Veterinarian-client-patient communication during wellness appointments versus appointments related to a health problem in companion animal practice

Jane R. Shaw Department of Population Medicine, Ontario Veterinary College, University of Guelph, Guelph, ON N1G 2W1, Canada

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Cindy L. Adams Department of Population Medicine, Ontario Veterinary College, University of Guelph, Guelph, ON N1G 2W1, Canada

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Brenda N. Bonnett Department of Population Medicine, Ontario Veterinary College, University of Guelph, Guelph, ON N1G 2W1, Canada

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Susan Larson Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205

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Debra L. Roter Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205

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Abstract

Objective—To compare the clinical interview process, content of the medical dialog, and emotional tone of the veterinarian-client-patient interaction during wellness appointments and appointments related to a health problem in companion animal practice.

Design—Cross-sectional descriptive study.

Sample Population—A random sample of 50 companion animal practitioners in southern Ontario and a convenience sample of 300 clients and their pets.

Procedure—For each practitioner, 6 clinical appointments (3 wellness appointments and 3 problem appointments) were videotaped. The Roter interaction analysis system was used to analyze the resulting 300 videotapes.

Results—Wellness appointments were characterized by a broad discussion of topics, with 50% of data-gathering statements and 27% of client education statements related to the pet's lifestyle activities and social interactions. Wellness appointments included twice as much verbal interaction with the pet as did problem appointments, and the emotional atmosphere of wellness appointments was generally relaxed. There were more social talk, laughter, statements of reassurance, and compliments directed toward the client and pet. In contrast, during problem appointments, 90% of the data gathering and client education focused on biomedical topics. Coders rated veterinarians as hurried during 30 of the 150 (20%) problem appointments; they rated clients as anxious during 39 (26%) problem appointments and as emotionally distressed during 21 (14%).

Conclusions and Clinical Relevance—Results suggested that veterinarian-client-patient communication differed between wellness and problem appointments. Owing to the emphasis on biomedical content during problem appointments, veterinarians may neglect lifestyle and social concerns that could impact patient management and outcomes, such as client satisfaction and adherence to veterinarian recommendations.

Abstract

Objective—To compare the clinical interview process, content of the medical dialog, and emotional tone of the veterinarian-client-patient interaction during wellness appointments and appointments related to a health problem in companion animal practice.

Design—Cross-sectional descriptive study.

Sample Population—A random sample of 50 companion animal practitioners in southern Ontario and a convenience sample of 300 clients and their pets.

Procedure—For each practitioner, 6 clinical appointments (3 wellness appointments and 3 problem appointments) were videotaped. The Roter interaction analysis system was used to analyze the resulting 300 videotapes.

Results—Wellness appointments were characterized by a broad discussion of topics, with 50% of data-gathering statements and 27% of client education statements related to the pet's lifestyle activities and social interactions. Wellness appointments included twice as much verbal interaction with the pet as did problem appointments, and the emotional atmosphere of wellness appointments was generally relaxed. There were more social talk, laughter, statements of reassurance, and compliments directed toward the client and pet. In contrast, during problem appointments, 90% of the data gathering and client education focused on biomedical topics. Coders rated veterinarians as hurried during 30 of the 150 (20%) problem appointments; they rated clients as anxious during 39 (26%) problem appointments and as emotionally distressed during 21 (14%).

Conclusions and Clinical Relevance—Results suggested that veterinarian-client-patient communication differed between wellness and problem appointments. Owing to the emphasis on biomedical content during problem appointments, veterinarians may neglect lifestyle and social concerns that could impact patient management and outcomes, such as client satisfaction and adherence to veterinarian recommendations.

Several studies1–4 published in the past decade have identified a gap between the content of the veterinary school curriculum and the actual skills required to be a successful veterinarian. In particular, multiple studies have indicated that veterinary students,5–7 new graduates,8,9 and veterinarians10 are lacking important skills related to compassionate, courteous, and effective communication with clients. Similarly, results of the American Animal Hospital Association compliance study11 suggested that a primary reason for client noncompliance was inadequate veterinarian-client communication. Given the enhanced recognition of the human-animal bond, the continuing increase in client expectations, and the growing awareness that breakdowns in communication are a major cause of client dissatisfaction, there is increased pressure to understand and enhance veterinarian-client-patient communication.12

