Speaking with pet owners is something veterinarians and veterinary technicians do constantly; as such, it is the most common “procedure” performed in veterinary medicine. Yet very few receive any guidance in this critical area during school or after. Does communication matter? Studies in human medicine have shown that the consumer perception of health care quality is highly dependent on the quality of interactions with doctor. A meta-analysis of 26 studies assessing patients’ and clinicians’ nonverbal communication during real clinical interactions and clinically relevant outcomes found clinician warmth and listening were associated with greater patient satisfaction (p<0.001 both), while nurse negativity was associated with less patient satisfaction (p<0.001). Also, the consumer satisfaction levels impact the clinical outcomes (people who liked their doctors did better). Other studies have shown that effective physician-patient communication has been correlated with at least five health outcomes including diagnostic accuracy, improved health status (BP, blood glucose, stress levels, pain management, etc.), improved adherence rates, better patient and physician satisfaction, and decreased malpractice risk.

Client satisfaction/retention is increased with good communication. The client feels respected and valued; this will lead to increased referrals and decreased liability. One survey showed that out of a multitude of factors pet owners desire in their veterinarian, the top factor was that the veterinarian was kind and gentle, number two was respectful and informative, and third was that there was a reputation for high quality care. Price was selected as number nine in importance. All members of the veterinary care team can play key roles in creating positive communications with clients. Showing kindness and respectfulness while providing information are all aspects of communication, aspects that can be improved upon with the use of specific skills and with practice. This talk will highlight four core skills and their application in difficult situations.

Non-Verbal Communication

A large percent of what we communicate is done via nonverbal channels. Thus, information that cannot be hidden is being exchanged at all times—both from the client to the veterinary care team member, and vice versa. The nonverbal aspects of communication are like a poker player’s “tell”—they give away what a client may be thinking or feeling, possibly contrary to what they are saying verbally. Thus, these unconscious nonverbal messages from a client more accurately reflect their feelings. Emotions are much more often communicated nonverbally than verbally. For example, we know when someone is mad because they raise the volume of their voice, have a different tone, change their posture, etc., not because they say “I’m so mad.”

Mixed messages occur when the verbal and nonverbal messages disagree. In these situations, the nonverbal message is more accurate and needs to be detected and addressed. A common experience is asking a client if they understand, and the client hesitantly says “yes,” often without meeting the speaker’s eyes. The nonverbals clearly say the client does not understand, and paying attention to that fact and trying to clarify things at that time will often save misunderstanding and upset in the future.

Another benefit to becoming aware of and following nonverbal clues is that they take up no extra time during an interaction. They are going on constantly during all interactions, and one needs to only consciously note them (and perhaps comment on them, see below) to help guide the discussion in a beneficial manner.

Empathy

Empathy does not mean one feels what the client feels, but rather that one can try to imagine what the client has or is experiencing. It is the proverbial “walking in someone else’s shoes,” and a key point is not only to imagine that experience but to show the client that understanding. Showing empathy is a key part in building rapport with a client. Just feeling empathy is not enough; the client will not know you feel it if you do not show it. Empathy can be shown in both verbal and nonverbal ways. Three key points of empathy are having a client know that they are being seen, being heard, and being accepted.

Being seen means not only physically seen, but seen as an individual person and not just a “client.” Ways to show back to the client that they are seen are to comment on a unique aspect of that individual unrelated to their pet’s medical concerns, such as their clothing (for example, if they are wearing a sport team’s logo), their pet’s collar, etc. It is also important that the client knows they are seen as a person when it comes to the medical issues, and that their emotions about these issues are noticed. A good way to show this by verbally stating what is seen: “you seem worried,” “you look very scared.” While these statements seem awkward or obvious at first, clients often greatly appreciate them. Firstly, clients value the empathy and bond more with the vet tech that shows it. Secondly, by bringing the emotion to the forefront, it can be dealt with and thus allow the client to feel it more and move on in the discussion about their pet. A statement as simple as “I can see this is difficult for you; I can’t imagine how hard it is for you to leave her overnight,” can be grounding for a client and may allow them to refocus on the medical conversation. Other nonverbal means to show a client they are seen is to use appropriate speaking tone and rate (e.g., quiet slower speaking in times of sadness) or posture in response to the client. Handing a box of tissues to a crying client is also a good means of showing empathy.

Being heard is a similar concept to being seen; the veterinarian not only needs to listen to the client, but needs to show them that they are heard, and ideally understood. This process is closely tied to one of the other core skills, reflective listening (see below). One way to view this process is as an “inhale and exhale.” Listen and take in what the client is saying (inhale) and then show appreciation and understanding of their experience (exhale). This showing to the client can be accomplished both verbally and nonverbally. Reflective listening (below) describes the verbal showing. Nonverbal showing would include appropriate facial expressions, nodding, leaning in towards the client, etc.

