Fear factor: Is routine veterinary care contributing to lifelong patient anxiety?

As clients have come to identify and treat their pets as family members, sophisticated specialty and diagnostic care has blossomed. Yet in one sector—veterinary behavior medicine—routine evaluation for prevention of and early intervention for common problems is often nonexistent. Instead, veterinarians often operate in reactive mode, addressing behavioral concerns only when they become a problem for clients, the veterinarian or the practice.

Recent research suggests that veterinarians may be missing their best opportunity to prevent relinquishment and suffering in pet dogs and cats. The secret to boosting their quality of life: implementing a fear and anxiety assessment at each veterinary visit.

It's time that we address behavioral concerns when they become a problem for a patient. To do this, we must assess and recognize fear and anxiety when signs first appear.

GETTY IMAGES/JAKUB WAJTOWICZ

Fighting an uphill battle

The bad news: Most veterinary schools still don't have full-time programs or full-time faculty members in veterinary behavior medicine, and even fewer support behavior-based research programs. As a result, most veterinarians in practice haven't been exposed to veterinary behavioral epidemiology, so they may not know what issues are common. And without training in veterinary behavior medicine itself, veterinarians may misread canine and feline signaling or be unaware of advances in neurodevelopment, leaving them unsure of when and how to treat a developing behavioral problem in a way that will benefit everyone.

While these patterns are pretty disheartening, new research shows that the situation might be even worse—veterinarians may not even realize when clients are actively seeking behavioral guidance. Two researchers looked at 17 client-patient visits with six veterinarians.1,2 During these visits, clients told veterinarians of 58 concerns they had about their dogs' behaviors. Only 10 of these 58 concerns (less than 20 percent) were discussed at all during the consultation, and none were fully pursued. Had the clients complained of finding 58 enlarged lymph nodes (3.4 per dog), it's hard to believe that only 17 percent of them would have been explored.

The good news: Veterinary behavior medicine is the only specialty in which any degree of accurate knowledge can save lives and change the course of an outcome from relinquishment, euthanasia or regular restraint to a full and happy life with clients vested in enduring, compassionate and sophisticated care. The single biggest impediment to growth in general and specialty practice may be the loss of a large proportion of young pets annually because of their behavioral challenges. Dogs and cats that don't live past 2 to 3 years of age don't eat therapeutic diets, don't need maintenance medications and don't require the types of sophisticated veterinary services that help specialty fields and practices grow.

With respect to fear and anxiety, there are two modes of intervention in which veterinarians can have a huge effect with very little practice: 1) identifying a puppy or kitten that is fearful, anxious and uncertain early in life, and 2) minimizing the role of veterinary care in inducing and maintaining fear.

Reinforcing an expectation of fear

As veterinarians, we often expect our patients to be afraid of us and to threaten us—many practices have muzzles in each exam room but not treats. We seem to forget that fear and threats may be related and that we can greatly influence fear. But just how much do we actually contribute to fear in our patients?

A study examining the behavior of dogs at veterinary hospitals found that 106 out of 135 (78.5 percent) of the dogs studied were fearful on the examination table.3 Eighteen (13.3 percent) of the dogs had to be dragged or carried into the practice; fewer than half of the dogs entered the practice calmly.

Another study that focused on the role of waiting rooms in creating patient stress reported the following:4

> Dogs that had recently been to the clinic had higher stress values than those that had not visited recently. This finding has profound implications for the invasive nature of some of the care provided by veterinary staff as perceived by the dogs.

> Dogs that stayed in waiting rooms that were not chaotic and had sufficient time to calm down were less stressed than those that were moved quickly.

> Weighing dogs on the scale is much more stressful than sitting in the waiting room. This finding supports the idea that we should teach dogs how to be weighed, as well as design and place scales so the dogs have some control over their participation in the process.

The time has come to question the extent to which these distressed behaviors interfere with our ability to assess patients and provide the state-of-the-art care they deserve. We also must determine to what extent we cause or contribute to these dogs' and cats' concerns. Quite simply, visits to veterinary practices can be scary for our patients: the floor is slick, there are strange sounds and smells, there's not enough interpersonal approach space, the table is cold and provides poor footing—even their people are tense.

