Martha Mallicote | DVM, MBA, DACVIM
University of Florida – College of Veterinary Medicine

Excellent client communication improves patient outcomes and quality of care and also protects
veterinarians from legal and licensure complaints. Conversely, difficult clients make our ability to
provide great veterinary care more challenging and more time-consuming. Let’s unpack the reasons
behind client communication challenges and difficult client expectations, and how to manage those
situations more effectively.

There is a growing body of literature that shows a relationship between quality of communication and
outcomes for both patient and practice health. Diagnostic accuracy requires accurate history taking and
missed diagnoses often result from breakdowns in history collection (56% of cases in one study).
Studies of doctor-client visits show significant differences in how clients and doctors ask questions,
speak, and listen. These differences affect the quality of data collected during the interaction. Improved
communication also results in improved client/patient adherence. Several studies have shown that when
trust is not established, less information is collected from clients and follow-up care is not sought. Third,
breakdowns in care team communication can compromise the quality and efficiency of patient care.
Ineffective team communication was the root cause for ~66% of reported human medical errors in
JCAHO data (1995-2005). Finally, poor communication can result in an increased risk of formal patient
complaints and liability suits. Up to 82% of formal complaints & malpractice cases are due to client
perceptions of misinformation or disrespect, lack of informed consent or detailed explanations for a
procedure, or a client feeling that their opinion did not matter.

Considerations for Building Client Trust

First impressions are incredibly important. Success in this small step requires proactively organizing the ‘welcoming ritual’. Most Americans wish to be addressed by name and want the clinician to introduce themselves. Appropriate touch — often a handshake — is expected and eye contact should be maintained. These two non-verbal components of the introduction are most likely to contribute to a client’s assessment of connectedness.

Nonverbal awareness is key to properly interpreting the client’s response to our discussions. About >80% of communication between individuals is nonverbal, and these behaviors are generally involuntary. This means that important information that cannot be hidden is being exchanged at all times — from client to veterinarian and from veterinarian to client. If the client has a concern with veterinary care, that will be signaled in the nonverbal channel, even if they verbally agree with the treatment offered. Luckily, using nonverbal communication does not require extra time; the doctor can simply notice and respond to those messages as the interaction proceeds.

How we communicate can influence diagnostic accuracy, often by allowing the client the opportunity to tell their story. Failure to get the story, by using a narrow data-gathering process, is a missed opportunity for complete diagnostic information. Open-ended questions are key to success in this area, and veterinarians are not always patient enough to do this well.

How we communicate can influence diagnostic accuracy, often by allowing the client the opportunity to tell their story. Failure to get the story, by using a narrow data-gathering process, is a missed opportunity for complete diagnostic information. Open-ended questions are key to success in this area, and veterinarians are not always patient enough to do this well.

Active listening presents an opportunity to both get a complete understanding of the case and build rapport with the client. Focus on the client and communicate your attention with nonverbal methods.Reflect back on what the client says by both directly restating key facts and summarizing back the information that has been communicated. Further, the clinician can demonstrate an appreciation of what the experience was like for the client with empathy statements. Empathy is most useful when the client is having an emotional response to information about their pet’s situation. Empathy is the single most important skill in building client relationships, yet it is commonly absent. In one veterinary study, empathy statements were expressed in only 7% of appointments.

About half of all client-veterinarian encounters end with the client unable to repeat the plan of action for their animal. It is key to ensure that the client agrees with and understands the plan, thus tools for ensuring client understanding are essential. One technique to “close the loop” is the Ask-Tell-Ask Method:

1. Ask the client to describe his/her current understanding of the issue, then;
2. Tell the client in straightforward language what you need to communicate — the bad news, treatment options, or other information — while avoiding medical jargon. Then finally;
3. Assess the client’s understanding. To do this, ask the client to restate what was said in their own words to ensure they fully processed what was said.

Delivering “Bad News”

Many challenging client communication scenarios center on discussions of “bad news” — whether that be a poor prognosis, an unexpected outcome, treatment failure or recurrence of disease, need for expensive treatment, and even medical errors. Ultimately, bad news is any information likely to be perceived by the client as distressful, unwanted, and/or unexpected. Particularly when delivering bad news, communication is the veterinarian’s responsibility. It is an essential task that should not be delegated and can have lasting effects on the client and patient. The good news is that effective delivery of bad news can strengthen the client-veterinarian relationship, and clinicians who develop skills for this task will have less stress and burnout.

In one study, about 20% of physicians said that they experienced strong emotions when they had to tell a patient that their medical condition would lead to death. The stress clinicians experience when they give bad news has a different course than the distress patients experience (Shaw et al., 2013). The clinician’s stress peaks during the encounter when the bad news is delivered, whereas the patient’s stress peaks after the encounter as the implications of the bad news are better understood. This mismatch in stress and distress is important to be aware of when delivering bad news to a client. At the very moment a clinician is breathing a sigh of relief (because they successfully delivered bad news), the client is still increasing in stress level.

As already discussed, the use of open-ended questions, reflective listening, and sharing empathy can all help to build rapport with clients. These skills should be again deployed when planning how to deliver bad news. Orient clients to the plan for your encounter when delivering bad news, so that they are prepared for what the conversation will cover. While it is useful to provide a warning that bad news is about to be shared, clients have also been shown to appreciate direct delivery of bad news instead of starting with a long introductory period of information sharing.

Communication is always a two-way interaction and a series of verbal procedures. Like other veterinary procedures, there are degrees of difficulty in various communication procedures and our clinical skills will improve with deliberate practice. While we cannot change the need to communicate about difficult situations and with difficult clients, the way we communicate can make the process easier for clients and ourselves.

Resources

Much of this content is sourced from the IHC Veterinary Communication Project modules. For more information, visit the Institute website at www.healthcarecomm.org and click on Veterinary Communication.

This post was written by FVMA Communications Team.