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Our team at dvm360.com and Firstline magazine asked practice manager Emily Shiver to answer your questions about life in practice for managers, technicians, assistants, client service receptionists and more. Got a question for her? Email us at firstline@mmhgroup.com.

Let’s face it. Many clients are extremely emotional— especially about finances— often making discussing treatment plans an arduous task. Here are some proven tips that will help you present these plans like a pro:

Familiarize yourself with the treatment plan before discussing it.

Sit next to or kneel beside the clients so that you are at eye-level with them.

Use terms the clients will understand and be descriptive with your explanations.

Once you finish discussing the plan, ask the client if they have any questions or concerns.

In a perfect world, the pet owner would respond positively, sign the treatment plan, and allow you to begin treating their pet. 7 out of 10 times— this is 

 the case— especially in an emergency situation. However, don’t panic—all is not lost. Instead of being intimidated, be empathetic. Let them know that you are committed to working through the treatment plan with them.

Here are some common client concerns about treatment plans and what to do about them.

Review all payment options with clients. (CareCredit, ScratchPay).

Prospectively, the doctor can have a Plan A or Plan B.

Be transparent about additional costs throughout treatment duration and the potential for recurrence. I do caution you at this step. I say this in my practice weekly—a feline urinary obstruction is a lot different than a laceration repair. If the client scrapes together the money to catheterize and hospitalize their pet, there is no guarantee they won’t be dealing with this same issue in 4 to 6 weeks. Make sure you have this conversation with them 

 moving forward with the initial treatment.

Walk them through the steps of the treatment in detail.

Try saying the following empathetic statements to calm you client’s fears:

“I know this is a hard decision, I am here to support you.”

“I share your concerns about Taylor. I will provide all the information you need to make an informed decision.”

“It sounds like you are overwhelmed with the options I have presented to you. I am committed to being by your side as you make this decision. How can I help?”

Additionally, if euthanasia is a humane option, then include it in your treatment plan options.

Presenting treatment plans with empathy and compassion helps to eliminate some of the stress of this delicate discussion. It also potentially erases the “all you care about is money” connotation. Remember to never pressure or guilt your clients into making a decision. The goal is to work together to achieve the best possible outcome for their pets.

Emily Shiver, CVPM, CCFP, is practice manager at Cleveland Heights Animal Hospital in Lakeland, Florida

Articles

My veterinary team is very uncomfortable going over treatment plans. What tools can I give them to be more successful?

Ask Emily: How to discuss treatment plans

With Thanksgiving only days away and COVID-19 cases spiking around the country, it's more important now than ever to keep you up to date with the latest pandemic news and our coverage of the veterinary industry.

, the first drug specifically approved for weight loss management in cats with chronic kidney disease (CKD).

Bond Vet, which launched its first clinic in June 2019, recently raised 

$17 million to open 10 or more veterinary clinics 

Second-year veterinary student Mariacamila Garcia Estrella shares her 

dos and don’ts for communicating with Latinx veterinary clients

News wrap-up: This week's headlines, plus how to communicate with Latinx pet owners 

There’s been a lot of talk in the veterinary profession about telemedicine, particularly since the start of the coronavirus disease 2019 (COVID-19) pandemic. But does it really live up to the hype? According to telehealth expert, Aaron Smiley, DVM, chief of staff at Devonshire Veterinary Clinic in Anderson, Indiana, and President of the Indiana Veterinary Medical Association, it does.

While veterinarians are good at offering free telemedicine services, they aren’t so good at monetizing their remote expertise, Smiley said at the 

 virtual conference. But incorporating telemedicine into your practice not only saves you time, it generates new revenue and makes clients happy.

During his lecture, Smiley outlined the benefits and explained how to incorporate paid telehealth services at your clinic, using real data to support his claims. (To learn more about how veterinarians are utilizing telemedicine during COVID-19, check out 

With so many people fostering and adopting pets during COVID-19, teams at many veterinary clinics are burning the candle at both ends to match the high demand, said Smiley. But how can you take care of clients who have been with you forever 

 accommodate new ones with this large influx of patients? Smiley says the answer is asynchronous, paid telemedicine.

Asynchronous telemedicine involves interacting with your clients conveniently and efficiently via a telehealth app like 

, and others. Instead of being glued to your computer, clients are sending you images, videos, and messages at different times throughout the day, allowing you to juggle other appointments and work-related tasks.

