A guide to oral communication in veterinary medicine

THE EMERGENCE OF CLINICAL COMMUNICATION AS A 2.1 Connectivity and the Provider–Patient Relationship 28 2.2 Past Assumptions about Relationship-Centered Care 29 2.3 Challenging Past As

A GUIDE TO

ORAL COMMUNICATION

IN VETERINARY MEDICINE

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Book layout by Toynbee Editorial Services Ltd, Great Easton, UK

Printed by Replika Press Pvt Ltd, India

Photos by the author unless otherwise indicated

Contents

CHAPTER 1 WHAT DO OUR CLIENTS UNDERSTAND?

THE EVOLUTION OF THE DOCTOR–PATIENT RELATIONSHIP,

1.1 The Development of Medical Paternalism 4

1.2 The Limitations of Medical Paternalism 6

1.3 The Evolution of Relationship–Centered Care 7

1.4 The Modernization of Medicine Drives Relationship–Centered

1.5 The Concept of Health Literacy 10

1.6 How Do Health Literacy and Relationship–Centered Care

CHAPTER 2 HOW CAN WE HELP OUR CLIENTS TO UNDERSTAND?

THE EMERGENCE OF CLINICAL COMMUNICATION AS A

2.1 Connectivity and the Provider–Patient Relationship 28

2.2 Past Assumptions about Relationship-Centered Care 29

2.3 Challenging Past Assumptions 29

2.4 The Kalamazoo Consensus Statement and Relationship-Centered

2.5 The Changing Face of Medical Education 32

2.6 The Changing Face of Veterinary Education 33

2.7 Communication as a Teachable Skill 36

2.8 Present-Day Challenges Associated with Teaching

2.9 The Future of Communication Training in Veterinary Curricula 42

CHAPTER 3 HOW CAN WE STRUCTURE THE CONSULTATION FROM THE

VANTAGE POINT OF CLINICAL COMMUNICATION?

THE CALGARY–CAMBRIDGE GUIDE AS A BLUEPRINT FOR A

3.1 The Shift from Medical Paternalism to Relationship-Centered Care 49 3.2 Relationship-Centered Care in Veterinary Medicine 50

3.3 The Development of Consultation Models 50

3.4 The Calgary–Cambridge Model 53

3.5 The Revised Calgary–Cambridge Model for Veterinary Patients 57 3.6 Limitations of Consultation Models 58

4.1 Our Journey through Healthcare as Consumers 67

4.2 The Veterinary Client’s Experience 69

4.3 Starting the Client’s Journey off on the Right Foot 69

4.4 Prep Work May Seem Silly, But … 70

4.5 Greeting the Client: What the Veterinary Team Can Learn from

4.6 Greeting the Veterinary Client: Finding Common Ground 74

4.7 Attending to the Client’s Comfort 78

4.8 Acknowledging and Attending to the Patient 80

CHAPTER 5 DEFINING ENTRY-LEVEL COMMUNICATION SKILLS:

5.1 Introduction to Reflective Listening 86

5.2 Clinical Conversations, Defined 87

5.3 Why Should Healthcare Providers Listen? 87

5.4 Why Is Effective Listening such a Difficult Task? 88

5.5 Active or Reflective Listening, Defined 89

6.4 The Impact of Empathy on Case Outcomes 103

6.5 Empathy versus Sympathy 104

6.6 The Human–Animal Bond Creates Opportunities for Empathy

6.7 The Dangers of Making Assumptions about Client Emotions 106

6.8 When Might Clients Become Emotional? 106

6.9 The Challenges Associated with Empathetic Displays in

6.10 Displaying Empathy through Actions in Clinical Practice 109

6.11 Displaying Empathy through Words in Clinical Practice 109

6.12 The Potential Dangers of Empathy in Clinical Practice: the

6.13 The Potential Dangers of Empathy in Clinical Practice: the

6.14 The Decline of Empathy? 113

CHAPTER 7 DEFINING ENTRY-LEVEL COMMUNICATION SKILLS:

7.1 The History of Nonverbal Cues in Clinical Conversations 123

7.2 The Importance of Nonverbal Cues in Clinical Conversations 124

7.3 What Contributes to Accuracy in Judgment Making Based

7.4 What Are Nonverbal Cues? 125

7.10 When Words and Nonverbal Cues Do Not Align: How to

7.11 Nonverbal Skills Development 143

CHAPTER 8 DEFINING ENTRY-LEVEL COMMUNICATION SKILLS:

8.1 The Comprehensive Patient History 149

8.2 Why is it Critical to Elicit the Patient’s Concerns? The Human

8.6 The Art of History Taking: Introducing Two Styles of Questioning 155

8.7 Closed-Ended Questions, Defined 156

8.8 The Open-Ended Question or Statement 159

8.9 Is there a Place for Both Open- and Closed-Ended Questions? 163

8.10 Client Preferences for Open-Ended Questions Based upon

CHAPTER 9 DEFINING SUPPLEMENTAL COMMUNICATION SKILLS:

