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Tuesday, March 8, 2011

Proper Communication

LeAnne emailed me with the following...

I am currently in the process of applying to veterinary school (I have an interview next week at UC Davis - wish me luck!) and I'm a full time technician at a four doctor canine and feline practice. My question stems from my experiences at work and from contemplating my own future as a veterinarian.

Part of my job is to restrain pets during exams. Because I'm pre-vet, I like to stick around after the exam to listen to the doctors go over their observations and recommendations. One of the doctors surprises me regularly by using a lot of veterinary words such as "palpation", "crepitus", "cranial abdomen", and other words that it seems to me lay people may or may not know (she says things like "I don't feel anything when I palpate the cranial abdomen"). On the other hand, she also seems to use a lot of veterinary slang as well; for example, she refers to taking an xray as "taking a picture" (I wonder if anyone ever thought she was actually taking a picture with a camera?). Once, she told someone with a puppy who was leaking urine that she wanted to ultrasound him in back to "see if he had a bladder"--meaning check to see if his bladder was full--so we could get a urine sample. The owner blinked her eyes and said, "is it possible that he might not have a bladder?" to which the doctor replied, "sure, especially if he just urinated." The owner okay'd the ultrasound and nothing more was said. I asked the doctor in back if she thought the client could have misinterpreted her and thought that the puppy may have no bladder at all. The doctor just laughed and said, "geez, I hope not!"

It got me wondering about client communications and the assumptions that doctors make about client comprehension. It seems a lot of people just nod and say okay even when they don't have the darnedest clue what the doc's going on about. What about things like the efficacy of tests--even ones that come back negative--or the fact that, depending on the nature of the ailment, the first medication or treatment tried may not always be the most effective? There are so many situations in which techs and doctors talk about things they know well or even bored to reiterate but are like greek to someone who has never heard them before.

I was wondering if you might comment about generally about how you address this issue both within yourself as a doctor and with the vets and techs that work under you. Also, how do you "dumb it down" without insulting those clients who CAN keep up with the big words and the jargon?

This is an excellent topic of discussion and one that's often overlooked in veterinary training.  Medical terminology is very much a foreign language (quite literally considering the Greek and Latin origins of most words), and doctors spend all of their years of training learning this language.  It becomes so ingrained in us that it can be easy to forget that others don't understand what we're talking about.  At the same time this terminology is very specific and allows us to communicate with colleagues much more specifically than when using "ordinary" language.  For example, an average person might say that there's a lump in the "upper belly".  While the person might have a good idea of where this might be, it's actually very non-specific.  A doctor might say that there is a mass in the "dorsal cranial abdomen" which means more to a medical professional.

I remember similar experiences to yours, LeAnne.  When I was going an externship while in vet school I was at a surgical referral practice in Charleston, South Carolina.  One of the doctors was trying to explain to the client about the fracture in the dog's foot.  He was using terms like "distal phalanx", "comminuted fracture", and other very specific and proper medical terms.  I remember looking at the client and seeing a very blank look on his face, indicating a complete lack of understanding.  Yet the vet never seemed to notice or possibly didn't care.  That experience really stuck with me.

One of the first lessons is that there are really three different populations of people you will be talking to as a vet.  The first is the average client who has no medical background or experience.  In these cases you need to avoid using medical terms, keeping it to common terms (x-rays rather than radiographs, ear flap rather than pinna, hip socket rather than acetabulum, and so on).  The second group is people with human medical backgrounds who understand anatomy, physiology, and medical conditions, though not necessarily veterinary-specific situations.  I generally speak to these people (nurses, MDs, paramedics) with mostly proper medical terminology, but will sometimes ask questions to make sure they're following me.  The third group is the veterinary colleagues, and you can speak to them with as much terminology as you want.

You also have to avoid professions-specific slang or lingo.  "Chem panel", "CBC", "rads", and other terms are not always understood by people, and yet aren't specifically appropriate medical terminology.  There are ways to say these things and have people realize what you are saying, such as "organ chemistry analysis", "blood cell count", and "x-rays".  Each clinic may also have certain language they use that other veterinarians may not even understand.  How many vets know what a "comp" is?  In Banfield Pet Hospitals (in the US) this is slang for a "Comprehensive Exam".

This is a learned skill and one that you have to actively develop.  In general I avoid detailed medical terms and try to use common terms.  If I absolutely have to use medical terminology or if it's just easier when describing a problem, I'll define it for the client before using it.  I only slip into specific veterinary terms when I'm talking with other veterinary professionals, and then I gladly do so because it's much more specific.  

