Clients' confidence: How can we earn it?

What is the definition of "confidence?" Webster's dictionary defines it as an assurance of mind or firm belief in the trustworthiness of another.

Trust is defined as confidence in the honesty, integrity, reliability and justice of another. According to this dictionary, the words confidence and trust may be used interchangeably.

Trust is one of the highest forms of human motivation. Trust, or lack of it, is the root of success or failure in relationships with clients, colleagues and employees. It fosters a climate in which veterinarians and clients can work cooperatively to establish shared objectives of patient care and seek reasonable ways of achieving them. Ironically, it usually requires many positive actions for us to earn and maintain our clients' confidence and loyalty, yet that trust can be undermined if they perceive that even one of our actions is uncaring or self-serving.

How can we gain and sustain the confidence and trust of our clients in our ethical character (what we are as persons) and our professional competency (what we do as veterinarians)? To foster deeper understanding about how we might earn and maintain our clients' confidence, please consider the questions that follow. Where appropriate try to answer as if you were one of your clients with access to all of your professional activities and your innermost thoughts. In other words, they could read your mind, assess your speech and evaluate your actions.

Maintaining competency

Recall that the Veterinarian's Oath states in part, "I accept as a lifelong obligation the continual improvement of my professional knowledge and competence."

In this context, would my clients maintain their confidence in me if they knew my attitude about the importance of continuing to learn and the level of my desire to remain professionally competent?

Am I committed to learning a living?

Am I at times over-confident, or am I teachable (i.e., am I willing to learn from the knowledge, experience, wisdom of others)?

What priority do I place on keeping current with new knowledge published in journals, textbooks and the Internet?

How current are the textbooks in my hospital? How often do I read them?

Would I regularly attend continuing-education seminars if there weren't a legal requirement to do so?

Do I strive to attain and maintain a level of professional competence that would allow me to provide the quality of medical care that I would desire if I were the patient?

If I or a member of my family faced a serious illness, would I have confidence in a physician with study habits comparable to mine?

Quality of patient care

Would my clients maintain confidence in me if they could assess the pattern of timeliness of my responses to legitimate requests for needed veterinary care?

Would they maintain that confidence if they knew whether I conscientiously applied the principle of recommending the same standard of care for my patients that I would use if I were choosing diagnostics and therapy for myself?

Would they maintain their confidence in me if they were able to follow me step by step as I directed the care provided to their animals?

When we offer the type of care for our patients that we would select for ourselves, then at the very least our clients know that our primary motive for doing so is based on the Golden Rule.

Won't you agree that clients are more likely to have confidence in our recommendations and to comply if they know that we have their best interests at heart?

Experience

Would my clients maintain their confidence in me if they knew the level of experience I have with my proposed plan of therapy, and my familiarity with associated therapeutic benefits and risks?

Do I have a balanced view of my limitations?

When uncertainty exists as to whether a particular drug, medical or surgical procedure is in the best interests of the patient, do I try to answer the following questions?

Based on all the information available, would I choose this course of therapy if I were this patient?

Based on my knowledge of my own skill and experience with this type of problem, would I consent to the proposed diagnostic and therapeutic plan if I were in this patient's situation?

What diagnostic and/or therapeutic goals are likely to be achieved?

If I follow the proposed plan of action, in all probability will the overall benefits of this plan of action justify the associated risks and costs?

Informed consent

Would my clients maintain their confidence in me if they could match my words with my thoughts and actions?

Have I ever misrepresented the probable course of events of a patient's illness to my clients?

Do I have a tendency to overstate the benefits of therapy while minimizing the risks? Would my clients maintain their confidence in me if they knew I had concealed information about serious side effects associated with the proposed diagnosis or therapy?

Do I routinely explain the differences between specific, supportive and symptomatic therapy?

Do I consistently inform my clients when I am recommending the extra-label use of a drug?

Do I encourage incorporation of my clients' preferences in decision-making?

Do I give them the opportunity to understand the benefits and risks of various types of diagnostic and therapeutic options with the goal of assisting them in making informed decisions?

Referrals

Would my clients maintain their confidence in me if they knew my philosophy about referrals?

Am I realistic in conveying my level of competency when dealing with difficult medical problems?

Would my clients find that I value the viewpoints, judgment and experiences of others, or would they find that I have misled them by indicating an ability to manage a patient's illness that is beyond the my expertise or the capability of my hospital?

Won't you agree that treating our patients as we would want to be treated encompasses patient referrals? However, do we have a tendency to avoid referrals by rationalizing that when we inform our clients that needed care is beyond our expertise they will lose confidence in us and go elsewhere?

