Archives for category: medical


The Vice President, Mike Pence, toured the Mayo Clinic, without a mask, in the middle of a pandemic.

When questioned by reporters as to why he was not wearing a mask in line with hospital policy, a policy that the Mayo Clinic stated that Mr. Pence was aware of in advance in a now deleted tweet, the Vice President stated that he is tested regularly as are those around him and he wanted to be able to “look people in the eye.”

Footage of Mr. Pence’s visit can be seen below.

Later that same day, a question was posed on Quora (where I spend an inordinate amount of time) that got me thinking.

Why didn’t someone in authority at the Mayo Clinic stand up and tell Mike Pence, “If you don’t wear a mask, you are not entering this hospital.” Should that person who was in charge on that day be fired for failing to protect the patients?

A fair question, but one of the reasons the question gave me pause for thought, was that I had faced a similar dilemma a couple of days earlier.

Like most veterinarians, the animal hospital I am Hospital Administrator for is operating locked down – with clients being made to wait in their cars and only patients and staff allowed in the building. In addition, all staff have their temperature taken before entering the building and wear a mask for their whole shift. That policy worked just fine, until the day a client walked into the lobby and refused to leave when asked by staff members.

I was called into the lobby by one of my front desk supervisors. When I arrived, the unmasked client was defiant and refused to leave the lobby when asked multiple times. The client was upset that her dog was sick and currently hospitalized. She felt that it was too hot for her dog to be brought out to her in her car for her to visit with, and therefore was demanding entry to see her dog. I explained that I knew nothing of the situation, and that I would be more than happy to help in whatever way I could, but none of that was going to happen until she left our lobby and returned to her car.

I have had to ask clients to leave the premises in the past, and I have even had to call police to make it happen. As I was talking to this client it was running through my head that I might have to do this again, or at least threaten to, to protect the doctors and staff. However, it was also running through my head that we had a hospitalized patient who was in the middle of treatment. Could the forced removal of a client from the building be interpreted as denial of care? It is doubtful that the client is going to continue their pet’s treatment at our hospital if the relationship breaks down to this point. What happens to the pet? Is the pet well enough for an orderly discharge? What happens if the pet dies either directly, indirectly, or just shortly after being discharged?

All of this with raised voices in the lobby, out of the blue, with no time for refection or the advice of others.

Now, as it happens, the client did return to her car and a quiet chat with the doctor, car side, resolved the immediate issue. But what if we would have called the police and had the client removed from our property, her pet discharged before being even close to well, and things had continued to deteriorate? Review and social media warfare for sure. Local news and / or regulatory involvement? Quiet possibly.

Upon reflection, I would do the same thing again and I actually feel more than ever that even if I had ended up calling the police it would still have been the right call. But I’m sure others would have disagreed. And some of those may have been people that I report to – including the staff it was my aim to protect.

I don’t run an organization anything like the size, or complexity, of the Mayo Clinic and one can’t imagine what it must be like to hold that position, in human healthcare, in the middle of a pandemic. Having a dignitary like the Vice President means national news coverage. It is the kind of publicity that public relations departments were created for. It could mean government dollars, PPE, and access; all of which are sorely needed right now.

If, of course, it goes well.

If it goes wrong, all of that could be in jeopardy and a lot more; The reputation of the Mayo Clinic in the eyes of half of the electorate, for example. As Mike Pence has stated, the risk from him is probably minimal, given the protective bubble he currently finds himself in. The example that he sets, however, is awful. It is an example of “the rules don’t apply to me” because of XYZ – much like my lobby client.

I cannot condemn the administrators at the Mayo Clinic though. Standing up to people because it is the right thing to do, can have serious consequences. Embarrassing the Vice President of the United States would have had serious consequences for the hospital, the staff, and the administrators. Being right is not always a defense from consequence. To make that kind of decision in the heat moment, is an almost impossible. And it is certainly impossible to make it and to not double guess yourself.

The issue reminds me of the incident at University Hospital in Salt Lake City where nurse Alex Wubbels was arrested for not going against a policy agreed upon between the police and the hospital. She would not provide a blood sample without the consent of the patient. The clip below shows Nurse Wubbels on the phone with the hospital administrator, and the police officer concerned, right before her arrest. The arrest of Nurse Wubbels was national news.

All decisions have consequences. In the Alex Wubbels case, the arresting officer was fired, and his supervisor was demoted two ranks. The City of Salt Lake also settled a lawsuit for half a million dollars. But this took serious guts on the part of the hospital, and of course Nurse Wubbels. It would have been so easy to bend the rules for people who you work with routinely, want and need to have a good working relationship with, and even been seen as doing the right thing in many corners.

Being right can often be a balancing act. Second guessing decisions made in the heat of the moment, particularly when confronted by authority, or just someone who is confrontational, is often unhelpful. As managers, we have to fall back on integrity and the momentary weighing of risks.

