In my last Bovine Veterinarian article (July/August 2013) I wrote about “Opportunities to improve dairy health management.” I ended saying dairy veterinarians need to capitalize on opportunities to become more engaged in health management and establish the value of such professional service.
Progress has been made with development of protocols outlining health-management best practices for typically larger operations with a hired workforce. Yet, health-management assessments performed across the country found only 50 percent or fewer dairies have written protocols for the identification and treatment of the common diseases of dairy cattle. Many veterinarians are training employees on the hows and whys of those protocols. But just over half the farms with written protocols were following them as written. Sharing what was observed during hospital pen treatments with attending veterinarians, they too often said, “They are doing what?” or “No, that’s not what we do.” Protocol drift has become almost accepted as an inevitability on the dairy.
If you don’t know that intended best practices are consistently being implemented you don’t have a valid veterinary-client-patient relationship (VCPR). This is a concern for every veterinarian who wants to be a trusted, valued health-management advisor to his or her dairy clients. If you developed the protocol, you better make sure dairy personnel are compliant. If that protocol doesn’t pan out because it wasn’t consistently, effectively implemented you lose credibility. That is why the VCPR is so important. That is why I think controlling the input processes that impact health (process management) and health-data management are keys to the future of dairy practice.
Harry S. Truman said, “There is nothing new in the world except the history you do not know.” This article presents nothing new but intends to outline a practice model focused on effective implementation of health-management best practices.
How reproductive exams became known as “herd health”
In 1968, Dr. David Morrow published a paper in the Journal of Dairy Science entitled “Programmed Dairy Herd Health.” At about that time there were 12 million dairy cows in the United States on nearly 650,000 dairies, with an average herd size of 19 cows. The paper describes a general health program best implemented by monthly veterinarian visits to the farm. The program was predicated on the idea that “The most important single factor responsible for the rapid recovery of a sick animal is early veterinary diagnosis and treatment.” This was a new practice model at the time. Rather than waiting for problems to occur, farmers should schedule monthly veterinarian visits.
During routine visits, discussion of “important feeding and management practices helpful in preventing and controlling disease” would occur. However, once these best practices were established, there was limited monthly billable work aside from sick-cow work. The game changer, a mere one column of text in an eight-page paper, was the section “Reproductive Health Program.” It detailed a “reproductive examination schedule…indicated for all cows,” much of which is performed today:
1) Retained-placenta cows should be examined one to two times prior to breeding.
2) Examine cows fresh 30 days before breeding.
3) Examine cows with abnormal discharge during heat.
4) Examine cows with abnormal heats and heat cycles.
5) Examine no-heat cows 45 to 60 days fresh.
6) Examine cows bred two to three times.
7) Examine for pregnancy cows bred 45 to 60 days prior and repeat two to three months later since about 7 to 10 percent will abort.
That action list ensured a steady supply of routine work for the veterinarian each month on each dairy. It brought value to the dairy as evidenced by the fact that it remains the focus of dairy veterinary services today. But what was a professional service then might be perceived as a technical one now. And many dairy veterinarians are seeing demand for that service dry up. Perhaps what they need now is an action list of health-related services of demonstrable value performed on a routine basis — a “health examination schedule.”
Becoming a “consultant” is probably not the answer
As the need for veterinary reproductive exams has been replaced by systematic hormone injections, pregnancy test kits and ultrasound performed by farm personnel, dairy veterinarians need to establish their value as health-management professionals. In a Bovine Practitioner paper from 2004, Fetrow, Cady and Jones described an urgent need to “seek a sustainable future for dairy veterinary medicine.” Dairy consultation is not the answer, at least not for many. Competition from companies that “bundle” health-management consultation as a value-added service to product sales present a challenge, and the authors suggested such work was not sustainable because “good consultants work themselves out of a job.” Finally, client perception of the value of veterinary services is based on paying a fee for physical services and drugs rather than paying for “intellectual effort.” Though challenges exist, there is opportunity for dairy practitioners to be valued and make a living by providing health-management services to dairy farms.
Become THE health-management advisor to the dairy
A take home message from Dr. Ken Nordlund’s keynote presentation at the AABP Annual Conference in 2012 was to position yourself as an advisor to a process of decision making.
Nordlund suggested the attending veterinarian has limited value as the “answer person” when a cadre of top experts are lined up to provide “free” consultation to large dairy clients. I often hear complaints from practitioners about the free corporate consultant taking away their business. I empathize with their situation. However, if you are the trusted health-management advisor your clients will refer any “free” company consultants to you. You should welcome these consultations as a “third-party audit” you use as part of the continuous improvement of your health-management programs.
Many veterinarians cite a routine presence and intimate knowledge of the dairy as a value outside consultants don’t necessarily bring to the table. Recognize that as the attending veterinarian, you could be just as myopic because of that familiarity. Maintain an open mind and keep defenses down. Probably the greatest value familiarity with the dairy brings is knowledge of its managerial capabilities to successfully implement recommendations.
