Triad of Care: Nutrition

The Triad of Care is made up of the animal owner, primary veterinarian and veterinary specialist who communicate about the needs of your pet in order to improve their quality of life. For our second podcast episode we had Lindsay Bullen, DVM, DACVIM (Nutrition) sit down with primary care veterinarian, Dr. Cassi, to discuss how the Triad of Care works to ensure the best care for their patients. 

Transcript

Brendan Howard:

As a pet owner, one great way you can ensure your animal's health is getting the nutrition right. That means talking to your primary care veterinarian and maybe a veterinary nutritionist, especially in complicated health situations. Let's talk about the talk surrounding nutrition. Welcome to a new podcast episode from VetSpecialists.com, powered by the American College of Veterinary Internal Medicine, ACVIM.

ACVIM is the certifying organization for veterinary specialists in six disciplines: cardiology, large animal internal medicine, neurology, oncology, small animal internal medicine, and yes, nutrition, which was just added this past year. I'm your new host, Brendan Howard, and today we're looking at communication surrounding nutrition and pets. We're exploring the triad of care, a triangle with three points: pet owner, family or primary care veterinarian, and veterinary specialist. Who's at the center of this triad?

Of course, the pet. Every point of this triangle is someone who wants the best for your favorite animal. What happens when cases get complicated and a specialist is added in? Let's find out. My guest today on this big issue come from two points on the triad. Dr. Lindsey Bullen, a board certified veterinary nutritionist at Friendship Hospital for Animals in Washington, DC, and primary care practitioner Dr. Cassi Fleming, goes by Dr. Cassi, a staff veterinarian for the veterinary education website VetFolio.

First, veterinary nutritionist Dr. Bullen pulls back the curtain and tells us why the veterinary nutrition specialty is important for optimal pet health and just what veterinary nutritionists do.

Dr. Lindsey Bullen:

The thing that I love about nutrition is that you can have two patients, the same species, same age, same disease, and treat them completely differently because you have to take into consideration that pet-parent aspect. I love that nutrition is a puzzle. I would say a day in the life of a board certified veterinary nutritionist is not going to be the same across the board. First of all, there's only about 100 of us, slightly more than 100 now that have ever been boarded since 1980. We are a very, very small college.

A lot of people don't even know that nutritionists exist, but we do, I promise. In terms of what we do, a lot of people think that, oh, you just choose the food. That's the result of what we do. Nutritionists are actually experts in biochemistry and metabolism, and we have to have that strong background in internal medicine, which is why we're part of the American College of Veterinary Internal Medicine. We diagnose the diseases. We can treat with medications. Of course, we'll treat with medications when and where appropriate.

But once we figure out that pet's individual biochemical and metabolic needs, then we can truly target the best diet for them by evaluating the individual nutrient amounts, the individual ingredient sources, all of those things. For me, again, very different from all my brethren out there, if you will. Most board certified nutritionists are either working in pet food manufacturing to ensure or at least make the diets as safe as possible so that your pets not only survive, but thrive. Other board certified nutritionists work in academia training veterinarians like myself.

One of my biggest pet peeves and things I'm trying to work on is that there are not enough board certified nutritionists to go around to all the vet schools, so nutrition education is unfortunately lacking in a lot of veterinary schools. It's up to the specialists or to the general practitioners, I should say, like the amazing Dr. Cassi, to seek out advanced nutritional training. And then you have the weirdos like me that do their own thing. I'm in private practice at an amazing specialty hospital in the DC area, Friendship Hospital for Animals.

I have the privilege to work with thousands of patients every day. My favorite part about my job is that I have the opportunity to collaborate not just with the pet parents because they're one of the most important team members, but also to collaborate with my amazing colleagues, and that's specialists, but especially my general practitioners.

Brendan Howard:

Let me ask you, Dr. Cassi. As we think about nutrition, the first experience pet owners have is they typically get an animal and then maybe they go online for their first food. But chances are they just go to a pet store and there's a bunch of wet food or dry food for their cat or dog. Boom, nutrition. And maybe they think, oh, there's something for a kitten, or they think there's something for an older cat. There's something for an indoor. There's something for an active, and we're kind of done.

