Communication in veterinary medicine is a growing discipline, and communication is recognized as a core clinical skill. The Association of American Medical Colleges developed a taxonomy of competency domains for all health-care professionals, and interpersonal and communication skills are key competencies.1 Communication is one of the core competencies assessed by the AVMA Council on Education during the accreditation process2 and 1 of the 7 professional competencies recognized by the North American Veterinary Medical Education Consortium.3 The communication competencies include employing effective communication with clients, colleagues, other health-care professionals, and the public and in oral, electronic, and written formats.3 These conversations include routine visit communication, tasks such as elicitation of relevant patient history, client education and counseling, and the presentation of diagnostic and treatment options as well as the less common tasks of delivering bad news and disclosing a medical error or an adverse event.3
Results of client focus groups and in-depth inter-views4–6 reveal that clients want to be involved in the decision-making process and would like veterinarians to tailor client education to their previous experiences and information preferences. They appreciate it when a veterinarian takes time to listen, answer all their questions, and repeat key information.5 Veterinarians have an important role in clearly explaining how their recommendations promote the health and well-being of pets.7
Veterinarian-client communication is correlated with clinical outcomes. In a study8 in which closed- and open-ended solicitation of client concerns were compared, open-ended inquiry elicited more concerns and client dialogue with decreased odds of a new concern arising at the closing of the interview than did closed-ended inquiry. Investigation of the relationship between veterinarian-client communication and adherence to dentistry and surgical recommendations revealed that enhanced adherence was associated with clear recommendations, relationship-centered care, client satisfaction, an empathetic and unhurried atmosphere, longer appointment time, and use of positive rapport–building statements.9 Moreover, evaluation of the association between veterinarian-client communication and veterinarian satisfaction with the veterinary visit, or appointment, revealed that veterinarian positive talk was positively correlated with veterinarian satisfaction of wellness visits (ie, pets brought to the veterinarian for routine examination) and client rapport building and veterinarian-to-pet talk were positively correlated with veterinarian satisfaction of problem visits (ie, pets brought to the veterinarian because of a health problem).10
During the past decade, the veterinary profession and veterinary-client-patient relationship have been substantially affected by societal changes. Perhaps the biggest societal change is the recognition of the relationship between people and their companion animals.11 Provision of veterinary services in a manner that acknowledges the human-animal bond leads to better outcomes for veterinary practices and their patients.12,13 Another change is the proliferation of the internet and access to readily available information about animal healthcare. Some pet owners consult web-based resources rather than seek the advice of a veterinarian.14,15 Other pet owners conduct internet research before bringing their pets to a veterinarian and come to the appointment armed with questions and greater expectations than they have in the past.11 Most client complaints about veterinarians to regulatory bodies are related to poor communication and deficient interpersonal skills, and breakdowns in communication are a major cause of client dissatisfaction.14 Finally, the economic landscape of veterinary medicine has changed considerably during the past decade. Evidence suggests that the number of patient visits to veterinarians is decreasing despite an increase in pet ownership.15–17
In response, Partners for Healthy Pets was established in 2011 to provide veterinarians with tools, including communication skills, to ensure that pets receive preventative healthcare through regular visits to a veterinarian.18 Veterinary schools, organizations, and industry partners are investing in enhancing curricula, publishing articles, developing web-based resources, and offering continuing education sessions focused on veterinarian-client communication. Enhancement of communication skills is integral for a positive adaptive response to the evolution of veterinary practice and involves embracing the human-animal bond, empowering information-seeking behaviors of clients, meeting client expectations, educating clients, and building strong relationships.
Evidence-based recommendations guide medical communication skills training.19,20 Best practices in communication teaching and learning include delineation and definition of essential skills, observation of learners, detailed and descriptive feedback, video or audio recording and review, repeated practice and rehearsal of skills, and active small group and 1-on-1 learning.21 Experiential methods such as simulation are more likely to change behavior, through providing opportunities to practice and try alternative approaches, and receive feedback than are other methods.21
The study reported here is part of a case-based pretest–posttest interventional study of 3 veterinary practices in Denver. Few interventional studies have been conducted to assess the efficacy of communication skills education in a veterinary practice setting. In general, case-based studies are useful for studying educational innovations and evaluating programs through the application of processes in the field to enhance understanding and improve practice.22 A case study is a holistic means of describing social interactions and producing a rich account in a real setting mired by complexity. Case studies are often pilot studies that test hypotheses and inform future study design and research methods. The limitation of case-based studies is their lack of generalizability or representation; however, useful insights from cases can be transferred to similar contexts.
The first phase of this project was previously described23 and involved the participation of 4 veterinarians in a year-long curriculum that included interactive communication modules, individual coaching, and communication laboratories. Findings indicate that communication intervention was effective in enhancing the implementation of veterinarian-client communication skills by those veterinarians.23 After the intervention, the veterinarians gathered twice as much lifestyle and social data and used 1.5 times as much partnership building and positive rapport building, compared with results of pretraining visits.23 The clients responded by providing 1.4 times as much lifestyle and social data and expressed 1.7 times as many emotional statements in posttraining visits.23
Given the resource-intensive nature of a year-long curriculum, the goal of the second phase of the project was to assess the efficacy of a 6-month intervention. The study reported here is a case-based study of a 6-month communication education program at 1 veterinary practice to improve the implementation and use of veterinarian-client communication skills. The objective of this study was to evaluate veterinarian-client communication and veterinarian and client satisfaction with veterinary visits before and after veterinarians underwent a 6-month communication skills training program in a practice setting.
Materials and Methods
Study design
A 6-month-long, case-based pretest–posttest interventional study was conducted at a 3-doctor companion animal practice in Denver. The intervention period was from October 2009 through March 2010, with 2 months of data collection before and after the communication skills training (intervention). This timeline was based on the rollout of the intervention in the larger, multiple–veterinary hospital case-based study. For each of the 3 participating veterinarians, 6 client interactions were measured before and after the intervention, resulting in 36 video-recorded wellness and problem visits. Six visits per veterinarian were video recorded to capture representative client interactions within the financial limitations of the study. The video recordings were obtained with a handheld video camera set up on a tripod in the examination room. Additionally, visit satisfaction surveys were administered to the 3 veterinarians and 180 of their clients before and after the intervention. All practice team members participated in the project during the intervention period. Because of complications associated with collecting a comparable sample of video recordings of veterinarian-technician pairings before and after the intervention, only the veterinarian interactions were evaluated in the study. The practice team was composed of 10 veterinary professionals (3 veterinarians, 5 technicians, 1 receptionist, and 1 office manager). The Human Subjects Research Committee of the Colorado State University Research Integrity and Compliance Review Office approved the research protocol.
Communication skills education
The intervention consisted of 6 monthly 8-hour sessions at the practice, which allowed for repetition and reiteration of skills over time. Although the entire practice team participated in the intervention, measurement of the efficacy of the intervention focused only on the veterinarians. The fundamental principle of the intervention was client-centered care. The Calgary-Cambridge Guide,21 an evidence- and skills-based communication instrument, was used to delineate key communication skills and provide an organizational structure for the clinical interview and framework for the practice, observation, and feedback that occurred during the teaching sessions.
