt to the person who was there, who was looking the pet owner in the eye, who was looking at the pet and who was trying their best and who was working with the information that they had at the moment as opposed to standing back and saying, well, clearly, we have it written down that this is how we do these cases. So that was sort of the point that I was trying to make there.
Stephanie Goss:
Sure, for sure. Well, that feels like armchair quarterbacking, right?
Andy Roark:
Yeah, exactly.
Stephanie Goss:
It's like you're being asked to make a call or make a judgment when you weren't in the middle of things. And so I think there's validity there. And I certainly felt that. And like I said in the beginning, this is … I could have written this and I struggled because to your point, I wasn't in the room but my manager, my leader was– she was the tech on the case with the doctor. And so now I have that situation of two people with medical backgrounds with experience who have radically different takes on how to manage the thing. And now I wasn't in the room, but I'm being asked to make judgment calls on how do we move this forward and holy hell, it's hard. It's so hard.
Andy Roark:
And I have 100% seen those things where a doctor and technician were on the same case and they had very different opinions about how it went. And it's very hard. And if you're the manager who gets brought into that and you weren't there and you didn't see what was happening, boy, it's a nightmare case, it's a hard case. I do want to point out at this point, this is a problem of success in a lot of ways, which means you get problems like this when people care a lot about what they're doing and they care about doing a good job. And so these are not awful problems to have in that they only come around because you have people who are really engaged and who really care. And so I do think that that's a good thing.
Stephanie Goss:
And I think that's one of the most powerful tools for when we get into action steps because leveraging that and acknowledging how much they care on all sides will go a tremendous way towards making this a future-facing conversation and dropping that anxiety level over, “Hey, we've got to talk about the disagreement.”
Andy Roark:
I completely agree. I guess my last part in head space is I would 100% make sure that this conversation is not framed as right and wrong. “That the technician is right and the doctor's wrong or the doctor's right and the manager's wrong.” I would not frame it that way. I don't think that's productive. I think it leads to hurt feelings. There is no arbiter of medical care in the sky who says, “Yes, this was the optimal way to proceed.” That's not even possible. I mean, I'll say I've seen cases where the doctor practiced the pinnacle highest premium standard of care, and the pet owner left and got really angry when they got home because they were like, “I couldn't afford this and you did all of these things and now I'm not coming back because I can't afford you guys anymore and blah blah blah.”
And again, medically speaking, the doctor did the best thing. Yet, there's a client who's angry on the phone saying, how dare you do all of these things when I just wanted my pet taken care of in this basic simple way. And you go, “I don't know what's right.” If you work the case up to the point that the pet owner never comes back again, was that optimal? I doubt it, but I don't know. You know what I mean?
So anyway, that's why … I try to throw those shades of gray in there, not to irritate anybody about what the standard of care should be, but just to say there's not a right answer. There's only guidelines, there's only sort of our values and how we position ourselves. There's only consistency, and consistency is really important. And so when we start to get into action steps, we're going to start to talk about what matters and what's important. But I do think that … I guess we can put this as groundwork, starting to have some agreements in our team about what our values are, about what we care about. Those things are really important for having these conversations. If you don't have sort of team values, core values, things like that that say these are the things we care about, this is a really hard conversation to have. If we can come up with some things that we all agree on about what's important in the way we treat each other about the what's important in the way we treat the pet owners, then we can use those as touchpoints to start to make some standards.
But if we don't have any conversations about what's important to us, what our identity as a team is, then it's really hard for us to make standards because the standards that you are interested in and the standard that I'm interested in, they can be wildly different. And we've seen that. Anybody who's been in vet medicine for very long has seen some practices where they just let the doctors completely run however they want. And you've got one doctor who may or may not be the senior doctor who's like, “No, we're doing it. We're doing old school.” And you've got new doctors who go, “I can't look, I just can't. Look at that.” And I'm not trying to throw anybody under the bus or ageist anything, but just give an example of a common one we see is people who practice medicine very differently.
I've seen old-school doctors who have kept up and done a lot of learning and they are amazing, much better doctors than I am. So it's not anything about anything other like that. I use that as a classic example of doctors doing very different things in the same building. And it happens a lot. And boy is it hard to get them onto the same page, and they can get really defensive really fast.
