Solving the Clinico-pathologic Puzzle: Case Studies

Fred L. Metzger DVM, ABVP
Metzger Animal Hospital
State College, PA

Diagnose your Laboratory

            Do you grumble every month when the reference laboratory bill arrives? Do you clench your teeth when opening the in-clinic reagent invoice? If not, then you probably aren’t utilizing laboratory diagnostics to their full potential. Evaluate your yearly income categories and rank them accordingly like medications, laboratory, vaccines, surgery, radiology, diets, etc. Calculate the ratio of income derived from laboratory diagnostics versus vaccine income. Practices emphasizing laboratory diagnostics have ratios of 1.5:1 or higher. Are laboratory diagnostics fulfilling your practices medical and financial potentials?

Missed opportunities?

            If your laboratory diagnostics to vaccine ratio is less than 1.5:1 consider a diagnostic work-up for your diagnostic work-ups. Are you missing diagnostic opportunities? Are you performing complete laboratory profiles? Are you maximizing the advantages of in-house diagnostics? Are you taking full advantage of your reference laboratory? Are you utilizing the benefits of combining the benefits of in-clinic testing with outside lab testing?

Do you discriminate against your clients?

Are you missing diagnostic opportunities? Pre-judging clients can seriously impact your practice’s reputation and financial health. Chances are your best clients don’t wear three-piece suits and drive luxury cars. Right? Our clients expect and our patients deserve complete diagnostic work-ups. Frequently, patients are presented in supposedly diseased states yet appear healthier than we do! Don’t clients present their pets for “not being themselves” or “ain’t doin’ right”? Are these patient’s truly sick or are the owners over-reacting?

At our hospital a sick patient is defined as sick if the client thinks the patient is sick until we prove otherwise. Don’t clients frequently say the pet looks a lot better in your office than at home? Don’t they sometimes apologize for wasting your time? Who should determine if a patient is sick in the first place? The client who observes the patient everyday in the pet’s natural environment under normal behavioral conditions or the veterinarian who evaluates the pet for 15 minutes in an unfamiliar environment with strange smells, sights, and sounds? Shouldn’t both of you make the decision together using information provided from both parties? Missing diagnostic opportunities negatively impacts your patient’s medically and your practice financially. Work them up!

Do you have all the pieces?

Diagnostic tests are puzzle pieces; you need all the pieces to correctly solve the puzzle.  Missing puzzle pieces results in an incomplete picture or worse yet, the wrong picture. Complete blood profiling usually includes the puzzle pieces hematology, biochemical profiling, electrolyte analysis and complete urinalysis. Thyroid, cortisol, bile acids and other secondary tests (puzzle pieces) are usually requested based on findings from the initial laboratory profile. Medical problems may be misdiagnosed if complete profiles are not performed. Incomplete blood tests are analogous to a radiographic diagnosis made by one view-a dangerous way to diagnose. Incomplete profiling may lead to several potentially life-threatening situations. Patients with serious health problems may be diagnosed as healthy because too few tests were performed. Another potentially serious situation exists when diseases with similar lab abnormalities overlap leading the clinician to the incorrect diagnosis and treatment. Get all the pieces and correctly solve the puzzle!

Convenience stores stores and large grocery stores

            Why do convenience stores exist in the same towns as large grocery stores? Convenience stores charge more for the same item we could buy a few hundred feet away from a grocery store. Yet convenience stores are located in nearly every town and frequently multiple stores exist within close proximity to large grocery stores. Why?

            Convenience and large grocery stores serve different purposes in the overall-shopping scheme. Convenience stores offer easy access, less waiting, and frequently provide a few services (gasoline) you can’t get at the grocery store plus most are open 24 hours and on holidays. Large grocery stores offer lower prices, better selection, specialty foods and a bakery and meat department. Each store offers many similar products yet most people shop at both stores to maximize the shopping benefits.            

Veterinarians and shoppers have many similarities. Many veterinarians utilize in-house laboratories for the same reasons shoppers use convenience stores while reference laboratories share many similarities with large grocery store.

What do diagnostics tests and groceries have in common?

