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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.

  • 1.

    Adams C, Kurtz S. Skills for Communicating in Veterinary Medicine. Otmoor Publishing; 2017.

  • 2.

    Lue TW, Pantenburg DP, Crawford PM. Impact of the owner-pet and client-veterinarian bond on the care that pets receive. J Am Vet Med Assoc. 2008;232(4):531540.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Donnelly AL. Client communications that enhance client understanding and patient care. In: Proceedings of the North American Veterinary Community Conference. North American Veterinary Community; 2015:401403.

    • Search Google Scholar
    • Export Citation
  • 4.

    Volk JO, Felsted KE, Thomas JG, Siren CW. Executive summary of the Bayer veterinary care usage study. J Am Vet Med Assoc. 2011;238(10):12751282.

  • 5.

    Kirnos C. How preventive care will grow your business. In: Proceedings of the 2018 American Association of Feline Practitioners Conference. American Association of Feline Practitioners; 2018:14.

    • Search Google Scholar
    • Export Citation
  • 6.

    McCurnin DM, Proffenbarger EM. Small Animal Physical Diagnosis and Clinical Procedures. WB Saunders Co; 1991.

  • 7.

    Defarges A. The physical exam. Clin Brief. 2015;7380. Accessed April 20, 2020. https://www.cliniciansbrief.com/article/physical-exam

  • 8.

    Jacobsen AP, Khiew YC, Murphy SP, Lane CM, Garibaldi BT. The modern physical exam—a transatlantic perspective from the resident level. Teach Learn Med. 2020;32(4):442448.

    • Search Google Scholar
    • Export Citation
  • 9.

    Singh H, Giardina TD, Meyer AN, Forjuoh SN, Reis MD, Thomas EJ. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med. 2013;173(6):418425.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Belshaw Z, Robinson NJ, Dean RS, Brennan ML. “I always feel like i have to rush…” Pet owner and small animal veterinary surgeons' reflections on time during preventative healthcare consultations in the United Kingdom. Vet Sci. 2018;5(1):20. doi:10.1136/vr.104835

    • Search Google Scholar
    • Export Citation
  • 11.

    Robinson NJ, Belshaw Z, Brennan ML, Dean RS. Topics discussed, exams performed and strategies implemented during canine and feline booster vaccination consultations. Vet Rec. 2019;184(8):252. doi:10.1136/vr.104835

    • Search Google Scholar
    • Export Citation
  • 12.

    Robinson NJ, Brennan ML, Cobb M, Dean RS. Capturing the complexity of first opinion small animal consultations using direct observation. Vet Rec. 2015;176(2):48. doi:10.1136/vr.102548

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Coe JB, Adams CL, Eva K, Desmarais S, Bonnett BN. Development and validation of an instrument for measuring appointment-specific client satisfaction in companion-animal practice. Prev Vet Med. 2010;93(2-3):201210.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Coe JB, Adams CL, Bonnett BN. A focus group study of veterinarians' and pet owners' perceptions veterinarian-client communication in companion animal practice. J Am Vet Med Assoc. 2008;233(7):10721080.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Janke N, Coe JB, Bernardo TM, Dewey CE, Stone EA. Pet owners' and veterinarians' perceptions of information exchange and clinical decision-making in companion animal practice. PLoS One. 2021;16(2):e0245632. doi:10.1371/journal.pone.0245632

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Rijnberk A, van Sluijs FJ. Medical History and Physical Exam in Companion Animals. 2nd ed. Elsevier Ltd; 2009.

  • 17.

    Helmer O. The Delphi method. In: Linstone H, Turoff M, eds. The Delphi Method: Techniques and Applications. Addison-Wesley Publishing Co; 1975:1012.

    • Search Google Scholar
    • Export Citation
  • 18.

    Hasson F, Keeny S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs. 2000;32(4):10081015.

  • 19.

    Hsu C-C, Sandford BA. The Delphi technique: making sense of consensus. Pract Assess Res Eval. 2007;12(10):18. doi:10.7275/PDX9-TH90

  • 20.

    Okoli C, Pawlowski SD. The Delphi method as a research tool: an example, design considerations and applications. Inf Manage. 2004;42(1):1529.

    • Search Google Scholar
    • Export Citation
  • 21.

    ACVIM consensus statements. American College of Veterinary Internal Medicine. Accessed July 19, 2021. https://www.acvim.org/Publications/JVIM/Consensus-Statements

    • Search Google Scholar
    • Export Citation
  • 22.