9.1 Defining Medical Jargon 170

9.2 The Limitations of Medical Jargon: the Provider’s Perspective 170

9.3 The Limitations of Medical Jargon: the Patient’s Perspective 173

9.4 Easy-to-Understand Language Implies Transparency 178

9.5 Implications for the Veterinary Medical Profession 179

9.6 Strategies for Overcoming the Use of Medical Jargon 181

CHAPTER 10 ENHANCING RELATIONSHIP-CENTERED CARE THROUGH

10.1 The Shift towards Partnership 191

10.2 Are Veterinary Clients Experts? 192

10.3 Setting the Stage for Relationship-Centered Care 193

10.4 Establishing Partnership with the Client 194

CHAPTER 11 ELICITING THE CLIENT’S PERSPECTIVE TO ENHANCE

11.1 Phrases that Effectively Elicit the Client’s Perspective 203

11.2 Softening These Phrases 204

11.3 What Happens When We Do Not Use This Skill 205

CONTENTS

11.5 Eliciting the Client’s Perspective Also Helps Clients Open Up

CHAPTER 12 ASKING PERMISSION TO ENHANCE RELATIONSHIP-CENTERED

12.1 Incorporating Permission Statements into Clinical Scenarios 213

12.2 What if the Client Doesn’t Say “Yes”? 214

12.3 Alternative Phrasing of “May I?” 215

12.4 Other Clinical Scenarios that Benefit from Asking Permission 216

12.5 The Clinical Importance of Asking for Permission among

CHAPTER 13 ENHANCING RELATIONSHIP-CENTERED CARE BY ASSESSING

13.1 What Happens When We Do Not Assess the Client’s Knowledge? 227

13.2 Revisiting the Same Scenario to Assess our Client’s Knowledge 228

13.3 Other Reasons to Assess our Client’s Knowledge 229

13.4 Assessing Knowledge Is Respectful 230

CHAPTER 14 MAPPING OUT THE CLINICAL CONSULTATION:

14.1 Defining the Consultation Map 234

14.2 Using Signposting to Outline Differentials 236

14.3 Using Signposting to Discuss Treatment Plans 236

14.4 Using Signposting to Rein in a Chatty Client 237

14.5 Using Signposting to Preface Actions, Such as Reviewing the

CHAPTER 16 COMMUNICATION SKILLS THAT FACILITATE COMPLIANCE:

16.1 Defining “Contracting for Next Steps” 263

16.2 Examples of Contracting for Next Steps in Clinical Practice 265

16.3 Contracting for Next Steps Tells the Client What to Expect 267

16.4 Contracting for Next Steps Reinforces Our Role in Patient Care 268 16.5 Modifying How Contracting for Next Steps Is Phrased 268

16.6 Be Prepared for the Client to Say “No” to the Initial Plan 269

17.1 The Value of Agenda-Setting 273

17.2 The Final Check-In as a Relationship Builder 276

17.3 Pairing the Final Check-In with Appropriate Nonverbal Cues 276 17.4 What If the Client Does Not Stop Talking? 278

CHAPTER 18 DEFINING TWO NEW SKILLS THAT COMPANION-ANIMAL

CLIENTS VALUE:

COMPASSIONATE TRANSPARENCY AND UNCONDITIONAL

18.1 What Is Transparency in Healthcare? 285

18.2 Barriers to Transparency in Healthcare 286

18.3 Transparency in Veterinary Medicine through Words 287

18.4 Transparency in Veterinary Medicine through Actions 288

18.5 Veterinary Clinical Scenarios that Involve Transparency 288

18.6 Example of a Situation that Would Have Benefited from

18.7 Unconditional Positive Regard in Healthcare 290

18.8 Unconditional Positive Regard in Veterinary Medicine 291

18.9 Veterinary Clinical Scenarios that Involve Unconditional

CHAPTER 19 USING COMMUNICATION SKILLS TO INITIATE THE

19.1 Preparing for the Visit 300

19.2 Developing Rapport 303

CONTENTS

CHAPTER 20 USING COMMUNICATION SKILLS TO GATHER DATA:

20.1 Taking a Complete History at a Wellness Appointment 313

20.2 Taking a Complete History at a Sick Visit 318

CHAPTER 21 USING COMMUNICATION SKILLS TO GATHER DATA:

21.1 Explaining Physical Examination Findings in an Apparently

21.2 Explaining Physical Examination Findings in an Ill Patient 331

21.3 Forward Planning 335

21.4 Planning Next Steps in an Apparently Healthy Patient 336

21.5 Planning Next Steps in an Ill Patient 341

COMMUNICATION SKILLS IN VETERINARY

Exercise 23.1 – Defining Communication Skills I 359

Exercise 23.7 – Converting Closed-Ended Questions into Exercise 23.8 – Converting Open-Ended Questions into

