As of late, I find myself approaching client education a bit differently than I once did. When I first started out as a veterinarian, I would spend a great deal of time in a room with a client, explaining diagnostics, treatment plans, and disease processes. I fancied myself quite the communicator. Lately, I've taken the "less is more approach" - much like human MDs. Whisk in, discuss physical exam findings, recommend some tests, and whisk out. Part of this is necessity - we've been very busy in the ER, and part of this is because of the following:
Over the last 2 years, it has become readily apparent that people just don't listen. Or even if they do listen, they only hear and process about 1% of what I say. This has become obvious recently because my technicians will often go into the room after me to discuss the medical plan with the owner. My tech will then come back out and say, "Ms Smith didn't realize that you were recommending Fluffy stay the night. Could you go back in there and explain everything again?" This happens so many times in a weekend now that I'm beginning to question whether it's me or them.
I cannot decide if it's my technique, the owners unfamiliarity with medical topics, the owner's disinterest in medical topics, or the emotional distress most people are under when they visit the ER with a pet. Perhaps it's a combination of all of these things.
So, pet owners out there - answer me this: how can your veterinarian better serve you in the communications department? Currently, I give everyone an informational hand-out regarding their pet's particular disease process (as long as I have a fairly firm diagnosis and a hand-out). I also try to answer questions and pause during my explanations to ask if there are any questions. Still, people don't always seem to "get it."
What could your vet do to better communicate with you?
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DISCLAIMER
Any similarity between my stories and any person or animal, living or dead, is strictly a coincidence. Names, breeds, sexes, and details of the stories have been changed to protect the guilty and innocent alike.
About Me
- The Homeless Parrot
- I am an emergency veterinarian in North Carolina. Despite the crazy people I deal with, the awful cases of injured and sick animals, and the overall stress of emergency work, I absolutely love what I do. Happily married since I was 20, I have a wonderful husband who has a PhD in Mathematics, and a daughter around whom our world currently revolves. We also have a zoo living in our house that can be alternately wonderful and maddening. There are cats, parrots, and a dog who is very low on the totem pole. Our days are never dull and we are learning to balance the demands of work and family. If you'd like to contact me: homelessparrot@gmail.com
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Medical terminology
- Azotemia - elevation in kidney enzymes (BUN and creatinine) indicating dehydration, kidney failure, or urinary obstruction
- Lactate - a salt/ester of lactic acid that is produced as energy for a cell when oxygen levels are low. In critically ill animals, elevated lactate can be an indicator of inadequate blood flow to organs (perfusion), decreased delivery of oxygen, and/or decreased oxygen uptake. Values > 6-7 are usually considered to be poor prognostic indicators for survival.
- GI sloughing: when the cells lining the GI tract die (can be secondary to MANY things, including heatstroke) with resulting bloody diarrhea, bacterial translocation into the bloodstream and sepsis
- TTJ: transfer to jesus: code for when an animal needs to be euthanized or die
- DIC: disseminated intravascular coagulation: a very, very bad thing - when the hemostatic system gets out of whack, and clots start forming in the blood vessels until all clotting factors are wasted. once those are gone, internal hemorrhage ensues, followed by death, usually. also known as "death is coming"
- Pleural effusion - fluid contained in the pleural space (chest) - this is not the same as fluid in the lungs (see pulm edema) - in cats can be caused by infection in the chest, heart failure, cancer, FIP, feline leukemia, FIV, and in some cases, the cause is never found (idiopathic)
- Anisocoria - unequal pupil size (related to any number of causes including brain damage/head trauma)
- Laterally recumbent - lying on side, unable to rise
- Hyperglycemia - elevated blood glucose
- Hyperkalemia: elevated blood potassium - a life-threatening condition related to several disorders (kidney failure, antifreeze toxicity, urethral obstruction...etc)
- Sepsis - refers to a bacterial infection in the bloodstream or body tissues. This is a very broad term covering the presence of many types of microscopic disease-causing organisms.
- Nephrectomy - kidney removal
- Splenectomy - removal of spleen
- Pulmonary edema - condition in which fluid accumulates in the lungs, usually because the heart's left ventricle does not pump adequately ( can be caused by heart failure, electrocution, drowning, too many IV fluids, to name a few)
- Tick borne diseases - any of a myriad of diseases transmitted by ticks - including but not limited to Rocky Mtn Spotted fever, Lyme disease, Ehrlichia
- Fine needle aspirate - A method of sampling in which a needle is used to suck in cells or tissue bits for diagnoses (good for diagnosing masses/lumps)
- Blood glucose - The principal sugar produced by the body from food–especially carbohydrates, but also from proteins and fats; glucose is the body's major source of energy, is transported to cells via the circulation and used by cells in the presence of insulin (normal range in a dog/cat is 75-100)
- PCV - packed cell volume - the volume of packed red cells in milliliters per 100 ml of blood (normal range 35-45)
Diseases I see/treat frequently
- Dystocia - difficulty birthing. May be responsive to oxytocin administration (Pitocin, as in people) but may require c-section.
