Introduction

The physical exam is a central part of companion animal healthcare appointments, including wellness appointments. Further, explaining the process of the companion animal physical exam (CAPE) and its findings has been described as an integral part of veterinarian-client-patient interactions.¹ Yet, in a study involving 1,400 pet owners in the US, > 1 in 10 of the respondents said their pet received a physical exam during a veterinary visit even though, as the authors stated, it was highly probable that a physical exam did take place.² The authors speculated that the veterinarians did not make the clients aware that an exam was being performed. Dr. Amanda Donnelly, a practice management consultant, states that “While conversing with the client is desirable and necessary, don’t make the mistake of having the pet owner completely miss out on the value of the exam because they didn’t even realize the pet was being examined.”³ In addition, it has been shown that an opportunity exists for veterinarians to improve their communication of the value of the services that they provide.⁴ Thus, by placing greater emphasis on communicating the benefits of an annual CAPE, veterinarians could likely improve animal health through increased client adherence with veterinary recommendations and increased early detection of problems through more regular visits. Placing more value on the CAPE may also increase client and veterinarian satisfaction as well as improve veterinary practice sustainability by generating greater adherence to wellness appointment bookings by veterinary clients. Further, establishing a baseline, best-practice CAPE has the potential to improve overall patient care.

Specifically, the problem of not emphasizing the value of the CAPE as a part of the wellness appointment is illustrated by the findings of a veterinary care usage study,⁴ which found 63% of dog owners and 68% of cat owners who were taking their pet to the veterinarian less frequently than in the past, said that annual wellness appointments were unnecessary. These trends are in contrast to veterinarians’ knowledge that morbidity and mortality rates may be decreased by early detection of disease,⁵ and as McCurnin and Proffenbarger⁶ state, “normal as well as abnormal findings can be very helpful in the diagnostic process”. Looking further into the CAPE, it is important to note that it contains several different components. If some components of the CAPE are missed, it may not be possible to arrive at the correct diagnosis.^7–9 Nevertheless, time is a limiting factor because several other elements need be included in a wellness appointment.¹⁰ In addition to taking the patient’s history and performing a physical exam, veterinarians may be required to discuss topics such as parasite prevention, diet, microchipping, neutering, routine dental care, grooming, behavioral problems, breed-specific health problems, and pet insurance during wellness appointments.¹¹ Moreover, discussing the benefits of core and optional vaccinations for dogs and cats is also time-consuming. Although time constraints are a constant concern, wellness appointments are a significant aspect of private veterinary practice. Studies have documented that one-third of all companion animal consultations in England and Scotland¹² and half of all companion animal consultations in Ontario, Canada,¹³ were wellness appointments. Since the wellness appointment has been shown to be an essential segment of primary care veterinary practice, it follows that the CAPE within the appointment is also paramount; thus, increasing the perceived value of the CAPE could have significant benefits.

A starting place for improving the perceived value of CAPE is to establish a baseline, best-practice, healthy companion animal exam (ie, a focused exam that acknowledges the time constraints that veterinarians often identify).^10,14,15 Although many veterinary textbooks list the recommended components of the CAPE,^6,16 consensus on what constitutes the essential components of the CAPE has not been established. A method is needed to establish a baseline, best-practice, healthy CAPE as a first step in promoting components of the CAPE to owners of seemingly healthy pets. An approach that can be employed is the Delphi Method of Consensus,¹⁷ which involves the use of expert panelists and set rounds of questionnaires that are completed until a predetermined level of consensus is reached.¹⁸ This method of consensus has been used to establish consensus within the fields of economic and information technology forecasting, environmental, and sociology studies as well as in health research.^19,20 In veterinary medicine, it has been used in a number of studies, for example, to produce 48 consensus statements on animal diseases by the American College of Veterinary Internal Medicine (ACVIM),²¹ determine priorities in zoonoses research,²² identify signs of pain in cats,²³ ascertain the role of the veterinary pharmacist²⁴ and determine the future of food supply veterinary medicine.²⁵

The objective of this study was to establish a baseline, best-practice CAPE for a seemingly healthy and friendly dog or cat using the Delphi Method of Consensus. To achieve this, an expert panel of small animal veterinary internists and primary care veterinarians teaching the CAPE at veterinary colleges was used.

