How we say it matters: Relationship-based communication gets the best outcomes
While it’s the veterinarian’s job to determine which diagnostic and treatment options are appropriate for a patient, the decision of which option to pursue ultimately belongs to the client. That choice is largely based on the information provided by the veterinary team—and it turns out that how we have this conversation matters a lot.
Establishing goals of care
The veterinarian can best determine the order in which to present options by understanding the client's hopes and limitations. This starts with having a goals-of-care conversation prior to presenting options.
The more you know about a client’s circumstances, the better you can guide them toward the highest level of care for the patient while causing the least amount of stress to the client.
For example, if you aren't aware of what finances are available, you could spend all the client's funds on diagnostics and not leave anything left to treat the pet. Instead, you can ask, "What is your budget today?" of a client who has expressed financial limitations.
Another helpful question is: "What is your goal for today's visit?" This invites clients to express their concerns openly, and it can be especially helpful for clients seeking a second opinion or advice on end-of-life care.
Presenting a spectrum of options
“Veterinarians must be confident in the treatment options offered," said Carolyn Brown, DVM, vice president of medicine for Community Medicine at the ASPCA.
Clients may perceive hesitations or a lack of confidence in an option, which may make them feel guilty for choosing it, even if it is the only feasible option financially. Veterinarians gain confidence in a spectrum of diagnostic and treatment plans over time based on clinical experience, anecdotal evidence from colleagues, and scientific evidence for alternative options, which is growing thanks to ongoing research.
It is essential that veterinarians focus on clarity and compassion when presenting these options. “I try to be as clear as possible when speaking with clients and do not use medical jargon and euphemisms,” said Brown. “It is my goal to avoid having clients spend time and energy deciphering what I am saying when they have so many other considerations and concerns to balance.”
Pet families should understand the advantages and disadvantages of each option presented as well as the prognosis and expected outcomes.
Many times, cases can be approached incrementally, where an initial, less invasive or expensive option is chosen, knowing additional testing or treatment may be needed based on the patient response. Once a diagnostic and treatment plan is made, the client should be prepared for what the next steps are for their pet, what to monitor for, and when to return for a recheck or contact the veterinary team with concerns.
Case study: Bucky
The information gained during goals-of-care conversations can guide veterinarians to present options in an order that is most appropriate for the given situation, taking into consideration patient status, comfort, and quality of life, client goals and limitations, and scientific evidence.
For example, Mrs. Smith brings Bucky, her 3-year-old male neutered mixed breed dog in for evaluation of diarrhea after being boarded while the family was on away. She mentions that she is frustrated by cleaning up diarrhea all day, but that finances are tight after returning from vacation.
Bucky is bright, alert, and responsive, eating well, and has a normal physical examination. Dr. Kay, the veterinarian, considers the history, physical examination findings, and client’s concerns. Her top differential diagnosis is stress colitis.
“I can’t imagine how frustrating it is having to clean up after Bucky while you’re trying to unpack from vacation,” Dr. Kay begins. “There are many potential causes for diarrhea, and it can sometimes be difficult to determine the exact cause. I suspect in Bucky’s case the diarrhea is due to stress from being in the kennel. This usually responds very well to treatment with a bland diet and probiotic. Diagnostic tests such as bloodwork and x-rays would help to rule out other, more serious causes of diarrhea. We can perform these tests today or see how Bucky responds to symptomatic treatment. If you elect to treat today and Bucky worsens or doesn’t improve within three days, you should return for further evaluation.”
In this approach, Dr. Kay acknowledges Mrs. Smith’s concerns and gives her two potential options for how to proceed. She doesn’t make the decision for her client. By educating Mrs. Smith about why diagnostics are important and offering the alternative option of symptomatic treatment in a nonjudgmental way, Dr. Kay ensures that Bucky receives treatment for his diarrhea while being nonjudgmental of his family’s current financial situation.
The ”relationship-centered” communication toolbox
“Relationship-centered” communication is the goal, and that means establishing mutual trust and allowing the client to have an active role in the conversation. While strong relationships are developed over time, this type of communication can still be used in emergency situations or during a first-time visit.
- Open-ended questions: These types of questions often start with the words what, why, or how and require an answer that is more than just yes, no, or a few words. Instead of "Is Oscar drinking more?" ask, "What are Oscar's drinking habits like?" Answers to these types of questions provide important context that can help guide the way options are presented.
- Active listening: Show you are engaged in what the client is saying using nonverbal cues such as nodding and maintaining eye contact. Say short phrases such as “I see …” or “Go on …” to encourage the client to continue talking. It is essential to avoid interrupting the client to interject your own opinion or ask other questions.
- Reflective listening: This allows you to clarify what you’ve heard. After the client finishes speaking, provide a short summary to check understanding and allow for additional clarification.
- Nonverbal communication: The majority of communication is nonverbal. Facial expressions, postures, tone of voice, hand gestures, and more all influence the way our words are interpreted. Being aware of these aspects of communication will help to improve relational communication.
A whole-team approach
Working within a spectrum of care can mean lengthy conversations at times, as options are weighed within the pet family’s individual circumstances. The good news is that every member of the veterinary team can engage in these conversations. Embracing a team approach to spectrum of care communication will improve both the relationship with the patient care team and patient outcomes.
In next month's column, we will discuss the vital role that veterinary team members play in successful spectrum of care communication.
Kate Boatright, VMD, is a small animal veterinarian, speaker, and author in western Pennsylvania. She graduated from the University of Pennsylvania in 2013 and has worked in rural small animal general practice and emergency clinics ever since. She is passionate about inciting positive change in the profession through mentorship and servant leadership in organized veterinary medicine. She writes a monthly column for NEWStat on the role of the spectrum of care in improving outcomes in clinical practice.
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Disclaimer: The views expressed, and topics discussed, in any NEWStat column or article are intended to inform, educate, or entertain, and do not represent an official position by the American Animal Hospital Association (AAHA) or its Board of Directors.