    Steele SG, Booy R, Mor SM. Establishing research priorities to improve the One Health efficacy of Australian general practitioners and veterinarians with regard to zoonoses: a modified Delphi survey. One Health. 2018;6:715.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Merola I, Mills DS. Behavioural signs of pain in cats: an expert consensus. PLoS One. 2016;11(2):e0150040. doi:10.1371/journal.pone.0150040

  • 24.

    Ceresia ML, Fasser CE, Rush JE, et al. The role and education of the veterinary pharmacist. Am J Pharm Educ. 2009;73(1):16. doi:10.5688/aj730116

  • 25.

    Prince JB, Andrus DM, Gwinner KP. Future demand, probable shortages, and strategies for creating a better future in food supply veterinary medicine. J Am Vet Med Assoc. 2006;229(1):5769.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Olczak J, Jones B, Pfeiffer D, Squires R, Morris R, Markwell P. Multivariate analysis of risk factors for feline hyperthyroidism in New Zealand. N Z Vet J. 2005;53(1):5358.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Norsworthy GD, Adams VJ, McElhaney MR, Milios JA. Relationship between semi-quantitative thyroid palpation and total thyroxine concentration in cats with and without hyperthyroidism. J Feline Med Surg. 2002;4(3):139143.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Broussard JD, Peterson ME, Fox PR. Changes in clinical and laboratory findings in cats with hyperthyroidism from 1983 to 1993. J Am Med Assoc. 1995;206(3):302305.

    • Search Google Scholar
    • Export Citation
  • 29.

    Freeman L, Becvarova I, Cave N, et al. WSAVA 2011 Nutritional Assessment Guidelines. J S Afr Vet Assoc. 2011;84(2):254263.

  • 30.

    Willems A, Paepe D, Marynissen S, et al. Results of screening of apparently healthy senior and geriatric dogs. J Vet Intern Med. 2017;31(1):8192.

  • 31.

    Greer RJ, Cohn LA, Dodam JR, Wagner-Mann CC, Mann FA. Comparison of three methods of temperature measurement in hypothermic, euthermic, and hyperthermic dogs. J Am Vet Med Assoc. 2007;230(12):18411848.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Döring D, Roscher A, Scheipl F, Küchenhoff H, Erhard MH. Fear-related behaviour of dogs in veterinary practice. Vet J. 2009;182(1):3843.

  • 33.

    Goic JB, Reineke EL, Drobatz KJ. Comparison of rectal and axillary temperatures in dogs and cats. J Am Vet Med Assoc. 2014;244(10):11701175.

  • 34.

    Paepe D, Verjans G, Duchateau L, Piron K, Ghys L, Daminet S. Routine health screening: findings in apparently healthy middle-aged and old cats. J Feline Med Surg. 2013;15(1):819.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Belshaw Z, Robinson NJ, Brennan ML, Dean RS. Developing practical recommendations for preventative healthcare consultations involving dogs and cats using a Delphi technique. Vet Rec. 2019;184(11):348. doi:10.1136/vr.104970

    • PubMed
    • Search Google Scholar
    • Export Citation

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Twenty-five components of a baseline, best-practice companion animal physical exam established by a panel of experts

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  • 1 Department of Population Medicine, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
  • | 2 Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada

Abstract

OBJECTIVE

To establish the components of a best-practice, baseline companion animal physical exam (CAPE).

SAMPLE

25 small animal veterinary internists and 20 small animal primary care veterinarians, all teaching the CAPE at veterinary colleges in the US, Canada, and Australia.

PROCEDURES

Using the Delphi Method of Consensus, 3 rounds of online questionnaires were sent to participants. The first round included demographic questions, questions about teaching the physical exam, and an open-ended question allowing participants to record details of how they conduct a CAPE. In the second round, participants were asked to rate components of the CAPE, which were derived from round 1, as “always examine,” “only examine as needed,” or “undecided.” Following round 2, any component not reaching 90% consensus (set a priori) for the response “always examine” was put forth in round 3, with a summary of comments from the round 2 participants for each remaining component.

RESULTS

35 components of a baseline CAPE were identified from round 1. The 25 components that reached 90% consensus by the end of round 3 were checking the oral cavity, nose, eyes, ears, heart, pulse rate, pulse quality, pulse synchrony, lungs, respiratory rate, lymph nodes, abdomen, weight, body condition score, mucous membranes, capillary refill time, general assessment, masses, haircoat, skin, hydration, penis and testicles or vulva, neck, limbs, and, in cats only, thyroid glands.

CLINICAL RELEVANCE

The findings establish an expert panel’s consensus on 25 components of a baseline, best-practice CAPE that can be used to help inform veterinary curricula, future research, and the practice of veterinarians.

