Today’s consumers, especially those from—or younger than—the Millennial generation, want the convenience of fast, easily accessible information and they have the same high expectations when it comes to the delivery of health care. Telemedicine is an innovation that has the potential to meet these needs in both human and animal health care, and COVID-19 has brought this medical delivery format to the forefront. Unfortunately, challenges still exist in the United States, both in telemedicine usage and acceptance, with laws not yet meshing with today’s reality.
The Human-Animal Bond
The human-animal bond can be a mutually beneficial relationship, influenced by several behaviors that are vital to the health and well-being of both the owner and pet. The role of veterinarians is to augment the potential of this connection between people and animals by supporting the health and well-being of the animal. Many pet owners want the best for their companions, with pets often considered to be members of the family. Because of that, there can be feelings of anxiety when it becomes challenging to provide fully for pets’ needs.
Fortunately, technological innovations have made caring for pets more convenient and accessible than ever in multiple ways. New trends and innovations that first gained a foothold in other sectors, especially those in human medicine, are continually being modified and updated to meet the wants and desires of the multi-billion-dollar global pet industry.
Recent innovations include the creation of a technological ecosystem in which owners have access to reliable pet services. Great examples include BabelBark, which helps connect owners to veterinarians and other services, and Rover, which helps match up dogs to local dog sitters. There are also litter box monitors that track usage, fitness trackers like PitPat and FitBark, which monitor activity levels, and smart food bowls like Obe ProBowl. Meanwhile, interactive technology like CleverPet’s hackerpet can keep pets engaged while owners are gone to help maintain or improve their cognitive health.
As increasing numbers of innovative smart solutions provide convenient and accessible pet care, it is likely that demand and usage of them will also continue to rise.
Disasters and Pandemics
How, though, will animal care be delivered when disaster strikes? Natural disasters and pandemics, such as the current COVID-19 outbreak, pose a huge hurdle as to how the veterinary profession will continue to practice the golden standard of medicine. Fortunately, all states have declared veterinary practice as an essential business that can remain open during the pandemic. But, like most other businesses, veterinary practices have had to adapt. The American Veterinary Medical Association (AVMA) suggests that practices temporarily defer all elective procedures, such as routine annual wellness visits, spays, and neuters, and to use personal protective equipment (PPE.)
Struggles faced by many veterinary practices during this pandemic include staffing issues, lack of PPE, cancellations of numerous appointments, dips in revenue, not being able to pay their bills and salaries, and more.
So, how can the veterinary industry continue serving their clients and patients with as little interruption as possible during current and future crises? Telemedicine.
What is telemedicine?
The Federation of State Medical Boards defines telemedicine as “the practice of medicine using electronic communications, information technology, or other means between a licensee in one location and a patient in another location, with or without an intervening health care provider.”
In veterinary medicine, a license may include primary care veterinarians, specialists, and subspecialists. The information may be used for diagnosis, therapy, follow-up, and/or education, and may include but is not limited to any of the following: patient medical records, medical images, real-time text communication, live two-way audio and video, output data from medical devices, and sound and video files.
Multiple platforms exist in veterinary medicine, which includes ones that can connect primary care veterinarians to clients and primary care veterinarians to specialists/consultants, and can focus on after-hours tele-triage. These may be enterprise solutions or they could be homegrown. Overall, these different platforms can provide improved care in multiple ways that otherwise may not have been available to the client, patient, and veterinarian.
Expected Benefits of Telemedicine
Veterinary telemedicine allows for improved access and convenience to medical care by enabling a client and patient to remain at a remote site. This is crucial in situations like the COVID-19 pandemic in which clients are not allowed to bring their pets in for routine care. It can also aid in breaching the barrier of access to veterinary care to clients who live in remote area, as well as possibly being a more affordable option for clients who otherwise would not seek veterinary care due to financial constrictions.
Telemedicine can also offer more efficient medical evaluation and management. Often times animals do not act the way they do at home when they are being seen by a doctor or technician. Unfortunately, many animals experience white coat syndrome and can be stressed due to the car ride, being in an unfamiliar place, being with strangers, or having had previous poor experiences at a practice.
There are plenty of instances, for example, where animals have been taken to see a veterinarian because of lameness and, by the time the doctor sees the animal, the limping has gone away. Lab results, as another example, can become skewed due to stress felt by the pet. So, why place a patient in situations that are scary or stressful to them when it can be avoided in certain cases? Thanks to modern technology, there are better ways to manage and evaluate many patients.
In addition, obtaining the expertise of a distant specialist can now be possible with telemedicine, no matter where the client lives in the country. Specialists are not typically as readily accessible as general practitioners and now many clients can take advantage of their knowledge and skills in a patient’s care.
Potential Risks of Telemedicine
As with all innovations, there will undoubtedly be an increase in malpractice with the use of telemedicine. For example, before ultrasounds or radiographs, a doctor could have easily missed a specific diagnosis and that could have been considered an acceptable norm. However, as technology has improved and become more readily available, veterinarians are held to higher standards and thus the risk of malpractice is higher.
In telemedicine, such potential risks could include how the information being transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by the veterinarian(s) and consultant(s). Failures of equipment could happen, which could potentially delay medical evaluation and treatment. A breach of privacy of personal medical information could occur if security protocols fail. Plus, a potential lack of access to complete medical records for whatever reason may result in adverse drug interactions or allergic reactions or other judgment errors.
However, the benefits of convenience, efficiency, and easy access for animal health care can far outweigh the potential risks when it comes to the use of telemedicine. When looking at human telemedical care for comparison purposes, a recent Vivify Health survey showed how 83% of consumers are interested in receiving virtual care. Plus, according to the American Hospital Association, 76% of hospitals connect with patients through telehealth and almost every state Medicaid program has some sort of coverage for telehealth services.
Question: What is holding back the veterinary field from jumping with both feet into telemedicine? Answer: the veterinary-client-patient relationship (VCPR) definition. The AVMA currently defines a valid VCPR as one where the following applies:
- The licensed veterinarian has assumed the responsibility for making medical judgments regarding the health of the patient(s) and the need for medical therapy and has instructed the client on a course of therapy appropriate to the circumstance.
- There is sufficient knowledge of the patient(s) by the veterinarian to initiate at least a general or preliminary diagnosis of the medical condition(s) of the patient(s).
- The client has agreed to follow the licensed veterinarian’s recommendations.
- The licensed veterinarian is readily available for follow up evaluation or has arranged for:
- Emergency or urgent care coverage, or
- Continuing care and treatment has been designated by the veterinarian with the prior relationship to a licensed veterinarian who has access to the patient’s medical records and/or who can provide reasonable and appropriate medical care.
- The veterinarian provides oversight of treatment.
- Such a relationship can exist only when the veterinarian has performed a timely physical examination of the patient(s) or is personally acquainted with the keeping and care of the patient(s) by virtue of medically appropriate and timely visits to the operation where the patient(s) is(are) kept, or both.
- Patient records are maintained.
The AVMA also specifically states in Section 5 and commentary of the AVMA Model Veterinary Practice Act that “a veterinarian-client-patient relationship cannot be established solely by telephonic or other electronic means.” A physical exam is necessary in order to establish a VCPR. The U.S Food and Drug Administration (FDA) supports this definition. Individual states do have the authority to define these specific terms more clearly within the definition of VCPR and, as of May 2020, every jurisdiction, except Alaska, Connecticut, Delaware, and the District of Columbia, has spelled out their requirements for a VCPR.
On the other hand, the American Association of Veterinary State Boards (AAVSR) does not believe a physical exam is necessary in order to determine VCPR. In their opinion a VCPR is established when “both the Veterinarian and Client agree for the Veterinarian to assume responsibility for making medical judgments regarding the health of the animal, the Veterinarian has sufficient knowledge of the animal(s) to initiate at least a general or preliminary diagnosis of the medical condition of the animal(s), and the Veterinarian has provided the client with information for obtaining timely follow up care.”
Challenges with the VCPR
The federal standards for a VCPR were put into place to define when and how a veterinarian “legally” becomes the veterinarian for a particular animal. However, laws often trail innovation, especially during disastrous events, and the VCPR challenges are an ideal illustration of how laws don’t always dovetail with current realities. A study in MDPI, for example, showed that over 90% of cat and dog owners had visited a veterinarian at some time, but that only about 40% of them visited a veterinarian annually. These pet owners, for whatever reason, choose to not go to the veterinarian, which means their pets’ health care can go unattended. COVID-19, meanwhile, adds to the challenge.
