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Common Mistakes to Avoid in Achieving Long-term Success with Dermatology Patients
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Not appreciating appropriate clinical timelines
While most veterinarians focus on the needs of the client and pet at the time of a specific office visit, it is important to realize that for many dermatologic conditions opportunities exist on a time continuum for intervention and client education. In some instances, the first discussions with the owner may take place long before there is even a skin problem to treat. This might also prompt a discussion of the likely costs associated with long-term management, so the owners might consider their options for risk management strategies, including pet insurance.
Appreciating appropriate timelines also helps in treatment selection. When a twoyearold atopic patient presents with pruritus, the first tendency might be to treat with glucocorticoids (corticosteroids) to achieve short-term relief. However, when you reflect on how that same patient might look at 8 or 10 years of age with such treatment, there is often a different perspective on what the long-term liabilities are for such short-term gains, and alternative more targeted treatments might be selected given the need for sensible long-term solutions.
It’s also important to schedule effectively. No one can solve a complicated dermatology case in a single visit, regardless of the appointment’s duration. You can address the client’s primary concerns, but be clear with the client that the pet’s problems will likely not be solved with that single visit. The key to successful dermatology management is scheduling frequent re-evaluation appointments. The success of this strategy is predicated on sharing the action plan with pet owners, so they can understand and appreciate what is expected to be accomplished, and according to what timeline.
We must also be aware that even well-accepted theories of cause and effect can and do change over time, and that we must be prepared to change with them. For example, we once thought of atopic dermatitis as a classic Type I hypersensitivity reaction primarily driven by mast-cell dynamics in response to inhaled allergens. We now know that the major allergen presentation occurs across the skin surface via Langerhans cells and that inflammatory mediators such as interleukin-31 (IL-31) and other pruritogenic cytokines are most responsible for the scratching that we see in our allergic patients. This helps explain why antihistamines are often of limited benefit, and points the way to more targeted therapies that can and should be considered.
Not appropriately framing client expectations
Many pet skin problems cannot be cured, regardless of the medication selected, so set realistic expectations with clients early in the process. Fortunately, control of the condition and a better quality of life for the pet can be attained with appropriate management. For the pet with atopic dermatitis, you might explain to clients that this is no different than addressing other incurable but manageable medical conditions such as diabetes mellitus or degenerative joint disease (osteoarthritis). We can often achieve excellent long-term control with ongoing treatment and close monitoring, but it’s unlikely that we’ll be able to “fix” the underlying problem. Usually once owners appreciate that the goal is control rather than cure, their expectations tend to be more reasonable and realistic.
Not viewing the situation in terms of Quality of Life
Veterinarians might sometimes view dermatologic problems as minor medical issues because often the pet's life isn't at risk, but pet owners may not share that same perspective. Pet owners may not know what a diseased liver looks like, but they are certainly aware when their pet keeps them awake at night while scratching, has bald patches in its fur, or harbours offensive odours, rashes, parasites, or skin colour changes associated with a variety of skin diseases. There might also be a certain amount of guilt associated with friends and relatives asking why they have not done a better job of treating their pet's skin ailments, even when the pet owner has done everything they have been instructed to do. Veterinarians and hospital staff would do well to consider what pet owners find stressful, in addition to what might be causing the pet discomfort.
Not following evidence-based standards of care
Most pet owners don't want their pets to serve as learning tools, so they appreciate knowing that veterinarians know what they are treating, the chances of success, what problems might be encountered, and the alternatives available should the need arise. Pet owners also appreciate that such knowledge is evidence-based and reflects established expertise, even if not direct experience. They find comfort in consistent messaging from hospital staff, specialists, and even internet resources.
Standards of care should be created by hospitals to provide this assurance, and to guarantee the best care to all patients and all pet owners, regardless of the individual experience and expertise of the clinician currently treating that pet. Protocols are often used for standardized approaches to basic preventive and acute care (e.g., parasite control, treatment of sarcoptic mange) while care pathways represent a model for approaching problems that might require long-term or even lifelong care (e.g., atopic dermatitis, demodicosis, pemphigus foliaceus, etc.).
When creating standards of care for your hospital, remember to build into the model specific points at which referral to a specialist should take place. The best referral happens as part of a well-conceived plan, not as an afterthought. It helps to prepare clients early on that the first course of treatment may not resolve the problem, and if so, that you may try other options or recommend the assistance of a specialist. Clients will appreciate your efforts to inform them now, rather than when they are frustrated, upset, and depleted of funds.