LeAnne, does this veterinarian realize what she is doing?  Has anyone brought up to her the possibility that clients won't understand?  Since communication is a skill, it may take some training and someone to point out ways to improve.

Lastly and possibly most importantly, there is something simple that many people forget.  Ask for comprehension!  Before I leave a room, the last thing I always do is ask the client if they have any questions.  When explaining something complicated, I'll ask them if they understand what I'm talking about.  This gives people the chance to (even permission to) gain further comprehension and ask any questions they may have been afraid to at the beginning.

Great question, LeAnne.  Good luck with your application.

7 comments:

  1. One of the things my hospital does which I absolutely love is send home a discharge instruction sheet with every patient, whether they were an outpatient visit, or in the ICU for a week, or just had surgery. They are typed in typed in DVMax's word processing software, another great love of mine.

    Using a bilateral FHO, here's an example of our sheet, obviously simplified quite a bit:

    "Thank you for bringing Fluffy to see us today. Fluffy had a bilateral femoral head ostectomy, which means that our board-certified surgeons removed the head and neck of each thigh bone, due to their fracture after Fluffy's recent hit-by-car accident. Fluffy is being sent home with several medications. If you notice any vomiting, diarrhea, or other indications that Fluffy is not reacting well to the medications, stop them immediately and call the office. Tramadol is a pain medication and needs to be given with food, twice daily. Rimadyl is an anti-inflammatory medication and needs to be given with food, twice daily. Cephalexin is an antibiotic and needs to be given with food, three times daily. Please make sure you walk Fluffy with the sling we have provided, and only take him on very short walks to urinate and defecate for the next three days. In three days Fluffy has a recheck appointment with the surgeons."

    If the client is a medical professional as you mentioned, the doctors will tailor their instructions to their higher level of understanding. For most of our clients, they write in very easy-to-understand lay terms. A tech or a doctor always goes over the instructions with the owner at discharge as well, to make sure they understand them all. Lastly, (since we are a referral hospital) we send a more medically-termed summary of the visit and any labs, etc. to the referring veterinarian as well.

    Our clients are very happy with our paperwork, especially since it's easy to read!

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  2. I wanted to add my two cents here. I think you're walking a fine line between dumbing information down too much and using too much medical terminology. I prefer to talk to clients in a professional manner, but try not to assault them with bizarre veterinary lingo.

    One extremely useful technique we learn is "chunk and check". You break down what you're trying to convey across into "chunks" and check in with the client every so often to make sure they understand what you're saying.

    It's also important to read your client's body language and facial expressions to see if they're tuning out, and if so, change your communication style or ask him/her a question instead of just spitting out knowledge at them.

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  3. I think one of the best things that a vet ever did for me as a client was after I first went to the vet ophthalmologist she called to see if I had any questions or needed anything clarified. I think during the visit there was so much information and terminology that while I understood mostly what she was saying I was overwhelmed to the point I didn't even ask how much sight my dog had during the visit. The vet opth was really good at explaining too, she had diagrams and drew an individual picture of the cataract, but it was good to be able to ask the questions I was too overwhelmed to ask. I always kind of feel like a bother when I call for clarification at my regular vet's office, even when the post op instructions say to call with questions.

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  4. One of the things I really love about where I used to work at the CSU Vet Teaching Hospital was the emphasis on communication skills. I learned a lot (and I was just an admin assistant!) and I know that the students really liked the classes. They have a full class for communications for senior students and use two way windows for role plays (with actors as pet parents.) I know that I really appreciate it when my vet takes the time to really explain and know that I understand, so I'm happy that students are getting this info in their program, at least in Colorado and hopefully other schools too!

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  5. Thank you Dr. Bern and to everyone for the comments!

    In my career as a veterinarian I will always try to keep this issue on the forefront of my mind. I think there is certainly a human element -- I know I occasionally skip a step in explaining heart worm prevention, for example, once in a while -- due to stress, distraction, frustration, or even boredom. It seems to be something of a lifelong effort to develop a flow that one can stick to day in and day out.

    I did want to answer your question, Dr. Bern, about whether my concerns have been addressed with the doctor. As a technician (particularly as the newest member of the team) I haven't felt like it was my place to mention anything directly or enough of a concern to bring my observations to my superiors. She is, after all, an otherwise absolutely excellent doctor, and I have much to learn from her. But I do make sure it ask clients before they go if they have any more questions. They usually say no. Maybe I don't give them enough credit :)

    Thanks again for the thoughts everyone.

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  7. I really like this post and hope it's okay with everyone if I incorporate some snippets (with due credit of course) into my own blog, The Learning Vet. Communication is so key! And I really like some of the points brought up with this. Thanks for sharing!

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