Being a veterinarian can seem like an impossible job most days. Who else juggles being a dentist, dermatologist, orthopedic specialist, cardiologist, surgeon, oncologist, radiologist, and mind reader to a patient that can’t talk?

Veterinarians tend to be honest, caring, selfless, hardworking, and creative problem solvers (think James Herriot), but many of us have sky-high debt and constantly face pushback from clients about the costs of specialized care. Pet owners want it all, but they do not want it to cost too much.

Although the coronavirus disease 2019 (COVID-19) pandemic has only added to these challenges, it presents a unique opportunity for us to improve our boundary setting and our people-pleasing natures, gain perspective on what we can and cannot control, and take care of ourselves so we can take care of others.

With people spending more time at home with their pets, the human-animal bond is stronger than ever, making the service we provide essential. The work we do benefits the mental health of our human clients just as much as it does the physical health of our patients.

If you or your team members are suffering from compassion fatigue during these unprecedented times, tap these 5 useful strategies to help everyone come out on top.

Investing in your well-being has never been more crucial. Try to find an activity that refreshes you. I have found a 2- to 5-minute meditation first thing in the morning very helpful (the Calm app is great). If meditation does not appeal, I have also found leisure reading (not the internet, and not about COVID-19) calming. Online exercise classes or even a morning walk or jog can be incredibly mind-clearing. Whatever you choose, make sure it is something you can maintain. Create a routine and follow it daily. Remember, you have to put the oxygen mask on yourself before you can help others. Self-care is not selfish; it is necessary.

Compassion fatigue may look different during the pandemic. For example, your team may be manifesting it in new ways such as making mistakes, being more withdrawn, or having problems focusing and staying on task. Pay attention to all signs of isolation, anxiety, and stress. 

As leaders, veterinarians should regularly check on their teams and maintain open communication. A simple “Hey, are you having a rough day?” goes a long way.

COVID-19 significantly affects our clients as well. Many are experiencing financial strain, hindering their ability to pay for veterinary care. Some clients are delaying elective items and other less urgent services. Acknowledging that clients are coping with their own anxiety and stress helps us not to absorb all the responsibility for things beyond our control.

. Telehealth has become an increasingly popular platform during the pandemic. Not only did it allow us to continue providing quality care to patients, but it has increased client loyalty. I like to think of telemedicine as a client gratitude builder during COVID-19 and suspect the trend will continue far beyond the pandemic. It is also important to note that placing value on our services and receiving income for client-driven telemedicine consults is beneficial to our profession. Telemedicine helps us set appropriate boundaries with clients and to stop giving away our time and expertise for free.

Additionally, clients love participating in their pets’ appointments and are so appreciative when they are able to watch the examination.

 We have fully transitioned to inpatient drop-off and curbside protocols, and it appears we will not be doing otherwise anytime soon. Many veterinarians are discussing ways to maintain curbside protocols beyond the pandemic.

Although curbside care has inconveniences, such as a lot of walking between the office and parking lot, it can also streamline workflow and reduce stress. Using telemedicine to connect with clients during curbside appointments has been exceedingly helpful. Utilizing a videoconference app (my practice uses 

) to take a history, ask questions, and perform an examination in front of the client is far more efficient and less time-consuming than going back and forth on the phone throughout the curbside appointment. It has also helped our new clients to feel connected to the appointment, even though they are parked outside.

 I have developed the following internal mantra during COVID-19: I can do anything for a short time. That needs repeating. I can do anything for a short time. This mantra reminds me that the pandemic will eventually pass, and when it does, I believe our teams and practices will be stronger and more committed than ever.

Amy C. Garrou, DVM, is Medical Director at Washington Heights Veterinary Clinic in Houston, TX. Her areas of interest include internal medicine, endocrinology, soft tissue surgery, cardiology, and telemedicine. She is a member of the American Veterinary Medical Association, the Texas Veterinary Medical Association, the Harris County Veterinary Medical Association, the Veterinary Information Network, and the International Association of Veterinary Pain Management. She serves on the board of the Houston Zoo, YPO (formerly Young Presidents’ Organization), Gulf States Chapter, and the Harris County Veterinary Medical Association.

