Coping with Cushings syndrome

Welcome to the team meeting on Cushing's syndrome, the most commonly diagnosed endocrine disorder. As dogs age, their health may change rapidly, so it's important to educate our clients about the signs of disease to help offer pets early diagnosis and treatment whenever possible. This chronic illness cannot be cured-it must be managed throughout the pet's life.

The four meeting parts below will help you educate your team members about this condition, including the importance of ongoing testing and treatment. You'll find a trainer's script and team activities in each section. We recommend beginning with part No. 1 then progressing through to part No. 4 to give your team the most complete understanding of the topic. Do this, and your team will have the tools to deliver a successful team-wide approach to Cushing's syndrome.

Press the links below to access the meeting tools.

Expert contributors

Thank you to the following experts for their contributions to the material for this meeting:

Audrey Cook, BVM&S, MRCVS, DACVIM-SAIM, ECVIM-CA

Clinical Associate Professor

Small Animal Internal Medicine

Department of SA Clinical Sciences

College of Veterinary Medicine

College Station, Texas

Tammi Powell, RVT

Heekin Animal Hospital

Taylor Mill, Ky.

Lisa Greenawalt, CVT

Haines Road Animal Hospital

St. Petersburg, Fla.

Part 1: Team knowledge

Educate team members and clients about the signs of disease to help offer pets early diagnosis and treatment whenever possible. To create a team approach to Cushing's syndrome, start by making sure team members understand the condition, including common signs, the basics of diagnosis, and the importance of ongoing testing and treatment. View Part 1.

Part 2: Implementation

Now that team members know about Cushing's syndrome and how pets are diagnosed, focus on their role, both as a team and as individuals, to implement a program in your practice that supports clients. The key ingredient: A can-do attitude. Team members need to prepare for the fact that they will be working with clients who have just received less-than-welcome news about their pet's health. View Part 2.

Part 3: Client communication

Success depends on another important factor: your clients. One of the most important messages you want your team members to walk away with is this: They will spend much more time talking with clients than actually treating the pet. Learn how to prepare them to face clients with a lot of questions and concerns. View Part 3.

Part 4: Marketing and follow-through

You've started to develop and share tools to help clients and patients deal with this syndrome. In this section, you'll review tips to keep your program going strong and take it to the next level. Brainstorm a marketing plan, explain the importance of follow-through, and teach team members how to help clients help their pets. Keep your momentum going by reviewing the final section of this four-part team meeting. View Part 4.

Part 1 resources

Download these handouts and tools before your team meeting:

• Part 1: Meeting guide: Explains the thinking behind the meeting and activities

• Part 1: Trainer's script: Step-by-step meeting dialogue

• Pretest: Cushing's syndrome: Assess team members' knowledge of Cushing's syndrome

• Pretest: Cushing's syndrome key: Trainer's answer key with background information

• Team handout: Cushing's syndrome defined: Educate team members about one of the most commonly diagnosed canine endocrine disorders

• Activity: Tongue twisters: Challenge your team to tackle these twisters

Part 1: Team knowledge

As dogs age, their health may change rapidly, so it's important to educate team members and clients about the signs of disease to help offer pets early diagnosis and treatment whenever possible. To create a team approach to Cushing's syndrome, start by making sure team members understand the condition, including common signs, the basics of diagnosis, and the importance of ongoing testing and treatment. (Click here for a script that walks you through exactly how to hold a meeting on this topic.)

To get started, it's important to define Cushing's syndrome for your team. You want to explain that Cushing's syndrome is one of the most commonly diagnosed canine endocrine disorders. It is characterized by hypercorticism, meaning excessive amounts of cortisol, a hormone normally produced in response to stress by the adrenal glands. Cushing's syndrome is most often seen in older dogs, and may spontaneous or iatrogenic in origin. Iatrogenic simply means that the problem was initiated from outside the patient, inadvertently induced with cortisol or other glucocorticoid medication used to treat many conditions. Iatrogenic Cushing's is not the focus today as it can be reversible if the causative drug can be tapered and preferably discontinued.

