This edition first published 2010
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Library of Congress Cataloging-in-Publication Data

Handbook of veterinary communication skills / edited by Carol Gray, Jenny Moffett ; foreword by Cindy L. Adams ; introduction by Jane R. Shaw.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-4051-5817-6 (pbk.: alk. paper) 1. Interpersonal communication. 2. Communication in medicine. 3. Veterinary medicine–Practice. 4. Veterinarians–Psychology. I. Gray, Carol, BVMS. II. Moffett, Jenny.

[DNLM: 1. Communication. 2. Interpersonal Relations. 3. Veterinarians–ethics. 4. Veterinarians–psychology. 5. Veterinary Medicine. SF 610.5 H236 2010]

SF610.5.H364 2010

636.089’0696–dc22

2009033003

A catalogue record for this book is available from the British Library.

1 2010

Foreword

In 1994, I was awarded a fellowship at the Ontario Veterinary College to study the effect of companion animal death on humans. At the time, awareness was increasing on preparing entry-level graduates to deal with this aspect of practice. End-of-life curricula varied between schools in terms of the time available to teach as well as the subject that was taught. The growing awareness of the need for effective communication with clients when their pets were close to death or deceased increased acceptance of the importance of communication in general.

When I graduated in 1998 and began my career in veterinary medicine, I was in a position to develop a research programme and communication curriculum that went beyond the issue of end of life to broader communication. This focus prepared graduates to deal with several issues in practice using a core skills set that varied depending on the context, urgency, and so on. At the time, only a smattering of veterinary schools in the United Kingdom and Australia were drawing attention to the importance of teaching communication in veterinary curricula. In general, traditional curricula paid little or no attention to communication. Practitioners communicated in a manner that was aimed at satisfying the veterinarian’s need for data to solve patients’ problems. The expansive literature in the medical field on the relationship between communication and outcomes of care was largely unknown to the veterinary profession. Good communication was considered a mechanism for making money, and any strategies for economic success were largely anecdotal rather than based on research evidence.

Over time, some influential studies revealed that the veterinary profession was lacking in terms of achieving results that included ‘compliance’ and employee and client satisfaction. The suggested strategy for ameliorating this situation was to teach students how to communicate, work in a team, and develop and manage a good business. Industry partners were starting to draw attention to the relationship between practice protocols such as ‘compliance’ and satisfaction; however, there was little awareness of how to distil communication into skills or ways to achieve the desired results.

A decade later, major changes have taken place and we are able to improve communication substantially. Veterinary schools worldwide have started to devote time to teaching communication and assessment. In addition, faculty members have begun to learn both communication skills and how to integrate communication teaching into courses on discipline and skills.

A great deal of communication research that has taken place in the medical field is applicable to veterinary medicine. Communication research into comparing the professions has also been carried out in veterinary medicine. Models for teaching communication have enabled veterinarians to develop more quickly than medical practitioners simply by adapting the models to our profession. We have been using textbooks from medicine to teach in veterinary medicine, and while this is useful to a point, there comes a time when the literature must reflect the context in which it will be applied.

To be successful, any textbook emphasizing communication in veterinary medicine needs to be practical and context specific. It needs to teach as well as convince the reader that communication is a necessary skill. The textbook needs to persuade the reader that communication is not ‘psychobabble’ but a core clinical skill that is no longer optional. Without skills and a commitment to continual learning, practice success and patient care are at risk. The Handbook of Veterinary Communication Skills meets all these requirements. The authors have done a superb job of describing communication skills and the major issues in the profession, including end-of-life situations using a skills-based approach. In addition, the handbook raises awareness of the various contexts in which practitioners need communication skills. The handbook examines a topic that has been largely untouched – self-care. So many tasks inherent to the profession, such as euthanizing animals, have previously been treated as inconsequential. The chapter on self-care now remedies this situation by promoting reflective practice to encourage the professional to engage in healthy coping strategies and take care of clients and colleagues in challenging aspects of practice.

Communication is poised to expand in our profession. The Handbook of Veterinary Communication Skills will provide teachers and students with a much-needed resource for both teaching and learning. All veterinary educators, students and veterinary professionals would benefit from reading this book.