Developing an understanding of veterinarian-client-patient communication requires a method for characterizing communication. Although a number of coding systems have been developed to characterize medical communication, the RIAS is more widely used than any other and provides insight into medical communication on multiple levels, including the content and emotional tone of the medical dialog, the process of the clinical interview, and the overall communication pattern used by the physician.13 The communication content reflects the topical nature of the medical dialog and is classified as biomedical topics, lifestyle and psychosocial topics, and anticipatory guidance topics.14 Biomedical content includes discussion of the medical condition and its diagnosis, treatment, and prognosis, whereas lifestyle and psychosocial content includes discussions about lifestyle, work-life balance, interpersonal relationships, and mental health. Anticipatory guidance topics generally foreshadow anticipated developmental or physical milestones related to maturation or aging.

We previously reported details of 2 studies10,15 in which we applied the RIAS in a veterinary setting. In the first of these analyses,10 we described general characteristics of veterinarian-client-patient communication during routine appointments in companion animal practice. We found that the definition of biomedical talk in human medicine could be applied in the veterinary setting, although the specific context of lifestyle discussions differed. Lifestyle discussions in companion animal practice were found to involve the pet's daily living activities (eg, exercise regimen, environment, diet, and sleeping habits) and social interactions (eg, personality or temperament, behavior, human-animal interactions, and animal-animal interactions).10 Anticipatory guidance topics incorporated discussion of expectations throughout normal development of an animal within its life stages, including feeding, training, and behavioral changes.

We also found that communication processes that occur during primary care appointments in human medicine16 are similar to those that occur during appointments in companion animal practice.10 This includes such processes as data gathering, building relationships by acknowledging and responding to client emotions and emotional needs, client education and counseling, and establishment of an active partnership. In brief, we found that during a typical veterinary appointment, which lasted 13 minutes on average, 9% of the medical dialog was devoted to data gathering (primarily through closed-ended questioning), 48% was devoted to client education and counseling, 30% focused on emotional responsiveness and relationship building, 7% was directed toward client activation and partnership, and 6% was used to provide orientation and direction.10 We also found that veterinarians verbally dominated the medical exchange and contributed 62% of the medical dialog statements (54% directed to the client and 8% directed to the patient), whereas the client contributed 38% of the medical dialog statements.

In a subsequent examination of the data,15 cluster analysis of 4 key communication variables (biomedical question asking, biomedical information, lifestyle question asking, and lifestyle information) was used to identify patterns in the interview style of study veterinarians. As has been reported previously for physicians,17,18 2 distinct communication patterns were identified. Overall, 58% of the appointments were classified as being primarily biomedical in focus, whereas 42% were classified as representing a balance between biomedical and lifestyle content during data gathering and client education (ie, classified as having a biolifestyle-social communication pattern). A key finding of this analysis was that veterinarian communication patterns were highly associated with appointment type. Of the 150 wellness appointments that were analyzed, 103 (69%) involved a biolifestyle-social communication pattern and 47 (31%) involved a biomedical communication pattern. In contrast, of the 150 appointments related to a health problem (ie, problem appointments) that were analyzed, 127 (85%) involved a biomedical communication pattern and only 23 (15%) involved a biolifestyle-social communication pattern.

We believe that describing differences in communication dynamics between wellness and problem appointments may aid in understanding the unique contexts of these appointments. Studies on human medical communication indicate that effective communication is related to important clinical outcomes, including patient satisfaction,17,19,20 physician satisfaction,17 patient adherence,21 patient health outcomes,22 and frequency of malpractice complaints.23 Thus, understanding differences between wellness and problem appointments may allow us to make recommendations to better achieve desired outcomes. The purpose of the study reported here was to compare the clinical interview process, content of the medical dialog, and emotional tone of the veterinarian-client-patient interaction during wellness and problem appointments in companion animal practice. Videotapes used in 2 previous studies10,15 were analyzed to capture the nature and flow of interactions (ie, veterinarian to client, client to veterinarian, and veterinarian to patient) during these appointments, and clinical implications of the results were evaluated in light of evidence-based guidelines for medical communication.

For the present study, we hypothesized that there were 3 important differences in veterinarian-client-patient communication between wellness and problem appointments. First, we hypothesized that conversational emphasis on process-oriented tasks (ie, data gathering, client education, relationship building, and establishing a partnership) would differ between wellness and problem appointments. Specifically, we anticipated that more of the communication during problem appointments would be devoted to gathering data on the patient's medical problem, educating the client about the pet's medical condition, creating a diagnostic or therapeutic plan, and providing prognostic information. Furthermore, we hypothesized that veterinarians would provide more emotional support to concerned clients and engage those clients as partners in decision-making about further diagnostic testing or the therapeutic plan.