- DKA - diabetic ketoacidosis: the extreme end of the diabetic scale. A patient that is diabetic can develop DKA when other diseases make the blood glucose hard to regulate. Other diseases that are commonly associated include urinary tract infection, pancreatitis, pyometra, skin infection, and cancer. In DKA, the body starts metabolizing fat and producing acids that cause a drop in blood pH, nausea, weakness, severe dehydration, electrolyte derangments, and death.
- DCM - dilated cardiomyopathy: an idiopathic (cause unknown) cardiac disease in which the heart chambers become very thin/dilated, and cardiac output drops radically. Causes arrhythmias, tachycardia, and sudden death. Seen in large breed dogs like Dobermans, Great Danes, etc.
- Lymphoma - cancer of the white blood cells, the most common and treatable form of cancer in dogs
- Blocked cat - slang term for a male cat with a plug of mucus and crystals obstructing the urethra (fairly common in male cats) definitely a life-threatening because urine can't get out of the body! If present long enough, causes shock, acute renal failure, hyperkalemia (elevated potassium), coma, and death. Symptoms include straining in the litterbox, yowling while trying to urinate, producing small, bloody drops of urine (also symptoms of feline cystitis, a non-lethal condition)
- GDV - stands for gastric-dilatation and volvulus - a condition of large breed, deep-chested dogs (usually) in which the stomach rotates 180 degrees on its axis and thus - nothing can enter or leave, considered the "mother of all emergencies" - it warrants immediate surgery and carries a guarded prognosis
- IMHA - immune-mediated hemolytic anemia. A disease in which the immune system attacks the red blood cells and destroys them. It causes profound anemia and is life-threatening. Causes are primary (no known cause) and secondary ( tick borne disease, cancer, and heavy metal intoxication). Treatment is immunosuppression with drugs primarily. Prognosis is guarded at best.
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12 comments:
Maybe something like the "inverted pyramid" used in journalism would be useful. By this I mean leading with the most important information and filling in details after. So it might go something like "Fluffy has an obstruction and can't urinate. It's very good that you brought him here because this is fatal if it is not treated, but the good news is that this is a very treatable condition. We will have to sedate him and place a urinary catheter to relieve the obstruction. He will need to stay in the hospital with the urinary catheter and on IV fluids to support his kidneys for 2-3 days. When he goes home, he will need to be on a special diet to help reduce the risk of this happening in the future." Then you might go over the estimate and sedation consent forms and tell the client when s/he can expect to hear from you. Then you'll solicit questions. Hopefully what happens is that even if they have only a very superficial understanding of what is happening and why, at least there are no big holes in that understanding. I'm also a big fan of written handouts on common disease processes that clients can read at their leisure.
I think your experience is a very common one. I've certainly seen it many times. It's a tough conversation when you realize that a client expected that their pet's surgical fracture repair or laryngeal tieback surgery would mean he was instantly 100% fixed, especially when you're already several days post-op! On the other hand, I recently had a patient who'd had a leg amputated after being HBC and his family was very surprised when I said that in a few months he'd probably be back playing at the dog park and doing pretty much everything he could do before. Either no one had told them this, or more likely they didn't hear it. The dog is making great progress. I'm just glad the misunderstanding didn't cause his family to euthanize him or to try to save his horribly mangled leg.
Of course I can't answer your question :) But I will say that I think I still spend too much time in the exam room trying to explain things, trying have clients understand CHF, DKA, CRF, pancreatitis, etc, etc. Probably most of it is in one ear and out the other.... but I make myself believe that it makes a difference, at least for some of them.
I'm not sure there is anything you need to do differently other than break the information down into smaller units and speak slowly. People actually hear only 25-50% of what's spoken to them because they are thinking things like "OMG, what's that mean? Can I afford that? How's that gonna affect my schedule today? How dumb will I sound if I ask her to explain that, etc . . .? We spend most of our non-speaking time thinking about what we're going to say in response so . . . watch your clients' eyes for that glazed-over look, then expect the tech to relay the questions. I'm supposed to be a trained listener in my professional life and, even though I try my darndest to 'hear' everything the vet says and all the options she gives me, I find even I need for her to repeat things and I always end up with a question for the tech. Maybe it's also just human nature to filter out things we didn't really want to hear in the first place. Keep up the good work. VV
One thing I've always wished my vets would do is to write down what they're recommending. So after we go over "Fluffy has so-and-so, and I'd like to do XX diagnostics and then keep her overnight on fluids" for example, you'd hand them either a handwritten or printed-out summary of exactly what you just said. Sometimes I think people need time to process things, especially medical things they're not familiar with.
The handouts you're doing now sound great, maybe you can just write your recommendations/diagnosis etc. on the bottom before you hand it to the client.
My 0.02. :)
make sure to speak in english....medical terminology is intimidating. Make eye contact and ask them to look at you. If they are glancing away repeatedly, they aren't hearing you. Lower the volume of your voice so they have to actively work to hear you.
After 10 years of practice, I still spend time going over test results and treatment plans with clients. I write it all down in the medical record, then hand the client the carbon copy of the record. At the bottom of this sheet, I write a handful of major bullet points. My printing is legible, and large. I hand clients copies of test results, with notations and the interesting parts highlighted. I e-mail copies of radiographs. I give out well-written brochures and handouts when I can, preferably with color photos and diagrams. I try to remember: clients can be visual, auditory and tactile learners, and attempt to incorporate all three.