Cindy L. Adams
Associate Professor of Veterinary Medicine-Clinical Communication University of Calgary, Alberta, Canada

Introduction: The veterinarian–client–patient relationship

INTRODUCTION

To set the stage for the conversations that follow in this book, it is helpful to take an indepth look at the veterinarian–client–patient relationship. This relationship serves as the foundation for all that we are trying to achieve in veterinary medicine, including satisfying the client, caring for the animal and promoting professional fulfilment. The dynamics of the veterinarian–client–patient relationship are complex with multiple dimensions to take into consideration.

As you read on:

Reflect on what approach meets your style. Often, we recognize a pattern that suits us most, is our dominant style and is our default pattern during times of stress. We are in our comfort zone in interacting with clients in this manner.
Take time to identify the relationship style preference of your clients. The overall goal is to demonstrate elasticity in your client communication so that you can tailor your approach to meet the client’s needs and to enhance clinical outcomes. Frequently, communication challenges result from a mismatch in communication styles. Expanding your repertoire will enable you to meet the needs of a diverse clientele.
As an initial assessment, ask yourself, ‘Who is doing the talking?’ This is a simple litmus test for assessing your communication style. Are you doing all the talking, or are you creating space for the client to share their story and take an active role in the conversation? How much time do you spend listening to the client during the clinical interview?

A PARADIGM SHIFT

Recent societal changes have caused a paradigm shift in the veterinarian–client–patient relationship. Over the past decade, these changes have caused substantial transformation in the veterinary profession. One of the major changes is the increasing recognition of the relationships that people may have with their companion animals (Blackwell 2001). When asked about their relationship with their pets, 85% of pet owners reported that they viewed their pets as family members (Brown & Silverman 1999). In conjunction with this, there is a growing recognition that provision of veterinary services in a manner that acknowledges the human–animal bond will lead to better outcomes for veterinary practices and their patients (Brown & Silverman 1999). Appreciating the impact of animal companionship on the health and well-being of humans creates a new dimension in public health. Veterinary professionals’ responsibilities have expanded to include the mental health and well-being of their clients, as well as those of their clients’ pets (Blackwell 2001).

With the advent of the internet, today’s veterinary professionals are faced with educated clients armed with questions and greater expectations. Veterinarians’ responsibilities for addressing questions and providing client education are increased. In an increasingly litigious society, consumers are not forgiving of unprofessional services (Blackwell 2001). Most complaints to regulatory bodies are related to poor communication and deficient interpersonal skills (Russell 1994), with breakdowns in communication being a major cause of client dissatisfaction.

An adaptive response is integral to successfully addressing these societal and professional changes. Given growing client expectations, the strong attachment between people and their pets and increasing consumer knowledge demands a shift in communication style from the traditional paternalistic approach to a collaborative partnership. Many clients are no longer content with taking a passive role in their animal’s health care and want to take an active role in decision making on their pet’s behalf.

VETERINARIAN–CLIENT–PATIENT RELATIONSHIP STYLES

The relationship dynamic between veterinarian and client is based on three criteria (Emanuel and Emanuel 1992):

Who sets the agenda for the appointment (i.e. the veterinarian, the veterinarian and client in negotiation, or the client).
Importance placed on the client’s values (i.e. the veterinary team assumes that the client’s values are the same as the veterinarian’s, the veterinary team explores the client’s values with the client, or the veterinary team does not explore the client’s values).
Functional role of the veterinary professional (i.e. guardian, advisor or consultant).

Paternalism

On the basis of these criteria, three veterinarian–client–patient relationship styles have been described (Shaw et al. 2006). At one end of the relationship spectrum lies paternalism, characterized as a relationship in which the veterinary professional sets the agenda for the appointment, assumes that the client’s values are the same as the veterinarian’s, and takes on the role of a guardian. Traditionally, paternalism is the most common approach to medical visits. Shaw et al. (2006) reported in veterinary medicine that 58% of all visits were paternalistic, and, specifically, in 85% of problem visits veterinarians use a paternalistic approach. The topic of conversation is primarily biomedical in nature, focusing on the medical condition, diagnosis, treatment and prognosis (Shaw et al. 2006).

In a paternalistic relationship, the veterinary team does most of the talking and the client plays a passive role. This approach is often referred to as the ‘data dump’ and symbolized by a ‘shot-put’ (Silverman et al. 2005). Throwing a shot-put is unidirectional, the intent is on the delivery, the information to be delivered is large in mass and it is challenging to receive the message. Intuitively, it seems like this directive approach enhances efficiency and promotes time management. The challenge is that the agenda and subsequent diagnostic or treatment plan may not be shared between the veterinarian and client, compromising the ability to reach agreement, move forward and achieve full compliance. This could result in a roadblock, taking steps backward to recover and regain clients’ understanding, commitment and trust.

