Philip Richmond, DVM, CAPP, CPHSA, CCFP, delivers the keynote address on the first day of the 2024 Fetch dvm360 conference in Atlantic City, New Jersey.

Phillip Richmond, DVM, CAPP, CPHSA, CPPC, CCFP, kicked off his keynote address on the first day of the 2024 Fetch Kansas City conference by asking attendees to close their eyes and asked them to picture the best day they have ever had at their clinic. He asked them to think about the people that were around, what the attendees were doing, and exactly made it so special. Richmond then asked attendees, including fellow Fetch faculty members such as Adam Christman, DVM, MBA, and Tasha McNerney, CVT, CVPP, VTS (Anesthesia and Analgesia), to share their experience and what made these days so special to them.

As people continued to share, Richmond pointed out that there is a common thread amongst the special days that were shared: the people involved in the clinic. Throughout the rest of his keynote, Richmond encouraged attendees to follow along and play the red and green cape, a thought exercise commonly used in positive psychology.

“So in this exercise, you can have 1 of 2 capes. Those capes will give you a massive superpower. If you pick the red cape, you'll fight injustice. You'll catch the bad guys. You'll hold back oppression, poverty and sickness. You'll become a warrior against all that is bad in the world. If you pick a green cape, it gives you the power to bring more good to the world, to elevate humanity to its highest point, empathy, kindness, joy, all these things are maximized now,” explained Richmond.

When it comes to green capes, how can veterinary teams elevate and experience the things that make them feel joyful on a regular basis? According to Richmond, a lot of that relies on the people teams are working with and the clients whose pets they help. The key is to make people feel as though they matter within the clinic, because they do. Taking the time to learn more about who you work with and what they are like as a person inside and out of the clinic can provide a deeper understanding of what makes them feel valued. For leadership, this means getting to know everyone so when it is time for a new voice to be heard, or if someone has an idea to improve the workspace, they are comfortable sharing it.

“At our practice, [it’s] very important [that] we come in and we try to spend 5-10 minutes with every new hire, and just personally get to know them, get their name… Again, things that I think that we do as human beings but knowing how important that is. And then the second thing is, how do I add value? How am I valuable to this practice? You show me how I make a difference. Again, as leaders in a hospital, which most of us are, regardless of our title, showing each other how we make a difference, giving that gratitude, that explaining how you walk through a case, the impact that you made on the clients and the team,” explained Richmond.

As a leader, getting to know those you lead also helps you better understand the struggles and success each person has. For example, there may be a technician in a clinic who is interested in learning more about dental procedures or looking to improve their skills. By talking to them and learning that, leaders can take steps to help them through trainings and shadowing others to help. This demonstrates to the team that you not only listen to them but are there to encourage and uplift them.

To get a better understand of your team, Richmond encouraged leaders to set a 30-minute meeting and ask the team red and green cape questions, such as 'what is something that can be done to make your day 3-5% better?' He does not want a huge lift to be put on teams but there may be small things that could be done to significantly improve the morale of the team, and all you need to do is ask about. A massive game changer for your clinic can be available to you right now, you just need to ask your team the right questions and hear their answers.

Richmond P. Red Cape | Green Cape: The Balancing Act of Firefighting and Flourishing in Vet Med. Presented at: Fetch dvm360 Conference; October 14-16, 2024; Atlantic City, NJ.

Articles

Fetch Coastal began with Phillip Richmond, DVM, CAPP, CPHSA, CPPC, CCFP, educating attendees on ways to create a healthy veterinary clinic 

Veterinary medicine's green and red capes 

Why are fungal diseases often difficult to identify and how should veterinarians approach these dermatological cases? In her lecture, "Dermatologic Conundrums: Fungal Diseases," presented at the Fetch Coastal conference in Atlantic City, New Jersey, Joya Griffin, DVM, DACVD, lectured on unusual fungal diseases and offered approaches for a diagnosis.

“They're things that when they come into [the] clinic, they look very atypical... It's not something that you would treat on a day-to-day basis. It's going to be a little bit different, a little bit unusual, maybe severe. Sometimes these have been going on for a long time,” Griffin said.

With challenging dermatologic cases, returning to the basics is essential. Considering factors like the patient’s travel history, indoor/outdoor status, medications, and prior treatments or flea control measures is crucial. This information is important for excluding possible conditions and formulating a differential diagnosis

In her lecture, Griffin also shared that she likes to begin with cytology.

With climate change, fungal diseases have been on the rise. “If you're from the northeast, you may think that you may not see a lot of fungal disease. However, it's coming with climate change… And some of these [unusual fungal] cases, actually one of the very first cases I did see when I was at Cornell [University] in New York over 10 years ago,” said Griffin.