Here’s something else to consider. Because 81% of Americans that own cellphones have smartphones, they have access to internet-based information to learn about their pet’s health, and some people are likely use this information to self-diagnose their animal companions. The most accurate source of information and medical treatment is not available to them, though, since veterinarians cannot engage with treating a client’s pet via electronic tools without having done a physical exam according to the current VCPR definition.
So, even though telemedicine is readily available to use, the definition of the VCPR is acting as a barrier instead of a doorway to veterinary care for many pet owners.
The Doctor-Client Relationship in Human Medicine
As of October 2018, all 50 states allow for a physician to establish a relationship with a new patient via telemedicine, though state laws differ in their specifics. A few states, such as Alabama, include some caveats to that general rule, restricting the setting in which a patient must be located in order to establish the doctor-client relationship.
Prior to that, in 2014, physicians voted to approve the following definition of a doctor-client relationship in telemedicine. The relationship can be established in a number of ways, including:
1) A face-to-face examination—an exam using two-way, real-time audio and visual capabilities, like a videoconference—if a face-to-face encounter would be required for the same service in person
2) A consultation with another physician who has an ongoing relationship with the patient
3) Meeting evidence-based telemedicine practice guidelines developed by major medical specialty societies for establishing a patient-physician relationship
Once the doctor-client relationship is established, physicians can use telemedicine technologies with their patients at their discretion within their licensed state(s).
Current State of the VCPR Amidst Coved-19
The global pandemic has increased the awareness of the use of telemedicine and its challenges. The FDA and state boards have responded by assessing the VCPR, with the FDR reiterating that the VCPR definition cannot solely be met through telemedicine while also loosening the regulations on extra label drug use in animals. Some state boards, such as in Pennsylvania, have softened their stance on the VCPR, with that state deciding that “during the COVID-19 pandemic, there may be instances when your best medical and professional judgment weighs in favor of establishing a VCPR without an in-person physical examination.”
Other state boards, like in California, have emphasized the importance of the current law with its requirement of a physical exam to establish a VCPR.
Need for Guidance
As telemedicine becomes more customary in veterinary medicine, the need for revised standards and guidelines is evident. During this process, the veterinary field must work through many of the same types of questions and challenges that the human medicine field has needed to deal with. For the veterinary industry, these may include:
- What is the definition of a VCPR in light of the use of telemedicine?
- Will state boards still require a veterinarian to be licensed in the state where the patient resides?
- Can a state board require informed consent forms before a veterinarian can practice telemedicine—and, if so, what should be in these forms?
- What medical cases can and cannot be managed via telemedicine?
- What fees and costs are associated with providing telemedicine services?
- Who is allowed to provide telemedicine services? Is it just the veterinarians or can other qualified staff provide it?
- How will the client’s privacy and security be maintained?
- Will the standards of care for telemedicine be the same as those for in-person examinations and treatments? If not, what differences will exist?
The veterinary field can look towards the American Association of Telehealth (ATA) as well as veterinary groups such as the AAVSB, AVMA’s Telehealth Resource Center, the Veterinary Telemedicine Community Facebook Group, and the newly established Veterinary Virtual Care Association (VVCA) for guidance in helping to answer these questions and establishing standards when it comes to the delivery of veterinary telemedicine.
Telemedicine Becoming a Staple of Pet Health Care
For telemedicine to become a staple of pet health care, each state must hold an open and informed debate amongst the veterinarians that are licensed to practice in that state. The veterinarians need to come to a consensus on the issue of telemedicine and whether a physical exam to establish a VCPR should be mandated by law or left to the professional judgment of the attending veterinarian. Once a general agreement is made, the state associations can reach out to their designated state boards to “lobby the legislature to make the applicable changes. This could be as little as authorizing the use of telemedicine and establishing guidelines for providing telemedicine consultations.”
Tips for Veterinarians
Telemedicine will someday become standard in veterinary medicine. It is no long a question of if, but when. Telemedicine is in fact the hot topic in the industry and is frequently being brought up in forums, along with veterinary news and social media outlets, and is being discussed and debated at conferences. Texas A&M College of Veterinary Medicine has even begun a full-time telemedicine position at their teaching hospital and is pioneering the way of incorporating telemedicine into the veterinary students’ curriculums. Not only are future generations of veterinarians being prepped to make telemedicine a part of their daily practice, but so are pet owners.
As human health care technology advances, so will clients’ expectations when it comes to the care of their pets. There is a change in culture happening. As Millennials and Generation Z consumers have become adults, they have embraced the pet-owning and pet-loving lifestyles to a far greater extent than the previous generation. More and more young adults are putting off having children and are getting pets instead. In the American Pet Product Association National Pet Owners Survey of 2019-2020, Baby Boomers account for 32% of pets owned, while households headed by younger cohorts account for 62% of pet ownership.
Millennials are currently the largest consumer group in the world. One can expect this generation to want the convenience of pet care to be at the tip of their fingers, just as easily accessible as ordering food from Grub Hub, booking a ride with Uber, or buying things in One-Click from Amazon. Veterinary medicine therefore needs to be fast, easily accessible, and readily available.
Since this is the wave of the future, it is best that veterinarians prepare for the changes now. Look at it as practicing preventative medicine instead of reactive medicine. Simply put, adapt, or die.
To summarize the future of telemedicine, Joshua Newman, M.D., chief medical officer, Salesforce Healthcare and Life Sciences, said in a statement that “Patients today are choosing their providers, in part, based on how well they use technology to communicate with them and manage their health. Care providers who build deeper patient relationships through care-from-anywhere options, the use of wearables and better communications post-discharge, will be in a strong position to be successful today and into the future.”
The 1960s were a time of unparalleled scientific
discovery and social experimentation. It seems fitting, then, that in 1964
Δ9-tetrahydrocannabinol (THC) was isolated and defined. Since then, significant
progress had been made in the discovery and understanding of the endogenous
cannabinoid, or endocannabinoid, system.
Endocannabinoids are incredibly diverse in function.
The numerous identified endocannabinoids are known to undergo various methods
of metabolism, with many byproducts themselves being active. Receptors are
found on many cell types and can vary in effect based on factors as mundane as
species, muscle sub-type, and diet. Research has shown both positive and
negative effects of endocannabinoids – they both promote and fight heart and
liver disease; reduce bone development in fetuses and neonates but reduce
osteoporosis in the elderly; and improve female fertility but decrease sperm
quality. To complicate matters further, the effects of plant cannabinoids, or
phytocannabinoids, appear to overlap only partially with endocannabinoids. Our
understanding of the delicate balance in the endocannabinoid system is in its
It is not difficult to appreciate the therapeutic
promise of endocannabinoids and their related phytocannabinoids, most prominent
of which is cannabidiol (CBD). There exists a large, complex, untapped
pharmacological target with many effects. However, it would be prudent to not
outpace our understanding of the endocannabinoid system. Few in vivo studies have been performed in
humans and even fewer in our core veterinary species. From what we do know of
our veterinary species, cannabidiols may be metabolized differently and into
different metabolites and CBD has low bioavailability with oral administration in
dogs likely due to poor absorption and a large hepatic first pass effect. The
argument should not be if CBD has therapeutic effects but if CBD products can
and should be recommended or sold.
AND DRUG ADMINISTRATION
The only FDA (Food and Drug Administration) approved
CBD product is the seizure medication EPIDIOLEX®. Although found to be
effective and safe enough for approval, the FDA noted many unknowns in the
summary review of the approved new drug application. Animal models used for
toxicology studies may have been inappropriate as their metabolism of CBD
produces different byproducts than those of humans. Peak drug concentrations
could be up to five times higher if the product is taken with a high-fat meal.
Product usage increased liver enzymes in a dose-dependent manner. There was
limited review of concomitant drug interactions.
The pharmaceutic industry seeks to assure the
identity, strength, quality, purity, and potency of drug products. The FDA is
tasked with assessing investigational new drug applications (INDs) and new drug
applications (NDAs) for safety and efficacy. Pharmaceutical companies submit an
IND after completing research, development, and pre-clinical toxicology
testing. After approval of an IND, the company can begin testing on humans:
Phase 1 clinical testing for safety, Phase 2 for efficacy, and large-scale
Phase 3 for population and dosage variation with consultation from FDA. Should
the drug continue to appear promising, the company will submit an NDA for FDA
review. The FDA will assess the data, labelling, and production facility prior
to granting approving for the new drug. The new drug will be approved only at
specific dose(s) for specific condition(s) under certain manufacturing
While the FDA thoroughly reviews drug products,
oversight of supplements is more limited. In fact, supplements, in most cases,
do not need approval prior to being sold. There is no review process to ensure quality
and efficacy, determine appropriate dosages, and ascertain interactions and
side effects. FDA resources are not leveraged against supplement manufacturers
unless they are investigating adverse effects, reported issues, adulterated
products, or false claims. A supplement may not “claim that it will diagnose,
cure, mitigate, treat, or prevent a disease” – by making those claims a
supplement becomes a drug in the eyes of the FDA. Additionally, the FDA does
not recognize animal supplements – only animal drugs and foods.