Now is a good time to take a moment to clarify terminology for your team. While they may have heard of both Cushing's disease and Cushing's syndrome, it's important to explain that they are not interchangeable terms. Cushing's syndrome refers to any dog with signs due to excessive cortisol , such as thirst, hunger, panting, and so on, but this can be due to inherent disease-a pituitary tumor or an adrenal tumor-or due to the administration of steroids. Cushing's disease specifically refers to a dog with pituitary-dependent hyperadrenocorticism.

5-minute activity: Cushing's syndrome pretest

Depending on your team members' level of training and their experiences with their own pets, they may know more or less about Cushing's syndrome. To help you focus on what your team members need to learn, it's a good idea to administer a quick pretest to gauge their knowledge.

A pencil-and-paper activity can elicit groans from your team, so the goal is to keep it quick and make it fun. For example, you could make it a challenge by offering a small reward for the person that finishes the quickest with the most right answers. Because technicians might have an advantage with some of the clinical material, consider choosing a winner from each group. Make it a timed test-three minutes to fill in the answers and two minutes for you to review the answers together and identify the topics you need to cover most.

One final note: Because some of the information about the disease sounds clinical, some of your front office staff may balk at learning new vocabulary words, like hyperadreno corticism or low-dose dexamethasone suppression test. Remind these team members that they need to be and sound knowledgeable when they talk to clients on the phone or try to explain a bill or estimate. Confident pronunciation and a basic understanding of the disease will boost the client's view of the whole practice.

Describe the disease

Now that you know what team members know-and don't know-about the disease, it's a good idea to briefly discuss the tests the doctor will use to diagnose the Cushing's syndrome, as well as the importance of ongoing treatment. This is a good time to remind team members that pets with this condition require careful monitoring for their ongoing health, so they will be important partners with clients to make sure the pet is monitored carefully, both at the practice for scheduled testing and follow-up visits and at home.

Pass out the handout, “What is Cushing's syndrome?” A quick review of the pretest will show you what team members already know about the disease. Use this handout to quickly cover the topics your team members still need to learn. You may ask the veterinarian or an experienced technician to lead this part of the discussion, encouraging team members to ask questions about anything they don't understand. Ask the presenter to emphasize the importance of ongoing testing and to quickly review common signs so all team members are ready to recognize red-flag patients. You'll also want the presenter to explain that clients may assume some of the signs their pets experience are simply signs of aging. All members of your team play a role in helping to identify a pet that needs to be seen by the veterinarian for an examination and further diagnostics.

1-minute activity: Tongue twisters

A quick way to improve vocabularies, practice pronunciation, and lighten the mood of the room is by practicing a few tongue twisters. Remind team members that learning correct pronunciation now will save them embarrassment later when they're describing conditions, diagnostics, and treatments to clients.

Continue to Part 2: Implementation

Part 2 resources

Download these handouts and tools before your team meeting:

• Part 2: Meeting guide: Explains the thinking behind the meeting and activities

• Part 2: Trainer's script: Step-by-step meeting dialogue

• Activity: Five things game: Divide staff members into groups and then set the topic

• Cushing's syndrome monitoring checklist: Team handout to encourage follow-up care

Part 2: Implementation

In Part 1 of this meeting, team members learned about Cushing's syndrome and how pets are diagnosed in your practice. Next, you will focus on their role, both as a team and as individuals, to implement a program in your practice that supports clients. The key ingredient is a can-do attitude. (Click here for a script that outlines exactly what to say to get to this point.)

In the case of Cushing's syndrome, your team members need to prepare for the fact that they will be working with clients who have just received less-than-welcome news about their pet's health.

The team's role often begins after the doctor has made the diagnosis. It's important for team members to remember to explain to clients that the signs their pet is experiencing are not a normal part of aging, and with treatment you can likely improve their dog's well-being and overall quality of life. Remind team members that they'll spend much more time talking with clients and educating them about Cushing's syndrome and the need for rechecks than actually diagnosing or treating the pet. Also explain that, like diabetic pets, animals with Cushing's syndrome suffer from a chronic illness that will be managed throughout the pet's life, not cured.

7-minute activity: Lock in followups

Many follow-up visits may be necessary for pets with Cushing's syndrome, so start by explaining to team members that they'll need to be diligent to lock in follow-up appointments and manage clients' expectations as the pet responds in its own way to treatment.