In her session, Griffin also shared dermatological cases with severe and unusual presentations that were not responding to empirical treatment and required multimodal therapy and experimental treatments. One such case was of Buttercup, a 9-year-old domestic shorthair indoor/outdoor castrated male feline, who presented with a nonhealing wound on the right forepaw. Buttercup had a visibly pigmented dorsal lesion.

Griffin shared that she began with a fine needle aspirate, which showed filamentous pigmented organisms. The diagnosis was confirmed as phaeohyphomycosis, a fungal infection typically seen in canines and caused by inoculation into wounds through bites or wood, and caused by pigmented, dematiaceous fungi.

“Usually these limbs [with phaeohyphomycosis], these lesions, will have kind of a blue, gray, pigmented look to them, and they can resemble abscesses like cysts in the tissue, and so they're often treated as a foreign body perennial, especially in dogs. They’re fairly uncommon in cats…,” Griffin explained.

Diagnosing these cases will typically come from cytology, Griffin noted. However, biopsying patients and doing tissue cultures is often necessary.

Talking about Buttercup’s case, Griffin said, “so what's important about this case is that he required long course of systemic therapy to try to keep this disease at bay. And this was really a limb sparing technique, because in other instances, this cat would have had his leg amputated.”

According to Griffin, Buttercup did well for approximately 2 years. “We ended up tapering him to pulse dosing, which is where, instead of giving the antifungal [treatment] every single day, we would do a week on, a week off, to try to keep the disease at bay,” Griffin said. However, the lesions recurred, and Buttercup’s owners eventually decided to have his leg amputated.

Griffin explained that phaeohyphomycosis lesions can usually be seen. “If you have a solitary nodule, or even abscess draining tract type lesions, you can see that pigment in the surface of the skin. So, looking at it clinically, you might be able to find that. If you're able to do an aspirate of it, I'd recommend doing fine needle aspirate and looking at the cytology... And then if things aren't improving with empirical therapy, I would definitely biopsy and consider tissue culture,” she explained.

According to Griffin, treatment for the condition involves excision, or systemic antifungal therapy if attempting a limb-sparing technique.

Griffin J. Dermatologic Conundrums: Fungal Diseases. Presented at: FetchCoastal; October 14-16, 2024; Atlantic City, NJ.

Joya Griffin, DVM, DACVD, talked about unusual fungal diseases and a case of phaeohyphomycosis in a feline at the Fetch Coastal conference in Atlantic City

Diagnosing unusual fungal diseases: Phaeohyphomycosis

Julia E. Miller, DVM, DACVD, an assistant clinical professor at the Cornell University College of Veterinary Medicine in Ithaca, New York, discussed the proper approach when presented with a pruritic dog in the clinic, during her 2-part session, “The Itchy and Scratchy Show: How to Confidently Diagnose Canine Allergies,” presented at the Fetch Coastal dvm360 conference in Atlantic City, New Jersey. In her lecture, Miller focused on cases of canine atopic dermatitis (cAD), including likely causes, and proper diagnostic procedure.

cAD is multifactorial, and, as emphasized by Miller, an especially complex diagnosis. Types 1 and 4 of the condition show hypersensitivity. Type 1 indicates that the condition is immediate and involves the lgE cell, and Type 4 indicates a delay, involving T-cells (CD4+, CD8+). There are various triggers, and numerous mediators released, including histamine, leukotrienes, prostaglandins, proteases, cytokines, among others.

In the inflammatory syndrome, skin is the main route of exposure. Part of its complexity, the condition is the result of an inherited predisposition to develop hypersensitivities to environmental allergens that do not induce a problem in nonallergic individuals. Common allergens include dust mites, pollens, dander, insect particles, and mold.

Before a dog should be called atopic, they should undergo a thorough history-taking, a detailed dermatological physical exam (PE), and all other differentials, or “itchy conditions,” should be ruled out, according to Miller. These alternative conditions include ectoparasites, flea allergy dermatitis (FAD), neoplasia, and secondary microbial infections—including Staphylococcal folliculitis and 

"When you're diagnosing allergic dermatitis, [it's] always a diagnosis of exclusion," Miller explained. "That means you must do a workup before you get to the point that you call a dog atopic."

Miller emphasized the importance of history-taking in making a proper diagnosis. Although, questions need to be specific to dermatologic factors that may be in play. “Your traditional history-taking questions that you ask of any other patient do not apply to derm patients,” Miller said during her presentation. “[Dermatologic-specific] history-taking makes all the difference.” A comprehensive background should include breed, age at onset, seasonality, pruritic/pruritis level, whether or not other pets or humans are also itchy, whether the itch or rash presented first, response to treatments, what flea preventative the dog is on, gastrointestinal signs, diet, and whether it is endocrinopathy-associated.