“Most of the time, we think of telemedicine as being synchronous, sitting down at a computer and doing a video consult with a client,” said Smiley. “But veterinarians do not have to do consults this way. On the human side, insurance companies require synchronous telemedicine for reimbursement but veterinary medicine does not have that constraint.” If you’re looking to convert to paid telemedicine, use asynchronous telemedicine, he advised. Don’t schedule time for live telemedicine video chats, he explained. “Veterinary patients do not ‘perform’ well on-demand, clients are busy, and most veterinarians do not have extra time in their calendars to block out synchronous telemedicine appointments."

About half of Smiley’s daily cases load is managed via telemedicine. “That’s a big chunk of my practice that’s remote,” he said. “Telemedicine is a supplement to traditional practice and will never replace a physical exam but it does help us to meet the needs of many of our clients and patients.” Asynchronous telemedicine is also efficient for your front desk staff. Instead of your receptionist going back and forth with clients on the phone about medical concerns that they cannot directly answer, asynchronous telemedicine allows clients contact the doctor directly.

Veterinary telemedicine is not new. It has been offered and proven to be a vital tool by generations of veterinarians, said Smiley. Our profession has been offering telemedicine to our clients and their animals since the advent of the telephone. Here are some specific medical recheck issues where Smiley utilizes paid telemedicine:

 We offer to interpret glucose curves via paid telemedicine.

Ask owners to send you a message/video of any seizure after you start medical management.

Monitor arthritis therapy with a video of the animal moving in its “natural” environment.

Ask the owner to send a video of the animal breathing to appreciate the resting respiratory rate.

Seasonal allergies can be reevaluated with pictures and videos of the animal.

Recheck the animal with a video or picture of the infected area to confirm that therapy is effective.

Sometimes, when veterinarians discuss diagnosing patients remotely, there is a fear of the worst-case scenario. Smiley calls this the “what-if” game.“What if I miss something? What if I need a diagnostic test like blood work?” “What if the client doesn’t tell me everything I need to know? ”Smiley’s argument is that he uses the same medical knowledge for a remote and an in-person exam. He collects a history, observes the pet, talks to the owner, and then uses those building blocks to create the most appropriate plan for that patient.“ If you’re going to play the what-if game for virtual exams, you have to ask the same questions of yourself for the in-person exam,” said Smiley, adding that the complexity of treating a live animal ensures that veterinarians will never be able to fully satisfy every “what-if” question, regardless of the type of exam or number of diagnostic tests.

Smiley examined 2560 telemedicine cases with clients with whom he has an established veterinarian-client-patient-relationship. Here is the breakdown of the types of cases they were:

10%: Courtesy tele-triage with technicians/nurses

“This is what you are doing in small animal practice every day,” said Smiley.

Here’s a look at some of the conditions Smiley diagnoses remotely:

The dog is bright, alert, and the owner has a history of feeding something they ought not too, said Smiley

 A video with the flash on typically allows good visualization of the vertical ear canal. If a cytology is needed, you can ask the owner to schedule a nurse/technician appointment and have the results sent back to the doctor and owner through the telemedicine app.

 “I think veterinarians can diagnose arthritis (especially feline) better when the exam is done remotely because animals are more comfortable at home and do not hide their pain as often,” said Smiley.

 A picture of caudal dorsal alopecia is almost pathognomonic for fleas.

Telemedicine consults can seem like a huge time sucker, but remember, it’s all asynchronous, said Smiley. The average length of 1 of his consults is about 271.65 minutes. That may sound like a lot, but it equates to him sending about 12 messages and the client sending 9 messages. Again, these messages aren’t always back to back and might be stretched out over the course of a few days, he explained. It depends on how busy the client is and how busy you are. Additionally, Smiley receives an average of 1.5 videos and 2.5 photos per telemedicine consult.

The biggest impediment to paid telemedicine is that veterinarians don’t always realize that they’re worth it, said Smiley. “When veterinarians forget their worth, they become blinded to the high value animal owners place on their medical expertise. Veterinarians revert back to the misconception that a client will only pay for services when they are rendered in-person,” Smiley said. “But it’s not true. You are worth it, and your clients are willing to pay for it.”

Using data from more than 2500 cases, Aaron Smiley, DVM, explains how adding paid telehealth services improves veterinary practice workflow, increases revenue, and boosts client satisfaction.