Exercise 23.2 – Defining Communication Skills II 360

Exercise 23.3 – Examples of Communication Skills in Use I 361

Exercise 23.4 – Examples of Communication Skills in Use II 362

Exercise 23.5 – Open- vs Closed-Ended Questions I 363

Exercise 23.6 – Open- vs Closed-Ended Questions II 364

Exercise 23.9 – Reflective Listening I 367

Exercise 23.10 – Reflective Listening II 368

Exercise 23.11 – Empathy I 370

Exercise 23.12 – Empathy II 372

Exercise 23.13 – Nonverbal Cues 374

Exercise 23.14 – Barriers to Communication 374

Exercise 23.15 – Reducing Barriers to Communication 375

Exercise 23.16 – Body Language and Communication I 375

Exercise 23.17 – Body Language and Communication II 376

Exercise 23.18 – Medical Jargon I 377

Exercise 23.19 – Medical Jargon II 378

Exercise 23.20 – Medical Jargon III 379

Exercise 23.21 – Medical Jargon IV 380

Exercise 23.22 – Medical Jargon V 381

Exercise 23.23 – Medical Jargon VI 382

Exercise 23.24 – Partnership 383

Exercise 23.25 – Eliciting the Client’s Perspective 384

Exercise 23.26 – Assessing the Client’s Knowledge 385

Exercise 23.27 – Signposting I 386

Exercise 23.28 – Signposting II 386

Exercise 23.29 – Signposting and Transparency 387

Exercise 23.30 – Putting It All Together 388

Scenario 25.1: Greeting the Client at a Wellness Visit I 410

Scenario 25.2: Greeting the Client at a Wellness Visit II 410

Scenario 25.3: Greeting the Returning Client I 410

Scenario 25.4: Greeting the Returning Client II 411

Scenario 25.5: Taking a Clinical History at the Wellness Visit

Scenario 25.6: Taking a Clinical History at the Wellness Visit

Scenario 25.7: Taking a Clinical History at a Sick Visit – Feline I 413

Scenario 25.8: Taking a Clinical History at a Sick Visit – Feline II 414

Scenario 25.9: Taking a Clinical History at a Sick Visit – Canine I 415

Scenario 25.10: Taking a Clinical History at a Sick Visit – Canine II 416

Scenario 25.11: Explaining Physical Examination Findings

Scenario 25.15: Explaining Radiographs I 423

Scenario 25.16: Explaining Radiographs II 424

CONTENTS

Scenario 25.18: Explaining Radiographs IV 427

Scenario 25.19: Explaining Bloodwork I 428

Scenario 25.20: Explaining Bloodwork II 429

About the Author

Ryane E Englar, DVM, DABVP (Canine and Feline Practice) graduated from Cornell

University College of Veterinary Medicine in 2008 She practiced as an associate

veterinarian in companion animal practice before transitioning into the educational

realm as an advocate for pre-clinical training in primary care She began her debut

in academia as a Clinical Instructor of the Community Practice Service at Cornell

University’s Hospital for Animals She then transitioned into the role of Assistant

Professor as founding faculty at Midwestern University College of Veterinary Medicine

While at Midwestern University, she had the opportunity to work with the inaugural

Class of 2018, the Class of 2019, and the Class of 2020 While training these

remark-able young professionals, Dr Englar became a Diplomat of the American Board of

Veterinary Practitioners (ABVP; Canine and Feline Practice) She relocated to Kansas

State University in May 2017 to design and debut the Clinical Skills curriculum She is

currently on faculty at the University of Arizona College of Veterinary Medicine Her

research areas of interest include clinical communication and educational outcomes

Dr Englar is passionate about advancing education for generalists by thinking outside

of the box to develop new course materials for the hands-on learner This labor of love

is preceded by three texts that collectively provide students and clinicians alike with

functional, relatable, and practice-friendly tools for success:

• Performing the Small Animal Physical Examination (John Wiley & Sons, Inc., 2017)

• Writing Skills for Veterinarians (5M Publishing, Ltd., 2019)

• Common Clinical Presentations in Dogs and Cats (John Wiley & Sons, Inc., 2019)

Dr Englar’s students fuel her desire to create They inspire her to develop the tools that

they need to succeed in clinical practice If the goal of educators, as they are tasked by

the accrediting bodies, is to create “Day One”, so-called “Practice-Ready” veterinarians,

then this text and her others complement the mission

When she is not teaching or advancing primary care, she trains in the art of ballroom

dancing and competes nationally with her instructor, Lowell E Fox

Preface

People are curious about our profession It is why conversations about who we are and

what we do follow us wherever we go: on buses or planes, boats or trains, whether travel

is national or abroad Our seatmates seem compelled to ask about our professional lives

Animal Planet enthusiasts want to know if everything they see on television is real

They ask if there are really dog cardiologists and cat eye doctors, and if it’s true that hip

replacements can be performed on alpacas

Fans of Gray’s Anatomy and The Good Doctor often ask how we stomach the blood

and gore of emergency medicine, trauma, and surgery They are inspired, yet intimidated

that veterinarians can wear so many hats to be so many things for so many people

Those who are aware that mental health issues plague our community often inquire

about our physical and emotional wellbeing They ask how we find balance between

bringing our patients into this world and taking them out of it They thank us for our

service They ask us what we need

Others do not recognize that rain precedes rainbows, and ask only what it is like

to play with kittens and puppies all day I used to cringe, but now I see it as a learning

opportunity to provide a more accurate frame of reference for the professional identity

that we wear on our sleeves, right alongside our hearts

From this rather eclectic mix of questions, typically one theme emerges

Non-veterinary acquaintances often ask what propelled me to become a veterinarian Their

quest to understand me and my career aspirations often ends with a variation of this

sentiment:

“Why didn’t you become a human doctor?” they ask “Don’t you like people?”