Being accepted is an inherent desire in people, and this acceptance will help an owner to be open and honest with the care team member and help them also to voice concerns or questions that they may be embarrassed to mention otherwise. It also helps clients to work through difficult problems and see the vet tech as supportive as opposed to adversarial. There are several categories of statements that one can make to help a client feel accepted, and intentionally using these statements will take conscious effort and can be of great benefit in improving the client-technician bond. Three types of statements include:

1.  Non-judgmental comment: “You were in a very difficult situation.”

2.  Normalizing comment: “It is so common for people to miss these masses until they get very large.”

3.  Self-disclosing comment: “My cat has behavioral issues too.”

These techniques for expressing empathy become even more critical with clients for whom it is difficult to feel empathy; verbally showing acceptance via the above phrases can help the client-veterinarian bond even for clients with whom it is very hard to bond. Note that showing a client that they are seen, heard, and accepted is also tied to reflective listening.

Open Ended Questions

Open ended questions are not just important in finding out the history, they are helpful during any discussions, including testing and treatment choices, as well as for assessing owner understanding. Additionally, they greatly increase the client-veterinarian bond by allowing a client to tell their story—a key part to feeling understood and valued as a person. This “story telling” does not need to be very long or unguided; specific techniques can be used to redirect clients that may be verbose. Very often, open ended questions save time in a discussion, as they allow the care team member to understand the true nature of the client’s concerns without misleading results that the use of only closed-ended questions may provide.

Closed ended questions begin with words such as “when, is, did, who, where.” These questions result in very short answers, often times “yes” or “no” or other one-word answers. Closed-ended questions create an atmosphere that is more like an interrogation than an interview, and they are very much centered on what the medical professional wants to know. These questions certainly play a role in an interview—they are helpful in emergency-type situations as well as in clarifying information. They are best used after open-ended questions.

Open-ended questions often begin with “what or how or tell me.” Avoiding “why” is preferred, as that word seems to carry judgment (“why did you do that?”). Open ended questions allow the client to talk and express their thoughts and concerns. While the client is “telling their story” they will use their own natural vocabulary; this allows the veterinary technician to ascertain what type of vocabulary to use in return when speaking to the client for greatest understanding. A very helpful way to start a visit with a client is to ask a big, broad question such as “What has been going on?” If you already know the complaint (e.g., receptionist took a brief history; the patient is hematuric), open ended inquiry can still be used while including the information you have: “So, Fluffy is having blood in her urine. Tell me what has been going on.” This technique both allows the client to know that you know their concern, and also allows them to share more and feel that their thoughts are worthwhile. Open ended questions are a powerful tool in improving a bond with the client, versus a rapid fire, just-the-facts interrogation style: “When did you notice the blood? Is she drinking more? Any straining?” etc.

In regards to conversations after the initial visit, open-ended questions continue to be very helpful. Even with ongoing cases and familiar owners, don’t assume an understanding of what the client is thinking. Open ended questions can avoid misunderstanding in difficult discussions. For example, rather than “Are you thinking about euthanasia?” and having an owner get upset because they were not, ask “what are your thoughts about options from here?”. Also, “ask rather than tell” is a great rule of thumb. When a new diagnosis has been made, asking a client what they know about the disease, rather than jumping into a description of the problem for the client, can save time in a discussion and avoid unnecessary client education. This asking not only allows the veterinarian to begin a discussion at an appropriate level, but also importantly shows the client that their knowledge is valued—this leads to a better client/veterinarian bond as the client feels treated as a unique and important individual.

Reflective Listening

Reflective listening is the technique, also called active listening, by which an individual “reflects” back what has been said, thus showing interest in and understanding of the meaning of what the speaker is saying. With this technique, the listener repeats back to the client what was said or even implied, often via paraphrasing. This technique is a key component of showing empathy, as stated previously. Also, reflective listening is an excellent tool for checking understanding by the care team member. Reflective statements not only allow the client to know they are heard and seen, they also allow the client to correct any misconceptions and add to the veterinary technician’s summary if needed.

A few simple tricks of reflective listening include nonverbals stated above, such as nods, smiles, mm-hmms, and hand gestures. Also, when unsure what to say, or wanting an owner to expound without your input, a simple verbal repeat of the last word of phrase said can be helpful: Client: “Momo has just been acting crazy.” Vet tech: “Crazy?”

Reflective statements can seem awkward at first; having a “stem” with which to begin is very helpful. The classic stem is “what I hear you saying is…” Other stems may feel more natural and include “so, you are saying…,” “it sounds like…,” “you are...”. A complete statement could be something like: “It sounds like you are worried that Turner is having a poor quality of life right now.” The client can then correct if that is not their main concern, or can feel a sense of relief that they are understood if that is the concern. Another example of a reflective statement in action is: “So you are concerned about the cost of the treatment?” This may elicit a “Yes, it seems very expensive” or maybe “No, the cost isn’t the problem, it is the time involved.” Thus, the true concern can be addressed. This paraphrasing is one of the most effective listening tools available when one wants to convey to someone that what they are saying is important, and it is also an excellent way to verify correct understanding of what the client meant to express, which leads to improved diagnostic and therapeutic patient management.

Summary

By actively employing a few communication techniques in daily interactions with clients - or staff, family or friends - difficult situations may not only be improved but often avoided. Employment of these techniques takes concentration; intentional communication is a phrase used to describe this effort. While at first the effort may seem artificial and uncomfortable, the skills (as all learned skills) will grow over time and become a more natural part of one’s communication with others.