Evidence‐based veterinary medicine (EBVM) is a set of tools for generating reliable research evidence, disseminating it to clinicians, and using it to support clinical decision making. EBVM provides a system for ensuring that the information clinicians need is not only accurate and relevant but available and easy to use. In the research environment, EBVM guides the design and conduct of scientific studies to minimize bias and ensure the data generated are reliable. EBVM includes techniques and training for clinicians to help identify their information needs and then find relevant and useful evidence. EBVM is useful in meeting our ethical obligations to pet owners. Pet owners have an ethical and often a legal right to be informed about the possible risks and benefits of medical interventions. EBVM methods should be a core part of veterinary medical training. EBVM helps veterinarians provide better care and client communication with greater confidence and less time and effort.
Veterinary medicine has made incredible strides regarding the sophistication of care that can be provided by veterinarians in practice. In practice, incremental care has been a part of veterinary medicine since its founding. The veterinary healthcare team are informed service providers. There are both ground‐up and top‐down approaches to implementing incremental care practices in the profession. Organized veterinary medicine also has a role to play. Incremental care is a philosophy that holds that there are medical options falling along the entire cost spectrum for most health conditions and that all the available options should be discussed with pet owners. This is in contrast to “gold standard care,” in which only the most effective and most expensive treatment options are, at least initially, presented. Licensing boards and legislatures are inconsistent in their approach to standards of care in veterinary medicine.
Prevalence and incidence are both terms used to describe the occurrence of a disease over a period of time. Epidemiology focuses on factors of disease, such as cause, risk factors, frequency, and distribution/pattern. Prevalence and incidence are terms commonly used when describing the study of epidemiology. Prevalence can be expressed over a period of time, referred to as period prevalence, and can also be expressed at a specific point in time, known as point prevalence. There are two ways in which incidence can be expressed: incidence risk and incidence rate. Prevalence is commonly utilized in veterinary medicine as it does not require defining the population that is at risk of developing that disease. Hemangiosarcoma is an aggressive form of cancer that is most commonly encountered in German shepherd dogs, Labrador retrievers, and golden retrievers. The incidence rate is the number of new cases per year divided by the at‐risk population per unit time.
Veterinary medical checklists are an effective strategy to reduce avoidable errors. Failures occur in every industry, including veterinary medicine. Comparisons are more difficult to make between veterinary medicine and the aviation industry due to the paucity of studies in the veterinary literature. There is one tool in particular that the aviation industry has relied upon that has gradually trickled into various facets of human healthcare: the checklist. In aviation, checklists may be used for ordinary procedures, such as take‐offs and landings, as well as for malfunctions and emergencies. Checklists in veterinary surgery are an appropriate tool to address surgical instrument retention, among other surgical errors. In addition to surgical errors, medical errors may occur in veterinary practice. Checklists are also important aspects of convergence schedules, to ensure that client communication is managed appropriately. Human‐based errors in medicine and surgery can and will happen to some degree to every veterinary practice and every healthcare provider.
Today's consumers want their healthcare on their own schedules, and at their own convenience. Veterinarians providing telehealth must comply with all laws and regulations associated with their license to practice veterinary medicine. Telehealth has the potential to enhance animal care and the delivery of veterinary services, and regulations are evolving accordingly. Veterinarians with a valid Veterinarian‐Client‐Patient Relationship (VCPR) have professional discretion to confer with specialists and consultants, but they remain the physicians of record and do not transfer that VCPR to the specialist or consultant. Veterinarians providing telehealth must be legally authorized to practice veterinary medicine. Technology is available that allows remote monitoring of pets, and this can be an important resource when considering virtual care. Remote monitoring can play a key role in wellness care. Veterinarians may initially have some worries that offering telehealth services will cannibalize their office visits, but such fears are generally unfounded.
Pet‐specific care is a concept that can revolutionize our approach to providing veterinary healthcare. When marketing veterinary services, it is important to know the client signalment as well as the patient signalment. The most effective way to market veterinary services is to customize the marketing strategy to target client demographics. Baby Boomers grew up during the American‐dream, white picket‐fence era post World War II. Steve Jobs and Bill Gates are both members of the Baby Boomer generation. Generation X is often referred to as the bridge between Millennials and Baby Boomers. Generation X also has strong brand loyalty, particularly to those brands who give back. Millennials began entering the workforce as the economy crashed, and as a result are the largest generation of entrepreneurs. The youngest generation that is beginning to develop its buying power is Generation Z, the iGeneration, or Gen Z.
