Conventional wisdom says veterinary dermatology is more telemedicine-friendly than, say, internal medicine because the patient’s problem is on the outside rather than the inside. This means lesions, redness, pustules and the like can be visualized in photos, videos or a live camera feed and shared with a practitioner.
However, with otitis, the problems can reach deep into the ear, requiring the use of an otoscope. And, of course, there’s often the need for cytology, which isn’t something that can be performed electronically.
Does that mean telemedicine can’t play a role in treating otitis? Hardly. The key, experts say, is to be fully aware of the limitations that telemedicine imposes and to work within those parameters in full transparency. This means focusing on communicating with the client and, often, making the patient comfortable until an in-person exam can be performed.
Here are the insights of three veterinarians — two general practitioners and one dermatologist — who build bonds with clients by using telemedicine in ear cases.
Dr. Stacee Santi: If It Quacks Like a Duck …
Stacee Santi, DVM, of Durango, Colorado, is the creator of the Vet2Pet app that lets veterinary practices customize how they engage with clients through mobile devices. She has a long history in general and emergency practice and no shortage of otitis cases.
Many otitis patients are what Dr. Santi calls “repeat offenders” or “frequent fliers,” and these are the cases she thinks are best suited for telemedicine.
“If this is a golden retriever that I’ve seen every spring for six years in a row and I have a history of cytologies, I would absolutely be comfortable looking at a few telemedicine photos, asking some questions and starting therapy,” she said. “That could rattle some veterinarians, but it wouldn’t rattle a lot of us, because 99 out of 100 times we’re going to nail it.”
To rule out urgent conditions like a ruptured eardrum, head tilt or severe pain, Dr. Santi might ask a client to send a video of the pet. Is it running around the yard or standing quietly with its head down? If the latter, the pet needs to be seen in person.
She sometimes uses the Kleenex test, meaning the client puts a tissue in the pet’s ear, swirls it around and sends a photo of the tissue.
“If it’s black and it smells like your kid’s gym socks, it’s probably yeast,” she said.
To be sure, the client can put that tissue in a baggie and drop it off at the clinic, where a technician can do a cytologic examination. “Instead of a fecal sample, it’s a cytology sample,” Dr. Santi said.
She tells veterinarians to use their comfort level.
“If I was a new grad, I wouldn’t be comfortable with this,” she said. “But I’ve been out 20 years and I’ve seen many otitis cases, so I would give that a whirl. If it quacks like a duck and walks like a duck, it’s probably a duck.”
Offering telemedicine can be a boon both to busy clients and busy practitioners.
“Telemedicine isn’t going to drive revenue,” Dr. Santi said. “What it does do is give clients a more enhanced experience with you. It also helps you manage your schedule better. If you don’t allow that golden retriever to come in on the telemedicine channel, and the only option is to have them come into the clinic as a walk-in/work-in, then you’re going to work overtime and miss lunch. Which one do you want?”
Of course, most telemedicine episodes need to be followed by an in-person exam to make sure the treatment is working and the pet is healthy. But here’s where a veterinary professional can really blow clients’ minds and use telemedicine to drive business.
“I can check to see if that pet is due for anything else,” Dr. Santi said. “Let’s say I tell you, ‘I want to do a recheck in 10 to 14 days. I noticed you’re also due for a wellness exam, vaccines and a heartworm test. Should we book all that right now and take care of your semi-annual?’ People love that because it maximizes their time. What they don’t love is to come in for a recheck and then you schedule them for a dental.”
Taking this approach not only increases compliance with follow-up appointments, Dr. Santi said, it also boosts the perception of value.
Dr. Jeff Werber: Ear Emergencies Often Aren’t
Jeff Werber, DVM, the founder of Century Veterinary Group in Los Angeles and creator of the Airvet telemedicine platform, is all about keeping clients out of the emergency room. His service provides after-hours consultations for pet owners who want to know whether a situation is urgent.
Very few ear infections are true emergencies, but clients don’t know that, Dr. Werber said.
“By the time they reach me on Airvet, they’re truly worried,” he said.
If he can, Dr. Werber looks at the ear through the camera and asks about inflammation levels, discharge and the pet’s apparent comfort level. While respecting the rules surrounding the need for a veterinarian-client-patient relationship, he might offer suggestions for an over-the-counter product like hydrocortisone or diphenhydramine to help the pet feel better until it visits its regular veterinarian.
“I often hear from them the next morning,” Dr. Werber said. “They send me a chat — our cases remain open for three days — and say, ‘You were right!’ Clients love it.”
Dr. Werber’s inspiration for telemedicine grew out of his method of practicing veterinary medicine.
“I was the idiot who gave clients his cell phone number, so I was providing true concierge care,” he said. “I was never getting paid for it, but I was scoring a lot of points.”
The payoff was a religiously loyal clientele.
Dr. Werber recognizes that many millennial veterinarians who value a work-life balance don’t want to be accessible to clients 24/7. Millennial pet owners, on the other hand, demand that level of accessibility. Telemedicine can fill the gap by providing access to a doctor during those evening and weekend hours.