Maybe then there's another circle of like that says it's for kidneys and my vet told me my cat or dog has a problem with kidneys. That's it. Just the bags and the cans, the cans and the bags. I'm wondering you in general practice, as you think about who gets referred, what are the conditions that do get referred and get more complicated that somebody would have to go to a veterinary nutritionist for?

Dr. Cassi Fleming:

First of all, there's a lot of different approaches from pet owners I find to nutrition. I think that's part of the conversation that we have with pet owners is really drilling down to what is motivating nutritional decisions. Because just like in humans, there's a lot of opinions and they can be very tightly held opinions. It can be anything from what's the cheapest bag of dog food on the shelf, or I hate the way canned food smells. You will never get me to feed any canned food.

But then there's the opposite of people who go online and they do all this research and they're really truly trying to find the best food for their diet. And oh my gosh, my heart goes out to those owners because there's so much information out there and it's so conflicting. That's an opportunity for us as general practitioners to really help guide and educate because it can be so overwhelming out there. And then you have other owners who want to feed a homecooked diet.

They don't want a commercial diet, and a lot of times also people who have sought out a lot of education and they're really trying to do the best thing for their patients. There's a really wide spectrum that we're addressing here in general practice when it comes to nutrition. For me in particular, I really like wellness visits because I think it's a great opportunity to connect with owners and drill down to some of the things they may not have thought of at home.

I try to make the effort not to say, "Oh yeah, your dog looks healthy. We did the core vaccines. We did your heartworm test. Okay, thanks. See you next year." I guess when you're in that exam room and your vet asks you what are you feeding your dog, there's a lot behind it. There's a lot of information we're trying to gather to make really good recommendations for your pet. It might be that you have a really healthy pet and you need a maintenance diet. We want to make sure that you're feeding the best one, at least the best one we can figure out for your pet.

But then also certainly medical conditions. Actually it is kind of funny. Just recently, I emailed Dr. Lindsey and I said, "Hey, I have this patient and we are trying to manage Cushing's disease. There's some things going on in the urine. We've also got some cognitive issues we're concerned about and arthritis. I'm trying to put all of these together and choose the right diet and the right supplements and bring it all together."

Dr. Lindsey Bullen:

Did I respond to you?

Dr. Cassi Fleming:

You definitely did, yes. In a very timely manner, I must say.

Dr. Lindsey Bullen:

Okay, good. I was like, oh God, please tell me I actually responded.

Dr. Cassi Fleming:

No, you absolutely did. Exactly like what you're saying, being an expert in biochemistry and all of this, I mean, the response came back. It was quick. It was super thorough, tons of knowledge about what we were feeding and supplementing already and how to modify that. Incredibly helpful. And then it's then my job as the general practitioner to take that back to my client and relay the value of what we just did and make sure that we're making good recommendations for that pet.

Dr. Lindsey Bullen:

I absolutely love what Dr. Cassi said, and I think one of the most important things to keep in mind is that developing that positive, trustful, mutually respectful and trusting long lasting relationship is absolutely the basis for the general practitioner and their client/pet parent. You can't have patients without the client. As a specialist, sometimes I'll have chronic cases that I work with and then I can develop those relationships, but a lot of times I'm sending them back to folks like Dr. Cassi.

I have to make sure that, A, the client feels okay with it, but B, Dr. Cassi and my colleagues feel comfortable with it. I just think it emphasizes so much how important a truly collaborative environment this is, because I don't want the clients to go home after our conversation and just be like, "Okay, thanks for nothing, or I can't do that."

I really have to make sure that I'm communicating in a way that the client understands, but also empowering the general practitioner to take the lead. I want them to help support these guys and make them feel comfortable because they're the ones that truly have already established that relationship, which is so important.