Articles

One veterinarian offers advice on coping with pandemic pressures while strengthening well-being among team members.

5 strategies to help avoid compassion fatigue during COVID-19

During the past decade I’ve treated thousands of pruritic dogs and cats, some with very extreme presentations, and lengthy diagnostic and therapeutic histories. Regardless of how mundane or shocking the presentation, I rely on a steadfast diagnostic foundation to ensure that no diagnoses are missed. My passion is not dogma; rather, it’s the art of communication and tailoring therapy to meet the needs of patients and clients. With these principles firmly in place, I confidently enjoy even the most challenging of cases, placing focus on the client and the patient.

The first thing to keep in mind is that pruritus control, when strategically executed, does not interfere with the diagnosis. Rather, it enhances client adherence and confidence.

Look for lesions associated with folliculitis, such as patches of alopecia, papules, pustules, crusts, comedones, or collarettes. If any of these are present, perform multiple deep skin scrapes for Demodex (D canis and injai in dogs, and D cati, albeit rare, in cats). Obtain multiple cytologic preparations to assess for staphylococcal infection. In cats, crusted papules may arise due solely to hypersensitivity, or they may represent staphylococcal infection, so remember to look.

Consider a dermatophyte culture with or without polymerase chain reaction (for a rapid result), particularly if no Demodex or cocci are found. Should your cytologies, deep skin scrapes, and dermatophyte culture provide no diagnosis, then perform multiple skin biopsies, because your patient may have a less common diagnosis such as pemphigus foliaceus, sebaceous adenitis, or cutaneous lymphoma.

Also examine your patients for nonspecific inflammatory lesions, including patchy erythema, lichenification, and seborrhea. Consider impression smear or acetate cytology to assess for bacterial and/or Malassezia surface overgrowth. Perform deep skin scrapes for Demodex as well as superficial skin scrapes to assess for Cheyletiella, Sarcoptes (dogs), and D gatoi (cats). and D gatoi (cats). 

Superficial scrapes do not yield reliable results for 2 pruritogenic mites: Sarcoptes scabiei in dogs and D gatoi in cats. Of note, D gatoi may mimic the classic “fur mowing” presentation of feline hypersensitivity. Diagnosis is frequently made via response to therapy. The isoxazolines work well against both mites.

Ensure that strict flea control is in place for all dogs and cats in the home. I particularly like the isoxazoline products (eg, Simparica; Zoetis) for parasite prevention.

Treat secondary Staphylococcus and Malassezia for a minimum of 2 weeks and recheck the patient during therapy. Infections enhance dermatitis severity and confound interpretation of ectoparasite control and elimination diet trials. Once infections are resolved, if you are pursuing a diet trial or have diagnosed the patient with atopic dermatitis (environmental allergy), consider preventive maintenance topical therapy at least twice weekly in key areas of recurrent secondary infection (eg, miconazole and chlorhexidine wipes on the interdigital spaces).

Food allergy is diagnosed via an 8-week elimination diet trial, and atopic dermatitis is a diagnosis of exclusion. Allergy testing for the diagnosis of atopic dermatitis, whether intradermal or serologic, is not reliable because false positives do occur. I use these tests solely to identify allergens for inclusion in immunotherapy. If you have performed your baseline diagnostics and are still unsure about the diagnosis, consider referral to a dermatologist.

Rapid and reliable canine itch relief options include oclacitinib (Apoquel; Zoetis), lokivetmab (Cytopoint; Zoetis), and systemic corticosteroids (eg, oral prednisolone). Oclacitinib and lokivetmab are well tolerated and efficacious, and do not require a washout period or discontinuation for allergy testing. Treatment is chosen based on patient factors and client preference. For patients aged less than 1 year, I prescribe lokivetmab. It is prudent to rule out demodicosis prior to prescribing oclacitinib or corticosteroids.

Rapid and reliable chronic atopic dermatitis options for dogs include lokivetmab, oclacitinib, modified cyclosporine (Atopica; Elanco), and allergenspecific immunotherapy. Immunotherapy can take up to a year to provide noticeable benefit, so I invariably initiate immunotherapy with concurrent antipruritic therapy. If corticosteroids must be used, try to reduce the dose to the lowest every-other-day dose possible to reduce adverse effects, such as calcinosis cutis.

