Materials and Methods

Videotapes obtained for 2 previous studies^10,15 were used in the present study. Details of the study design, including sampling strategy and data collection, have been described previously.¹⁰ Briefly, a random sample of 50 veterinarians was recruited from the population of companion animal practitioners in southern Ontario. Participants were contacted by one of the authors (JRS) to inform them of the project, obtain consent, and arrange a site visit. All clients who arrived for a scheduled appointment during the site visit were invited to participate in the study. Fifty veterinarians and 300 veterinary medical appointments were videotaped. For each veterinarian, a minimum of 6 appointments was videotaped, including at least 3 wellness appointments and 3 problem appointments. A brief survey was administered to veterinarians and clients to obtain information on demographic traits of participating practices, veterinarians, clients, and pets. The Human Ethics Committee at the University of Guelph approved the research protocol.

Appointment types—A wellness appointment was defined as a veterinary encounter with a presumably healthy juvenile, adult, or geriatric dog, cat, or small mammal that had been brought to the veterinary clinic for an annual examination. A problem appointment was defined as a veterinary encounter with a dog, cat, or small mammal experiencing a health-related issue. Appointment type was classified by the researcher (JRS) on the basis of the primary reason for the appointment. When > 6 appointments were videotaped for any individual participating veterinarian, 6 appointments were selected for analysis on the basis of case representation and video and audio quality.

Demographic data—Practice data that were collected included the number of veterinarians in the practice, appointment duration, practice type (ie, exclusively small animal or mixed animal practice), and location of the practice (ie, rural, suburban, or urban). Data collected regarding participating veterinarians included age, years of clinical experience, gender, ethnicity, and previous communication skills training. Data obtained regarding participating clients included how long they had known the veterinarian, number of visits per year to the veterinarian, age, gender, educational background, and household income. Clients were also asked to report the species, breed, sex, and age of their pet and the number of pets in the household.

Videotape analysis—Videotapes of the 300 medical appointments were submitted to the laboratory of Dr. Debra Roter at the Johns Hopkins Bloomberg School of Public Health for analysis with the RIAS. For each videotape, a trained coder dissected the veterinarian-client-patient dialog into individual statements (Appendix) and then, using the RIAS framework, assigned a variable to each statement that conveyed a complete thought.¹⁰ Interactions were analyzed in 3 directions: veterinarian to client, client to veterinarian, and veterinarian to patient.

Evaluation of the clinical interview process— Communication variables were grouped to reflect the 4 tasks of the clinical interview (ie, data gathering, client education, relationship building, and establishing a partnership). Data gathering encompassed question asking during the history segment of the appointment that was used to gain an understanding of the patient's problem. Client education involved providing information to the client about the pet's illness or about how to care for the pet and was used to motivate the client to adhere to the treatment plan. Relationship building involved developing a rapport with the client and responding to the client's emotions. Establishing a partnership involved encouraging client participation and facilitating expression of the client's expectations, preferences, and perspectives to engage in shared decision-making.

Determining content of the medical dialog—Content of the veterinarian-client-patient communication related to data gathering and client education was classified into 4 topics: biomedical, lifestyle activities, social interactions, and anticipatory guidance topics, reflecting the content-based codes within the RIAS. Biomedical content included discussion of the medical condition and the diagnosis, treatment, and prognosis. Lifestyle activities included discussion of the pet's exercise regimen, environment, diet, and sleeping habits. Social interactions included discussion of the pet's personality, temperament, or behavior and human-animal and animal-animal interactions. Because of the low frequency of discussion of lifestyle and social topics, these categories were combined into a single category called biolifestyle-social. Anticipatory guidance topics incorporated discussion of expectations for normal development of an animal throughout its life stages, including changes in behavior, feeding, sleeping habits, exercise routine, and socialization with people and other animals. Content of the veterinarian-client-patient communication related to relationship building was classified as positive talk, negative talk, social talk, and rapport building. Content related to establishing a partnership was classified as facilitation and orientation.

