Your complete guide to reducing fear in veterinary patients

2014-07-31

A step-by-step plan for a more humane approach to companion animal care.

The cat on the left is exhibiting anxiety signs including being hyperalert and running off.

The autonomy provided by verbal speech in a language we understand cannot be underestimated. Anyone who has needed help in a country where the language spoken is not their own has experienced the acute paralysis associated with not being able to seek or understand help. Even our attempts to mitigate such helplessness reveal how profoundly important accurate communication is: Many phrase books tell you how to ask where a toilet is, but, ironically, to understand a verbal answer, you need some facility in the language-which was the problem in the first place. If you end up getting to the toilet, it's likely because someone pointed or kindly dragged you by the arm to a suitable location. In other words, you shared a signaling currency allowing you to indicate your ostensible goal.

No technique is more underrated in veterinary medicine than using a signaling currency that allows goals to be shared and accomplished. New research shows that dogs especially can have quite large vocabularies of human words comprising nouns, verbs and modifiers1,2 and are excellent at reading and responding to human intentional signals, the easiest of which to study is pointing.3 There are few publications on how well humans have learned canine and feline language, but the studies that exist suggest we misread all but extreme canine vocalizations (we recognize a real and impending threat),4 and we mis- or incompletely read many physical signals of stress and distress5 (see dvm360.com/appeasement for a complete listing).

Our communication skills with the humans who accompany our patients may also be problematic: the median and mean lengths of time clients talk before being interrupted by their veterinarian are 11 and 15.3 seconds, respectively.6 Listening is a learned skill that requires patience. Good listening allows you to direct conversations to the targeted nuggets of information that are most relevant. Good listening also does something crucial for the nonverbal partner in the exam: It provides a cadence of normal conversation, a soundtrack of calming discourse. 

When we do not use a shared signaling currency or provide the cadence of calm conversation, we can expect our patients to become distressed or experience the same acute paralysis that we do when we cannot articulate our needs in a way that allows them to be met. This is what happens in veterinary practices every day of the week.7,8 When patients lose autonomy, they are more fearful, and the more fearful the patient, the more likely they are to further lose autonomy as part of the veterinary experience. Simply put, positive experiences mean less fear and fewer awful expectations; bad experiences mean worsening fear and more awful expectations. 

What's worse is that fear may remain unrecognized or tolerated until it becomes a problem for us. We pursue manipulations of fearful animals, sometimes mistakenly believing that the patient is compliant or tolerant rather than behaviorally shut down-until the patient struggles or is aggressive. Then we apply restraint, which intensifies the cycle. 

For patients that don't have it in them to fight back, this is a formula for learned helplessness. Those that do fight back frequently are labeled dangerous and featured in discussions of euthanasia. If the communication relationship with the client was not compromised before the euthanasia discussion, it certainly is afterwards. 

How can we change this experience? We can look to human pediatric hospitals for some encouragement. Far from the bondage and discipline approach to child care that was the scary rule in the 1950s and 1960s, children's hospitals now strive to provide some degree of autonomy to their patients-they recognize that struggle and restraint worsen stress and make sick kids sicker. If we veterinarians follow the same principles and apply a set of basic rules to all eight parts of a veterinary visit, we can make some profound changes.

Getting started

Before an individual practice makes any changes, it's best to measure the onus of the problem. There are three ways to do this:  

Train staff and practice observing. Have your staff use a standardized set of checklists to evaluate the amount of distress the patient is showing in common practice situations (a clinic stress value scale can be found at dvm360.com/facingfear). Allow multiple staff members to evaluate the same dogs and cats. Compare their evaluations. This will tell you how your staff observes behavior and who's really good at it. Have a discussion about which behaviors different people are relying on to form their opinions and what those behaviors mean. If you are not sure, get a book or video or hire a specialist for an hour of his or her time-a radical thought, but one that will pay for itself. Once you have had a few sessions like this, ensure that everyone is evaluating the same things and assess your patients for a few weeks. If you engage in this exercise you will do more than just evaluate your patients; you will educate your staff and they will be more engaged.

Get the client's input. Have your staff call clients who have just been for a visit and those who are getting ready to come for a visit and ask about the pet's behavior. Use or adapt the stress value scale and record the information in a standardized manner.  

>Was the dog or cat afraid before the appointment? 

>How could the client tell? 

>Was the dog or cat upset by the appointment? 

>What concerned the patient? What upset the client? 

>Is the patient's fear a concern for the client? 

>What does the client do to get the patient ready for an appointment? 

>Is the client stressed by the appointment? If so, when does the client begin to plan for the visit? 

These questions will tell you how many clients are aware of their cat's or dog's distress, whether they think the distress is due only to the exam or to the anticipation of it and, if the latter, whether the client's anxiety may be affecting the dog or cat. At the very least, clients frequently own up to being embarrassed by what they think of as poor behavior at the veterinarians's office. By conducting these phone calls, your staff will learn a lot about how to ask the right questions, and your clients will learn that you're concerned about their pet's welfare-because you're asking about it. 

You would pay a lot for advertising that could convey such care. Let your care and competence be your calling card.

Get your practice on video. Videorecord your entryway, waiting room and exam rooms and watch the videos when you are fresh and undisturbed. Use a chart of signs of anxiety (see dvm360.com/fearfree for such a chart) and the ones you see on your checklist from the stress value scale. Fast-forward through some sequences-aberrant behavior pops out in fast-forward. Watch until you've identified patterns, until you're confident you understand what's going on or until you realize you don't know what to watch for-in which case, reach out for help. As anyone who has housetrained a dog or a child knows, behavior is a “pay me now or pay me later” proposition, but everyone pays. Investing in the encouragement of calm behaviors is more profitable and a better experience than any other choice.