FDA personnel have been closely monitoring the CBD
industry. Manufacturers are claiming CBD supplements are entirely legal because
the Farm Bill removed hemp, or cannabis with less than 0.3% THC, from the
Controlled Substances Act. Manufacturers neglect to realize that the Farm Bill
did not change the FDA’s duty to regulate drugs and supplements, nor the
definition of a supplement. Adding a substance approved as a drug – in this
case, CBD – to a supplement means the supplement has either been adulterated,
and should be removed from the market, or it is truly a drug product that must
seek FDA approval.
Some manufacturers push the envelope further by making
explicit or implicit therapeutic claims of their supplement products. Recall,
therapeutic claims can only be made for approved drugs. A quick internet search
of animal marketed CBD products yields claims such as “alleviating allergies”,
“treating a range of disorders”, “does no harm to the kidney, liver, or GI
tract”, “stimulate deep tissue healing”, “reduce itchiness and rashes”, and
“reduce the anxiety experienced by many animals.” Some products do not have
claims but vaguely suggest a product may be good for an animal with a certain
condition. There does not appear to be a well-defined line in the sand of how
much you can say, but keep in mind that the FDA defines a drug this way:
- A substance recognized by an official
pharmacopoeia or formulary.
- A substance intended for use in the
diagnosis, cure, mitigation, treatment, or prevention of disease.
- A substance (other than food) intended to
affect the structure or any function of the body.
- A substance intended for use as a
component of a medicine but not a device or a component, part or accessory of a
- Biological products are included within
this definition and are generally covered by the same laws and regulations, but
differences exist regarding their manufacturing processes (chemical process
versus biological process.)
The FDA is quick to act, however, when obvious and
distinct claims are made of CBD products. Take as an example Curaleaf, who
received a warning letter from the FDA in 2019 regarding claims made for both
human and animal CBD products. The FDA determined that based upon therapeutic
claims made the CBD products were unapproved new animal drugs. These claims
included “pain relief”, “relief of muscle spasms”, and treating “diabetes.”
Claims were not only made in product descriptions, but also on company blogs
and social media accounts. Other warning letters include quotations from
consumer testimonials and claims that may appear vague.
The legality of CBD products is further muddled on a
state level. In decriminalizing and/or legalizing hemp or marijuana products
for people, states have presented a message inconsistent with the FDA’s. Some
states believe that regulatory changes will lead to agricultural gains. Manufacturers
and suppliers may feel sheltered by state or local laws and look to market
products with therapeutic claims. In fact, the FDA itself states that it may
consult with state partners prior to pursuing enforcement against offending
products and that it “supports researchers who conduct adequate and
well-controlled clinical trials which may lead to the development of safe and
effective marijuana products to treat medical conditions”.
States that have approved human medical usages of hemp
or marijuana products were obligated to ensure human physicians could determine
a patient might benefit from the product. Human physicians became sheltered
under select state laws and are now able to openly discuss and recommend or
prescribe CBD products. In some instances, states may require a human physician
provide written documentation for patients.
However, veterinarians and animals were excluded in
state medical marijuana laws. California attempted to fill the legislative gap
in 2018 by allowing veterinarians to discuss CBD within a valid VCPR
(veterinarian-client-patient relationship) but forbids administrating or
dispensing any product for an animal patient. The AVMA (American Veterinary
Medical Association) notes FDA approved product usage is allowed in an
extra-label fashion under AMDUCA (Animal Medicinal Drug Use Clarification Act)
in select circumstances. Should the patient be a food producing species,
veterinarians must attempt to determine withdrawal times.
Veterinary medical associations are aware that
veterinarians have been placed into a difficult spot. Clients can obtain
products for themselves – sometimes at their doctor’s suggestion – and know of
animal CBD products. Clients want to discuss CBD with their veterinarian and
veterinarians want to provide their professional opinions. Medical associations
have tried to cautiously weigh in on the topic. The AVMA dodges the discussion,
stating that non-FDA products are not known to be safe or effective. The
Colorado Veterinary Medical Association notes an increase in toxicities but
suggests conversations can occur within a VCPR. Unsurprisingly, the California
Veterinary Medical Association allows veterinarians to discuss CBD products,
noting that administration is still illegal. The Michigan Veterinary Medical
Association vaguely states there may be increased legal risk if things go wrong
and that they will not recommend something until the FDA says it is safe. Some
states – such as Connecticut, Missouri, and Tennessee – are attempting to
prevent medical board disciplinary action if a veterinarian discusses CBD. Ironically,
the FDA advises consumers interested in pet CBD products to consult with their
It is entirely reasonable that a veterinarian seems
confused about what prudent actions can or should be taken. It is obvious to
the FDA, clients, and veterinarians that there is therapeutic potential in CBD.
Veterinarians want to find new ways to care for their patients and assure their
position as an authority source. However, they are not legally shielded, and the
legality of available products is questionable.
Thankfully, the FDA has committed to clearing the air.
The FDA is on the record saying they want to make regulatory approval more
efficient for CBD products and are actively considering ways to allow marketing
of non-drug CBD supplements and foods. Agency representatives regularly give
very transparent speeches which are posted on the FDA webpage. They reaffirm
the FDA’s goal of providing a layer of safety and reliability for both the
prescriber and the patient in all products and look to obtain the same
assurances for CBD products. It would be wise to pay attention to the FDA
updates that will surely be coming – the FDA is active on social media.
The FDA is more than willing to partner with research
institutions to learn more about the pharmacokinetics and pharmacodynamics of
CBD. Veterinary schools are leading the charge to find out how and how well CBD
products work for dogs. For example, UPenn’s (University of Pennsylvania)
School of Veterinary Medicine is currently performing a double-blinded study on
the effects of a CBD product on dog mobility. This study, along with most other
similar studies, is sponsored by the product manufacturer. Veterinarians should
be skeptical of sponsored studies and thoroughly evaluate study methodology,
results, and conclusions, but can look forward to learning more about the
efficacy and side effects of specific products.
Despite all the uncertainty, many clinicians are
interested in making specific product recommendations or stocking CBD items.
Veterinarians need to make themselves aware of the most current information regarding
safety of CBD and the efficacy, purity, and stability of the product they
promote. It is important the product does no harm to the patient and is not an
unwise expense for the client. Consider things such as:
- How pure is the product?
- What pesticide residues are present?
- Are there heavy metals or solvents in
- What additives are in the product?
- How does the product need to be stored?
Will it go rancid?
The product selected should be reviewed for unapproved claims – on the product,
on product packaging and literature, on the webpage, and on social media –to
limit risk of product shortage due to FDA enforcement actions or liability.
Many other unknowns plague veterinarians carrying CBD
products. State laws and medical boards offer very little protection, but we do
not know how this will change in the future. Laws, both local and federal,
influence insurance coverage and banking services. It remains unclear if
veterinarians assume risks that are not covered under the insurance policies or
if other policies, leases, and banking agreements would be violated by carrying
and selling CBD products.
Although the prospect of CBD products is great, there remains much that is unknown and unclear. The legal landscape is ever evolving. A prudent veterinarian will watch FDA, legislative, and medical board actions, review current literature, and will consider all risks associated with discussing, recommending, stocking, and/or selling products. They will not be tricked by the smokes and mirrors of opinions but make decisions based upon facts and consideration of risk.
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- Ashley, D. (2019, July 22). Warning Letter Curaleaf, Inc MARCS-CMS 579289 — JULY 22, 2019. Retrieved from FDA: https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/warning-letters/curaleaf-inc-579289-07222019
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- Di Marzo, V., & Piscitelli, F. (2015). The Endocannabinoid System and its Modulation. Neurotherapeutics, 12:692–698.
