Let's face it... We have all felt this new grad struggle. It is an easy trap to fall into when you graduate and realize that cases are not as cookie cutter as a multiple choice question, finances play a role in decisions, more than one solution to a problem exists, and the list goes on...
This was one of the BIGGEST challenges we had to overcome as new vets and even sometimes today it is still a challenge for us. Over time, we developed ways to manage these situations, and it definitely took us time and practice. While we were learning, there were plenty of days where we were both running 30-45+ minutes behind on appointments and just felt like we were scrambling to keep up for the day.
One pro tip we have is writing down a list of all the pet's problems in order of importance, and then focusing on the most pressing matters in that visit. Satisfying the owner’s primary concern, while balancing what you deem the most concerning problem (hopefully they align!), can be a helpful approach to these situations where the list is 8+ problems long.
Taking this approach consistently from the start will help you to come up with your diagnostic and treatment plan. Be sure to reassess the other problems listed as you get your diagnostic results to see if they fit in somehow too.
The best way to learn how to overcome analysis paralysis is through practice. We made up a common example for you of a typical appointment we see on our schedule. These appointments used to give us anxiety as we knew we would get behind, but never fear! Working through this example will provide you with a good structure for all of your appointments.
Let's get started...
Princess Fluffy is a 10 yr FS Toy Poodle. She presents for her senior annual visit to update her bordetella, heartworm check, fecal, and blood work.
Once your assistant goes in the room, Mrs. West casually mentions that she JUST started having diarrhea yesterday and she is coughing more than she normally does.
On exam, you note grade II/IV dental disease (with odor that could knock you on the floor), a grade II/VI heart murmur (stable from 6 mo's ago), a dry nonproductive cough on tracheal palpation, and she is 20% overweight.
𝑨𝒍𝒓𝒊𝒈𝒉𝒕 𝒅𝒐𝒄, 𝒘𝒉𝒂𝒕 𝒅𝒐 𝒚𝒐𝒖 𝒅𝒐!? 𝑯𝒆𝒓𝒆 𝒊𝒔 𝒚𝒐𝒖𝒓 𝒉𝒐𝒎𝒆𝒘𝒐𝒓𝒌...
1. Organize your problem list from most to least important.
2. What is your plan for today?
Work through the above before moving on to this next part...
First of all, your list may vary slightly. This is just what we would have done, as sometimes a problem can be similarly ranked in importance to where a slight variance is not a huge deal...
1. Acute diarrhea
2. Heart murmur
3. Acute on chronic cough
4. Dental disease
Diarrhea is first because it is a sudden change, and the owner brought it up. It is VERY important to address the owner's concerns so that they are happy with the visit.
The heart murmur is second because a change in her heart condition could be a more life threatening reason for the sudden increase in her cough. It is important to communicate this to the owner when discussing the cough.
Third is the cough, which can be due to many things in this breed. Think big picture differentials always, and then narrow.
Some big categories to consider for an acute on chronic cough include:
- Cardiac dz (MVD with heart enlargement worsening cough vs. heart failure vs. heartworm dz vs. other)
- Upper airway dz (tracheal collapse vs. laryngeal paralysis vs. other)
- Lower airway dz (infectious vs. allergic vs. chronic bronchitis vs. other)
𝕊𝕠, 𝕨𝕙𝕒𝕥 𝕨𝕠𝕦𝕝𝕕 𝕪𝕠𝕦 𝕕𝕠 𝕟𝕖𝕩𝕥?
1. Run her senior wellness testing to gain more info (CBC, Chem, UA, T4, Heartworm check, Fecal, possible Snap proBNP for cardiac, etc.), as this will guide your next steps. You do not need answers today, since she is stable.
2. Get medications together for her diarrhea. Head to our stories for what we like to do!
3. Discuss chest x-rays and ask if owner wishes to do to be thorough. Provide an estimate and discuss options for performing today vs. a different day (will discuss next week). If she wants to be conservative, consider antitussives vs. antihistamines, etc. as a short trial to assess response to therapy.