Once you have an idea of the patterns of your patients' concerns, make a written list of them. This makes the problem tangible. You may talk to colleagues across town and find that their concerns are not yours. Perhaps they have a bigger or smaller waiting room. Maybe they have separate dog and cat entrances. Maybe the investment you made in rubberized, nonslip flooring is paying off in more ways than just less back pain. 

We are taught in medicine to use a systems approach, and that methodology can help us here. For the eight major divisions of a veterinary visit, a list of quick tips and dos and don'ts can make a start. If you are having problems or feel frustrated or just feel you do not have the time to do this, please consider hiring a specialist in veterinary behavioral medicine (dacvb.org) to come to your practice for just one visit to make suggestions. The burden of the fearful pet is one we must all share until we no longer need to do so.

Anxiety signs: Ears lowered, dilated pupils, hardened stare

CATS

Step 1: Preparing for the veterinary visit 

Types of carriers

>The vast majority of cats will need to be transported in a carrier, except for those few that are leash- and-harness-trained (see wikihow.com/leash-train-a-cat).

>Instruct clients about the type of carrier they should buy. Have photos and websites available and make sure the carrier discussion is part of every kitten exam. 

>The carrier should have good ventilation, enough space for a thick towel and for the cat to stand up, and an easy-open top. There are now lots of variations on this-some allow you to unlock half of the top of the carrier; some allow gradual folding so you can place a towel over the cat as you undo the top-but all should allow you to take the carrier apart in a dimly lit examination room with minimum noise and fuss.

Teaching use of the carrier 

Cats must be taught how to use carriers and that they are good things. Teaching cats to use the carrier requires an investment of time on the client's part and involves standard reward, shaping, desensitization and counterconditioning techniques.9-10  The best time to teach crate comfort is in kittenhood, so entering and being calm in a carrier should be a major focus of the first kitten appointment, emphasized at follow-up kittenhood appointments, and included in any kitten classes you offer (see the sidebar “Safe travels” at dvm360.com/safetravels for more information).

Step 2: Getting to and into the building

If your clients have succeeded with the previous step they can get the cat into the building without undue distress. It's best if you have a cats-only waiting area; some buildings even have quiet, cats-only entrances.

Step 3: Managing check-in and the waiting room

The cat should be checked upon entry for any signs of nausea, salivation or wooziness. Some cats experience motion sickness in cars and may benefit from mild sedation or antiemetic medication prior to the next visit.

Step 4: Weighing the patient

>For practices that have floor scales in waiting rooms and for cats that are larger, weighing the crate plus cat on the scale is acceptable if done gently and without intrusion from other patients and clients. The client can weigh the crate before the appointment and note the weight on the crate-have your staff discuss this when they call the client before the appointment. For cats that will require examination in the crate, if the owner did not weigh the crate prior to arrival, the crate can be weighed later. And for cats who are examined outside of the crate, the crate can be weighed while the cat is out of it. 

>Small cats should be weighed on scales that measure small differences. Cats wrapped in towels can be gently placed on the scale and the towel weighed separately. 

>Cats that are already clicker-trained can be clicker-trained to leap onto and stand on a scale. This underused technique is easiest to use with bold kittens, and clients love it when their cats can do things like this.

Step 5: Examining the patient

Having a cats-only exam room helps with cats' responses to nonfeline odors and with meeting their special needs. The following tips may help to prevent fear: 

>Play low-volume classical music or white noise.

>Speak softly. 

>Sit down.

>Talk to the client first while allowing the cat to acclimate to the surroundings.

>Dim the lights and, preferably, use targeted lighting as needed. If there is lots of natural light in the room, this is good for everyone, but you may wish to provide a screen so that cats are not forced to look at bright light.

Managing odors

Cats are exquisitely sensitive to odors and mark with urine and feces as well as facial and body secretions. Any animal that spends this much time engaging in the olfactory environment is going to be attuned to the very different and scary olfactory environment of a clinic. Accordingly, use these strategies to minimize odor-related stress:

>Air out rooms as much as possible and use disinfectants that do not have strong odors followed by air-drying. If possible, open a window; cats are intrigued by odorant molecules in scent trails and may pay more attention to them than to stressors. 

>If using bleach, ensure that the room and surfaces are dry and well-aired because even a 1 percent solution can kill olfactory neurons. If olfaction is how you get your information, loss of olfactory neurons is a stressor and will render the patient more, not less, anxious. 

>Much has been written about using synthetic pheromonal products in carriers, waiting rooms and exam rooms, but there are no data supporting their interventional use.9-13

Step 6: Administering tests and treatments

>If the cat willingly walks out of the carrier or is able to be taken from the carrier without undue stress or distress, physical examination can usually be accomplished in accordance with the stress-free goal.

> As with all animals, struggle and stress are lessened if the patient can be examined in natural postures (standing) or in ones comfortable to them (your lap, the client's lap).

>Examination should be a natural part of the flow of conversation and history taking. If the cat struggles or is distressed, allow the cat to go back into the carrier.

>If the cat is worried but still manageable, examine the cat piecemeal in the carrier. This may require covering parts of the cat with a towel at times (see step 9) but if you go slowly you can be successful. 

>True restraint is painful and scary-try not to use it. Butterfly catheters make blood samples easy to obtain and a vacutainer-type adapter sends the blood directly to the tubes, eliminating a step and reducing the risk of venous collapse associated with syringes.

> If the cat is extremely distressed and the exam is not medically urgent, you may wish to delay further evaluation and discuss anti-anxiety medications or some level of sedation with the client so that the cat is able to have the kind of medical care he or she deserves.

Step 7: Discharging the patient 

>If the cat is distressed, minimize change. Allow the cat to remain in the carrier, covered, and conduct all discharge and payment interactions either in the exam room or with the clients elsewhere, whichever minimizes the distress of that cat. 

>Consider anti-anxiety medication at the time of the appointment so that the cat aborts the full neuromolecular loop of making molecular memory of the scary experience.