Stephanie Goss:
For sure. And I think your point is a great one, and when you do have agreements about how you're going to work, what your values are, even like you're going to talk to each other or manage through conflict, which is one of our action steps here coming up. But even if you don't have that, your point about this is a problem of success, they both care. The doctor cares about the patient and is trying to do the best thing for the patient. And this manager or managers or whoever is concerned about it, cares about the patients as well. It's not less or they're caring about … And maybe they are caring about different things, but they both care.
And so starting there and being able to say, Hey, I know we're having this conversation because I know how deeply you both care about your work and I want to use that to figure out how do we come to some agreement on how do we deal with this in the future. Using that works whether you have stuff formalized or not. And it works whether you have … The problem is with all doctors, I had that exact conversation when my doctors all disagreed on how to manage a certain type of case and what kind of drugs we were going to carry. And I was like, “Look, you guys all agree, you're all really smart. I don't have a degree in veterinary medicine. I'm not going to make the call here, but I need us to work together to figure out what is going to be our agreement between us” because the team can't have it four different ways.
And so it's about how do we find that common ground. And so I think that head space of “this is the problem of success” is a really healthy one to help move into those action steps of talking about it.
Andy Roark:
I also think to some degree, it can make the conversation easier when you have multiple points of view because then you can clearly say, “I'm not picking sides.” We need to come together and find a path that has us all doing the same thing. So anyway, I think that's probably where I'd be for head space. So it's just sort of summarize real quick. Remember this is a problem. We're not really talking about the problem. You have to be very careful here about people's emotions, self-worth, self-identity, values, things like that. So just we want to be really, really careful here. The combo to start off with is going to be assume good intent and coach to assume good intent and then seek first to understand is try to understand what's happening, what's going on.
Remember to put your standards of care forward as a living document. Whatever your standard of care is today, that's not going to be your standard of care in 10 years. You're going to continue to evolve and change as we learn things. And so that also makes the standards of care a less scary, chiseled-in stone thing. It's something that we can talk about, and that's okay. Remember the end result that you want to try to get. The end result is important. The end result is not to make the doctor apologize or to take the manager down a peg. If that's what you're trying to do. You are off base. The end result is to come to an understanding so that next time the case comes in, we have some agreement about how we're going to proceed as a team so everybody feels included and safe and onboard, and that's the end result that we're looking for.
And so if you pull the flaming raging sword of justice and you go seeking to figure out who is right and who is out of line, is it the doctor that is wrong and negligent, is it the manager that is overstepping her bounds, none of that's going to end well. In any sort of way, it ain't worth it. Just go in there and talk to everybody and figure out what's happening and what we're going to do next time.
And the last thing I would say is remember just to lay down why are we doing this. And that's going to be my first part in the action steps. “Why is this even important?” And I think a lot of people fall into the idea of, well, this is a test, and there are rules and you broke the rules or you didn't break the rules. And I go, “Who wants to play that game?” That doesn't make any sense. “This person was wrong, and I know the rules and I'm going to show them they were wrong.” I go, “Okay, if that makes you feel better, you can do that, but you should really enjoy it because you're going to have weeks of pain in the neck trying to get past this conversation, and it's fallout.”
Stephanie Goss:
For sure. Okay, well, let's take a break and then come back and talk about where do we go from here, how do we manage this.
Hey friends, I just wanted to talk for a quick second about some maths with y'all because I've been thinking a lot about the workshops and normally, here's where we tell you what's coming up and we've got some great stuff happening. So you're going to want to head to unchartedvet.com/events and check out the upcoming calendar. But I want to talk about maths because if you are not already an Uncharted member, you can attend any one of our workshops and pay $99 a piece. Most of them are just $99. You can do it as a one-off, great and fine. However, that adds up really quick. And if you do the monthly workshop with us, and I've seen some of you there as repeat customers, which is amazing, but you could spend almost $1,200 over the course of the year doing workshops with us. Or you could pay $699 and get a 12-month membership, which means you get all of the workshops that we do at no extra charge.
You also get access to our amazing conversation in the community, our community members, and all of our community resources. And it is hopping over there. We've got conversation 24/7, we have got activities, we've got book club. We're writing our handbooks together in handbook helper group this year. We are talking about development and leadership growth, doing our development pathway this year. We are doing hallway conversations where we're talking about topics. These are sessions that are community-led, community-driven. It is topics about things that are going on in your practice that you want to talk about with your peers. All of that is happening and it's all included for your $699 membership. So simple maths, do you pay almost $1200 for the year or do you pay $699?