The components of the intervention included interactive communication modules, individual coaching, and a communication laboratory. During each practice visit, a 1-hour interactive, skills-based, topical communication module was presented to all practice team members to define, discuss, and practice essential communication skills. Topics discussed in those sessions included principles of client-centered care, 4 core communication skills (nonverbal communication, open-ended inquiry, reflective listening, and empathy), history taking, shared decision making, financial, and end-of-life conversations (eg, delivering bad news, euthanasia decision making, grief, and loss).
Most of the practice visit was spent conducting 1-on-1 communication coaching sessions in the clinic. Individual team members were observed interacting with real clients, and descriptive feedback was provided on their performance. Reflective self-assessment was integral to those coaching sessions and started each feedback session. The practice members set learning objectives for each coaching session that served as the initial focus for feedback by the process of agenda-led, outcomes-based analysis.21 Initially, we focused on the clinicians, but later we followed the client through the practice so that we could observe interactions between team members as they passed the case along from the client service coordinator to the veterinary technician to the veterinarian and back to the client service coordinator. The intent of the team-based approach was to enact change at the practice level and thereby create continuity of client and patient care throughout each step of the veterinary visit.
During the practice visit in the 4th month, a simulated client learning laboratory, the gold standard for teaching medical communication skills,21 was conducted to allow participants to practice specific communication techniques. Prior to the laboratory, participants identified key communication skills on which they wanted to work. After communicating with a simulated client, each participant provided a self-assessment and received feedback from their simulated client, coach, and peers. All sessions were video recorded, and team members reviewed their video, completed a reflection exercise, and created a personal learning plan.
Demographic data
A brief survey was administered to obtain descriptive information on the demographic characteristics of participating veterinarians, clients, and pets. Data collected for participating veterinarians included age, years of clinical experience, gender, ethnicity, and previous communication skills training. Data obtained for 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, sex, and age of their pets.
Appointment type
A wellness appointment was defined as a veterinary encounter with a presumably healthy juvenile, adult, or geriatric dog or cat for a routine examination. A problem appointment was defined as a veterinary encounter with a dog or cat with a health-related issue. The type of appointment was designated by the veterinarian at the time of the visit.
Veterinarian-client-patient communication
Video recordings of the 36 veterinary appointments were purposively selected and coded by experienced RIAS coders by use of adapted coding algorithms established in prior veterinary communication studies.24,25 The RIAS is the most widely used quantitative communication assessment instrument to evaluate dialogue in medical settings.25 Interactions were coded to capture 3-directional exchange (veterinarian to client, client to veterinarian, and veterinarian to pet). For the purpose of the study reported here, only the veterinarian-client interactions were analyzed. The video recordings were analyzed in a randomized order; therefore, the coders were unaware whether the encounter occurred before or after the intervention.
Intercoder reliability was performed on a 10% random sample of the video-recorded visits. The mean intercoder reliability was 0.94 (range, 0.81 to 0.98) for veterinarian-client communication and 0.86 (range, 0.38 to 1.00) for client-veterinarian communication. There was 100% agreement (within 1 point on a subjective scale) among coders on veterinarian and client emotional tone ratings.
Determination of the content of the veterinary dialogue
Visit communication was broadly categorized as biomedical content, lifestyle activities, social interactions, and anticipatory guidance, which reflected the 4 summary categories of RIAS codes.24 Biomedical content integrated discussion of a medical condition, diagnosis, treatment, and prognosis. Lifestyle activities included discussion of the pet's exercise regime, environment, diet, and sleeping habits. Social interactions reflected discussion of the pet's personality, temperament, or behavior and human-animal and animal-animal interactions. Anticipatory guidance topics incorporated discussion for expectations of normal development of an animal throughout the various stages of life (juvenile, adult, or geriatric animal). Because lifestyle and social topics were discussed infrequently, the data for those 2 categories were combined into a lifestyle-social communication category.
Determination of the emotional tone
In addition to topical content, coders also judged the emotional tone of the visit in regard to positive (ie, interest, friendliness, responsiveness, sympathy, respectfulness, or interactivity) and negative (ie, anger, anxiety, dominance, or hurriedness) emotions on a Likert scale from 1 to 5 where 1= low and 5 = high. Separate ratings were assigned for positive and negative emotions to both the veterinarian and client.
Summary measures of communication dynamics
Two summary measures of communication dynamics, verbal dominance and a client-centeredness score were used to describe the communication relationship (ie, the power relationship between the veterinarian and the client). The verbal dominance score26,27 reflected the balance of the dialogue between the veterinarian and client and was calculated as the total count of veterinarian statements divided by the total count of client statements. A score of 1 indicated that the dialogue was equally shared, whereas a score < 1 indicated that the client dominated the discussion and a score > 1 indicated that the veterinarian dominated the discussion.
The client-centered score was equivalent to the patient-centeredness ratio used in a number of prior RIAS studies in medical communication. It was calculated as the ratio of the sum of lifestyle-social, rapport-building, and facilitative behaviors by veterinarians and clients (ie, data representative of the client's agenda) to the sum of biomedical questions, information giving, and closed-ended questions (ie, data representative of the veterinarian's agenda).27–30 This measure has concurrent validity and has been linked to patient satisfaction and reported rapport.29–34
Veterinarian visit satisfaction
The satisfaction of a veterinarian with a specific visit (veterinarian visit satisfaction) was assessed by use of an adapted 20-item scale developed for human physicians by Suchman et al.35 One item (“This was a very satisfying visit for me”) evaluated global visit satisfaction. The original instrument35 assesses 4 dimensions of physician satisfaction (satisfaction with the physician-patient relationship, data-gathering process, effective use of time during the visit, and cooperative nature of the patient). Veterinarians completed the questionnaire after the visit. For this study, 2 modifications were made to the instrument to reflect the nature of the veterinarian-client-patient relationship; patient was replaced with client and a new item was added (“This patient [pet] is pleasant to work with”). All items were rated on a Likert scale, where 1 = strongly disagree and 5 = strongly agree.
Veterinarians completed the questionnaire after each visit. To evaluate the usefulness and reliability of the instrument in a veterinary context, factor analysis of the items was previously conducted, and the results were consistent with the scale structure developed by Suchman et al35 for use with human physicians.10
Client visit satisfaction
The satisfaction of a client with a specific visit (client visit satisfaction) was measured with a 15-item questionnaire developed by Coe et al.36 One item (“This was a very satisfying visit for me”) evaluated global client satisfaction. All items were rated on an unbalanced rating scale (1 = poor and 6 = could not be better). Clients completed the questionnaire after the visit. On the basis of findings of a decision, or D, study, collection of a minimum of 61 completed CSQs/veterinarian was necessary for the instrument to reliably differentiate veterinarians with an overall generalizability, or G, coefficient of 0.70; therefore, 30 CSQs were obtained for each veterinarian both before and after the intervention, resulting in a total of 60 CSQs for each veterinarian. The CSQ has strong reliability (G-coefficient for internal consistency = 0.96) and construct validity as determined by the relationships of client age and gender and type of visit to satisfaction.