If the cat is not distressed, congratulate the client and reward the cat.

-Cats love salty treats like patés, liver spreads, Marmite or Vegemite-use a tongue depressor to offer them-or offer tiny tinned shrimp: These can be rinsed, dried and frozen on a flat sheet and stored in the freezer as individual treats which can be almost instantly warmed.

-If the cat loves play, have a new toy to take home or play with a feather toy during the exam. Then send them on their way.

Step 8: Concluding the visit by taking the patient home

If the cat was calm on the way to your clinic but had a bad experience there, consider that the trip home may not be so calm. Medication either during the visit or after the visit may help the cat learn not to loathe veterinary visits and to associate them with less stress and distress than would have otherwise been the case. 

Anxiety signs: Barking, growling, snapping

DOGS

Step 1: Preparing for and engaging in the veterinary visit

Types of carriers 

Unlike cats, dogs come in an enormous range of sizes. Clients with smaller dogs may prefer to use a carrier. 

> If clients decide to use a carrier they will need to go through all of the steps already described for cats. 

> I am a big fan of leads and either head collars or harnesses for the vast majority of dogs. If a dog is to wear only a flat-buckle collar, it must be taught to do so and everyone must be sure that the dog cannot and will not back out of it and escape. I saw this happen once as a student. When the dog was partway through the door to the veterinary hospital he realized where he was, backed out of the collar and fled. He was never seen again. (Anyone who remodels their clinic would benefit from double doors that cannot both be opened simultaneously except in the case of a deliberate override.) 

>All dogs should be able to walk calmly on harnesses, head collars or flat-buckle collars: no pulling, no choking, no gagging, no shrieking. If any of this occurs, you already have a behavioral issue that needs attention for humane reasons involving the dog's well-being. Again, consider evaluation by or referral to a specialist, a behavior consultant or a certified professional trainer.

>Use only clear, proven, positive, gentle and humane techniques. No choke collars (metal or fabric), no prong collars (metal or plastic, embroidered or not), and no shock or electric collars. All of these create problems for the patient. 

>If clients wish to use crates to transport smaller dogs, this is fine, but ensure that those dogs also have the ability to walk on a  lead well and enjoyably. This is a flexibility and safety issue.

Step 2: Getting to and into the building

>If the dog balks getting into the car, in the parking lot or approaching the hospital building, see if it can be encouraged to come inside using treats, toys and verbal rewards. If the dog balks a bit but can be jollied along, see how far you can get. If at any point the dog puts on the brakes, ask yourself if it is in everyone's best interests to go further.

>If the appointment is not discretionary and you must see the patient immediately, consider administering medication and allowing the client and patient to either sit in the car for 15 to 20 minutes or in a quiet corner of the waiting or exam room if they can get there without force. If neither of these are possible and the dog must be seen, choose the least stressful option.  Once the dog has been seen and treated, describe in the discharge instructions the need for a plan to teach the dog to go to the veterinarian with less stress and help the client implement this. 

>If the appointment is discretionary (e.g., few vaccines are emergencies), discuss with the client the pros and cons of delaying the appointment and using behavior modification and medication in advance of the rescheduled appointment for the sake of the dog.

Step 3: Managing check-in and the waiting room

>If a waiting room is large and relatively quiet, a dog can become calmer if allowed to sit there.8 This allows the dog to take in information about the place and people in its own time. This also gives clients time to complete a short behavioral questionnaire and the staff time to assess and record the dog's stress level. 

>If the dog is distressed in the waiting room and the exam room is empty, the client and dog should go to the exam room immediately and all check-in procedures conducted remotely. 

>If the dog is calm in the car but not in the waiting room-and your staff will learn this because they'll be calling the client before the appointment-the dog can wait in the car while the client either enters the clinic to complete paperwork or stays with the dog and texts or calls the clinic to say he or she is waiting in the car. This strategy works best when preplanned, hence the pre-appointment phone call. 

>If clients wait in the car with their dogs-or down the street in a park or elsewhere-the staff should text or phone them (determine this in advance) when the exam room is available and coordinate moving the dog as seamlessly as possible through the hospital. No one should knock on a car window.

Step 4: Weighing the patient

>Weighing dogs is stressful because scales move. Dogs can see shades of blue, so if your scale is flush with the floor, a blue covering will flag it as special. This is important because if the dog steps on it accidentally and it moves, the dog does not have to fear the whole floor, just the blue part. While not optimal, this is better than the alternative. 

>Dogs can be taught to walk onto and stand on a scale. It's worth a lot for clients to invest in this skill because it transfers to all sorts of things. Clients can start by teaching their dog to “go to your mat” at home and then generalizing this to other places and things.14 

>If scales are built into tables, the tables invariably move. Now the dog must be taught to walk onto the table while the table-scale combination moves beneath it and to sit or lie still while being weighed. The same techniques used to teach dogs to “go to your mat” will work here.

>If the dog can stand still and happily for examination but not for a moving scale, ask how important it is to weigh the dog (keeping in mind that some states do not consider the medical record valid without a weight). It may be better to have a separate weighing appointment for these dogs.

>Some scales lock or can be wedged still. In such cases teaching “go to your mat” plus a deep breathing and stillness response can work well. The dog gets on the scale, lies down, takes a deep breath and is calm, and the scale is unlocked or the brace quietly and slowly removed. 

>Regardless, if you teach pups early to get on the scale and make it a fun game-“On, sit, off!” Repeat-you will have fewer problems.

Step 5: Examining the patient

>Your staff may be able to determine in advance where the dog is best examined. Some patients need to skip the hospital altogether and have their exam in the parking lot. 

>Most dogs that are not accustomed to being picked up and put on a surface do better on the floor. If you want a larger dog to stand on a table, teach it to do so, securely and in its own time. Here are some guidelines:

-Give the dog autonomy: teach using stairs, a stool or a version of a gangplank (commercial or homemade) to get the patient to the table. 