Assessing risk accurately and using that assessment to inform medical care for patients is a skill that can be developed and improved. Wellness care is all about reducing risk. Some health risks are nearly universal, such as exposure to contagious diseases and parasites. In ill patients, risk analysis helps to guide us toward the most likely diagnoses so that we can diagnose and treat the pet appropriately. Risk assessment also guides our client education efforts. Some diseases are high risk for a great many dogs and cats. We should ensure that every client is aware of these common risks and has the opportunity to prevent or screen for these diseases when possible. The second way to prioritize risk is by seriousness of problem. A point scoring system may be useful for recommending wellness screening laboratory testing. Wellness plans can be designed to be the same for every patient or individualized for each patient.
With pet ownership comes risk that the pet may require substantial healthcare services and at considerable expense. Pet health insurance is one of the most common ways in which pet owners mitigate pet health risk. The ways in which individuals manage risk typically fall into one of four categories: avoidance, mitigation, transfer, and acceptance. Risk avoidance is the elimination of an exposure that has the potential to result in a negative outcome. Risk mitigation is an activity that may lessen the chance of a negative outcome associated with a particular risk. Most pet owners do not understand or plan for the true financial risk that comes along with being a pet owner. The best way to be fully prepared for the true financial risk of pet ownership is to transfer the risk to an insurance company by purchasing pet health insurance. Most people transfer risk through purchase of an insurance policy.
Owning a pet and providing appropriate veterinary care for that pet's lifetime costs more than most pet owners realize, and veterinarians need to be prepared to discuss costs at the time they make their recommendations. Transparent and upfront cost discussions with clients based on appropriate healthcare recommendations will lead to improved relationships, happier and more trusting clients, happier team members, and better outcomes for pets. Providing appropriate preventive and end‐of‐life care for a pet is only the tip of the iceberg when it comes to the total cost of pet ownership. If cost of care is a barrier, a veterinarian should offer payment assistance options rather than modifying the recommendations.
As more and more people embrace the perception of pets as family members, the veterinary profession has worked hard to meet the needs of a more demanding audience of veterinary caregivers. The escalating discrepancy between emotionally invested owners and the higher cost of advanced veterinary medicine has been widely characterized by industry analysts as an affordability crisis. The primary concern is that as the gap between veterinary cost and ability to pay widens, a lower percentage of pets will receive the treatments the industry has prepared for them. This chapter presents the primary affordability factors affecting the demand for veterinary services. It also presents supply‐side considerations factoring into the affordability of veterinary care. Pet owners are finding it difficult to pay for the more expensive veterinary services offered by an increasingly sophisticated veterinary profession, leading to what industry analysts have described as an affordability crisis.
Professional service providers have been particularly vexed after the provision of their service with both billing and collecting from their clients. There are whole consulting industries whose sole purpose is to provide professional service providers with the skills and support to actually charge a “full” price without providing discounts, and buoy the self‐worth of the provider. The goal of a sound patient payment discount program should be to: reward for expected good behavior on the part of compliance, reward the client for achieving strategic financial benchmarks, and reward intended patient intangibles such as marketing the practice to other potential clients. Some pet owners may prey on the humanistic trait of most veterinary hospitals to emphasize patient care over finances.
Blockchain may be a foreign concept to many, but it is an important topic because it is demonstrating real benefits in many aspects of human healthcare and is bound to gain more prominence in veterinary medicine as well. It could be particularly useful in pet‐specific care in which various stakeholders could have secure privileges to various aspects of the medical record. In a blockchain, individual records are bundled together into blocks, and then linked sequentially within the chain. The three parts of the process are thus: the record, the block, and the chain. To make sure only authorized users have access to the information, blockchain systems use cryptography‐based digital signatures to verify identities. Blockchain is more difficult to hack, and tends to be more secure than traditional systems.
The concept of placebo is well known in human medicine. In fact, the caregiver placebo effect may be evident around 30–40% of the time regarding subjective evaluations, such as for lameness in dogs and cats. Another manifestation of caregiver placebo effect can be seen as a feature of being enrolled in a study, or receiving an intervention perceived as new and potentially exciting – known as the Hawthorne effect. One very interesting aspect of placebo studies is that sometimes they can still provide benefits even if the patient/client knows they are administering placebos. This is known as the honest placebo effect. The nocebo effect is an interesting phenomenon in which people have negative expectations about something and that alone is enough to make them perceive an ill effect.
