'What do we tell our clients?'

A client comes into the office with a printout of some Internet article claiming that veterinarians are recommending vaccines that are simply unnecessary. What do you tell this client? More importantly, how do you train your staff to handle this?

Exam room technician Linda Slover is discussing the Risk Factor Questionnaire with a client. This, of course, takes place prior to the doctor's appearance in the exam room. The information obtained by this questionnaire helps the doctor determine which vaccinations to recommend.

It has finally happened. The American Animal Hospital Association (AAHA) has released canine vaccine guidelines. Some practitioners may dread it and consider the recommendations as a "practice buster." To others, it may represent a change that was long overdue. Regardless of how practitioners view the guidelines they came at a time when the Internet will carry it everywhere, so it is real.

Facing the challenges

Our challenge, as you have been reading in related articles in DVM Newsmagazine, is to find a way to stay current with recommendations and yet continue to practice good health care. The concern of course is the loss of our "vaccine hook." Some of us have been actively building new wellness care programs all along to make this transition easy and even sensible; others, unfortunately, have buried their head in the sand, hoping it wouldn't happen. Wherever you stand on this issue, the word will travel fast and it will surely be an issue that as a veterinarian you must address.

Our credibility may be challenged by some of the media's representation or misrepresentation on this issue. It places a major responsibility on our clients to recognize the need for having their pets periodically examined. It may even drive clients to the Internet to obtain more of their animal care information. A well-crafted response by practitioners is essential, and how we respond may greatly influence the future success of our practice.

Table 1: Risk factor questionnaire

Disseminating the information

Go to your computer and type in the phrase "vaccinations for pets" on a search engine and see how many responses appear. I did this and instantly got 67,300 matches. I pursued as many as time would permit and it was shocking to see how many self-proclaimed "authorities" we have now. Many articles, some written by degreed professionals, were outright degrading to practitioners. It may be very difficult for our clients to decipher whom to believe.

The support staff must address these issues:

1. We must first assess the client's concern. Has damage occurred to our credibility? Has the client come across counter information from outside sources? If so we must first repair our credibility.

2. We must then demonstrate to the client that we are absolutely committed to providing the best care possible and that we have been reviewing the vaccine dilemma for some time. Remind the client that our vaccine recommendations are constantly being reviewed and changed when necessary. We are constantly studying new information regarding duration of immunity, geographic variations in disease prevalence, and life style risks of exposure. Accordingly, we offer what we regard as the best vaccination protocol for each pet in his or her individual environment.

3. Next, we must make them aware of the controversy on both sides of the issue. For example, while new guidelines may recommend revaccination every three years there is little, if any, documented proof that they will in fact protect the pet for that long. We recognize that recent technology has produced products that are far superior to previous products and may likely produce immunity longer than one year. Yet, the fact remains that they are only licensed for one year. It becomes our responsibility to make clients aware that deviating from the manufacturers' recommendations violates legal licensing requirements and calls for off-label usage. With some clients it may be wise to obtain a signed acknowledgement.

4. We must alleviate their concerns for safety. They must be told that we are not wishing to cause harm to their pets. For the most part vaccinations have prevented an enormous amount of disease and suffering in animals and have caused very little concern for safety. We advise clients that many of the stated claims on the Internet regarding safety are grossly unfounded or exaggerated.

5. Finally, we must set forth a plan that meets their needs. While impractical, and somewhat controversial, a few clients may desire a titer test to determine if there is a need for additional vaccinations. Some will be pleased with a risks factor assessment. For others, it may simply be a continuation of the previous program.

How staff can specifically respond to client inquiries

Vaccination is an ingredient of wellness care. Since the support staff is the main purveyor of wellness care it behooves the practitioners to first focus on educating the support staff.

Figure 2: Vaccination reminder

The support staff fields the calls, responds to client questions and is in a prime position to protect the doctor-patient relationship. The support staff must be educated. They need to make the following points to clients.

• The staff explains to the client that while the American Association of Feline Practitioners (AAFP) and the AAHA may publish guidelines, it may not be that easy to make blanket recommendations for all pets in any practice. Staff members present a questionnaire to the client. The responses are reviewed and that information is added to our existing knowledge base regarding the client and the pet (Figure 1, p. 40).

