How to make your lab work for you

The author running an EKG, which he cites as “easy, simple to interpret, and a high-profit item.” Courtesy Dr. Shawn Messonnier Laboratory testing, when combined with a thorough history and proper physical examination, contributes to forming a correct diagnosis. This improves medical care for the patient as we are treating a known (proper diagnosis) versus an unknown (suspected diagnosis or simply clinical signs and symptoms,) and easily increases practice profitability without the need to simply try to find ways to “increase the bill.” Below I will address some of the commonly performed laboratory tests, as well as those not commonly performed but likely should become commonplace in our practices. I will also share some ways the entire staff can and should become involved in the proper utilization of lab testing. Note: I cover only those tests I personally believe should be commonly performed in our practices, and not those less commonly needed or specialty testing. Blood profile Most veterinarians complete a basic blood profile at least annually. Since pets age quicker than people, we have been doing a biannual visit for many years and included a blood profile plus other testing, as well. We all know waiting 12 months, especially for older pets more likely to show abnormalities, can be a death sentence for some. Evaluating pets every six months makes more sense and allows diseases to be caught earlier, which can save lives and save your clients money. While you have a choice of which blood profile should be run, most owners can afford a basic mini-profile at least every six to 12 months, and this is fine for younger animals. For older animals I prefer a complete “senior” profile including, at a minimum, a TT4 and preferably also a FT4. Microscopic fecal examination A microscopic fecal exam can identify parasites in asymptomatic pets, as well as pets with GI signs. Your techs can perform these tests while helping the client and get an immediate answer allowing treatment while the pet is in the office. The test is of minimal cost to you and is a high profit item to the practice. Since some parasites are zoonotic, I recommend this test every six months. Remember to have your staff (typically your receptionist) remind owners to bring in a fresh fecal sample for the visit. I have found even when reminded via the phone and a follow-up email or text, many owners still say they were never told to bring in a fecal or urine sample—hence the importance of a fecal loop and taking all dogs outside to try to get a urine sample! The author viewing a urine sample; another recommended test to make your lab work to improve health and profits. Courtesy Dr. Shawn Messonnier Urinalysis The urinalysis is another test that is easy for the techs to do (at least the dipstick and specific gravity part of the test) and costs so little to run yet returns a wealth of information and profit. Interpreted in light of clinical signs and the blood profile, a number of conditions can be discovered, including significant proteinuria, glucosuria and ketonuria, alterations in specific gravity, and the presence of casts, crystals (which may point to the need for radiography or ultrasonography,) and sometimes neoplastic transitional cells. Most clients will not bring in a urine sample nor know how to collect one (from dogs) so make sure your staff is trained in explaining the collection process to them. For many cats that are not overweight, getting the specimen via cystocentesis if the pet has a palpable bladder is easy and will allow the test to be run. Ear and skin cytology I love cytology and think it should be used frequently in practice. It’s another test that has very little cost but big financial returns. Cytology is essential in allowing proper diagnosis of ear infections (bacteria, yeasts, or mites,) and skin disorders (yeasts, bacteria, occasionally autoimmune.) It’s a high return test for diagnostic value and allows correct treatment of dermatological issues. Gram stain Anyone who treats birds is very familiar with a Gram stain. I find it is also helpful in cases of diarrhea, especially if clostridial enterocolitis is suspected. This is another test that is easy to do with a good return on investment. Tumor cytology All veterinarians see pets with a variety of lumps and bumps. Aspiration cytology with a needle is needed to determine if the lump is benign, malignant, an abscess, or a cyst. Even if you do not take the time to really learn cytology and choose to send all of your cases to your outside lab, I still think it is important to be able to do minimal cytology. As I teach the externs who spend time at our practice, every doctor should be able to determine if the lump is any of the following: lipoma, a cyst, an abscess, a typical well granulated mast cell tumor, or “something else” that requires a pathologic diagnosis by a specialist. This allows you to give the owner some sort of answer even if you rely on your outside lab for confirmation. Tumor and skin biopsies In some cases, a diagnosis cannot be reached via cytology, and a histopathological diagnosis is needed upon removal of the tumor. In other cases, the cytology may have made a diagnosis, but the biopsy is needed to confirm the diagnosis and grade the tumor for prognostic information. As a general rule, if you cut it out, biopsy it. Sometimes clients may not want to spend the extra money for a biopsy or say they do not care about the specific diagnosis, “Since we won’t do anything if it’s cancer.” In these instances, you have three choices: Tell clients a diagnosis via biopsy is required for you to remove it so you can protect yourself legally. Tell clients a diagnosis via biopsy is required for you to remove it so you can plan for possible problems that may arise if it is cancer even if they won’t treat it. Cancer can spread and cause systemic or organ-specific signs. You need to know up front that this could cause the pet problems later, and to help you prescribe a specific treatment, regardless of the client’s desire to treat, and truthfully, many will change their minds once they hear the “C” word. Put the fee for the biopsy in the quoted price of the surgery to prevent an extra biopsy fee that could be declined. Skin biopsies are highly valuable, but not performed nearly as much as needed, or early enough in the disease process for proper diagnosis and treatment. Punch biopsies are easy to do, and often can be done with a local anesthetic +/- sedation, and in a number of cases (especially chronic dermatitis unresponsive to various treatments) are the only test that can give an exact diagnosis. Cultures and sensitivity As a holistic doctor, I rarely prescribe antibiotics in my practice, and even more rarely prescribe them without the benefit of a culture and sensitivity. To reduce antibiotic resistance as well as confirm a bacterial cause for acute and chronic diseases, a culture and sensitivity is needed to guide proper diagnosis and treatment. While expensive, it is cheaper than chronic antibacterial use that results in failure to cure and extra cost to the owner. Following the culture and sensitivity and proper treatment, a follow-up