Determining emotional tone—During their analysis of the videotapes, coders judged the emotional tone by assigning global ratings on a Likert scale from 1 to 5 (1 = low and 5 = high), reflecting the extent to which the veterinarian and the client expressed positive (eg, interest, friendliness, responsiveness, sympathy, and respectfulness) and negative (eg, anger, anxiety, dominance, depression, emotional distress, and hurried) emotions. Ratings were based on nonverbal communication between the veterinarian and the client, and separate ratings were assigned for the veterinarian and the client. Emotional tone ratings were assigned by 2 coders; intercoder agreement for scores assigned for individual emotions, determined on the basis of the Pearson correlation coefficient, ranged from 60% to 100%.

Statistical analysis—Statistical analyses were performed at the appointment level (n = 300), with the data set stratified into wellness and problem appointments. Responses for each appointment type were averaged, and differences were analyzed with paired t tests. The Shapiro-Wilk test was used to determine whether data were normally distributed; data that were not normally distributed were log transformed. Because many of the count data included zero, small bias correction factors were added when performing log transformations (typically, 0.05 to 1.0). If the normality assumption was not adequately met following log transformation of the data, the Wilcoxon signed rank test was used in place of the paired t test. All statistical analyses were performed with standard software.^a Values of P < 0.05 were considered significant.

Results

Demographic data—Full demographic characteristics of the study population have been published.¹⁵ In summary, of the 50 veterinarians who participated in the study, 26 (52%) were female. Forty-three (86%) were white. Mean age was 41 years (range, 26 to 68 years). Thirty-nine (78%) of the participants worked in multiveterinarian practices. Twenty-four of the 48 (50%) veterinary practices were located in suburban regions. Of the 300 clients, 220 (73%) were female. Mean age of all 300 clients was 43 years (range, 14 to 86 years), and clients came from a variety of socioeconomic and educational backgrounds. Of the 418 pets, 158 (38%) were cats, 255 (61%) were dogs, and 5 (1%) were small mammals (ie, rabbits, guinea pig, ferret, and rat) of various ages and either sex. Forty-five of the 300 (15%) appointments were first-time interactions with the veterinarian.

There were several significant differences in client and pet demographic characteristics between wellness and problem appointments. Clients who had brought their animals for a problem appointment reportedly made significantly (P < 0.01) more visits to a veterinarian on an annual basis (mean, 3.7 visits/y; range, 0 to 30 visits/y) than did clients who had brought their animals for a wellness appointment (mean, 3.3 visits/y; range, 0 to 75 visits/y). For 31 of the 150 (21%) wellness appointments, the client had brought > 1 pet, whereas clients had brought > 1 pet during only 7 (5%) problem appointments (P < 0.01). Eighteen (12%) problem appointments included a puppy or kitten, 77 (51%) included an adult animal, and 47 (32%) included a geriatric animal. In contrast, 39 (26%) wellness appointments involved a puppy or kitten, 65 (43%) involved an adult animal, and 27 (18%) involved a geriatric animal. The distribution of animal age was significantly (P < 0.01) different between appointment types.

Appointment duration—There was no significant (P = 0.43) difference in appointment duration between wellness and problem appointments. Mean duration of wellness appointments was 13 minutes (range, 2 to 46 minutes), and mean duration of problem appointments was 14 minutes (range, 2 to 49 minutes). For both types of appointments, the veterinarian contributed approximately 60% of the total conversation (approx 50% directed toward the client and 10% toward the pet), and the client contributed approximately 40%. Veterinarians talked twice as much to the pet (10%) during wellness appointments as they did during problem appointments (5%; P < 0.01).

Veterinarian-to-client communication—During both data gathering and client education, veterinarians directed significantly more biomedical statements and significantly fewer biolifestyle-social statements toward clients during problem appointments than during wellness appointments (Table 1).