• Life styles vary greatly. Certainly life styles affect the possibilities of exposure. Obviously some pets are exposed to contagious diseases in kennels, grooming salons and traveling. Outdoor cats become exposed to more disease than indoor cats and so on.
• Geographic prevalence of disease varies greatly from one area to another. The staff explains that it is our obligation to recommend the appropriate preventative heath care practices for our geographic area and that may include specific vaccinations. Furthermore, it is entirely possible that specific vaccination recommendations may not always coincide with published guidelines of the AAFP or AAHA. A perfect example in our practice is feline leukemia. Previous large numbers of positive cases of feline leukemia have led to strong recommendations for feline leukemia vaccination. Yet feline leukemia is not listed as a core vaccine. To ignore this increased geographic prevalence and discontinue vaccinating for leukemia would be a grave misservice to clients in our practice.
• The guidelines are for "healthy" animals and many of our pets are less than healthy. Senior-age pets may have a diminished response to vaccination due to age-related suppression of the immune system. Pets with endocrine disease, immune-mediated disease or cancer, and those undergoing treatments for such diseases, may also have a diminished response to vaccination, and have reduced duration of immunity. An example on the human medicine side is that flu epidemics are countered by recommending vaccinations for the young, old and immune compromised.
• The AAHA and AAFP guidelines also assume that a thorough puppy or kitten vaccination series was completed in earlier years. Animals coming from shelters or animal welfare agencies may not have had a complete puppy or kitten series and likely do not have a solid base immunity and may not respond the same as pets that had a solid program.
• Kennels and obedience classes in our area do not accept the guidelines at this time. If clients are anticipating using such facilities they may need to continue annual vaccinations until their recommendations change.

Bringing it all together

As we implemented our program it began with computer-generated vaccination reminder as before. Only now vaccine codes are tagged to "annual preventative healthcare visit" rather than to a specific vaccination for next year's annual reminders. By doing it in this fashion we can customize each pet's vaccination recommendations to reflect his or her specific needs at the time of the visit (Figure 2).

The doctor analyzes the physical exam findings, lab test results along with any new historical information. Pertinent recommendations for further action, if indicated, are then made. A strong effort is always made to make some positive recommendations for the betterment of the pet. This endorses the value of the exam and the laboratory testing and may ultimately improve the life of the pet.

After reviewing the risk factors (age, lifestyle, etc.) the doctor then makes an appropriate vaccine recommendation to the client. The client has the option to accept or decline the recommendation and ultimately makes the final decision. The vaccination(s) is given at the end of the visit to once again emphasize the importance of all the other items (physical exam, counseling and lab testing) placing less value on the vaccination. In some situations, we stagger the vaccines over two or three years, giving different vaccines each year. In other situations, we give all the vaccinations annually. The program differs from previous programs in that the patient's risk and clients' concerns are now included in the decision. Vaccinations actually become a small ingredient of the annual visit and hopefully clients will realize this and agree.

What do clients really expect from the annual visit?

I surveyed my clients to obtain knowledge as to what they perceived as important issues of the annual visit (Figure 3).

Figure 3: Client Survey

It was also interesting to note that while clients initially made the appointment on the expressed need for vaccinations they came in with a list containing numerous behavior or nutritional questions, or other health care concerns. This demonstrates that while the initial interest may have been the vaccination it was actually a focal point for an opportunity to ask all sorts of other questions regarding the health care of their pet. This key observation may be revealing the solution to finding a replacement for the vaccine "anchor." That replacement anchor is a new wellness care plan that is structured to focus on client's needs as revealed by their questions.

Keeping the "annual visit" without the "annual vaccination"

The key to our success will be devising a means of keeping the "annual visit" when not performing an "annual vaccination." A quick look at our human medical colleagues (family practitioners, internists, obstetricians) shows us that annual health care exams and laboratory testing are commonly performed with minimal regard to vaccinations being given. In fact, dentists do very well at getting their clients to return every six months. On the other hand, our image has become that of a "vaccinator" and not "a physician for animals."

Changing client behavior will require a major effort by the entire practice team. The good news is there is still time to achieve this task. In fact, most clients still today consider vaccines to be the most important reason for visiting a veterinarian. Prove this to yourself. The next time you are in a public setting being introduced to strangers and it becomes known that you are a veterinarian, listen closely to the comments that follow.

Their comments will tell you exactly what the public's perception of veterinary care encompasses. It usually sounds something like this, "Oh, I just took my dog to the veterinarian yesterday to get his shots." Shots, shots, shots! The majority of the public still places a high value on vaccinations. For now we can use that vaccination visit to educate clients on the real services that veterinarians have to offer.

But we must act fast to restructure our wellness programs. Soon clients will be asking many more questions and may be forming new opinions regarding your practice. Currently only about 10 percent of all clients question the necessity of "all those vaccines." Approximately one half get their information from the Internet, while others get information from pet magazines, breeders, neighbors, friends and special news media broadcasts. No matter what the source, practitioners must begin crafting their response now. By demonstrating sound medical skills and performing truly worthwhile programs of wellness care practitioners can reclaim the title of physician for animals.