Risk assessment is affected by our own biases. For example, we are more likely to diagnose a disease, correctly or incorrectly, that we have recently read about or seen. We are less likely to diagnose or talk with a client about a disease we have never seen, even if we know the clinical signs and likely presentation. The brain is more likely to follow a familiar path. After a personal experience with a certain disease, whether in a patient, a family member or our own pet, we develop blinders to possibilities other than the scenario we already know. For example, if a family member had a bad experience with cancer, a client is less likely to let us treat their pet for cancer. The picture they have of cancer treatment affects how they regard the risks or rewards of treatment.
Also, things that frighten us more become higher risks in our minds, as when we are more worried about air travel than traveling by car, though the risk of a car accident is far higher than that of a plane crash.
All these factors create incentives to utilize logic and systems to help with risk assessment.
2.7.10 Risk Assessment for Well Patients
When deciding what to go over with a client at a wellness visit, it may be useful to divide risks into categories. Look for risks in each and then refine your list into no more than three things to teach about. Risks are often defined by what the pet owner is not doing, such as not giving a monthly heartworm preventive on schedule or not feeding a nutritious brand of cat food. Try these common topics:
age related
breed specific
contagious diseases
oral care
parasites
weight/nutrition.
If a client is already giving recommended heartworm and intestinal parasite preventives as directed, educating about parasites would not be as important as teaching about something the client is not doing, for example leptospirosis vaccination. If the pet is a normal weight but has moderate tartar build‐up, we obviously would be talking about dental care and not obesity management. By looking at each category individually, it is fairly simple to come up with two or three topics to discuss.
Even when we have a scenario where there is too much to discuss – say we are seeing an overweight, older golden retriever with arthritis, bad teeth, and an ear infection – we can usually manage to prioritize. Which topics could wait until the recheck visit? We could choose to talk about otitis and arthritis now and postpone the obesity, senior screening, and dental disease topics until we recheck the ear and the arthritis in two weeks. That would also give us time to get an estimate ready for the dental work needed.
A point scoring system may work better for recommending wellness screening laboratory testing. You would give one, two or three points in each of the categories. We would want to rank the most common and most treatable higher with a higher point score. So, if the disease we are screening for is uncommon, we would give the test for that disease one point. If it is a common disease, we would give three points. So, for each of these three categories, award one, two, or three points.
More common
More important
More cost‐effective
Let's look at the following possible tests: complete blood count (CBC), chemistry panel, thyroid profile, urinalysis, urine protein:creatinine (UPC) level.
If we are recommending laboratory testing for a senior pet and the client is willing to spend a certain amount of money, we might choose a chemistry panel, CBC, and thyroxine (T4) for an overweight Labrador retriever. The T4 would get a score of 3 for each of the three categories.
For a normal‐weight soft‐coated wheaten terrier, the calculation is different. We would recommend the chemistry panel and CBC but instead of the T4 we might choose the UPC ratio. In the retriever, hypothyroidism is more common and for the wheaten, glomerulonephropathy (GN) is a big concern. Here is a link to a client education video on GN in soft‐coated wheaten terriers: www.youtube.com/watch?v=eTwyUbiFPbU.
If the Labrador is young, however, the T4 becomes less important – it is neither as important nor as cost‐effective if there are unlikely to be clinical signs of hypothyroidism. If it's an older Scottish terrier we are seeing instead of a wheaten, our top concern might be transitional cell carcinoma, so the urinalysis is more important than the UPC.
Whether to offer clients standardized wellness care plans that are the same for everyone, or individual, customized ones is a philosophical decision that every practice must make (see 10.17 Payment and Wellness Plans). Both for wellness packages and diagnostic protocols for disease states, it is a choice whether to individualize or generalize.
Individual plans take more time and effort, but are less likely to include unnecessary tests.
Generalized plans are less expensive to administer and help to prevent missed diagnoses because of underestimated risk. It may make more sense to generalize in a large corporate practice with many recent graduate veterinarians, or in an emergency case where you do not have time to waste waiting for one test result before deciding on the next. A boutique practice in a high‐end market with an experienced team may be more likely to customize.
A health risk assessment form (see 1.2 Providing a Lifetime of Care) can assist the veterinary healthcare team in using client‐provided information to guide recommendations. The comments and recommendations need to be tailored to an appropriate locale and demographic. For example, a schnauzer and a Doberman pinscher both have risk for heart disease but not the same kinds. For the schnauzer, auscultation is warranted to listen for a mitral valve murmur and perform an ECG to look for atrioventricular (AV) block. In the Doberman, the focus is on looking for ventricular premature contractions (VPCs) caused by cardiomyopathy.
In a digital report card sort of format, it is easier to choose and print those risks that applied, and the client would not see those recommendations that weren't applicable to them.
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 higher risk for death, pain or illness. We should ensure that every client is aware of these less common but serious risks and has the opportunity to prevent or screen for these diseases when possible.
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.
In ill patients, our risk analysis helps to guide us toward the most likely diagnoses so that we can diagnose and treat the pet appropriately.