Underestimating the role of compliance
When it comes to managing many skin conditions, client compliance is an issue that must be considered.
Before dispensing any medications to owners, be realistic in your expectations for what can be reasonably accomplished at home. Better yet, have that exact conversation with owners, including asking open-ended questions of their previous experiences, so you can plan your treatment accordingly. Owners are more likely to be compliant treating clinical signs they can judge (e.g., control of scratching or pain), and can be less compliant with things that aren't as obvious, such as administering antibiotics orally at specific intervals or remembering to give parasite-control products on schedule when no parasites are seen.
Because compliance is such an important issue in the resolution of most dermatologic problems, clinicians must recognize this and create treatment plans accordingly. If it is medically prudent to do so, injectable medications should be first-line therapy, since they offer convenience to the owner and guaranteed compliance. The next preferred medications are ones that can be administered once daily, followed by those that can be administered every 12 hours. It is unlikely that oral medications needing to be administered more often than twice daily will be given on schedule other than by the most dedicated of pet owners. It is also important to remember that administering a medication twice daily is not the same as administering it every 12 hours, so even clients that remember to give a medication twice in any given day might not give it at the appropriate interval consistent with the drug's pharmacokinetics. If so, the pet is not receiving the true intended benefit of that medication.
Finally, cost might be one consideration in medication selection, but if the goal is for the pet to actually receive all the benefit of any selected medication, compliance should be the main selection attribute. The most costly medication (in terms of time and medical outcomes) is actually the medication that fails to deliver the anticipated benefits because it was not administered appropriately.
Lacking realistic product and pricing models: Veterinary hospitals benefit from carrying appropriate products in inventory, pricing them competitively, and tracking compliance to ensure that pets and owners are actually receiving the full benefit of products dispensed and administered.
While clients might want to browse retail store shelves for the best bargains, when it comes to treating their pets with medical issues, they typically want a firm recommendation made by the veterinarian, not a list of possible treatments that the owner can consider. Be prepared to make clear product recommendations, and be prepared to explain why this is the best option for a particular pet. Some clients will always want the least costly option, but veterinarians owe it to their clients to make firm recommendations, based on evidence-based criteria of what is in the pet's best interest.
Considering dermatology clients a nuisance: You are in business to serve the needs of your clients. Due to the nature of dermatologic diseases, you will see most of your dermatologic patients and their owners many times during the year, for many years to come. That gives you a great opportunity to bond with these pet owners and help shape a positive and mutually beneficial veterinarian-client-patient relationship. These are exactly the clients that you should crave for your practice. The next time the pollen count rises and your telephone starts ringing frequently from clients with itchy pets -- don't curse -- give thanks! If properly counselled, these are probably the most dedicated clients you will have in your practice.
Recommended Reading
- Ackerman, L: Seven common mistakes to avoid in achieving long-term success with dermatology patients. Veterinary Medicine and Science, 2015; DOI: 10.1002/vms3.1
- Ackerman, L: Proactive Pet Parenting: Anticipating pet health problems before they happen. Problem Free Publishing, 2021
- Ackerman, L; Pet Specific Care for the Veterinary Team. Wiley-Blackwell Publishing, 2021.
- Ackerman, L; Ball, E; Brunt, J; et al: The Zoetis Lifelong Care Initiative: Putting the Promise into Practice. Clinician's Update, 2013, 1-8.
- Marsella, R; Sousa, CA; Gonzales, AJ; Fadok, VA: Current understanding of the pathophysiologic mechanisms of canine atopic dermatitis. J Am Vet Med Assoc., 2012; 241(2): 194-207.
- Pucheu-Haston, CM; Bizikova, P; Marsella, R; et al: Review: Lymphocytes, cytokines, chemokines and the T-helper 1 – T-helper 2 balance in canine atopic dermatitis. Vet Dermatol, 2015; 26: 124-132.
- Weese JS; Faires, MC; Frank, LA; et al. Factors associated with methicillin-resistant versus methicillin-susceptible Staphylococcus pseudintermedius infection in dogs. J Am Vet Med Assoc, 2012; 240(12): 1450-1455.
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