Materials and Methods

This study was approved by the University of Guelph’s Research Ethics Board (protocol No. 20-05-028). The online survey process took place from August 25 to December 7, 2020.

Distribution of the Delphi survey

Round 1—To recruit the group of SAVIs, an email invitation to participate in the Delphi study was distributed by the principal author (JCDC) to everyone on the list of SAVIs (Figure 1). To recruit PCVE, an email invitation was distributed by one of the authors (JBC) to all the members of the PCVE group using the AAVMC PCVE listserv.

Flow chart describing the 3 rounds of the Delphi study. PCVE = Primary Care Veterinary Educators. PE = Physical exam. SAVI = Small animal veterinary internists.

Citation: Journal of the American Veterinary Medical Association 260, 8; 10.2460/javma.21.10.0468

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Flow chart describing the 3 rounds of the Delphi study. PCVE = Primary Care Veterinary Educators. PE = Physical exam. SAVI = Small animal veterinary internists.

Citation: Journal of the American Veterinary Medical Association 260, 8; 10.2460/javma.21.10.0468

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Flow chart describing the 3 rounds of the Delphi study. PCVE = Primary Care Veterinary Educators. PE = Physical exam. SAVI = Small animal veterinary internists.

Citation: Journal of the American Veterinary Medical Association 260, 8; 10.2460/javma.21.10.0468

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The round 1 questionnaire consisted of demographic questions, closed-ended questions specific to teaching the physical exam and an open-ended question allowing participants to record details of how they conduct a CAPE. The demographic data collected through the online survey included age with the option of 5 group categories (18 to 30, 31 to 40, 41 to 50, 51 to 60, and 61 years or older), gender with 4 options (man, woman, my gender identity is not listed above, and choose not to respond), year of graduation from veterinary school, university where participant obtained their DVM degree, any board certifications or specializations held by the participant, and their current university of employment. Specific to teaching the physical exam, participants were asked to describe their methods of assessing students on the CAPE and the percentage of their CAPE teaching time they spend using different delivery methods (ie, lecture, laboratory, online, and a text box for any other methods of delivery). They were also given the opportunity to upload teaching materials they use to teach the CAPE. To capture each participant’s view on the steps required to perform a complete physical exam, participants were asked the open-ended question “What steps do you believe are the requirements for performing a complete physical exam, from beginning to end, on a healthy dog or cat?” Participants were given the choice of writing their answer into a text box on the questionnaire or uploading a verbal recording of their response as an audio file. At the end of the questionnaire, participants interested in participating in subsequent rounds of the Delphi study were invited to submit their email addresses via a separate link to ensure anonymity of participants’ questionnaire responses in round 1.

Round 2—All participants who provided their email addresses at the end of round 1 were invited to participate in round 2 (Figure 1). Common to the Delphi technique, the questionnaire for round 2 was formulated from participants’ answers during round 1, including any uploaded teaching material specific to the CAPE. Specifically, round 2 assessed whether participants believed each component of the CAPE identified during round 1 should be included in a complete baseline, best-practice, CAPE. Participants were given 3 options, to indicate their level of support for including each physical exam component: always examine, examine only as needed, or undecided). During round 2, participants were also provided a text box for each physical exam component to provide comments on their decision. Similar to round 1, participants were directed to a separate link at the end of round 2, for participants to provide their email, to indicate interest in participating in the third round of the Delphi study.

Round 3—All participants who provided their email addresses at the end of round 2 were invited by email to participate in round 3 (Figure 1). The questionnaire for round 3 consisted only of CAPE components for which consensus was not already reached at the conclusion of round 2. Participants’ comments associated with their answer on a specific CAPE component from round 2 were summarized and anonymously provided alongside each remaining CAPE component. These comments shared participants’ opinions on their justification for choosing 1 of the 3 options previously described during round 2. Further, when participants commented in Round 2 that details pertaining to a component of the CAPE were ambiguous or needed clarification the research team provided additional details in an attempt to clarify that component of the CAPE. Based on comments made by some of the participants, 1 component was divided into 2. In addition, during round 3 the researchers also clarified that the physical exam should be considered in the context of conducting the exam on a friendly and well-behaved animal. Finally, the percentage of agreement for “always include” from round 2 was provided to participants during round 3, to inform participants of the direction the component was trending. The participants were again given 3 options to choose from (ie, always examine, only examine as needed, or undecided), and text boxes for comments on each question were provided as in round 2. At the end of the questionnaire, participants were again directed to a separate survey link to provide their email address if interested in participating in a potential fourth round of the Delphi study, if it was needed.