The answer is shockingly simple, yet it often surprises my audience: “Yes Yes, I like

people.”

It is not at all what they were expecting to hear

In truth, to be a successful veterinarian, you have to like, care about, and respect

people Your patients are attached to owners Your owners will come to your door with

past life experiences, personalities, and perspective

You will never have the opportunity to get to know, medically manage, operate on,

treat, or cure animals unless the person who is tethered to the other end of the leash or

travel carrier seeks out you and your services

Veterinary education emphasizes how to treat animal patients – and rightly so You

can-not be a proficient clinician unless you understand the animal body, in health and disease

You cannot be a competent surgeon unless you commit your mind and muscle memory to

learning anatomic landmarks, instrument ties, and gentle tissue handling skills

Yet, in reality, you cannot take any of these actions without client consent In the

poker game of life, your clients hold the cards They determine whether to play (commit

to care), hold (consider care), or fold them (decline care altogether) In the absence of

financial constraints, how you treat your patients’ people determines the level of care

that you and your team can provide

Client communication is essential both to the delivery of high quality medicine and

to the success of veterinary practice Today’s clients come armed with knowledge and

questions They have access to information at their fingertips that their parents and their

grandparents never had They have formulated their own opinions and ideas They have

insight and intuition

We may be the expert in the consultation room about medicine, but they are the

experts about their pets Nothing can be accomplished in terms of healthcare unless we

take active measures to deconstruct this artificial divide

We should not fear that our client is perhaps our best resource Our role as educator

is antiquated only if we let it be, that is, if we expect to be the “sage on the stage” and

assume that our client has nothing to offer us

Quite the contrary, our client holds the key to patient outcomes Much of whether a

patient’s health status improves depends upon client compliance and adherence to our

recommendations There must be client “buy-in.” We lose both “buy-in” and our

cred-ibility the moment we fail to see common ground (the wellbeing of the pet) and fail to

engage the client in shared decision making

The era of relationship-centered care has only just begun It is not going away The

fact that pet care is in many ways client-driven challenges us as professionals to partner

with “pet parents” to effect change Our ability to manage patients’ healthcare rides on

our willingness to listen and communicate, both of which are teachable skills

Communication drives relationships and connectivity It builds client loyalty and

encourages client retention It creates a safe and supportive environment for client

inter-actions with the veterinary team A client who feels respected is more likely to exhibit

transparency with information-sharing, or ask questions about treatment options

When there is dialogue, there is hope for mutual understanding

Dialogue may not always lead to agreement or perfect outcomes, but it forges a bond

that communicates, “I am here, and I am listening Help me to help you help your loved

one.”

Communication drives action as much as it drives relationships Communication is

how we accomplish all that we do Patient care is only as effective as we can convey its

value, through words and non-verbal cues

Communication is therefore not just an art or “soft science.” Communication is not

something you are either born with or without Communication is not just a nicety or

an added bonus

Communication is an evidence-based discipline that our clients depend upon in

order for them to have what they need to make educated decisions

For that reason, communication is a job requirement as much as the capacity for

PREFACE

It behooves us to learn how to be better speakers so that, at the end of the day, we can

be better people to other people who have called upon us What they need is precisely

what we can give, but only if we can effectively communicate our desire to help them

experience, sustain, and nurture companionship

Our clients do what they do, not in spite of this bond, but because of it, each day,

every day, all so that they might come to know the love of a dog or the love of a cat

That love and humanity speaks to us, as veterinarians

It’s our responsibility to learn how to speak back

Dedication

I live and dream in photographs I work best when I am surrounded by them I smile

when I look at the faces of those who mean so much, and they smile back at me I

trea-sure them all as snapshots in time, moments that I never want to forget, as if I ever could

I hold onto my photographs as tightly I hold onto hope They remind me of good times,

happy times, peaceful times, and younger times

Yet, does time ever really stand still? Can a single photograph ever stop the clock

between what once was, what is, and what will be? Every yesterday and every past

relationship collectively set the stage for who we are today, just as every today prepares

tomorrow’s you for the path that lies ahead

Albert Einstein was once quoted as saying:

The distinction between the past, present, and future is only a stubbornly persistent

illusion

He was right Past, present, and future blend into one another in the same way that a

stream meets a river that meets the sea

In the timeline of life, the past, present, and future create a perfect path for the

imper-fect journey: they are so intimately associated that they forever bind us to one another,

to places and faces, to connections that, once made, will always be People may move

on Geography may change Relationships may end

At the end of the day, we are a product of every experience, every memory, every

bond, and every life that came before us, just as we in turn become the foundation for

the lives that follow ours In that way, the circle of life becomes the circle of meaning