Second, we hypothesized that the content of the information requested from and provided to clients would differ between wellness and problem appointments. Specifically, we expected that question asking and information giving during problem appointments would be predominantly biomedical in nature, focusing on the medical condition, diagnostic and therapeutic plans, and prognosis, whereas information exchanged during wellness appointments would include a greater emphasis on lifestyle activities (eg, the pet's exercise regimen, diet, and sleeping habits), social interactions (eg, the pet's personality and behavior and human-animal interactions), and anticipatory guidance topics (eg, developmental expectations throughout the animal's life stages).

Third, we hypothesized that emotional tone or atmosphere would differ between wellness and problem appointments. Emotional tone reflects nonverbal communication (ie, the message that is communicated without the use of words and is conveyed through facial expression, eye contact, position, posture, movement, timing, and voice qualities). Given the routine nature of wellness appointments, we suspected that veterinarians and clients might appear more relaxed during wellness appointments and express stress, anxiety, or concern during problem appointments.

Materials and Methods

Videotapes obtained for 2 previous studies10,15 were used in the present study. Details of the study design, including sampling strategy and data collection, have been described previously.10 Briefly, a random sample of 50 veterinarians was recruited from the population of companion animal practitioners in southern Ontario. Participants were contacted by one of the authors (JRS) to inform them of the project, obtain consent, and arrange a site visit. All clients who arrived for a scheduled appointment during the site visit were invited to participate in the study. Fifty veterinarians and 300 veterinary medical appointments were videotaped. For each veterinarian, a minimum of 6 appointments was videotaped, including at least 3 wellness appointments and 3 problem appointments. A brief survey was administered to veterinarians and clients to obtain information on demographic traits of participating practices, veterinarians, clients, and pets. The Human Ethics Committee at the University of Guelph approved the research protocol.

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

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

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

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

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

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

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

Results

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

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

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

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

Table 1—

Distribution of the components of veterinarian-to-client communication during wellness appointments and appointments related to a health problem (ie, problem appointments) in companion animal practice.

ComponentNo. of statements during wellness appointmentsNo. of statements during problem appointmentsP value
MeanRangePercentageMeanRangePercentage
Data gathering160–459140–4880.18
Biomedical80–375120–427< 0.01
Biolifestyle-social70–28420–221< 0.01
Anticipatory guidance0.40–12<10.010–1<1< 0.01
Client education817–558469512–43252< 0 01
Biomedical540–37930859–39347< 0.01
Biolifestyle-social220–14713100–1135< 0.01
Anticipatory guidance40–77210–19< 1< 0.01
Building a relationship556–25332494–217270.03
Positive talk321–12418333–131180.70
Negative talk00–3000–400.53
Social talk60–69320–191< 0.01
Rapport building171–11610140–1098< 0.01
Establishing a partnership231–9813243–116130.68
Facilitation120–497130–5670.64
Orientation110–547111–6060.81
All statements17534–93910018234–8121000.23

Data were obtained through analysis with the RIAS of videotapes of 150 wellness and 150 problem appointments conducted by veterinarians in private companion animal practice in southern Ontario (3 wellness and 3 problem appointments for each veterinarian).

DATA GATHERING

On average, 9% of the total number of statements directed by veterinarians toward clients during wellness appointments and 8% of the total number of statements during problem appointments were devoted to data gathering (Table 1). Number of data-gathering statements by veterinarians did not differ significantly (P = 0.18) between wellness and problem appointments. However, number of biomedical data-gathering statements was significantly (P < 0.01) higher and number of biolifestyle-social data-gathering questions was significantly (P < 0.01) lower during problem appointments than during wellness appointments. During both types of appointments, datagathering statements related to anticipatory guidance were uncommon, but number of anticipatory guidance statements was significantly (P < 0.01) higher during wellness appointments than during problem appointments.