Consumerism

At the opposite end of the spectrum lies consumerism, which is characterized by a reversal of the traditional power relationship between veterinarians and clients: the client sets the agenda for the appointment; the veterinary team does not explore the client’s values; and the veterinary team plays the role of a technical consultant, providing information and services on the basis of the client’s demands. The consumerist approach was not reported in veterinary visits and seems to be an infrequent approach (Shaw et al. 2006). While the paternalism model has been criticized for ignoring the client’s perspective, the consumerism model errs in limiting the role of the veterinary team. The challenge in this situation is to engage with the client as a working partner and to build trust with the veterinary team to reach an agreement between the client and the veterinarian agendas.

Partnership

Between these two extremes is relationship-centred care, which represents a balance of power between veterinarians and clients and is based on mutuality (Tresolini & Pew-Fetzer Task Force 1994; Roter 2000). In the relationship-centred model, the relationship between veterinarians and clients is characterized by negotiation between partners, resulting in the creation of a joint venture, with the veterinarian taking on the role of advisor or counsellor. Respect for the client’s perspective and interests and recognition of the role the animal plays in the life of the client are incorporated into all aspects of care. Shaw et al. (2006) reported that 42% of all veterinary visits were characterized as relationship centred, and specifically in 69% of wellness visits, veterinarians used a relationship-centred approach.

The conversation content of relationship-centred visits is broad including biomedical topics, lifestyle discussion of the pet’s daily living activities (e.g. exercise regimen, environment, travel, diet and sleeping habits) and social interactions (e.g. personality or temperament, behaviour, human–animal interaction and animal–animal interactions) (Shaw et al. 2006).

In addition, a relationship-centred approach encompasses building rapport, establishing a partnership and encouraging clients’ participation in the animal’s care – all of which have the potential to enhance outcomes of veterinary care. This collaborative relationship is symbolized by a ‘Frisbee’ (Silverman et al. 2005). In playing Frisbee, the interaction is reciprocal, the intent is on dialogue, the delivery is airy, light and free. Small pieces of information are delivered at a time and the deliverer and the receiver adjust their message to stay on target. Intuitively, it seems like this facilitative approach takes more time; however, it was found that relationship-centred care appointments were shorter in length due to achieving common ground between the veterinary team and the client (Shaw et al. 2006).

Communication style has implications for the veterinary team, client and patient outcomes, based on research on the physician–patient communication that reported a positive relationship between aspects of relationship-centred care and patient satisfaction, physician satisfaction, patient health outcomes and a reduction in malpractice risk.

Specifically, the following principles of relationship-centred care are associated with significant outcomes:

Broadening the explanatory perspective of disease beyond the biomedical to include lifestyle and social factors is related to expanding the field of inquiry and improved diagnostic reasoning and accuracy (Silverman et al. 2005).
Building a strong relationship is associated with increased accuracy of data gathering (Silverman et al. 2005), patient satisfaction (Bertakis et al. 1991; Buller & Buller 1987; Hall & Dornan 1988) and physician satisfaction (Levinson et al. 1993; Roter et al. 1997).
Encouraging participation, negotiation and shared decision making promotes patient satisfaction (Bertakis et al. 1991; Buller & Buller 1987; Hall & Dornan 1988), adherence (DiMatteo et al. 1993) and improved health (Stewart 1995).

SHARED DECISION MAKING

Shared decision making is a key component of relationship-centred care. There is two-way exchange between the veterinarian and the client, identifying preferences and working towards consensus. An interactive approach (e.g. Frisbee) is promoted in giving information, in contrast to direct transmission (e.g. shot-put) (Silverman et al. 2005). With a direct transmission approach, the sender assumes that his or her responsibilities are complete once the message has been formulated and sent, whereas with an interactive approach, the interaction is considered complete only if the sender receives feedback about how the message was interpreted, whether it was understood, and what impact it had on the receiver.

Silverman et al. (2005) recommend using a ‘chunk and check’ method (e.g. Frisbee) when giving information, to avoid giving a one-sided speech and providing a large amount of information all at once (e.g. shot-put). The aim of this technique is to increase recall, understanding and commitment to plans. It consists of giving information in small pieces (i.e. chunks), followed by checking for understanding before proceeding further (i.e. check). In this manner, the information-giving process is responsive to the client’s needs and provides an opportunity for the client to participate in the conversation, provide feedback or ask for clarification.

