Future of Veterinary Teaching Hospitals

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

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

3. History • Internships began in 1950-60’s, residencies in 1960-70’s. • Board certification became the norm for entry level clinical faculty positions in the 1970-80’s • Clinical Departments began to divide responsibilities into academic & hospital, and Hospital Directors began to be hired in the 1980-90’s, and have continued to be hired in the 21st century. • Veterinary Colleges became more dependent on hospital income in 1990-2000’s.

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

5. Problems Identified at these meetings • Difficulty in faculty staffing of VTHs due to attraction of private specialty practices • Future funding for VTHs is up in the air – revenue and gifts are probably the best future source of funding since an increase in central core funding is not likely • Decreasing of state subsidies, and an increase in the competition for cases and potential faculty

6. Many faculty/specialists find that there is too much red-tape in universities. • Research, teaching, and service – hard to be good at all three, can be in direct conflict with each other. Some think there is also a 4th mission – to teach the business aspect of veterinary medicine • Increased reliance on tuition and fees, stagnant VTH revenues in some areas • State revenue as a % of total revenue for vet schools has on the average decreased from 55% to 33% over last 10-20 years

7. Average # of state-funded faculty positions has been static at most schools, some increase in non-state funded positions (from donation dollars or revenue dollars), at same time as increase in # of students • Decreasing to static applicant pool for vet students, increase in number of veterinary schools to choose from • Suboptimal distribution of caseload (need more primary cases for teaching, too many tertiary cases)

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

9. In private practice, a vet earning $65,000 should produce at least $300,000 in revenue, but the VTH is not a typical practice so the faculty do not typically produce that amount of revenue. • Practice owners want from graduates: veterinary knowledge, communication skills, people skills, business skills, how to manage workload • Adequate caseload is not always there in academia for teaching and research needs

10. Specialists are finding that the VTHs have a lack of money, equipment, and new space, are inefficient, and that some are located in nondesirable locations. • The faculty feel like they have a loss of control over the work day; too many goals; long days and weekends; and they have found that they now can teach in private specialty practices and not just in academia. • Present faculty can be poor role models for interns and residents – show unhappiness and frustration.

11. The Need to Change • The SVMs and VTHs must be willing to change to accommodate the above issues, prioritize the missions of their clinical programs.

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

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

14. Work with University to get more competitive salaries for specialists, maybe signing bonuses • Develop Incentive Plan – part of revenue goes back to individual faculty or their section of the hospital for their use • Develop satellite practices so as to augment money generated and improve 2° type cases • Offer consulting time to faculty or increase it

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

16. Maintaining and Enhancing Case load • Develop good relationships with RDVMs, establish a Practitioner’s Advisory Board • Hire a Referral Coordinator(s) to deal with RDVM issues • Hire a Marketing Manager for the VTH to market to RDVMs and the public

17. Carry out client and RDVM surveys - to identify areas where improvement is needed • Make clinicians and staff realize they are competing against private specialty practices for caseload, so must give better service • Bring in an outside consultant to help identify how the VTH could be more efficient • Need new faculty to introduce themselves or be introduced to RDVM population by giving CE seminars, and going to local veterinary meetings.

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

19. VTHs might need to start hiring a Hospital Administrator/Director with a MBA, MHA, or similar training. • VTHs need to have a strategic plan, establish benchmarks, have a good financial reporting system. • Clinical Track faculty – good move to hire them but who should pay for them? VTH, Clinical depts.?

20. Suggestion is to take charging away from clinicians, put technicians in charge of billing, but get faculty involved in budget process to increase understanding of where revenue dollars are going to. • Spend less time on student rounds and start admitting cases sooner in the day (earlier than 9:30 or 10:00 am.) • Community Practice Service – good way to get primary care cases, but probably needs to be run like a private practice, not like the rest of the VTH.

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

22. Next Steps That were Taken • A VTH Task force (AAVMC, AAVC, NAVCA) was created in 2004 that worked to prepare a “white paper” addressing concerns for future of VTHs – thought that this paper could be used for local support, consultant backgrounding, and accreditation standards. • A Benchmarking Task force was also created in 2004/2005 – (AAVMC, AAVC, NAVCA) to developbenchmarks that all VTH’s can complete annually and use to determine efficiency of their own model compared to others.

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

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

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