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214. How to make dermatology CHEAPer... · The Derm Vet Podcast

• 0:00
  Well, welcome to another episode of the Dermvet podcast.
• 0:04
  I am really excited because I got asked to put together a new Dermatology lecture for the World Congress of Veterinary Dermatology, which you've heard me talk a bit about.
• 0:16
  It's in Boston, this July.
• 0:19
  It happens every four years where all the veterinary dermatologists in the world come together for one meeting and we are so excited to have it, you know, close to us in the United States, but just so excited after not having in 2020 to finally have all the veterinary dermatologist in general practitioners, technicians, anyone that's really interested in Durham, this is definitely the place to be.
• 0:43
  This is the first time I have been asked to speak at one of the veterinary Dermatology conferences beyond abstract presentations.
• 0:51
  And I wanted to give a glimpse into a lecture that I'm currently putting together that I'm really excited about.
• 0:57
  I was asked to put together a lecture about, you know, kind of Dermatology on a budget, which can be really daunting because as we know with these long term diseases, it can be expensive and it can be really frustrating.
• 1:11
  And it's great when you have an owner who can do everything you feel like necessary, but that's just not the real world that we live in.
• 1:18
  We have to be willing to provide different access to care points and just make sure that we can do our best to use our mind and really utilize the tools we have in an efficient way, cost wise and time wise.
• 1:32
  So I came up with what I hope comes across as kind of clever because I'm really excited about an acronym to consider how and the way that I'm kind of titling this lecture, how to make Dermatology cheaper.
• 1:47
  With that, the cheap portion of that stands for psychology because you know, I always have to have that in there somewhere, history, examination, assessment and plan.
• 1:59
  That doesn't mean I'm necessarily giving you tools to make Dermatology free.
• 2:03
  Of course, we have to know our worth, but I'm just wanting you to really think about and consider how we're using the tools we have to be diligent about the workup of that pet for the owner.
• 2:17
  Because it is great to have certain protocols in place, but I don't think you should scrape Pluck smear every single case.
• 2:25
  Of course, I think if you don't know what's going on, you should go back to the basics.
• 2:29
  I talk about that a lot, but to be upfront, I do not do skin scrapings on every case.
• 2:35
  If I don't think it's my, I'm not going to skin scrape.
• 2:38
  Of course, as you gain more experience working up Dermatology cases, you get more comfortable with that, but I just want you to know, like I'm satelaging almost everything.
• 2:49
  I'm not skin scraping everything.
• 2:50
  I'm not treco-gramming everything.
• 2:52
  I'm not, you know, ringworm testing everything because I really want to be efficient with my client's money.
• 2:58
  So having protocols like doing certain tests again, it's great to try to standardize that to some degree, but we have to make sure we're really thinking about how we're utilizing the cost and owner is giving us to take care of their pet.
• 3:14
  So cheap is a way that I can kind of get my mind around.
• 3:17
  If I have a case, then maybe there is some cost consciousness.
• 3:21
  What can I really maximize with that money to get me to hopefully a really great long term plan, whether it's future diagnostics, we'll save up for and prioritizing those or the treatment I think is really going to make sense for that pet.
• 3:37
  So let's go through this cheap protocol.
• 3:39
  Of course, satology, the C is first or else I probably would have put that a little bit later on, but satology, you know, as I always say, is our minimum database in dermatology.
• 3:51
  It is so important and I know the cost of satology can add up when you're repeating it a lot.
• 3:56
  When you think about the information we get from other tests that maybe cost more, satology, I feel like is one of the best bangs we were buck as far as an actual diagnostic test because we can rule out certain things, right?
• 4:12
  If we see a dog with skin lesions that are scaly and really itchy, you know, I always say you can't smell yeast and diagnose it.
• 4:19
  We have to find it.
• 4:20
  If you put the cost and the satology to look under the microscope for that pet and we find a lot of malcezia, we can potentially save the cost of a bacterial culture and sensitivity that doesn't need to happen and we know that's more expensive.
• 4:35
  If we see that there's not much bacteria but there's a bunch of inflammatory cells, he has biopsies not cheap, but if we prioritize that as the next step because we do think it's an autoimmune disease, then that's still going to save the owner some cost.
• 4:51
  So, satology really, if you think about it can tell you inflammation, if there's infection or not, you can even get hints of other diseases like acantholytic carotenicides with pimpagas, dermatophyte spores, you know, we don't see it on all ringworm cases but occasionally we do and that can give us an indication of what's going on, neoplastic cells.
• 5:10
  There's so many different things that can tell us, you know, if you're suspecting dermatophyte of course doing a fungal PCR or DTM, those are helpful, but it's really only giving you a yes or no on one disease process versus satology being able to tell you so much.
• 5:27
  So, really collecting satology as your baseline is going to be more cost effective for that owner so we can either guide them to the test that makes sense for their pet or start appropriate treatment.
• 5:40
  You know, I don't like antibiotic roulette none of us do.
