Getting the message across

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Veterinary graduates acquire many diagnostic and therapeutic skills during four or more years of study and are eager to apply their new knowledge to the diagnosis and treatment of complicated diseases like diabetes, hyperadrenocorticism, congestive heart failure and other medical or surgical challenges.

Because these skills and knowledge seem to be the key to addressing health problems of patients, it is surprising — in fact, shocking — when new practitioners realize that, sometimes, technical expertise isn't enough to achieve a satisfactory health-care outcome.

Every veterinary student knows that the profession involves more than dealing with animals. Every interaction with a patient requires an interaction with a human, too. It is, after all, love and concern for their animal companions that induces clients to bring their pets to the veterinary clinic.

Interaction with the client is essential to identifying the problem(s), obtaining permission to do what should be done, engaging the client to participate in the health-care process and, of course, getting paid for all of this.

The skill of teaching

Over the past few years, veterinary educators have begun to acknowledge the importance of teaching communication skills. Most veterinary curricula now include some measure of communication training, and an increasing number of continuing-education venues and journal articles are addressing some communication topics.

Despite the fact that veterinary communication experts recognize that one of the keys to ensuring optimal patient outcomes is effective client education, one aspect of that still receives scant attention: the skill of teaching.

There is an assumption that client education is achieved by just telling the client what needs to be done and perhaps handing out a relevant brochure. If the real measure of success of the communication between veterinarian and client is that the patient receives necessary health care, then we may not be doing a very good job of educating our clients.

The surprising and sad results of the 2003 AAHA compliance study demonstrated that clients were not adhering to recommended actions to the degree presumed by veterinarians. Much of this poor adherence has been attributed to inappropriate or deficient hospital processes, such as scheduling, sending reminders, developing and applying follow-up protocols and other practice-management tools. Certainly, these tactics can have an effect when the problem is forgetfulness on the part of the client or inadequate information provided by the veterinarian or veterinary staff.

But might the issue be something more basic? Do our clients really learn what they are supposed to be doing?

Before clients reliably adhere to a recommended course of action, they must know what they are supposed to do and why. Unfortunately, getting this across to them is more complicated than just "telling." It does not require a Master's degree in education to be an effective client educator, but it is important to understand the principles of adult learning and to be able to customize the message according to the client's unique learning and communication styles.

This first article in a series of three will demonstrate how to apply the principles of adult learning during client communication.

Although some clients may introduce the pet as belonging to a child, the adult is the final arbiter of health-care decisions. When a child is involved, it is important to ensure that the child understands proper care for the pet, but in almost all cases the adult will be the mentor, the reminder, the enforcer and the ultimate caretaker of the pet.

Obviously, it is imperative that the adult be thoroughly educated about the animal's needs and be motivated to meet them. Adults learn differently than children. The term andragogy is used to differentiate the principles of adult learning from pedagogy, which refers to teaching children. There are six basic assumptions upon which andragogy is based. Each can be modified to make them relevant to effective education of clients. They are:

1. The need to know

Adults are relevancy-oriented and must know why they need to learn or do something. Any change from their current way of doing things must be justified, because time is at a premium and there are many other demands on their attention. One's "need to know" is based on the gap between his/her current knowledge and what he or she must know in order to perform the job.

A Harvard psychologist conducted an experiment in which she tried to move to the front of a long line at a copy machine. In some cases, she simply stated that she had five pages to copy and asked to move ahead. In others, she stated that she had five pages and asked if she could go ahead because she was in a rush. By simply adding the "because" clause, she increased compliance from 60 percent to 94 percent.

Of course, educating a client about routine health care, such as appropriate dental care, heartworm prevention, nutrition, vaccinations, etc., is much more complex. But the principle is the same. Knowing why and understanding the relevance of information will induce owners to comply with instructions.

Beware of falling into the trap of "data dumping" or "doctor speak." There are limits to a client's capacity to absorb and comprehend information. Be alert for signs of information overload, such as nonverbal expressions of withdrawal or discomfort. Provide information in chunks and check in with the client after each concept, asking if she or he has questions or would like clarification. Don't introduce more than three new concepts at a time, saving additional information for the next visit. Be very conscious of the words you use, and speak in layman's terms.