Pass out the out handout “Cushing's Syndrome Monitoring Checklist.” Use this form to lead the discussion about your practice's recheck schedule and tailor your own recheck checklist. Before the meeting, it's a good idea to run the monitoring checklist by your veterinarian to make sure it matches his or her preferred recheck schedule.

Once your team knows the schedule, it's time to make sure the rechecks happen. A good way to generate a plan that will help your team lock in their approach is with brainstorming. This is a good time to try the “Five Things” Game.

Divide staff members into groups and pass out the “Five Things Game Sheet.” Then set the topic. For example, you might ask team members to brainstorm five things on these topics or others:

• Five things every Cushing's syndrome patient should leave the practice with

• Five responses to client objections about the cost of treatment and monitoring

• Five things every client needs to know about a pet with Cushing's syndrome

Team members will collect points for completing the list, with extra points awarded for originality. Your goal is to get team members to think about solutions and offer creative responses to your top problems, whether it's client compliance or team implementation.

Remind team members that their personal experiences can be very helpful in making a connection with clients. Clients with dogs that suffer from Cushing's syndrome will need support.

Cushing's syndrome and clients: Role by role

If you've already completed “Don't get Burned by Ear Infections,” you'll remember breaking your team into sections for this next activity. Remember, if you have additional time, it's always a good idea to hold all of the training together so team members are cross-trained. Otherwise, you'll divide the teams into your front and back office staff. You'll need assistance to hold both discussions at the same time, so nominate a trusted team member to lead the discussion in each group, and you can float between the two and help keep conversations on track.

5-minute activity: Tech talk

Ask team members to keep the team tool, “Cushing's Monitoring and Follow-up Checklist,” in front of them during this discussion. Use the form as a starting place to discuss your practice's recheck schedule. If you brainstormed ways to lock in recheck appointments during the “Five Things” activity, this is a good time to discuss some of those ideas and how you might implement them in practice.

Remind technicians that Cushing's patients often suffer from other conditions as well. For example, perhaps FiFi is hypothyroid , has mobility issues, and routinely takes an NSAID. Be aware of other testing you might be able to combine with your Cushing's monitoring. For example, can you draw blood for thyroid monitoring and a biochemical profile at the same time to minimize your patient's need to undergo multiple blood draws? Can subsequent testing be synchronized? Explain that this attention to detail will help earn your client's trust and appreciation.

It's a good idea to assign one point-person to each case. Discuss how your team might coordinate care so that clients work with a familiar team member who can offer continuity to their visits. Talk about how this can be especially important during induction, when you're waiting to see how the pet will respond to treatment and attempting to achieve cortisol suppression . Your point-person may use a calendar or reminders in your computer system to check in with clients frequently. Check-ins between appointments will help you identify any side effects more quickly and keep a close eye on adrenal function.

A solid bond with caregivers will help you identify any problems early and offer support and care in a timely fashion. During the induction period, when the pet is starting medication, your team might consider calling owners every other day-or even daily-to check in on pets. Consider these questions to offer clues about the pet's health:

• How is the pet's activity level?

• How is its appetite?

• Is it drinking more or less?

• How often is it taking bathroom breaks? Is it more or less than before?

• What questions do you have for me?

Finally, remind clients to call you if they notice any unusual signs or behavior, even if they do not think it is linked to the pet's Cushing's. Any sign may be a signal it's time to visit the veterinarian.

When clients arrive for recheck testing, the technician can ask, “Have you given the medication today, and if so, when?” This will help ensure the pet is prepared for testing and you'll get more accurate results.

5-minute activity: Receptionists and rechecks

As with the technicians, it's a good idea to pass out the team tool, “Cushing's Monitoring and Follow-up Checklist.” Remind receptionists that they play an important role in locking in this follow-up care.

Take a few minutes to discuss each of these ideas and whether you practice them at your hospital. If they're steps you already take, discuss ways you might improve client follow-through.

• Schedule the follow-up appointment at check-up, before the client leaves the hospital.

• Call, text, mail, or e-mail appointment reminders.

• Plan follow-up calls with clients who've canceled in order to reschedule any missed rechecks.

• Call clients periodically just to check in and see if they have any questions or concerns you can address or pass on to the clinical staff.