The human–animal bond (HAB) is the glue that keeps companion animals in families. Veterinary clinics and the wider community benefit from strong HABs. The HAB may affect owner decisions as to the choice of pet and where it is acquired, how the pet lives with them and owner lifestyle such as where they live, work, and take holidays. When veterinary clinic staff are aware of the HAB in general and, more specifically, the nature of their personal bond with their pets, it can help them support owners and accept different approaches to pet care. Compassion fatigue can occur when staff are interacting with clients whose attachment levels are very different from their own beliefs and attitudes about the HAB. Education of staff about the HAB and how it varies with different people can help staff accept owner decisions and minimize staff stress.
Veterinary professionals should play an active role in promoting the human–animal bond among their clients. Education should be taken beyond the typical exam room discussions to include alternative methods that are easily absorbed by pet owners. The human–animal bond is a mutually beneficial relationship between people and animals. In addition to traditional exam room conversations, some opportunities are considered to educate veterinarians' clients. These include: enhanced exam room communication, custom literature, practice blog and social media, educational open house, and community event. The entire veterinary healthcare team should contribute to educating clients on important topics that impact the human–animal bond. To promote the human–animal bond, veterinary professionals should educate clients on the importance of preventive care, fear, and stress in animals, positive reinforcement training, enrichment, exercise and nutrition, pain in pets, and pet health insurance.
The very good news is that pain management is now a central, and increasingly sophisticated, feature of small animal medicine and surgery, with an increasingly wide array of tools at the disposal of all members of the veterinary team. Underrecognized and undermanaged pain inflicts very real physiological and medical consequences, resulting in significant patient morbidity and in the extreme can contribute to mortality. Evidence‐based industry guidelines and consensus statements are available to direct veterinary clinicians to the highest, wisest, safest multimodal strategies for acute and chronic pain. Several clinical metrology instruments are validated for both dogs and cats to assign scores for acute postsurgical pain.
Disasters, man‐made or natural, can be devastating. Lives can be disrupted or lost, property damaged or destroyed. It is vitally important that veterinary practices have a written disaster plan to cover emergency relocation of animals, back‐up of medical records, continuity of operations, security, fire prevention, and insurance and legal issues. For practices affected by a disaster, first and foremost there needs to be an evacuation plan for people and animals. Veterinarians should be included in the larger local or state government's disaster planning, and veterinarian should have a role in the incident command system. Disaster planning needs to include preparation for continuity of operations. Sometimes clients will have to go to an emergency shelter that also allows pets. Having medical records, medications, food, and water ready to go will make the evacuation less stressful.
Sterilization surgery is considered the norm in North American dogs and cats, and is increasingly performed at young ages to prevent breeding of adopted dogs, and potentially reduce behaviors that may lead to relinquishment. The primary purpose of gonadectomy is to manage canine and feline populations. The majority of American veterinarians advocate for elective sterilization surgery. Most American dogs and cats undergo elective ovariohysterectomy (OVH) or castration within their first year of life. Neutering curbs unfavorable behaviors: castrated male dogs roam, mount, and urine‐mark less frequently, and male cats are less likely to spray. OVH is the standard sterilization surgery for bitches and queens in the US. Ovariectomy (OVE) may be performed as a minimally invasive technique using laparoscopy. The desire for less invasive procedures has led to the successful adoption of OVE in other countries. Pet overpopulation is a global, multifaceted, animal welfare issue.
The veterinary healthcare team (VHT) is on the front line of the intersection of animals and the people in their lives, and the One Health concept recognizes the interconnection between people, animals, and the environment they share. The VHT should be knowledgeable about how their actions fit into the larger picture of the human/animal environment. Zoonotic diseases are those that can pass between people and animals. Connection between human and animal health is the use and misuse of antibiotics. Antibiotic use should be restricted for appropriate bacterial diseases and education by the VHT will help clients understand this use. A distrust of commercial pet foods has led some clients to make their own pet food or sometimes veterinarians recommend homemade diets for pets with specific medical conditions. Clients with a love for exotic pets pose a unique challenge for VHTs. Wildlife poses a unique threat to pets and people.
Cancer is a disease of dysregulated genes. Personalized cancer medicine (Pmed) is a therapeutic approach to pet‐specific care that most often analyzes the molecular features of a patient's cancer, and uses this information to design treatment plans that target critical genetic alterations in that patient's tumor. Pmed can also be used to form the scientific rationale for new drug development that starts with the cancer patient rather than cancer cells in tissue culture. It is clear that cancer is a disease of dysregulated genomics. New genomic characterizations of cancer has fueled the field of precision medicine as a therapeutic approach, delivered recent drug approvals in human oncology, and is increasingly available to all species of cancer patients. Precision cancer medicine can be utilized to improve the understanding of a patient's cancer.