'Rule of the 9s' helps client communication


Asking the right questions critical during physical examination

The "Rule of the 9s" can help you overcome a significant problem in veterinary medicine- client communication problems.

I was amused and intrigued on a rerun of the the Bob Newhart show whenthe audience was informed that his mother demanded that he chew each mouthfulof food 20 times. Seems silly, but it really slows down a meal; and in thisrush, rush world, it does make some sense.

The Newhart "model" prompted what I call the Rule of the 9s.

Exam room etiquette is the rule these days, and we all know the ritual:walk in with a smile; say "good morning"; shake the client's hand;greet the patient, after the exam provide written home care instructions;say goodbye and thank him or her for entrusting you to provide care fortheir pets.

But what is increasingly important is the substance of what happens in-betweenthe opening and the closing of the exam room activities.

We can divide the visit into four sets of activities:

· Take the history

· Examine the patient

· Make entries into the medical record

· Provide comments, including home care instructions.

The Rule of the 9s is simple; ask nine questions during the history-taking,verbally identify nine items on the examination, make nine entries intothe medical records and make nine comments and recommendations to the client.

At first this might seem difficult, but by adopting a formatted routine,these steps really open up the line of communication and lets the clientknow that you are an active listener.

We all know some clients come with prejudices, opinions, computer printouts, and really don't have a desire to provide certain amenities for theirpets, horses or livestock.

Clients are giving us essential clues all the time with obvious statementsand body language, but most of the time we need help to get all the goodinformation.

The active listening using the Rule of the 9s makes life much easierfor us as we listen to the selected words, tones and body language of theclient.

A case could be a simple cat abscess, bird wing trim, dog fight woundor horse foot abscess - but by taking all four steps and with nine mental"stops," great information comes out, even new issues.

Messages unearthed

The messages communicated to us in many ways are unearthed by consistentlyusing the Rule of the 9s. Active listening facilitated by the Rule of the9s (or variations thereof) is a cornerstone of client communication.

Clues that make us sit up and take notice might be: Rather than fix theChow Chow torn up hock from a dog fight, the client is thinking about puttinghim to "sleep." Or, "The last vet gave my horse acepromazine,and... I am going to sue him for pain, suffering because horses should notget that drug."

Or possibly, "My wife died two weeks ago from cancer and Uma ismy last connection to her."

Taking history

History taking is essential with verbal questions. So, upon taking thehistory with each visit it can be as simple as a complete run-on sentencewhile pausing to get the answers. History questions start off by clarifyingthe reason for the visit. Then, the veterinarian can proceed to asking questionsin a systematic process. Any limping, weight gain or loss, scratching, depressionor seizures, sight or ear issues, fainting spells, exercise intolerance,lumps or bumps identified, sneezing, coughing or excessive panting, polydipsiaor polyuria, incontinence, vomiting or diarrhea, clarify foodstuffs, badbreath?

Thorough exams

Examinations need to be systematic for thoroughness. With the examination,we will begin at the head, and proceed through the body systems.

· The weight is good

· Hips are stiff

· The L7S1 joint is painful

· The skin and hair feel good

· The cranial nerves are working nicely

· The ears look good

· We have some geriatric changes in the lens, but the retinasare good.

· Heart has a normal sinus rhythm at 120 per minute.

· Lymph nodes are normal

· No evidence of jaundice

· Lungs are clear

· Testes are abnormal with one being mushy and the other hard.

· The lips and anus look healthy

· Teeth have some periodontal problems

· The anal glands are full

So, bingo, just like that, two steps have been taken. And when you engagethe client in the process, good information flows.

At this point in the examination, the client has forgotten all the traumaand stresses outside of the veterinary office and he or she is clearly focusedon the physical examination.

Medical records

Medical record entries are essential for our long-term memory. So, forthis part of the Rule of the 9s, remember that nine specific notes mustbe made into the medical record, by the veterinarian or the assistant(s)in the room with the veterinarian.

Comments for clients

The Rule of the 9s is easy here also. Address the specific issue andreason for the visit, then go down the list with recommendations addressingall the issues identified in the history. Come up with eight more stepsor items to put on the "9s List". Preemptively address for theclient: diet, exercise, water consumption, medications, recommended diagnostics,surgeries, identify and remind client on flea and tick control, the nextstool check, the next annual- including any needed boosters, recommend andprovide the opportunity to make an appointment for the next visit beforethey leave the office today.

Reality has it that we must present preventive health care and otherpertinent issues many times before they "register," so take thetime on each visit to reinforce what they are doing or introduce them toissues they are avoiding.

Follow these steps

Here are some additional thoughts that will help open up communicationwith your clients.

Early in the history, make sure to have reviewed the master problem listand review the medical record in front of the client. Use this as a timeto engage the client - "Remember that time in 1999 when..."

Use the MENSCHRUG acronym system approach to the physical exam. The medicalrecord data can be expanded by the use of acronyms. By using a predeterminedexamination format and protocol even little things, like examining the retina,can be included.

Written versus verbal notes - trust only the written word and do nottrust your memory to make the notes later, make all the notes before theyleave the exam room.

Before leaving the room, make sure all issues and client questions havebeen identified, heard and commented upon.

Legible records are essential and keep the master problem list updated.If staff and doctors refuse to keep neat, legible, thoughtful records sendthem away permanently.

Keep the client focused with questions, and listen to the answers. Wecan look pretty stupid if we ask them twice, "What are you feeding?"

Sit down as much as possible because it helps put clients "at ease."

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