If you're not currently a member, you should head over to the website and use this argument to convince your boss: “Hey boss, I need to be a part of this amazing community because Stephanie told me so and because she's telling you that you will save money.” Hopefully that works, but I couldn't resist. I hope to see you at our upcoming workshops again unchartedvet.com/events for everything that's coming. And now back to the podcast.
Andy Roark:
So when we start to manage this action steps, this is just some multipart approach. This is not one where you roll in and swing for the fences. I don't know, maybe other people are better than me. There's no way I walk into this with the idea of we're going to have a meeting and this'll be over. That's a fool's game. That's not going to happen. This is a series of meetings. This is a meeting with the manager and separately, a meeting with the doctors or doctors, and then it's going to be a meeting together. And the reason it's because I'm going to need to get both of these individuals into the right head space to talk to each other. And if I don't do some pre-work to set them up to have this conversation, the whole thing's going straight in the ditch.
Stephanie Goss:
Yes, I would agree with that for sure.
Andy Roark:
So let's talk about the manager. So the manager's the one who's looking at the record and she says, “This is not up to our standard of care. I have a problem with this, I'm upset about it.” Seek first to understand. Same thing here. “What's important to you about the standard of care? You're clearly really in this. Why is this important, I want you to tell me why it's important.” And they'll think to you that you're jerking them around and “I need to understand why does this person care about the standard of care? Is it because they feel like it's important for them to know what's going on as the manager? Is it that they're worried about the perception of the staff of this happening? Is it they're worried about patient care?” I don't know what's important to them about standard of care until I ask them.
And a lot of times, we skip this step. We just start talking about the standard of care as if it is by itself important. The standard of care is just a guideline, but that guideline means things, but it means different things to different people. And it's important for different reasons to different people. And so the first question for me is, what's important about the standard of care? And I need to start to find that out. So do you agree with that as kind of an opening position?
Stephanie Goss:
I love it. Yeah.
Andy Roark:
All right, cool. So I want to talk then, and I want to start to put into the person's mind the idea. So we're talking about the standard care and we're talking about this why the standard care is important. And then what I need to generally do is introduce the idea on standard of care. I need to introduce the idea to this person that standard of care is flexible and it is highly context-dependent.
Stephanie Goss:
Sure.
Andy Roark:
Meaning now it's never okay to be negligent. We know that. However, it's never okay to be negligent, full-stop period. And there are different approaches that we take based on what we see in the exam room and also what the pet is going to allow us to do. We have all sent patients home at the end of the day that should have been hospitalized. They should have gone to the emergency clinic, but they weren't going to the emergency clinic. And we all see that. And so there's plenty of examples about standard of care. It's flexible. And I would sort of say, how do we know what's acceptable, how do we know what makes a good standard of care? And I always try to get vulnerable with people here and say, “You know what, I'm a doctor. I do a podcast for a living where I talk to people about medicine all the time, and I'm constantly learning and I'm constantly updating and things that the inflow of data is absolutely unceasing.”
And then also, spectrum of care data is really blowing up. We're starting to see a lot more coming out about more conservative treatment options and what are the outcomes with this and we didn't have that data before. And so anyway, I'll put forward when we start talking about things like that, the classic one for me was the Colorado State parvo outpatient treatment. And when I was getting trained in everything, hospitalization of parvovirus patients was absolutely critical. That's it, it had to happen. And lo and behold, we end up getting this protocol out of Colorado State that's an outpatient treatment protocol.
And only when we see the numbers do people go, “Oh wow, this is a radically different than what I anticipated the outcomes would be.” And so inpatient parvo treatment gives you about a 90% success rate. And Colorado State's outpatient parvo treatment gives you 80% success rate. So not the same. In hospitalizing inpatient does give you a higher success rate. However, I don't think many of us would say, oh, the outpatient is unacceptable, but we didn't used to know that. That's fairly new. And so anyway, I start to have some conversations about medicine changing and standards changing, and it's all sort of figuring these things out. I'm trying to get this person to recognize that the standard has some wiggle to it, and there's some reasons that we move around it, and it's not a perfect measure. And so what I'm really trying to do is set them up in a position to give the other person grace.