Brendan Howard:

This is a perfect lead in because this leads into where there could be a huge problem, which is ACVIM has been talking about this concept of triad of care with these three people you're talking about, which has the pet owner and the general practice veterinarian and the veterinary specialist are the three points on this triad. And then in the middle is the pet. We're all trying to help the pet. Anywhere along these three lines, communication totally breaks down. For instance, in this example Dr. Cassi gave, there's a number of complicated conditions that are all interacting.

Now we have to get what could be a complicated nutritional answer from the nutritionist, and then maybe it gets relayed directly to the pet owner or maybe it gets relayed back to the GP. And then when that person has questions, maybe the GP has the answers, maybe they don't. It's going to be this weird game possibly of telephone.

My question is, and either of you can answer first, where does communication break down in either the pet owner needing answers and not being able to figure out who to get it from, or the GP getting jumped because the pet owner's going directly to nutritionist, but the nutritionist isn't responsible for all the pets care? I could see how the triad can get complicated. What are ways it breaks down?

Dr. Cassi Fleming:

This is a really good question because there's a lot of areas, you're right, that it can break down. I think it's becoming more and more important for us to provide written recommendations probably from the veterinarians, whether it's the specialist or the GP to the pet owners where the recommendations break down, because we'll run into situations where we say stuff and it rolls off our tongue because we talk about it every day. We may use abbreviations.

We may use jargon and things that we very naturally speak about. And hopefully if we say something that a pet owner doesn't understand, they will ask us to clarify, but not always. I will say, if there's pet owners out there listening, please, if you don't understand something, ask us to clarify. We're more than happy. We will not think anything negative.

But we might think we explained something really well, and that person may walk out having no idea what we said, or they might think they know what we said, and then they get home and their spouse asks them, "Hey, how did it go," and they realize they actually have no idea what we said. I would say probably the importance of written recommendations to be very specific in that way.

Dr. Lindsey Bullen:

For me, instead of focusing on the areas that break down, because it's literally all the areas, any point of the triangle can break down, and I think it's equally so just because it's truly dependent on the individuals involved, right? This is one of the reasons I am so passionate about communication training, not only for myself, but also passing that on to my mentees and my staff members and my colleagues, just because there's so much of a breach in communication, and that is where lack of trust will come in and miscommunication issues.

There's just a lot of mess that happens if there's even a single accidental breach in communication. For example, occasionally my written documents will go to a client's spam, and that is an unfortunate event. It happens, and I've had several clients that were understandably frustrated when they did not receive their report in the promised amount of time. I had sent them, but they had gone to spam. There's this breach in communication.

One of the things that veterinarians and I would say pet parents can do to help with that is set clear expectations and not only hold your partners in this team accountable, but hold yourself accountable, man. That's one of the biggest things that I communicate with my colleagues, but also my pet parents that I work with is empower yourself to hold yourself accountable. What I mean by that is when we start off, I want to make sure that my clients have clear expectations of what I physically can do for their pet, but I also ask them what their expectations are.

And I listen so that I can make sure that I'm actually understanding what they're looking for, and I can communicate effectively if I can do that or not. Because if I don't understand what they're looking for and I don't communicate my ability to do that, then again, the whole thing can break down. The other thing I've found over the years is that the more veterinarians are backlogged with cases, the busier we are, sometimes that, of course, leads to a breach in communication. One of the worst ways that can happen is if we forget to send our records to the primary veterinarian.

We might have the best written plan in the world, and the client gets it, may or may not understand all of it. Of course, that's where this training again comes into play with our younger veterinary professionals, is encouraging them and teaching them how to communicate to all different experiences in terms of the medical field. We want to make sure that no matter if it's a kid or a veterinarian or an engineer like my husband, whoever picks up this piece of paper should be able to understand what we are saying and what we're asking them to do.

Again, it could be the best thing in the world. If I forget, or if my team forgets to send it to my colleague, the primary veterinarian, or another specialist I'm working with, they have no idea what I've recommended, which means they could be recommending something that will negatively impact what I've recommended, or I might've recommended something that will negatively impact what they're doing. Again, it's just this cluster that the poor pet parent has to wade through.