• When clients schedule a recheck appointment, remind them to give the medication in the morning. Schedule the recheck for four hours after the medication is given to offer the most accurate test.

• When clients arrive for a recheck, ask whether they've given the medication this morning, and if so, when? Remind them you'll only get accurate results if the test is given four to six hours after the pet receives the medication . If the pet hasn't received the medication, reschedule as necessary.

Another very important role your front office team has is to often talk to clients first when they call with a concern. Small changes in a pet with Cushing's syndrome could signal a big problem, so take a minute to review some of the common signs of Cushing's syndrome with receptionists.

To keep the conversation interactive, you might ask your front office staff to recall as many signs as they can from your previous discussion of common signs and offer a reward to the person who can name the most. It's important to reinforce the message that everyone on your team needs to be able to recognize those red-flag phone calls and respond appropriately.

Continue to Part 3: Client communication

Part 3 resources

Download these handouts and tools before your team meeting:

• Part 3: Meeting guide: Explains the thinking behind the meeting and activities

• Part 3: Trainer's script: Step-by-step meeting dialogue

• Team handout: Client questions: Most common client questions and answers

Part 3: Client communication

Part 1 and Part 2 of this program focused on hyperadrenocorticism and the team's role in caring for Cushing's patients. But success depends on another important factor: your clients.

One of the most important messages you want your team members to walk away with is this: They will spend much more time talking with clients than actually treating the pet. So prepare them to face clients with a lot of questions and concerns. Explain to team members that, as with other conditions, clients may be worried about costs, especially when you explain the need for regular recheck visits. (Click here for a script that walks you through the meeting dialogue.)

One approach for team members to help put the cost in perspective for clients is to look at the cost in terms of other expenses. For example, they might explain to clients that the cost of their pet's care is comparable to a cup of coffee a day, or less than the cost of a sandwich. This often makes the expense seem more manageable.

It's also important to let the owners know that this will require continuous management. Some will have financial constraints, and it's important to convey that treatment is an ongoing process. Remind team members to recognize that some clients will have financial limits, so it's key to make sure they don't make clients feel guilty about concerns over cost. Try to educate clients as much as possible. Some clients may hear about the cost of treatment and begin to tune out the rest of your message. Remind clients about what they can expect if they do or do not choose to treat their pets, so they have a clear perspective of their options. They'll also need to have a  clear understanding of all the anticipated costs, from the initial medications your veterinarian recommends to the recheck costs and ongoing treatment.

It's also a good idea to talk as a team for a minute about client's questions regarding life expectancy. Remind your team members that it's not unusual for pets with Cushing's syndrome to suffer from other conditions, which may complicate the  prognosis. So while it's important to stay positive about what treatment can do for a pet, they want to avoid making predictions or promises. In cases where a client presses for answers, tell team members it's appropriate to refer this question to the doctor.

2-minute activity: Explaining Cushing's disease-the icemaker example

Your trained technicians may already understand the negative feedback loop between the pituitary and adrenal glands and how Cushing's syndrome occurs. The challenge is making it understandable to your front office team members and to pet owners. Consider offering the icemaker example as a way for team members to describe the disease process to clients.

Think of how your icemaker works. There is a bin that contains ice in your freezer and when the amount of  ice decreases to a certain level, it triggers the water supply to fill trays that freeze and dump into the bin. This process restores the amount of ice to a desired level. The mechanism signaling the production of ice is halted until it is needed again.

In Cushing's syndrome, the mechanism that tells the icemaker to quit producing ice is defective, or ice is made in excess even though the signaling mechanism is working.  Either  way, your freezer becomes flooded with ice-more than you need or can use and you can't shut it off. Eventually, it affects the efficiency of the entire refrigeration unit.

7-minute activity: Tough talks with clients

Clients may have a lot of questions and need a lot of handholding, especially when their pet is first diagnosed with Cushing's syndrome. So explain to your team that the time you spend with each client initially answering questions and offering support will usually pay dividends, both in the client's level of compliance and in their ability to make their pet more comfortable.

