Marilyn Iturri is a former editor of Veterinary Practice News magazine who has worked in the veterinary and pet publishing sector for 20 years. Also a veteran of daily newspapers, she freelances as an editor and writer for diverse clients. She lives in Southern California and may be reached at email@example.comRead Articles Written by Marilyn Iturri
Compliance has long bedeviled veterinary medicine. Even when clients know what they need to do, they don’t always follow through. That is especially true in dermatology cases when both the diagnosis and the deciphering of a proper treatment can take time. Educating and keeping clients engaged in their pets’ care can be a challenge when a treatment isn’t one and done.
Compliance, like dermatology, is a team sport, and clinicians, technicians and customer service representatives must work together to reinforce with clients the steps necessary to relieve the itch. Gaining compliance is an obstacle early on and likely occurs before the veterinarian refers a pet to a specialist.
“The reality is a large percentage of owners never make it to a specialist,” said Karen E. Felsted, CPA, MS, DVM, CVPM, CVA, of PantheraT Consulting. So, it behooves GPs to stay up to date on the science of dermatology.
“General practitioners should make sure they’re getting appropriate continuing education for dermatology, not just continuing to throw the same drugs at the patient on and on,” she said. “They need to develop a progressive plan in diagnostics and drugs. They need to have an idea of, ‘Here’s how far I’m going to take it. We’ll do these diagnostics in this order with these therapeutics. But if we don’t see progress in “X” number of months, it’s time for a referral.’”
Complicated and Time-Consuming
Educating pet owners in dermatology cases and getting their buy-in is paramount.
“The generalist and team need to say from the beginning that derm cases can be complicated and time-consuming to resolve,” Dr. Felsted said. “The owner needs to understand that ‘The resolution could be a challenge, but let’s start with the simple things and see how we do.’
“Don’t scare them to death,” she added, “but you should give them some understanding that these cases can be challenging.”
And with that comes the understanding that the recommended care and follow-up can be expensive. Every veterinary practice, not just those seeing complex cases, should offer a couple of payment alternatives, Dr. Felsted said, and everyone on the team needs to know how to provide that information to the client.
With all payment plans, the practitioner must understand who takes on the risk if a client stops making payments. Some services are cheaper, Dr. Felsted said, but if the client defaults, the risk might fall on the clinic.
Dr. Felsted recommends that practitioners ask these questions when considering a payment service:
- What are the terms?
- What’s the longest possible finance period?
- Is the practice charged a fee?
- What happens if the client stops making payments? Would the debt revert to the clinic?
- How long does the application approval take? Can it be easily done in the clinic?
Pet health insurance can be useful, but by the time a patient has an issue, it might be considered a preexisting condition.
“When talking to clients about the benefits of insurance, one of the reasons to sign up early on is that if something complicated comes up, you’re covered,” Dr. Felsted said. “This is particularly important if the client has a breed that’s prone to certain things like skin issues.”
She said clients who see a veterinary specialist understand the likely monetary commitment. “But if you look at AVMA statistics on the percentage of pets who see a specialist, it’s very small,” Dr. Felsted said. “You could make the case that probably 95% of clients with itchy dogs never see a specialist.
“Every veterinarian has clients for whom specialty care is not realistic financially,” she added. “They should take dermatology CE to do as much as possible for pet owners for whom a referral is not an option.”
Follow-Up Is Critical
Chronic diseases require chronic management, said Rusty Muse, DVM, DACVD, the medical director at Animal Dermatology Group.
“It takes time to go through a patient’s history, and a good workup requires a good history,” he said.
“Today, we have lots of different therapies designed for stopping the itch. We also have to manage any secondary infections to control the organisms while sorting things out. If clients expect to find one thing to manage it all, they’ll be disappointed.”
Follow-up is critical, Dr. Muse said.
“Veterinarians and dermatologists need to see if the pet has a complete response to assess its clinical signs,” he said. “We usually see a patient six to seven times a year.”
Even after a diagnosis is made, finding the therapeutic combination that controls the clinical signs and makes the patient comfortable can take time. Specialists might have the edge in educating clients in that regard.