Rapid and reliable itch relief options for cats include systemic corticosteroids (eg, oral prednisolone, dexamethasone) and oclacitinib. Of note, although oclacitinib is not approved in cats, recent studies support its efficacy

 in feline hypersensitivity, as well as its safety

supports a more frequent and higher dosing schedule in cats compared with dogs. Doses documented include 0.4 to 2 mg/kg every 12 to 24 hours.

 The 2-mg/kg dose has been associated with gastrointestinal upset.

 I typically start at 0.5 to 1.0 mg/kg twice daily for 1 to 2 weeks followed by daily therapy. It has been well tolerated in my patients. Long-term tablet therapy may prove difficult for clients and their cats.

Treatment options for chronic atopic dermatitis in cats include cyclosporine, allergen-specific cyclosporine, and allergen specific immunotherapy. With regard to the safety of oclacitinib in cats, information is limited to 3 studies, all spanning a period of 28 days.

 Therefore, it is prudent to consider baseline complete blood cell count, chemistry, and urinalysis findings and repeat these tests every 3 to 6 months initially, and in otherwise healthy patients perhaps consider at least annual monitoring. As with dogs, if long-term corticosteroids are used in cats, use the lowest every-other-day dose required to provide acceptable relief.

Moderately to severely affected dogs will require maintenance administration of 1 of these therapies for good control. The addition of weekly bathing with a moisturizing shampoo, daily fatty acid therapy, and topical antimicrobials and barrier restoring (eg, phytosphingosine) optimizes control. Even with consistent treatment, breakthrough itch will occur periodically occur and may prompt temporary or longer term changes in therapy.

Antihistamines provide lackluster results, so I do not recommend them for acute pruritus. Chronic administration of antihistamines as an adjunct immunotherapy and/or fatty acid regimen may help reduce pruritus and have a steroids paring effect. Studies regarding pharmacokinetics and efficacy of antihistamines are relatively few. The most evidence based in the dog are hydroxyzine and chlorpheniramine.

Ortalda C, Noli C, Colombo S, Borio S. Oclacitinib in feline nonflea-, nonfood-induced hypersensitivity dermatitis: results of a small prospective pilot study of client-owned cats. Vet Dermatol. 2015;26(4)

Noli C, Matricoti I, Schievano C. A double-blinded, randomized, methylprednisolone-controlled study on the efficacy of oclacitinib in the management of pruritus in cats with nonflea nonfood-induced hypersensitivity dermatitis. Vet Dermatol. 2019;30(2):110-e30. doi:10.1111/ vde.12720

Lopes NL, Campos DR, Machado MA, et al. A blinded, randomized, placebo-controlled trial of the safety of oclacitinib in cats. BMC Vet Res. 2019;15(1):137. doi:10.1186/ s12917-019-1893-x

Ferrer L, Carrasco I, Cristòfol C, Puigdemont A. A pharmacokinetic study of oclacitinib maleate in six cats. Vet Dermatol. 2020;31(2):134- 137. doi:10.1111/vde.12819

Eichenseer M, Johansen C, Mueller RS. Efficacy of dimetinden and hydroxyzine/chlorpheniramine in atopic dogs: a randomised, controlled, double-blinded trial. Vet Rec. 2013;173(17):423. doi:10.1136/ vr.101907

Tips for providing optimal diagnostics and treatment for your veterinary patients with skin concerns.

Think like a dermatologist: untangling itch

To fully maximize your veterinary practice, the first step is: knowing why you’re in business and understanding the value of your practice, according to cofounder of Florida Veterinary Advisors, Tom Seeko.

In his talk with Adam Christman, DVM, MBA, Seeko breaks down 4 key strategies to maximize your practice and build your net worth, and they are as follows:

One of the biggest threats to practice owners, says Seeko, is that most don’t know the value of their business. “It’s surprising how many times the [practice owners] we bump into have never had a real evaluation.”

 Cashflow is vital to your business, so make sure you’re not spending money on unnecessary things, have clean records, and know how much you are saving, Seeko tells Christman. 

