Have You Heard? The importance of communication in the exam room

When you walk into an examination room, you know you’ve got at least four years of solid clinical information at your synaptic disposal. But client communication is as important as clinical knowledge. For one thing, it is the key to compliance, which can make or break a patient’s treatment outcome. If clients don’t understand or trust you, they may not follow your recommendations. Studies in the human and veterinary literature are investigating how well most doctors communicate with clients and are dissecting the discussions to determine what is really going on in the exam room.

A recent study from Ontario Veterinary College at the University of Guelph published in the Nov. 15th issue of the Journal of the American Veterinary Medical Association evaluated how effectively veterinarians communicate in the exam room. They explored the differences between appointments made for routine examinations, which they called wellness appointments, and appointments made for specific medical problems, which they called problem appointments.

The researchers videotaped six visits from a random sample of 50 companion-animal practitioners from southern Ontario—three of these six appointments were wellness appointments and three were problem appointments. The videotapes were analyzed at John Hopkins Bloomberg School of Public Health using a roter interaction analysis system. With this system, each veterinarian and client statement throughout the visit was assigned to one of three categories—biomedical topics, lifestyle and social topics, and anticipatory guidance topics. Biomedical topics are those that concern managing a medical condition such as diagnosis, treatment, and prognosis. Lifestyle-social topics concern such things as a pet’s diet, sleeping pattern, temperament, and daily activities. Anticipatory guidance topics concern what is expected of a normal pet as it ages.

Not surprisingly, the interactions in problem appointments focused more on biomedical topics, while wellness appointment interactions included more lifestyle topics with some anticipatory guidance. Overall, the study detected no negative statements, such as disapproval or criticism, during either type of appointment. More of the problem appointments had a tense atmosphere, likely related to the seriousness of the problem. More of the wellness appointments had a relaxed and fun atmosphere.

The study also briefly examined veterinarian to patient communication. Veterinarians spoke directly to pets more often in the wellness appointments. They complimented the pets, such as “You are so pretty”; gave reassurance, such as “This won’t hurt”; gave directions, such as “Stay still”; and even directed comments at pets meant to pass on information to their owners, such as “You’ve put on some weight.”

The researchers concluded that some of their findings provide guidance for practitioners as they anticipate future client interactions.

First, spend more time gathering data. For both types of appointments, veterinarians only used 8% to 9% of the appointment time to gather a patient’s history. This initial interaction with the client can reveal pertinent information in problem appointments, leading to a quicker, more accurate diagnosis, and in wellness appointments, uncovering a potential problem the client is unaware of.

Second, use open-ended questions. The researchers found that 87% of the questions veterinarians asked were close-ended: requiring a “yes” or “no,” such as “Is Oliver housetrained?” Open-ended questions, such as “How is Oliver’s crate-training going?” are of more benefit because clients may reveal information that they would not have otherwise. The more details you can get from clients, the more you can hone in on a problem or identify an unforeseen one, increasing diagnostic accuracy.

Third, ask what the client thinks. There may be a tendency to lecture clients instead of interact with them. But clients’ direct involvement will give them more ownership of the issues raised and spur them to action. In the study, veterinarians did not ask the client’s opinion in 30% of wellness appointments and in 50% of problem appointments. In human medicine, creating an active role for patients increases their satisfaction and adherence to recommendations.

Fourth, during problem appointments, don’t forget about the client’s and patient’s lifestyle and building rapport. It’s easy to concentrate during these appointments on the disease at hand, as occurred in this study. But opening up the conversation to what the client’s lifestyle is like may help veterinarians better understand the pet’s illness. It may also increase compliance since you can customize the treatment plan and what is needed for compliance. And building rapport is another factor in increasing compliance. Medical communication studies also show a positive association between rapport and the accuracy of data collection and patient satisfaction.

The researchers felt that, overall, veterinarian-client interactions were positive and supportive but that there is room for improvement when it comes to promoting true client involvement through relationship-centered care. They believe that more emphasis on effective communication in veterinary school and continuing education can only enhance the partnership between veterinarians and clients, and, subsequently, the health of pets.

Source: Shaw JR, Adams CL, Bonnett BN, et al. Veterinarian-client-patient communication during wellness appointments versus appointments related to a health problem in companion animal practice. J Am Vet Med Assoc 2008;233(10):1576-1586.