Martha Friedman, DVM, DACVD
A veterinary dermatologist has specialized expertise and training in the diagnosis and management of animal skin, ear, hair and nail disorders; the most common of these is allergic skin disease. A board-certified veterinary dermatologist receives three to four additional years of training after receiving the DVM degree, including publication of original research and the completion of a specialty board examination. The goal of a veterinary dermatologist is to use this expertise to form a collaborative partnership with the primary care veterinarian (pcDVM), and improve both patient outcomes and the client experience.
Despite dermatologic conditions being one of the primary reasons that pet owners seek veterinary care, dermatologists experience one of the lowest referral rates among specialists. Why is this?
Often, there is an assumption that a client will not be interested in a referral if offered, or that referral could be harmful to the veterinarian-client-patient relationship and the practice’s bottom line. Despite these concerns, research continues to show that involvement of veterinary dermatologists in the management of relevant conditions improves the relationship between the pcDVM and the client and improves patient outcomes. So, when should you refer?
Client Factors
Maintaining Client Trust and Satisfaction
The pcDVM should first consider client driven factors, since even the most well-intentioned treatment plan can be overshadowed by poor client satisfaction. The American College of Veterinary Dermatology conducted the Collaborative Partnership Client Survey to examine these factors. This survey interviewed nearly 300 clients who had seen their pcDVM for a dermatologic problem in their pet, followed by subsequent care from a board-certified veterinary dermatologist. The survey found that most clients reached a tipping point of frustration if the pcDVM could not solve the initial complaint by the third appointment. A staggering 73% of clients reached this tipping point, leading many to seek a second pcDVM opinion and often to refuse to return to the original clinic, even for unrelated problems. Most clients were not referred to a dermatologist until at least the fifth appointment with the pcDVM. If instead these clients had been referred prior to the third visit, they would have ultimately saved an average of 25% in medical costs. You may risk increasing costs to the client and ultimately losing them by delaying a referral. The majority of clients reported they would have been more satisfied with their pcDVM if they had offered a referral or offered it sooner. If a referral is made early enough, it has numerous benefits, including improving client satisfaction, maintaining and restoring trust, saving the client money and preventing the loss of future revenue through client retention.
Despite dermatologic conditions being one of the primary reasons that pet owners seek veterinary care, dermatologists experience one of the lowest referral rates among specialists. Why is this? Often, there is an assumption that a client will not be interested in a referral if offered, or that referral could be harmful to the veterinarian-client-patient relationship and the practice’s bottom line. Despite these concerns, research continues to show that involvement of veterinary dermatologists in the management of relevant conditions improves the relationship between the pcDVM and the client and improves patient outcomes. So, when should you refer?
Poor Client Compliance
Many dermatologic conditions, notably allergies, are chronic and not readily curable. For this reason, excellent communication is necessary to manage client expectations, improve client understanding of the disease and ensure compliance. This can be VERY time consuming. If you find that the allotted appointment slots at your clinic are simply not adequate for the extensive communication necessary for successful management of dermatologic disease, a referral may be beneficial.
Common barriers to referral may include:
- Perception of higher costs associated with seeing a specialist
- Fear of looking less competent if a referral is made
- Fear of losing clientele and revenue
Patient Factors
Patient factors, such as clinical presentation and response to therapy, are equally important to assess when considering referral. The decision on when to refer is not always clear-cut, and will vary among veterinarians based on their personal comfort level with managing skin disease, performing and interpreting diagnostics and formulating treatment plans. It cannot be overemphasized that it is NEVER inappropriate or too early to offer a referral to a dermatologist. The following scenarios describe situations that should prompt discussion of referral with your clients:
Chronic and Recurrent Disease
If a patient’s dermatologic condition is not getting better, or it gets better but keeps coming back, consider referral. This scenario is most common with allergic skin disease causing chronic and recurrent itch, skin infections and ear infections. With chronicity comes secondary changes to the structure and integrity of the skin and ears, which can require even more complex infection management. Consider referring these cases early to avoid client frustration and to avoid the need for invasive procedures down the road (e.G., TECA-BO for end stage ear disease).
Allergy Testing
If you have worked up a presumably allergic patient and have concluded that the pet is suffering from atopic dermatitis associated with environmental allergies, consider referring them for allergy testing. Intradermal skin testing is considered the gold standard for allergy testing. While reputable serum tests do exist and can be performed in general practice, simply running the test does not equate to successful management of the allergic skin disease. Performing an allergy test is analogous to running a serum chemistry panel. The lab will tell you which values are abnormal, but expertise is required to interpret the results and formulate a treatment plan accordingly. The same is true for allergy testing. It has been shown that a larger proportion of tested patients are started on hyposensitization when testing is overseen by a dermatologist, leading to better compliance and more successful outcomes.
Failure to Achieve Expected Response
A patient’s initial presentation may seem simple enough; the tried and true treatment protocol is followed and success is expected. But sometimes, much to your dismay, the patient is back in your office the next month looking even worse. If the treatment is adjusted but clinical signs still fail to resolve, you should discuss referral with your client. One example scenario is treating a dog for presumed allergies when in fact the patient is suffering from cutaneous lymphoma. These two diseases can have similar clinical presentations that require a highly trained eye to distinguish them. Making this distinction as soon as possible is imperative since the treatment and prognosis for allergies and cutaneous lymphoma are drastically different. Regardless of why the pet fails to respond to therapy, there is no downside to offering a referral and getting a fresh set of eyes on the case.
Biopsy
Offering a referral prior to performing a skin biopsy may save you the frustration of receiving an inconclusive pathology report. The presence of a secondary infection may impede the pathologist’s ability to make a diagnosis and should be addressed prior to performing a biopsy. Also, when evaluating diffuse or multifocal dermatologic disease, sample selection is especially important. Pathologists are very reliant on the provided patient history, lesion description and clinical differential diagnoses. If you are not comfortable providing a complete list of appropriate differentials, referring the case may increase the likelihood of getting a definitive diagnosis.
Atypical Lesions
Depending on your comfort level managing immune- mediated and uncommon infectious diseases, you may want to consider referring if a patient presents with lesions indicative of these conditions. You should keep an eye out for lesions on the nasal planum, mucocutaneous junctions, paw pads, pinnae or in the oral cavity. Ulcerations, vasculitis, hyperkeratosis, bullae or multifocal draining nodules may also increase suspicion for these diseases.
Summary
It is never a bad idea or too early to refer to a board-certified veterinary dermatologist. The relationship you form with dermatologists in your area will enhance your practice in countless ways. Collaboration through referrals can serve to improve client satisfaction, improve patient outcomes and benefit all parties involved. Dermatologists in your area can be found at ACVD.org by using the “Find a Dermatologist” tab.
About the Author
Dr. Martha Lane Friedman earned her Doctorate of Veterinary Medicine from the Auburn University College of Veterinary Medicine. She completed an internship in Small Animal Medicine and Surgery at Louisiana State University, followed by a residency in Veterinary Dermatology. Dr. Friedman was board certified as a veterinary dermatologist by the American College of Veterinary Dermatology (ACVD) in 2017. She is currently providing veterinary dermatology services with Auburn Veterinary Specialists – Gulf Shores.