• 5:43
  So if I know that I've had cases where they've just been on azolept or azolept or azole because it's assumed it's yeast, but when we run a satology we see like, oh, actually we have a lot of bacteria, all the money that owners put towards something like yeast treatment and repeat veterinary visits could have just gone into a culture which would make more sense.
• 6:04
  So that's why satology really is something that can help make dermatology a bit cheaper.
• 6:09
  If you train yourself how to, you know, examine it, there's lots of digital satology machines that are out now as well like, DrewView, Bysometica or the images, Bysoleta.
• 6:20
  So there's lots of opportunities to get help with satology if you don't feel comfortable as well.
• 6:26
  Then we break into the other things that require you to use your mind.
• 6:31
  So history that would be the age of cheap history is one of those valuable diagnostic tools we have in dermatology as well.
• 6:38
  It can give a ton of information that sometimes is even more valuable than the exam itself because you're just finding things out like is it seasonal?
• 6:47
  Well, but seasonal then obviously we don't need to do a diet trial.
• 6:50
  It's a lot of a similar to pet, but you just want to make sure you take the time to record and evaluate that thorough history of those intake forms if that makes sense.
• 6:59
  Really spending the time during that exam which by the time the owners in the room with you they've accepted that fee.
• 7:06
  So at that point taking the time to get a really good history can be so beneficial in assuring that we do know the next steps of what we need to do.
• 7:17
  Do they have GI histories?
• 7:20
  Are the other pets affected?
• 7:22
  Is everyone on Ectoparasite control?
• 7:24
  Do we have other systemic signs that are present?
• 7:26
  If you have an older dog who's all of a sudden broken out with pyadurma, but you also find out they became P-U-P-D around the same time.
• 7:33
  Maybe we were prioritizing a cushing's test rather than putting the money into allergy medications.
• 7:39
  So there's certain indicators that can really help you in a history with your differential list.
• 7:45
  Just like back in vet school we're all creating a differential list when we evaluate these pets.
• 7:50
  You know you're just doing it quicker in your head as you're gaining the information.
• 7:53
  My differential list is like shifting positions as I'm talking to the owner depending on what they're telling me.
• 8:00
  You know did they first break out with parietists when they were two?
• 8:04
  Well then I'm going to have a different differential list and if they say oh no but they never had a sign or history of parietas until they were 12.
• 8:12
  So that history is extremely extremely valuable in trying to really prioritize what you were spending your clients money on when working out their pet.
• 8:22
  The E and sheep examination do not overlook the importance of your examination.
• 8:29
  A couple things that I would really really try to emphasize for you.
• 8:34
  Yes it's important to focus on what the owner comes in concerned about but please try to do your best to still do a full dermatologic examination.
• 8:42
  They come in concerned about one lesion and it's an epidermal cholera and they think it's going to be ringworm.
• 8:49
  You know it's probably back to olfoliculitis then the question is why.
• 8:52
  You know they're like oh they've never really bothered anything else.
• 8:55
  You look in their paws are really red, their axillary region is really red and that could suggest that you might have an allergic pet.
• 9:03
  They just might not have thought about the fact that yes of course the dog looks as paws all the time.
• 9:12
  These are still things that we can pick up on that can give us an indication of what could be the primary cause especially true for things like ears right.
• 9:21
  Owners always come in oh the ears are infected and that's what they're worried about and that makes sense because ears are really annoying if you deal with a pet with you know ear disease it's painful it's uncomfortable there's an odor to it.
• 9:33
  So owners come in and say I'll just have an ear infection if you just focus on the ear infection and don't look at the rest of the pet you may miss some clues that could really tell you the reason why that's happening and when we talk about making dermatology cheaper you have to think about the long term implications of that as well.
• 9:52
  Every veterinary visit every test we run every medication is another cost to that owner.
• 9:57
  So taking the time to do a thorough examination allows it so we figure out the primary cause we educate that owner on the primary cause so hopefully we can save those repeat visits as much as possible because they're not just getting infected all the time because the primary causes not controlled that's also going to be beneficial.
• 10:17
  So examination again something that we want to take the time pick up on things like distribution of lesions if you have a dog that comes in their nasal planums completely deep pigmented and swollen side of point injections probably not the best use of that owners finances unless they also have signs of allergic disease and they're uncomfortable because ultimately we probably need to figure out what autoimmune or deep infectious or plastic disease process that's there.
• 10:45
  So we want to be using that examination and those distribution of lesions to really prioritize the things that we want to spend the clients money on.
• 10:55
  The A of cheap assessment so again this is kind of pulling all those little things that we just talked about together.
• 11:01
  We put that piece of the puzzle in place and see what we think is the best use of that owners money.
• 11:08
  So the psychology, the history, the examination that's only decide now what are the next steps?
• 11:14
  You know are we at a point we feel comfortable starting a treatment plan is this an allergic dog?
• 11:19
  We are going to do infection control in apaquil is the pieces of the puzzle not really looking like it's something like an allergic pet.
• 11:26
  Do we need to say for biopsy is it worthwhile to do something like a fungal PCR?