CLIENT EDUCATION

Number of client education statements directed by veterinarians to clients was significantly (P < 0.01) higher during problem appointments than during wellness appointments (Table 1). In addition, number of biomedical client education statements was significantly (P < 0.01) higher, and number of biolifestyle-social client education statements was significantly (P < 0.01) lower during problem appointments than during wellness appointments. Again, client education statements related to anticipatory guidance were uncommon during both types of appointments but were significantly (P < 0.01) more common during wellness appointments than during problem appointments.

BUILDING A RELATIONSHIP

Significantly more conversation was invested in relationship building during wellness than during problem appointments (P = 0.03). Number of positive talk statements was not significantly (P = 0.70) different between wellness and problem appointments (Table 1). However, veterinarians expressed significantly (P < 0.01) more laughter during wellness appointments (mean number of statements, 8.0; range, 0 to 64) than during problem appointments (mean, 5.6; range, 0 to 52). In addition, veterinarians expressed significantly (P < 0.01) more statements of approval during wellness appointments (mean, 2.3; range, 0 to 17) than during problem appointments (mean, 1.6; range, 0 to 13). Negative statements (ie, disapproval or criticism) did not occur during either type of appointment. Numbers of social statements and rapport-building statements made by veterinarians were significantly (P < 0.01) higher during wellness appointments than during problem appointments. Specifically, veterinarians made significantly (P < 0.01) more statements of reassurance during wellness appointments (mean, 11.7; range, range 0 to 96) than during problem appointments (mean, 8.0; range, 0 to 34) and made significantly (P = 0.01) more self-disclosure statements during wellness appointments (mean, 1.7; range, 0 to 27) than during problem appointments (mean, 0.89; range, 0 to 11). However, veterinarians made significantly (P < 0.05) more statements of concern during problem appointments (mean, 5.1; range, 0 to 88) than during wellness appointments (mean, 3.9; range, 0 to 30).

ESTABLISHING A PARTNERSHIP

Overall, the number of statements related to establishing a partnership did not differ between wellness and problem appointments (Table 1). However, veterinarians were significantly (P < 0.01) more likely to ask for the client's opinion during wellness appointments (mean, 1.2; range, 0 to 7) than during problem appointments (mean, 0.77; range, 0 to 7). In contrast, veterinarians were significantly (P < 0.01) more likely to ask about the client's understanding during problem appointments (mean, 3.5; range, 0 to 22) than during wellness appointments (mean, 2.5; range, 0 to 27).

EMOTIONAL TONE

No significant differences were detected between wellness and problem appointments with regard to ratings for expression of positive emotions by veterinarians (Table 2). However, veterinarians were rated as being significantly (P = 0.04) more hurried or rushed during problem appointments than during wellness appointments, with veterinarians perceived to be hurried or rushed during 30 of the 150 (20%) problem appointments but only 19 of the 150 (13%) wellness appointments.

Table 2—

Scores for emotional tone during wellness and problem appointments in companion animal practice.

EmotionWellness appointmentsProblem appointmentsP value
MeanSDMeanSD
Veterinarians
Anger or irritation1.010.161.000.001.00
Anxiety or nervousness1.010.161.020.141.00
Dominance or assertiveness3.490.500.430.510.36
Interest or attentiveness4.020.574.070.580.31
Friendliness or warmth3.910.823.780.830.09
Responsiveness or engagement4.070.594.120.570.46
Sympathy or empathy3.060.783.080.871.00
Hurried or rushed2.160.742.290.710.04
Respectfulness3.530.563.540.560.68
Clients
Anger or irritation1.020.181.010.080.75
Anxiety or nervousness1.110.341.270.48< 0.01
Depression or sadness1.010.161.020.140.35
Emotional distress or upset1.030.211.150.40< 0.01
Dominance or assertiveness3.270.533.330.600.35
Interest or attentiveness3.780.593.770.610.65
Friendliness or warmth3.450.763.270.830.09
Responsiveness or engagement3.790.643.790.661.00
Sympathy or empathy2.550.622.580.640.65
Hurried or rushed2.330.772.440.710.07
Respectfulness3.440.513.330.540.05

Data were obtained by assigning scores on a scale from 1 to 5 (1 = low and 5 = high) for the extent to which veterinarians and clients expressed each positive and negative emotion during videotape analysis of 150 wellness and 150 problem appointments conducted by veterinarians in private companion animal practice in southern Ontario (3 wellness and 3 problem appointments for each veterinarian).

Client-to-veterinarian communication—In analyzing client-to-veterinarian communication, data gathering involved the client asking questions of the veterinarian about biomedical, biolifestyle-social, and anticipatory guidance topics (Table 3). Client education involved the client providing information about these topics.