Stephanie Goss:
Well, and I love that. And I think the other thing as a leader, as a business owner, and as a manager that might come out of that conversation is where are the gaps in learning and potential opportunities for learning with the team. And what I mean by that is if you ask the question, how do you know what's acceptable? And the answer is, well, you said that that's what the standard is, so that's what I expect everybody to do. That's an incredible opportunity to teach not only your manager, but also probably other members of your support team about the why. And that is a huge opportunity that is only going to get identified if you ask that question. So I love starting there.
Andy Roark:
Well, and then roll that together with the why is the standard of care important– what's important about it to you? And now you've really got something, and you can see me starting to get the manager rocking just to where they're not going to be so rigid that it's right or wrong, do or die. Depending on the person and where they go, I would start with all of those things and get them to hopefully buy into the idea that this isn't as set in stone as we wish it was. It's just not. And we deserve to at least try to figure out what the other person was looking at and what they were dealing with. And then oftentimes, if I can get them to empathize, and I would love … Again, all of these things are priming this person to have another conversation. And so I want to then try to get them into empathizing a bit with the doctor.
And maybe they don't need to; maybe they're already empathizing but a lot of times just getting someone into that head space makes all the difference in the world. It's like when your kid comes home and they've had an argument at school or somebody was mean to them, and you say to them, “Well, how do you think that person was feeling?” Or “What might have made them act that way?” And it's an example, I'm trying to teach my kid empathy. I'm trying to get them to say, okay, I can understand how that person would've been mad. They shouldn't have hit me, but I also shouldn't have called them Johnny Big Teeth.
Stephanie Goss:
Great.
Andy Roark:
Or whatever. I get it. I said, “But I get it. I understand why that would make him mad.” And again, it is trying to get that. So the same questions I start to have with the manager, and this is not a punitive conversation, it is a hundred percent an empathy conversation, but I'm going to try to get them to think about, Hey, if you were a doctor and the staff was looking up to you and the manager came in and started challenging your medical decisions, how would you feel? What emotions do you think you would feel? And this is just us talking, “Getting ready to go talk to Dr. Smith, but what do you think Dr. Smith's emotions are?” And just get them to hear, “Well, I'd be embarrassed, and I would feel like I'm not being supported.” Totally. Those are all emotions Dr. Smith has. And again, this is me talking somebody else into a healthy head space to go have this conversation.
So, anyway. And then the last part too is I would start to talk about some consequences of what are the downsides of conflict like this that we want to try to mitigate. So for example, if these are things that are happening and the staff is aware of them, I'm worried because here I've got my doctors, and I want to build a workplace that's built on trust. I want my techs to trust my doctors.
Stephanie Goss:
Of course.
Andy Roark:
I want my doctors who trust my techs. I want everybody to trust our team manager, and our manager to trust everybody on the team. And so undermining the doctor credibility and unless we have a really, really, really, really good reason to, is generally a bad idea. And I don't want to undermine the trust that the staff has in this doctor. Definitely not until we get to talk about what happened and where are we, you know what I mean? And again, I can't change what happened yesterday. We can only go forward. And I feel like here at the end, I should go back and put the statement in. I feel like I've tried of made this point, but just to be totally clear, I'm not talking about a doctor being negligent or doing awful things. I'm 100% talking here about a disagreement over standard of care that is well above negligence, but not what our stated standard is for this hospital.
Stephanie Goss:
Yeah. A common example that I can think of is … So, the standard of care for a diabetic patient is we're going to do a full glucose curve and an exam, and you have a set … this is what we're going to do and this is how frequently we're going to do it. And then the patient comes in for the exam. And to your point, the doctor takes in all of the information in the exam room, they take in the info from the owner, and then they make a decision that deviates from that standard of care. Maybe it's doing a mini curve instead of a full curve, or maybe it's sending them home to do a curve at home versus doing it in the hospital.
Andy Roark:
They didn't do an exam because they did an exam three days ago or last week.
Stephanie Goss:
When they were here for an ear infection. And so they were just like, “It's fine.” But it's one of those things that's a deviation that someone is like, “There's a reason why we say that we're going to do it this way.” And that is 100% true. It is also a hundred percent true that the doctor's job is to take all of that information and make decisions with it. And so that's why you're in this middle ground. You are right, and they are right. And now I need to figure out a way for us to work together so that nobody feels like they were wrong here because you're both doing what you're supposed to be doing. And veterinary medicine is about the shades of gray. And there are always going to be times where the doctor says, I'm going to do this instead of this time, or I'm going to make this decision. Or as a manager, I'm going to make this exception for customer service. We live in a world of gray.