Any dog or cat that is not physically ill should be able to happily walk in the door of a veterinary hospital. If the patient is shaking, trembling, drooling, hiding, lying flat on the floor, scanning the environment, urinating, defecting, vomiting or trying to leave, it goes without saying that it is not enjoying the experience. So we need to change our behavior to change this response for three important reasons:

1. We need to distinguish between patients whose early fear is a truly pathological diagnosis and those that are just afraid of what we're doing to them and where we're doing it. If most of our patients are afraid, we can't adequately evaluate their early behaviors.

2. While we can manhandle puppies and kittens and often falsely dismiss fear as "normal," to do so sends the wrong message to the patient and the client. We shouldn't manhandle any pet, nor will we be able to manhandle many of these patients as they age and grow without the increased costs incurred by additional staff time, the effects of stress, and job-related injuries. Modern zoos have abandoned forceful handling. Children's hospitals are now open, engaging places where kids participate in the delivery of their care. So why are we still struggling with our veterinary patients?

3. The delivery of veterinary care may teach cats and dogs that humans can be threatening. This realization will contribute to the development or worsening of any behavioral problem.

These three factors suggest that—unwittingly and without malicious intent—our delivery of veterinary care can be a causal factor in worsening patient behavior.

Making a frightening first impression

In a study not yet fully published,5 patients that were videotaped as pups were reexamined at 18 months of age for fearful behaviors. It's no surprise that virtually all the pups that had been fearful when younger were fearful as adults—and they were fearful in the same contexts. Some of dogs that were considered normal pups had developed behavioral concerns, fears among them.

Addressing this anxiety at the outset of a doctor-patient relationship is vital. Nothing in any puppy or kitten's life will have prepared it for the sensory overload that will occur at their first and subsequent veterinary visits.

> These puppies and kittens will never have encountered the noise range and frequency that defines a busy veterinary practice.

> The general lighting is different and often invasive, and it's unlikely anyone has looked in the patient's eyes with a penlight before.

> The global odor must be complex. Even if these puppies and kittens were born in a home with lots of animals, they have never faced so many and such diverse smells at once.

> Most puppies and kittens will never have had the social experience of encountering so many humans and animals at once and in such close quarters.

> Many young patients are walking for the first time on flooring that may interfere with their balance and traction.

> Finally, if the client is clutching at the patient or at the restraints (leads, harnesses, carriers and collars), the patient can only take this as a signal to react.

Our mitigation should focus on decreasing arousal and on increasing affiliative behaviors. In short, we want to create behavior-centered practices. We accomplish these goals by using calm environments, teaching patients that going to the veterinarian need not be scary, and avoiding situations that are perceived by the dog or cat as punishing or frightening. Instead we need to ensure that these experiences are seen as fun and rewarding.

If we take the few minutes needed to assess how fearful the pet is and if we change our clinics and our behaviors to encourage more and better cooperation, we are likely to save lives daily and engender an enduring loyalty and trust from clients. It's about time.

Note: In part 2 of this series, the author will discuss how to quickly assess the level of fear in every patient and outline what veterinarians can do during consultations to alleviate those fears and build a more behavior-centered practice.

Dr. Karen L. Overall is a researcher, editor of The Journal of Veterinary Behavior: Clinical Applications and Research, and author of more than 100 publications, dozens of chapters and a new book, The Manual of Clinical Behavioral Medicine for Dogs and Cats.

References

1. Roshier AL, McBride EA. Veterinarians' perception of behaviour support in small-animal practice. Veterinary Record 2013;172(10):267.

2. Roshier AL, McBride EA. Canine behaviour problems: discussions between veterinarians and dog owners during annual booster consultations. Veterinary Record 2013;172(9):235.

3. Döring D, Roscher A, Scheipl F, et al. Fear-related behavior of dogs in veterinary practice. Veterinary Journal 2009;182(1):38-43.

4. Hernander L. Factors influencing dogs' stress level in the waiting room at a veterinary clinic. Student report. Swedish University of Agricultural Sciences, Department of Animal Environment and Health, Ethology and Animal Welfare programme. 2008. Available at: http://ex-epsilon.slu.se:8080/archive/00003006/.

5. Godbout M, Frank D. Persistence of puppy behaviors and signs of anxiety during adulthood. Journal of Veterinary Behavior: Clinical Applications and Research Res 2011;6(1):92.