Monetizing veterinary telemedicine: It can be done

Bond Vet, which launched its first clinic in June 2019, recently raised $17 million to open 10 or more veterinary clinics by the end of 2021. The New York-based animal health company says private investment firm Talisman Capital Partners will pay for the expansion after a Series A funding round.

“We’ve seen more than 13,000 pets since we launched our very first clinic, and it’s clear that there is consumer demand for a new kind of veterinary experience," says  Bond Vet cofounder and chief executive officer Mo Punjani. “This round of funding will help us to continue realizing our mission to elevate and enhance the veterinary space.”

Since its initial launch last year, Bond Vet has provided both urgent 

 primary care, according to a company release. Additionally, walk-ins and scheduled appointments are welcomed in most of their locations without the need for membership.

With the veterinary profession notorious for 

high burnout rates, compassion fatigue, suicide, and depression

, Bond Vet says it’s also dedicated to the wellbeing of its employees—which, in turn, allows them to provide exceptional care to their patients.

“To date, we’ve built an incredible team of veterinarians, nurses, veterinary assistants, and care coordinators with a new, differentiated approach, making us one of the largest veterinary employers in New York City," says cofounder and chief veterinary officer of Bond Vet Zay Satchu. Satchu also vows to develop exceptional staff and patient care by hiring, cross-training and utilizing the company’s robust continuing education program.

“We believe the best way to drive a best-in-class experience for pets, pet parents, and our team members is to do it from the ground up. The Bond Vet team has done exactly that, and we’re excited to expand our impact in the industry,” says Matt Bennett, a partner at Talisman Capital.

The animal health company plans to open at least 10 clinics by the end of 2021.

Bond Vet raises $17 million towards veterinary hospital expansion

The US Food and Drug Administration (FDA) announced last month the approval of Elura, the first drug approved specifically for weight loss management in cats with chronic kidney disease (CKD).

Cats with CKD may begin to lose weight prior to diagnosis and typically continue to lose weight as the disease progresses, thus worsening their prognosis and shortening their lifespan.

“Capromorelin is a ghrelin receptor agonist known to increase appetite and weight gain and is approved as 

 for appetite stimulation in dogs. Elura is the second product that the FDA has approved for the management of unintended weight loss in cats,” according to the 

Elura’s safety was evaluated in a 56-day study in which the drug was administered to cats with unintended and documented weight loss and a history of CKD. Researchers found that cats receiving Elura had gained weight and cats in the control group had lost weight.

Additionally, a 6-month safety study of healthy domestic shorthair cats dosed with water or Elura at 1, 3, or 5 times the labeled dose of 2 mg/kg once daily, found that Elura caused weight gain in all treatment groups. Additionally, cats in groups given 3 and 5 times the labeled dose of Elura consumed more food than cats in the other groups.

The most common adverse reactions associated with Elura in both studies were vomiting and hypersalivation—both were seen more frequently in male cats.

Elura is available by prescription only, as it should be administered only by veterinary personnel with the expertise to ensure safe use of the drug, assess the patient for contraindications and monitor for adverse reactions. The drug is supplied in 15 mL bottles with an oral dosing syringe.

Elura increases appetite and weight gain in cats suffering from chronic kidney disease.

FDA approves weight loss management drug for cats with CKD

Providing relief for animal suffering is an important component of the Veterinarian’s Oath and a common aspect of practicing veterinary medicine. At the inaugural Fetch dvm360® virtual conference, veterinary pain management expert Robin Downing, DVM, MS, DAAPM, DACVSMR, CVPP, CCRP, presented a multimodal approach to both acute and chronic pain management in dogs and cats.

According to the International Association for the Study of Pain (IASP), pain is defined as an unpleasant and emotional experience associated with actual or potential tissue damage.

 The IASP further explains that the inability to communicate in no way negates the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment. This is particularly applicable for veterinary patients, which lack the ability to communicate in a traditional way yet still experience pain. Downing reminded attendees of the old Buddhist proverb “Pain is inevitable. Suffering is optional.” It is our duty to prevent suffering in our patients.

Downing described pain as a complex and 3-dimensional experience. The first dimension is the sensory component, which is the traditional informational component of pain. The second is the emotional dimension that occurs with suffering. The third is the cognitive component, in which past experiences of pain can influence both future perceptions of pain and assessment of perceived threats.