Statistical analysis
Categorical client demographic variables obtained before and after the intervention were compared by use of χ2 tests. The distributions of continuous client demographic variables were evaluated for normality with Shapiro-Wilk tests; variables with values of P > 0.10 were considered normally distributed. Data obtained before and after the intervention were compared with t tests for continuous client demographic variables that were normally distributed and with Wilcoxon rank-sum tests for continuous variables that were not normally distributed.
The effect of the intervention on veterinarian and client visit satisfaction was evaluated for each item of the respective instruments used by means of linear regression. The regression model included variables for veterinarian, visit type (wellness or problem), intervention (before or after training), and the interaction between veterinarian and intervention. Veterinarian was included in the model to account for the lack of independence among observations owing to repeated measures for the same veterinarian. The interaction between veterinarian and intervention was evaluated to determine whether the effect of training differed among veterinarians and was retained in the model if its inclusion improved model fit (likelihood ratio F test P ≤ 0.10).
Comparisons of RIAS variables for veterinarians and clients that measured counts of events before and after intervention were performed by use of randomeffects negative binomial regression with veterinarian included in the model as the panel variable and intervention (before or after training) included as a fixed effect. The effect of the intervention for each global effect variable was evaluated by use of linear regression, which included variables for veterinarian and intervention. Veterinarian was included in the model to account for the lack of independence among observations owing to repeated measures for the same veterinarian.
The data distributions for percentage and ratio measures (eg, proportion of talking done by client and ratio of veterinary to client talk) were assessed for normality by Shapiro-Wilk tests. Measures that were not normally distributed were transformed with a Box-Cox transformation to normalize the respective distributions. Each measure was then evaluated with a mixed linear regression model that included a fixed effect for intervention (before or after training) and a random effect for veterinarian. All analyses were performed with commercially available statistical software.a Values of P ≤ 0.05 were considered significant.
Results
Demographics
The 3 participating veterinarians were all Caucasian and included 2 females and 1 male with a median age of 39 years (range, 33 to 45 years). The veterinarians had been in clinical practice for a median of 10 years (range, 5 to 13 years). The remainder of the practice team (5 veterinary technicians, 1 receptionist, and 1 office manager) was also Caucasian and included 6 females and 1 male with a median age of 31 years (range, 24 to 47 years) and had been working at a veterinary clinic for a median of 3 years (range, 1 to 19 years) at the time of study initiation.
Thirty client demographic surveys were completed for each of the 3 participating veterinarians both before and after the communication training (intervention); thus, 90 surveys were completed before the intervention and 90 surveys were completed after the intervention, resulting in a total of 180 completed surveys. The demographic characteristics of the client or patient populations did not differ before or after the intervention (Table 1).
Demographic characteristics of clients and patients before and after each of 3 veterinarians at a companion animal practice in Denver underwent a 6-month communication skills training program (intervention) in a practice setting.
| Client or patient | Variable | Before intervention | After intervention | P value |
|---|---|---|---|---|
| Client | No. of years known veterinarian | 2.75 (0.08–17.0) | 3.0 (0.0–20.0) | 0.56 |
| No. of visits/y | 2 (0–15) | 2 (0–18) | 0.82 | |
| Age (y) | ||||
| Gender | 43.5 (11.0–79.0) | 43.0 (6.0–76.0) | 0.61 | |
| Female | 66 (73) | 58 (64) | 0.20 | |
| Male | 24 (27) | 32 (36) | ||
| Education | ||||
| < High school | 1 (1) | 1 (1) | 0.85 | |
| High school | 26 (29) | 21 (23) | ||
| College | 44 (49) | 47 (53) | ||
| Postgraduate | 19 (21) | 21 (23) | ||
| Income (US dollars)* | ||||
| < $30,000 | 6 (8) | 3 (5) | 0.79 | |
| $30,000–$50,000 | 7 (10) | 7 (11) | ||
| > $50,000–$75,000 | 23 (31) | 17 (27) | ||
| Patient | Age | 5.0 (0.2–17.0) | 6.0 (0.2–19.0) | 0.12 |
| Sex | ||||
| Female | 51 (57) | 45 (50) | 0.37 | |
| Male | 39 (43) | 45 (50) | ||
| Species | ||||
| Canine | 74 (82) | 76 (84) | 0.69 | |
| Feline | 16 (18) | 4 (16) | ||
Values represent median (range) or number (%) of population. For each veterinarian, 30 clients completed a visit satisfaction survey (CSQ) before and after the intervention. Thus, 90 CSQs were completed both before and after the intervention; however, the clients that completed the survey after the intervention were not the same clients that completed the survey before the intervention.
Not all survey participants provided a response to this question.
Communication dynamics
The mean visit length was 23.7 minutes (range, 11.0 to 45.5 minutes) before the intervention, and increased significantly (P = 0.04) by 5.4 minutes following the intervention. The mean amount of talk from the veterinarian to the client during each visit after the intervention (438 statements; range, 224 to 614 statements) was significantly (P < 0.01) increased from that prior to the intervention (343 statements; range, 172 to 614 statements). However, the ratio of veterinary talk to client talk after the intervention did not differ significantly (P = 0.21) from that before the intervention, when 57% of the conversation was contributed by the veterinarian (53% directed to the client and 4% directed to the pet) and the remaining 43% of the conversation was contributed by the client. The overall mean verbal dominance (P = 0.44) and client-centeredness (P = 0.21) scores after the intervention did not differ significantly from those before the intervention (Table 2).
Mean ± SD values for RIAS total talk and verbal dominance measures for the 3 veterinarians of Table 1 before and after the intervention.
| Variable | Before intervention | After intervention | P value |
|---|---|---|---|
| Visit length (min) | 23.7 ± 10.2 | 29.1 ± 8.6 | 0.04 |
| All veterinarian to client talk (No. of statements) | 342.78 ± 130.77 | 437.78 ± 107.61 | < 0.01 |
| All client to veterinarian talk (No. of statements) | 280.33 ± 116.86 | 322.00 ± 94.12 | 0.11 |
| All veterinarian to pet talk (No. of statements) | 26.39 ± 21.07 | 25.83 ± 18.21 | 0.96 |
| Proportion of all talk veterinarian to client | 0.533 ± 0.070 | 0.559 ± 0.062 | 0.21 |
| Proportion of all talk client to veterinarian | 0.426 ± 0.067 | 0.408 ± 0.061 | 0.36 |
| Proportion of all talk veterinarian to pet | 0.041 ± 0.024 | 0.033 ± 0.020 | 0.27 |
| Verbal dominance score* | 1.41 ± 0.41 | 1.50 ± 0.36 | 0.44 |
| Client-centered care score† | 0.765 ± 0.318 | 0.651 ± 0.314 | 0.21 |
For each veterinarian, 6 appointments were video recorded both before and after the intervention for analysis with the RIAS. Thus, there were 18 videos analyzed both before and after the intervention.
The verbal dominance score reflected the balance of the dialogue between the veterinarian and client and was calculated as the total count of veterinarian statements divided by the total count of client statements; a score of 1 indicated that the dialogue was equally shared, whereas a score < 1 indicated that the client dominated the discussion and a score > 1 indicated that the veterinarian dominated the discussion.