Understand how you’re spending money on employees. 

Be familiar with all employee salaries and make sure you have adequate staff. 

A lot of practices don’t have enough staff to support the overall inflow of business that they’re getting,” says Seeko.

Many practice owners wait until they’re ready to leave a practice before creating their exit strategy. But according to Seeko, everyone should have an exit plan right when they get into business.

Listen below to learn more about these 4 strategies and how to implement them at your clinic.

Podcasts

On this episode of The Vet Blast Podcast, Dr. Christman is joined by financial advisor Tom Seeko, who discusses potential threats to your clinic, how to manage cash flow, and other ways to amplify your clinic.

Episode 37: 4 key elements to help maximize your veterinary practice

The American Association of Veterinary State Boards (AAVSB) announced recently the completion of the Standards & Policies for the much-anticipated PAVE (Program for the Assessment of Veterinary Education Equivalence) for Veterinary Technicians. The core mission of the new PAVE is to assess the educational equivalences of veterinary technician and nurse graduates on an international scale on behalf of participating AAVSB Member Boards, according to an 

PAVE evaluates the education equivalence of graduates of non-accredited veterinary programs outside the United States and Canada on behalf of participating AAVSB member boards.

 in the early 2000's, it was a game changer for both our Member Boards and licensure applicants,” says AAVSB president Roger Redman, DVM, in the release. “In the past few years, our membership has made it clear the demand to expand PAVE into the veterinary technician/nurse profession is immense.”

The PAVE for Veterinary Technicians certificate will be recognized by jurisdictions that accept it as substantiating the educational requirements as one criterion toward credentialing eligibility. The certificate is 

a credential to practice as a veterinary technician. To be credentialed to practice, candidates who receive the certificate must also meet additional statutory criteria, including successful completion of the Veterinary Technician National Examination (VTNE).

Since requirements vary from jurisdiction to jurisdiction, the AAVSB urges candidates to directly contact the specific veterinary board(s) in which they desire credentialing.

For more information about the new PAVE program, go 

PAVE for Veterinary Technicians is a new program formed to assess the education equivalence of international veterinary technician/nurse graduates.


AASVB unveils Standards & Policies for new PAVE for Veterinary Technicians

The trailer rolled into the clinic parking lot, eliciting sighs of amazement from a group of onlookers. Mr Pep was the client’s name, and he was bringing in his sick cow. The other clients who happened to be at the clinic with me stood with dropped jaws as he pulled across the expanse from the road to the building.

It’s not every day you see a cow riding on a flatbed trailer. This was no ordinary flatbed; it must have been 5 feet off the ground, and it had a cow strapped down on it with those “come along”–type straps that people use to bind round bales—not your ordinary bovine delivery method.

Pep had called early that morning to tell me that he had a “real sick” cow that I needed to come out and examine. My reply included phrases such as, “I’m really busy this morning. It will be quite a while before I can get away,” “It would be better if you could bring her in. I don’t want anything to happen to her, so we could get to her quicker if you could load her up,” and “Get her here as quick as you can.”

It was now 5:00 pm, and I had almost completely forgotten he had phoned.

Strapped to that trailer was the skinniest cow I had ever seen. She looked like something from an Ace Reid cartoon. Every rib was visible, and her flanks were so sunken they almost touched in the middle. I was amazed.

“What are you feeding her, Pep?” was all I could think to say as I stood over her.

“I got a giant pile of food for ’em out there,” he replied with great conviction.

“Do all of your cows look like this?” was the next logical question.

“No. About half of ’em are big and fat.”

I learned early on in my career that the last thing you ever want to do is argue with an opinionated cow raiser about nutrition. So I treated the cow as best I could, and Pep went merrily on his way.

Three days later, he called me to treat another cow. This time, things around the clinic were quiet, so I drove out to his place on the outskirts of Clarendon. Pep told me that the cow we treated at the clinic was much better, but another one had gone down, and 2 or 3 others were in bad shape. What I saw when I arrived amazed me. He must have had a hundred cows grazing in what looked like a junkyard.