Pain is categorized as either adaptive or maladaptive. According to Downing, adaptive pain is the pain that protects us, and the same holds true with our pets. The types of pain that fall into this category are transient nociceptive pain in response to a noxious stimulus (such as what occurs as a warning sign to avoid further injury) and inflammatory pain. By contrast, maladaptive pain has no such beneficial effect, and pain in this category is considered pathological. Neuropathic pain, functional pain, and windup pain are all types of maladaptive pain. In the case of windup pain, the area of perceived pain expands beyond the original site of pathology due to sensitization of nociceptors in the peripheral and central pain pathways, in response to a barrage of afferent nociceptive impulses. Any of these types of maladaptive pain may become chronic.

Studies have shown the beneficial results of administering intraoperative local analgesia to prevent chronic pain. Intraoperative local analgesia can lessen the occurrence of chronic pain postoperatively, lower the doses of postoperative analgesics needed to control pain, and improve patient outcomes.

Identifying pain in our patients can be clinically challenging, and pain is easily overlooked. Using a systematic approach, Downing starts her assessment with a thorough physical examination. Patients exhibiting the third dimension of pain—in which their past pain experience is triggering fear, anxiety, or stress (eg, the perception of threats)—may require alterations to your diagnostic plan. This is a cyclic when anxiety exacerbates pain, and pain exacerbates anxiety. Previously complacent pets may now exhibit fear in these situations due to the presence of pain.

Give any pet that is reluctant to be handled the benefit of the doubt that they may be in pain and may require analgesic treatment before continuing with diagnostic tests. In these situations, consider which components of your plan for that visit are truly necessary at that time. Postpone any procedures or diagnostic tests that are not deemed necessary until pain control has improved, and the patient is more tolerant and less stressed.

A diagnostic plan should be determined as appropriate for the patient, in order to reach a diagnosis. As Downing noted, the reason for this is to ensure proper treatment of the appropriate underlying condition. For example, suppose you forgo diagnostic radiographs in a dog experiencing lameness. In that case, you may miss osteosarcoma and head down an inappropriate treatment path that could result in treating the patient for osteoarthritis, missing the true problem, and whittling away at a prognosis that was already limited. Once you have determined the location of the pain, the underlying cause, and whether the pain is acute or chronic, you can develop a plan to address the pain directly.

Chronic pain is best addressed using a multimodal management plan. Patients with chronic pain are typically less active and often overweight. This cycle can resemble the chicken and egg dilemma. In general, overweight patients put more stress on their joints, are more prone to injuries, and may develop chronic pain. Likewise, patients with chronic pain will be less active and thus prone to weight gain. Regardless, normalizing body condition is crucial. In dogs, also ensure the patient is not hypothyroid and treat as appropriate. (Don’t be fooled by euthyroid sick syndrome, which can occur when patients are painful).

Ultimately, with chronic pain, there is a need to break the pain cycle pharmacologically. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the cornerstone of pain management, for both chronic and acute pain. NSAIDs decrease inflammation and modulate pain at various levels of the central and peripheral nervous system. Some patients may have experienced a previous failure or sensitivity to an NSAID. This does not mean they will have a similar failure or reaction with another NSAID. In these cases, Downing feels it is worth attempting therapy with a different class of NSAID; however, if a sensitivity occurs again, eliminate NSAIDs as a viable option.

Another target for maladaptive and chronic pain is the dorsal horn of the spinal cord. Targeted therapy would include such medications as gabapentin and amantadine. According to a study Downing conducted, the appropriate gabapentin dosage for maladaptive pain is 5 to 10 mg/kg orally every 8 to 12 hours, titrated up to effect.

Beneficial effects may be noted within 24 to 48 hours but reach steady state with peak activity in 10 to 14 days. Gabapentin is safe for long-term use, but do not discontinue the drug abruptly or rebound pain may occur. Sedation is the primary side effect and is typically transient. Persistent sedation can be addressed by dose reductions. Amantadine is an N-methyl-D-aspartate antagonist and may be used in combination with NSAIDs and gabapentin. Amantadine is also well tolerated for long-term use and is typically dosed at 2 to 5 mg/kg per day orally. Downing noted that, in a study of dogs with osteoarthritis of the stifle and elbow, tramadol was shown to have no effect on pain management and is not recommended.