Taking the client’s perspective into account and establishing mutual understanding and agreement encourage the client to fully participate in the discussion and commit to the diagnostic or treatment plan. This entails encouraging the client to contribute to the conversation (e.g. check) (‘What questions do you have?’), picking up on client cues (‘You seem a little hesitant about surgery’), asking for the client’s suggestions (‘What options have you and your husband discussed?’) and checking for the client’s understanding (‘What will be the most difficult for you?’). Use open-ended inquiry to explore the client’s perspective (‘How do you feel Max is doing since the surgery?’); ascertain the client’s thoughts (‘What do you attribute to his good progress?’); and assess the client’s starting point (‘What do you know about the risks of arthritis?’). Extrapolating from medical communication outcomes-based studies, obtaining the client’s expectations, thoughts, feelings and fears about the pet’s health or illness enhances client participation in the appointment, with the potential to increase client satisfaction and adherence to veterinary recommendations (Stewart et al. 1995).

CONCLUSION

The questions posed at the beginning of this chapter included the following: ‘Which relationship style reflects your approach?’, ‘What is your client’s style?’ and ‘Who does the talking in your visits?’ Given the answers to these questions, what steps would you like to take to expand your repertoire to meet the needs of your client? Flexibility in your approach is instrumental in meeting the diverse preferences of your clients. It seems appropriate to incorporate both paternalism and partnership in your toolbox and to interchange your pattern to meet that of your client. Matching the relationship between the veterinarian and the client enhances the potential of achieving significant clinical outcomes, including enhancing client satisfaction, improving patient health and, as a result, professional fulfilment.

REFERENCES

Bertakis KD, Roter DL, Putnam SM (1991) The relationship of physician medical interview style to patient satisfaction. Journal of Family Practice 32:175–181.

Blackwell MJ (2001) The 2001 Inverson Bell Symposium Keynote Address: Beyond philosophical differences: the future training of veterinarians. Journal of Veterinary Medical Education 28:148–152.

Brown JP, Silverman JD (1999) The current and future market for veterinarians and veterinary medical services in the United States. Journal of the American Veterinary Medical Association 215:161–183.

Buller MK, Buller DB (1987) Physicians’ communication style and patient satisfaction. Journal of Health and Social Behaviour 28:375–388.

DiMatteo MR, Sherbourne CD, Hays RD (1993) Physicians’ characteristics influence patient’s adherence to medical treatments: results form the medical outcomes study. Health Psychology 12:93–102.

Emanuel EJ, Emanuel LJ (1992) Four models of the physician-patient relationship. JAMA 267:2221–2226.

Hall JA, Dornan MC (1988) Meta-analyses of satisfaction with medical care: description of research domain and analysis of overall satisfaction levels. Social Science and Medicine 27:637–644.

Levinson W, Stiles WB, Inui TS (1993) Physician frustration in communicating with patients. Medical Care 31:285–295.

Roter DL (2000) The enduring and evolving nature of the patient-physician relationship. Patient Education and Counseling 39:5–15.

Roter DL, Stewart M, Putnam SM (1997) Communication patterns of primary care physicians. Journal of the American Veterinary Medical Association 277:350–356.

Russell RL (1994) Preparing veterinary students with the interactive skills to effectively work with clients and staff. Journal of Veterinary Medical Education 21:40–43.

Shaw JR, Bonnett BN, Adams CL (2006) Veterinarian–client–patient communication patterns used during clinical appointments in companion animal practice. Journal of the American Veterinary Medical Association 228:714–721.

Silverman J, Kurtz SA, Draper J (2005) Skills for Communicating with Patients. Radcliffe Medical Press, Abingdon, UK.

Stewart MA (1995) Effective physician–patient communication and health outcomes: a review. Canadian Medical Association Journal 152:1423–1433.

Stewart M, Brown JB, Weston WW (1995) Patient-Centered Medicine: Transforming the Clinical Method. Sage, Thousand Oaks, CA.

Tresolini CP, Pew-Fetzer Task Force (1994) Health Professions Education and Relationship-Centered Care: Report of the Pew-Fetzer Task Force on Advancing Psychosocial Education. Pew Health Professions Commission, San Francisco, CA.

Handbook of Veterinary Communication Skills

Contributors