dermatology

Re: dermatology

Bob Russell — Wed, 24 Aug 2011 14:50:53 GMT

Most of the skin cases I refer are those where I feel I am losing the owners confidence. I spend a lot of time emphasising that allergies are incurable and compare with hay fever.

Sometimes you can feel the owners frustration and I would rather my patients got a 'better' opinion from a specialist than be moved from pillar to post, one GP to another. I try to investigate, it is not rocket science but there is always a vet down the road that will take that short cut with preds. It makes it sound as if I am anti-preds but we do have a fair number of patients on them however this is after proper discussion of the options. A lot of clients just want a non-itchy pet and are not willing or able to pay for in depth investigation.

I have seen a number of animals where even basic parasite control has been ignored by previous vets but I am sure other vets could justifiably accuse me of missing the obvious on occasions!

Re: dermatology

patrick murphy — Wed, 24 Aug 2011 13:08:58 GMT

hear,hear. it was the tone that I objected to. of course there are skin idiots out there, but there also heart,ortho, etc. idiots as well.

in our practice we call it diplomatitis, so the only person that you can refer to is another diplomate, based on their assumption.

I also think that it is drummed into new graduates, for whatever reason that we should refer,refer,refer, and that removing anal glands for example (true) is the preserve of a soft tssue specialist.

I truly believe that unless a new graduate gets into a place where the boss has some gumption that they will pass through their careers losing a lot of the things that bring job satisfaction to an old gp such as myself, and my bet with myself is that with 24 hour out of hours cover that some graduates may go through their career never having experienced the buzz of say a really great ceasar.

just my view

Re: dermatology

Clive Ansell — Tue, 23 Aug 2011 19:55:21 GMT

[quote user="Richard Fox"]

Well we charge 17.50 plus VAT for skin scrapes but obviously that doesn't include a consult I presume the 36.50 is inc a consult? Otherwise we need to put our prices up

[/quote]

£36 was for taking the scrapes and microscopy done in house, in addition to a repeat consultation.

If samples were sent to you; £17.50 for you, plus time and expertise taking the samples, plus mark up and/or lab interpretation fees, plus VAT the £36 is not too far out (£30 plus VAT really £6 directly to HMRC)

Re: dermatology

Hannah Wynne Richards — Tue, 23 Aug 2011 18:21:28 GMT

I referred an awful lot of skin cases in the 1st few months after I bought this practice. My predecessor was one of the "put everything on steroids " types, so I had a practice full of repeat steroids, whose owners all thought he was the best veterinary surgeon in Swansea. Luckily, at exactly the same time, a dermatologist started in a referral centre down the road. Rather than say "Mr X was a fool " which would lose me clients, I said "This has been going on a long time A new specialist has just opened up, so it might be better to gradually reduce the steroids, and when he's off them, the specialist can have a look

Apart from that I did once refer a dermato;logy case as soon as I saw it. A cat came in to morning surgery, and although I didnn't know what it was, I knew it looked weird At that time, Chris Chesney had clinics every 3 weeks in Cardiff. He had a clinic that day, and the owners were insured, and willing to travel, so I sent it straight up.He phoned back, rather exited because it was a feline demodex, and he had only seen a couple in his whole career-incidentally, he's a specialist dermatologist who has spent a considerable length of time in 1st opinion practice, and both respects hard-working practitioners, and understands our problems

Wynne

Re: dermatology

Richard Fox — Tue, 23 Aug 2011 17:59:30 GMT

Well we charge 17.50 plus VAT for skin scrapes but obviously that doesn't include a consult I presume the 36.50 is inc a consult? Otherwise we need to put our prices up

Re: dermatology

Rob Reid — Tue, 23 Aug 2011 17:07:20 GMT

I think the dermatologists do make a point - I have certainly seen 2nd opinion skin cases where basic things have been missed, suggesting that there are GP vets out there who could/should be doing better.

I agree though, that the tone of article is a tad demeaning, and I do wonder how the tone might alter if some of the referral dermatologists came and worked in a bust 1st opinion practice for a few weeks and faced some the practical challenges that us GPs have to confront.

Re: dermatology

Robin Grimmer — Tue, 23 Aug 2011 14:47:48 GMT

[quote user="patrick murphy"]

did anyone else find the article in Veterinary Times about what a shabby job we gp's do on skins, before finally referring them to the gurus a bit demeaning?

. I sure did.

[/quote]

Yes I read it but to be honest they are probably right.

But then they are only seeing referred cases that are a/ insured and b/ the clients are so fed up that will do whatever the specialist wants eg stick to that hypoallergenic diet rigorously.