2. The learner's self-concept

In general, adults have a sense of independence and responsibility for making decisions. They resent the feeling that others are imposing their wills on them. For physicians, three models of health-care decision-making have been described.

• In the paternalistic model, the doctor makes all the decisions. Information flow is one-way, and any deliberation that occurs is between the doctor and other professionals.

• At the opposite end of the spectrum, the informed (or consumer) model puts all decision-making in the hands of the patient. Information is still one-way from the doctor, but the patient decides on the course of treatment after consulting family, friends or others.

• In the middle is the shared decision model. The doctor and the patient share information that allows the physician to understand the unique components of the patient's life that may affect decisions. Deliberation occurs between doctor and patient, and the final decision is reached by negotiation and agreement.

In one study, 62 percent of the patients preferred shared decision-making; 28 percent preferred consumerism; 9 percent preferred paternalism. Research has demonstrated that when the patient and physician are congruent on the decision-making model, there is increased satisfaction on the part of the patient and a self-perception of better health.

Although similar research has not been done in veterinary medicine, these results are relevant to the doctor-client relationship. The client's preference can be determined by asking how much information she or he desires.

"Would you prefer that I give you a detailed description of the condition, or would you just like the key points?"

"Have I given you enough information?"

Use open-ended questions to invite the client to tell his or her story. Use partnering terms to invite the client to participate in the process.

"We'll work together to make Fluffy better."

"It is important for us to agree on the proper treatment for Fluffy."

3 The role of the learner's experience

Each adult comes into a learning environment with a wealth of life experiences. This has both positive and negative effects. The doctor can tap into some of the client's experiences to validate the need for a needed procedure. Negative effects might arise from the client's fear of change, from misinformation or from an unpleasant experience that the client may relate to the current situation. The doctor should first present the problem and then probe to ascertain the client's experience and preferred solutions. This should be followed with a discussion of the pros and cons of a recommended approach. Above all, the doctor must show respect for the client's knowledge and experience.

Application of many of the basic communication skills (empathetic statements, reflective and active listening, use of partnering statements) will help the client make the leap from their past experience to the new one.

4 Readiness to learn

Adults move from one stage to the next in the learning process. And they vary in the ease with which they advance to the next level. When moving from one level of knowledge to another, the client is likely to retain concepts in short snippets. First, the doctor must identify the client's current level of knowledge. Then, taking into account the client's learning and communication styles (to be discussed in the next article), begin to move the client to the next stage. After each level of learning, stop to see if the client needs clarification or time to process the information.

"Does that make sense to you?"

"Did I explain that adequately for you?"

If the client is comfortable, move on to the next level. Do not hesitate to ask the client to repeat information so you can evaluate his/her understanding.

5 Orientation to learning

Adults are practical and goal-oriented. Generally, they are not interested in knowledge for its own sake, but need to know how it is relevant to their lives. How does this recommended action affect the client's life and the patient's life? What outcomes can be expected and how will that benefit the client, the patient, the family? Instructions must make frequent references to the impact of the procedure or information on the client and patient.

"Giving these heartworm pills takes only a couple minutes each month and may prevent Fluffy from suffering a potentially fatal infection with heartworm and having to undergo a long, hard and expensive treatment."

6 Motivation

Adults respond to external motivators (better pay, promotions, bigger house) and to internal motivators (self-esteem, sense of well-being, quality of life). The well-being of a patient can fit into either or both of these categories. There may be impediments to a client's learning that may outweigh any motivating factors. These may include a negative self-image, limited resources, time constraints or personal problems such as child care or transportation difficulties.

After discussing a needed procedure, the client should be asked if there is any reason she or he may not be able to accomplish it. Impediments should be acknowledged and respected, and solutions proposed.

The concept of adult learning offers an excellent framework for building a protocol for educating clients. If you apply these concepts during your interactions with clients, they will not applaud you for knowing these six principles. But they will notice that you treated them with respect as individuals, you spoke to them in terms they understood and, most important, they learned something.

In the next article, we will discuss customizing the interaction with clients according to the client's preferred learning and communication styles.

Dr. Timmins is president of the Association for Veterinary Family Practice and director of the Center for Animals in Society at the University of California-Davis.