But the balancing act is rarely black and white.

By Mike Falconer

(Clicking on the image above will take you to Amazon where a tiny percentage goes to help fund my book buying habit.)

“Lean” is a way of thinking about business and business operations based on the Toyota Production Method. Often linked with Six Sigma much trumpeted by GE, Lean focuses more on employee engagement than the statistical analysis of Six Sigma.

A full description of the benefits of Lean, or even Lean Vs. Six Sigma, or Lean Six Sigma are out side the scope of this blog post (for that you can check out the author’s own excellent blog post on the subject of Lean Sigma and Lean plus Six Sigma here.) However, I should probably give some background on why I want to read this book and my interest in lean.

The simple answer is that I had become aware of the short comings of much of the veterinary specific continuing education when it comes to larger hospitals – particularly when it comes to employee engagement and communication. I’ll never forget sitting in on a not very good seminar on internal communication at a veterinary conference and then finding out that the speaker’s hospital had less than ten employees. There is nothing wrong with practices of that size, but the ideas were not scalable – I have supervisor meetings larger than ten people! Because of these issues I started to look to the human healthcare world for ideas and inspiration.

I did this with some trepidation.

Human healthcare has some serous issues and in many ways could learn a lot from the veterinary world – not lease in the use of resources and customer service which seems at times to be virtually non-existent. Having said that, lots of others have similar feelings about human healthcare and there are a number of people trying to make major changes hospital wide.

One of those people that I came across was Mark Graban, the author of Lean Hospitals.

I had been communicating back and forth with Mark over Twitter about healthcare and process issues that interested us both and so I decided to give “Lean” a serious look.

I should make clear, that Lean Hospitals is very much a human healthcare book. For those in the veterinary profession, a significant amount of translation and out right rejection will need to take place. However, for those with large facilities to run and with hopefully a mandate to improve, there is a lot to learn from Lean and the Lean Hospitals volume that I am imperfectly reviewing here.

Lean is about reducing waste. Not just physical waste, but the waste of your employees and your patients / clients time and resources. The general principle is that by harnessing the knowledge of your employees about what they do, and by actually looking at and standardizing how your employees work you can create internal systems that not only save time and money but that are safer for patients and employees. Coupled with this is the idea of a culture of continuous improvement and error proofing of the workplace.

A lot of these ideas will be familiar to anyone who has attended a management seminar in recent years. What seems to make lean and Lean Hospitals different is how it is all held together and that is has real processes and tools for implementation and analysis.

As a book, Lean hospitals takes the form of a workbook, with each chapter giving not only a formal conclusion and lesson points but also a list of questions for group discussion. Although, Mark primarily works in the human healthcare world now, Lean Hospitals is written almost from a lay persons perspective and so the use of human medical terminology or assumption of knowledge of those processes is kept to the bare minimum.

On the downside, Lean as a process, is replete with jargon which mostly takes the form of Japanese words or phrases originally inherited from the Toyota Production method. Although there seems to be no real reason to have to use these terms, other than that some of the ideas need a name of some type, they can be a little off putting and require a certain amount of referring to the glossary (which is excellent!)

Lean Hospitals is also a little expensive for a business book, although cheap by text book standards, but makes up for this by being an excellent read throughout.

The most insightful passage in the book relates that healthcare is full of brilliant dedicated people that daily have to battle with broken systems and goes on to quote Fujio Cho, the Chairman of Toyota Motors: “We get brilliant results from average people managing brilliant systems. Our competitors get average results from brilliant people working around broken systems.”

For those looking for an introduction to the world of Lean, or even just a set of interesting ideas from progressive human healthcare to cherry pick, Lean Hospitals is an excellent starting point.

As House M.D. ends its eighth and final season I wanted to say thank you to the show for a number of things as they relate to my professional world and give it a (little) bit of a hard time for couple of others. I should make perfectly clear that I am a huge fan and that apart from a couple of minor missteps the show has been amazing television. I apologize for any spoilers!

Parasites and Zoonosis

I freely admit that I do not watch a lot of hospital shows. Apart from the odd episode of ER, House is really the only medical show I have had much time for. But House, as far as I’m aware, has had more than its fair share of parasites. From a veterinary perspective this is amazingly refreshing. As someone who seems to spend their life talking about zooanosis to doctors, staff, and the public, it is great to see some worse case scenarios played out in fiction, with a grounding in scientific fact.

Any one remember the episode with the giant tapeworm? I bet if you’ve seen the episode and your pet(s) have ever had tapeworms you won’t soon forget it. Or there is the episode autistic boy with roundworms, the team members infected with Naegleria fowleri, the homeless woman with Rabies, or the woman who catches Bubonic Plauge from her pet dog. Admittedly these are all extreme cases, but the mere fact that they are on television in some ways is a minor miracle considering that most people do not even want to talk about parasites and zoonosis.