Plus, if clients stick with their regular veterinarians the next day instead of making a trip to the emergency room, there’s less chance the ER hospital will send the patients to its in-house specialist the next morning.
“I hate when these emergency clinics take over a case and never let the primary vet know what happened,” Dr. Werber said. “I don’t like the primary doc losing control of his or her case.”
Dr. Werber has decades of experience with pet ear problems, so he’s highly confident when he says he would send a patient to the ER only in the case of a laceration with lots of bleeding or something like a snakebite. Other doctors might be less experienced.
“I say, ‘If you’re not comfortable or 100% sure, don’t be cocky. Send them,’” Dr. Werber said. “But I tell them to call ahead to let the emergency clinic know this is what your hunch is — ‘Please evaluate this first.’”
Dr. Werber points to demographics to make his case for telemedicine.
“What’s the largest segment of pet owners? Millennials,” he said. “What’s the fastest-growing? Millennials. What’s the highest-spending? Millennials. Well, guess what? This is tailor-made for millennials. They want convenience, they want it fast, and they don’t want to travel.”
Dr. Ashley Bourgeois: It’s All About the Client
No one’s trying to claim that telemedicine replaces an in-person exam, said Ashley Bourgeois, DVM, DACVD, the part owner and practicing specialist at Animal Dermatology Clinic Portland in Portland, Oregon. “But there’s still a lot of benefit we can provide if the client can’t get into the building,” she said.
Like Dr. Santi, Dr. Bourgeois uses telemedicine more with established clients and known-quantity patients with whose issues she is familiar. Some of her clients can’t come in because of COVID concerns, or they’re first responders whose hours don’t line up with the clinic’s.
“If they have half an hour open for a telemedicine appointment, being able to walk through the history and have them send pictures ahead of time allows us to care for clients who otherwise might turn to the internet or their friends for advice,” she said.
Dr. Bourgeois won’t prescribe systemic medication without cytology, but if the client is adamant about not coming in, she might try aggressive topical therapy.
“Maybe I can have them flush the ear once a day with a product I feel is safe without an otoscopic exam and see how they do,” she said. “I’m honest with them that, ‘Hey, we’re going to try this, but without cytology, we don’t really know what we’re treating. If this doesn’t work, we need to get your pet in so it doesn’t progress and get worse.’”
In cases where the problem can’t be dealt with over telemedicine, Dr. Bourgeois’ clients usually agree to come in.
“When you can explain your concerns and they can look you in the eyes over video chat and understand why … they listen. They’re appreciative that you even tried,” she said.
At Dr. Bourgeois’ clinic, if a doctor does a telemedicine exam and then determines the pet needs to be seen in person, the telemedicine fee will cover the clinic visit as well.
“In these cases, we know exactly what we’re going to do — cytology, maybe a sedated otoscopic exam — and we can get right to it,” she said. “And owners don’t feel like they were double-charged.
“This establishes trust for your relationship moving forward.”
Part of using telemedicine effectively is accepting its limitations, Dr. Bourgeois said.
“There are definitely downfalls to it,” she said. “But you just have to explain that to the owner — to say you can’t do cytology or look in the pet’s ear. I think telemedicine is more a way of talking to the client to direct where you’re going to go next versus the be-all and end-all of that situation.”
She echoed what many telemedicine-friendly veterinarians say: It’s a supplemental tool, not a replacement for an in-person exam.
“If it’s another avenue where I can talk to that client and I’m managing the case — the internet is not managing the case — then I’m happy to offer it,” Dr. Bourgeois said.
TELEMEDICINE AND OTITIS
Here are some ways that veterinarians can use telemedicine to serve ear patients and their owners:
- Discuss the problem and collect the patient history via a two-way video chat or by phone.
- Determine whether a problem is urgent enough to require immediate care.
- Evaluate and discuss images showing redness, discharge and so on.
- Evaluate and discuss video to check for normal behavior versus, for example, head tilt, pain signals and signs of nystagmus.
- Demonstrate a home-care technique such as ear flushing or the application of a topical product. (Record these demonstrations to build a client education video library.)
- Recommend an over-the-counter product or home-care technique to relieve discomfort until an in-person exam can be done.
- Conduct a follow-up recheck after an in-person exam.
WHAT’S BOTHERING PATIENTS
Your veterinary practice probably gets many otitis cases, but have you ranked all the common conditions afflicting your dog and cat patients?
Pet health insurance provider Trupanion reported that an ear issue was the second-most-frequent health condition seen in pets since COVID-19 was declared a pandemic. No surprise, said Steve Weinrauch, BVMS, MRCVS, the chief product and veterinary officer at Trupanion.
“Even though we’re in a pandemic, it’s clear to see that the things that our pets are usually impacted by doesn’t change,” he said.
From March 1 to May 31, 2020, Trupanion paid about 6,000 claims for otitis.
According to Trupanion claims data, the top 10 health conditions for pets during the pandemic are:
- Allergies
- Otitis
- Vomiting and diarrhea
- Lameness
- Mass
- Urinary tract infection
- Arthritis
- Cruciate rupture
- Seizure
- Diabetes