Abstract

OBJECTIVE

To establish the components of a best-practice, baseline companion animal physical exam (CAPE).

SAMPLE

25 small animal veterinary internists and 20 small animal primary care veterinarians, all teaching the CAPE at veterinary colleges in the US, Canada, and Australia.

PROCEDURES

Using the Delphi Method of Consensus, 3 rounds of online questionnaires were sent to participants. The first round included demographic questions, questions about teaching the physical exam, and an open-ended question allowing participants to record details of how they conduct a CAPE. In the second round, participants were asked to rate components of the CAPE, which were derived from round 1, as “always examine,” “only examine as needed,” or “undecided.” Following round 2, any component not reaching 90% consensus (set a priori) for the response “always examine” was put forth in round 3, with a summary of comments from the round 2 participants for each remaining component.

RESULTS

35 components of a baseline CAPE were identified from round 1. The 25 components that reached 90% consensus by the end of round 3 were checking the oral cavity, nose, eyes, ears, heart, pulse rate, pulse quality, pulse synchrony, lungs, respiratory rate, lymph nodes, abdomen, weight, body condition score, mucous membranes, capillary refill time, general assessment, masses, haircoat, skin, hydration, penis and testicles or vulva, neck, limbs, and, in cats only, thyroid glands.

CLINICAL RELEVANCE

The findings establish an expert panel’s consensus on 25 components of a baseline, best-practice CAPE that can be used to help inform veterinary curricula, future research, and the practice of veterinarians.

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.79 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.

Study design

The Delphi Method of Consensus has been identified as a research approach to establish expert consensus for veterinarians to base clinical decisions.21 A 3 iteration, unmodified, Delphi Method of Consensus1820 was determined to be the most feasible and practical approach to obtain concordance among selected expert veterinarians working and teaching within an academic setting regarding the baseline, best-practice, CAPE. In keeping with Delphi survey methodology, the expert panelist remained anonymous to each other throughout the study. Consensus criteria were developed a priori and deemed to be reached when at least 90% of the respondents agreed that the specific component was part of a baseline CAPE. Survey software (Qualtrics; SAP American Inc) was used to administer the questionnaires.

Study participants

Participants were all veterinarians involved with teaching the CAPE to veterinary students at American Association of Veterinary Medical Colleges (AAVMC) member institutions. Two different groups were recruited to account for potential differences in perspective. The first included small animal veterinary internists (SAVIs), who are diplomates of either the ACVIM or and were teaching at a veterinary college in the US or Canada. An email contact list was compiled of SAVIs by searching the websites of all AAVMC member institutions in the US and Canada for diplomates of either the ACVIM and European College of Veterinary Internal Medicine faculty who were identified as teaching the CAPE to veterinary students. The second group included members of the Primary Care Veterinary Educators (PCVE) group associated with the AAVMC, comprised primarily of clinical faculty or instructors involved with delivering primary care clinical curricula at AAVMC member institutions globally. The goal of the Delphi study was to recruit a combined pool of 20 to 40 expert panelists from the 2 groups, to contribute throughout the Delphi process.19 Each round of questionnaires was pilot tested by veterinarians who were not involved with the study, and then revised as needed.

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.

Figure 1
Figure 1

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

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.

Statistical analysis

Statistical software (Stata IC16.0; StataCorp LP) was used for all statistical analyses. Descriptive statistics were computed and analyzed to provide background information on the participating experts. The mean and median number of years in practice of participants in round 1 were calculated based on year of graduation from veterinary school. To explore differences between the SAVI and PCVE panelists, the number of years in practice was compared using a t test. In addition, the proportion of panelists that self-identified as women in the SAVI and PCVE panelists in round 1 was also compared using a χ2 test. A value of P < 0.05 was considered significant.

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).

Table 1

Demographic information for the small animal veterinary internist (SAVI) and primary care veterinary educator (PCVE) panelists who participated in round 1.

CharacteristicSAVI panelists (n = 25)PCVE panelists (n = 20)Total panelists (n = 45)P value
No. (%) by gender identity
Female15 (60)17 (85) 32 (71)0.07
Male 9 (36) 3 (15) 12 (27)
Not identified1 (4)0 (0)0 (0)
No. in age category (y)
18–30000NC
31–406713
41–509514
51–605611
61 or older527
Years in practice
Mean ± SD22.9 ± 9.3915.9 ± 6.9820.21 ± 9.100.02
Median201419
Range7–387–307–38

— = Not applicable. NC = Not calculated.

Table 2

Physical exam components that achieved consensus in rounds 2 and 3, along with percentage agreement and round in which consensus was achieved.