Age can be a significant indicator in the diagnoses of cAD. Miller shared that, if a patient began itching between the ages of 1 year and 4 years, that should trigger a red flag for cAD. Exceptions, however, include breeds with predispositions, like French bulldogs, bully breeds, GSD, wheatens, and more. 

"I will tell you this, in the world of doodles... in the world of pit bulls... in the world of [French bulldogs], some of these atopic dogs are starting at about 6 months of age," Miller said. "They've kind of lowered the threshold."

When diagnosing cAD, seasonality is trivial factor. cAD can be seasonal, nonseasonal, or nonseasonal with seasonal flares. In dogs with cAD, paws, axillae, abdomen, perianal skin, and face, are common areas where pruritus and secondary conditions are developed. Nearly all dogs with pruritus have atopic conditions.

According to Miller, most dogs with uncomplicated atopic dermatitis show a satisfactory response to 1 mg/kg/day of prednisone. If a dog is not responding to prednisone, ectoparasites, secondary 

 dermatitis, food allergy, epitheliotropic lymphoma, or a secondary bacterial infection should be considered. Alternatively, a new steroid may be required.

Miller J. The Itchy and Scratchy Show: How to Confidently Diagnose Canine Allergies. Presented at: Fetch dvm360 Conference; October 14-16, 2024; Atlantic City, NJ.

Methods for diagnosing cases of canine atopic dermatitis were covered during a session at the 2024 Fetch Coastal dvm360 conference 

Diagnosing canine atopic dermatitis 

Philip Richmond, DVM, CAPP, CPHSA, CCFP, founder and CEO of Flourishing Phoenix Veterinary Consultants, LLC, shared an anecdote about the importance of psychological safety during his lecture on the topic at the Fetch dvm360 conference in Atlantic City, New Jersey. He described a situation that occurred early in his career in which an assistant saw a need to reassess a patient he had treated on a busy workday. After listening to the team member and re-examining the patient, he concluded that his colleague made the right call in pulling him aside to discuss the case.

“Had I not listened to what that assistant said to me…that dog wouldn't be here. [The patient] would have died because I was absolutely treating that dog wrong. And the thing is, in that moment, a lot of things [had to have] happened over the previous 2 to 3 years where a certified veterinary assistant could say to me, ‘you're making a mistake and I need you to stop what you're doing.’ It was a collaborative thing,” said Richmond.

The case was an example of how a team member was empowered by feeling psychologically safe at work in the clinic. “There's a lot of confusion around that term because it's kind of wonky. It puts 2 words together that we kind of sort of know what they mean individually. And you slam them together and it's like, ‘oh, you're just talking about, like, safe spaces and being nice.’ And that is not what psychological safety is,” said Richmond.

So, what is psychological safety? According to Richmond, psychological safety is an environment where there is a feeling that it is safe to take interpersonal risks with the team. “I feel like I can make a mistake and not be raked over the coals. I feel like I can challenge myself and step into something that I would normally do, and I'll be supported and lifted up. It does not mean that I'm not held accountable for what I do,” he continued.

For more on psychological safety, check out this 

 on psychological safety in the veterinary clinic

During the lecture, Richmond provided a framework for creating psychological safety in the workplace that included generosity, honesty, conquering incivility, listening appreciatively, and growing from failure. He noted that some staff behaviors that can lead to a negative environment, which can also affect patient care. These include judgmental attributes such as assuming the worst, biting your tongue (and not speaking up when needed), complaining, and shaming or throwing blame. According to Richmond, that negativity can become an “emotional contagion.”

“Our evolutionary adaptation is to match the emotion of others, and so that spreads that that emotion. So that absolutely happens. If we can make the charitable assumption, it does negate [that emotion],” said Richmond. Actions of curiosity such as slowing down and asking questions, lifting up other team members, assuming others are capable, and providing supporting accountability, are helpful.

“It doesn't mean that we just let people totally off the hook, but we try to get curious about why there's a challenge with that person doing a task. That's what the support of accountability means; assuming we share a responsibility, we create a safe space of each of us to be accountable,” Richmond continued.

, veterinarians exposed to uncivil behavior from clients also have their psychological safety affected.

 “If we go into a room, and a client is mildly discouraging, if you will, and I come out of that room and go into treatment and go, ‘Oh, that Mrs Smith. She's a piece of work. She's this, she's that'….All that negativity, it's what's called emotional contagion,” said Richmond.