Time reminds me that nothing is permanent and nothing is forever Rather, experiences,

people, and places are fluid They can change They can evolve

Change can be scary at times But change is what keeps us alive It is what keeps our

heart beating and our lungs breathing It keeps us yearning for the next chapter It keeps

us honest and humble

Change makes all things possible Dreams Goals Aspirations

And just like that, in the blink of an eye, days pass So, too, do weeks, months, and

years until one day we see the Bigger Picture Like a climber who stands tall at the

mountain’s summit, seeing the world through a whole new lens for the very first time,

we realize what and who this life is all about, what and who we live for

We are forever shaped – and changed – by those with whom we surround ourselves

In the spirit of coming to that realization, it is only fitting that I dedicate this text to

key faces from my past, present, and future – not because they are distinct entities, but

because their memories co-exist in the moment that is the here and now, where they

thrive inside of me

In honor of the Past, I dedicate this text to my beloved maternal grandmother,

Doris Buchanan

Grandma was one of my favorite cheerleaders in life

She saw in me what I hoped to convey to the world,

at my very best: my passion for medicine, my

com-mitment to science, and my perseverance to power

through the obstacles to get to the Other Side She

called me her “shining star” because she saw

poten-tial in me, long before I chased after the very same

opportunities that would one day chase after me

Thank you, Grandma, for being among the first

to transform my world, my present and future, by

teaching me to replace the question, “Can I?” with

the statement, “Yes, I can.”

In honor of the Present, I dedicate this text to my parents, Jill and Richard Englar

My mom is the most selfless person that I know For

as long as I can remember, she has put the needs of

others before her own Whether through her work

as a licensed and certified social worker in Hospice

or her concurrent career as a parent for life, she has

taught me the importance of responsibility,

establish-ing ties, engagestablish-ing in dialogue, makestablish-ing connections,

building bridges, and giving back to the community

Mom has also been the gold standard communicator

for my entire life As a child, I didn’t always have the

words to speak my mind I was quiet and introverted

I thought more than I spoke Yet Mom was always

there to encourage and nurture She gave me the

time and space to develop into my own person, one

that I wanted her to be proud of As I have matured, I

DEDICATION

have come to see that Mom’s strength of character comes from the power to wield words

in a positive way and to deliver them responsibly, with good intent More than that, she

is a trailblazer, forever reminding me to be unafraid of the path less taken

Thank you, Mom, for everything It was from you that I learned to be me

My dad is an educator whose love of teaching inspires me As a department chair for

social studies, he has also painted a realistic picture of effective leadership, and defined it

in a way that I respected from the start He showed me by example that it was possible to

lead with a gentle nature rather than an iron fist His perspective on office infrastructure,

management, and business relations has been invaluable as I transition through various

roles and phases in academia As I age, I would like to think that I take after him in the

classroom, both in terms of energy level and creativity in terms of thinking outside the

box

Thank you, Dad, for your work outside of the classroom, too I appreciate you

stand-ing in as my second set of eyes to review each and every textbook draft before it goes to

print, no matter what length Somehow, you always manage to make deadline and catch

that one mistake that would have gnawed at me for a lifetime

In honor of the Future, I dedicate this text to my one and only niece, Beatrix Rae

Englar-Green

At the time that this text goes to print, Bea is the ripe

age of three years young Technology allows me to

visit with her more frequently, from afar, and with

every phone call, I see her developing into a

beau-tiful person There is no other smile like hers – and

no other laugh, too She is a burst of energy, and a

ray of sunshine She is a bold investigator with an

active mind, amazing hand-eye coordination, and a

refreshing sense of genuineness that is so often lost in

adulthood I see that spark in her eye, and it makes me

happy Happy to see her so full of life and living life

as it was intended: joyful and free, exuberant and fun

Bea represents the future that we all hope for, for

our little ones A future filled with opportunity, where

she can flourish in any activity she sets her mind to,

in a world where she can truly do anything and be

anyone

Thank you, Bea, for bringing out the kid in all of us, and for reminding me that it’s

okay to finally live a little, to have a laugh, and have some fun

Acknowledgments

As youth, we are heavily influenced by what and who others think we should be

Adulthood may lessen the hold that others have over us, yet those we care for as we

mature continue to shape our identity and sense of self-worth

If someone you greatly esteem tells you that you are capable, then you are apt to

believe it If, on the other hand, someone tells you that you cannot do “X” or achieve

“Y,” then you reach the proverbial fork in the road, where you can go one of two ways

Either you are driven into action to prove him wrong, or you allow yourself to be crushed

by the weight of another’s failure to believe in you

I wish I could say that I was the bold and daring adventurer who marched to the beat

of my own drum and didn’t care what other people thought But the truth is that I was

far less adventurous then, as I am now, and those were the days long before I channeled

my inner Katniss Everdeen The truth is I held onto every word that others spoke of me

