Dr. Peter Weinstein owns PAW Consulting and is the former executive director of the Southern California Veterinary Medical Association and the former chair of the American Veterinary Medical Association’s Veterinary Economics Strategy Committee. He teaches a business and finance course at the Western University of Health Sciences College of Veterinary Medicine.Read Articles Written by Peter Weinstein
As frustrating as cancer, as challenging as kidney disease and sometimes as expensive as both, chronic otitis is debilitating to the pet suffering from it and to the pet owner looking for relief of both their pet and credit card. And as with so many of the conditions that veterinarians treat, success relies on an accurate diagnosis and ongoing client compliance.
Plenty of clinical resources can help with the diagnosis and treatment of otitis. However, even after an accurate diagnosis of the offending organism, a thorough understanding of the primary or secondary cause, and a great treatment plan, huge barriers to long-term success present themselves. These obstacles — call them client compliance and cooperation — are frequently outside of your control.
The questions to be addressed here are:
- How can we improve client compliance?
- How can we make the cost of care for a chronic condition less of a barrier to compliance?
For whatever reason, certain breeds have a higher predilection to ear issues. So, why not talk about the possibility of otitis before the condition arises? Remember that the average pet owner doesn’t know the word “otitis” but does appreciate a child’s ear infection. Our teams need to help clients understand the differences between a cocker spaniel with otitis externa and a kid with otitis media. It is also our job to teach clients to look in their pet’s ears, smell the ears and learn to gently clean the ears well before a problem arises.
Whenever a new ear infection case comes in, we should spend as much time talking to the client about the potential chronicity of the issue as we spend talking about how to treat the problem. The risk of recurrence is too high to ignore. The good news: If otitis never, ever comes back, we look like heroes. The bad news: If we don’t tell clients about the risk and otitis keeps coming back, the owner faults us for not clearing it up the first, second or third time.
No Pain, Lots to Gain
Raise your hand if you have used four team members to restrain a relatively cooperative dog suffering from a red, smelly, painful ear infection. All the while, the client waits, wondering and worrying.
Success in treating otic disease comes from recognizing that ear conditions can hurt. If we use brute strength to clean a patient’s ear, we will not be thorough. We will create a patient even harder to care for the next time. Also, imagine how unsuccessful pet owners will be at home when they try to clean and medicate the ear of pets who were handled aggressively in your clinic. And you wonder why compliance with ear treatments is so low?
No matter how sweet the patient, consider using mild sedation and other pain-control modalities when cleaning and flushing ears. Sometimes, we put off sticking a swab in the ear for a day or two so that medications and analgesics can reduce the inflammation.
When treating an ear infection, assign a pain score and share it with the client in a manner she will understand. And then get permission to sedate the pet before you stick an otoscope cone or camera into a red, swollen, inflamed ulcerated and infected stenotic ear canal.
And by the way, won’t all this cost the client more? Yes, and it should. If you can do a better job of diagnosing and treating by using sedation, the number of subsequent visits might decrease. Sensitivity to pain control early will improve outcomes later.
The Client’s Crucial Role
One of the synonyms of compliance is obedience. Another is conformity. Our role in practice is to get clients to be obedient and to conform during the short-term care of their pets’ ear infections. This requires lots of positive reinforcement and support.
Ear infections routinely require client involvement at home. This can be as simple as administering oral antibiotics or applying ear medications, or as challenging as cleaning the ears while the golden retriever flings stinky, sticky ear cleanser, wax and infection all over the kitchen.
In the beginning, communicating the importance of the client’s role is imperative. You must convey that obtaining an optimal outcome requires a team: the doctor, staff, client and patient. Your staff must do a lot of the teaching and training to show how to clean and medicate. If you want compliance to fail, send home the antibiotics, ear medications and ear cleanser with instructions to “use as labeled.” If you want unhappy and non-compliant clients, just tell them to read the labels. Someone on the veterinary team must show clients how to clean and medicate if you want any level of compliance.
Ear infections are a readily visual condition. Compliance is enhanced by teaching and training. Start by letting the client observe the red, swollen, infected ear and get a whiff. Next, let the client look through an otoscope if doing so is possible and not painful. And finally, show the client what you saw under the microscope from the cytology you collected and explain why you want to do a culture. If you have a video otoscope, take lots of pictures and show them to the client — before and after cleaning, the status of the eardrum, the volume of gunk down deep.
Also, show clients the shape of the canine or feline ear canal. The L-shape versus a person’s straight canal should be demonstrated using ear models. The L-shaped canal is one of the huge challenges of getting the pet ear totally clean.