ComponentNo. of panelists who chose alwaysAgreement (%)Round No. with consensus
Examine oral cavity251002
Examine nose251002
Cursory eye exam251002
Cursory ear exam251002
Auscultate heart251002
Pulse rate251002
Auscultate lungs251002
Respiratory rate24100*2
Palpate peripheral lymph nodes251002
Palpate abdomen for organomegaly24100*2
Body weight24100*2
Body condition score251002
Mucous membrane color24100*2
Capillary refill time251002
General assessment24962
Palpate body for masses24962
Examine haircoat24962
Pulse synchrony with heart rate23922
Examine skin23922
Hydration status23922
Thyroid gland palpation for older cats23922
Pulse quality211003
Examine penis and testicles or vulva20953
Palpate neck19903
Palpate limbs19903

Only 24 panelists responded to these questions.

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.

Table 3

Physical exam components that did not achieve consensus, with percentage agreement, by the end of round 3.

ComponentNo. of panelists who chose alwaysAgreement (%)
Muscle condition score1886
Neurologic assessment1781
Palpate spine1676
Axillary or rectal temperature1571
Palpate joints of limbs1571
Palpate mammary glands1571
Rectal exam of medium- to large-breed dogs1362
Rectal exam of any sized dog943
Palpate tail943
Ophthalmoscopic exam629
Otoscopic exam419

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 consensus20,23,35 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.

Acknowledgments

The authors received no financial support for the research of this article, and the authors declare that there are no conflicts of interest.

The authors thank research assistant Harley English-Dixon.

References

  • 1.

    Adams C, Kurtz S. Skills for Communicating in Veterinary Medicine. Otmoor Publishing; 2017.

  • 2.

    Lue TW, Pantenburg DP, Crawford PM. Impact of the owner-pet and client-veterinarian bond on the care that pets receive. J Am Vet Med Assoc. 2008;232(4):531540.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Donnelly AL. Client communications that enhance client understanding and patient care. In: Proceedings of the North American Veterinary Community Conference. North American Veterinary Community; 2015:401403.

    • Search Google Scholar
    • Export Citation
  • 4.

    Volk JO, Felsted KE, Thomas JG, Siren CW. Executive summary of the Bayer veterinary care usage study. J Am Vet Med Assoc. 2011;238(10):12751282.

  • 5.

    Kirnos C. How preventive care will grow your business. In: Proceedings of the 2018 American Association of Feline Practitioners Conference. American Association of Feline Practitioners; 2018:14.

    • Search Google Scholar
    • Export Citation
  • 6.

    McCurnin DM, Proffenbarger EM. Small Animal Physical Diagnosis and Clinical Procedures. WB Saunders Co; 1991.

  • 7.

    Defarges A. The physical exam. Clin Brief. 2015;7380. Accessed April 20, 2020. https://www.cliniciansbrief.com/article/physical-exam

  • 8.

    Jacobsen AP, Khiew YC, Murphy SP, Lane CM, Garibaldi BT. The modern physical exam—a transatlantic perspective from the resident level. Teach Learn Med. 2020;32(4):442448.

    • Search Google Scholar
    • Export Citation
  • 9.

    Singh H, Giardina TD, Meyer AN, Forjuoh SN, Reis MD, Thomas EJ. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med. 2013;173(6):418425.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Belshaw Z, Robinson NJ, Dean RS, Brennan ML. “I always feel like i have to rush…” Pet owner and small animal veterinary surgeons' reflections on time during preventative healthcare consultations in the United Kingdom. Vet Sci. 2018;5(1):20. doi:10.1136/vr.104835

    • Search Google Scholar
    • Export Citation
  • 11.

    Robinson NJ, Belshaw Z, Brennan ML, Dean RS. Topics discussed, exams performed and strategies implemented during canine and feline booster vaccination consultations. Vet Rec. 2019;184(8):252. doi:10.1136/vr.104835

    • Search Google Scholar
    • Export Citation
  • 12.

    Robinson NJ, Brennan ML, Cobb M, Dean RS. Capturing the complexity of first opinion small animal consultations using direct observation. Vet Rec. 2015;176(2):48. doi:10.1136/vr.102548

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Coe JB, Adams CL, Eva K, Desmarais S, Bonnett BN. Development and validation of an instrument for measuring appointment-specific client satisfaction in companion-animal practice. Prev Vet Med. 2010;93(2-3):201210.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Coe JB, Adams CL, Bonnett BN. A focus group study of veterinarians' and pet owners' perceptions veterinarian-client communication in companion animal practice. J Am Vet Med Assoc. 2008;233(7):10721080.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Janke N, Coe JB, Bernardo TM, Dewey CE, Stone EA. Pet owners' and veterinarians' perceptions of information exchange and clinical decision-making in companion animal practice. PLoS One. 2021;16(2):e0245632. doi:10.1371/journal.pone.0245632

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Rijnberk A, van Sluijs FJ. Medical History and Physical Exam in Companion Animals. 2nd ed. Elsevier Ltd; 2009.

