When Kathryn Primm, DVM, CVPM, called to find out why her client’s dog missed a follow-up appointment after two weeks of otitis treatment, she got a response that changed her practice permanently. “The client said her dog’s ears were fine, she didn’t need a recheck, and we were just trying to get extra money.”
Needless to say, Dr. Primm, who owns Applebrook Animal Hospital in Ooltewah, Tennessee, was frustrated at being unable to see the case through to the end. The patient’s ears had been so swollen that she had been unable to see the eardrum, and she strongly suspected that the infection was resistant to first-line therapies.
Dr. Primm decided that if she couldn’t help that patient, she’d help the rest. Now, every sick pet, including otitis patients, receives a courtesy recheck.
“I decided to put my money where my mouth is,” Dr. Primm said. “I think it reinforces the idea that we’re not just trying to get money out of our clients; we really care if the pet is feeling better or not.”
Why Rechecks Are So Important
As Dr. Primm’s story illustrates, otitis cases can be frustrating all around to clients, to veterinarians and even to veterinary dermatologists, said Melissa Hall, DVM, DACVD, of Animal Dermatology Clinic in Tustin, California.
“When it comes to ear infections, you have to deal with the infection itself, but then you also have to go on a quest to find the underlying trigger,” Dr. Hall said. “And unless you identify that underlying trigger, it’s going to come right back again.”
The initial appointment is usually about getting the infection under control, addressing swelling and managing pain, Dr. Hall said. For some simple cases involving the external ear only, that’s enough. But many patients need more extensive and ongoing care, which means the second appointment can be even more important because it sets the stage for the entire plan.
“That recheck is a great time to say, ‘OK, let’s start talking about potential triggers. Is your dog itchy and licking at its paws? Does this ear infection seem to pop up around the same time every year? Have we had ear infections since we were a puppy?’” Dr. Hall said.
The answers to these types of questions help Dr. Hall determine whether something like an environmental allergy or food allergy is behind the ear disease.
Another common issue with otitis cases is that, as in Dr. Primm’s case, the ear canal is so swollen and painful that the veterinarian can’t use an otoscope to visualize the tympanic membrane. A follow-up appointment is necessary to see if it has ruptured and whether the middle and inner ear are affected. Also possible? The pet might not be feeling better at all.
“One of the most important things I do with every ear case is, if there’s debris or pus or exudate in that ear, I swab it and I do an otic cytology,” Dr. Hall said. “That’s even more important at the recheck. Maybe you were super focused on all that bacteria you saw the first day, and then on the recheck, you swab it and now there’s a ton of yeast. The skin is still red, the ear is still swollen, the pet’s still itchy and shaking its head, but now you have a whole different beast.”
So, the recheck is essential for many reasons:
- To ensure that the treatment is working.
- To figure out why it might not be working.
- To determine whether deeper ear structures are affected.
- At a minimum, to ensure that a simple infection is well-controlled before it progresses and becomes more complex.
All of this means that client communication is at the heart of effective otitis management.
Manage Expectations
When pet owners come in hoping for a quick fix, Dr. Primm has to tell them straight-up: Otitis is rarely a one-and-done.
“It’s all about managing expectations,” she said. “If you warn them that it’s likely to come back and that we’re in this together to get it under control and manage it long term, they’re less likely to think you’re just after money. And they’re also less likely to think you’re incompetent.”
Dr. Primm often sees otitis cases from other practices, and those clients say the other veterinarian “just never could fix him,” she said. “If that other vet had said, ‘Nobody can fix him, this is going to be an ongoing issue,’ they would probably still have that client.”
Dr. Hall agreed. “Unfortunately, a lot of our clients treat veterinary medicine how they treat human medicine,” she said. “They just want me to give their pet a shot or a pill to make it better. But when we talk a lot about any type of chronic ear issue, there is no simple fix. So we definitely need to be setting expectations, discussing long-term management, and making a plan together. If we’re able to institute a plan early on, knowing there’s a high likelihood the problem will come back, then the owner is not going to be so upset when it does.”
A Step-by-Step Approach
Of course, many general practitioners in busy practices don’t have 45 minutes to an hour to discuss all those issues in a single appointment. Which brings us back to follow-up appointments.
“It takes some time to provide all the education and really get to know that particular owner and pet,” Dr. Hall said. “You might not have that time at the initial appointment. But at the recheck or subsequent rechecks, you get a little bit more time. Maybe this time we talk about this aspect of it, next time we’ll focus on that one. It breaks it up so you’re not completely running behind your entire day just because you have an ear case.”
In fact, otitis cases are a chance to highlight your expertise as a veterinarian. For example, when Dr. Primm suspects that a seasonal allergy is behind her patient’s ear problems, she tells the client, “You’re probably going to see me next year. Don’t be surprised if this pops up again.” Then she sets a follow-up reminder in her practice management software to reach out to the client a couple of weeks before that date the following year.
“I say, ‘Hey, remember me? I think we’re going to see an ear issue.’ And when they do, they think I’m a genius,” Dr. Primm said. “It’s not that I’m psychic; it’s just that I’m experienced. It also makes people feel special because you remembered and you cared.”
Strengthen the Bond
As Dr. Primm, Dr. Hall and other savvy veterinarians have discovered, otitis cases can be an opportunity for a veterinary practice rather than a source of frustration. First off, helping patients in misery is inherently rewarding, and it’s the reason most veterinary professionals got into the business in the first place.
“I had a lot of ear infections when I was growing up, and I remember the headaches and pain when I was a little kid,” Dr. Hall said. “But our pets can’t say, ‘Wow, I’ve had a headache for a week and a half now.’ I can understand why they get grumpy. I’ve seen ear infections create so much pain that it’s hard for them to chew.”
Otitis also can endanger the relationship between a pet and its family. A pet with an ear disease might snap when someone tries to touch its head. Or the smell emanating from its ears might keep away family members. The pet might develop vestibular syndrome and start falling on its side, horrifying the owners enough to raise the specter of euthanasia. If the veterinarian can develop a plan to help the problems go away — even if it means referral to a specialist, surgery or both — that practitioner becomes a hero to the family, a savior of the human-animal bond.
“I’ve been able to get through the most difficult times in my life because I could squeeze my dog and my cat once in a while,” Dr. Hall said. “Anytime they’re uncomfortable, it hurts me. So I think we need to look at ear cases and tell clients, ‘Yes, this is frustrating. But we’re going to go through it together.’”
What’s more, enlisting the pet owner as an essential part of the team can be incredibly empowering to the client.
“I try to create a path to get the owner involved,” Dr. Hall said. “No one knows an animal better than the owner. You may say, ‘Yes, I’m having you do a bunch of little things, but these little things can add up to a much better quality of life for your pet. You’ll have a more loving animal, you’ll be more connected, you won’t have that odor or have to cringe every time they shake their head or scratch their ear.’”
Dr. Primm said that with her otitis courtesy rechecks, the value she gains from bonding with clients and caring for patients far outweighs any lost revenue from medical progress exams.
“Having them in my exam room, seeing our posters asking them to review us online and creating a positive feeling that we really care about their pet, it just increases our opportunity to communicate with that client. I think it’s totally a benefit,” she said.
In the end, whether with ear problems or any other condition for which rechecks are essential, “It’s all about that bond,” Dr. Hall said.