- Dixie Brands, Inc. (2019, May 28). Clinical Trial at the University of Pennsylvania’s School of Veterinary Medicine to Study Effectiveness of Cannabinoids to Treat Dogs for Joint Immobility Using Dixie Brands’ Therabis Formulation. Retrieved from https://dixie.mediaroom.com/2019-05-28-Clinical-Trial-at-the-University-of-Pennsylvanias-School-of-Veterinary-Medicine-to-Study-Effectiveness-of-Cannabinoids-to-Treat-Dogs-for-Joint-Immobility-Using-Dixie-Brands-Therabis-Formulation
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- FDA. (2019, October 16). FDA Regulation of Cannabis and Cannabis-Derived Products, Including Cannabidiol (CBD). Retrieved from https://www.fda.gov/news-events/public-health-focus/fda-regulation-cannabis-and-cannabis-derived-products-including-cannabidiol-cbd
- FDA. (2019, April 2). WARNING LETTER Advanced Spine and Pain, LLC MARCS-CMS 565256 — MARCH 28, 2019. Retrieved from https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/warning-letters/advanced-spine-and-pain-llc-565256-03282019
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- MVMA. (2019, March 11). MVMA Statement on Medical Marijuana, Hemp, and CBD. Retrieved from https://michvma.org/news/7217306
- Neurogan. (n.d.). CBD Horse Massage Oil 1000mg – Topicals for Horses | Neurogan. Retrieved from https://www.neurogan.com/cbd-products/for-pets/horse-massage-oil/
- ProCon.org. (2019, July 24). Legal Medical Marijuana States and DC: Laws, Fees, and Possession Limits. Retrieved from https://medicalmarijuana.procon.org/view.resource.php?resourceID=000881
- Pure Hemp. (n.d.). CBD Pet Shampoo – 20mg — Pure Hemp. Retrieved from https://purehempshop.com/products/pet-shampoo
- Samara, E., Bialer, M., & Mechoulam, R. (1988). Pharmacokinetics of Cannabidiol in Dogs. Drug Metabolism and Disposition, 16(3): 469-472.
- Schiller, L. (2019, August 13). Remarks at the National Industrial Hemp Council 2019 Hemp. Retrieved from FDA: https://www.fda.gov/news-events/speeches-fda-officials/remarks-national-industrial-hemp-council-2019-hemp-business-summit-08132019
Imagine you’re a practice
owner, and your practice currently has a 12-year history of consistently
grossing $1.5 million—and is actually on track to earn upwards of $2 million
this year! You have three exam rooms and three certified veterinary technicians,
and you’ve just hired an ambitious associate veterinarian to bring your total
up to three full-time associates, with plenty of support staff. Your practice’s
operations are clearly excellent and the camaraderie is there but, you’re
ready. You’ve decided that enough of your life has been dedicated to the
prosperity of your practice and you want to enjoy the remainder of your life
with your family. You have made the decision to sell your practice.
meet with an attorney, create your practice’s profile, and garner the attention
of many corporate consolidators (CC) and private contractors (PC). Prior to
entertaining any offers, your attorney asks you about your plans, including
whether you’d like to remain involved in the practice, post-sale. You respond,
“I think I want to retire altogether. I love my practice and my staff, and I’ll
visit from time to time, but I’m pretty sure I want to spend the rest of my
time with my family.” Your attorney then asks about the property and you are at
a loss; you thought that once you sold the practice, the property would be sold,
too. Your attorney informs you that this is not the case and sends you home
with homework to complete, something you haven’t had to do in quite some time. Now
you have to ponder about what you want to do with your real estate if you sell
you want to relinquish or retain ownership of the real estate?
This is the first
question that any facility owner who also owns the property needs to answer
because this will dictate what language will be used in letters of intent
(LOI). You’ll need to determine whether you want to retain the ownership of the
property and lease it to the future buyer or sell the property.
If you’re looking to
relinquish ownership of the real estate, then you’ll need to determine how and
when this will change hands—and if this is your plan, then the remainder of
this article will be purely informational. On the other hand, if you want to continue
to retain ownership of the property and become a landlord, then you should continue reading.
As a third scenario, if
you currently lease your property from a third-party landlord, then your
responsibility is to inform the buyer about your current lease’s terms and help
to facilitate the transfer of the contract from your name to theirs.
the composition of the lease?
from this point on, that you’re the owner of your property and you want to
lease it to the buyer, here’s what might happen next. Typically, the buyer will
present you with a drafted lease with their terms—which likely represents their
interests—and you will have to negotiate from there. Since this will be a
steady stream of income for you, we’ve provided you with information to maximize
the revenue you’ll receive.
For clarification purposes:
“Buyer”/“Tenant” = Buyer of your practice;
“Seller”/”You” = Practice Seller & Property Owner/Landlord
Terms & Renewals
discussing the value of a lease to buyers, you’ll have to think long term,
literally. Most buyers, especially the CCs, express interest in having an
initial 10- to 15-year lease to retain a firm grasp on the practice’s property and
to ensure longevity. This may differ for PCs. You could add more value to the
lease by giving the buyer options to renew at five or ten-year increments. This
assures continued operations for the practice, allows for early renewal
negotiations, and makes it easier for you to refinance the property, if need be.
Now, depending upon your terms, you should determine how much you will charge the
buyer for rent. Typically, rent is calculated as the sum of the base rent and
additional rent, but you should also consider the valuation of your property. That’s
because the fair market value (FMV) of your property may help to drive the base
rent that you set for the buyer.
to a base rent can represent a risk for both you and the buyer. Here’s why. Your
initial lease term would be dictated by the FMV or, rather, the price your
property would sell for on the open market; however, the FMV excludes the value
your practice adds to the property. Zach Goldman, owner of the real estate investment
trust (REIT) company, Handin Holdings, states that the valuation of a piece of
real estate is therefore equal parts of art and science. It involves noting the
global picture along with (1) the structure of the specific building, (2) the
real estate market of the area, (3) the quality of the practice’s operations,
and (4) the economic reliability of the tenants (i.e., will they be able to pay
how you value your property isn’t necessarily how others will perceive its
value. As a practicing veterinarian and owner of the practice, you’ve undoubtedly
worked tirelessly to ensure the prosperity of your clinic. The sacrifices
you’ve made and the time you’ve spent developing the practice to bring it where
it is today, though, doesn’t necessarily add much value to the property itself.
Daniel Feinberg, vice president of finance at the REIT company, TerraVet
Solutions, notes that a common misconception they face when speaking to
veterinary practice owners is that they are often infusing their personal
experiences into the property value. He advises all future practice sellers to
work with REITs, like TerraVet, to help determine the value of their properties
from an objective lens; this way, as a seller, you can work on adding value to
your property prior to entertaining offers.
Once you’ve appropriately
valued your property, you can then determine how much you should charge for
your initial term of the buyer’s lease. We advise that you read the terms of
the lease provided by the buyer very carefully; CCs will typically request a
“reset to FMV” once it’s time for them to renew their lease. This can
effectively eliminate cash flow certainty during the renewal periods and,
clearly, this does not always work in your favor. Whether or not this will be
advantageous to you is highly dependent upon a number of factors, including
your geographic location. Typically, if an FMV reset is included, then an
appraisal will be needed. If you aren’t sure whether this would negatively or
positively impact you, you could create appraisal rules and limitations to
include within your lease. You’ll want to answer questions that add clarity to
and substantiates the FMV reset; these are questions such as:
- What appraisal method will be used and who
will be conducting the appraisal? Your choice or buyer’s choice?
- How will the future rent be determined?
Will it be based on the property’s best or highest value?
- Will the FMV-based rent take into
consideration the practice’s value?
These are only a few
questions that will need to be answered and you can find more information by
contacting your real estate attorney or a REIT company.
rent is the amount charged to the buyer to simply occupy the premises. It can
be calculated in a variety of ways, with the two most common methods being the
- Based upon a percentage of a tenant’s
gross revenues: This will complicate the lease because the lease parties need
to agree on (a) the method used to calculate the practice’s gross revenues; and
(b) a process to resolve disagreements.
- Based on dollars per square feet, with “square
feet” able to be defined in a number of ways: Most commonly, leases charge a
dollar per foot of either the “rentable space” or the “rented space.” The
former results in a higher rent, but will likely be refuted—and, therefore, the
latter will be more easily accepted. No matter what standard is used, you will
need to clearly define square footage.
you choose the first or second option to calculate base rent, you will likely
need to negotiate specific.
rent,” meanwhile, comprises all other costs, usually related to the facility’s
operations, that your buyer is required to pay you in addition to the base rent.
