What to tell patients about the test
When something new diagnostic test comes along which impacts on patient care it’s important to think about how it is integrated into daily practice. A common question with the test strip is “How do I sell it to patients?” It is not so much as an issue of selling, but how to integrate it as a routine standard to ensure you are offering the highest standards of care by confirming the right diagnosis is being made. This article looks at how you can introduce the test strip as a means of improving the standard of care you provide whilst improving your business. This article is a follow up to my earlier blog post on how to market the test strip: Click Here
How do I introduce the idea to patients?
Introducing formal fungal testing into clinic where there is a charge attached is best suited for new patients who present with nail dystrophy. Remember, around 50% of patients presenting with nail dystrophy will have fungal nail infection (and it follows that 50% won’t) (1). So, when discussing with your patient its important to emphasise this and in order for you to offer the most appropriate treatment you will need to ascertain the cause to establish the diagnosis. Therefore, a test is required. Without it, you won’t be able to best advise the patient on management. Moreover, you would be guessing the diagnosis. Research has shown 1 in 3 fungal nail diagnosis made by visual diagnosis alone are incorrect (2).
What if I guessed and I was wrong?
A prime example could be where onychomycosis is incorrectly diagnosed in a patient who doesn’t have it (a false positive). The patient maybe offered expensive laser treatment for example or a year of applying a topical lacquer for a condition they simply don’t have. This is not only unethical but a waste of time and money. I regularly see new patients who have been told they have fungal nails, have been treating them but they are not looking better. Upon testing they have no evidence of the disease. A difficult conversation to have with patients but nevertheless they are clearer on what the problem isn’t. This common scenario of “false positive” diagnoses also adds to the collective view that fungal nails are untreatable when a percentage maybe just mis-diagnosed.
What if the patient doesn’t want it?
For your routine patients where you have been treating previously for suspected fungal nails, they may find it difficult to understand why you need to test now after all this time and so it may not be the best course of action. Occasionally, a new patient consults about their nails as they think they might be fungal, declines to have a formal fungal test. Of course, they are quite entitled to do so. In this case, it is difficult for the practitioner, but I always advise patients that without this knowledge it is difficult to be sure what they have so I cannot give specific advice. For all my patients requiring a test, I always mention that via the GP they can obtain a free microscopy and culture from a nail clipping, but this can take up to 3-4 weeks and has a high chance of returning a false negative result for various reasons (3). The latter point being the main reason why many podiatrists have given up sending patients along this route.
I find it difficult to charge that!
A common scenario is "I don’t like the idea of charging". If the patient were to attend a dermatologist privately with the same problem, no dermatologist would ever diagnose the condition without first undertaking a suitable test. Subsequently they would be charged for the initial consultation, a follow up consultation (to receive the results) and the full price of the mycology test. These costs combined could be £250-£350 in total before any treatment is discussed. Compare that that with your podiatry consultation fee and the test. You would still be much better value for money! In addition, you would be best placed to offer a range of topical treatments for the patient.
How do I best treat onychomycosis when I've diagnose it?
Reviews do exist on this subject from a medical perspective (see Ameen et al.,  Click Here) but as podiatrists we offer additional topical treatments which are less reviewed and less evidence-based. In a forthcoming blog post I will visit this issue.
What if its not fungal?
This is another common question and yes, there will be patients with no evidence of fungal infection. On that basis have a look at my earlier blog on that subject: Click Here.
As podiatrists, we should be able to offer our patients the best standard of care. Mycological testing for suspected fungal nail infection is not a luxury - it is a standard and it is safe practice as outlined by the national guidelines (4, 5) and should always be undertaken if the nail is going to be treated. Explaining to the patient why a test is necessary will help them to understand the need for establishing a diagnosis, especially as onychomycosis treatment can be prolonged and require their assistance.
1. Walling HW, Sniezek PJ. Distribution of toenail dystrophy predicts histologic diagnosis of onychomycosis. J Am Acad Dermatol. 2007;56(6):945-8.
2. Tsunemi Y, Takehara K, Oe M, Sanada H, Kawashima M. Diagnostic accuracy of tinea unguium based on clinical observation. The Journal of Dermatology. 2015;42(2):221-2.
3. Piraccini B, Alessandrini A. Onychomycosis: A Review. Journal of Fungi. 2015;1(1):30.
4. National Institute for Health and Care Excellence. Clinical Knowledge Summaries: Fungal Nail Infection: National Institute for Health and Care Excellence; 2013 [cited 2014 April 2014]. Available from: http://cks.nice.org.uk/fungal-nail-infection#!scenariorecommendation.
5. Ameen M, Lear JT, Madan V, Mohd Mustapa MF, Richardson M. British Association of Dermatologists' guidelines for the management of onychomycosis 2014. Br J Dermatol.