Nurse-led appointments

The veterinary appointment hasn’t changed in quite some time. Pet parents bring their pet to the clinic and check in with reception staff, after which a veterinarian examines their pet and provides care. The veterinarian themselves is the main provider of care for the pet, with occasional assistance from veterinary technicians.

However, the veterinary industry is on the cusp of a massive staffing shortage. To successfully navigate it, veterinarians will need help, especially from clinic staff. Enter the idea of veterinary nurses leading medical appointments, pioneered and promoted by Dr. Shlomo Freiman, Felix&Fido’s co-founder. While veterinarians are the only members of the care team allowed to make diagnoses or prescribe medications, there are a lot of other duties that support staff can take on, up to and including conducting appointments and collecting necessary data under the remote supervision of a veterinarian.

In today’s installment of Tuesdays with Shlomo, Dr. Freiman explains how creating a veterinary nurse position could reshape the industry, easing staffing issues, expanding care options, and generally providing better access to care for pets. Read on for his take on how technology can empower support staff, how we can expect to access veterinary care in the future, and why we should embrace the idea of nurse-led appointments (NLAs).

What does it mean for an appointment to be “nurse-led”?

Technically, we are referring to LVTs, or “licensed veterinary technicians,” as there isn’t an official definition yet of nurse practitioner or even veterinary nurse within veterinary medicine. That said, an NLA is an appointment where the LVT meets with the client while being supervised remotely by a doctor of veterinary medicine (DVM).

You mentioned in one of our previous interviews that technically nurses don’t exist yet in the veterinary world. Can you explain that a bit?

It’s not a term that officially has been accepted in the industry for various reasons, but we have adopted the term “nurse.” Given what we do at Felix&Fido, we think nurse is a more accurate term than a technician.

That makes sense. An animal is not a computer or an air conditioner. Either way, you’ve utilized LVTs within your practice to do more than they are traditionally expected to. What are the limits of that? What does their license allow them to do?

There’s some variation in the specifics of what LVTs can and can’t do between states. For example, in Washington state, a licensed veterinary technician can extract teeth, which is not the case in many other states. There are also different definitions, depending on the state, for what is and isn’t allowed under direct supervision versus indirect supervision. Direct supervision means that the veterinarian is right there, as opposed to indirect where the veterinarian is involved but maybe not in the building. In general, however, it’s easier to say what veterinary nurses are not allowed to do. They’re not allowed to diagnose, prescribe medications, come up with a treatment plan, and perform most procedures and all surgeries. Outside these areas they are generally allowed to operate freely. The main point I want to make with regard to NLAs is that there are a lot of ways within the legal limits to utilize LVTs that we have not typically taken advantage of in the veterinary industry. Currently, LVTs are typically limited to holding pets still, filling out paperwork, fetching supplies, and similar helping duties.

Ideally, you would not only start involving LVTs more in care, but actually create a different position, right? Something that involves extra training and even a different certification?

We’d like to create something similar to a nurse practitioner, but the legal framework for that doesn’t exist yet in the vet space. This may change in the future. It would require developing a new certification program, and that’s something we hope to advocate for and advance as part of our work at Felix&Fido.

Would that be something you’d have to accomplish through legislation?

Basically, yes. But also changes in training and education. We would need to create the programs to support it and, perhaps more importantly, create a major shift in attitude among DVMs and veterinary administrators.

What prompted you to rethink the role of support staff in veterinary care? You come from several decades in a traditional clinic environment — was it that you saw the imminent staffing crisis, which you’ve mentioned in other interviews, or just saw a better way to do things?

It’s a combination of factors. In my clinic experience, empowering our LVTs to do more made sense for the business, it made sense for the support staff, it made sense for the client, and it especially made sense for the patient. Think about a pipe that has to handle a certain capacity. In most ecosystems in the veterinary space, that pipe — which is the DVM and the number of pets they can see in a single day — is the constraining factor. Everything has to come through the DVM. The more complicated cases, the cases that absolutely have to be seen by a DVM, should still be seen by a DVM. Not every use case is appropriate for a NLA, but many are. A good example would be an ear infection in your dog. That’s not a life-threatening case, which means your vet might need to see other, more urgent cases first, but it is a miserable condition. We know how to diagnose it and what causes it and how to treat it, we treat this all the time. Why shouldn’t we just have a veterinary nurse do most of the ‘heavy lifting” on cases like this under the supervision of a DVM?

What are some other use cases that are well-suited to NLAs?

We looked at data from Petriage, the AI patient portal we use, to see what kinds of cases are coming to a typical general practitioner, and ears, eyes, skin, and minor GI are over 50% of cases. A lot of these cases, if triaged appropriately, can be managed by using a different workflow. Going back to example of the ear infection, which is a classic use case, all I need as a vet to make a diagnosis and recommend treatment is a good history of the pet’s health and a certain amount of data: images of the ears, images of the ear canal, images of the eardrum, and a microscopic image of a swabbed sample from within the ear. The technician can collect that sample, process it, put it under a digital microscope, and send me the image. When I have all this information, I can make the diagnosis and write the appropriate prescription, and then the veterinary nurse can communicate all that to the pet parent. The DVM does not need to be physically present. I do want to make clear that it is always the DVM who makes an official diagnosis and writes any necessary prescriptions, but they can do that remotely now.