            Many similarities exist between convenience stores and in-clinic testing. Both are open 24 hours and on holidays. Both are more expensive than their larger counterparts yet price rarely seems to become an issue if the service is needed. When was the last time a client called your hospital to request the price of your CBC, biochemical profile or electrolytes? Convenience stores provide 24-hour emergency service and several items like gasoline not available in their larger counterparts.  In-clinic laboratories also provide 24-hour emergency laboratory service and several items like same day preanesthetic testing, blood gas analysis and ammonia testing not available at reference laboratories.

            Many similarities exist between large grocery stores and outside laboratories. Both provide greater selection and lower prices. Reference laboratories can provide full profiles for lower cost compared to in-clinic testing. Milk costs less at the grocery store doesn’t it? Reference laboratories provide many tests requiring special instrumentation or techniques like histopathology, TLI (trypsin like immunoreactivity), endogenous ACTH, fibrin degradation products, among many others. Many outside laboratories also provide consultation with board certified experts if requested.

            Veterinarians should use in-clinic and reference laboratories much like shoppers use convenience and grocery stores- to improve time management, customer service and improve the bottom line.

Are you maximizing your in-house laboratory (convenience store)?

            In-house testing has revolutionized the practice of veterinary medicine. (See 10 Compelling Reasons to Offer In-house Testing Vet Econ Nov 1996) In-clinic testing now includes many capabilities including hematology, biochemical profiling, electrolyte analysis, endocrine assays and blood gas testing among others. In-house testing improves patient management by permitting clinicians to diagnose many diseases and treat immediately.

Benefits of in-house testing include better emergency service, better medicine, and better time management; improved client communications, more convenient preanesthetic testing and adds value by providing immediate results

In-house testing assists the veterinarian to diagnose problems in the emergency setting when outside laboratory services are unavailable. Your in-hospital lab can provide stat results to help narrow the list of differential diagnoses. Some patients simply cannot wait-next day diagnosis of acute renal failure may be too late!

 In-house laboratories help clinicians practice better medicine by providing veterinarians with needed information to diagnose before treatment. Immediate laboratory results allow the doctor to treat the patient based on medical information today not tomorrow. Let’s say Mrs. Johnson brings Cocoa to you with the history of acute vomiting and lethargy. You send blood to the outside lab for analysis because it’s cheaper and the turn around time is only 12 hours. Do you actually wait until the lab results return or do you give an anti-emetic in the meantime and send her home because you have no answers yet? Shouldn’t we wait until the laboratory results arrive before treating? What if Cocoa has acute pancreatitis? Wouldn’t it be better medicine to diagnose Cocoa with pancreatitis now and place her on IV fluids in the hospital increasing her chances for recovery? Oh, and you would have prevented the call from Mrs. Johnson at 3 am telling you Cocoa is worse and still vomiting. You won’t get much sleep tonight!

Do you value leisure time? Do you enjoy talking on the phone? In-clinic testing allows better time management for doctors and clients. Immediate results permits the discussion of laboratory results before the client leaves the hospital thereby eliminating the dreaded next day phone call. Do clients really have a clue when you phone them and waste eight minutes to report Mitsy has a slight elevation in glucose and alkaline phosphatase but not to worry because there is no glucosuria and the lymphopenia is most compatible with stress, which explains the elevated alkaline phosphatase? Oh, the husband then calls ten minutes later because he thinks you said he is stressing the dog and he loves that little dog. Go ahead and waste more time! Get off the phone!

Improved client communication is a major advantage of in-house testing. Imagine performing laboratory work during the same office call thereby allowing you to actually remember the client’s name and that Honey is a male dog. Receiving results during the same office call allows the doctor to ask more case specific historical questions or re-investigate the physical exam. Perhaps you’ll consider other diagnostics such as radiology or ultrasound based on your immediate laboratory findings. For example, Honey a 5 year-old male cocker spaniel is presented for “not being himself”. You perform a limited physical exam because Honey doesn’t appreciate your professional probing. The in-house CBC, biochemical profile, electrolytes and urinalysis reveals a very regenerative anemia (reticulocytosis, occasional nucleated red blood cells), lekocytosis with left shift, and a normal platelet count. You more carefully re-palpate the abdomen and discover spleenomegaly. Radiographs confirm spleenomegaly without other abnormalities. A positive saline-slide agglutination test confirms immune-mediated hemolytic anemia. You discuss the case and treatments options with Honey’s owners and prepare an estimate for treatment. You also provide a copy of an article about immune-mediated hemolytic anemia from a textbook and highlight important points for the owner. The clients leave a deposit and you begin treatment immediately and continue your appointments.