Discussion

Results of the present study suggested that as we had hypothesized, veterinarian-client-patient communication differed between wellness and problem appointments in companion animal practices, with differences reflecting the unique contexts of these appointments. In general, wellness appointments were characterized by broad topics of discussion, including lifestyle activities, social interactions, and anticipatory guidance topics. Veterinarians emphasized rapport building and interacting with the pet, both veterinarians and clients engaged in social conversation, and the atmosphere was relaxed and friendly. On the other hand, problem appointments were characterized by a narrow focus on biomedical information exchange and client education, clients expressed more concern, and during some appointments, the emotional atmosphere seemed tense. No differences were found in time spent in data gathering, relationship building, or establishing a partnership between wellness and problem appointments.

During both wellness and problem appointments, only 8% to 9% of the veterinarian-to-client communication, on average, was devoted to gathering data. Further in-depth analysis of the history segment of the clinical appointment is required to fully assess the efficacy of data gathering. However, these initial results raise concerns regarding the effectiveness of data gathering during problem and wellness appointments, particularly given that in human medicine, results of history taking and the initial physical examination have been shown to be critical in forming clinical judgments about diagnosis, treatment, and prognosis.²⁴ In human medicine, for instance, up to 88% of diagnoses have been determined by the time the history had been obtained and a physical examination had been performed.²⁴ In 56% of cases, the diagnoses were established by the end of the history segment, and in 73% of cases, the diagnoses were established at the end of the physical examination.²⁵ Because the quality of data gathering during the clinical appointment is so crucial to clinical effectiveness, efficiency, and accuracy, it is vital to designate adequate time to obtain key historical data.

Importantly, in our previous study¹⁰ of the same videotapes used in the present study, we found that data gathering was primarily (87%) composed of closedended questioning. Evidence in medical communication indicates that asking closed-ended questions limits the field of inquiry and has the potential to negatively affect diagnostic accuracy.²⁵ Open-ended questions are exploratory in nature and more likely to reveal highquality information from the client's point of view. In addition, open-ended questions initiate a collaborative process early in the clinical interview, which is integral to achieving shared decision-making.²⁵ Shared decision-making involves exploring the client's perspective (eg, “How do you feel Molly's weight is impacting her overall health?”), ascertaining the client's thoughts (eg, “What do you think might be contributing to Molly's weight gain?”), and assessing the client's starting point (eg, “What do you know about the risks Molly might face as a result of being overweight?”). Extrapolating from results of outcome-based studies²⁶ of medical communication, we believe that eliciting information on a client's expectations, thoughts, feelings, and fears about the pet's health or illness will enhance client participation in the appointment and may potentially increase client satisfaction and adherence to veterinary recommendations.

During problem appointments in the present study, data gathering was predominantly focused on biomedical topics. However, exploring the broader life setting of the client and pet allows a veterinarian to gain a greater understanding of the pet's illness.²⁷ Multiple factors have an impact on any particular client's decision to provide treatment for his or her pet. Taking time during the clinical interview to learn about the client's unique situation may aid in acceptance of the diagnostic or treatment plan. It may be important to assess the degree of attachment between the client and the pet, to discuss the client's financial resources and develop a plan within those limits, to identify the primary animal caregiver and discuss the feasibility of the plan in regard to that individual's ability to provide care for the pet, and to gather information related to life events that may impact the pet's health, such as a recent move, divorce, death of a family member, or birth of a child. Broadening the data-gathering portion of the clinical appointment ensures that the veterinarian and client have a shared understanding early in the process, which should enhance agreement and adherence.²⁶

It was not surprising that veterinarians spent more time on client education and focused on biomedical topics when educating clients during problem appointments in the present study. The biomedical approach is the approach that veterinarians have traditionally been taught to use during clinical appointments. Problem appointments focus on instrumental biomedical tasks, such as obtaining a history, making a diagnosis, developing a treatment plan, and educating the client. However, a sole emphasis on biomedical topics limits the field of inquiry, whereas including lifestyle and social factors broadens the perspective, enhancing the diagnostic and treatment plan.^26,27

Traditionally, veterinarians have focused primarily on biological or physical explanations of disease. However, not all animal diseases are purely biological in origin.²⁷ Thus, using a combined biological and sociologic perspective may allow the veterinarian to capture information on a more complete range of problems in veterinary medicine.²⁷ Behavioral problems and obesity are examples of disease processes with biological, life-style, and social dimensions. Depending on the problem, broadening the focus to include animal behavior, environmental conditions, mental health and well-being, and human-animal interactions may enable the veterinarian to more accurately locate the source of the problem and care for the total health of the animal.²⁷