Table 3—

Distribution of the components of client-to-veterinarian communication during wellness appointments and appointments related to a health problem (ie, problem appointments) in companion animal practice.

ComponentNo. of statements during wellness appointmentsNo. of statements during problem appointmentsP value
 MeanRangePercentageMeanRangePercentage 
Question asking50–17460–3440.02
Biomedical40–14350–344< 0.01
Biolifestyle-social10–810.60–8<10.06
Anticipatory guidance0.10–4<10.030–1<1< 0.01
Providing information556–20847611–245480.17
Biomedical260–12922460–19036< 0.01
Biolifestyle-social301–11925140–10611< 0.01
Anticipatory guidance20–3620.20–7<1< 0.01
Building a relationship566–25647555–200441.00
Positive talk433–21336454–168360.42
Negative talk0.30–4<10.40–10<10.20
Social talk50–93420–412< 0.01
Rapport building70–29670–3860.71
Establishing a partnership40–29350–2740.37
Facilitation20–24240–2130.59
Orientation10–10120–121< 0.01
All statements12321–40210013017–4011000.36

See Table 1 for key.

QUESTION ASKING

Mean number of questions asked by clients during problem appointments was significantly (P = 0.02) higher than mean number asked during wellness appointments (Table 3). This reflected the fact that clients asked significantly (P < 0.01) more biomedical questions during problem appointments than during wellness appointments. Few anticipatory guidance questions were asked during either type of appointment, but such questions were significantly (P < 0.01) more common during wellness appointments than during problem appointments.

PROVIDING INFORMATION

The overall number of statements by clients providing information to the veterinarian did not differ significantly (P = 0.17) between wellness and problem appointments (Table 3). However, clients provided significantly (P < 0.01) more biomedical information statements and significantly (P < 0.01) fewer biolifestyle-social information statements during problem appointments than during wellness appointments. Clients were significantly (P < 0.01) more likely to provide information on anticipatory guidance topics during wellness appointments than during problem appointments.

BUILDING A RELATIONSHIP

Overall numbers of positive talk and negative talk statements by clients did not differ between wellness and problem appointments (Table 3). However, clients expressed significantly (P < 0.01) more laughter during wellness appointments (mean, 10.0; range, 0 to 42) than during problem appointments (mean, 7.3; range, 0 to 49). Clients also expressed significantly (P < 0.01) more approval during wellness appointments (mean, 3.6; range, 0 to 17) than during problem appointments (mean, 2.5; range, 0 to 22). Overall, clients expressed few negative statements but expressed significantly (P < 0.05) more criticism statements during problem appointments (mean, 0.12; range, 0 to 5) than during wellness appointments (mean, 0.02; range, 0 to 2). Clients also expressed significantly (P < 0.01) more social talk during wellness appointments than during problem appointments. Finally, with regard to rapport building, clients expressed significantly (P < 0.01) more statements of concern during problem appointments (mean, 4.7; range, 0 to 24) than during wellness appointments (mean, 3.4; range, 0 to 16).

ESTABLISHING A PARTNERSHIP

Overall, the number of statements made by clients that related to establishing a partnership did not differ between wellness and problem appointments (Table 3), although there was a small but significant (P < 0.01) difference in number of orientation statements made by clients. This was attributable to a significantly (P < 0.01) higher number of transition statements (ie, statements that indicate movement in the discussion to another topic, area of discussion, or train of thought or action) during problem appointments (mean, 1.5; range, 0 to 10), compared with wellness appointments (mean, 1.0; range, 0 to 7).

EMOTIONAL TONE

No significant differences were detected between wellness and problem appointments with regard to ratings for expression of positive emotions by clients, with the exception that scores for respectfulness were significantly (P = 0.05) higher during wellness appointments than during problem appointments (Table 2), with clients perceived to be respectful during 67 (45%) wellness appointments and 55 (37%) problem appointments. Clients were rated as being significantly more anxious or nervous (P < 0.01) and significantly more emotionally distressed or upset (P < 0.01) during problem appointments than during wellness appointments. Clients were perceived as anxious or nervous during 39 (26%) problem appointments and 16 (11%) wellness appointments and were perceived as emotionally distressed or upset during 21 (14%) problem appointments and 4 (3%) wellness appointments.