-Ensure that all steps, planks and the table have nonslip flooring. It can be rubberized flooring or an old yoga mat, but you must be able to clean it and it must stop dogs from slipping without catching toenails and hair.

-Small dogs may be used to being placed on tables but still should walk on a rubberized mat, yoga mat or fleece cover so they do not slip and the table is not cold.

-If getting onto the table is a game with staged rewards, dogs will immediately go to the table at all appointments.

>Let the dog have autonomy in determining the pace at which the examination occurs.

-We are taught to examine dogs starting at the tip of the nose and moving though the tip of the tail. Unfortunately, a recent study has shown that dogs are more stressed when people handle their head, neck or muzzle or hold the dog by the collar. These human behaviors cause the dog to respond with sympathetic system arousal as indicated by behavioral and cardiovascular measures.15

-Instead, start the examination with the body parts the patient offers first. Ears may be more easily accessible from the back forward than from front to back because there is less need to handle the head. Dogs do not see well close up, so the movement of your hand past their eyes can become a risk they cannot adequately assess. 

-Slow, steady pressure has been shown to have a calming effect in many contexts. Leave one hand on the dog, if the dog is calm, and using slow pressure move calmly to examine the dog. 

-If you are sitting down and doing your exam on the floor, most dogs can be asked to assume positions that will help you examine them-and which they might be unlikely to exhibit if you are towering over them. For example, many dogs lean against people when they sit: This presents a first-pass opportunity to examine hips and stifles. If further exam is warranted, you are more likely to get farther if you have developed a trusting relationship with the dog during the first-pass exam and the dog realizes it has some control over the pace of the exam.

Tips that may prevent fear 

>Play low-volume classic music or white noise.

>Speak softly. 

>Sit down. Have clients sit in a comfortable chair that helps them to relax, not one that is painful to balance on.

>Talk to the clients first while allowing the dog to acclimate to the surroundings.

>Dim the lights and, preferably, use targeted lighting as needed. If there is lots of natural light in the room, this is good for everyone, but be aware of possibly needing some shade for dogs with light-colored eyes or vision issues. Older dogs may do best with low-level lighting so they can see you better.

Managing odors

>Air out rooms as much as possible. Use disinfectants that do not have strong odors followed by air drying. If possible, open a window. 

>If using bleach, ensure that the room and surfaces are dry and well-aired because even a 1 percent solution can kill olfactory neurons. If olfaction is how you get your information, loss of olfactory neurons is a stressor and will render the patient more, not less, anxious. Dogs use olfaction for identifying everything, including risk.

>There is no scientific evidence that pheromonal products lessen the stress or distress of dogs in clinical settings.16

Step 6: Administering tests and treatments

>As with all animals, struggle and stress are lessened if the patient can be examined in natural postures (standing) or in ones comfortable to them (your lap or the client's lap if the dog is small).

>Examination should be a natural part of the flow of conversation and history taking. 

>Small dogs may benefit from towel wraps as cats do. Some dogs do better if they are wearing eyeshades, head covers such as Calming Caps or wraps such as Thundershirts, but you must know ahead of time if this is true. Again, this is where your staff can play a major role in learning whether such interventions can be tried at home and can benefit the dog. If clients are shown how to use these tools they are more likely to try them. Clear communication seldom lets you down.

>True restraint is painful and scary for dogs as it is for cats. The same tips for drawing blood outlined in the cat exam section apply here.

-If dogs have been hurt for blood draw, try using topical gel or crème lidocaine or a lidocaine-prilocaine mix (a little cheaper than lidocaine alone) on the area. Wait a few minutes to manipulate the region and you might be surprised. 

-Taking temperatures and emptying anal sacs are pretty invasive and potentially painful events. The use of lidocaine or a lidocaine-prilocaine mix can be nearly miraculous. Once dogs are certain they will no longer be hurt, their tails are not tugged on so much, and they can easily be taught to “show me your bum.”

>If a dog is extremely distressed and the exam is not of medical urgency, you may wish to delay further evaluation and discuss anti-anxiety medications or some level of sedation with the client so that the dog is able to have the kind of medical care he or she deserves.

Step 7: Discharging the patient 

>If the dog is distressed, minimize change. Allow the dog to remain in the carrier, covered, or in the room with the client and conduct all discharge and payment interactions either in the exam room or remotely once the dog is safely in the car or home, wherever he or she is most comfortable.

>Consider anti-anxiety medication at the time of the appointment so that the dog aborts the full neuromolecular loop of making molecular memory of the scary experience.

>If the dog is not distressed, congratulate the client and reward the dog with play, a new toy, treats, huge amounts of praise-and do not rush them out the door. The praise portion of the visit needs to be as long as possible so that the dog can adequately gauge how safe and reliable the experience was.

Step 8: Concluding the visit by taking the patient home

>If the dog was calm on the way to your clinic but had a bad experience there, consider that the trip home may not be so calm. Medication either during the visit or after the visit may help the dog to learn not to loathe veterinary visits and to associate them with less stress and distress than would have otherwise been the case. 

>If the dog was distressed, consider buffering his or her brain against the damage caused by the stress/distress. Give the dog 1,200 to 1,500 mg of omega-3s daily.17-19 

Any successful effort to mitigate fear and distress in our patients and to make exams Fear Free for them and easier for us will rely on a signaling currency that allows goals to be shared and accomplished. It's hard work for all of us to understand and find those signaling currencies. Mitigating fear requires that we alter our behaviors and thoughts, also. Change is a lot more complex than stocking treats, putting a toy in a crate and adjusting the lighting. These step-by-step plans are a good outline for where to start, but their larger intended effect is to alter our pattern of observations so that we use those observations to improve everyone's quality of life. 