Routine assessment of the processes that impact health should continue even when “the numbers look good.” Developing a health examination schedule
To continue being relevant, veterinarians need sustainable health-management- related activities that bring value to the dairy at every visit. During his keynote address at AABP in 2012, Dr. Kee Jim indicated the need for a practice business model where “both parties had a vested interest in success.” Clearly a model where revenue is based on death and disease puts your business success at odds with the client’s. There is some opportunity in focusing on problem cows. However, the greatest potential may be activities that control variation through the early identification of “out of control” processes of health management and timely interventions to prevent sick animals and improve client profitability.
What follows is a draft list of activities that could be included in a comprehensive health-management service that also includes routine data management, evaluation of outcomes and benchmarking. Benchmarking is dismissed by some, but the fact remains that clients want it and as Dr. Jim pointed out, give them what they want or someone else will.
The frequency listed for each activity is a theoretical starting point, but routine monitoring should continue at an interval that would allow early identification of unacceptable variation.
Draft health examination schedule
1. Transition management monitoring:
• (Weekly) Blood ketone and calcium monitoring of fresh cows combined with fresh-cow disease rates, removals by 14, 30 DIM and week-4 milk production.
• (Weekly) Body-condition scoring at dry, move to the close-up pen, and post-fresh.
• (Weekly) Stocking density in far dry, close-up/maternity and fresh pens.
• (Weekly) Ration/feeding evaluation: Feedbunk scoring, particle separation on as-fed and push-out feed, manure scoring/ evaluation and cud chewing of close-up and maternity pens.
2. Udder health monitoring:
• (Weekly) Within a month cover all milking shifts/all pens: Cow hygiene scoring in parlor, stall/loafing area hygiene scoring in the pens. (two to three times per week) String samples for SCC and culture to monitor environmental hygiene and determine bedding frequency.
• (Weekly) Within a month cover all milking shifts: Percent teats poorly pre-dipped/post-dipped.
3. Locomotion monitoring and hoof-care audit:
• (Weekly/monthly) Examine cows in lockup for back arch (BA); release any with BA and locomotion score. Record and monitor BA/locomotion data. Evaluate or schedule for evaluation those with BA and locomotion score 3 to 5 within 24 hours.
• (Monthly/quarterly) For herds where farm personnel or professional trimmers evaluate lame cows: Observe a representative sample of lame cows being evaluated for proper trimming procedures, accuracy of disease identification, incidence of unidentified disease and compliance with treatment protocols.
4. Disease identification/treatment audit:
• (Weekly/semimonthly) Examination of a representative sample of fresh/hospital-pen cows and calves identified with disease and treated the last one to two days. Assess and record accuracy of disease identification and incidence of unidentified disease, treatment protocol compliance and health-data- recording protocol compliance.
5. Rumen health monitoring (post transition):
• (Weekly/monthly or after major ration change) Feedbunk scoring, particle separation on first fed and refused TMR, manure scoring/ evaluation, cud chewing.
• (Monthly or after major ration change) TMR audit.
6. Stockmanship/welfare audit:
• (Initial assessment then weekly/monthly) Initial assessment that identifies opportunities to improve work efficiency, cow/worker conflicts that could result in welfare/safety issues. Routine monitoring of conflict situations that cannot be immediately remediated.
The output of these activities should all be recorded in a health- and production-management relational database through which the veterinary practice can efficiently monitor input processes and outcomes of the health-management program and how they are related. Learn more about such a database at www.goodhealthrecords.com; click on HEALTHSUM.
Implementing the health examination schedule
Many of the activities on this list are usually done when asked to troubleshoot a problem. In this new health-management service model they are performed routinely to maintain control of health-management processes, thereby reducing protocol drift. Some of the activities on the list could be performed by a trained technician. However, the veterinarian should be involved enough to preserve that constant “behind the cow” vantage point that sets him or her apart fromoutside consultants.
Dairy personnel performing these activities should be objective, well-trained at the task and, most importantly, focused on doing them well. Dairy personnel often have too many competing responsibilities and too little time. Have you ever observed that all cows body-condition-scored at dry off by dairy personnel have the “ideal” 3.5 score? Clearly no one is utilizing those data or they would notice that unlikely uniformity.
Once health improvements are realized and “the numbers look good” there will be a desire to stop monitoring. Although some activities could be discontinued or reduced in frequency, a core set of input measures needs continuous monitoring for early recognition of potential problems and economic loss. As discussed earlier, veterinary service needs to be valued for maintaining health and productivity rather than only dealing with death and disease. Perhaps the service could be marketed as an insurance policy to protect against losses previously incurred or that could have occurred in its absence, whereby clients pay a premium every month. Once health goals are achieved clients would actually receive indemnity payments and free veterinary services if disease incidence exceeds a specified level based on underwriting considerations. They would likely include compliance with health-management protocols and exclusions due to malicious and natural acts.
The list presented is not comprehensive and these ideas about the future of dairy practice are not complete and may be naive. The intent is to start a discussion of what sustainable, client-valued, revenue-generating activities dairy practitioners could perform into the future. A goal of our work at Washington State University Veterinary Medicine Extension is to facilitate changes so more veterinarians can make a living as health-management professionals in an increasingly consolidated and specialized industry. Help us help you by providing your thoughts on the ideas presented in this article. Post your comments on BovineVetOnline. com or send email me at jrwenz@ vetmed.wsu.edu.
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Source: Bovine Veterinarian