Results

Round 1—Forty-five expert panelists completed round 1 (Table 1). There was a significant (P = 0.02) difference in the number of years in practice between the SAVI an PCVE panelists. All responses for the open-ended question “What steps do you believe are the requirements for performing a complete physical exam, from beginning to end, on a healthy dog or cat?” were written, none were submitted as audio files. The number of participants from each group was considered adequate for round 1¹⁹ and fit within the original methodology parameters. The response was 15% for both groups (20/135 for PCVE group and 25/163 for the SAVI group). A statistically significant (P < 0.02) difference was found when comparing the mean number of years in practice (22.9 and 15.6, respectively) between SAVI and PCVE. During round 1, participants identified 35 potential components of a baseline CAPE (Table 2).

Round 2—From round 1, 13 of 20 (65%) PCVE and 19 of 25 (76%) SAVI panelists provided their email addresses to be invited to participate in round 2. Of these, 25 of 32 (78%) completed round 2. Of the 35 potential components of the CAPE included in round 2, consensus was reached on 21 components with at least 90% endorsement (Table 2). Five physical exam components approached consensus, with 80% to 88% agreement on the response “always included.” One or more participants submitted a comment for 26 of the open text boxes provided for the 35 CAPE components.

Round 3—Twenty-two of the 25 (88%) participants from round 2 provided their email addresses for round 3. Of the 22 panelists who were sent email invitations to participate in round 3, 21 (95%) responded. For the component “rectal exam for medium and large dogs” in round 2, some participants voiced a concern for the need to include small dogs. To address this concern, the rectal exam component was made into 2 questions for round 3. One question was worded as “rectal exam for medium and large dogs,” and the other question was worded as “rectal exam for any size of dog.” As well, during round 2, thyroid gland palpation for cats 5 years old and older reached 90% consensus; however, several participants commented that 5 was not the age that thyroid gland palpation should begin. For this reason, an extra question was added to the round 3 questionnaire asking “What is the minimal age that you recommend a cat’s thyroid gland be palpated? Please provide a numeric number in years.” The responses ranged from 0 to 8 years, with a mean and median of 5 years.

Of the 15 potential components of the physical exam presented in round 3, 4 achieved at least 90% consensus (Table 2). The range of consensus for the remaining physical exam components was 19% to 85% (Table 3). No new information was provided from participants’ comments during round 3. Due to the low probability of achieving further consensus from a fourth round of the survey, a decision was made to stop the Delphi study at the end of round 3. The 11 components of a CAPE that did not reach expert consensus by the conclusion of round 3 are displayed.

Discussion

To the authors’ knowledge, this is the first study to establish a consensus on the components of a baseline, best-practice CAPE. A total of 25 physical exam components reached consensus among SAVI and PCVE expert panelists. Identifying a baseline, best-practice CAPE for a seemingly healthy, well-behaved cat or dog should inform veterinarians, veterinary educators, and veterinary students about the baseline components when performing the CAPE and should be helpful given the time constraints that companion animal veterinarians experience.^10,14,15