The client-centered score was calculated as the ratio of the sum of lifestyle-social, rapport-building, and facilitative behaviors by veterinarians and clients (ie, data representative of the client's agenda) to the sum of biomedical questions, information giving, and closed-ended questions (ie, data representative of the veterinarian's agenda).
See Table 1 for remainder of key
Veterinarian-client communication
The mean number of closed-ended questions regarding lifestyle and social information asked by veterinarians per visit after the intervention (4 questions; range, 0 to 12 questions) was 60% lower than that prior to the intervention (7 questions; range, 0 to 16 questions; P = 0.05). The mean number of biomedical education and counseling statements made by veterinarians to clients per visit after the intervention (191 statements; range 86 to 318 statements) was 1.4 times that prior to the intervention (137 statements; range, 50 to 380 statements; P < 0.01). Following the intervention, veterinarians facilitated client communication 1.5 times times as frequently (mean, 51 statements [range, 26 to 99 statements] after intervention vs 35 statements [range, 11 to 74 statements] before intervention; P < 0.01) and expressed emotional rapport statements 1.25 times as frequently (mean, 35 statements [range, 17 to 55 statements] after intervention vs 28 statements [range, 11 to 43 statements] before intervention; P = 0.04) as they did before the intervention (Table 3). After the intervention, clients provided veterinarians 1.3 times as many biomedically relevant statements (mean, 98 statements [range, 32 to 209 statements] after intervention vs 76 statements [range, 12 to 190 statements] before intervention; P = 0.05) and engaged in twice as much social conversation with their veterinarian (mean, 4 statements [range, 1 to 11 statements] after intervention vs 2 statements [range, 0 to 5 statements] before intervention; P < 0.01) as they did prior to the intervention (Table 4).
Mean ± SD values for RIAS veterinarian-speaking-to-client variables for the 3 veterinarians of Table 1 before and after the intervention.
| Category | Variable type | Question type | Before intervention | After intervention | P value |
|---|---|---|---|---|---|
| Data gathering | Biomedical | NA | 14.3 ± 9.6 | 15.9 ± 7.2 | 0.34 |
| Closed-ended | 13.0 ± 8.9 | 14.1 ± 6.8 | 0.44 | ||
| Medical | 9.6 ± 6.2 | 10.3 ± 5.2 | 0.52 | ||
| Therapeutic | 3.1 ± 4.3 | 3.6 ± 3.6 | 0.58 | ||
| Other | 0.28 ± 0.67 | 0.22 ± 0.43 | 0.99 | ||
| Anticipatory guidance | 0 | 0 | — | ||
| Open-ended | 1.3 ± 1.1 | 1.8 ± 1.7 | 0.22 | ||
| Medical | 1.1 ± 1.0 | 1.2 ± 1.4 | 0.76 | ||
| Therapeutic | 0.17 ± 0.51 | 0.56 ± 0.98 | 0.10 | ||
| Other | 0 | 0 | — | ||
| Anticipatory guidance | 0 | 0 | — | ||
| Bid for repetition | 0 | 0.1 ± 0.2 | — | ||
| Lifestyle-social | NA | 9.5 ± 6.5 | 6.8 ± 4.6 | 0.21 | |
| Closed-ended | 8.9 ± 5.8 | 5.9 ± 4.1 | 0.13 | ||
| Lifestyle | 7.2 ± 5.5 | 3.9 ± 3.5 | 0.05 | ||
| Social | 1.7 ± 1.9 | 2.1 ± 2.6 | 0.86 | ||
| Anticipatory guidance-social | 0 | 0 | — | ||
| Open-ended | 0.6 ± 1.2 | 0.9 ± 1.3 | 0.48 | ||
| Lifestyle | 0.6 ± 1.2 | 0.8 ± 1.3 | 0.57 | ||
| Social | 0.1 ± 0.2 | 0.1 ± 0.3 | — | ||
| Anticipatory guidance-social | 0 | 0 | — | ||
| Client education | Biomedical | NA | 136.6 ± 78.2 | 190.7 ± 66.2 | < 0.01 |
| Lifestyle-social | NA | 33.8 ± 22.2 | 42.4 ± 45.9 | 0.89 | |
| Building a relationship | Positive talk | NA | 50.7 ± 21.0 | 56.1 ± 19.4 | 0.29 |
| Emotion handling | NA | 27.7 ± 9.9 | 35.4 ± 12.1 | 0.04 | |
| Negative talk | NA | 0.4 ± 0.6 | 0.2 ± 0.4 | — | |
| Social talk | NA | 2.4 ± 2.8 | 2.8 ± 2.0 | 0.35 | |
| Establishing a relationship | Facilitation | NA | 35.4 ± 16.7 | 50.9 ± 18.9 | < 0.01 |
| Procedural | NA | 30.9 ± 12.5 | 35.2 ± 16.2 | 0.33 |
Biomedical variables integrated discussion of a medical condition, diagnosis, treatment, and prognosis. Lifestyle activities included discussion of the pet's exercise regime, environment, diet, and sleeping habits. Social interactions reflected discussion of the pet's personality, temperament, or behavior and human-animal and animal-animal interactions. Anticipatory guidance topics incorporated discussion for expectations of normal development of an animal throughout the various stages of life (juvenile, adult, or geriatric animal). Because lifestyle and social topics were discussed infrequently, the data for those 2 categories were combined into a lifestyle-social communication variable.
— = Not calculated. NA = Not applicable.
Mean ± SD values for RIAS client-speaking-to-veterinarian variables for the 3 veterinarians of Table 1 before and after the intervention.
| Category | Variable type | Before intervention | After intervention | P value |
|---|---|---|---|---|
| Question asking | Biomedical | 9.72 ± 8.24 | 13.89 ± 9.07 | 0.34 |
| Lifestyle-social | 1.39 ± 2.12 | 2.00 ± 2.72 | 0.63 | |
| Providing information | Biomedical | 76.39 ± 51.77 | 98.22 ± 44.58 | 0.05 |
| Lifestyle-social | 55.56 ± 35.13 | 44.83 ± 26.34 | 0.59 | |
| Building a relationship | Positive talk | 106.33 ± 52.83 | 123.22 ± 38.45 | 0.14 |
| Emotional rapport | 16.11 ± 8.11 | 18.22 ± 8.08 | 0.41 | |
| Negative talk | 0.44 ± 0.78 | 1.00 ± 1.33 | 0.12 | |
| Social talk | 1.72 ± 1.45 | 3.72 ± 2.70 | < 0.01 | |
| Establishing a partnership | Facilitation | 0.83 ± 1.25 | 0.94 ± 1.16 | 0.76 |
| Procedural | 11.06 ± 7.21 | 13.83 ± 9.39 | 0.41 |
Emotional tone
Coders assigned both veterinarians and clients an emotional tone score on a Likert scale of 1 to 5, where 1 = low and 5 = high. After the intervention, both veterinarians (mean Likert score, 1.70 after intervention vs 2.40 before intervention; P = 0.01) and clients (mean Likert score, 2.67 after intervention vs 3.00 before intervention; P = 0.05) appeared less hurried or rushed during appointments, compared with before the intervention. Also, clients appeared significantly (P = 0.05) more sympathetic toward the veterinarians after the intervention (mean Likert score, 3.89), compared with before the intervention (mean Likert score, 3.39).