These efforts often seem to be in vain, though I feel a small stab of vindication when a client pages me after hours and I say: "do you have the sheet I gave you? what does it say; I don't have mine handy" (a lie; it's there in front of me). Frequent client responses?
1. "Ohhhhh..." (the most common)
2. "Twice a day? Does that mean in the morning and at night?"
3. "I wouldn't say he's painful, but he's been really uncomfortable since yesterday."
4. "I don't think it's infected, but you said to call if it's red or swollen. Oh, it's been draining pus and he's been limping since this morning; is that important?"
5. "I know you said to call if he wasn't better in 2 days, but he was getting better, then he wasn't, and now I think he might be better, but he's still not quite right, and do you really think he needs to be seen again? Can't I get more pills without paying for another exam?" (usually several months after initial appointment)
6. "I can't find it/spilled coffee on it/pet or child ate it. What did you say to do again?" (translation: client has ADD, or can't read, and I try to be understanding with these, much as I want to say "take your Ritalin!!!" to the first group).
Will be following the responses to your post for insight. It's a fascinating topic; after all, if your clients are like mine, they're capable of absorbing huge quantities of (usually erroneous) information obtained from the internet and various friends who attended one month of vet tech school before dropping out to breed dogs.
I like to ask some clients how much they would like me to explain (particularly about things like disease processes, how diagnostic tests work, etc.), especially if I can't get a feel for how much information they'd like from me. I feel like some clients want to know everything you can tell them about everything, whereas other clients don't really care about all the possibilities and just want you to get an answer for them and *then* explain the disease process, etc.
I also find pictures or drawings to be a huge help in some cases (hey, I'm on a neuro rotation currently and there are some things that I can't even figure out unless someone draws me a picture).
I have in some cases offered to do a follow up phone call the next day to discuss the issues more in depth, particularly if the client isn't tuned in at the moment for whatever reason (just got a bunch of bad news, is up in the middle of the night, wild children racing around the room, etc.). That's probably more feasible to do as a vet student than as a practitioner in the real world, though.
However, I still find communication to be one of the most difficult things in this field, and I'm sure it is something I will be struggling to continually improve throughout my entire career.
One thing I love about my vet is that he's blunt. I'll admit at first, I found it off-putting. He doesn't use long, convoluted medical terminology either. He puts is out there plain and simple.
Example: I tried to switch my dog from the prescription dogfood Urinary SO to a high protein, OTC one. When my dog (who has Cushings among other things) got really sick, I had to tell my vet what I'd done.
My Vet: Are you trying to kill your dog? If you are, then excess protein will do it. Look at this (points to chart). This is on the SO. It's high-normal. And this is now. (Holds my gaze). I prescribe things for a reason.
My vet has NO bedside manner, no patience, and undoubtably pisses a lot of people off. But he's saved several of my pets lives, helped ease my 16 YO Border Collie into passing, and I've been with him 12 years now. Until he retires, I'll stay with him because the man knows what he's doing.
Granted, this won't work for everyone. In my case, I value his knowledge and true dedication to my pets' welfare over his personality.
In an emergency situation it's almost like all bets are off in what people take in. One of the best things you can do is to frame your questions in ways the owners have to answer with more than a yes or no..
The thing with questions is people often don't know enough about the situation to know what questions to ask. Hand out are good, it often gives people a place to start.
I find my vet uses a lot of medical terminology that I'm not usually familiar with & I'm not even sure she knows when she does this. I think the advice to write things down is great, using handouts with diagrams is great & consider the different learning styles that people have. Being concise & direct is also a good strategy. It's easy to confuse people with too much info.
I also think asking them questions to see if they understand can help. For example, "Will your schedule allow you to give this medication 3 times a day? Do you know what symptoms to look for?". Things that will indicate to you whether the message was received or not.
Well I could tell you a horror story about how NOT to communicate, but it'd take for ever to type, so lets go with this: when my older cat developed pacrititus (yah, spelled it wrong sorry) during the ID and followups my new vet took the extra minute to explain, with small words, why she was doing the tests she was doing, and what the test results were, AND what the numbers should have been. Now I have a college education, but I appreciated the simple explanation. It didn't take a ton of extra time, but it ment I had a clue how to explain it to my husband when I got home.
As for the horror story....lets just say that tellng me "I'm the vet, and I went to school for this" isn't a good way to win me over, especially when I already disagree with you!
My pet vet speaks very slowly, he has a Southern accent and a low voice, and is very very very thorough. (ie, takes FOREVER)He is like Mr. Rogers only slower and with a drawl. We actually joke about it at home, who has an hour to talk to Dr. M on phone? But he is good, gentle, and patient, with our 4 leggeds and with us. Worth his weight in gold. He is also in his late 50s, and has been there and done that, and has the spiel, to tell his patient's owners about it, in detail. Slow is good. I have found as a physician, sitting down is good if the patient is on a stretcher/ family sitting down. But hand outs are priceless, particularly for instructions.
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