Some similar results were noted between the present study and a previous study¹¹ involving 662 private practice veterinarians in the UK; however, in the previous study, participants were asked to report what they do in practice when performing a CAPE, rather than what they think should be done in practice. Of the private practice veterinarians surveyed in the UK study, ≥ 80% of participants reported that they always perform 7 of 18 CAPE provided components, which were also CAPE components identified by participants in round 1 of the present Delphi study. Six of the 7 components were identified for both dogs and cats of the components always performed by the participants of the UK study. These were as follows: examine skin and haircoat, examine mouth and teeth, examine eyes and ears, weigh patient, auscultate the chest, and palpate the abdomen. For dogs only, they also identified palpating the lymph nodes. In addition to these components, the following components in the present study also reached consensus set at least 90% agreement: general assessment, examine nose, check pulse, check pulse synchrony, respiratory rate, auscultate lungs, check mucous membranes, assess hydration status, check capillary refill time, palpate neck, palpate limbs, assess body condition score, and palpate thyroid for older cats. In contrast to the present Delphi study, the UK study indicates that only 57.9% of veterinarians reported always checking the capillary refill time of dogs, 54.2% reported they always checked the pulse of dogs, and 7.6% reported always performing lameness exams. The percentage of veterinarians who reported that they always perform these components of the CAPE was even lower for cats in the UK study. The primary difference between the 2 studies is that the UK study recorded veterinarians’ self-reporting on what was occurring in practice and the present Delphi study examined what a panel of experts believed should be done in relation to the CAPE. Aside from the wording of the questions, some discrepancies in the results of the 2 studies could be attributed to other differences between those who work in an academic institution versus veterinarians who work in private practice. Cultural and clinical protocol differences, as well as time allotted for each appointment, may also have played a role in dissimilarity between the results of the 2 investigations because the Delphi study involved veterinarians within Canada and the US, whereas the other study involved veterinarians working in the UK. In terms of the generalizability of the findings for a baseline, best-practice CAPE, more research is needed to further understand cultural or practice influences that may affect the expectations and practicality of primary care, private practice veterinarians conducting what experts, identified for the present study, established as a baseline, best-practice CAPE for every dog and cat.

The results of the Delphi study revealed other intriguing findings. Although “palpating the thyroid gland of cats” reached consensus in round 2, the participants had differing views on the age of a cat when this component should always be performed. The present Delphi study identified the age range for starting to palpate a cat’s thyroid gland is from 0 to 8 years, with both a mean and median of 5 years. This may be a conservative starting age, given that a case control study²⁶ reported the age range for onset of cats with hyperthyroidism is 7 to 18 years, with a mean and median of 13 years and 12 years, respectively. Given that thyroid gland enlargement has been reported to be detectable in 83% to 96% of cats with hyperthyroidism,^27,28 there is likely no harm in palpating for the thyroid gland of a cat at any age. Findings of the present Delphi study supported the inclusion of consistently palpating the thyroid gland of all cats from ≥ 5 years of age as part of a baseline, best-practice CAPE.

Other key points to note are the components that almost reached consensus. One of 2 components of the physical exam that came very close to reaching 90% consensus is muscle condition score (MCS) at 86% consensus. Muscle condition score is a more recently recommended component of the CAPE.²⁹ For veterinarians, low MCSs can be indications of disease processes even when body condition scores are normal or elevated.³⁰ Study participants commented that not all veterinary colleges have started teaching this and that students often forget to note it during physical exams. As obtaining MCS becomes more prominent in veterinary practice, it is possible that in the future, it will be considered part of a baseline, best-practice CAPE.

Performing a neurological assessment throughout the exam achieved 81% consensus in the present study. This contrasts with the UK survey of private practice veterinarians, where only 2.1% of private practice veterinarians reported that they always include it in their physical exams.¹¹ The difference in the results of the present Delphi study and the UK study may be due to the participants’ interpretation of the neurological exam. In the present Delphi study, a separate, complete neurological exam was not implied in the survey. Rather, a clarifying statement added to the component “neurological assessment” during round 3 was “please consider general observations for any neurological abnormalities during the general physical exam, are investigated further if found” (ie, not ignored). In comparison, for the UK study, participants were asked if they always perform a neurological exam. In a study³⁰ of 98 apparently healthy senior and geriatric dogs, 18 dogs were found to have neurological abnormalities. Further investigation into the prevalence of neurological abnormalities in apparently healthy dogs and cats of all ages may further inform the need to include neurological assessment in the baseline, best-practice CAPE.