  • 17.

    Helmer O. The Delphi method. In: Linstone H, Turoff M, eds. The Delphi Method: Techniques and Applications. Addison-Wesley Publishing Co; 1975:1012.

    • Search Google Scholar
    • Export Citation
  • 18.

    Hasson F, Keeny S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs. 2000;32(4):10081015.

  • 19.

    Hsu C-C, Sandford BA. The Delphi technique: making sense of consensus. Pract Assess Res Eval. 2007;12(10):18. doi:10.7275/PDX9-TH90

  • 20.

    Okoli C, Pawlowski SD. The Delphi method as a research tool: an example, design considerations and applications. Inf Manage. 2004;42(1):1529.

    • Search Google Scholar
    • Export Citation
  • 21.

    ACVIM consensus statements. American College of Veterinary Internal Medicine. Accessed July 19, 2021. https://www.acvim.org/Publications/JVIM/Consensus-Statements

    • Search Google Scholar
    • Export Citation
  • 22.

    Steele SG, Booy R, Mor SM. Establishing research priorities to improve the One Health efficacy of Australian general practitioners and veterinarians with regard to zoonoses: a modified Delphi survey. One Health. 2018;6:715.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Merola I, Mills DS. Behavioural signs of pain in cats: an expert consensus. PLoS One. 2016;11(2):e0150040. doi:10.1371/journal.pone.0150040

  • 24.

    Ceresia ML, Fasser CE, Rush JE, et al. The role and education of the veterinary pharmacist. Am J Pharm Educ. 2009;73(1):16. doi:10.5688/aj730116

  • 25.

    Prince JB, Andrus DM, Gwinner KP. Future demand, probable shortages, and strategies for creating a better future in food supply veterinary medicine. J Am Vet Med Assoc. 2006;229(1):5769.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Olczak J, Jones B, Pfeiffer D, Squires R, Morris R, Markwell P. Multivariate analysis of risk factors for feline hyperthyroidism in New Zealand. N Z Vet J. 2005;53(1):5358.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Norsworthy GD, Adams VJ, McElhaney MR, Milios JA. Relationship between semi-quantitative thyroid palpation and total thyroxine concentration in cats with and without hyperthyroidism. J Feline Med Surg. 2002;4(3):139143.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Broussard JD, Peterson ME, Fox PR. Changes in clinical and laboratory findings in cats with hyperthyroidism from 1983 to 1993. J Am Med Assoc. 1995;206(3):302305.

    • Search Google Scholar
    • Export Citation
  • 29.

    Freeman L, Becvarova I, Cave N, et al. WSAVA 2011 Nutritional Assessment Guidelines. J S Afr Vet Assoc. 2011;84(2):254263.

  • 30.

    Willems A, Paepe D, Marynissen S, et al. Results of screening of apparently healthy senior and geriatric dogs. J Vet Intern Med. 2017;31(1):8192.

  • 31.

    Greer RJ, Cohn LA, Dodam JR, Wagner-Mann CC, Mann FA. Comparison of three methods of temperature measurement in hypothermic, euthermic, and hyperthermic dogs. J Am Vet Med Assoc. 2007;230(12):18411848.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Döring D, Roscher A, Scheipl F, Küchenhoff H, Erhard MH. Fear-related behaviour of dogs in veterinary practice. Vet J. 2009;182(1):3843.

  • 33.

    Goic JB, Reineke EL, Drobatz KJ. Comparison of rectal and axillary temperatures in dogs and cats. J Am Vet Med Assoc. 2014;244(10):11701175.

  • 34.

    Paepe D, Verjans G, Duchateau L, Piron K, Ghys L, Daminet S. Routine health screening: findings in apparently healthy middle-aged and old cats. J Feline Med Surg. 2013;15(1):819.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Belshaw Z, Robinson NJ, Brennan ML, Dean RS. Developing practical recommendations for preventative healthcare consultations involving dogs and cats using a Delphi technique. Vet Rec. 2019;184(11):348. doi:10.1136/vr.104970

    • PubMed
    • Search Google Scholar
    • Export Citation

Contributor Notes

Corresponding author: Dr. da Costa (jdacosta@uoguelph.ca)