Combining forces: How general practitioners can work with dermatologists

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General practitioners (GPs) typically refer patients to specialists when a patient's medical condition requires expertise beyond the scope of primary care. This referral process is crucial for ensuring that individuals receive specialized diagnostic and treatment interventions. Effective collaboration between GPs and specialists can ensure clear communication for the client and medical team. In dermatology cases, specifically, severely allergic diseases, acute-onset skin disease, chronic otitis externa, and more can be examples in which referral to a dermatologist would benefit both the patient and the owner. However, Julia E. Miller, DVM, DACVD, a dermatologist with Animal Dermatology Group in Louisville, Kentucky, and an assistant clinical professor of dermatology at Cornell University College of Veterinary Medicine in Ithaca, New York, explained to attendees at the Fetch conference in Charlotte, North Carolina that the rate of referral for dermatology cases are less common than other specialties.^1,2

One reason for this could be the lack of client education about veterinary dermatologists. Some clients might think their pet’s GP is the only one who can help and without the GP’s recommendation of seeing a dermatologist, they would never know it’s an option. Miller stated, “What [clients] don't realize is that animal dermatologists do it all. We do the bumps on the skin, we also do ear infections, and we also manage allergies, which is very different than how human [medicine] is.”

Miller stressed that GPs could help educate clients about veterinary dermatology and provide information or resources. One of Miller’s suggestions is a website called petsgetallergies.com, and on there, clients can learn more about what veterinary dermatologists do and the diseases and conditions they can treat. Clients can also use this resource to find a dermatologist near them or they can go on the American College of Veterinary Dermatology (ACVD) website to search, as well. “What I really like about this website is it's very much geared towards clients… You could guide them towards this website because it really has some very digestible owner-friendly information.” Miller said.

In 2019, the American College of Veterinary Dermatology (ACVD) conducted a survey of pet owners who have been referred to a dermatology specialist.² Dermatology was the second to least likely veterinary specialty to receive a referral from a GP, with only behavior being less likely. Oncology, orthopedic, and ophthalmology were some of the highest referrals.² Only 27% of clients reported that their dogs were successfully treated after their first visit with their GP and 73% of clients visited their GP more than 3 times before they were referred. This highlights the fact that most of these dermatologic cases are complex and chronic.^1,2

A survey in the United Kingdom assessed the prevalence, diagnosis, and treatment of dermatological issues in small animals within general practice. Among the 3707 observed consultations, 795 (21.4%) involved a pet with a dermatological problem. In dogs and exotic species, pruritus was the predominant presenting sign, comprising 30% to 40% of dermatological consultations. In cats, cutaneous swellings were the most common presentation (36%).³

This case to referral discrepancy is perplexing and Miller said to attendees, “it tells me that we really do need to do more referrals, because we're seeing an awful lot of these cases.”

Another reason for the low number of referrals could be because most dermatology cases are not dire or deadly, but rather chronic conditions that take a lot of effort to treat or manage. However, Miller challenges this idea by stating, “Also remember that pets can be surrendered to shelters because of chronic skin disease. And they're surrendered because dermatology cases have a financial burden, time commitment, and you have a chronic sick dog. that's a big deal, right? So maybe they're not deadly, but they certainly have a lot of negative consequences to our owners.”

GPs might postpone the referral of their patients to specialists because they believe their treatment selection will be effective. However, in that same ACVD study, the diagnosis in 46% of cases made by the GP did not align with that of the dermatologist.² Miller underscored that referring cases to a dermatology specialist can streamline a patient's treatment and expedite their recovery process.

Open collaboration between the GP and dermatologist is paramount for setting a patient up for success. The synchronicity between both veterinary professionals can create a unified treatment plan and contributes a seamless progression of the therapeutic process. However, it is important to remind the client of the reality that, despite a quick referral, many dermatological cases are chronic and require patience and persistence before there is a noticeable improvement in the pet's condition.

“So get to know if your friendly neighborhood dermatologist, they are happy to talk through cases with you and that can be a really good resource,” Miller said.

References

1. Miller JE. Tips and Tricks for Successful Referral and Co-management with your Neighborhood Dermatologist. Presented at: Fetch dvm360 conference; March 15-17, 2024; Charlotte, North Carolina.
2. Hanna B. Earlier dermatology referral rewards primary care practice (part 1): easing client expenses and enhancing patient care. DVM360 magazine. May 2022: 42-43. https://www.dvm360.com/view/earlier-dermatology-referral-rewards-primary-care-practice-part-1-easing-client-expenses-and-enhancing-patient-care
3. Hill PB, Lo A, Eden CA, et al. Survey of the prevalence, diagnosis and treatment of dermatological conditions in small animals in general practice [published correction appears in Vet Rec. 2006 Jun 3;158(22):763]. Vet Rec. 2006;158(16):533-539. doi:10.1136/vr.158.16.533