So thank you Dr. House for spreading the word about zoonosis and parasites. Every little helps!

The Diagnostic Process

One of the great gifts that House M.D. gave the veterinary, and probably the wider medical community at large, was giving the public a greater understanding of the diagnostic process. Admittedly, House’s methods are often very unsound, but that fact the he and his team regularly are a loss for what is going on is extremely refreshing. We all in the veterinary profession have heard the complaints:

“Why do you have to do that Parvo test?”
“Why do you need that bloodwork?”
“You did that expensive bloodwork and there is nothing wrong!”

Even a casual viewing of House M.D. shows what is supposed to be one of the world’s foremost diagnosticians performing tests that come out negative and going down blind alleys searching for an elusive diagnosis. By bring the diagnostic process into the living room, House has helped acquaint the public with the idea that a certain level of trial and error are to be expected in any evidence based search for answers.

On more than one occasion I have used the show to help explain to a frustrated client why it took three separate diagnostic tools or lab tests to get diagnosis and why we couldn’t just immediately go to the correct one. So thank you Dr. House for helping to shed light on the diagnostic process!

Superstar Bad Behavior

I went into at some length in a post a couple of months back about what I call “The Steve Jobs Effect.” This is this the phenomena of some doctors, and other professionals, feeling that because they are so good at what they do, it excuses almost any level of behavior. Now House M.D. is very much fiction and levels to which the character of House delves would lead to his dismissal by pretty much any employer – never mind at a medical facility. The sarcasm, plain offensive behavior, and even harrasment, does make for great television, but, although it rarely reaches the epic proportions of House – it does happen in real world.

So not so much thanks, Dr. House, for reenforcing the stereo type that great skill can excuse bad behavior!

The Cuddy Episode

Every now and again on a long running T.V. show the writers shake things up by imagining the world they have created from a different perspective. On the show House M.D. this took the form of a very underrated episode from the perspective of Dr. Lisa Cuddy, the Dean of Medicine (Hospital Administrator to you and I).

The episode (5 – 9), shows the administrator doing very administrator type things – facing off with a vendor, placating the Board, dealing with major H.R. headaches (being short staffed and theft). The episode also deals with the thorny issue of billing and a patient who does not feel they should pay their bill (sound familiar). It is great to see these challenges, admittedly extremely exaggerated for added drama, and that these types of issues as just as much the part of running a medical facility as what the viewers watch Dr. House do every week.

I do have a problem with the episode however. After doing a great job of explaining to a patient why their bill is fair, the episode ends with Dr. Cuddy ripping up the patient’s check. I understand that it is supposed to show how kind-hearted the star of the episode is, but it undermines everything she states earlier in the episode. I also don’t buy that the character would do this.

So thank you Dr. House, sort of, for a great episode showing the role of administrators everywhere.

I, like a lot of people, am going to miss House M.D. But I am grateful that we’ve been able to have eight great seasons of television, and even more grateful that an intelligent show has shown some of the issues that I personally and professionally care about. So long Dr. House, for all your faults, we’ll still really miss you.

The wildfires that have been threatening Sierra Vista, Arizona created a epic pet emergency in addition to the human drama.

Dr. Pam Drake and Hospital Administrator Kathryn Honda from New Frontier Animal Medical Center, threw open their doors as soon as the evacuations were announced. By the 17th, New Frontier was looking after 300 pets spread across three locations.

Having run a practice in, and lived in, Sierra Vista and consider Kathryn and Dr. Drake friends, I felt that I needed to help if I could.

The view of the Monument Fire from the New Frontier parking lot.

When I arrived at New Frontier on the morning of 18th the scene that greeted me was on of controlled and cheerful chaos. A loose dog, in the parking lot which I helped to retrieve from underneath a parked pickup truck, seemed to underline the whole morning. After touching base with Kathryn, and finding out how I could help, I headed for the main dog shelter – annex 2. New Frontier’s main building was acting as a triage center and treatment center for any pets that required significant medications. Annex 1, the main cat shelter was an empty office space in a strip mall. Annex 2, the main dog shelter, was behind the main Fedx depot in Sierra Vista. Both annexes had been generously donated by a local property management company.

Annex Two – the carriers and cages had been donated by members of the public.

Although the staff of New Frontier had done a great job of documenting the influx of pets, the sheer volume, inexperienced volunteers and multiple locations had led to multiple lists of pets. My job, for the day it would turn out, was to inventory and create an single list in Excel that the staff could refer to and find pets for the owners and contact owners about their pets. With a population of that size just knowing how many we had and where they were seemed a minor problem until you tried to manage them as a pollution rather than as just an evacuation.