• 11:31
  So those are the things that we want to make sure we're really taking the time to assess.
• 11:35
  Again the protocols are great but we want to really think like do I really think this pet has means and I should spend the owners money on a trichogram or a skin's grade.
• 11:47
  You know do I really think this pet could have to amount of itosis or am I just checking something off the list to do?
• 11:56
  You know those are the things I want to you need to do the beginning of your career maybe but as you get more educated you really want to think about the test that should be necessary for that pet based on your examination your history and your psychology because this is the point where you're coming together and saying okay you know I think this is more auto immune.
• 12:15
  I don't necessarily need to spend the money on fungal culture versus doing the exact same test on every single pet.
• 12:21
  So again with experience in just seeing these cases and of course I've had cases that I don't think it's something, I don't think it's dramatic, I don't do it and then they come back in the lesions of change or progressed a bit and that's okay.
• 12:33
  You know of course we want to be complete and what we think is necessary but sometimes lesions change.
• 12:39
  Sometimes the history changes sometimes it seems straightforward and it's not and that's okay too that's kind of part of the evolution of dealing with the skin diseases that can change that can progress sometimes you clear up the infection and all of a sudden something's really obvious so don't be afraid to prioritize but also to come back and be like oh maybe I should have done this because sometimes that happens in these cases.
• 13:04
  Then finally we're going to put together the plan.
• 13:06
  So after we've made our assessment the plan is going to be split to me into kind of two categories.
• 13:11
  The diagnostics like what further diagnostics do we need to do maybe the owner cannot necessarily afford it today but we can educate the owner on why we should do that in the future.
• 13:22
  So a dog that has a pyadurma that you're worried could have thyroid disease maybe they can't test the thyroid that day because they just need to focus on treating the infection with their finances but maybe in a month you know we could work up to testing for thyroid and we just educate them that we feel like that's the best next step to working up their pets disease.
• 13:44
  The other category obviously being treatment so what are we going to spend the money on for treatment.
• 13:50
  And sometimes when we look at treatment we have to think about what's needed then and what's the long term future for this pet would cost.
• 13:56
  For example if I have an owner who says apacryl is just too expensive I can't do it that is true for some owners I will completely respect that but some owners if you really stick a step back and say okay I understand you've been through a lot so many different visits so many different infections.
• 14:12
  If we look at the cost of apacryl per month long term for your say non seasonal allergic pet and say they can't dollar a gtast the diet they can't do a diatriil if we look at the cost of that if your pet successfully is managed with that treatment in the long run and instead of seeing me once a month and having to do zytology and treat infection what if they only break out twice a year you know versus all the time.
• 14:39
  If those repeat cost of the veterinary visit the zytology that antimicrobials if those are also not cheap if we are not having to spend the money on that as much sometimes it's more cost effective for the owner and they just didn't think about that.
• 14:54
  So we have to look at yes as medication per month we have to make sure it's somewhat fits within the budget but also explain you know versus on their medications if one's well tolerated and maybe more expensive but you know we don't have to monitor as much lab work or the pet won't break out as much as they don't want to come spend the cost to see me as often maybe it's actually more cost effective in the long run for that pet.
• 15:16
  So we have to look at the acute cost but also the long term cost for that pet and that's where we just have to really decide what makes sense.
• 15:26
  So I love allergy testing but if an owner says that it's not realistic for them to be able to put the cost in allergy testing because remember we allergy test to put them on immunotherapy therapy.
• 15:38
  So if they can't commit to immunotherapy or finances are tight and you know for something that they're not sure how well it's going to work until they put a year of time into it that's not the right decision but I'm not going to push them to allergy testing.
• 15:51
  We might educate on it in case in the future that becomes an option but we're going to focus on the things that we actually can do to symptomatically help that pet and then over time I'll keep coming back to it if it does become a realistic option for the owner.
• 16:05
  When we start getting into resistant infections you know of course culture and certain antibiotics those can add up to those cost effective options we always can consider for things like a resistance to superficial pyiderma.
• 16:18
  Topicals you know if I have a pet who's not responding owner can afford a culture you know they could really get strung on you know every day every other day for accident bathing the loop bleached the loop bleached is very cheap it's time consuming and owners have to you know be careful about staining things but it's very cheap so there are ways we can try and even these difficult situations to make sure it's cost effective for the owner.
• 16:43
  So that is a little snippet into what I'll be speaking of in a longer format when I'm at the World Congress of Veterinary Nermontology in Boston and July.
• 16:53
  How to make dermatology cheaper cheap being cytology history examination assessment implant.
• 17:01
  So if you want to hear more expanded version of that I have one more talk I'm doing and also so many other wonderful talks are being given you know at the World Congress of Veterinary Nermontology.
• 17:12
  I really encourage you to meet in Boston meet all your fellow term nerd friends in Boston and come just get some of the best education you're going to get when it comes to veterinary dermatology and I hope to see you all there and see you hopefully at my lecture.
• 17:26
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