Reflecting back upon those days, it strikes me as how fortuitous, how blessed I was to

be surrounded by goodness and warmth, those who wished to buoy me up rather than

pull me down

Outside of my nuclear family, who has always loved and accepted me, I have always

looked up to educators Maybe it was because my father was a teacher and his colleagues

became family Maybe it’s because I was a bookworm For as long as I can remember,

knowledge has always fascinated me Others may have dreamed of power or status or

some fantasied superhero trait But in my imaginary world, I did not need a cape to fly

from Point A to Point B I just needed to think myself there

As a child, my imagination was my greatest skill I dreamed dreams into goals and

goals into action plans When I said at age five that I would be a veterinarian, I truly

meant it with every fiber of my being I was convinced that I could will it into reality My

professional conviction wasn’t just a phase, spoken by a stubborn, strong-willed child

It was a reflection of what I had heard all along, beginning at home and continuing into

the classroom: You can do and be anything

Lady Bird Johnson once said it best: “Children are likely to live up to what you believe

of them.” Others believed that I could, and so I did

During my formative years, I was blessed with great mentors They may have been

paid to teach me a subject, which each did, masterfully, in his own way But more

import-ant than book learning were the lessons that each one taught me about life At this time,

I would like to acknowledge five teachers who have been invaluable to my evolution as

a person and individual, scientist and doctor

On paper, Mr Dean Curtis taught me junior high math and science

In actuality, his life lesson to me was not to stifle

imag-ination and to follow your dreams, even if yours are

different than most

I used to think great teachers inspire you Now I think I had it wrong Good teachers inspire you;

great teachers show you how to inspire yourself every day of your life They don’t show you their magic They show you how to make magic of your own ~ Alfred Doblin

At that time, there were no interactive teaching videos

and the internet was only a fraction then of what it is

today Learning about cells on paper did not interest me I did not understand ribosomes

or mitochondria unless they were tangible concepts that I could grasp in my own two

hands So, I asked him if I could create a three-dimensional model of a cell Whereas

most people would have looked at the kid that I was then and said, “Why?” with disdain

or disbelief, he said “Why not?”

That same imagination served me well at recess While most of my classmates were in the

courtyard playing dodgeball, I was busy mapping the trajectory of boomerangs Little did I know

then that the boomerang of my childhood would later become an analogy for life Mr Curtis

once said something to the effect of that no matter where you go in life, no matter how high,

no matter how far, what matters is that you return, to your roots, to who and what you know

On paper, Mr Joseph Harris taught me high school inorganic chemistry

In actuality, he gave meaning to the Kreb’s cycle He

made learning about carbon chains fun He also inspired

me to consider how functional groups of medicinal

compounds were the key to their pharmacodynamic

and pharmacokinetic effects

Great teachers engineer learning experiences that put students in the driver’s seat and then get out of the way ~ Ben Johnson

This foundation in clinical science prompted my

inter-est, years later, in drug solubility, mechanism of action,

route of administration, metabolism and elimination, all

of which helped me to steer patient care towards solutions that would be most effective

ACKNOWLEDGEMENTS

On paper, Dr Bruce Currie taught me AN SCI 100 (Domestic Animal Biology) during my first semester of undergraduate study at Cornell University, within the

College of Agriculture and Life Sciences (CALS)

In actuality, he inspired new ways of thinking

The best teachers are those who show you where to

look, but don’t tell you what to see ~ Alexandra K

Trenfor

As part of our coursework, we managed Ezra’s Farm, an

on-campus, student-run barnyard, to immerse ourselves

in animal husbandry We got out of the opportunity

what we put into it Dr Currie provided the experience

of a lifetime for citified students like me, who had never

bottle-fed calves or stood knee-deep in pigsties During

those early morning shifts, I learned how to make

con-nections between the basic and clinical sciences I never again looked at an animal in

quite the same way Before Ezra’s Farm, my vision was superficial: when I saw a cow,

I saw a cow I couldn’t relate its movement to its structure Ezra’s Farm taught me how

to translate structure into function in a way that would benefit my patients for years to

come

On paper, Dr Abraham Bezuidenhout taught me Block 1 (The Animal Body) during my first semester of graduate study at Cornell University College of Veterinary

Medicine

In actuality, he blended rigor, proficiency in patient

care, compassion for humanity, and zest for life

Ideal teachers are those who use themselves as

bridges over which they invite their students to cross,

then having facilitated their crossing, joyfully

col-lapse, encouraging them to create bridges of their

own ~ Nikos Kazantzakis

Dr B pushed me harder than ever before Initially, he

was intimidating, and he did not hold back He said

what he wanted to, when he wanted to, in perfectly

con-structed, direct and formal statements When he called

upon you in class or in laboratory, you were expected to know the answer You studied

extra hard in his class because you had to But you also studied extra hard because, at

the end of the day, you did not want to let him down

Dr B’s greatness as an instructor was that he gave you the blueprint to build wings,

but he expected you to create them, for yourself, if you wanted to fly Answers were not

dispensed with ease and convenience Lessons were earned At the beginning, I thought

he was just making things harder for us I didn’t know then what I do now He ignited

our potential He gave us a shoulder to lean on and a stepstool to take that first leap in

the right direction But it was up to us to rise to the challenge, complete the climb, reach

unforeseen heights, and stretch ourselves beyond our wildest dreams Dreams were all

well and good, but dreams didn’t earn titles, accomplishments, or accolades Hard work

and sweat did

On paper, Lowell E Fox continues to teach me the art of American Smooth, International Standard, American Rhythm, and Latin dance