We found in the present study that veterinarians emphasized relationship building during both wellness and problem appointments. The difference in conversation devoted to relationship building was significant, with only a small difference in numbers of relationship-building statements between wellness and problem appointments. However, the emotional tone during wellness appointments tended to be relaxed, whereas veterinarians were rated as being significantly more hurried or rushed and clients were rated as being significantly more anxious or nervous and significantly more emotionally distressed or upset during problem appointments than during wellness appointments. It is unknown whether veterinarian stress or client anxiety made it difficult to establish rapport during problem appointments or whether the lack of rapport building during problem appointments contributed to the emotional tension. Communication dynamics are grounded in reciprocity theory,¹³ so that what veterinarians say and how they present themselves influences clients and vice versa. Communication evolves as the result of iterative veterinarian and client interactions.

Importantly, rapport building occurs over time. Subjectively, it seemed to us that during wellness appointments, veterinarians invested in building a strong veterinarian-client-patient relationship and that during some problem appointments, veterinarians used previously established relationships to take on more challenging discussions, such as decision-making, financial limitations, or end-of-life conversations. This strategy may be effective with long-term clients but would be challenging with new clients. The number of established veterinarian-client-patient relationships was the same for the 2 appointment types in the present study, so this does not seem to explain the differences in rapport building between the 2 appointment types.

Wellness appointments are typically routine appointments in veterinary medicine. In contrast, problem appointments can be complex and challenging, providing multiple sources of stress for veterinarians and their clients. Clients currently have more sources of information than they had in the past and often have higher expectations,^28,29 with the result that veterinarians may feel challenged when managing patients with complex medical and surgical problems. In addition, changes in the way clients view their pets may add additional pressure.²⁸ In a recent survey,¹ for instance, it was found that 85% of pet owners in the United States consider their pets to be members of the family. This may increase the emotional stress on the client when a pet becomes ill and may cause clients to appear unreasonably demanding. Client behaviors that are often labeled as difficult are frequently expressions of grief, including concern, anxiety, guilt, or anger.³⁰ Delivering bad news and discussing euthanasia with clients are difficult and stressful tasks,³¹ and dealing with financial issues can be a major source of stress.²⁹

Rapport building is an important task during the clinical appointment, and less time spent building a rapport with clients during problem appointments may decrease the potential to achieve important outcomes, such as client satisfaction and adherence to veterinary recommendations.^1,11,29 Medical communication studies report positive associations between rapport building and accuracy of data collection,²⁶ patient satisfaction,^19,20,32 and physician satisfaction.^16,33 Rapport building is highly valued by clients, as suggested by the fact that clients report that the veterinarian being kind and gentle is their number one criterion when choosing a veterinarian.¹ Client satisfaction is derived from a caring and compassionate veterinarian-client-patient relationship.^29,34,35

Success in client education is dependent on providing the right amount and type of information, customized for each individual, at the appropriate time.³⁶ Effective client education is based on interaction rather than on direct transmission.²⁵ Traditionally, the focus has been on providing information to the client through a lecture approach, and it was assumed that the client received the message. With an interactive approach, client education is dependent on a having a dialog with and receiving feedback from the client. This reflects a paradigm shift from guardianship to partnership.

Veterinarians emphasized partnership building equally during wellness and problem appointments in the present study. As we have previously reported,¹⁰ veterinarians, on average, devoted 13% of their conversation to partnership building. Similarly, previous authors have reported that physicians dedicate approximately 10% of the clinical appointment to partnership building.¹³ Building a partnership with the client entails encouraging the client to participate in the medical care of the pet. Importantly, there was evidence of client activation during both types of appointments in the present study. During wellness appointments, clients asked more questions and gave more directions, and veterinarians were more likely to ask for the client's opinion. However, in 30% of wellness appointments and 50% of problem appointments, veterinarians did not elicit the client's opinion. During some problem appointments, clients expressed statements of criticism, which indicated engagement and reflected the client's comfort with expressing alternate ideas or dissatisfaction. In addition, during problem appointments, veterinarians were more likely to ask for the client's understanding of their pet's medical condition.