To view the references for this article, visit dvm360.com/FearFreerefs

 

The cat on the left is exhibiting anxiety signs including being hyperalert and running off.

The autonomy provided by verbal speech in a language we understand cannot be underestimated. Anyone who has needed help in a country where the language spoken is not their own has experienced the acute paralysis associated with not being able to seek or understand help. Even our attempts to mitigate such helplessness reveal how profoundly important accurate communication is: Many phrase books tell you how to ask where a toilet is, but, ironically, to understand a verbal answer, you need some facility in the language-which was the problem in the first place. If you end up getting to the toilet, it's likely because someone pointed or kindly dragged you by the arm to a suitable location. In other words, you shared a signaling currency allowing you to indicate your ostensible goal.

No technique is more underrated in veterinary medicine than using a signaling currency that allows goals to be shared and accomplished. New research shows that dogs especially can have quite large vocabularies of human words comprising nouns, verbs and modifiers1,2 and are excellent at reading and responding to human intentional signals, the easiest of which to study is pointing.3 There are few publications on how well humans have learned canine and feline language, but the studies that exist suggest we misread all but extreme canine vocalizations (we recognize a real and impending threat),4 and we mis- or incompletely read many physical signals of stress and distress5 (see dvm360.com/appeasement for a complete listing).

Our communication skills with the humans who accompany our patients may also be problematic: the median and mean lengths of time clients talk before being interrupted by their veterinarian are 11 and 15.3 seconds, respectively.6 Listening is a learned skill that requires patience. Good listening allows you to direct conversations to the targeted nuggets of information that are most relevant. Good listening also does something crucial for the nonverbal partner in the exam: It provides a cadence of normal conversation, a soundtrack of calming discourse. 

When we do not use a shared signaling currency or provide the cadence of calm conversation, we can expect our patients to become distressed or experience the same acute paralysis that we do when we cannot articulate our needs in a way that allows them to be met. This is what happens in veterinary practices every day of the week.7,8 When patients lose autonomy, they are more fearful, and the more fearful the patient, the more likely they are to further lose autonomy as part of the veterinary experience. Simply put, positive experiences mean less fear and fewer awful expectations; bad experiences mean worsening fear and more awful expectations. 

What's worse is that fear may remain unrecognized or tolerated until it becomes a problem for us. We pursue manipulations of fearful animals, sometimes mistakenly believing that the patient is compliant or tolerant rather than behaviorally shut down-until the patient struggles or is aggressive. Then we apply restraint, which intensifies the cycle. 

For patients that don't have it in them to fight back, this is a formula for learned helplessness. Those that do fight back frequently are labeled dangerous and featured in discussions of euthanasia. If the communication relationship with the client was not compromised before the euthanasia discussion, it certainly is afterwards. 

How can we change this experience? We can look to human pediatric hospitals for some encouragement. Far from the bondage and discipline approach to child care that was the scary rule in the 1950s and 1960s, children's hospitals now strive to provide some degree of autonomy to their patients-they recognize that struggle and restraint worsen stress and make sick kids sicker. If we veterinarians follow the same principles and apply a set of basic rules to all eight parts of a veterinary visit, we can make some profound changes.

Getting started

Before an individual practice makes any changes, it's best to measure the onus of the problem. There are three ways to do this:  

Train staff and practice observing. Have your staff use a standardized set of checklists to evaluate the amount of distress the patient is showing in common practice situations (a clinic stress value scale can be found at dvm360.com/facingfear). Allow multiple staff members to evaluate the same dogs and cats. Compare their evaluations. This will tell you how your staff observes behavior and who's really good at it. Have a discussion about which behaviors different people are relying on to form their opinions and what those behaviors mean. If you are not sure, get a book or video or hire a specialist for an hour of his or her time-a radical thought, but one that will pay for itself. Once you have had a few sessions like this, ensure that everyone is evaluating the same things and assess your patients for a few weeks. If you engage in this exercise you will do more than just evaluate your patients; you will educate your staff and they will be more engaged.

Get the client's input. Have your staff call clients who have just been for a visit and those who are getting ready to come for a visit and ask about the pet's behavior. Use or adapt the stress value scale and record the information in a standardized manner.  

>Was the dog or cat afraid before the appointment? 

>How could the client tell? 

>Was the dog or cat upset by the appointment? 

>What concerned the patient? What upset the client? 

>Is the patient's fear a concern for the client? 

>What does the client do to get the patient ready for an appointment? 

>Is the client stressed by the appointment? If so, when does the client begin to plan for the visit? 

These questions will tell you how many clients are aware of their cat's or dog's distress, whether they think the distress is due only to the exam or to the anticipation of it and, if the latter, whether the client's anxiety may be affecting the dog or cat. At the very least, clients frequently own up to being embarrassed by what they think of as poor behavior at the veterinarians's office. By conducting these phone calls, your staff will learn a lot about how to ask the right questions, and your clients will learn that you're concerned about their pet's welfare-because you're asking about it. 

You would pay a lot for advertising that could convey such care. Let your care and competence be your calling card.

Get your practice on video. Videorecord your entryway, waiting room and exam rooms and watch the videos when you are fresh and undisturbed. Use a chart of signs of anxiety (see dvm360.com/fearfree for such a chart) and the ones you see on your checklist from the stress value scale. Fast-forward through some sequences-aberrant behavior pops out in fast-forward. Watch until you've identified patterns, until you're confident you understand what's going on or until you realize you don't know what to watch for-in which case, reach out for help. As anyone who has housetrained a dog or a child knows, behavior is a “pay me now or pay me later” proposition, but everyone pays. Investing in the encouragement of calm behaviors is more profitable and a better experience than any other choice.