Such costs could be a security deposit (often one to three months’ rent) and
reimbursing the landlord for property taxes (monthly or quarterly). In most cases, the buyer doesn’t pay the property
taxes directly; this would typically be handled by you and then you would be reimbursed
by the buyer. You could, however, require the buyer to pay you an estimate of
property taxes monthly or quarterly in advance, subject to an annual
reconciliation mechanism. This would consolidate the buyer’s payments while
concurrently allowing you to receive a portion of the property tax amount in
of Net Leases
net leases help to define the relationship and responsibilities between the
buyer and seller. The type of net lease—single, double, or triple—determines
whether the buyer will pay, in addition to the rent, any of the following three
expenses: property taxes, property insurance premiums or maintenance costs. You
can equate the type of lease with the amount of responsibility, in addition to
the rent, that the buyer will have. Single net lease requires the buyer to be
responsible for property taxes, a double net lease will require the buyer to
pay for taxes and insurance premiums, and a triple net lease will require the buyer
to pay for all three additional expenses.
goal is to minimize your responsibilities as a landlord as much as possible. Therefore,
most leases are triple net leases. Reducing your responsibilities increases the
likelihood that the buyer will negotiate with you on topics like rent during
the initial term of the lease, liability insurance requirements, and a host of
other things. Your best option would be to require a triple net expenses lease while
only being required to cover the maintenance and replacement costs of the
property’s structural components, such as a roof replacement or maintenance of
the property’s foundation.
increases can be considered the norm in most veterinary practice leases today.
These escalations are usually based on the Consumer Price Index (CPI), produced
by the Bureau of Labor Statistics (BLS), which is essentially an average price
measured over a time range. The CPI allows for you to adjust the buyer’s rent
to accommodate the price change of the current real estate market. Most
commonly, the escalation is represented by a percentage increase over a specified
period of time. Although you are able to determine a percentage and offer it
within the lease, we typically see a two to three percent increase annually.
You can think of this as a compounding scheme whereas you will establish the
base rent for the initial year of the lease, and each year after the buyer will
pay an additional percentage. To illustrate, here is an example:
have the buyer pay a base rate of $25,000 annually during your initial ten-year
lease. However, you will add the caveat that states how there will be a two
percent escalation that will be applied to the base rate annually. This type of
increase would result in the tenant paying nearly an additional $41,000 at the
conclusion of their ten-year lease term.
provides a better, more stable and predictable method of forecasting what
income you will receive from the buyer. Ideally, you’ll consider their rent in
conjunction with the buyer’s responsibilities as a tenant, so you need to also consider
what kind of net lease you’d prefer for the buyer to have.
addition to your lease, you can also request an annual financial report of the
practice. While most landlords don’t request this information, there are many
reasons why you should. Annual financial reports allow for you to gauge the
operations of the practice and determine whether the buyer will be financially
self-sustaining. When requesting the financial reports from the buyer, they
should typically provide you with a balance sheet, profit and loss statement,
and a statement that acknowledges any changes in the financial position as well
as any supplemental details to explain the change. These combined reports will provide
an overall view of the financial well-being of the buyer, as well as assure you
of their financial stability throughout the lease term(s).
seems like a very clear and straightforward issue, right? We generally assume that
the buyer will provide the guaranty, but who exactly is the buyer? In this day and
age when most of the CCs are owned by a larger corporate parent, you have to
ensure that the buyer who is purchasing your practice can provide a guaranty
for your lease. The company backing your lease could range from, say,
Midwestern Pet Hospital, a single hospital with a limited, regional reach, to Animal
Hospital Operations, a generally well-known company with multiple hospital
ownerships. If you did your due diligence, you would discover that Animal
Hospital Operations is owned by Krispy Kreme, a company with the financial
assets to assure you they are committed.
order for Krispy Kreme to provide you with stability, using that example, you
would need to confirm that their name is listed in the lease agreement. In
comparison, a review of financial statements shows that Midwestern Pet Hospital
has had a fluctuating history of financial stability and only within the past
three years has begun producing competitive revenue. Which buyer would you
choose to back your lease? You’d likely selected Krispy Kreme and rightfully
so. The point here is that you should always ensure that the buyer can either
provide a corporate guaranty from their parent company or can provide enough
evidence to convince you that they can uphold tenant responsibilities and,
essentially, foot the bill.
assignment clause in a lease essentially allows for the tenant to transfer the
lease, and all associated tenant responsibilities, to a different entity.
However, this is typically an area that you as the landlord will want to
specify and limit. Commonly, CCs like to freely transfer their leases to any
affiliated entities, which would almost certainly diminish the value of your
property for multiple reasons. First, if the buyer was allowed to sublet or
freely assign the lease, then they would receive the revenue generated from the
sublet, not you. Second, if the tenant isn’t up to par, then the value of the
property itself could be driven downward. Therefore, it’s in your best interest
to add provisions to prevent this free assignment. For example, you can
negotiate by stating that the buyer can only assign their lease to a guarantor
with a net worth that is equal to or greater than the existing guarantor. This
ensures that your property’s value does not decrease and that the tenant
responsibilities are financially accounted for.
there any outstanding rights of first refusal or offer (ROFR/ROFO) with your real
ROFR and ROFO concept can be off-putting for many buyers and could severely
diminish the quantity of offers you may receive. To explain, there are many
variations on a theme when discussing ROFRs and ROFOs, but they all center on
the fact that, as the seller, if you receive an offer to purchase the property,
you are legally bound and required to send notice of the full offer to whomever
holds the ROFR/ROFO. If the offer is incomplete or if you don’t give the holder
sufficient notice of the offer, you have now made yourself, as the seller,
vulnerable to one of two scenarios:
- being sued for failing to protect the
rights of the ROFR holder
- losing the interest of the buyer because
the ROFR holder didn’t respond or didn’t receive the notice of the full offer
with enough time to respond
some instances, there’s the ROFO, which is currently defined as “an offer made
in good-faith” by the seller. This means that the seller will inform the holder
of a reasonable offer before any official listing of the property or
entertaining of such offer. The holder can either refuse or accept the offer. With
a right of first refusal, the ROFR holder can opt to match or counter the
buyer’s offer. This leaves you vulnerable to losing your initial buyer’s
interest because the buyer won’t, or can’t, raise their offer to purchase the
estate. Your practice facility’s future is subject to the demands of the holder.
You can choose to accept their offer or remain the landlord. As you can see,
the impact of the ROFO/ROFR can be quite significant; therefore, you should carefully
review any and all documents for such a clause.
are your expectations of the buyer?
a practice owner preparing for the next step, it is important that you think
about your lease, your practice, and your future, post-sale. You have to
determine what responsibilities you are expecting the buyer to take on and be
willing to negotiate those from the
very beginning. Knowing what terms of your lease are non-negotiable from
your perspective before you begin the bidding process could prove to be
advantageous because you can provide them with your terms and negotiate from
there. With respect to the lease obligations, the buyers can’t change the terms
of the deal or alter the purchase price later in the process because you’ve
already informed them of your lease terms and have negotiated the obligations
at the start. Informing your buyers of what the lease terms are in the
beginning and having that full transparency gives you the most leverage to
guide the conversation how you see fit.
what does all of this mean?
are numerous points to consider prior to the sale of your practice to prepare
you for negotiations. The process of
selling your practice can be long, and it can easily be extended if you have
not addressed your personal, practice and/or property needs. Many sellers are
not prepared to deal with a facility lease when they sell their practice, but
doing your homework now can give you the knowledge and confidence to negotiate
a lease with your buyer that will benefit you for years to come.
- Lacroix, Charlotte. “Property Lease
Dangers, Part I” | Real Estate, 2012, Veterinary Business Advisors, Inc. http://veterinarybusinessadvisors.com/wp-content/uploads/2016/07/Property_Lease_Dangers_Part-1_2012.pdf
- Lacroix, Charlotte. “Property Lease
Dangers, Part II” | Real Estate, 2012, Veterinary Business Advisors, Inc. http://veterinarybusinessadvisors.com/wp-content/uploads/2016/07/Property_Lease_Dangers_Part-2_2012.pdf
- Lacroix, Charlotte. “Negotiating a
Commercial Lease” | Real Estate, 2018, Veterinary Business Advisors, Inc. https://veterinarybusinessadvisors.com/negotiating-a-commercial-lease/
Gregory G. “A primer on real estate options.” Real Property,
Probate and Trust Journal (2000): 129-195.
Lowell, ed. Blackwell’s five-minute veterinary practice management
consult. John Wiley & Sons, 2013.
- Bank, LiveOak. “Veterinary Acquisition Due
Diligence.” Veterinary Practice Acquisitions | Due Diligence Services |
Mergers, 2017, www.veterinariancpas.com/acquisition-due-diligence.htm
- Stein, Joshua “The Most Important Issue in
Every Ground Lease: Rent Resets and Redeterminations, Fair Market and
Otherwise” New York State Bar Association | Real Estate, 2018, http://www.nysba.org/WorkArea/DownloadAsset.aspx?id=86403
- McCormick, David; Mamalis, Leslie.