Evidence in human medicine indicates that taking the client's perspective into account and establishing mutual understanding and agreement encourages the client to participate fully in the discussion and to commit to the treatment plan.^13,26 In veterinary medicine, this would entail encouraging the client to contribute (eg, “What questions do you have?”), picking up on client cues (eg, “You seem a little hesitant about surgery.”), asking for client suggestions (eg, “What options have you and your husband discussed?”), and checking for the client's understanding (eg, “What will be most difficult for you?”). In human medicine, creating an active role for the patient enhances shared decision-making, which is related to increased patient satisfaction,^19,32 better adherence to recommendations,²¹ and improved health outcomes.²² Encouraging client participation in the clinical interview is a key mechanism for improving client compliance.¹¹

Limitations of the design of the present study, including limitations of the sampling procedure and of the quantitative procedure used to measure communication, have been discussed previously.¹⁰ Our previous analyses have suggested that the RIAS is a reliable method of assessing veterinarian-client-patient communication and is applicable to veterinary medicine.¹⁰ A limitation of the RIAS as it was used in the present study was the subjective nature of the emotional tone ratings. This was reflected in the fact that there was only moderate intercoder reliability.

The present study was exploratory in nature and did not take into account other interacting or confounding factors that may partially explain the differences in communication between wellness and problem appointments. In a previous analysis¹⁵ involving hierarchic modeling, few practice, veterinarian, client, or pet demographic variables were found to be associated with communication pattern use. Thus, it is likely that our findings reflect a true difference in veterinarian-client-patient communication between wellness and problem appointments. Given these differences, we recommended that future studies of veterinarian-client-patient communication include both types of appointments.

In our previous analyses of these videotapes,^10,15 most of the variation in results was detected at the appointment level. Thus, an important limitation of the present study was that only 6 appointments were videotaped for each veterinarian. A challenge for future studies will be to increase the number of appointments per veterinarian, while maintaining a representative sample of veterinarians. Another concern is videotaping appointments representative of the range of clinical experience,³⁷ as appointments included in the present study may not represent the entire range of wellness and problem appointments conducted by veterinarians in their day-to-day practice.

In human medicine, the recommended approach for physician-patient interactions is relationship-centered care, which is based on mutuality, negotiation between partners, and creation of a joint venture.^16,24,38 In veterinary medicine, relationship-centered care represents a joint venture between the veterinarian and client to provide optimal care for the animal. Respect for the client's perspective and interests and recognition of the role the animal plays in the life of the client should be incorporated into all aspects of care. Extrapolating from evidence in human medicine, we believe that using principles of relationship-centered care will be associated with clinically important outcomes in veterinary medicine. Specifically, findings indicate that broadening the field of inquiry to include lifestyle and social factors will improve diagnostic reasoning and accuracy^24,26; that building a strong relationship will be associated with increased accuracy of data gathering,²⁶ increased patient satisfaction,^19,20,32 and increased physician satisfaction^16,33; and that encouraging participation, negotiation, and shared decision-making will promote patient satisfaction,^19,20,32 increase adherence to recommendations,²¹ and improve health.²² Incorporating these principles of care alongside traditional biomedical tasks (eg, data gathering and information providing) optimizes quality of care.

Veterinary communication is a developing field within the veterinary profession. Enhancing communication competency requires creating communication curricula within the schools and colleges of veterinary medicine and offering continuing education programs in diverse venues for all members of the practice team. Given that this is an emerging field, descriptive studies are a valuable initial approach. The next step is to conduct outcome-based studies to investigate relationships between communication and clinical outcomes. There will be a need for focused studies on issues that are unique to the veterinary profession, such as fee-for-service payment, the human-animal bond, euthanasia, and ethical dilemmas. Communication curricula and a solid communication research agenda are integral to the success and ongoing evolution of the veterinary profession.