We totally get how the above can seem daunting. You are probably wondering how in the heck you are going to accomplish all of that without getting behind. Now, let's chat tips!!
It is SO easy to get behind on a busy appointment day. It happens to us ALL the time, even now! But, there are some basic things you can do, along with remind yourself of, in order to keep your cool on a busy day.
𝟷. 𝚈𝚘𝚞 𝚊𝚛𝚎 𝙽𝙾𝚃 𝚜𝚞𝚙𝚎𝚛𝚠𝚘𝚖𝚊𝚗(𝚘𝚛 𝚖𝚊𝚗).
𝟸. 𝙽𝚘 𝚘𝚗𝚎 𝚜𝚑𝚘𝚞𝚕𝚍 𝚎𝚡𝚙𝚎𝚌𝚝 𝚢𝚘𝚞 𝚝𝚘 𝚏𝚒𝚡 𝚎𝚟𝚎𝚛𝚢𝚝𝚑𝚒𝚗𝚐 𝚒𝚗 𝚘𝚗𝚎 𝚟𝚒𝚜𝚒𝚝. Set this expectation up from the start! Schedule a follow up, whether through another visit or phone call where you can discuss how their pet is doing with treatment along with going over your results from any testing performed.
𝟹. 𝙷𝚊𝚟𝚎 𝚊 𝚙𝚎𝚝 𝚍𝚛𝚘𝚙 𝚘𝚏𝚏 𝚏𝚘𝚛 𝚝𝚑𝚎 𝚍𝚊𝚢 if unexpected testing gets added on to a "routine appointment."
Let's go back to our example. How would you handle this with Princess Fluffy from last week?
𝑳𝒆𝒕'𝒔 𝒕𝒂𝒍𝒌 𝒆𝒇𝒇𝒊𝒄𝒊𝒆𝒏𝒄𝒚 𝒕𝒊𝒑𝒔 𝒕𝒐 𝒂𝒗𝒐𝒊𝒅 𝒕𝒉𝒆 𝒔𝒕𝒓𝒆𝒔𝒔 𝒔𝒑𝒊𝒓𝒂𝒍 𝒐𝒇 𝒂𝒏𝒂𝒍𝒚𝒔𝒊𝒔 𝒑𝒂𝒓𝒂𝒍𝒚𝒔𝒊𝒔!
Last week we talked about running routine blood work on Princess Fluffy, getting medications together for her diarrhea, and discussing testing/medications for her cough.
𝑯𝒆𝒓𝒆'𝒔 𝒉𝒐𝒘 𝒚𝒐𝒖 𝒄𝒐𝒎𝒎𝒖𝒏𝒊𝒄𝒂𝒕𝒆 𝒕𝒉𝒆 𝒂𝒃𝒐𝒗𝒆 𝒂𝒏𝒅 𝒔𝒕𝒂𝒚 𝒐𝒏 𝒕𝒊𝒎𝒆...
1. Mrs. West, since Princess Fluffy is stable, we are going to run a full panel on her today to be thorough and help guide us in her short and long term treatment plan. I will call with these results within the week, and we can also discuss how she is feeling on the medications at this time.
2. Discuss x-rays with Mrs. West next. If she wants to do them today, have her drop off or you can offer another appointment later to have more time. If she prefers medications first, prescribe these today, and then let her know you will check in when you call to go over blood work.
3. At the scheduled call 4 days later, check in on the diarrhea and cough, go over blood work findings, and see if she has any questions about x-rays, the medications for cough, and what she wants to do next.
Fluffy's diarrhea and cough are resolved with treatment, so you have a happy owner! If signs are still present and blood work is normal, discuss x-rays again.
Ultimately it is up to the owner if she wishes to pursue more testing, try a different medication, or just monitor. Any questions??
And just remember... This GIF will happen ALL the time