After a 14 hour day, I headed home as the fire seemed to have quieted down and things were very much under control at New Frontier and the two annexes.

Annex Two held 80 dogs and 45 cats

How wrong could I have been.

Due to a previous engagement I spent the 19th in Tucson. In the afternoon, my phone started to go crazy. The wind had dramatically picked up, the fire had jumped the highway and was baring down on both the major boarding facilities that were also acting as shelters – one was evacuated that that day. New Frontier was on pre-evacuation and had taken the decision to evacuate all their evacuees to a third annex. Coronado Veterinary Hospital was evacuated for the second time. My Tucson colleagues who are part of the Southern Arizona Veterinary Managers Group (SAVMG) were already raising the alarm and getting staff and supplies on their way to Sierra Vista, along with my boss who reached out to vendors and other veterinary practices. So off I headed back to Sierra Vista.

The cat room in Annex three

When I arrived, Annex three was already setup, annex one was completely full and annex two had become the central triage center. As night fell the mountains could be seen burning and smoke still covered Sierra Vista. I updated my spreadsheet, spoke to the media on behalf of New Frontier, and worked on a plan of action with Kathryn for the following day(s). I spent the night at Annex three as all the hotels for miles were full of evacuees.

The biggest issue on Monday the 20th was management. Lots of new volunteers, who needed to be trained to handle both unfamiliar dogs and cats as well as how we needed to document. It was also unfortunate that we had a number of volunteers who were comfortable with dogs of whom we had 100, but we had a shortage of cat friendly volunteers and we had 200 cats. Luckily for us, Laurie Miller from AAHA as well as a number of technicians and doctors from Tucson were on hand throughout the morning. They worked tirelessly, and very much got into the spirit of having to make things up as we went along. It was definitely a balancing act between the standards we like to uphold as veterinary professionals – particularly when it came to documentation and at the same time making things easy and friendly enough for the volunteers who were going to be the day in and day out help that would keep the operation running.

Sunday the 19th saw the creation of Annex Three

A scare in the morning of the 20th, brought up the specter of of parvovirus. Although the test was negative, a rush request was put into our SAVMG colleagues in Tucson to see if we could get 150 dose of Bordatella intranasal vaccine as kennel cough was potentially a bigger threat to our hastily thrown together population.

The view from Annex Three

As I left Sierra Vista for the second time it was interesting to reflect on the issues and problems that my weekend had brought up. The complete lack of infrastructure made communications extremely difficult, phones were a huge issue – I spent an incredible amount of time just driving between the various annexes. Facebook became a significant communications channel for both the pet rescuing community and the entire Sierra vista community at large. However, having spotty Internet access (iPhones and iPads) made access a chore with so much else going on.

Considering that New Frontier went from 0 to 300 pets in a matter of a day or two they did a remarkable job, made even more extraordinary that Kathryn and several other staff were evacuated themselves. The entire community pulled together in a quite extraordinary way and the support from our Tucson veterinary community and distributors / manufactures made everything possible.

As I write this much longer blog post than planned, the fires are seemingly under control (60% contained) and the Annexes are beginning to empty. Almost 60 homes have been destroyed and many more buildings damaged and one hopes that this is a once in a life time disaster.

Why we do what we do.


Photos of the fire can be found here:

Since it seems like everyone wants to talk about heartworms in an effort to sell you something, but is rare to hear anything new, it was really refreshing to really be scared by some of the statistics and language being used by the experts.

I was recently the guest of Novartis, the makers of Interceptor Heartworm prevention, at a small two day meeting in Tucson, on parasite control. Speaking were Dr. Noble Jackson from the University of Arizona (U of A) and Dr. Bowman of the Companion Animal Parasite Council (CAP-C).

Dr. Jackson has been looking at heartworm levels in the Coyote population in Arizona and the data is quite startling for those who believe that heartworm does not exist in Arizona. In Pinal County, which Includes Casa Grande where I live, the infection rate Dr. Jackson has seen is 34%. In Cochise county, that includes Sierra Vista where I used to live, the infection rate is 11%.

Now Dr. Jackson’s work is not finished or published yet, and the sample sizes are relatively small – 160 Coyotes for the whole state. But even allowing for statistical anomalies these results make you sit up and take notice.

Dr. Bowman, however, had the most disturbing news to my ears, in that there have been two confirmed cases of heartworms in humans. Heartworm infection in humans is extremely difficult to detect, since it looks a lot like lung cancer (infection shows up as coin sized lesions in the lungs that can only be definitively diagnosed by thoracotamy) and so the actual rate of infection is sure to be significantly higher.

There is currently mandatory reporting of heartworm positive cases in three states, and significant restrictions on exporting positive dogs.

Heartworms are not that scary for dogs, cat or humans compared to a lot of other parasites, the issue is that prevention is so easy and so successful that makes the current epidemic so sad.

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