Veterinarian-to-patient communication—Mean number of statements directed by the veterinarian to the patient was nearly 50% higher during wellness appointments than during problem appointments (Table 4). Thus, for most of the communication categories, number of statements directed by the veterinarian to the patient was significantly higher during wellness appointments than during problem appointments. Further analysis revealed that veterinarianpatient communication could be divided into statements directed to the pet and statements intended for the client and indirectly communicated through the pet.

Table 4—

Distribution of the components of veterinarian-to-patient communication during wellness appointments and appointments related to a health problem (ie, problem appointments) in companion animal practice.

ComponentNo. of statements during wellness appointmentsNo. of statements during problem appointmentsP value
 MeanRangePercentageMeanRangePercentage 
Client education1.30–1041.00–135<0.05
Biomedical0.80–640.80–1340.15
Biolifestyle-social0.40–610.20–42< 0.01
Anticipatory guidance0.10–2<10000.25
Building a relationship140–1014880–7042< 0.01
Positive talk70–462340–2620< 0.01
Negative talk0.30–2010.10–3<1< 0.05
Social talk0.50–540.30–51< 0.05
Rapport building60–501940–2421< 0.01
Establishing a partnership140–7248100–4553< 0.01
Facilitation90–493060–3931< 0.01
Orientation50–341740–2521< 0.01
All statements300–137100200–83100<0.01

See Table 1 for key.

Relationship-building communication directed to the pet was used to establish rapport with the pet and create patient comfort. Veterinarians provided significantly (P < 0.01) more compliments to the pet (eg, “You are so pretty.”) during wellness appointments (mean, 5.1; range, 0 to 46) than during problem appointments (mean, 3.1; range, 0 to 25). Similarly, veterinarians laughed and joked significantly (P < 0.01) more during wellness appointments (mean, 1.5; range, 0 to 17) than during problem appointments (mean, 0.78; range, 0 to 17) and provided significantly (P = 0.02) more reassurance statements (eg, “This won't hurt.”) to the pet during wellness appointments (mean, 5.6; range, 0 to 36) than during problem appointments (mean, 3.2; range, 0 to 17).

Veterinarians expressed significantly (P < 0.01) more facilitation statements (eg, instructions and directions such as “Stay still.”) during wellness appointments than during problem appointments (Table 4). Similarly, veterinarians provided significantly (P < 0.01) more orientation statements to the pet about what was going to happen next (eg, “I am going to take a look in your ears.”) during wellness appointments than during problem appointments. Lastly, veterinarians directed significantly (P < 0.05) more statements to the pet intended to indirectly provide information or clinical findings to the client (eg, “You have gained weight.”) during wellness appointments than during problem appointments.

Discussion

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In human medicine, the recommended approach for physician-patient interactions is relationship-centered care, which is based on mutuality, negotiation between partners, and creation of a joint venture.16,24,38 In veterinary medicine, relationship-centered care represents a joint venture between the veterinarian and client to provide optimal care for the animal. Respect for the client's perspective and interests and recognition of the role the animal plays in the life of the client should be incorporated into all aspects of care. Extrapolating from evidence in human medicine, we believe that using principles of relationship-centered care will be associated with clinically important outcomes in veterinary medicine. Specifically, findings indicate that broadening the field of inquiry to include lifestyle and social factors will improve diagnostic reasoning and accuracy24,26; that building a strong relationship will be associated with increased accuracy of data gathering,26 increased patient satisfaction,19,20,32 and increased physician satisfaction16,33; and that encouraging participation, negotiation, and shared decision-making will promote patient satisfaction,19,20,32 increase adherence to recommendations,21 and improve health.22 Incorporating these principles of care alongside traditional biomedical tasks (eg, data gathering and information providing) optimizes quality of care.

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

ABBREVIATION

RIAS

Roter interaction analysis system

a.

SAS, version 8.2, SAS Institute Inc, Cary, NC.

References

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    Shaw JR, Adams CL, Bonnett BN. What can veterinarians learn from studies of physician-patient communication about veterinarian-client-patient communication? J Am Vet Med Assoc 2004;224:676684.

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    Roter DL, Stewart M, Putnam SM. Communication patterns of primary care physicians. JAMA 1997;277:350356.

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Appendix

Components of veterinarian-client-patient communication.