And so that's where, to your point, getting them to put their empathy shoes on and imagine, ask themselves a question, what else could this mean, what else could they have been thinking, why else could they have made this decision even if they can't get themselves to have empathy … because I've been in situations where someone has been so fired up and so hacked off that if I ask them, “Could you imagine how they could have been feeling when you called them Johnny Big teeth,” they're going to be like, “Screw you.”
Andy Roark:
That's sticking now. Now that we're using it, that kid's Johnny Big Teeth forever.
Stephanie Goss:
They're like, “No, he couldn't have been feeling anything else except for my fist before I put it in his face.” But there is still a way to get them to feel the empathy. And so if that lever doesn't work, getting them to ask the questions about what else could this be about because we live in a world of gray in veterinary medicine, and there are … That is the job as a manager, that is also the job as a doctor, is to make those game time decisions. And it doesn't matter whether you're a practice owner working with a practice manager, whether you're an associate doctor working with a technician. We have to be able to lead the practice, whether we're leading for our patients in the moment in the exam room, or we're leading the team in front of everybody at a team meeting, we have to be able to lead and do our jobs knowing that we trust each other as a team.
And so we have to come to that place of common ground. And so your job as the middle ground person is to figure out how to get them to find that common ground and acknowledge the fact that you're both doing your jobs. No one is wrong. And we still have to find the shades that talk through the shades of gray hair.
Andy Roark:
Yeah, I completely agree. I just had a recollection of … I got in trouble for this one time of sort of a standard of care thing like this where it was like, I had this little miniature schnauzer and it had a bad corneal ulcer. So one of his eyes, and I don't remember which eye or anything … it was a bad corneal ulcer and that thing was not getting better. And I was wrestling with it and wrestling with it. And I had this, and the lady was this wonderful sweet old lady, but I had her coming in every five to seven days and I was restaining it. And every time she came in, it was our policy at the hospital to charge a recheck exam and to do it. And finally, after four or five times, I said, “All right, well, I'll see you back again.”
And she was like, “Dr. Roark, I think you're so great. Are you going to charge me $100 again today for this?” And I couldn't do it. And I was like, [inaudible 00:50:46]. At this point, I knew exactly what I was looking for. The dog didn't need a full physical exam, I just needed to get that eye stained. And she was wonderful. And she said that to me, and I stopped charging for those exams because I was like, Nope, she's going to come in. I'm going to stain her eye. We're going to see where we're doing, we're going to make adjustments and she's going to go. But she was so wonderful. And again, I understand that some people would be like, no, Andy, you can't do that. You should have charged her a hundred bucks every time. And was it the fact that she was a sweet little old lady? Yeah, that probably had something to do with it. Yeah, it probably did.
And again, but if you sat me down and … And they did. The management said something to me about, Hey, it's not standard of care to do this.
Stephanie Goss:
Yeah, how can you do this.
Andy Roark:
And I kind of said, “I hear that; I'm not going to do it.” And I told them. And again, it was one of those things too where I said, “You guys know me. You know that I take care of my cases, and I work up my cases, and this is rare. But in this case, I feel that this is warranted to be able to continue to give this person the care that they need for their pet.” And again, it was a one-off; it was not a common thing, but again, that was a thing where they said, “No, our standard of care is a recheck examination and a fluorescein stain.” And I was just like, “Come and look at this chart with me. Let's see what we're looking at here.” Anyway.
Stephanie Goss:
Well, you're talking about the why, right? So you have to do that with the manager, but then you also have to have the conversation with the doctor because you got to prime that pump, too.
Andy Roark:
I agree. So let's talk it through. So all of that stuff is the things I'm trying to do to get the manager ready and empathetic and open to having the conversation. And so then you got anything else you would say to the manager or are you feeling pretty good.
Stephanie Goss:
No, I feel good about that.
Andy Roark:
Okay. All right. Cool. So then we go to the doctors. The big things that I want to talk about where the doctors is, this is all much healthier if I can frame it as a forward-facing conversation of like, Hey guys, let's talk about medical standards. How do we want to set our medical standards, how do we want to get the team on board with these? Really, a lot of it is a temperature check on where your doctor's about medical standards. And if you have a team that generally agrees that medical standards are good and important, then we're going to start with the understanding that, hey, medical standards are important. If we have a team of doctors that all want to do it their own way and they don't agree about having consistency across the practice, we're going to step backwards, and we're going to do it.
