As veterinarians and animal health care team members there are many factors that compete for our attention. Balancing practice ownership and hospital operations, patient case management and client interactions is time consuming. As a result, most of our time is spent managing the present. What trends and opportunities are you missing by not planning for the future?
In 2005, researchers at Harvard and the Broad Institute of MIT released the genomic sequence of the dog. Researchers based at the National Cancer Center in Fredrick, Maryland published the first fully mapped feline genome in 2007. These groundbreaking pieces of research have allowed veterinary scientists to develop genetic tests that evaluate risk factors for large numbers of diseases ranging from cardiomyopathies and bleeding disorders to musculoskeletal conditions such as degenerative myelopathy in the dog. As these diagnostic screenings have become commercially available, the number of inherited genetic diseases that can be identified has increased and become extremely cost effective.
At the same time, genetic testing for humans is becoming widespread. Advertisements for tests that identify heritage are commonplace. Screening for devastating diseases, such as the breast and ovarian cancer-inducing BRCA gene mutation became well-publicized by actress Angelina Jolie’s personal story.
It should not be a surprise that owners are expecting veterinarians and veterinary teams to be able to provide a similar level of insight into not only the heritage of mixed breed dogs and cats, but also as a tool to help in managing their pets’ health. Have you implemented genetic planning for your patients? What do you need to know to integrate this new service center into your diagnostic testing protocols?
Why Genetic Testing?
There are several reasons that an owner might request that DNA testing be performed on their pets:
- to determine the breed composition in mixed breed dogs or cats,
- to screen for inherited diseases and carrier status in breeding animals
- to screen animals at risk of developing breed related diseases
- to help make definitive diagnoses for animals with clinical signs
- to ascertain parentage of pure breed animals
- to help minimize the risk of breeding animals that carry the genes for undesirable breed characteristics, such as coat length and color.
How Does This Knowledge Help the Client and Pet?
It is easy to understand the value in preventing the planned breeding of dogs or cats that might produce offspring affected by any number of genetic conditions that impact health or contribute to undesirable physical characteristics. However, the benefits to pets and clients far exceed this narrow scope.
By identifying the heritage of the mixed breed pet, veterinarians can provide invaluable insight into diseases that are common in the breeds that represent the ancestry of that pet. Not all diseases are easily screened for using DNA due to complex modes of inheritance. One example would be hip dysplasia, which not only has multiple genetic factors but also may be strongly influenced by environmental causes. Using genetic testing, a veterinarian can ascertain if the dog is descended from breeds that have a high likelihood of developing hip dysplasia. This allows the animal health care team to proactively partner with the pet owner in developing a life genetic plan. The plan will address strategies such as weight management, appropriate nutritional counseling and exercise recommendations to minimize the environmental risk factors contributing to hip dysplasia.
As illustrated in the example above, screening pets that are at risk for developing breed related diseases allows for veterinarians to partner with their clients to develop a life plan based on the genetic profile of the pet. Insight into the DNA profile of a patient helps veterinarians make good clinical choices that enhance patient safety. Knowing that a dog has the genetic mutation for multi-drug sensitivities helps practitioners avoid medications that might not be cleared appropriately, preventing severe drug toxicities. Pro-active management and appropriate life planning incorporates a team approach that helps to offer support and improved quality of life to both the pet and the pet owner.
What is a Genetics Life Plan and How Do I Incorporate it into my Practice?
A genetics life plan begins with the pet’s initial visit to the veterinary hospital. Along with a comprehensive physical examination and other wellness recommendations, team members discuss the advantages of genetics testing with clients. They explain that knowing the genetic make-up of the pet directly impacts the ability of the veterinary team to make more comprehensive health recommendations for the pet and provides the owner with better care options.
When the results of the test are received by the veterinarian, a consultation appointment is scheduled with the client. During this consultation, the genetics profile is discussed with the client. These results, as well as information gathered during the comprehensive physical examination such as body condition scores, pain scores, current exercise and nutritional programs and wellness diagnostics are combined to create an inclusive care plan for the pet. This plan may incorporate recommendations for additional diagnostic testing such as coagulation profiles, radiographs, echocardiography; rehabilitation services and nutritional changes. The owner should be provided with a written copy of this plan, with clear recommendations. Outcomes of additional diagnostic testing with modifications to the genetic life plan should be clearly communicated. This plan should be reviewed and updated on an annual basis, during the yearly physical examination appointment.
One very easy way to incorporate genetic testing into a practice is to include it as a wellness plan item for all puppies and kittens, as well as an add-on option for all adult wellness plans. This allows the client the opportunity to include this service in the monthly payments for the wellness plans.
How Do I Obtain Animal Health Care Team and Client Buy-In?
In my experiences as a hospital owner, managing DVM and technical services veterinarian, I believe that teams will endorse recommendations that benefit patients, if they understand the “why” behind the recommendations. By providing your team with an understanding of how genetic tests can help them provide enhanced patient care and safety, they will be positioned to convey these advantages to clients.
Below are some discussion points that can be used to help facilitate discussion and training:
- Ask your team what they know about genetics testing in animals.
- Share stories of how individual genetics tests have helped patients and their families.
- Have you used the ABCB1 test to screen mixed breed and herding dogs for multi-drug sensitivities? How has this information changed clinical drug usage such as decreased dosages of acepromazine or avoiding high doses of ivermectin to treat demodicosis?
- Did you confirm that the dog with hind end weakness had the genetic predisposition for degenerative myelopathy? What modifications did you make to the patient’s diagnostic and treatment recommendations based on these results?
- Do you have a case that, in hindsight, you regret not utilizing genetic screening? How might the patient’s and the pet owner’s outcome have differed?
- What concerns your team about recommending genetic testing?
Common Genetic Testing Concerns
When discussing the utilization of genetic testing with teams, the most common concern that I hear is: “What if the results indicate that the pet being tested has a disease that will be hard to manage or deadly? What if the owner wants to euthanize a pet that is currently clinically healthy?”
Be prepared to have a candid discussion around how your practice would handle these client concerns. One important point for teams to hear is that these tests provide the opportunity to partner with clients in developing a plan that will help better manage the patient and improve the quality of life. This patient benefit far outweighs the unlikely risk of a client requesting euthanasia.
This is just one more thing to try to “sell” to clients.
Genetic testing is a diagnostic that, for most pets, is only going to be done once during their lifetime. Clients deserve to be educated about the advantages conveyed by genetic testing (enhanced patient safety with clinical recommendations, pro-active care to manage and minimize the impact of the disease on the pet, prevention of breeding animals with inherited conditions). It helps provide pieces of the puzzle otherwise unknown so that the veterinarian and owner can partner together to make the best decisions for the health of the pet.
Genetic testing will not be embraced by all clients.
Some clients might be scared by the prospect of finding out that their pet has a genetically detectable disease that might impact the pet’s longevity, preferring not to know. Others might feel it is too intrusive or extreme. Teams should be confident in the value of their recommendations and embrace the idea that clients deserve to be educated about their options. When a client declines genetic testing, a notation should be made in the client’s file that it was offered and declined.
What benefit does your team see to genetics life plans?
It is helpful to role play the above points during team training meetings. A clear protocol regarding genetic screening recommendations should be developed by the team. This will help to establish a baseline for this new initiative and serve as a valuable training tool for new team members.