Louisa Rance offers some advice to new graduates
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IT is an often-stated fact that a significant number of complaints to the RCVS arise from a failure to adequately communicate with the client. The consulting room is the arena in which most client-vet interaction takes place, and a consultation entails much more than simply taking an accurate clinical history, carrying out a clinical examination, any ensuing work-up and dispensing advice and/or medicines, all of which are taught comprehensively on the veterinary degree course. The importance of informed consent, how to obtain it appropriately and providing reasonably accurate cost estimates is detailed in the RCVS Guide to Professional Conduct.
Another source of information, which tends to be overlooked, is what can be gleaned about the client, their beliefs, attitude to their pets and their expectations and, in return, the impression that the vet gives to the client about their own abilities and commitment to the animal. Failure to observe these more subtle and intuitive cues can result in fairly catastrophic breakdowns in communication that can be relatively easily avoided.
As I approach the milestone of 10 years in practice, here is some advice for newly qualified graduates, based on observations I have made in that time, which I have put in the context of a newly diagnosed hyperthyroid cat.
Louisa Rance is a veterinary surgeon at Battersea Cats and Dogs Home
The first part of the consultation requires obtaining a thorough clinical history from the owner. It is important not only to establish the facts, but also to take on board any assumptions or preconceptions the owner may wish to convey.
The (hypothetical) cat is presented with signalment and signs consistent with hyperthyroidism, but the owner is most concerned by its diarrhoea and has read about bowel tumours, which is what their previous cat died of, on the internet. Although this is not a differential that will be high on your list, it is worth taking the time to explain why you want to proceed with appropriate blood tests, and also why you won't be admitting the animal for an emergency colonoscopy.
Ignoring or brushing aside their concerns will not lessen the client's anxiety about their own perceived diagnosis, but could diminish the client's faith in your ability. Do not dismiss their concerns out of hand, but explain what your clinical plan is. I have to confess that ‘common things happen commonly’ is a phrase I often use in the consulting room
Once a clinical history has been obtained, the clinical examination is required. For most patients this will be straightforward, but there will be some animals for which, for reasons of temperament, this will not be easily achieved or safe. Sometimes this is remedied by simply asking a nurse rather than the owner to restrain the pet, or even asking the owner to leave the room. Our presumptive hyperthyroid patient is predictably fractious and the client has politely asked to remain with the cat because, no offence, she saw the recent Panorama programme, and would feel happier if she could be present.
For any invasive procedure done in the presence of an owner, it is essential before starting to make sure the client understands every step, including different levels of restraint the cat may be subjected to and how the attempt could fail (for example, if you are unable to get a vein). Most clients, having seen the initial difficulties with restraining very fractious animals, will agree to the animal being removed to a quieter area or will consent to sedation if necessary. As a new graduate, never feel compelled to do a phlebotomy or other invasive procedures in the presence of clients, and always be ready to call on the aid of more experienced colleagues.
Imagine now that you are in the same consultation with the same client and the same cat, but this time it is three days since she saw a colleague at an out-of-hours clinic who, according to the thorough clinical notes you obtained, diagnosed hyperthyroidism and commenced on the appropriate treatment course. The client is not very complementary about your out-of-hours colleague, complaining that the cat was taken out the back and then returned to her. They mentioned something was wrong with the thyroid and gave her some pills, and she was not happy as the cat was now vomiting (and, of course, the whole thing was very expensive). There was clearly nothing wrong with the care that the cat had received, but apparently different stages of the work-up had not been discussed, nor had the diagnosis or the treatment and its potential side effects.
Whether a diagnosis is obtained or not, it is essential to discuss all stages of the work-up with the client, and what the plan is if a positive or negative result is obtained. If treatment is required, then you should discuss how it works, along with any handling advice and side effects. The owner should also be aware when treatment should be effective, and what may be required if the planned treatment eventually does not work. It may be that your practice has information sheets for common conditions that you could hand out; otherwise, there are online resources that the owner can be directed to, along with gentle reminders that, in general, the internet is an unreliable source for veterinary advice.
A common fear in vets, recent graduates in particular, is how the expression of uncertainty is perceived by clients and that this can result in loss of client trust and confidence. An interesting study (Mellanby and others 2007) showed that vets tended to overestimate the negative effect that admitting ‘I don't know’ might have on their clients. This applies to all vets, but it does suggest that recent graduates should be able to express uncertainty and openly seek advice from senior colleagues or literature without losing face with clients. Of course, the realities of practice life often mean that time is at a premium, and it can be tempting to cut corners of communication in the consulting room, but this should be avoided. Just by being aware of the importance of communication and developing this, along with the other professional skills, will minimise avoidable miscommunication and result in clients asking to see you again.
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