Just know that it's going to increase the timeline it's going to take us to get to where we want to be. And that's okay. Be kind to yourself, be patient with yourself. The first thing we're going to have to do is get everybody to agree that it's important for us to be consistent, and we're going to have to talk to them about why consistency is important, and we're going to have to sell them on the fact that their jobs are going to be easier because the staff will be able to help them more when they know what we're doing and how we're doing it. And we're going to have to tell them we're going to do better medicine and they'll be better patient care and they'll make more money, or whatever their motivators are, we're going to have to get them to buy into a consistent approach across the board.
So that's the first part. And then after we get them to buy in for the needs of a consistent approach, then we're going to have to have the conversation with them about how do we set these medical standards. And that's sort of the conversation that we're going to need to have.
Stephanie Goss:
The only other thing that I would say about the doctors is that I would probably try and do some poking to get them to maybe … especially if there had been already disagreement and emotions, I would probably do some poking to try and get them to unpack the stories they might be telling themselves in their head when somebody who is non-medical staff is questioning, or even if it was a technician who has license is questioning a decision that they made. I would probably try one-on-one before we have the other conversation, get them to poke at that because if I can get them to be vulnerable, if I can get them to acknowledge to the other person, “Hey, when you ask me the question like this, this is the thoughts that went through my head,” I can help set the stage for the empathy to pour out and for the other party to say, “Oh my gosh, that was not what I meant, I never would have wanted you to feel that way.”
So I would probably do some digging with them to try and unpack what are the stories that they might be telling themselves in their head.
Andy Roark:
Yeah, I agree. If there's a specific case where it's this specific type of case where there's a disagreement, and especially if it was based on something that happened last week, I would do the same thing I would do with the manager of assuming good intent, seeking to understand what happened with this case, “walk me through this, walk me through what's going on,” stuff like that.
And then I think it's good to talk to your doctors, not at this time, not about this, but at some point separately talking to the doctors and saying, Hey guys, we've got our medical standards. How do you all want to be made aware of questions about our medical standards?
Stephanie Goss:
Sure. Yeah.
Andy Roark:
And I would say it to the group so that no one feels targeted out. Like, “Hey, Stephanie Goss. If a person has a problem with your medicine, how do you want to find out about that?” It's not that. It's just, Hey guys, the … So now it's presented as education is constant, standards are always changing, the staff wants to know what's going on. If they have questions, I want them to have-
Stephanie Goss:
They need a process.
Andy Roark:
… the ability to ask. And so I'm going to have them. Any of those questions will come up to us, how do you want me to ask you guys about that? Is this a phone call? Do you want me to do it in our one-on-ones? How do you guys want to want to hear about that? And by talking to all the doctors at the same time, I'm setting the expectation that this is a thing that's probably going to happen and it's going to happen to any of you. And it's not bad, it's just they're going to have questions. And so that if and when it happens, it doesn't feel like this horrible, nightmare, scary scenario.
And the last thing I would say is, great guys, we're going to work together on our standards, and I want to keep those things up to date with you guys. What is the best way for us to educate the staff about what our standards are? How do we want to communicate these things so that people know what to expect and how to best support you guys? And those are the types of questions.
Again, what I'm trying to do here is to get the doctor or the doctors into this head space of, Hey, medical standards are important, and the staff cares about medical standards and they're going to have questions about medical standards. And we are a collaborative team who talks through things like that. How do you want to participate in those things? How are we going to send good communication down the chain? And how are we going to receive questions coming up the chain? Because this is how we work together to make sure our hospital continues to function well, and everybody feels good about what we're doing.
And again, all of this is happening before I put the manager and the doctor or the doctors together. This is all priming the pump.
Stephanie Goss:
Okay. So we have meetings with them all separately, and then we've got to get them all on the same page.
Andy Roark:
Yeah. So we got to get them all on the same page. So bringing it sort of together, I'm a big believer that it's probably best if we have medical concerns to have them go through a medical director. And if we don't have a medical director at all, I think that that may be a problem. It's very dicey for the manager to walk in and drop medical concerns on the doctors. I think that's really hard. Part of my setup for this would be … I think this is where you use your medical director is those complaints and concerns should come to the medical director. That way it's almost like a peer reviewing the case and someone who's got some perspective of being in that situation and has some letters behind their name to carry weight of bringing it in. Oftentimes they may be able to add some context that affects how this is presented.