It's hard when you get an uninsured/limited funds chronic skin during a busy evening surgery. I try not to reach for the preds at least not til I've done some minimum diagnostics, but it's not an ideal world.

Re: dermatology

Clive Ansell — Tue, 23 Aug 2011 12:34:52 GMT

[quote user="robloxley"]

[quote user="Clive Ansell"]cost of scapes here is £36[/quote]

On top of the consult fee? I'd be interested how this is arrived at

[/quote]

Dunno, I'm just the locum following practice prices. in addition to the consult, yes of course.

£36 is peanuts and seems more than reasonable to me though for a highly trained, highly skilled professional carrying out a diagnostic investigation and interpretation of results. As I said earlier my local Peugeot dealership charges £75 for a teenage minimum wageite to plug a car into a computer and print off a readout.

Re: dermatology

Gareth Dowdeswell — Tue, 23 Aug 2011 12:34:47 GMT

Was interested to read in the article that apparently some vets just refer straight to a specialist without doing anything - must have very rich clients to be happy to go straight to referral!

[quote user="robloxley"]

[quote user="Clive Ansell"]cost of scapes here is £36[/quote]

On top of the consult fee? I'd be interested how this is arrived at

[/quote]

Doesn't seem unreasonable if that price includes interpreting the slides as well - charge is just under £30 here for the same.

Re: dermatology

Rob Loxley — Tue, 23 Aug 2011 12:26:02 GMT

[quote user="Clive Ansell"]cost of scapes here is £36[/quote]

On top of the consult fee? I'd be interested how this is arrived at

Re: dermatology

Rob Loxley — Tue, 23 Aug 2011 12:23:59 GMT

Hmm, I'm sure dermatologists do see a fair number of poorly managed skin cases referred which could have been 'sorted' in general practice, but equally, de facto, they don't see the large number that are well managed!
I can see why we might take issue with the tone of the article, maybe a better stance would be 'pitfalls to avoid in skin cases' but I agree with many of the sentiments. How many of us have seen second opinion 'allergy' cases that have had lots of expensive serology tests but nobody has looked and found the demodex or treated the household's cat for fleas?

Re: dermatology

Clive Ansell — Tue, 23 Aug 2011 12:20:22 GMT

I always try and get the owners to agree to skin scrapes and sellotape impressions if possible, not expensive and at least it is good to try and exclude ectoparasites rather than just assume they are not there because Stonghold/Advocate have been used. I have had 2 dogs this morning, one a WHWT and the other a Bichon both positive for Sarcoptes mites, these guys may well have been on preds (certainly the WHWT) without the skin scapes. The WHWT has been treated with Stronghold in the past too. Both clients moaning about the cost too, cost of scapes here is £36, so with consults and meds they will be around £80 - £100 each I guess.

Re: dermatology

Hannah Wynne Richards — Tue, 23 Aug 2011 10:33:26 GMT

Agree with you Patrick Don't specialists who continually sneer at GPs get up your nose ? Most unprofessional

Wynne

Re: dermatology

Amanda Nicholls — Mon, 22 Aug 2011 19:18:53 GMT

[quote user="Clive Ansell"]

I have seen a third opinion this morning; pruritic SBT ok while on preds but pruritus returns as soon as they are stopped. discussed case and advised full investigation, at which point the owner declined and remarked that I had said the same as the last 2 vets and he wasn't being ripped of by spending £100's on test! he left with another month's worth of preds and will no doubt be looking for a fourth opinion.

[/quote]

Common scenario with the uninsured pets, I find they are concerned about the possible side effects of long term steroids until they find out how much the alternatives cost!

I don't refer many derm cases, don't usually find them that difficult to investigate and treat (but after that article I am obviously doing it all wrong), I did refer a cat to an RCVS specialist a few months ago, mainly because the client was non compliant and complained a lot. He stormed in after the appointment and demanded to know what my cut was from the £500+ bill! When I told him £0 he said well why did you refer me she didn't say anything different to what you always say. Interestingly he has been much nicer since then and even remembers to apply the advocate monthly.

Re: dermatology

Clive Ansell — Mon, 22 Aug 2011 12:36:33 GMT

Not read the article yet, but will do.

I always try and do full work ups for skin cases where possible, but in most practices I work clients will not pay for it so its any combination of malaseb, stonghold/advocate, a pot of preds and off you go I'm afraid.

Re: dermatology

James Laidlaw — Mon, 22 Aug 2011 12:17:43 GMT

Seconded. I will be interested to read the replies in the letters column next week...