Veterinarian visit satisfaction
Veterinarians rated their satisfaction with the visit on a Likert scale, where 1 = strongly disagree and 5 = strongly agree. Overall veterinarian visit satisfaction after the intervention (mean Likert score, 4.06) was significantly (P < 0.01) higher than that before the intervention (mean Likert score, 3.46). Most notably, veterinarians perceived that clients complained less (P < 0.01) and were more personable (P < 0.01) and more trusting (P < 0.01) after the intervention, compared with before the intervention (Table 5). For the remaining items evaluated, the ratings varied among the 3 veterinarians. For example, after the intervention, 1 veterinarian expressed greater satisfaction for a given item, whereas the other 2 expressed less satisfaction for that item, and vice versa. Also, for some items, veterinarian visit satisfaction varied significantly between wellness and problem visits. Veterinarians rated global satisfaction (P < 0.01), established rapport (P = 0.02), confidence to treat the patient (P = 0.03), and client understanding of explanations (P = 0.05) higher for wellness visits than for problem visits, whereas they rated did not get all details (P < 0.01), visit not necessary (P = 0.02), visit was boring (P = 0.02), did not get detailed physical examination (P = 0.01), and like to change client relationship (P = 0.04) higher for problem visits than for wellness visits.
Summary statistics for the veterinarian visit satisfaction surveys for the veterinarians of Table 1.
| Question | Veterinarian | Before intervention (mean ± SD) | Intervention effect* | Intervention P value | P value for veterinarian-intervention interaction | Effect difference between problem and wellness visits | P value for effect difference between problem and wellness visits |
|---|---|---|---|---|---|---|---|
| Global satisfaction | Overall | 3.46 ± 0.78 | +0.60 | < 0.01 | 0.11 | −0.33 | < 0.01 |
| Got all details | Overall | 3.82 ± 0.66 | — | — | < 0.01 | −0.18 | 0.06 |
| A | — | +0.52 | < 0.01 | — | — | — | |
| B | — | −0.54 | 0.02 | — | — | — | |
| C | — | +0.36 | 0.11 | — | — | — | |
| Client complains | Overall | 1.72 ± 0.96 | −0.31 | < 0.01 | 0.34 | +0.12 | 0.24 |
| Client personable | Overall | 4.07 ± 0.97 | +0.41 | < 0.01 | 0.72 | −0.20 | 0.07 |
| Like to spend more time | Overall | 3.04 ± 0.72 | — | — | < 0.01 | −0.17 | 0.08 |
| A | — | +0.69 | < 0.01 | — | — | — | |
| B | — | +0.13 | 0.58 | — | — | — | |
| C | — | −0.57 | 0.02 | — | — | — | |
| Did not get all details | Overall | 2.00 ± 0.82 | — | — | < 0.01 | +0.29 | < 0.01 |
| A | — | −0.24 | 0.14 | — | — | — | |
| B | — | +0.15 | 0.52 | — | — | — | |
| C | — | −0.89 | < 0.01 | — | — | — | |
| Established rapport | Overall | 4.16 ± 0.60 | < 0.01 | −0.17 | 0.02 | ||
| A | — | +0.26 | 0.04 | — | — | — | |
| B | — | −0.14 | 0.45 | — | — | — | |
| C | — | +0.46 | 0.01 | — | — | — | |
| Time not well spent | Overall | 1.98 ± 0.82 | — | — | < 0.01 | +0.10 | 0.24 |
| A | — | −0.15 | 0.30 | — | — | — | |
| B | — | −0.39 | 0.06 | — | — | — | |
| C | — | −0.86 | < 0.01 | — | — | — | |
| Client trusts me | Overall | 3.83 ± 0.64 | +0.51 | < 0.01 | 0.11 | −0.04 | 0.61 |
| Did not influence client | Overall | 2.16 ± 0.76 | — | — | < 0.01 | −0.03 | 0.80 |
| A | — | −0.33 | 0.06 | — | — | — | |
| B | — | −0.04 | 0.86 | — | — | — | |
| C | — | −0.83 | < 0.01 | — | — | — | |
| Confident to treat patient | Overall | 4.81 ± 0.52 | — | — | < 0.01 | −0.11 | 0.03 |
| A | — | +0.02 | 0.86 | — | — | — | |
| B | — | −0.08 | 0.53 | — | — | — | |
| C | — | +0.53 | < 0.01 | — | — | — | |
| Visit not necessary | Overall | 1.62 ± 0.74 | — | — | < 0.01 | +0.18 | 0.02 |
| A | — | −0.09 | 0.46 | — | — | — | |
| B | — | +0.00 | 0.98 | — | — | — | |
| C | — | −0.73 | < 0.01 | — | — | — | |
| Client understood explanations | Overall | 4.08 ± 0.57 | — | — | < 0.01 | −0.13 | 0.05 |
| A | — | +0.25 | 0.03 | — | — | — | |
| B | — | −0.22 | 0.17 | — | — | — | |
| C | — | +0.80 | < 0.01 | — | — | — | |
| Patient is pleasant | Overall | 4.27 ± 0.86 | — | — | 0.05 | −0.13 | 0.29 |
| A | — | +0.42 | 0.04 | — | — | — | |
| B | — | −0.62 | 0.04 | — | — | — | |
| C | — | −0.00 | 0.99 | — | — | — | |
| Visit was boring | Overall | 2.11 ± 0.71 | — | — | 0.03 | +0.17 | 0.02 |
| A | — | −0.56 | < 0.01 | — | — | — | |
| B | — | +0.00 | 1.00 | — | — | — | |
| C | — | −0.39 | 0.03 | — | — | — | |
| Did not get detailed physical examination | Overall | 1.84 ± 0.70 | — | — | < 0.01 | +0.21 | 0.01 |
| A | — | +0.11 | 0.46 | — | — | — | |
| B | — | −0.12 | 0.57 | — | — | — | |
| C | — | −1.22 | < 0.01 | — | — | — | |
| Like to change client relationship | Overall | 2.22 ± 0.83 | — | — | < 0.01 | +0.20 | 0.04 |
| A | — | −0.49 | < 0.01 | — | — | — | |
| B | — | +0.01 | 0.95 | — | — | — | |
| C | — | −0.83 | < 0.01 | — | — | — | |
| Did not understand client | Overall | 1.71 ± 0.57 | — | — | < 0.01 | +0.05 | 0.25 |
| A | — | +0.03 | 0.70 | — | — | — | |
| B | — | −0.25 | 0.02 | — | — | — | |
| C | — | −1.03 | < 0.01 | — | — | — | |
| Client is demanding | Overall | 2.11 ± 1.21 | — | — | < 0.01 | −0.02 | 0.90 |
| A | — | −0.03 | 0.88 | — | — | — | |
| B | — | −0.54 | 0.06 | — | — | — | |
| C | — | −1.30 | < 0.01 | — | — | — | |
| Spent more time | Overall | 2.23 ± 1.10 | — | — | < 0.01 | +0.07 | 0.48 |
| A | — | −0.01 | 0.96 | — | — | — | |
| B | — | −0.41 | 0.08 | — | — | — | |
| C | — | −1.93 | < 0.01 | — | — | — |
For each visit for which a CSQ was completed (n = 180), the attending veterinarian completed a veterinarian satisfaction survey. Respondents rated each question on a Likert scale, where 1 = strongly disagree and 5 = strongly agree. A problem visit was defined as a veterinary encounter with a dog or cat with a health-related issue; a wellness visit was defined as a veterinary encounter with a presumably healthy dog or cat for a routine examination. Intervention effects were provided for each veterinarian only for those questions for which there was a significant (P ≤ 0.10) interaction between veterinarian and intervention.