What we have done, at least in my service, is to make check boxes to ensure that we are doing everything to the best of our ability every single time. We have this beautifully colored spreadsheet with x boxes, that's like an Xbox. I love that. Did Lindsey finish her record? Yes or no, so nobody falls through the cracks. Did I send it to the client? Did I send it to all the veterinarians? Did we save it on file in multiple locations? All of these check boxes to make sure that we have done the best that we can to communicate.

In addition to that, again, with these expectations, I always tell clients, if you do not understand something, if your pet is not feeling well, if they're not doing well, if they are doing well, it is up to you to reach out to us so that we can help. As much as I wish I had psychic and telekinetic and all these amazing abilities, my superpowers have not yet kicked in. I really, really rely heavily on the true expert of the pet, and that is the pet parent, to communicate when there's an issue.

Brendan Howard:

Do you have advice for what... You ask pet owners, hey, you need to watch and then let us know, but then there's sometimes when it breaks down, they might have the impression that, well, this is not an emergency. Whatever this nutrition thing is, it's a chronic thing we're working on. This little change, it's not important. I shouldn't let them know. Or they're just going to tell me, you have to come in. You have to come in. Come in.

I'm like, I don't have time, or I'm busy. What do you want pet owners to do to manage that communication thing so that they bring you all the information you want and then they feel listened to?

Dr. Lindsey Bullen:

Oh my God, that's a great question. Again, I think it really goes back to being proactive and being upfront ahead of time. For example, I have 17 patients that I need to try to finish their treatment plans before next week. That's a lot. It's a lot of patients. My beautiful partner is on leave right now, so I'm covering both. I'm covering the entire service, which I'm happy to do. I love it. I thrive in this. What we do is we have an automatic response on our email that says, "Hey, your email has at least gotten into our inbox."

That's one step of communication, so the client knows it's at least gotten to us. When I have my appointment with the clients, I tell them that we communicate by email. If you have not heard from us on time, you need to let us know. If something is urgent, absolutely, please call the hospital, but have backup forms of communication. Send us an email with urgent in the line if you truly feel it is urgent. Then it is up to me and my team to determine is it medically urgent or not.

Again, on that automatic response, we actually change the timeline. If our inbox and our caseload is low, we'll say, "Hey, turnaround time right now is about three business days. We'll get back to you." If it is currently what it is now, it is seven business days. Again, anything urgent or emergent, you have to put it in the title line. We have my amazing staff members, which are the legs I stand on. They monitor our inbox at least once an hour every working hour of the day. There is also a note, and I verbally communicate this and I write it in my treatment plans.

If you cannot get in touch with us, we strongly encourage you when in doubt to call your veterinarian. Because the truth is, if the pet parent thinks it's urgent or emergent, then it is, and it is emergent to us as well. But then it's my job and Dr. Cassi's job to figure out does it truly warrant a visit to the veterinarian, to Dr. Cassi or not? It is all about being proactive in terms of communication and empowering the pet parent if they have a question or a concern that is valid and they should reach out.

I don't ever want my pet parents to be hemming and hawing and wishing that they had contacted us sooner. Because if that happens, when I have a turnaround time on email communication like five to seven business days, it might be too late. I would always rather have them err on the side of caution and then allow me the opportunity to say, "Hey, this is important, but the good news is this is not medically emergent at this time. This is what you do while you're waiting for a response."

Brendan Howard:

Veterinary hospitals have the technology, the treatments, and the bright people with the medical know-how. It works seamlessly when we perfect the communication between the points of that triad of care: pet owner, primary care veterinarian, and veterinary specialist. That's it for this podcast episode from VetSpecialists.com. Thanks to our guests, Dr. Bullen and Dr. Fleming.

If you got excited about something here, please feel free to share this with other pet owners. If you want to learn more about veterinary specialists and the work they do, or find one to help your pet today, find us at VetSpecialists.com.