A helpful exercise is to role-play some of the common client questions and how you might respond. Pass out the client handout, “Answering Clients' Top Questions About Cushing's Syndrome.” Then ask team members to review the common questions and answers and role-play them in pairs. Encourage them to take turns being the client and the team member and to challenge themselves to come up with answers in their own words. Most important, remind them to stay positive because clients will pick up on the team member's mood and tone, along with the message they're trying to convey.

Continue to Part 4: Marketing and follow-through

Part 4 resources

Download these handouts and tools before your team meeting:

• Meeting guide: Explains the thinking behind the meeting and activities

• Trainer's script: Step-by-step meeting dialogue

• Team handout: 3 tips to help clients: These simple tips will help clients help their pets

Part 4: Marketing and follow-through

As your team has made it through parts 1, 2, and 3 of your meeting, you've started to develop and share tools to help clients and patients deal with this syndrome. In this final section, you'll review tips to keep your program going strong and take it to the next level. (Click here for a script for this section.)

Check your 'tude

This is definitely a case where the team's attitude matters, and it can have a profound effect on how clients perceive their pet's condition.

A good way to generate some positive vibes in your practice is to share a success story. Approach your veterinarian to see if he or she can come up with an example of a patient that suffered from Cushing's syndrome and explain the benefits of treatment. Before-and-after photos are another great way to show the benefits of effective management of this syndrome. Ask your veterinarian to share the success story with the team, focusing on the benefits to the pet and the client and reminding team members how debilitating untreated Cushing's syndrome can be.

7-minute activity: Brainstorm a marketing plan

The most effective marketing approach will be the one your team buys into, so take five minutes to break into small groups and brainstorm three to five ideas about how to educate clients and spread the message about Cushing's syndrome. To keep the discussion pressure-free, seed the groups with a few ideas, like using newsletters, waiting-room materials, and on-hold messages to discuss Cushing's syndrome.

This is also a good time to go back to the idea of checking in with clients. Your team might already plan to make frequent calls during the induction phase of medication, but a friendly phone call might go a long way to preserving a pet's health. Perhaps your practice can keep a list of patients with Cushing's syndrome next to the phones, and technicians and receptionists can periodically call clients during slow times just to check in. These phone calls might reveal valuable medical information that can offer early warning signs of a problem.

Let the brainstorming go on for about five minutes, then use the final two minutes for groups to share their favorite ideas. If team members share ideas you like, consider empowering them to come up with an implementation plan to make it happen in your practice. You may also consider offering a reward to the team member with the best idea, such as a special lunch out with the veterinarian or a special parking space near the door for a week.

Guarantee rechecks

As you know, client compliance can be a huge hurdle, and it can make the difference between success and failure with a treatment plan. Take a few minutes to explain the importance of follow-through when treating Cushing's syndrome. Remind team members that pets with this condition will need care for the rest of their lives, and team members can make a huge difference in motivating and encouraging clients to offer the right care and return for appropriate follow-up appointments. Cushing's syndrome is a treated rather than cured, which means a team approach that includes clients in their pets' care is critical.

For pets in your practice receiving medication, remind team members that when clients call to ask for refills, they can be reminded that their pets need to be seen at the practice to check on their progress before the next prescription can be refilled. This can make it easier to get clients in for follow-up testing.

5-minute activity: The trouble with accidents

One of the biggest challenges your team will face is supporting clients whose pets are having accidents indoors. Remind your team members that house soiling can be a huge frustration for clients, as well as damage the relationship between pets and their owners. It's important to take each client  question seriously because how they handle the client's concern will determine whether clients will call your team next time. It is important to offer solutions, especially since this change in behavior is due to a more frequent need to ‘go' rather than a true incontinence.

Pass out the handout “Cushing's Syndrome: 3 tips to Help Clients Help Their Pets” to lead your discussion. Discuss each of the tips and ask team members to suggest additional solutions to help make home care more comfortable for pets and their owners.

3-minute activity: Cushing's syndrome post-test

A great way to end your meeting is to ask team members to take the same test they took at the beginning of Part 1. They will undoubtedly get more answers correct. This is a tangible way to show them their progress. It also helps you decide whether there are areas related to Cushing's syndrome that should be revisited.

To close your meeting, congratulate your team. You've covered a lot of ground in four short meetings. Your clients and their canines are sure to benefit from it.