The intervention effect represented the difference between the means before and after the intervention (ie, before intervention mean – after intervention mean). A negative intervention effect or effect difference indicated that the mean Likert score before the intervention was greater than the mean Likert score after the intervention, and a positive intervention effect or effect difference indicated that the mean Likert score after the intervention was greater than the mean Likert score before the intervention.
Client visit satisfaction
For the CSQ, clients rated their level of satisfaction with the veterinary visit on an unbalanced scale, where 1 = poor and 6 = could not be better. Global client satisfaction after the intervention did not differ significantly (P = 0.13) from that prior to the intervention (Table 6). However, clients perceived that they had more involvement in the entire appointment (P = 0.04) and that the veterinarians had greater interest in their opinion (P < 0.01) after the intervention, compared with before the intervention. Client ratings varied among veterinarians in regard to examination of the pet and addressing of their concerns. Client satisfaction did not differ significantly between problem and wellness visits for any item assessed.
Summary statistics for the CSQs described in Table 1.
| Question | Veterinarian | Before intervention (mean ± SD) | Intervention effect* | Intervention P value | P value for veterinarian-intervention interaction | Effect difference between problem and wellness visits | P value for effect difference between problem and wellness visits |
|---|---|---|---|---|---|---|---|
| Attention to pet | Overall | 5.09 ± 0.84 | +0.17 | 0.15 | 0.25 | +0.02 | 0.90 |
| Veterinarian understood reason for visit | Overall | 5.09 ± 0.78 | +0.19 | 0.10 | 0.12 | +0.03 | 0.80 |
| Veterinarian's confidence | Overall | 5.22 ± 0.77 | +0.09 | 0.40 | 0.41 | +0.12 | 0.28 |
| Involved you in entire appointment | Overall | 5.13 ± 0.79 | +0.22 | 0.04 | 0.13 | +0.06 | 0.59 |
| Examination of pet | Overall | 5.09 ± 0.93 | — | — | 0.06 | +0.18 | 0.21 |
| A | — | −0.02 | 0.92 | — | — | — | |
| B | — | +0.54 | 0.11 | — | — | — | |
| C | — | −0.23 | 0.49 | — | — | — | |
| Explained treatment and procedures | Overall | 5.13 ± 0.79 | +0.09 | 0.47 | 0.12 | −0.06 | 0.61 |
| You understood the costs | Overall | 4.45 ± 1.37 | +0.13 | 0.54 | 0.64 | +0.08 | 0.69 |
| Involved you in decisions | Overall | 5.02 ± 0.93 | +0.20 | 0.12 | 0.14 | −0.01 | 0.92 |
| Discussed options with you | Overall | 4.85 ± 1.29 | +0.11 | 0.56 | 0.81 | +0.22 | 0.24 |
| Discussed cost with you | Overall | 3.96 ± 1.87 | +0.41 | 0.13 | 0.86 | +0.14 | 0.61 |
| Interested in your opinion | Overall | 4.84 ± 1.23 | +0.40 | < 0.01 | 0.23 | +0.06 | 0.71 |
| Information you received | Overall | 5.05 ± 0.85 | +0.14 | 0.21 | 0.24 | −0.01 | 0.91 |
| Addressed your concerns | Overall | 5.11 ± 0.81 | 0.09 | −0.07 | 0.53 | ||
| A | — | +0.14 | 0.45 | — | — | — | |
| B | — | +0.35 | 0.19 | — | — | — | |
| C | — | −0.24 | 0.37 | — | — | — | |
| Recognized role of pet in your life | Overall | 4.64 ± 1.59 | +0.31 | 0.15 | 0.15 | +0.04 | 0.84 |
| Amount of time spent with you | Overall | 5.05 ± 0.85 | +0.14 | 0.22 | 0.67 | −0.05 | 0.69 |
| Global satisfaction | Overall | 5.05 ± 0.86 | +0.18 | 0.13 | 0.11 | −0.03 | 0.82 |
Discussion
The study reported here represents the second phase of a multiple-veterinary hospital case-based project designed to evaluate the implementation of communication curricula in a practice setting. During the first phase of the project, 4 veterinarians participated in a year-long curriculum.23 Given the resource-intensive nature of a year-long training program, the present study was conducted to determine whether similar results could be achieved with a 6-month training program. The collective results of phases 123 and 2 indicate that both the 12- and 6-month interventions effectively enhanced veterinarian-client communication skills.
More differences than similarities were identified when the effects on veterinarian communication were compared between the 12- and 6-month curricula. Both curricula focused on the implementation of a client-centered approach with the intent to facilitate client input and active participation during the visit.23 After veterinarians went through the 12-month curriculum, they gathered more lifestyle-social data and expressed more positive emotions such as laughter, compliments, and statements of approval and agreement to build rapport with clients than they did prior to the intervention.23 After completion of the 6-month curriculum, visit length increased and veterinarians spent more time talking and building deeper emotional connections with their clients through expressions of concern, empathy, and reassurance; however, they gathered less lifestyle-social data than they did prior to the intervention. The effect on client communication also differed between the 12- and 6-month curricula. After veterinarians completed the 12-month curriculum, they were more likely to elicit lifestyle-social information and emotional statements from their clients than they did prior to the intervention.23 After veterinarians completed the 6-month curriculum in the present study, their clients tended to ask more biomedical questions, provided more biomedical information, and engaged in more social conversation with them, compared with before the intervention.
The findings of the present study supported the effectiveness of a 6-month intervention designed to enhance veterinarian-client communication and improve both veterinarian and client visit satisfaction. We did not expect the 6-month intervention to produce the same changes in veterinarian-client communication as the 12-month intervention because the characteristics and skills of the participating veterinarians differed as did the participating clients and patients and the leadership, culture, and processes of the participating practices. Compared with the 12-month curriculum, the coaches had less time to work with the practice team during the 6-month curriculum; however, that might have created a more focused and intense atmosphere, which enhanced learning of the communication skills.