“Monitoring Practice Profitability” Veterinary Hospital Managers Association
2013 Annual Conference, https://cdn.ymaws.com/www.vhma.org/resource/resmgr/imported/MonitoringPracticeProfitablityfinal.pdf
- Bank, Live Oak. “Veterinary Practice
Acquisitions Guide 2018” Veterinary Practice Acquisitions | Acquisitions, 2018,
Bureau of Labor Statistics. “Writing an Escalation Contract Using the Consumer
Price Index”. Real Estate. November 2012. Beyond the Numbers, Volume 1, Number
Most people today have social media accounts that they use to keep in touch with friends, to read the news, to scroll through pages of cute animal pictures and more. We also use online resources to make everyday decisions, including choosing doctors, restaurants and movies. Today, virtually every service, from hair dressers to plumbers and beyond, is chosen in part based upon their online ratings and reviews. In fact, 72% of customers say they rely heavily upon online reviews when choosing services.
As a consumer, this can seem like a great way to weed out poor choices and find the best service. In fact, 87% of consumers say that a business needs a rating of at least three stars for them to even consider using them.
From the business owner’s point of view, though, these reviews can cause frustration, especially the negative ones which even have the potential to impact self-esteem. As veterinarians, for example, most of us feel that we have provided reasonable levels of service to our clients. Therefore, we can be shocked to see how our service has been construed by a client in a negative review.
Mrs. Smith calls Corner Veterinary Hospital, asking for a refill of Fluffy’s metronidazole. The receptionist informs Mrs. Smith that Fluffy hasn’t been seen by a veterinarian for two years and, if Fluffy is not feeling well, she should be examined by a veterinarian. Mrs. Smith becomes angry and refuses the appointment. Later that day, Mrs. Smith posts a Yelp review that Corner Veterinary Hospital refused to give Fluffy her medications and is run by money-grubbing veterinarians who just want an excuse to get more money from her.
Susie works for Dr. Johnson at Corner Veterinary Hospital. Susie is eventually terminated for excessive absenteeism. A few days later, Suzie posts a Facebook review that Corner Veterinary Hospital is filthy, Dr. Johnson doesn’t actually know what he’s doing, and he orders unnecessary treatments to make more money.
Naturally, Dr. Johnson and Corner Veterinary Hospital become indignant with such representations of their character and services. What options does the practice have for combatting such reviews?
In general, online reviews can either be ignored, responded to, or alternatively, the client can be sued for defamation. When deciding how to respond, it’s important to consider that the practice’s current clients have already formed their own opinions from their own personal experiences, and are less likely to be significantly swayed by a single negative review. Any recourse should therefore be taken with the potential client’s viewpoint in mind.
Choosing Among Options
The first option is to not respond at all. In general, if a practice has numerous positive reviews and only a few negative ones, potential clients who are deciding whether or not to use the practice will be less likely to be swayed by the negative reviews. In that case, most potential clients will accept the fact that some people will never be satisfied. A few politely-worded negative reviews can actually make the reviews of the business seem more authentic overall and, fortunately, potential clients can typically recognize highly unreasonable people.
It can be tempting to want to remove negative online reviews from a website, especially those that are more extreme. In many situations, this attempt may be unsuccessful, but there are some steps that can be taken. If the review appears on the veterinary practice’s Facebook page, for example, then the offending party can be blocked from the page so that any comments will not be viewable. Also, the Facebook review feature can be turned off entirely, although this will also remove all positive reviews, too. If the review appears on websites outside the control of the practice, and it is grossly inaccurate, some websites can be contacted to have the post removed, but this is often not successful.
Some practices ask acquaintances to post positive reviews to skew their ratings. Sites such as Yelp have mechanisms in place to identify and filter out reviews from friends and family and, on general principle, this should be avoided altogether. A better method is to encourage current clients to leave online reviews; although it is not ethical to ask them to write positive ones, it is acceptable to request reviews from clients who had quality experiences at the practice.
Under certain circumstances, veterinarians who feel they have been wronged will want to defend their names and reputations. After all, it’s hard to sit back and watch yourself be misrepresented online. Many people therefore feel the urge to respond to these reviews and clarify facts of the situation. Veterinarians, however, need to be aware that responding to such posts with the specifics of the situation may violate patient privacy laws. So, what can you do? Some practices try to proactively protect themselves by having new clients sign a statement saying that they waive the right to patient privacy in the case that the client posts a negative review.
Unfortunately, such a waiver would not be protective in court. Since the waiver is signed before any incident would occur, that client would not have had all the facts needed to waive his or her rights to privacy.
According to the AVMA, “veterinarians and their associates must protect the personal privacy of clients, and veterinarians must not reveal confidences unless required to by law or unless it becomes necessary to protect the health and welfare of other individuals or animals”. In other words, providing information in response to a negative review that could identify the client or patient could be a breach of privacy. At best, the practice could use the occasion to clarify their standard policies.
In addition to legal concerns, any reply to such a review could be perceived as inflammatory and defensive in tone by potential clients. Again, it’s important to remember that the Google-search audience is comprised of potential clients who are trying to decide which veterinarian would be best for Spot. A negative review may be considered more interesting, and is more likely to be read by a potential client when it has a reply from the practice.
If read, then the tone and impact of the reply is the potential client’s first insight into the personality of the clinic. If the practice seems defensive and unwilling to take responsibility, then the potential client may perceive the clinic as being hard to work with and one that’s not looking out for the client’s best interest. Any attempt to set the story straight can sound like arguing and create an unpleasant impression to the client.
That doesn’t mean that the review must be ignored entirely. Perhaps the practice doesn’t have many reviews and this one long and negative review thereby seems glaringly obvious. If the practice feels the need to respond, a generic but specific reply can be posted, such as the following:
Hi Mrs. Smith. We’re sorry to hear about your experience at Corner Veterinary Hospital. Please call Barb, our office manager, at (xxx)-xxx-xxxx so we can address your concerns.
This style of reply doesn’t break any patient confidentiality, can make the client feel as though he or she has been heard and, perhaps more importantly, provides an empathetic tone for potential clients to see. A good reply includes some expression of empathy, the specific name and phone number of the contact person, and an invitation to a private conversation.
The possible outcomes of this are three-fold. The best-case situation would be that Mrs. Smith does call Barb, hears an explanation and is satisfied with the conversation. In that case, she might remove the review or edit it to a positive. The next best situation is where Mrs. Smith calls and is reasonably satisfied but makes no changes to the review. The worst situation is where Mrs. Smith calls, but is still unhappy with the outcome, and makes further negative posts.
To help prevent this last situation from occurring, make sure the contact person is reasonably available and has the knowledge and authority to address the concerns. If Barb is only available every other Tuesday from 10:00am-12:00pm, Mrs. Smith will likely become even more annoyed. If Barb doesn’t understand the policy enough to defend it or doesn’t have the authority to make any reasonable accommodations, Mrs. Smith will likely be just as frustrated in the end, or even more so.
Ultimately, you can do your best to resolve these types of situations, but keep in mind that there are some clients who will never accept that things cannot be done their way. Since, by law, Fluffy’s metronidazole cannot be refilled without an exam in the past year and Barb cannot change that regardless of how much she wants to help Mrs. Smith, this particular situation may never be satisfactorily resolved for all parties.
Reviews from Disgruntled People
Let’s say you receive a negative review from a client whom you’ve banned from the practice. Can that client be sued for libel? For a statement to be considered libel, it must be presented as fact, or be reasonably construed as fact by the average person. As long as the general gist of the story is true, even if some of the pieces are false, it may not be enough to constitute libel. Most reviews have some basis of truth to them, even if not every single detail is true, and these circumstances can make it very difficult for any practice to successfully fight a court case against a client. Plus, since almost all reviews are expressions of opinion, the practice will rarely have a solid enough case to make in court.
Moreover, pursuing a libel case can be quite expensive with a likelihood of success typically being slim. Besides, at the first hint of legal recourse, the client could immediately post that information to social media and create a publicity nightmare. Hence, any attempt at suing for libel is, in most cases, not worthwhile.
Another possible scenario involves unhappy employees or ex-employees. What recourse does the practice have against a disgruntled employee who has a bone to pick? Some websites, such as Yelp and Google, will block reviews from disgruntled employees if asked to do so. Plus, new hires could be asked to sign both a non-disclosure agreement as well as a non-disparagement agreement. Non-disclosure agreements prohibit employees from sharing information that is not publicly available, while non-disparagement agreements prohibit employees from making disparaging statements about their employer. Since most employers don’t (and shouldn’t) publicly disparage their employees, it is reasonable for them to request the same of their employees.