“It’s skewed for us because we’re in referral,” said Jennie Tait, AHT, RVT, a charter member of the Academy of Dermatology Veterinary Technicians and a frequent conference lecturer on dermatology. “We find that when we explain why we need to do something, they understand.
“By the time they get to us, they’re already willing to go above and beyond. We tell the client step by step what everything is going to cost. The price tag varies depending on the size of the animal. If it’s very large, for example, a course of Atopica can cost hundreds of dollars, plus the cost of therapeutic diets.
“We try to break it down per month so that the client has a general idea, and we try to taper costs. After one month on Atopica, say, if the animal responds, we move to give it every other day, cutting the cost in half.”
The recommended diagnostics depend on the patient’s history and the types of lesions, Tait said. “If cytology finds cells that suggest immune-mediated disease, then we might recommend a biopsy. It depends on what disease you might be chasing.
“Even with a diagnosis, you need to figure out which treatment combination works best for the patient,” she said. “In my world, which is referral, animals typically have been suffering for years. Our main concern is to make them comfortable.”
Once a patient is comfortable, Tait said, the team works to tease out the root of the problem.
One problematic area is food allergies, which clients can unknowingly exacerbate, she said. For example, asked what they feed their pets, clients don’t always think of supplements and treats. A capsulized supplement, for instance, might contain bovine cartilage-based ingredients, and even chicken-flavored toothpaste can cause a reaction.
Some clients still want to give treats.
“I liken it to a child with a peanut allergy,” Tait said. “How many peanuts would you give a child with an allergy? One, two? No. You wouldn’t give any.”
Symptoms can linger for up to three weeks after one adverse reaction.
Tait once owned a dog with a corn allergy. Getting her husband on board with respecting the allergy took time.
“Every morning, he’d ‘accidentally’ drop three or four cornflakes for the dog from his bowl of cereal,” she recalled. “Even three flakes can make a difference in an allergic pet.”
Most of the dermatology cases she sees involve lifelong conditions.
“Every piece of what we’re doing will improve the quality of life,” Tait said. “Educating the owner can’t be done in a typical 20-minute appointment. All our appointments are an hour long, whether the initial consult or recheck. The doctor is there for 20 minutes, and the rest of the time is with a technician. We make sure there’s a thorough understanding of what’s going on with the pet.”
The client is the most crucial part of the team. “If the owner is noncompliant, the best treatment in the world won’t help,” Tait said.
FOLLOW UP AND REINFORCE THE MESSAGE
Checking in on a pet’s dermatologic care benefits the animal and helps bond the owner to the practice. A follow-up involves asking many of the same questions as when an itchy pet was presented. For example, a technician can call or text to ask:
- Is Bella less itchy?
- Is Bella still chewing, biting, rubbing, scratching or licking?
- Have new hotspots or other lesions appeared?
- Is the skin pink? Pink skin isn’t normal; it should be white.
- Does Bella smell bad? An odor can indicate infection, often secondary to the itch.
Jennie Tait, AHT, RVT, says Veterinary Allergy Dermatology and Ear Referral in Morriston, Ontario, Canada, used to offer handouts so that clients could better understand their pets’ problems. Today, however, the support is digital.
“We include the patient’s history, what we saw on the exam, the diagnostic results, and lay out the plan going forward,” Tait said. “We offer links to pertinent online education. If the owner notices that things aren’t going according to plan, it’s up to the owner to contact us through our telehealth portal, uploading photos and virtually checking in. If necessary, we’ll proceed with Plan B.”
Even when the staff is stretched thin, Tait said, “The bottom line is making sure owners understand what’s going on, what we suspect and why we suspect it. There is no silver bullet for managing a chronic condition.”
CLIENT PAYMENT CHOICES
Examples of veterinary funding options that pet owners or clinics might consider are:
LINE OF CREDIT
- CareCredit: carecredit.com
VETERINARY CREDIT CARD
- Wells Fargo Health Advantage: bit.ly/3fJWCGO
MEDICAL PAYMENT PLAN
IN-CLINIC CHARITABLE PROGRAM
- Veterinary Care Foundation: veterinarycarefoundation.org
- GoFundMe: bit.ly/3qYSxVT