But I really do think working through your medical director is going to be the way to go. And then going into this, if we're going to have this group conversation, we say we're going to sit down with the doctors to talk about what our standard of care is going forward, or making adjustments or things like that. For God sake, start with commonality. And I think you touched on this at the very beginning. Like, what do we all believe in, what are we all trying to accomplish, what do we all think is important, what are we doing here? And I think if we lay down the commonality, what we're all in, we're all looking to do the best for the pets, we're all looking to do a good job, we're all looking to make sure that we make a positive impact in the world, we're all looking to feel like we're making impact day to day on our patients, us, the support staff, the pet owners, we're all doing this.
Now let's talk about standards for all of us so that we can all feel good about this. So start with commonality first, and then start to lay out the spectrum of what guidelines look like. There's a lot of flexibility in what we can do with guidelines. And so I often like to frame the spectrum to show the absurd extremes because it makes people feel not so far away. So for example, I would come in, I would start to have this conversation. I would say something like, “Hey, look, we do not want to have a zero consistency practice wild west. Everybody's free styling. The patient experience, the pet owner experience is radically different every time they come in. Nobody knows what we're doing or why we're doing it. The techs don't trust the doctors. We are not going to have that kind of practice. We are not. We're also not going to have a practice where we dump patients out in the street without any treatment because their owners can't or wouldn't pay for this set standard of care that we chiseled into a piece of stone. We're going to recognize that pet owners are out of our control. The pets are out of our control. And sometimes we have to adjust to the situation to get the best care possible and to protect the relationships that we have. So we're not dumping people out on the street if they're not willing to do everything we recommend. We're also not running a wild west show where everybody's just shooting it out over each case about what we're going to do and what we're not going to do. Let's get somewhere in between those extremes where we all feel good.”
I like that style of setting down two ridiculous extremes, and people go, “Well, obviously, we're not going to dump people on the street,” but what I'm trying to do is to get the people who like rules and who like to see right and wrong. If I set that down just as a joking way, just like I just did it, it frames the issue to say, there's not a right answer, there's a spectrum, and we are picking a space in that spectrum, and that takes a lot of the no subcutaneous fluids are in, or they are out. It's like, no, look, we're trying to land here in the middle. So anyway, I can lower the stakes a little bit and take away that right or wrong mentality. So I try to set it up that way. But that's the big thing.
And the last thing is focus on the future, not the past. Let's talk about what we want to do next time. And some of this stuff is going to be picking a hill and making it beautiful. I tell a story sometimes when I started landscaping, I didn't know where to start because I was just overwhelmed, and my dad told me to pick a hill and make it beautiful, and then pick another hill and make it beautiful. In a couple years, you're going to have something great.
And so a lot of times in management, you just pick a hill. You're not going to create standards for your whole practice in a week. if there's a thing and there's an issue, let's work on that. We're going to work on nutrition recommendations, and then we're going to work on pain control, and then we're going to work on dental standards, and we're going to keep going. And people say it's going to take years. And I'm going to say, you know what, you got years. This is going to be a lifelong process. And then here's the thing, when you get done, it'll be time to start over again and remake the first ones. So that's that. That's all I got.
Stephanie Goss:
Oh, that's where you choose to end.
Andy Roark:
That's it. That's all I got. All right.
Stephanie Goss:
That was a good one.
Andy Roark:
I just ran because we were getting long. Stuff was getting along. We got to get out of here. So I talked us all the way out.
Stephanie Goss:
You talked us out. No, that's great. I love it. I think that's a wrap.
Andy Roark:
Cool man. All right. Thanks for doing this with me. Thanks everybody.
Stephanie Goss:
Yeah, have a great week, everybody.
Well, that's a wrap on another episode of the podcast. And as always, this was so fun to dive into the mail bag and answer this question. And I would really love to see more things like this come through the mail bag. If there is something that you would love to have a talk about on the podcast or a question that you are hoping that we might be able to help with, feel free to reach out and send us a message.
You can always find the mail bag at the website. The address is unchartedvet.com/mailbag, or you can email us at podcastunchartedvet.com.
Take care of everybody, and have a great week. We'll see you again next time.