These types of negative interactions can affect mental health and lead to stress and withdrawal from clients. However, emotional support from colleagues and constructive responses to incidents can help mitigate negative interactions with clients.

“We have to have emotional intelligence around how we deliver a message. That makes an impact, it's not just the message itself, it's [also] how we deliver it,” said Richmond.

Richmond P. Psychological safety. Presented at: Fetch dvm360 conference; October 14-16, 2024. Atlantic City, NJ.

Irwin A, Hall D, Ellis H. Ruminating on rudeness: exploring veterinarians’ experiences of client incivility. 

. November 9, 2021. Accessed October 14, 2024. 

In his Fetch Coastal lecture, Philip Richmond, DVM, CAPP, CPHSA, CCFP, discussed ways to mitigate negative behaviors in the workplace.

Practicing psychological safety

In the era of social media, misinformation, and a abundance of nutrition options, having conversations with clients about their pet’s nutrition can be difficult. At the Fetch Coastal conference in Atlantic City, New Jersey, Danielle Conway, DVM, CVA, VSMT, CCRP, chief inspiration officer and nutritionist at Vital Vet Integrative Consultants—a nutrition education and consulting company for veterinary professionals and pet owners—talked about the importance of educating clients about their pet’s diet in her lecture, "Food for Thought: Pros & Cons of All Available Nutrition Options." She emphasized the importance of reintegrating nutrition discussions into practices, as well as nutrition consultations and recommendations.

Having the nutrition conversation with pet owners

Conway explained that the rise of “faux-sperts,” or social media influencers with unqualified credentials, is misleading clients about what constitutes a healthy and safe diet for pets.

 According to Conway, these influencers are using fear mongering, click bait, and “preying” on clients’ emotions and love of their pets to sell them something. 

To address this rising information gap, Conway told the audience to “meet their clients halfway.” “I found what's happening is that food is so intensely personal, and unless we are willing to meet clients at their truth a little bit… just hear their concerns, hear what their background is, what they're coming to you with, meet them at their truth, and then we'll be able to move them more towards evidence-based slowly,” said Conway.

“So maybe we're not going to get them from an unbalanced raw or eating a lamb's head in the backyard all the way onto your prescription therapeutic kibble diet. But hey, if we can take that lamb head, I don't know, maybe do like some little safer, like ground meat, balance it, make it safe. That's a step, right? We met them halfway,” she continued. 

Conway also explained that there is no one optimal diet for animal companions. Instead, the choice on what to feed pets is an individual one.

According to Conway, the Association of American Feed Control Officials (AAFCO) label has been highly criticized by social media influencers, leading many clients to distrust pet food labels. Conway explained to attendees that she likes to offer clients a handout that educates them on what AAFCO is and its role in animal nutrition.

Another misconception pet owners may hold is that by-products in pet foods—animal parts that are potentially safe to eat but are not commonly consumed by the American population—are bad. In reality, by-products are nutrient-dense and are a rich source of protein, minerals, and vitamins. Moreover, by-products are the parts of the prey that predators consume first.

 between grain-free pet food and nonhereditary dilated cardiomyopathy (DCM).

 She shared that nutritional DCM is not a global issue, and specific data is not consistent, as some patients do well on a grain-free diet.

Conway emphasized to attendees that when it comes to pet food, “it’s not so much about the ingredients, it’s about the formulation.” When determining what pet food companies are nutritionally appropriate, various factors should be considered, such as

Does that company have a veterinary nutritionist or food scientist on staff, and is the company maintaining a relationship with these experts?

Has the diet been AAFCO feed-trial tested and nutrient-analyzed?

What safety measures are being taken and are these methods validated?

When was the last time one of their products had a recall or voluntary recall?

Can the company provide the caloric value per can or cup?

What quality control measures are being taken? Does the food match the label?

For patients that require a therapeutic diet to manage a medical condition, it is important to explain to their owners why the patient needs to follow the therapeutic diet. “Prescription food is medicine,” said Conway, emphasizing that these foods have high quality control as they are AAFCO, FDA, and USDA regulated.

Conway D. Food for Thought: Pros & Cons of All Available Nutrition Options. Presented at: Fetch Coastal; October 14-16, 2024; Atlantic City, NJ.

Capuzzi J. Still seeking a grain of truth. 

December 15, 2023. Accessed October 14, 2024. 

