The goal of this presentation is to develop the skills needed to create a comprehensive problem list of clinical behavior problems. In order to successfully address behavior problems and to provide solutions it is critical to name the problem to be solved. This seems to be a simple task; however, in this lecture we will find out why this is harder than it seems. And why it is so critical to have this skillset mastered. We will further address those challenges. We will learn in this presentation how to create a problem list that is useful to the clinician in solving the behavior problem at hand. The quality of the problem list is tightly connected to the solution and veterinarians cannot afford to ignore this important skill. And although this approach is emphasized in the veterinary education when it comes to medical cases, it doesn’t seem intuitive to most clinicians when trying to solve behavioral cases.
“A problem named is a problem solved.”
There is certainly some truth to this saying when it comes to solving behavior problems. Why does it seem challenging for many students and practitioners to create a problem list in behavior medicine? Most clinicians are very familiar in creating a problem list for their medical cases, most use the “SOAP” approach to help them stay organized with their cases. When it comes to behavior cases however, objective documentation is often missing in the medical record.
Why? It seems more difficult for some reason to stay away from subjective descriptors or “lay-term” diagnosis provided by owners. We need to keep in mind that only veterinarians can diagnose a medical or behavioral condition and hence we are obligated as professional health care providers to conduct our own data collection in an objective manner using professional language and document them into the medical database of the patient.
Example 1: Doctor, my dog has “separation anxiety.” This is a commonly heard sentence in veterinary practice. Starting with this comment, or “lay term diagnosis,” the practitioner is now obligated to follow up with a series of questions to extract the objective descriptors of the ethogram or behavior catalogue. The clinician must go beyond this statement and create a problem list. “Separation anxiety” is a diagnosis and not a problem, hence should not be entered in the medical record as a problem. It can be entered under S: owner reports Fluffy is exhibiting “separation anxiety” consisting of vocalization when left alone.
Problem: Vocalization when left alone
It is especially critical in behavioral medicine to create a complete and accurate problem list, because in behavioral medicine there are no, or only very few, diagnostic tests available to help reach a diagnosis. In behavioral medicine, the clinician must rely heavily on history and observations for the diagnosis. Hence, it all starts with the statement of the problem or issue and based on this, the collection of good data can begin. But even before we can begin this process of collecting the data, there is a preliminary step that cannot be overlooked. It must begin with recognizing that there is a problem or an issue. In some cases, the problem is brought to the clinician’s attention:
Example 1: Dog is vocalizing when left alone. This was reported to the owner as a complaint by a neighbor. Clearly a problem for the owner and the neighbor. In other cases, the owner is unaware of the problem. The general practitioner is overall very familiar with bringing medical issues to a client’s attention, even if the client does not name the problem in the history or during the exam.
Example 2: Mrs. Smith, while listening to Fluffy’s heart today, I was able to detect a slight murmur. Similarly, veterinarians need to learn to treat behavioral observations the same way and understand that they need to be brought to owner’s attention to address the overall welfare of their patients.
Example 3: Mrs. Smith do you notice how Fluffy startled and then hid behind your legs when I dropped my otoscope accidentally on the table? Have you noticed similar fear behavior with any noises at home? Therefore, the first step in creating the problem list is indeed identifying the issue. In some cases, the client brings the issue to the attention of the veterinarian or staff, in other cases the owner is unaware and the DVM needs to bring the issue to the client’s attention.
Step 1: Identifying the issue:
Once the issue or issues are clearly identified, research then needs to be conducted in form of collecting data. The data needs to be specific, objective and documented in the medical record. Behavioral data needs to be entered along with any medical problems for a complete picture of the patient’s health status.
Step 2: Gather objective data: history and observation (this may require further diagnostics):
Before proceeding to the next step, it is critical to discuss the problem list with the owner and clearly communicate everyone’s interests (owner, family members, DVM), as well as the impact on the animal’s overall welfare.
Step 3: Understand everyone’s interests and needs.
Once all the data is gathered, the analysis of the data can begin. In behavioral medicine we need to fully understand that many problems are situational or context specific. Behavior needs to adapt constantly and what can be viewed as a behavior problem by some owners, may serve the function of coping or survival. With this in mind, the problem at hand could likely have multiple solutions. In order to find the right solution later in the process, it is critical to define the problem clearly and evaluate and explore the issue(s) in detail. This allows a root cause analysis to be performed. As veterinarians, we understand that systems and events are connected: What happened and why. With a root cause analysis approach, we can prevent problems from happening again in the future and then create (a) solution(s).
A detailed problem list would read as follows:
Example 1: Destruction (chewing, scratching) of door frames at main exit door, high pitched vocalization and urination immediately starting every time when owner has left the home.
Example 2: Grade 2/6 holosystolic heart murmur.
Example 3: Startle response followed by hiding behind owner’s legs after loud sudden noises only at the veterinary office or any other novel places
“A problem named is a problem solved”: With a detailed problem list the decision can be made based on the problem named and the context in which the problem occurs. The next step is moving towards creating the solution.
Step 4: Decision making process
Throughout the process it is critical to communicate clearly and frequently. It is also vital to not try to solve multiple problems all at the same time, but to triage and prioritize them one by one. With a detailed and comprehensive problem list, success can be defined and progress can easily be tracked leading to higher owner compliance and a better outcome.
Step 5: Follow up
It is important to referring back to the original problem list when reassessing the patient. Commonly, a client feels there is no progress because a new problem arises. Clients will often bring up new emerging behavior problems during recheck appointments. Hence, it is very helpful to refer back to what problem was addressed and how that particular problem is progressing. I will add terms like “managed,” “resolving,” or “resolved” to the problem list to keep track of progression during the treatment period. This will allow the owner as well as the clinician to objectively track progress or lack thereof. By referring back to the original problem list the owner can easily be reminded how much progress has been made, owner compliance can be checked, and treatment plans can be adjusted if needed.
Implementing the skills:
Problem solving approach acronym: IDEAL* (*adapted from source www.tedsf.org)
- Identify: History and observation. May have to bring problems to owner’s attention
- Define: Objective collection of ethogram before, during and after the event causing the concern(s)
- Explore: Understand everyone’s interests and patient’s welfare needs
- Action: Root cause analysis and problem-based solutions
- Lookback: Evaluate progress and overall success
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