Ironically, this philosophy could result in our clients being first to recognize the need for a referral. When a dissatisfied client initiates the request for a referral, the receiving veterinarian may face a difficult task in restoring the client's confidence in us (the primary care veterinarian).

In this circumstance, it is not unusual for clients to state that they have no intention of returning to the primary-care practice. If that occurs, the primary-care veterinarian may wrongly assume that the referral veterinarian is "stealing" clients. The primary-care veterinarian may believe that his/her "prophecy" of loss of clients by referral has been fulfilled.

Now switch to a scenario in which the primary-care veterinarian initiates the option of referral in a timely fashion. In this setting, the client's trust and confidence in the primary care veterinarian often is enhanced. Why? Because the clients gain firsthand knowledge that the referring veterinarian places the patient's and client's interest and welfare above his/her own financial or egoistic gain.

When referrals are timely, the receiving specialist is in the optimal position to reinforce the altruistic motive of the referring veterinarian to the client, who then is more likely to be motivated to return to the primary-care veterinarian for continued service.

Iatrogenic events

Won't you agree that iatrogenic disorders are at times caused by most, if not all, who practice veterinary medicine including highly trained and skilled specialists?

In that context, would my clients maintain their confidence in me if they knew how I respond to my errors in diagnosis and treatment?

Is my response to others about my mistakes governed by a heartfelt desire to be honest?

Do I recognize, admit and accept responsibility and accountability for my mistakes, or do I intentionally try to hide them or shift the blame?

Do I take corrective action to minimize repeating the mistake?

If I were to make a mistake that results in the need for additional diagnostics, treatment and/or hospitalization, would my clients maintain confidence in me if they knew my motive behind determining who should assume responsibility for the additional expenses?

Fees

Would my clients maintain their confidence in me if they knew the motives and principles used to derive my fee structure?

Would they find that my fees are primarily designed to generate adequate hospital income to provide an appropriate standard of care for my patients, or would they find that my fees reflect preoccupation with personal profit?

Would they find that I am a proponent of a prevailing philosophy of charging what the traffic will bear with the underlying motive of personal monetary gain?

Would they find that I have a balanced view of money in that I use sound fiscal principles to optimize business practices with the goals of allowing long-term employment of adequate numbers of properly compensated personnel with contemporary training, and of maintaining up-to-date facilities, equipment and medical supplies?

Would they find that I have used the need to sustain the financial health of my practice to justify performing unnecessary diagnostic tests or treatments on my patients? Would my actions show others that the humane elements of veterinary practice are as important to me, if not more so, as financial considerations?

Gossip

It is essential that we talk with our hospital staff about our clients on numerous occasions. Would my clients maintain their confidence in me if they knew what I was saying to others about them?

Do I talk about them in a way that I would want them to talk to others about me?

Does the information I share with others about my clients leave me with a good conscience?

Will my conscience allow me to make exactly the same statements with the same tone of voice and body language in the presence of the client about whom I are speaking?

Do I practice the principle that my words (as my treatments) should first do no harm?

Won't you agree that when we "bad-mouth" our clients behind their backs and "sweet-talk" them to their faces, we are at risk of undermining their confidence in us?

Success

Would my clients maintain their confidence in me if they knew the level of satisfaction I derive from being a member of the health-care profession?

Would they maintain confidence in me if they knew the criteria I use to measure success?

Are my actions and decisions as a veterinarian primarily based on a service or a profit motive?

Does my success formula encompass a heartfelt desire to contribute to the health and welfare of animals?

Epilogue

As veterinarians, one of the most important tools in our armamentarium is client confidence in our competency and character. However, we cannot buy that confidence; we must earn it. Doing so is an iterative process, requiring repeated evidence of our competence, responsibility and caring.

In today's climate of ever-increasing distrust, what basic ethical principle can we rely upon to help us gain and maintain our clients' confidence?

What basic ethical principle can we rely upon to help us formulate diagnostic and therapeutic options in such a way that we will serve the best interests of our patients, clients and ourselves?

What basic ethical principle will help us to choose the best course of action when existing rules and guidelines do not seem to apply?

What ethical principle can we rely upon to help us maintain our professional and moral integrity?

The answer is the familiar Golden Rule: Do for others what we would have them do for us.

Perhaps the most important question for us to contemplate daily is, "Do our actions reveal that we are committed to putting the Golden Rule into practice?"

By taking the initiative to apply this ethical gold standard to the care and welfare of our patients, we can be confident that it will help us gain and sustain our client's confidence in our character and professional competence.

(ADAPTED FROM AN ARTICLE BY THE AUTHOR IN THE 1999 ISSUE OF JAVMA VOLUME 215, PAGES 1238 – 1239.)

Dr. Osborne, a diplomate of the American College of Veterinary Internal Medicine, is professor of medicine in the Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Minnesota.