These need to be carefully worded documents, though, because the National Labor Relations Act gives employees the right to discuss wages, benefits, and other terms and work conditions with other employees.
As far as the non-disparagement agreement in connection with negative postings, this document can create leverage for an employer in court, but the employer will likely incur significant legal fees and probably receive negative publicity while pursuing charges. Unfortunately, the other fallout of such a clause is that, in the case of a harassment suit, an employer who has a non-disparagement agreement in place will likely have to pay higher settlement fees. In general, non-disparagement agreements are best avoided.
What If the Negative Client Review is True?
Sometimes, unfortunately, the hospital’s staff does perform poorly. For example, let’s say that Mr. Jones dropped Buddy off at Corner Veterinary Hospital for a routine castration. During the course of Buddy’s stay, a veterinary assistant walked Buddy outside. Buddy slipped his collar and disappeared into the woods. Mr. Jones is contacted, and the assistants make every effort to find Buddy, but to no avail. Mr. Jones is irate and posts an angry Google Review saying that Corner Veterinary Hospital is clearly not responsible and shouldn’t be trusted with anyone’s pet.
In this situation, Corner Veterinary Hospital stands to lose a lot, as this is clearly an egregious offense and is entirely true. The review can be ignored, and perhaps the practice will make that decision if there are sufficient positive reviews to outweigh it. A polite response asking the client to call the office is also a valid option, but the practice may want to make the response more apologetic. The response can also include an acknowledgment of what went wrong, with a description of what has been done to fix the problem, such as the following:
We’re very sorry that you’ve had this experience at Corner Veterinary Hospital. All our staff is very upset about this situation and continues to search for Buddy. Since we never want an incident like this to happen again, we are having all of our hospitalized patients walked with two leashes, including a slip lead that is more secure. We are also working on fencing in a section of our property for even more security. If you would like to discuss this further with us, please call Barb, our office manager, at (xxx)-xxx-xxxx.
While this is not an ideal situation by any means, showing concern, an acknowledgement of what went wrong, and a plan to prevent future issues may be the best method of preserving the practice’s reputation.
Ideally, practices should focus on performing in a way that will help to prevent negative reviews from being posted. While there are some clients who will never be satisfied, most reasonable clients will be happy when you have a friendly staff that provides them with good service, and the practice enforces transparent, reasonable policies. It is important to have a plan in place, though, so that you know how to respond, in general, when you do get a negative review.
You can use negative reviews to discover where your practice has the opportunity to improve its client service. Was Mrs. Smith unhappy, for example, because the receptionist offered her an appointment three days out when Mrs. Smith was already sick of cleaning up her cat’s diarrhea? Or was the receptionist unempathetic and hard to work with? While neither of these may be the case, every negative review is an opportunity to evaluate and potentially improve the practice’s policies.
Although no two mission statements are alike (nor should they be), it’s important to regularly audit yours—perhaps when you do your annual policy review, overall—to determine whether or not the statement is still relevant and actually being put into practice. Here is a helpful checklist.
- Is your mission statement still relevant? If not, why not? What needs changed?
- Is your purpose still the same?
- What about your core values?
- Do you offer different products and/or services, ones that have caused your mission statement to need to evolve?
- What makes your business unique? Is that clearly indicated?
- Can your entire team recite your mission statement?
- When you ask each member of the team (or, if at a large company, a sample of them) what the mission statement means, how consistent are the answers?
- How closely do they match what key staff believe the statement to mean?
- If there are gaps, where do they exist? How significant are they?
- In your policy manual, have you included concrete examples of how the mission statement could be put into practice? If not, would that be helpful?
- How do you explicitly communicate your mission statement to your customers or clients?
- Through signs that state it?
- In your website and printed materials?
- In your advertising?
- In company meetings, how often do you discuss the mission statement?
- When your company faces challenges and/or difficult choices, do you consult your mission statement when reviewing possible solutions? How is it your benchmark?
- When you create new policies, do you ensure that they mesh with your mission?
- How often do you review your policy manual to make sure that what’s included dovetails with your mission? As just one gut-check example, how well does your disciplinary policy match your mission statement?
- You can also review the following for matches and mismatches:
- Your organizational chart
- Job descriptions
- Any other employee handbooks or manuals
- Take a look at how you reward employees. Are you rewarding them for phrases contained in your mission statement? If, for example, your statement includes “providing compassionate care,” do you actually reward and promote based on that value, or are your rewards based on how well a person increases revenues or reduces expenses?
- What processes do you have in place for employees to report when they feel that procedures conflict with the mission statement? How are those reports handled?
- What procedures do you have in place to update the mission statement, when needed?
- As you read through this checklist, what items would be important to add or edit to match your business’s unique needs? Who will spearhead that initiative? What is the deadline?
To be successful in the workforce today, and throughout your life, you must successfully engage with people from the beginning to the end of each day. Often, it’s with people whose viewpoints don’t always match your own. And when viewpoints don’t match but you need to resolve the differences, it’s crucial to be able to effectively negotiate with the other parties to create a mutually-agreeable solution.
Quality negotiation skills are vital in situations such as accepting a job offer, asking your boss for a raise or to boost your workplace benefits, or when an organization to which you belong is making decisions that will impact people’s lives.
Traditionally, women have been more reluctant to negotiate than men, which means they have disproportionately suffered from the costs associated with not negotiating. Even today, there is a frequently-noted “confidence gap” between the genders, with one study showing that only 7 percent of women attempted to negotiate their salaries, whereas 57 percent of the men did.
Women are as competent as men in the workforce, with global studies by Goldman Sachs and Columbia University demonstrating that companies employing women actually outperform their competitors on every measure of profitability. So, the issue is confidence, not competency – but, because confidence is a critical component of success, this article will share information about how women can successfully engage and negotiate with others to receive what they deserve.
First, here is a definition of negotiation and why it’s necessary.
Nuts and Bolts of Negotiations
A negotiation is a process in which two or more parties attempt to resolve differing needs and interests through a series of communications. An employer, for example, may want to offer someone higher wages, but needs to consider the overall profitability of a company. Meanwhile, an employee may understand and support the need for a thriving business, but also needs to earn a certain wage to support his or her family.
Employers and employees negotiate because they each have what the other one needs, and they believe they can obtain a better outcome through the process than if they simply accept what the other party is offering. Sometimes, negotiations occur because the status quo is no longer acceptable for one or both parties. Negotiations take finesse because, besides dealing with specific tangible points (wages, insurance benefits and perks, as just three workplace examples), emotions play a part and ongoing relationships are involved. The parties are choosing to try to resolve their different positions through discussions, rather than arguing, or ending the relationship, having one person dominate the relationship or taking the dispute to another party with more authority.
So, here are helpful tips to help you to effectively negotiate for what you deserve.
Six Negotiating Tips for Women
Tip #1 Be Prepared
First, you must clearly define the issues involved and prepare for the negotiations. Be crystal clear about what you want to accomplish, your opening offer, your resistance point (the point at which you would be willing to walk away from the bargaining), and what alternatives you have if the negotiations don’t culminate in a solution that is acceptable to you.
Also, as much as possible, know relevant information about the other party to the negotiation. What is he or she likely to want? Understanding where this person is coming from and what he or she wants to accomplish will help you to manage the negotiation process more effectively.
Tip #2 Be Aware of Fears and Address Them Appropriately
Common negotiating fears include:
- that your position will not be solidly presented
- looking incompetent
- liking people and wanting to make them happy (but perhaps not being able to give them what they want!)/not wanting to affect someone else in a negative way
- worrying about failure
- feeling uncomfortable about talking about money
- aversion to conflict, overall
Sometimes simply recognizing your fears can be enough to put them into context and allow you to move forward. Other times, they point out weaknesses in your preparation – and, in that case, your fears can help you to solidify your research and negotiation approach. Overall, it can help to reframe your wants, focusing on the value they will bring to the other party, and to be prepared to share how your approach can solve the underlying problem of the other party.
Some women must also work on silencing their inner critic, a critic that might be saying how only “bitchy” women negotiate or that you somehow don’t deserve the full benefits of your hard work. Again, you can use these fears to identify places you need to bolster up your attitude and solidify your approach.