culture can be done to confirm a cure or the need for extended treatment. EKG Running a screening EKG is easy, simple to interpret, and a high-profit item. Companies make small, portable, and inexpensive three-lead machines that give good readings; abnormal findings can allow a more thorough five-to-seven lead strip and referral for a cardiology consult if needed. When we find an abnormality, we tell the client we need the more thorough and expensive EKG with printout, and we deduct the cost of the screening EKG from the final, more thorough EKG price. We price our biannual EKG with this small machine at a very inexpensive screening cost of only $15, which most owners can easily afford and add to the cost of their biannual visit. For pets with signs of cardiac disease (and presurgical screenings,) a more thorough EKG with appropriate testing is indicated. Inflammatory and vitamin D testing A (relatively) new level of testing is for inflammatory markers (CRP, HPT, TK) and vitamin D3. I use this test profile all the time in my practice to allow for early diagnosis of inflammatory diseases including cancer, and for hypovitaminosis D (which occurs in my practice in at least 90 percent of tested pets, making valuable this a test with a high diagnostic return.) Most owners are very open to this extra level of testing, as they have typically had personal experience with cancer and would appreciate any test that might provide early diagnosis of such a serious disease (and these tests are often included in blood profiles for people.) As a functional medicine/holistic veterinarian, I like this extra level of testing as it allows me to monitor patients for hidden cancers, infections, and inflammatory diseases. I also believe, based upon human medicine, that low vitamin D levels contribute to a whole host of problems including cancers, and restoring vitamin D to healthy levels can improve health in our patients and possibly lower chronic inflammatory and immune disorders. Since most tested patients show some abnormal results, I know these patients will need treatment and regular monitoring to ensure health, which is good for the pet and the practice. Staff typically assist with radiographs, but there are all sorts of ways they can help make other testing go more smoothly. Courtesy Dr. Shawn Messonnier Involving the staff A veterinary practice is not a solo event! The staff must be involved to properly care for our patients and reaffirm the health plans set out by the doctor. The first contact begins with the receptionist, who must be trained to explain what happens during a typical visit for a sick pet or a wellness visit. The receptionist does not need to know all of the medical details of which tests will be done or why, but can simply share that the visit typically involves some type of lab testing (blood, urine, fecal, etc.) and remind callers to do their best to bring in a fecal sample and urine sample (they need to know how these samples, especially the urine sample, will be collected; it’s still amazing the typical owner doesn’t know how to collect and store these samples, especially the urine sample!) While I mentioned the first contact with the practice is the receptionist, this is not technically true. Often, the very first contact is with the practice website (the receptionist is typically the first personal contact with the practice.) Therefore, it is critical your website describe in some detail what to expect on the first visit if you feel that the caller may not be open to your level of lab testing that is typically done on the first visit (especially if you are unique in your practice area in performing lab testing.) Handouts I am a big believer in handouts for two reasons: They provide a written explanation of what the pet needs, which reinforces your words during your discussion with the pet owner. They can be taken home so the owner does not forget anything that occurred during the visit, which is especially helpful when they want to explain to the family why testing was done during the pet’s checkup. I think it is important to approach writing the handout with the idea of explaining why a test is needed, and, when possible, relating it to our own doctor visits (how we give blood and urine during our checkups to allow for early disease diagnosis, and how we want this same level of care for our pets.) In our practice, disease-specific handouts are given to the owner after I have already explained what needs to be done for the pet following my examination and before the tech presents the treatment plan (which includes estimated costs) so the owner is prepared to agree to our plan. The handouts explain what testing we may need to do that day and makes it easier for the owner to say “Yes” to our treatment plan. I want to share a final thought about costs to the pet owner for all this testing. First, I strongly encourage you to seriously considering offering wellness plans for your practice. These plans, tailored to your needs and those of your patients and clients, can reduce the cost of testing by bundling services. Second, I strongly recommend suggesting one or two pet insurance companies to your clients. If you are doing a lot of lab testing, it is almost guaranteed problems will be found on the tests. Owners who already have pet insurance can continue monitoring their pets at minimal costs due to the insurance. Finally, while in theory I am not big on professionals discounting their work, in reality we all expect and often ask for discounts and your clients are no different. Do not be afraid to market specials throughout the year on your lab tests to encourage usage by those who might not be able to afford your regular pricing. Also, remember, even if you don’t markup your lab tests as much as you would like to encourage more clients to utilize them, offering them at a slightly lower cost can be beneficial because you are likely to uncover problems you will be treating. This means these pets will need treatment and further follow-up testing, which will typically make up for any lost profit on the pricing of the initial testing. As an example, most practices would agree that at least 50 percent (if not more) of pets tested with blood and urine tests will uncover some abnormality that requires treatment, further investigation, and follow-up testing. This is beneficial to the patient as disease is discovered before clinical illness, and beneficial to the practice by increasing profit through the practice of high-quality medical care, which benefits everyone! Shawn Messonnier, DVM, opened Paws & Claws Animal Hospital and Holistic Pet Center in Plano, Tex., in 1991. His special interests include holistic and functional medicine, exotic pets, dermatology, cancer, and internal medicine. In addition to serving clients, he has written for numerous veterinary and pet publications, and is also the author of several books, including the award-winning The Natural Health Bible for Dogs & Cats.

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How to make your lab work for you

Reminders on which laboratory testing can both increase medical care and your practice income

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