As I stood in the middle of Pep’s “pasture,” I assessed the herd. He was right; some of the cows were big and fat, but others looked as poor as any cattle I had seen in my life. My mind raced with every diagnostic differential I learned during vet school. I considered disease, poisoning, old cows with bad teeth, and other afflictions with big, Latin-sounding names.

As I pondered the situation with perplexity, it suddenly hit me: All the fat cows were tall, and all the short cows were skinny. My eyes moved from cow to cow…tall cow, fat…short cow, skinny…tall cow, fat…short cow, skinny. There was no variance as I scanned the entire herd.

“Pep, where is this pile of food you told me about?”

As we rounded the corner, I found my diagnosis. There, about 10 feet behind the barn, was another flatbed that was 5 feet off the ground. A large group of the short cattle were straining their necks, trying to reach to the “giant pile” of food that the tall cows had eaten back from the edge.

I counseled Pep for a while about pushing that feed off the trailer so the short cows could get to it. I could tell he thought that was going to be too much work, but he grudgingly agreed that he would do something to remedy the situation.

I drove by Pep’s place about a month later and decided to stop by to see how the short cows were faring. He was nowhere to be found, so I drove on over to the pasture and checked on the cows. Things looked good—tall cow, fat…short cow, fat.

You’ll never believe how Pep had addressed the problem. There, in the same spot as before, was the flatbed trailer with a pile of food on it. The only difference was that Pep had apparently hired a backhoe to dig a pit into which he could park the trailer. Now the trailer was lower to the ground, and all the cattle could get to the pile.

They just can’t teach you stuff like this in vet school.

Bo Brock, DVM, owns Brock Veterinary Clinic in Lamesa, Texas. His latest book is Crowded in the Middle of Nowhere: Tales of Humor and Healing From Rural America.

Making the right diagnosis sometimes requires a site visit.

Tall Cow, Fat

We are proud to continue to serve you with veterinary education in print, online, and in person in 2021. As you read through our family of publications this month and this year, you might notice small shifts in coverage. One of our major initiatives is to make sure 

 ® provide their respective audiences with the news, clinical insight, and business information the entire veterinary team needs to stay up-to-date, practice your best medicine, and manage your business successfully. 

To that end, dvm360 ® will continue to serve as our primary news publication, covering the latest industry information, issues affecting the profession, research, and advances in veterinary medicine. We’ll also be hearing more of the veterinary student voice this year, with both commentary and clinical content from the youngest members of the profession. And we’re looking to include more of your voice in the magazine this year, so if you want to share your insight about a clinical topic or offer your thoughts about any of the issues facing our profession, let us know. 

 which is undergoing the biggest content shift of our publications, is now geared toward practice owners and managers, with financial, human resources, and other business-related content aimed at providing the tools you need to own and manage a successful veterinary practice. 

 will continue to include news, clinical, and career focused content that veterinary technicians, assistants, and other team members need to help them be more successful at work. And because they affect all areas of practice and all veterinary professionals, each of our publications will cover the all-important topics of wellbeing, leadership, and technology and innovation.

Our conferences have evolved throughout 2020 to match the landscape of our profession and our world, and that will continue in 2021. We are offering 2 virtual Fetch dvm360® conferences early in the year (February 25-27 and May 13-15) followed by several live shows starting in June in Indianapolis, Baltimore, Kansas City, Atlantic City, and San Diego. There truly will be something for everyone in either the virtual or live space.

I encourage you all to participate in the live webinars we host throughout the year. They are free to attend and cover such important topics as technology, clinical mysteries, parenting while practicing, diversity, and much more! You can also take advantage of our newly updated Continuing Education Center (connect.dvm360. com/cecenter), which offers a wide variety of RACE-approved clinical and business-related sessions for the whole team. We’ve even got you covered with The Vet Blast Podcast and live chats on Instagram (@dvm360mag).

We have truly put the “multi” in our medical multimedia company this year. Be sure to follow us on all of our social media platforms (Facebook, Instagram, LinkedIn, Twitter, and YouTube) and subscribe to our newsletters so you stay constantly in the know. Thank you for your continued support as we navigate 2021 together

On behalf of the dvm360® family, we want to wish you and yours a happy, healthy, and prosperous New Year.