Overall, the 6-month curriculum resulted in the implementation of a more client-centered approach at the participating practice. Client-centered care is based on principles of patient-centered medicine37,38 and represents a joint venture between the veterinarian and client to provide optimal care for the animal.26 It includes broadening the explanatory perspective of disease to include lifestyle and social factors, building a strong veterinarian-client-patient relationship, and encouraging client participation, negotiation, and shared decision making. Although coined client-centered, this approach incorporates respect for the client's agenda, perspective, and interests as well as respect for the animal patient and recognition of the role the animal plays in the life of the client.
In the present study, there was evidence of a collaborative veterinarian-client-patient relationship through enhanced client education, rapport building, partnering, and less hurrying. Following the intervention, the veterinarians perceived an increase in overall satisfaction with their visits, specifically that clients complained less and were more personable and trusting. The clients reported that they felt more involved in the entire appointment and that their veterinarian was more interested in their opinion. These communication behaviors created a more client-centered atmosphere, even though there was not a significant change in the client-centered score.
After the intervention in the present study, the mean visit duration increased by 5.4 minutes. Veterinarians spoke more to their clients even though there was not a significant change in the proportion of veterinarian-to-client talk or the verbal dominance score. The increase in visit duration might have been attributable to the fact that veterinarians were still mastering their new communication skills39 or were spending more time educating clients about a medical condition, diagnosis, treatment, and prognosis. In response, clients tended to ask more biomedical questions and provided more biomedical information to the veterinarians. An increase in face-to-face client education is particularly important given that today's pet owners are consulting web resources, rather than seeking the advice of their veterinarians.15,16 With proliferation of the internet, veterinarians are faced with educated clients armed with questions and greater expectations,11 which increases the responsibility of veterinarians to provide quality client education.
The importance of client education was highlighted by the findings of 2 qualitative studies4,5 in which client expectations of veterinarian-client communication were investigated. A key theme that arose in both studies4,5 during in-depth interviews with clients and focus group discussions was that clients expect veterinarians to provide them with information. Clients want clear and complete explanations, provided upfront, in various formats, and in understandable language, and they want their veterinarian to ask the right questions and listen to what they have to say.4,5 This includes tailoring the explanation to each individual client, by eliciting the client's understanding of the disease, previous experience, and information preferences.6 An interactive approach to client education aids in client understanding and empowers them to make informed decisions and helps them cope with their pet's condition.6 Creating an active role for the client enhances the likelihood that they will adhere to the veterinarian's recommendations.9,39–41
Veterinarians of the present study asked fewer closed-ended lifestyle-social questions after the intervention. The interpretation of this finding is mixed. Acquisition of lifestyle-social history includes gathering information about the animal's behavior, environmental conditions, mental health and well-being, and human-animal bond and interactions.42 A decrease in the use of closed-ended questions has the potential to have a positive impact. Implementation of the 4 core communication skills, in particular the use of open-ended questions to facilitate data-gathering was a key focus of the intervention. Although there was not a significant increase in the use of open-ended questions after the intervention, the decrease in closed-ended questions to acquire lifestyle-social history may reflect an emphasis on an open approach to history acquisition by the veterinarians. The use of open-ended questions encourages a client to tell his or her story, promotes client participation in the visit, and aids veterinarians in understanding the client's perspective.8,39
However, the underlying purpose of the intervention was to promote client-centered care, which includes broadening the explanatory perspective of disease to encompass lifestyle and social factors. Therefore, the decrease in the number of closed-ended questions used to acquire lifestyle-social data was counter to our hypothesis that lifestyle-social data gathering would increase as the result of the intervention. Investigators involved in another RIAS study24 of veterinarian-client communication reported that veterinarians underused (< 1 statement per appointment) lifestyle-social questions when interviewing clients. An important aspect of lifestyle-social data gathering is understanding the relationships that people have with their companion animals.11 Providing veterinary services in a manner that acknowledges the human-animal bond leads to better outcomes for veterinary practices and their patients.12,13 Fully understanding the role and nature of the animal and the structure of the family and household is integral for veterinarians to identify and remove potential barriers to adherence of the management and care plan for the patient.9,26
Results of the present study indicated that the intervention enhanced the veterinarians' abilities to create a more active role for their clients. This included the use of statements or questions that encouraged client input in the decision-making process by reflecting back what the client had said, asking for the client's opinion, checking for the client's understanding, and requesting further clarification. Clients also perceived that they were more involved in the entire appointment and that their veterinarian was more interested in their opinion after the intervention. Clients expect veterinarians to be respectful of their decisions and work with them in partnership, and they want to be involved in discussing their pet's care and making informed decisions.4 Encouraging client participation enhances shared decision making and development of a mutually agreed plan of care for the pet.4,9
Veterinarians of the present study expressed more emotional rapport, including showing concern, expressing empathy, offering self-disclosure, and providing reassurance following the intervention, compared with before the intervention. After the intervention, veterinarians perceived their overall interactions with clients as more satisfying than before the intervention, with clients complaining less and being more personable and trusting. In response, clients offered more social conversation and appeared more sympathetic toward the veterinarians. All of these factors contributed to a warm and welcoming atmosphere, which put both the veterinarians and clients at ease. This mutual influence is supported by the reciprocity theory, which states that nonverbal and verbal communication are typically matched in social interactions.43 Rapport building is an important task during the clinical appointment, is highly valued by clients, and provides the foundation for a strong veterinarian-client-patient relationship steeped in trust, which sets the stage for effective information exchange.4,44,45
Both veterinarians and clients appeared less hurried or rushed following the intervention than they did before the intervention. During in-depth interviews conducted in other studies,4,5 clients emphasized the importance of veterinarians taking time to answer questions, repeat information, and listen attentively. In another RIAS veterinary communication study,9 veterinarians were perceived to be less hurried or rushed during appointments in which clients adhered to dental or surgery recommendations.9 In the present study, not only did the veterinarians appear less hurried after the intervention, the mean appointment duration increased significantly. This finding highlights the importance of striking a balance between quality and quantity of veterinary appointments, taking the time to be attentive to your client, soliciting all of the client's concerns8 and fully educating the client to enhance client satisfaction.4,6 Some practices have flexible appointment times so that veterinarians can fully address client and patient needs.
In the present study, the intervention appeared to improve global veterinarian visit satisfaction and components of client satisfaction. On average, veterinarians have approximately 200,000 clinical encounters during a 40-year professional career; thus, veterinarian visit satisfaction has the potential to have a substantial impact on overall professional fulfillment and satisfaction.10 This is particularly important given the current concern about wellness in the veterinary profession. The personal and professional costs of job dissatisfaction among health professionals include psychiatric morbidity (ie, stress, anxiety, and depression), alcohol and drug abuse, and suicide.46 Underscoring those issues is the fact that the suicide rate for veterinarians is twice that for other health professionals and 4 times that for the general population.47 On the basis of recent CDC statistics, 1 in 6 veterinarians have contemplated suicide.48 Although the present study was a case-based study and the generalization of its findings is limited, it is important to note that the veterinarian visit satisfaction improved for veterinarians who underwent communication skills training, and this improvement in visit satisfaction might potentially enhance the health and well-being of those veterinarians.