Having open conversations with clients about their pet's nutrition can help combat misleading information

Navigating pet nutrition and talking diets with clients

During her session, “The Itchy and Scratchy Show: How to Confidently Diagnose Canine Allergies,” presented at Fetch Coastal dvm360 Conference in Atlantic City, New Jersey, Julia E. Miller, DVM, DACVD, emphasized the importance of including allergic dermatitis in the differential list when presented with a pruritic dog. In the first half of her 2-part lecture, Miller taught attendees how to diagnose patients that present with allergies, in a step-by-step, checklist-based manner.

Miller shares that, while a presenting case of allergies is more than likely atopy, food allergies are responsible for 10-25% of allergic dermatitis cases. Allergic dermatitis is a diagnosis of exclusion, which requires the careful ruling out of other pruritic conditions. Once alternatives including ectoparasites, flea allergy dermatitis (FAD), neoplasia, and secondary microbial infections have been ruled out, food allergies should be considered. Food allergies are nonseasonal, and many dogs become sensitive to what they are used to, so a food change is not a prerequisite for diagnosis.

Cutaneous adverse food reaction (CFAR) is an adverse immunologic reaction to an allergen in the diet. Miller warns that the diagnosis of CFAR could be difficult, as the clinical picture is often identical to environmental allergies (atopic dermatitis). The only accurate diagnostic test that Miller advises is a strict, prescription diet trial.

“So, you’ve got your itchy dog, you’ve ruled out your ectoparasites, you’ve done an incredibly throughout derm [physical exam], you’ve done cytology… you’ve ruled out all of those secondary things, but you still have this non-seasonally itchy dog… you think you want to go with a food allergy, just to see what we’ve got going on,” Miller, said during her presentation. “So, ‘how do we diagnose a food allergy?’ It’s a prescription diet trial. That’s the only way to diagnose a food allergy. Period, end of story.”

The following should be avoided while conducting a prescription diet trial—Miller recommends adding these to a handout for owners:

Flavored flea, tick, and heartworm preventatives

Throughout the course of a diet trial, patients will likely require antipruritics for 3-6 weeks. Miller recommends Apoquel, glucocorticoids, and Cytopoint. All secondary infections should be cleared prior to the trial. She advises that diarrhea often clears up before pruritus.

After 3 weeks on the diet, more than 50% of patients will show marked improvement. That number increases to 85% at 5 weeks, and 95% at 8 weeks. Most cases do not require 3 months, and trials should not last longer than 4-6 weeks with no signs of improvement. If a patient does not react, and food can be ruled out along with all other causes of pruritus, it can be concluded that it’s atopy.

The options for prescription diet trials are commercial novel protein, hydrolyzed protein, or home-cooked meals. Proteins are the most common allergens, including chicken, beef, lamb, or fish, although any carbohydrate or fat could also be an allergen. There are no perfect diets that fit all patients, and it’s important to consider the patient’s diet history, appetite, and owner requirements.

It’s crucial to know which proteins are considered novel to a patient. There is also the potential for cross reactions between protein sources with close taxonomic relationships. Miller clarified that, if a patient is allergic to chicken, turkey and duck are not novel proteins. If a patient is allergic to beef, venison or lamb are not novel. Hydrolyzed proteins involve disrupting the protein structure, thereby removing any existing allergens within a patient’s diet. Some dogs with CAFR will still react to diets containing hydrolyzed versions of the food. Several novel protein diets including rabbit, fish, venison, kangaroo, black fly larvae, and more.

Miller recommends several commercial diets, including:

Purina Pro Plan Veterinary Diets HA with hydrolyzed soy and corn starch +/- hydrolyzed chicken or salmon

Royal Canin Veterinary Diet Hydrolyzed Protein (HP) with brewers rice, hydrolyzed soy protein and chicken fat

Ultamino with corn starch and hydrolyzed poultry-by-products aggregate (chicken feather)

Hill’s Prescription Diet z/d with brewers rice and hydrolyzed chicken liver

Blue Natural Veterinary Diet HF with hydrolyzed salmon, pea starch, and potatoes

Purina Pro Plan EL Elemental, with purified amino acids with corn starch and tapioca starch

Miller emphasized that [serum] food allergy tests are not clinically proven, and she does not trust them, she explains that intradermal allergy testing is ineffective and shared a story about saliva and hair allergy testing being completely fabricated. Meanwhile, over the counter diet trials are unreliable due to reasons dealing with cross contamination.

“They’ve done studies that show that there’s actually quite a bit of chicken in these [chicken-free dog foods] because they’re made on the same [food] lines,” Miller said. “So, over the counter diets are never a true diet trial, ever. Period. End of story.”

Diagnosing pruritic dogs with cutaneous adverse food reactions, or ruling it out, were covered during a session at the 2024 Fetch Coastal dvm360 Conference 