Tip #3 Recognize and Optimize Your Negotiation Style
Multiple negotiation styles exist, each on the spectrum of assertiveness and cooperativeness. Here are summaries of common styles:
- Competing (high in assertiveness, low in cooperativeness): these negotiators are self-confident and assertive, focusing on results and the bottom line; they tend to impose their views on others
- Avoiding (low in assertiveness and cooperativeness): these negotiators are passive and avoid conflict whenever possible; they try to remove themselves from negotiations or pass the responsibility to someone else without an honest attempt to resolve the situation
- Collaborating (high in assertiveness and cooperativeness): these negotiators use open and honest communication, searching for creative solutions that work well for both parties, even if the solution is new; this negotiator often offers multiple recommendations for the other party to consider
- Accommodating (low in assertiveness, high in cooperativeness): these negotiators focus on downplaying conflicts and smoothing over differences to maintain relationships; they are most concerned with satisfying the other party
- Compromising (moderate in assertiveness and cooperativeness): these negotiators search for common ground and are willing to meet the other party in the middle; they are usually willing to give and take and find moderate satisfaction acceptable
Simply by recognizing your style, you can highlight your strengths and know where to work on weaknesses. This isn’t to suggest that the process will be quick and easy, but it can be a vital step of the process in helping you get what you deserve on an ongoing basis.
Tip #4 Practice!
Becoming effective at negotiating seldom occurs overnight and it can be helpful to first practice your negotiation skills in areas where the process may not feel as intimidating. These can include negotiations:
- for resources, whether it’s asking for more equipment or to hire more people
- about how to use resources; with a common purpose, solutions can be reverse engineered fairly easily
- where you have expertise
- with big companies where nothing is personal
- where you have evidence to support your position, including facts, data and logical reasoning
Consider practicing what you’ll say in front of a trustworthy friend or colleague, or practice in the mirror. Imagine different scenarios for the upcoming negotiation and prepare how you might answer, doing so by answering out loud (which is quite different from simply running ideas through your head).
As you become more experienced with the process and as you experience some successes, even relatively small ones, this will help you to gain confidence and become better at negotiating, overall. This will then help to prepare you for more challenging or complex bargaining processes.
Tip #5 Fairness is Important
As long as both parties are committed to the relationship and believe there is value in coming to an agreement, negotiations can typically proceed. If one or both parties, though, are unreasonable, uninformed or stubborn – or listening to advisors with those characteristics – negotiations can fall through.
Or, if one party doesn’t necessarily need the deal and/or isn’t in a hurry – or knows that the other party is without other options and/or in a time crunch – then negotiations may not end up being fair in the long run.
You can’t change how fair the other party will be, but you can determine if your own position truly is fair. Don’t use the “gender card” to get your way, as just one example, because fairness and equality should be at the heart of every negotiation. Conversely, don’t accept an unfair agreement just because, for example, you’re tired of negotiating or you don’t think the situation can ultimately be fairly resolved.
Tip #6 Calmly Ask for What You Want
Be calm, be professional. Unfair as it may be, women who are negotiating can be watched especially closely to see if they show signs of emotion, whether anger or excitement. Ask for what you want, be willing to pause to let the other party consider what you said (rather than quickly filling in the silence) and then respond appropriately.
Always keep your pre-established resistance point front of mind. But, having said that, if a granted concession is unexpectedly greater in one area of more complex negotiations, consider if and how you might be willing to adjust your resistance point in another area as part of the overall negotiations.
Understanding Negotiation Terminology
Another way to close the confidence gap is to ensure you understand what negotiation terms mean and can use them – confidently. We’ll use the example of an employer-employee wage negotiation as our example.
Each person will have a target point, which are the wages he or she would like the other party to agree to. The difference between what an employee wants to be paid and the employer wants to pay is the bargaining range. Meanwhile, the resistance point is where a party would walk away from negotiations; if too low of a wage or raise is proposed, an employee may begin job searching or a job candidate may decline an offer; the employer also has a point at which he or she will reject a wage request and end negotiations.
When the buyer (employer) has a resistance point that’s above the seller’s (employee), this situation has a positive bargaining range. The employer, in this case, is willing to pay more than the employee’s minimum requirements, so this situation has a good chance of being satisfactorily resolved. With a negative bargaining range, though, one or both of the parties must change their resistance point(s) for there to be a possibility of resolution.
In a wage negotiation scenario, either the employer will offer a starting wage or raise, or an employee or job candidate will request a certain dollar amount; the first person to name a dollar amount is making the opening offer. If at least one of the parties has a BATNA – best alternative to negotiation agreements – then he or she will probably approach the discussions with more confidence, having another alternative. So, if an employer offers someone a job, but has another excellent candidate waiting in the wings, the employer has another alternative and can set a higher and/or firmer resistance point. Conversely, if an employee or job candidate has a unique set of skills that are especially needed today, that person probably has more options in the job market – perhaps even other pending offers. The quality of a negotiator’s alternatives drives his or her value by providing the power to walk away and/or set a higher and/or firmer resistance point.
Plus, there is more than one type of bargaining style. One way to differentiate them is to divide them into distributive bargaining and integrative bargaining.
In distributive bargaining, parties’ needs and desires are in direct conflict with one another’s, with each party wanting a bigger piece of a fixed tangible such as money or time, so these negotiations are typically competitive. Parties are not concerned with a future relationship with the other person. A slang term for this type of negotiation is “playing hardball” or “one upping” someone. Strategies often include making extreme offers, such as an employer offering a very low wage or a job candidate asking for an exceptionally high one. Tactics include trying to persuade the other party to reconsider his or her resistance point because of the value being offered – in this example, the job candidate might say that a high salary was required because of his or her abilities or an employer could say that lower wages would be compensated by a great work environment.
With integrative bargaining, though, the goal is win-win collaborations that will provide a good opportunity for both parties. The employer would acknowledge the employee’s value and need for a decent wage, and negotiate accordingly, while the employee or job candidate would recognize the value of working at a particular company as well as the fact that the employer has numerous other financial commitments to fulfill. They recognize that they need one another to maximize their respective opportunities and negotiate from a place of trust and integrity, with a positive outlook that recognizes and validates the other party’s interest in the transaction.
Here’s an interesting psychological truth. Negotiators are more satisfied with final outcomes if there is a series of concessions rather than if their first offer is accepted, because they feel they could have done better.
Salary and Benefits Negotiation Tips
When negotiating at a workplace, don’t focus solely on wage or salary. Also discuss benefits offered and workplace perks – meaning the entire package. This can include, but is not limited to, health care coverage, life insurance, retirement programs, vacation time and flextime. If you’re job hunting, investigate what companies are offering. Where do you think the place you’re interviewing falls on that spectrum? What is the minimum pay level that you’re willing to accept? What is your preferred wage? What benefits are important to you?
If you want to work at a particular company, but the pay rate isn’t quite what you want, ask if you can have a salary review in, say, six months. This doesn’t mean accepting a salary that is clearly sub-par, nor does it mean that you should try to put more pressure on a potential employer who is already offering you a good deal. It is simply something to consider in relevant circumstances.
What workplace perks might be desired? Would a company cell phone help you? Better equipment or software? If so, you could consider accepting somewhat lower pay if you get more tools to do your job.
Or, if you have children, you could negotiate coming in half an hour later so that you can take them to school or schedule a lunch break that coincides with when you need to pick them up. If you bring crucial skills to the negotiating table, you’re more likely to get these concessions than if you are entry-level.
If relevant, ask about company policy if you become pregnant. How acceptable is the policy to you? How important of a negotiating point is this for you? What about if you are injured in the workplace? Educate yourself on your workplace rights before negotiations occur, as well as company policy. If you are valuable to the business, perhaps you can negotiate some additional flexibility.
Who should be the first to make an offer? Some experts believe that, if you allow the other party to provide a starting dollar figure, he or she has shown his or her hand. But, research indicates that final figures tend to be closer to the original number stated than what the other party had originally hoped.
What NOT to Do
Beware of “between”! It probably feels reasonable to ask for a certain salary range – or range for a raise. But if you do that with a current or prospective employer, you have basically tipped your hand as far as how low you would go. Using the word “between” is actually a concession!
Another risky term: “I think we’re close.” A savvy negotiator will recognize “deal fatigue” on your end and perhaps stall in the hopes you’ll concede, just to complete the deal.
For Best Results
People tend to feel more confident when negotiations focus on an area of their expertise and/or where solid evidence exists to back them up. Overall, success is achieved when you first:
- Determine the interests of the other party
- Embrace compromise
- Observe the Golden Rule, treating others as you would like to be treated: fairly and reasonably, without defensiveness
- Be prepared, both in factual information and in strategy
Keeping these suggestions in mind will help you to achieve success in all areas of life.