Diagnose your Laboratory
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?
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!
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?
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
What do diagnostics tests and groceries have in common?
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.
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.
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)?
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
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
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!
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)?
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.
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?
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
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!”