Polysulfated glycosaminoglycan (Adequan; American Regent Animal Health) is also useful in dogs and cats. Polysulfated glycosaminoglycans are the building blocks of cartilage. Although they do not replace lost cartilage, they can heal microfractures and have indirect anti-inflammatory effects. Downing uses an extralabel dosing scheme of 2 mg/lb subcutaneously twice weekly for 4 weeks, then once weekly for 4 weeks, then every 10 to 15 days as maintenance. She prefers to dose Adequan subcutaneously rather than intramuscularly. As an injectable option, this may be of particular value in cats that do not tolerate oral medication administration.

Evidence varies for the value of nutraceuticals in chronic pain. Among the discussion points in her talk, Downing cautioned attendees in using the triglyceride formulation of omega-3 fatty acids because the esterized formulation is not bioavailable. There is some evidence that undenatured collagen type II (UC-II) may slow deterioration of articular cartilage in rodent models by promoting anti-inflammatory cytokines.

Microlactin is a milk protein for hyperimmunized cows that has immunomodulatory effects that decrease destructive chronic inflammation. As this is a different pathway and mechanism of action than NSAIDs and corticosteroids, it can be used in conjunction with either of these. The initial effect is seen within 5 to 7 days, with peak effects within 10 to 14 days. Side effects are typically minimal and limited to sporadic gastrointestinal signs. 

 contains the essential fatty acid eicosapentaenoic acid and can be used with hyaluronic acid of the appropriate molecular weight.

Downing emphasized that it is the formulation and manufacturing process, not just the ingredient, that is important when considering nutraceuticals for pain management. All of these products must be manufactured in a way that does not denature the compounds or interfere with their efficacy. For this reason, efficacy tests should ideally be conducted for each formulation used.

Downing acknowledged that, as part of the multimodal approach to managing pain, physiotherapy also has a role and should be incorporated into pain protocols. A plethora of modalities and tools can be used to manage pain. Assistive devices such as wheelchairs, slings, supportive vests, rolling carts, and wagons also play a role in managing patients with chronic pain that require mobility assistance. Modifications to the home environment play a role as well. Pet owners should be encouraged to videotape their home environment, so that you can assess for items that should be modified (eg, raise food and water dishes, cover slick floors, secure access to stairs, use ramps, modify play with other pets in the household).

The most important aspect of pain management is breaking the pain cycle by first capturing and controlling the pain. Once pain is controlled, medications can be titrated to the lowest effective dose. This is typically only possible after employing multimodal pain management protocols.

IASP announces revised definition of pain. International Association for the Study of Pain. July 16, 2020. Accessed November 10, 2020. 

https://www.iasp-pain.org/PublicationsNews/NewsDetail.aspx?ItemNumber=10475#:~:text=The%20definition%20is%3A%20%E2%80%9CAn%20unpleasant,pain%20for%20further%20valuable%20context.&text=Pain%20and%20nociception%20are%20different%20phenomena

Andreae MH, Andreae DA. Local anaesthetics and regional anaesthesia for preventing chronic pain after surgery. 

. 2012;10:CD007105. doi:10.1002/14651858.CD007105.pub2

Davis LV, Hellyer PW, Downing RA, Kogan LR. Retrospective study of 240 dogs receiving gabapentin for chronic pain relief. 

Budsberg SC, Torres BT, Kleine SA, Sandberg GS, Berjeski AK. Lack of effectiveness of tramadol hydrochloride for the treatment of pain and joint dysfunction in dogs with chronic osteoarthritis. 

 2018;252(4):427-432. doi:10.2460/javma.252.4.427

Bagi CM, Berryman ER, Teo S, Lane NE. Oral administration of undenatured native chicken type II collagen (UC-II) diminished deterioration of articular cartilage in a rat model of osteoarthritis (OA). 

 2017;25(12):2080-2090. doi:10.1016/j.joca.2017.08.013

Rebecca A. Packer, DVM, MS, DACVIM (Neurology/Neurosurgery), is an associate professor of Colorado State University College of Veterinary Medicine and Biomedical Sciences in Fort Collins. She is active in clinical and didactic training of veterinary students and residents and has developed a comparative neuro-oncology research program at Colorado State University.

Understanding the nuances of modern pain management can help you identify targeted treatments for your patients. 

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