Pre-anesthetic testing is now commonplace in veterinary practice (See Run Pre-anesthetic Tests Vet Econ July 1997). Successful pre-anesthetic programs combine proper staff training with an educational form for clients (see MAH pre-anesthetic form) explaining the benefits of pre-anesthetic testing.  In-house testing allows pre-anesthetic profiling immediately before anesthesia thereby providing medically relevant information. Furthermore maximize client convenience and compliance by providing same day pre-anesthetic testing using your in-house laboratory. At Metzger Animal Hospital we increased client compliance and decreased staff headaches by mailing our pre-anesthetic form with an instructional cover letter several days before the anesthetic event. This allows clients to contemplate their decision for several days and reduces the number of early morning pre-anesthetic pitches staff members’ dread. Just try it!

            Immediate results build immediate value. I always want the broken car part when I pick up my Jeep from the mechanic even though I know nothing about automobiles. I want to visualize where my money went. In- house laboratory reports allow you to educate clients about what you have done to diagnose their pet’s condition. Always copy results for clients and write notes on the printout for clients to take home and educate other family members. One of the most important non-medical advantages of immediate tests are results are available before clients pay the bill not a day later. This becomes a huge customer service advantage-give clients their broken car part!

Are you maximizing your outside laboratory (large grocery store)?

            Veterinary reference laboratories provide invaluable resources for practicing veterinarians. Histopathology, cytology, immunology, microbiology, endocrine assays, therapeutic drug monitoring, immune profiles, coagulation, among many others. Many reference laboratories also provide access to board certified specialists including pathologists, clinical pathologists, internists, radiologists, and others.  

           Veterinary research results in the creation of new and improved diagnostic tests and testing protocols. Keeping up with the changes can be time consuming and overwhelming; however, understanding the new recommendations increases our diagnostic capabilities and our utilization.

Are you maximizing the benefits of both?

            There should be no war between in-house and outside laboratory testing. Both have their proper place in modern veterinary practice. Convenience stores and large grocery stores coexist and so should your laboratories. Proper utilization involves maximizing the benefits of each laboratory to their fullest potential, which improves patient management, and your laboratory diagnostics to vaccine ratio.

Tiny, a 7-year-old 90-pound female spayed mixed breed dog is presented as a second opinion by the owner for “not being herself”. The first veterinarian reported a negative fecal flotation and heartworm antigen test and told the owner Tiny was just overweight and probably arthritic. Physical exam findings reveal an overweight patient with moderate dental tartar. In- house laboratory profiling reveals a mild anemia, which is characterized, as non-regenerative. Cholesterol and alkaline phosphatase are mildly elevated. Electrolytes are within the normal reference range. Urinalysis was not available. In-clinic total T4 was decreased. You review and copy results with Tiny’s owner and highlight a handout on hypothyroidism, which states confirmatory testing (free T4 by equilibrium dialysis and canine TSH) should be performed. You draw a little more blood for free T4 by ED and cTSH –lucky the patient is still in-house. Tiny’s owners thank you and pay today’s bill-happy they have a broken car part. You tell them you will call with outside lab results, which should be 2-3 days. Three days later your trusted veterinary reference lab reports to your bewilderment a normal free T4 by equilibrium dialysis and canine TSH. Luckily, your reference lab provides access to an endocrinologist who reminds you that hyperadrenocorticism frequently mimics the clinical picture of canine hypothyroidism and is a cause of non-thyroidal illness. The specialist recommends a urinalysis and low dose dexamethasone suppression test, which confirms hyperadrenocorticism. You report the results to Tiny’s owners and fax an article on Cushing’s disease.

Tiny’s owner tells all her friends her new veterinarian maximizes the benefits of in-clinic and veterinary reference laboraties. She goes to 7 eleven to buy gas and a drink then buys groceries at Winn-Dixie where her son drops a ketchup bottle- “cleanup on aisle three!”