But were it not for his love of science and evidence-based

medicine, I do not know if I could have excelled at

either

A great teacher never stops being a student ~ Jeffrey Benjamin

Lowell’s mind is always in motion I see the wheels

turn-ing in his mind every time he circles the dance floor

Just as he steps deliberately, with posture and poise, his

mind is sharp with purpose It sifts through details that

sharpen his understanding of those who he trains

Lowell studies his students in the same way that we

study dance: methodically He learns what each of us needs in order to succeed He

was the first to link dance to veterinary medicine in a way that made sense to me He

connected leg crawls in dance to grasshoppers, and pivots to marine life He talked to

me about microglia and compared walking actions to diabetic neuropathy He lit a fire

in me about dance because he made it relatable The science fact of the day became a

staple of our lessons He also wasn’t afraid to learn from me

Lowell learned how I measured success, in dance and in life He redefined for me

that success is not always about the perfect outcome It’s about learning how to channel

fear of the unknown into directed and deliberate action It is about recognizing that

sometimes what we think are dead ends are really just new beginnings, and that even

light can come from dark Even to this day, Lowell reminds me to push myself to reach

new limits – and to break through them

ACKNOWLEDGEMENTS

All five of these teachers influenced who I am today In return, I do what I can to pay it

forward

I do not know what my teaching legacy will be

I do hope that what my students glean from me is to live life fully, without regret, so

that they are never haunted by “What If?” So that, instead, they can say they tried to live

and they lived to try

If they try, they may or may not succeed But if they never try, then they will never

know how it all was supposed to turn out

About the companion website

Please visit the companion website to this book at this link:

https://www.5mbooks.com/communication-videos

The website gives access to 19 supplementary videos, which are signalled with the extra

online content icon at relevant points in the text These short videos capture different

communication skills that can be effectively interwoven throughout the consultation,

and incorporate good and bad points of practice As such, they are ideal training

mate-rials for young vets and vets new to practising in the UK and USA They are also a great

refresher for established vets who may want to brush up on skills that can round out their

communication style

The videos have been produced in partnership with the US-China Center for Animal

Health at Kansas State University Ryane Englar, DVM, DABVP (Canine and Feline

Practice) presents each episode Dr Englar is the author of Writing Skills for Veterinarians

published by 5m Publishing, as well as the forthcoming book, The Veterinary Workbook

of Small Animal Clinical Cases

The following subjects are covered:

• Greeting Your Client

• Assessing the Client’s Knowledge

• Mapping Out the Consultation

• Sectioning the Conversation into Bite-Size Chunks

• Contracting for the Next Steps

• Final Check-In

• Compassionate Transparency

• Unconditional Positive Regard

• Summarizing

Acronyms

AAHA American Animal Hospital Association

ACGME Accreditation Council for Graduate Medical Education

AKI acute kidney injury

BUN blood urea nitrogen

CCG Calgary–Cambridge Guide

CDC Centers for Disease Control and Prevention

CE continuing education

CHF congestive heart failure

CKD chronic kidney disease

CPA cardiopulmonary arrest

CPR cardiopulmonary resuscitation

CVO College of Veterinarians of Ontario

DKA diabetic ketoacidosis

EMRs electronic medical records

FeLV feline leukemia

FIV feline immunodeficiency virus

HWD heartworm disease

ICCVM International Conference on Communication in Veterinary Medicine

IHC Institute for Healthcare Communication

IRIS International Renal Interest Society

MRI magnetic resonance imaging

NAVMEC North American Veterinary Medical Education Consortium

OSCE objective structured clinical examination

OVC Ontario Veterinary College

URI upper respiratory infection

USG urine specific gravity

UTO urinary tract obstruction

Part I

Clinical Communication as an

Integral Part of the Veterinary

Profession

Chapter 1

What Do Our Clients

Understand?

