How can you fit a dermatology consultation into general practice?

One of the most abiding impressions many new graduates retain about clinical dermatology is how long it all takes – the long histories, the examination of innumerable samples and waiting weeks for the patient to improve. Sadly, this view is not without an element of truth and faced with the challenge of unravelling a chronic atopic in 10 minutes, a degree of anxiety is understandable. The purpose of this short article is to try to suggest strategies to make this process not only possible but enjoyable, and to improve the outcome for your clients. If that is not sufficient incentive to read further, the fact that 32 percent of dogs and 30 percent of cats presenting for an initial consultation have a skin problem should be!

What are the differences?

1. Cases frequently have a long history

These cannot always be fully absorbed in the time available and owners cannot always accurately recall details surrounding the initial and most informative stages of a problem. They may have become frustrated at the lack of progress and have lost motivation to pursue a change of management. Supporting clients through these stages needs a clear understanding of the history and the communication skills to identify and explain the key issues that need to be prioritised and addressed

2. Dermatology cases have visible lesions

Whilst this seems obvious, the fact that the clinical signs are frequently visible and accessible is an invaluable aid in helping to explain the disease process to the owner and motivating them to follow advice. The opportunity to accurately observe, describe, sample and understand the primary pathology is a privilege unavailable to any other discipline. This takes time!

3. The owner will be the principle carer

Some procedures, such as bathing and ear cleaning, can be tedious and are probably among the most challenging things we ask an owner to do. To competently perform these procedures requires a thorough understanding of the goals and how to achieve them, and the motivation to do so. This comes through education, explanation and often demonstration, all of which will challenge the clinician’s communication skills. This, too, will take time!

Addressing the need for additional consultation time

This can only be achieved through a limited number of strategies and which one best suits your practice will depend heavily on your appointment rotas, lay staff, client base, colleagues and a willingness to adopt some changes. The need for time can only be achieved in two ways – extending the consultation or restricting what you try to do within a shorter slot. The first strategy requires some reorganisation, whilst the second requires fewer changes but is probably harder to adapt to and achieve.

For new cases, all strategies start with your reception staff. They almost certainly already collect the information needed but what is important is how it is utilised when booking the consultation. When booking in a dermatology case, what type of consultation are you going to offer and which clinician will see it? The following points should all be clearly made to the owner when booking the first appointment. Once all relevant expenses have been accounted for, running a consultation room in general practice costs in excess of £200 an hour. Such consultation time must be paid for and should not run as a loss leader.

Strategy 1 – extending the consultation

1. All new dermatology cases are offered a double slot. This should be early enough in the day to allow the patient to be admitted for more detailed examination and sampling, freeing up more time for taking a detailed history. This in turn allows the clinician to identify the key issues that need to be addressed and have a clear “road map” for the process of investigation. If such appointments are made at the same time on allocated days, the clinician seeing the cases will know in advance that they are seeing a potentially complex case and will have the opportunity to read the history beforehand
2. We all like some parts of clinical practice more than others so it makes sense to allocate dermatology cases to a clinician who enjoys them. This will result in many important benefits, the most important of which is continuity of care
3. If the patient has been admitted, a discharge appointment is needed to clearly explain the results of any investigations and plan treatment and further work. It must be emphasised to the owner that dermatology cases often require a systematic step-by-step investigation and that if this is to succeed, it is essential that advice is followed closely and follow-up appointments are kept
4. Follow-up appointments should always be made with the same clinician. These too can be extended if they are part of a reserved dermatology session or may be incorporated within the normal appointment slots

There are several ways in which the above basic strategy can be expanded. Several slots could be allocated to dermatology forming a dedicated session once or twice a week for new cases and follow-ups. The strategy could be adopted for difficult or complex cases of any type or it could be held in reserve for cases being seen within the normal rota which are not responding well to management. In such cases, once attention has been drawn to the fact that little progress is being made, many owners will be appreciative of the special interest that their pet is being shown.

Strategy 2 – reducing the content

1. Most practices run 10- to 15-minute appointment slots and if this remains unchanged, dealing with dermatology cases becomes much more challenging. There will be little time to do more than briefly read the history, perform a cursory examination and ask a handful of questions so two factors become much more important. The first is the ability to admit the pet for further assessment – if this can be done, the physical examination can be delayed. The second is the ability to rapidly recognise and prioritise the key issues to address
2. The goal for the first consultation will be to identify the differential list for the principle or underlying problem and ensure that the first step towards confirming a diagnosis is taken. If, for instance, there are clear signs of a superficial pyoderma, then the first step will be to eliminate this problem and then reassess the case. At each subsequent appointment, another issue can be addressed and eliminated until a definitive diagnosis is reached
3. This step-by-step process is powerful and robust but it becomes essential that follow-up appointments are kept as planned. If appointments are missed, progress will be lost and secondary problems may relapse. This is the greatest challenge when adopting this strategy and success will depend on owner motivation and the clinician’s communication skills

The clear advantage of this second approach is that it will fit seamlessly into most appointment systems and offers maximum flexibility to both clients and clinicians. However, maintaining continuity of case supervision may be more challenging and this would be a serious disadvantage if it was lost. The benefits of case continuity cannot be overstated with respect to dermatology and ear cases. Such cases benefit from the development of a cooperative relationship between clinician and owner and this takes time to build. A clinician unfamiliar with the case cannot easily recognise whether there has been any improvement or deterioration and may have to repeat questions asked at previous consultations. They may have slightly different personal preferences regarding treatment and this can confuse owners. After several such changes, owners often become frustrated and as a result, less cooperative, compromising the chances of success. The best outcomes will always be achieved by a motivated clinician assuming personal responsibility for each case, maintaining continuity of supervision and communication whilst remaining open to advice and assistance.