Composite categoryVariableRepresentative statements and questions
Data gathering
 Biomedical information*Closed-ended questionsWhat breed of dog is Max?
Open-ended questionsWhat brings you here today?
Bid for repetitionI did not quite get that last part.
 Biolifestyle-social informationClosed-ended questionsDo you have any other pets?
Open-ended questionsHow is Max acclimating to your home?
 Anticipatory guidance informationClosed-ended questionsIs Max housetrained?
Open-ended questionsHow is the crate training going?
Client education
 Biomedical information*Information givingThis medication will help reduce the pain.
CounselingAdminister the medication 3 times a day.
 Biolifestyle-social informationInformation givingWalking daily is importantto weightloss.
CounselingDoggie daycare is good for socialization.
 Anticipatory guidance informationInformation givingWe will increase the dose as he grows.
CounselingObedience class helps with leash walking.
Building a relationship
 Positive talkComplimentsThat groomer has a good reputation.
Laughter and jokes
AgreementYes, that's right.
ApprovalYou have been helpful in holding him.
 Negative talkDisapprovalNo, I don't think so.
CriticismShe's never there when I need her.
 Social talkPersonal remarksDid you see the hockey playoffs?
 Rapport buildingEmpathyThis is distressing for you.
LegitimationI can see why you are worried.
PartnershipI'd like for us to work together on a plan.
ConcernI am concerned about the mass.
ReassuranceI really think this will help.
Self-disclosureI have the same problem with my dog.
Establishing a partnership
 FacilitationSeeking understandingCan you repeat what I just told you?
Seeking opinionWhat do you think is the cause?
Asking for reassuranceDo you think it is something serious?
CheckingSo, the problem started 2 weeks ago?
Back-channelsUm-hum, oh, yeah, right, okay.
 OrientationTransitionsI would like to ask you a few questions.
OrientationI would like to examine him now.

Includes topics related to the medical condition and its diagnosis, treatment, and prognosis.

Includes topics related to lifestyle activities, social development, and social interactions.

Adapted from Shaw JR, Adams CL, Bonnett BN, et al. Use of the Roter interaction analysis system to analyze veterinarian-client-patient communication in companion animal practice. J Vet Med Assoc 2004;225:222—229. Reprinted with permission.

  • 1.

    Brown JP, Silverman JD. The current and future market for veterinarians and veterinary medical services in the United States. J Am Vet Med Assoc 1999;215:161183.

    • Search Google Scholar
    • Export Citation
  • 2.

    Cron WL, Slocum JV Jr, Goodnight DB, et al. Executive summary of the Brakke management and behavior study. J Am Vet Med Assoc 2000;217:332338.

  • 3.

    Lewis RE, Klausner JS. Nontechnical competencies underlying career success as a veterinarian. J Am Vet Med Assoc 2003;222:16901696.

  • 4.

    Volk JO, Felsted KE, Cummings RF. Executive summary of the AVMA-Pfizer business practices study. J Am Vet Med Assoc 2005;226:212218.

  • 5.

    Tinga CE, Adams CL, Bonnett BN. Survey of veterinary technical and professional skills in students and recent graduates of a veterinary college. J Am Vet Med Assoc 2001;219:924931.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6.

    Hendrix CM, Thampson IK, Mann CJ. A survey of reading, writing and oral communication skills in North American veterinary medical colleges. J Vet Med Educ 2001;28:3440.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7.

    Walsh DA, Osburn BI, Schumacher RL. Defining the attributes expected of graduating veterinary medical students, part 2: external evaluation and outcomes assessment. J Vet Med Educ 2002;29:3642.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8.

    Heath TJ, Mills JN. Starting work in veterinary practice: an employer's viewpoint. Aust Vet Pract 1999;29:146152.

  • 9.

    Heath TJ. Experiences and attitudes of recent veterinary graduates: a national survey. Aust Vet Pract 1997;27:4550.

  • 10.

    Shaw JR, Adams CL, Bonnett BN. Use of the Roter interaction analysis system to analyze veterinarian-client-patient communication in companion animal practice. J Am Vet Med Assoc 2004;225:222229.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11.

    American Animal Hospital Association. The path to high quality care: practical tips for improving compliance. Lakewood, Colo: American Animal Hospital Association, 2003.

    • Search Google Scholar
    • Export Citation
  • 12.

    Shaw JR, Adams CL, Bonnett BN. What can veterinarians learn from studies of physician-patient communication about veterinarian-client-patient communication? J Am Vet Med Assoc 2004;224:676684.