Can the LVT pass along a prescription, or do they need the vet to physically be there and sign it and hand it off?

The vet definitely doesn’t not need to physically be there. The DVM can put a signed prescription directly into the pet’s medical record. I want to really emphasize, of course, that we’re only doing these types of remote or out-of-clinic appointments with pets that we already have a VCPR (veterinary client pet relationship), which is established via an initial physical exam by a DVM. Because we already have VCPRs in these cases, our vets can go ahead and prescribe relevant medication remotely.

That seems important, given that a big part of the Felix&Fido model is disrupting the traditional model of where and how visits happen. If you can send a prescription digitally, you can have an equally effective appointment almost anywhere, right?

With technology we can conduct a NLA almost anywhere. In fact, we currently partner with a popular pet store chain here in Seattle called Mud Bay to do in-store clinics. These “neighborhood clinics,” as we call them, are small footprints in select Mud Bay locations where we can do both DVM appointments and NLAs for existing patients with VCPR. That said, NLAs can also happen in-clinic. We can conduct an NLA anywhere that we could conduct a traditional DVM appointment, really. That’s why it’s such an effective way to distribute and ease workload. If the doctor is doing surgery or seeing a different patient, nurses can be taking on simpler cases and communicating with a different DVM offsite.

How important will these alternative appointments be going forward? I can’t remember the exact name of the study, but you shared some stunning numbers about the coming coverage gap.

You’re talking about the Banfield [Pet Hospital] one, which predicted in 2020 that by 2030 there’s going to be 75 million pets without access to veterinary care because of veterinarian shortages. Even if it was a little bit inflated by the surge in pet adoption during the pandemic, half of that number would still be a huge number of pets with no access to care. We have to innovate to provide more capacity. We have to spread the workload around. Additionally, we really have to try to figure out how we can retain more veterinarians. Luckily, another underappreciated aspect of NLAs and alternative workflows is actually vet retention. Remote work was not typically an option for veterinarians. Now it can be, with one veterinarian remotely supervising multiple nurses or LVTs. A majority of veterinarians are women and this is relevant because women are the number one group of workers — in general, not just in veterinary medicine — that research shows really value working from home. The remote model and the NLA model can be major quality-of-life improvements for those veterinarians, and can potentially keep veterinarians practicing who would otherwise have left the industry or severely reduced their hours.

In terms of quality of care, is there any difference between having an NLA or traditional appointment with a DVM?

I think NLAs can actually be better. I say better because the nurses often have more time to spend with pets and pet parents than doctors. They can pay more attention to the pet and pet parent and spend more time communicating about their issues and concerns. Ultimately, that’s the type of care experience we’re trying to provide. It doesn’t matter who provides the care, as long as it’s the safest and best possible care that the pet can get. So far at Felix&Fido the clients have mostly been happy to have their issues resolved and managed quickly, even when it doesn’t involve direct communication with the vet.

What do you see as the future of veterinary care overall? You’ve talked a lot about telehealth and NLAs, but I also know that you are working with AI and I’m very curious how that plays into things. What can people expect going to the vet — or not going to the vet, as it may be — to look like in the next few years, decade, couple of decades?

To be successful in today’s veterinary industry, veterinary management and DVMs are going to have to use technology to be more effective. More effective in how they deliver care, more effective in how they reduce stress among the care team, and more effective in how they reduce or manage the workload. It will take more than NLAs and AI to accomplish that, but they are both essential parts of the overall solution. We’re already using Petriage’s AI technology to onboard and triage clients. As the technology develops, AI will be able to help a lot with administrative tasks like writing down records and handling basic communication with clients.

To quote Dr. Marc Succi of Mass General Brigham, from an Oct 2023 interview about how AI will affect the human medical field: “AI won’t replace doctors, but doctors who use AI will replace doctors who do not. It’s the equivalent to writing an article on a typewriter or writing it on a computer. It’s that level of leap.”

Basically, while AI will be able to take on a lot of work that is currently done by humans, it won’t replace a lot of jobs in this industry. We need people and we need them to be delivering care in the most efficient way possible, which is why NLAs are going to be so important going forward. In-person care is not going to go away, but it’s going to be heavily supplemented by alternative appointment styles, like NLAs and telemedicine. While we’ve already become accustomed to this in the realm of human medicine — even more so due to the pandemic — the veterinary industry has been slow to adapt to this new reality. When we do, it’s going to be a win-win situation for everybody involved — for the DVM, for the support staff, for the management, for the bottom line, and, most importantly, for the pets and the pet parents.