Once the client has a clear understanding of what an ear infection is, why pets get ear infections, which breeds are prone to otitis and how to clean and treat the ear, four other compliance issues come to the fore. Let’s explore.
Clients seem reluctant to pay for follow-up visits. But in otitis cases, rechecks are imperative to determine the progress, the treatment success and, when possible, a cure. You must be transparent with clients about how you will handle rechecks when it comes to the cost of care. Can you leverage your staff to do otitis externa rechecks as long as the diagnosis and the treatment plan don’t change? I don’t see why not. Could you use telemedicine in a similar fashion? In some cases. Understand your state practice act regarding the leveraging of staff and virtual care.
Rechecks and reevaluations are a must. No questions asked. Clients must know that. So, how do you couch rechecks so that they’re not a barrier to treatment success? Transparency from Day One, the convenience of virtual care, and the use of highly trained and educated technical staff.
2. Cost of Care
Compliance failure due to the cost of care is so frustrating. We know that after a few charged rechecks, compliance can drop off tremendously.
Can you put together a prepaid otitis externa treatment package that includes a number of rechecks, cleanings, cytologies and cultures? Absolutely. Wellness plans don’t have to be the only prepackaged service that encourages clients to sign up at a discount.
If an otitis package increases compliance, think about the positive outcomes and happier clients as compared to the chronic recurrences of infection due to insufficient treatment and too few follow-up assessments.
Otitis is an expensive condition when it becomes chronic. That fact must be clearly communicated. What can you do for your clients and, more importantly, for their pets so that cost isn’t the barrier? Again, leverage your staff and telemedicine to keep down costs. Include them in your discussions early on and in any prepaid otitis externa treatment packages you create.
Otitis smells. Otitis hurts. Cleaning an ear at home takes time, and then the pet doesn’t cooperate and runs into the next room. Bringing a pet to your clinic every 10 days so that the doctor can look at an infected ear isn’t easy on a client.
Using veterinary nurses during visits (and charging for their time) can open more appointment slots for clients needing reevaluations. Telemedicine is a convenient option and can help determine progress. However, only a look inside the ear canal can determine the true status of an otitis case.
Have you considered sending a staff member to a client’s house for ear cleanings and medicating pets (and charging for it)? What can you do for clients so that maintaining ear care is not inconvenient and actually enhances compliance and improves outcomes?
Another resource that delivers convenience is an online pharmacy. Encourage clients to reorder ear cleaners, antibiotics and otic medications through a website you control. The online pharmacy will allow you to OK a number of refills. By doing so, a pet owner can request a refill at 3 a.m. — a time when millennials think about this stuff — and have it shipped to their door. Alert clients at the time of diagnosis that you offer the online service for their convenience, but make sure they understand that the pet needs to be seen again for a reevaluation of the ear.
- When it comes to your pharmacy, remember these facts:
- A plethora of over-the-counter ear cleansers are available at local pet stores. Your clients will shop there if you don’t offer convenience and competitive pricing.
- Some of the products you sell are available at pet stores and at cheaper prices.
- By operating an online pharmacy, you can charge competitively because you don’t have the overhead and staff time tied up with refills.
- You will lose money to pet stores and online merchants if you don’t offer the convenience of an online resource.
- You will lose clients if you don’t offer convenient medication refills.
It’s amazing how clients who don’t want to bring their pets to a veterinarian are able to earn veterinary degrees overnight. “It looks better, so I don’t really need to continue treating.”
The probability or likelihood of curing many cases of otitis depends on the underlying cause — a foreign body has a better prognosis than does otitis secondary to atopy.
The conversation about cures needs to be part of the discussion early on because you might never be able to truly cure otitis. Compliance will decline and client frustration will increase if the conversation never takes place. Starting on Day One, you need to talk with clients about the likelihood or improbability of a cure to prevent false hopes and expectations. This sets the stage for the need for compliance.
The Six C’s of Compliance
Few conditions in veterinary medicine are as frustrating as otitis. It crops up out of nowhere and sometimes doesn’t go away. The pet might seem better on the outside, but the infection is festering deep in the dark, L-shaped ear canal.
Remember this about compliance:
- Compliance comes from communicating early, often and clearly about what is going on in the patient’s ear and what to expect.
- Compliance comes from coaching clients about the challenges of finding a cure and, most importantly, teaching them to treat the condition at home
- Compliance comes from offering convenient rechecks by using your staff or virtual care.
- Compliance comes from offering the convenience of an online pharmacy and preapproved refills.
- Compliance comes from offering cost savings via prepaid otitis externa treatment plans.
- Compliance comes from being committed to the client and being available for needed follow-up care.
If you commit your team and practice to your clients and help them understand the challenges of otitis, they will commit to you with their compliance.