Once you have an idea of the patterns of your patients' concerns, make a written list of them. This makes the problem tangible. You may talk to colleagues across town and find that their concerns are not yours. Perhaps they have a bigger or smaller waiting room. Maybe they have separate dog and cat entrances. Maybe the investment you made in rubberized, nonslip flooring is paying off in more ways than just less back pain. 

We are taught in medicine to use a systems approach, and that methodology can help us here. For the eight major divisions of a veterinary visit, a list of quick tips and dos and don'ts can make a start. If you are having problems or feel frustrated or just feel you do not have the time to do this, please consider hiring a specialist in veterinary behavioral medicine (dacvb.org) to come to your practice for just one visit to make suggestions. The burden of the fearful pet is one we must all share until we no longer need to do so.

Anxiety signs: Ears lowered, dilated pupils, hardened stare

CATS

Step 1: Preparing for the veterinary visit 

Types of carriers

>The vast majority of cats will need to be transported in a carrier, except for those few that are leash- and-harness-trained (see wikihow.com/leash-train-a-cat).

>Instruct clients about the type of carrier they should buy. Have photos and websites available and make sure the carrier discussion is part of every kitten exam. 

>The carrier should have good ventilation, enough space for a thick towel and for the cat to stand up, and an easy-open top. There are now lots of variations on this-some allow you to unlock half of the top of the carrier; some allow gradual folding so you can place a towel over the cat as you undo the top-but all should allow you to take the carrier apart in a dimly lit examination room with minimum noise and fuss.

Teaching use of the carrier 

Cats must be taught how to use carriers and that they are good things. Teaching cats to use the carrier requires an investment of time on the client's part and involves standard reward, shaping, desensitization and counterconditioning techniques.9-10  The best time to teach crate comfort is in kittenhood, so entering and being calm in a carrier should be a major focus of the first kitten appointment, emphasized at follow-up kittenhood appointments, and included in any kitten classes you offer (see the sidebar “Safe travels” at dvm360.com/safetravels for more information).

Step 2: Getting to and into the building

If your clients have succeeded with the previous step they can get the cat into the building without undue distress. It's best if you have a cats-only waiting area; some buildings even have quiet, cats-only entrances.

Step 3: Managing check-in and the waiting room

The cat should be checked upon entry for any signs of nausea, salivation or wooziness. Some cats experience motion sickness in cars and may benefit from mild sedation or antiemetic medication prior to the next visit.

Step 4: Weighing the patient

>For practices that have floor scales in waiting rooms and for cats that are larger, weighing the crate plus cat on the scale is acceptable if done gently and without intrusion from other patients and clients. The client can weigh the crate before the appointment and note the weight on the crate-have your staff discuss this when they call the client before the appointment. For cats that will require examination in the crate, if the owner did not weigh the crate prior to arrival, the crate can be weighed later. And for cats who are examined outside of the crate, the crate can be weighed while the cat is out of it. 

>Small cats should be weighed on scales that measure small differences. Cats wrapped in towels can be gently placed on the scale and the towel weighed separately. 

>Cats that are already clicker-trained can be clicker-trained to leap onto and stand on a scale. This underused technique is easiest to use with bold kittens, and clients love it when their cats can do things like this.

Step 5: Examining the patient

Having a cats-only exam room helps with cats' responses to nonfeline odors and with meeting their special needs. The following tips may help to prevent fear: 

>Play low-volume classical music or white noise.

>Speak softly. 

>Sit down.

>Talk to the client first while allowing the cat to acclimate to the surroundings.

>Dim the lights and, preferably, use targeted lighting as needed. If there is lots of natural light in the room, this is good for everyone, but you may wish to provide a screen so that cats are not forced to look at bright light.

Managing odors

Cats are exquisitely sensitive to odors and mark with urine and feces as well as facial and body secretions. Any animal that spends this much time engaging in the olfactory environment is going to be attuned to the very different and scary olfactory environment of a clinic. Accordingly, use these strategies to minimize odor-related stress:

>Air out rooms as much as possible and use disinfectants that do not have strong odors followed by air-drying. If possible, open a window; cats are intrigued by odorant molecules in scent trails and may pay more attention to them than to stressors. 

>If using bleach, ensure that the room and surfaces are dry and well-aired because even a 1 percent solution can kill olfactory neurons. If olfaction is how you get your information, loss of olfactory neurons is a stressor and will render the patient more, not less, anxious. 

>Much has been written about using synthetic pheromonal products in carriers, waiting rooms and exam rooms, but there are no data supporting their interventional use.9-13

Step 6: Administering tests and treatments

>If the cat willingly walks out of the carrier or is able to be taken from the carrier without undue stress or distress, physical examination can usually be accomplished in accordance with the stress-free goal.

> As with all animals, struggle and stress are lessened if the patient can be examined in natural postures (standing) or in ones comfortable to them (your lap, the client's lap).

>Examination should be a natural part of the flow of conversation and history taking. If the cat struggles or is distressed, allow the cat to go back into the carrier.

>If the cat is worried but still manageable, examine the cat piecemeal in the carrier. This may require covering parts of the cat with a towel at times (see step 9) but if you go slowly you can be successful. 

>True restraint is painful and scary-try not to use it. Butterfly catheters make blood samples easy to obtain and a vacutainer-type adapter sends the blood directly to the tubes, eliminating a step and reducing the risk of venous collapse associated with syringes.

> If the cat is extremely distressed and the exam is not medically urgent, you may wish to delay further evaluation and discuss anti-anxiety medications or some level of sedation with the client so that the cat is able to have the kind of medical care he or she deserves.

Step 7: Discharging the patient 

>If the cat is distressed, minimize change. Allow the cat to remain in the carrier, covered, and conduct all discharge and payment interactions either in the exam room or with the clients elsewhere, whichever minimizes the distress of that cat. 

>Consider anti-anxiety medication at the time of the appointment so that the cat aborts the full neuromolecular loop of making molecular memory of the scary experience.