The Evolution of the Doctor–Patient

Relationship, Patient Autonomy, and

Health Literacy

The physician–patient relationship was conceptualized in the writings of Hippocrates, who

was credited with authoring the Oath that to this day continues to be recited, in modified

form, at commencement ceremonies for graduating doctors of innumerable disciplines.(1)

This Oath has undergone multiple transformations, yet the Oath in its original state

set the stage for a tradition of paternalism in the practice of medicine.(2)

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods

and goddesses, making them my witnesses, that I will fulfill according to my ability

and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in

partnership with him, and if he is in need of money to give him a share of mine, and

to regard his offspring as equal to my brothers in male lineage and to teach them this

art – if they desire to learn it – without fee and covenant; to give a share of precepts

and oral instruction and all the other learning to my sons and to the sons of him who

has instructed me and to pupils who have signed the covenant and have taken an

oath according to the medical law, but to no one else

I will apply dietetic measures for the benefit of the sick according to my ability and

judgment; I will keep them from harm and injustice

I will neither give a deadly drug to anybody if asked for it, nor will I make a

sugges-tion to this effect Similarly I will not give to a woman an abortive remedy In purity

and holiness I will guard my life and my art

I will not use the knife, not even on sufferers from stone, but will withdraw in favor

of such men as are engaged in this work

Whatever houses I may visit, I will come for the benefit of the sick, remaining free

of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves

What I may see or hear in the course of the treatment or even outside of the treatment

in regard to the life of men, which on no account one must spread abroad, I will keep

to myself holding such things shameful to be spoken about

If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot

Translated from the Greek by Edelstein.(3) The Oath has since been modernized Those who recite it no longer pledge their alle-

giance to the ancient Greek gods, and the increasing emphasis on separation of church

and state in modern times has removed spirituality from most renditions.(1) Assisted

suicide and abortion continue to be hot-button topics in bioethics, and cases of each

frequent the legal system, calling into question the rights of patients, including the rights

of the unborn.(1, 2) Today’s surgeons are trained to “use the knife” to heal, contrary to

the Oath in its original form, and patient confidentiality may need to be breached in

certain circumstances, as when there is evidence of abuse or neglect.(1)

In spite of these alternations and regardless of its relevance to modern times, the

tradi-tion of the Oath has persevered along with its present day interpretatradi-tion, Do not harm.(1)

1.1 The Development of Medical Paternalism

Do not harm gave birth to the concept of medical paternalism by ascribing the

philos-ophy of doctor-knows-best to the physician and granting him the power to act upon

this belief.(4–6) For instance, if sharing a diagnosis with a patient was thought to be

detrimental to his health, then the physician had the right to withhold this information

from the patient Information withholding included terminal diagnoses, such as cancer

(5, 7, 8) A study by Donald Oken identified that nearly 90% of practitioners in the 1960s

withheld this diagnosis

Some physicians avoid even the slightest suggestion of neoplasia and quite cifically substitute another diagnosis Almost everyone reported resorting to such falsification on at least a few occasions, most notably when the patient was in a

spe-WHAT DO OUR CLIENTS UNDERSTAND ?

It was believed that transparency in relaying a terminal diagnosis would extinguish hope

and that lost hope might precipitate suicidal ideation.(9) It was thought to be kinder

to allow patients to live with false hope rather than no hope at all Physicians were, in

a sense, privileged gatekeepers of information that could be withheld if doing so was

deemed to be essential to the patient’s physical and/or mental wellbeing.(10)

In addition to withholding information about death and dying, physicians also failed

to communicate risks about medical and surgical procedures out of fear that “many

peo-ple would refuse to have anything done, and therefore would be much worse off.”(11)

Patient autonomy was sacrificed for what was perceived to be clinical benefit.(4–6, 12)

Patient decision making was non-existent Even guardians were not active participants

in healthcare decisions of those under their care, including minors, such as newborns

Whether or not to initiate or continue life-saving measures was largely under the

pur-view of doctors Consider, for instance, early neonatal intensive care units and decision

making about whether or not to resuscitate infants Informed consent was rarely granted

and physicians bore sole responsibility to make the call

At the end it is usually the doctor who has to decide the issue It is … cruel to ask

the parents whether they want their child to live or die …(13)

This attitude of paternalism was reinforced by the belief that “the healer has always been

possessed of a body of knowledge and skills unavailable to his patient.”(14) Because the

physician was assumed to know more than the patient, he or she was expected to act on

the patient’s behalf to maximize wellbeing.(6, 9)

Case outcomes were therefore doctor-driven The good doctor was one who

orches-trated patient care behind-the-scenes to minimize physical harm or emotional trauma.(9)

The good doctor made choices to protect the patient, in the way that he or she saw fit.(9)

This philosophical approach to medicine placed a heavy burden on the physician

and his or her capacity to make life and death determinations about the welfare of the

patient, without eliciting the patient’s perspective on the matter.(9)

Physicians were expected to make decisions based upon sound evidence; yet

deci-sions were often made based upon fear of how a patient might react: “I would be afraid

to tell [a diagnosis that carried a poor prognosis] and have the patient in a room with a

window.”(8)

So, it was that, historically, clinical decisions and case outcomes were

physi-cian-driven Patients were told what physicians felt they needed to know In exchange,

patients were expected to submit to physicians’ orders and comply with the diagnostic

and treatment plans that were prescribed

Patient perspective was neither expressed nor welcomed Patients did not have a say

in their own care Their experiences and insight took a backseat to the

doctor-is-always-right attitude, and patients were frequently interrupted when the physician felt that it was

time to move on.(15, 16)

Patients were pawns in the chess game of healthcare They were trained to follow

instructions, not to question them.(17) As a result, interpersonal communication was