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

    Roter DL, Hall JA. Doctors talking with patients/patients talking with doctors: improving communication in medical visits. Westport, Conn: Auburn House, 2006.

    • Search Google Scholar
    • Export Citation
  • 14.

    Roter D, Larson S. The Roter Interaction Analysis System (RIAS): utility and flexibility for analysis of medical interactions. Patient Educ Couns 2002;46:243251.

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

    Shaw JR, Bonnett BN, Adams CL, et al. Veterinarian-client-patient communication patterns used during clinical appointments in companion animal practice. J Am Vet Med Assoc 2006;228:714721.

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

    Roter DL. The enduring and evolving nature of the patient-physician relationship. Patient Educ Couns 2000;39:515.

  • 17.

    Roter DL, Stewart M, Putnam SM. Communication patterns of primary care physicians. JAMA 1997;277:350356.

  • 18.

    Bensing JM, Roter DL, Hulsman RL. Communication patterns of primary care physicians in the United States and The Netherlands. J Gen Intern Med 2003;18:335342.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19.

    Bertakis KD, Roter DL, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Fam Pract 1991;32:175181.

    • Search Google Scholar
    • Export Citation
  • 20.

    Hall JA, Dornan MC. Meta-analyses of satisfaction with medical care: description of research domain and analysis of overall satisfaction levels. Soc Sci Med 1988;27:637644.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21.

    DiMatteo MR, Sherbourne CD, Hays RD. Physicians' characteristics influence patient's adherence to medical treatments: results form the medical outcomes study. Health Psychol 1993;12:93102.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22.

    Stewart MA. Effective physician-patient communication and health outcomes: a review. Can Med Assoc J 1995;152:14231433.

  • 23.

    Roter DL. The patient-physician relationship and its implications for malpractice litigation. J Health Care Law Policy 2006;9:304314.

    • Search Google Scholar
    • Export Citation
  • 24.

    Sackett DL, Haynes RB, Guyatt GH, et al. Clinical epidemiology: a basic science for clinical medicine. Boston, Mass: Little, Brown & Co, 1991.

    • Search Google Scholar
    • Export Citation
  • 25.

    Silverman J, Kurtz SA, Draper J. Skills for communicating with patients. Abingdon, Oxfordshire, England: Radcliffe Medical Press, 2005.

  • 26.

    Stewart M, Brown JB, Weston WW, et al. Patient-centered medicine: transforming the clinical method. Abingdon, Oxfordshire, England: Radcliffe Medical Press, 2003.

    • Search Google Scholar
    • Export Citation
  • 27.

    MacMillan FD. Development of a mental wellness program for animals. J Am Vet Med Assoc 2002;220:965972.

  • 28.

    Blackwell MJ. The 2001 Inverson Bell Symposium Keynote Address: beyond philosophical differences: the future training of veterinarians. J Vet Med Educ 2001;28:148152.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 29.

    Antelyes J. Client hopes, client expectations. J Am Vet Med Assoc 1990;197:15961597.

  • 30.

    Lagoni L, Butler C, Hetts S. The human-animal bond and grief. Philadelphia: WB Saunders Co, 1994.

  • 31.

    Hart L, Hart B. Grief and stress from so many animal deaths. Companion Anim Pract 1987;1:2021.

  • 32.

    Buller MK, Buller DB. Physicians' communication style and patient satisfaction. J Health Soc Behav 1987;28:375388.

  • 33.

    Levinson W, Stiles WB, Inui TS. Physician frustration in communicating with patients. Med Care 1993;31:285295.

  • 34.

    Case DB. Survey of expectations among clients of three small animal clinics. J Am Vet Med Assoc 1988;192:498502.

  • 35.

    Osborne CA. Client confidence in veterinarians: how can it be sustained? J Am Vet Med Assoc 2002;221:936938.

  • 36.

    Maguire P, Fairbairn S, Fletcher C. Consultation skills of young doctors: II. Most young doctors are bad at giving information. Br Med J (Clin Res Ed) 1986;292:15761578.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 37.

    Ram P, Grol R, Rethans JJ. Assessment of general practitioners by video observation of communicative and medical performance in daily practice: issues of validity, reliability and feasibility. Med Educ 1999;33:447454.

    • Crossref
    • Search Google Scholar
    • Export Citation
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