Another component of the CAPE that did not reach consensus was body temperature measurement. Body temperature has been traditionally considered to be a vital assessment in veterinary medicine, along with heart rate, respiratory rate, pain assessment, and nutrition.²⁹ Interestingly, only 15 of 21 (71%) of the expert panelists in our Delphi study thought that body temperature should be included as a component of a baseline, best-practice CAPE. Further, only 5.2% of private practice veterinarians in the United Kingdom reported always taking the body temperature of a dog during the physical exam.¹¹ During the Delphi study, several of the expert panelists commented that performing rectal body temperature was invasive and that the results rarely influence decision-making outcomes during healthy animal exams, questioning the benefit of the procedure for a healthy patient. Further, taking rectal temperatures of fearful or fractious dogs can be difficult.³¹ In a 2009 study,³² 78.5% of dogs exhibited fear-related behavior during a standardized exam, which included taking rectal body temperature. Although a comparison group of dogs that received a standard exam without temperature taking was not used in that study, it is possible that taking a rectal temperature could further increase the stress level that a fearful patient is already experiencing. While obtaining axillary temperatures might be perceived as less invasive than rectal temperature measurement, there has been found a clinically important amount of variation between the 2 procedures.³³ Based on our consensus study, this traditional vital parameter may no longer be considered a baseline measure within a CAPE of a healthy dog or cat and instead is a component of a CAPE that should be performed as needed basis at the discretion of the veterinarian. Further research is needed to explore how often body temperature results influence the decision-making process of primary care veterinarians when examining an otherwise healthy animal. In general, more research is warranted to investigate the direct impacts of the identified components of the baseline, best-practice CAPE in improving overall patient outcomes for dogs and cats.

There are other CAPE components of note that did not reach consensus in the present Delphi study. Less than 50% of the experts felt that rectal exams for any sized dog, tail palpations, ophthalmoscopic exams, and otoscopic exams should always be performed. The SAVI and PCVE panelists expressed concern about time constraints and recommended only incorporating these components when the history or other physical exam findings indicate a need for them. Common themes in the panelists comments also included invasiveness and usefulness of the health data generated, for example, when using an otoscope to examine ears or when performing rectal exams. In the present Delphi study, only 29% of the expert panelists chose “always include” for ophthalmoscopic exam, the rest indicated it should be performed as needed. In a study³⁴ of 100 cats, aged 6 to 14 years, perceived to be healthy by their owners, not one was found to have fundoscopic abnormalities secondary to systemic hypertension. Based on the results of the present Delphi study, the investigation of some components of the physical exam should be dependent on the clinical presentation of the patient.

One consideration in relation to which components reached consensus is the level of agreement set a priori needed to reach consensus. No set cut-point exists for consensus in Delphi studies. Although some researchers have suggested 70% to 80% agreement to reach consensus^20,23,35 in the present study, consensus was set at 90% agreement to strengthen the inclusion criteria for the CAPE components. It was imperative that outcomes of the present study have powerful support for 2 main reasons. First, the results will support future research into the perceived value of a baseline, best-practice CAPE, and second, the results may impact the focus of physical exam curriculum in veterinary education and performance of CAPE in private practice.

The participants of the current Delphi study were all veterinarians who teach the CAPE to veterinary students at accredited veterinary colleges. Even though there was a significant difference in years in practice found between the SAVI and PCVE groups of panelists, all panelists were seasoned veterinarians with at least 7 years of experience in veterinary practice. As well, unlike an epidemiological observational study, the participants in a Delphi study are not required to statistically represent a population.²⁰ The most important requirement of the panelists, in keeping with traditional Delphi methodology, is they are qualified experts in relation to their knowledge and experience with the topic. The present Delphi study incorporated 2 populations of veterinary educators to broaden the scope of practice and perspective shared during the Delphi study. Veterinary educators were surveyed rather than private practice veterinarians because they are teaching the CAPE to future veterinarians and are well positioned to identify the essential components.

Strong consensus was achieved among the experts in the present study for inclusion of 25 specific components of a baseline, best-practice CAPE. The application of the results of this study can inform veterinary student curriculum, inform future research, and be recommended for veterinarians already in primary care practice. To promote the benefits of an annual CAPE, further studies could use this consensus as a starting point to examine the direct impacts of the identified components of the baseline, best-practice CAPE in improving overall patient outcomes using large cohort studies. As well, further studies could investigate how veterinarians can best communicate the value of each component to their clients.