Clients perceived that they were more involved in the entire appointment and that the veterinarian expressed more interest in their opinions after the veterinarians had undergone the intervention. Clients are more likely to adhere to a veterinarian's recommendations if they feel that the veterinarian considers them an equal partner in the care of their pets.9 Because of societal changes, the paradigm for the role of a veterinarian is shifting from an expert in charge of animal care to more of a partner or facilitative role in animal care.49 This shift is likely the result of multiple factors such as the recognition of the importance of the human-animal bond,13 access to knowledge through the internet15,16 resulting in an empowered and knowledgeable client base,11 economic pressures leading to a decrease in the number of patient visits to veterinarians,15,16 and an increasingly litigious society.14 To successfully adapt to those societal and professional changes, veterinarians need to expand their relationship repertoire to include developing partnerships with their clients.
Interestingly, global veterinarian visit satisfaction differed significantly between wellness and problem visits in the present study. This finding was consistent with the results of another study.10 Wellness appointments are generally characterized as client-centered with an emphasis on rapport building, social conversation, and attentiveness to the pet in a relaxed and friendly atmosphere, whereas problem appointments are characterized as narrowly biomedical with a tense emotional atmosphere in some cases.50 Human physicians also report that it is more satisfying to work with healthy rather than sick patients.51–53 Coe et al36 reported that clients also find veterinary wellness visits more satisfying than problem visits; however, the client visit satisfaction did not differ significantly in this study between wellness and problems visits.
Multiple aspects of the communication curriculum, including implementation of the client-centered communication model, delineation of skills (Calgary-Cambridge Guide21), and experiential- and learner-centered educational techniques (ie, observation, constructive feedback, video recording and review, opportunities for practice, and individual coaching), influence changes in communication behaviors.21 The underlying principle of the intervention used in the present study was client-centered care through fostering of a collaborative relationship and creating a reciprocal interaction and dialogue with the client. The concepts and skills were reinforced through parallel processes. The coaches created a client-centered learning atmosphere by developing teacher-learner partnerships. Modeling of the concepts and communication skills during interactive presentations and feedback sessions reinforced the lessons. The use of coaching with real clients and patients allowed veterinarians to practice the skills within the demands and constraints of the practice setting, whereas coaching with simulated clients in the communication laboratory enabled the veterinarians to focus solely on practicing their communication skills.
The 6-month intervention that used experiential techniques produced detectable changes in a small subset of communication behaviors. Our perception was that the practice enrolled in the present study had a high-functioning practice team and strong practice leadership that shared a vision for quality care of clients and patients and had effective teamwork prior to the intervention. Consequently, the magnitude of the changes detected following the intervention was smaller than what might have been detected in another less cohesively run practice. Moreover, the communication skills coaches visited the practice on a monthly basis, and more frequent visits (eg, every 2 weeks) may have enhanced learning and retention of lessons between visits. However, it is ideal for the participants to have opportunities to practice skills between training sessions.
From a training aspect, there were several differences between the 12-month intervention implemented during phase 123 and the 6-month intervention implemented in the present study. Both interventions included monthly visits by the training coaches to the participating practices, but because of the difference in intervention duration, the practice of the present study was visited half as frequently as the practice in phase 1. Additionally, 4 communication laboratories were conducted during the 12-month intervention, whereas only 1 communication laboratory was conducted during the 6-month intervention. We added 2 teamwork exercises at the beginning and end of both interventions. The symbolism and mission statement exercises were based on the Healer's Art course54,55 and were intended to deepen the participants' connection to day-to-day work, clients and teammates, and veterinary practice. It created an opportunity for participants to find new meaning in work and build community by being heard and hearing the stories of others. The purpose of those activities was to frame the intervention on both ends with a reminder of the shared vision and passions of the practice team. Despite the differences between the 2 interventions, both resulted in successful outcomes; therefore, inpractice coaching seemed to be an effective methodology for producing behavioral change.
This present study was a case-based study and involved only a small sample of veterinary visits at 1 veterinary practice in Denver. Although this resulted in low statistical power, significant changes in communication behaviors were detected. The veterinary visits that were video recorded were selected arbitrarily. Therefore, it is unlikely that those appointments were representative of the full spectrum of appointments in day-to-day practice, and the generalizability of the results is limited. The time- and resource-intensive nature of the project prevented the enrollment of other practices to increase sample size and recruit a diverse population of veterinarians and veterinary visits. Additionally, given the 6-month duration of the intervention, it is possible that events or changes in policy and procedure or business management outside of the intervention could have affected the findings. Veterinarians may have been more attentive to their communication skills during video-recorded appointments (Hawthorne effect), although with repetitive observation and the video recording of multiple appointments, the veterinarians likely became acclimated to the process and the Hawthorne effect diminished. Another limitation of the present study design was that the communication skills of the veterinarians were measured 2 months after completion of the intervention. It would have been informative to measure maintenance of the communication skills longitudinally. Likewise, in an ideal situation, the curriculum would include regular visits by the coaches to the participating practice to provide educational booster sessions and continue to grow the participants' knowledge base and reinforce skill development over time.
In the present study, the 3 veterinarians and other practice team members of a companion animal practice in Denver underwent a 6-month training program to enhance their communication skills and promote a client-centered approach to the practice. Various aspects of the veterinarians' communication skills and the overall satisfaction of both veterinarians and their clients with appointments were compared before and after the intervention. Results indicated that the intervention resulted in veterinarians who spent more time educating their clients, building rapport with their clients, and facilitating client input in an unhurried environment, which enhanced overall veterinarian visit satisfaction and various aspects of client visit satisfaction. Communication education and assessment in a veterinary practice is a unique methodology that enables the practice team to identify challenges as they arise, create a common culture for learning, and strive to enhance client and team communication.
The findings of this study have the potential to positively influence the wellness of veterinary practitioners46–48 and the financial performance of veterinary practices,15–17 2 issues that are very important to the veterinary profession. The enhancement of veterinarian visit satisfaction through communication skills education may promote veterinarian professional health and well-being. Veterinarians who facilitate client contribution during appointments, provide client education, and strive to improve client visit satisfaction are more likely to build and maintain strong relationships with their clients. Long-term trusting relationships translate into an increase in the number of patient visits and benefit the financial health of the practice. Veterinarians require exceptional interpersonal skills if they are to adapt and thrive in a society that embraces the human-animal bond and where clients have ready access to and actively seek information on pet health and have higher expectations of veterinarians than ever before. Veterinarians who are able to meet those expectations, educate their clients, and build strong relationships with both their clients and practice team are necessary for the continued health of the veterinary profession.
Acknowledgments
Supported by grants from the College Research Council of Colorado State University College of Veterinary Medicine and Biomedical Sciences, Zoetis, Antech Diagnostics, and Hill's Pet Nutrition. The practice group of the participating practice also provided partial support for the study.
The funding sources did not have any involvement in the study design, data analysis and interpretation, and writing of the manuscript.
The authors thank Carrie Katona for technical assistance and Susan Larson for training of the RIAS coders.
ABBREVIATIONS
| CSQ | Client satisfaction questionnaire |
| RIAS | Roter interaction analysis system |
Footnotes
STATA, version 10.1, StataCorp LP, College Station, Tex.
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