If the cat is not distressed, congratulate the client and reward the cat.

-Cats love salty treats like patés, liver spreads, Marmite or Vegemite-use a tongue depressor to offer them-or offer tiny tinned shrimp: These can be rinsed, dried and frozen on a flat sheet and stored in the freezer as individual treats which can be almost instantly warmed.

-If the cat loves play, have a new toy to take home or play with a feather toy during the exam. Then send them on their way.

Step 8: Concluding the visit by taking the patient home

If the cat was calm on the way to your clinic but had a bad experience there, consider that the trip home may not be so calm. Medication either during the visit or after the visit may help the cat learn not to loathe veterinary visits and to associate them with less stress and distress than would have otherwise been the case. 

Anxiety signs: Barking, growling, snapping

DOGS

Step 1: Preparing for and engaging in the veterinary visit

Types of carriers 

Unlike cats, dogs come in an enormous range of sizes. Clients with smaller dogs may prefer to use a carrier. 

> If clients decide to use a carrier they will need to go through all of the steps already described for cats. 

> I am a big fan of leads and either head collars or harnesses for the vast majority of dogs. If a dog is to wear only a flat-buckle collar, it must be taught to do so and everyone must be sure that the dog cannot and will not back out of it and escape. I saw this happen once as a student. When the dog was partway through the door to the veterinary hospital he realized where he was, backed out of the collar and fled. He was never seen again. (Anyone who remodels their clinic would benefit from double doors that cannot both be opened simultaneously except in the case of a deliberate override.) 

>All dogs should be able to walk calmly on harnesses, head collars or flat-buckle collars: no pulling, no choking, no gagging, no shrieking. If any of this occurs, you already have a behavioral issue that needs attention for humane reasons involving the dog's well-being. Again, consider evaluation by or referral to a specialist, a behavior consultant or a certified professional trainer.

>Use only clear, proven, positive, gentle and humane techniques. No choke collars (metal or fabric), no prong collars (metal or plastic, embroidered or not), and no shock or electric collars. All of these create problems for the patient. 

>If clients wish to use crates to transport smaller dogs, this is fine, but ensure that those dogs also have the ability to walk on a  lead well and enjoyably. This is a flexibility and safety issue.

Step 2: Getting to and into the building

>If the dog balks getting into the car, in the parking lot or approaching the hospital building, see if it can be encouraged to come inside using treats, toys and verbal rewards. If the dog balks a bit but can be jollied along, see how far you can get. If at any point the dog puts on the brakes, ask yourself if it is in everyone's best interests to go further.

>If the appointment is not discretionary and you must see the patient immediately, consider administering medication and allowing the client and patient to either sit in the car for 15 to 20 minutes or in a quiet corner of the waiting or exam room if they can get there without force. If neither of these are possible and the dog must be seen, choose the least stressful option.  Once the dog has been seen and treated, describe in the discharge instructions the need for a plan to teach the dog to go to the veterinarian with less stress and help the client implement this. 

>If the appointment is discretionary (e.g., few vaccines are emergencies), discuss with the client the pros and cons of delaying the appointment and using behavior modification and medication in advance of the rescheduled appointment for the sake of the dog.

Step 3: Managing check-in and the waiting room

>If a waiting room is large and relatively quiet, a dog can become calmer if allowed to sit there.8 This allows the dog to take in information about the place and people in its own time. This also gives clients time to complete a short behavioral questionnaire and the staff time to assess and record the dog's stress level. 

>If the dog is distressed in the waiting room and the exam room is empty, the client and dog should go to the exam room immediately and all check-in procedures conducted remotely. 

>If the dog is calm in the car but not in the waiting room-and your staff will learn this because they'll be calling the client before the appointment-the dog can wait in the car while the client either enters the clinic to complete paperwork or stays with the dog and texts or calls the clinic to say he or she is waiting in the car. This strategy works best when preplanned, hence the pre-appointment phone call. 

>If clients wait in the car with their dogs-or down the street in a park or elsewhere-the staff should text or phone them (determine this in advance) when the exam room is available and coordinate moving the dog as seamlessly as possible through the hospital. No one should knock on a car window.

Step 4: Weighing the patient

>Weighing dogs is stressful because scales move. Dogs can see shades of blue, so if your scale is flush with the floor, a blue covering will flag it as special. This is important because if the dog steps on it accidentally and it moves, the dog does not have to fear the whole floor, just the blue part. While not optimal, this is better than the alternative. 

>Dogs can be taught to walk onto and stand on a scale. It's worth a lot for clients to invest in this skill because it transfers to all sorts of things. Clients can start by teaching their dog to “go to your mat” at home and then generalizing this to other places and things.14 

>If scales are built into tables, the tables invariably move. Now the dog must be taught to walk onto the table while the table-scale combination moves beneath it and to sit or lie still while being weighed. The same techniques used to teach dogs to “go to your mat” will work here.

>If the dog can stand still and happily for examination but not for a moving scale, ask how important it is to weigh the dog (keeping in mind that some states do not consider the medical record valid without a weight). It may be better to have a separate weighing appointment for these dogs.

>Some scales lock or can be wedged still. In such cases teaching “go to your mat” plus a deep breathing and stillness response can work well. The dog gets on the scale, lies down, takes a deep breath and is calm, and the scale is unlocked or the brace quietly and slowly removed. 

>Regardless, if you teach pups early to get on the scale and make it a fun game-“On, sit, off!” Repeat-you will have fewer problems.

Step 5: Examining the patient

>Your staff may be able to determine in advance where the dog is best examined. Some patients need to skip the hospital altogether and have their exam in the parking lot. 

>Most dogs that are not accustomed to being picked up and put on a surface do better on the floor. If you want a larger dog to stand on a table, teach it to do so, securely and in its own time. Here are some guidelines:

-Give the dog autonomy: teach using stairs, a stool or a version of a gangplank (commercial or homemade) to get the patient to the table. 

-Ensure that all steps, planks and the table have nonslip flooring. It can be rubberized flooring or an old yoga mat, but you must be able to clean it and it must stop dogs from slipping without catching toenails and hair.

-Small dogs may be used to being placed on tables but still should walk on a rubberized mat, yoga mat or fleece cover so they do not slip and the table is not cold.

-If getting onto the table is a game with staged rewards, dogs will immediately go to the table at all appointments.

>Let the dog have autonomy in determining the pace at which the examination occurs.

-We are taught to examine dogs starting at the tip of the nose and moving though the tip of the tail. Unfortunately, a recent study has shown that dogs are more stressed when people handle their head, neck or muzzle or hold the dog by the collar. These human behaviors cause the dog to respond with sympathetic system arousal as indicated by behavioral and cardiovascular measures.15

-Instead, start the examination with the body parts the patient offers first. Ears may be more easily accessible from the back forward than from front to back because there is less need to handle the head. Dogs do not see well close up, so the movement of your hand past their eyes can become a risk they cannot adequately assess. 

-Slow, steady pressure has been shown to have a calming effect in many contexts. Leave one hand on the dog, if the dog is calm, and using slow pressure move calmly to examine the dog. 

-If you are sitting down and doing your exam on the floor, most dogs can be asked to assume positions that will help you examine them-and which they might be unlikely to exhibit if you are towering over them. For example, many dogs lean against people when they sit: This presents a first-pass opportunity to examine hips and stifles. If further exam is warranted, you are more likely to get farther if you have developed a trusting relationship with the dog during the first-pass exam and the dog realizes it has some control over the pace of the exam.

Tips that may prevent fear 

>Play low-volume classic music or white noise.

>Speak softly. 

>Sit down. Have clients sit in a comfortable chair that helps them to relax, not one that is painful to balance on.

>Talk to the clients first while allowing the dog to acclimate to the surroundings.

>Dim the lights and, preferably, use targeted lighting as needed. If there is lots of natural light in the room, this is good for everyone, but be aware of possibly needing some shade for dogs with light-colored eyes or vision issues. Older dogs may do best with low-level lighting so they can see you better.

Managing odors

>Air out rooms as much as possible. Use disinfectants that do not have strong odors followed by air drying. If possible, open a window. 

>If using bleach, ensure that the room and surfaces are dry and well-aired because even a 1 percent solution can kill olfactory neurons. If olfaction is how you get your information, loss of olfactory neurons is a stressor and will render the patient more, not less, anxious. Dogs use olfaction for identifying everything, including risk.

>There is no scientific evidence that pheromonal products lessen the stress or distress of dogs in clinical settings.16

Step 6: Administering tests and treatments

>As with all animals, struggle and stress are lessened if the patient can be examined in natural postures (standing) or in ones comfortable to them (your lap or the client's lap if the dog is small).

>Examination should be a natural part of the flow of conversation and history taking. 

>Small dogs may benefit from towel wraps as cats do. Some dogs do better if they are wearing eyeshades, head covers such as Calming Caps or wraps such as Thundershirts, but you must know ahead of time if this is true. Again, this is where your staff can play a major role in learning whether such interventions can be tried at home and can benefit the dog. If clients are shown how to use these tools they are more likely to try them. Clear communication seldom lets you down.

>True restraint is painful and scary for dogs as it is for cats. The same tips for drawing blood outlined in the cat exam section apply here.

-If dogs have been hurt for blood draw, try using topical gel or crème lidocaine or a lidocaine-prilocaine mix (a little cheaper than lidocaine alone) on the area. Wait a few minutes to manipulate the region and you might be surprised. 

-Taking temperatures and emptying anal sacs are pretty invasive and potentially painful events. The use of lidocaine or a lidocaine-prilocaine mix can be nearly miraculous. Once dogs are certain they will no longer be hurt, their tails are not tugged on so much, and they can easily be taught to “show me your bum.”

>If a dog is extremely distressed and the exam is not of medical urgency, you may wish to delay further evaluation and discuss anti-anxiety medications or some level of sedation with the client so that the dog is able to have the kind of medical care he or she deserves.

Step 7: Discharging the patient 

>If the dog is distressed, minimize change. Allow the dog to remain in the carrier, covered, or in the room with the client and conduct all discharge and payment interactions either in the exam room or remotely once the dog is safely in the car or home, wherever he or she is most comfortable.

>Consider anti-anxiety medication at the time of the appointment so that the dog aborts the full neuromolecular loop of making molecular memory of the scary experience.

>If the dog is not distressed, congratulate the client and reward the dog with play, a new toy, treats, huge amounts of praise-and do not rush them out the door. The praise portion of the visit needs to be as long as possible so that the dog can adequately gauge how safe and reliable the experience was.

Step 8: Concluding the visit by taking the patient home

>If the dog was calm on the way to your clinic but had a bad experience there, consider that the trip home may not be so calm. Medication either during the visit or after the visit may help the dog to learn not to loathe veterinary visits and to associate them with less stress and distress than would have otherwise been the case. 

>If the dog was distressed, consider buffering his or her brain against the damage caused by the stress/distress. Give the dog 1,200 to 1,500 mg of omega-3s daily.17-19 

Any successful effort to mitigate fear and distress in our patients and to make exams Fear Free for them and easier for us will rely on a signaling currency that allows goals to be shared and accomplished. It's hard work for all of us to understand and find those signaling currencies. Mitigating fear requires that we alter our behaviors and thoughts, also. Change is a lot more complex than stocking treats, putting a toy in a crate and adjusting the lighting. These step-by-step plans are a good outline for where to start, but their larger intended effect is to alter our pattern of observations so that we use those observations to improve everyone's quality of life. 

To view the references for this article, visit dvm360.com/FearFreerefs