Part 1: Know Yourself—Set the Stage for Collaborative Decision Making, Active Listening, and Caregiving
It’s not what you look at that matters, it’s what you see.
—Henry David Thoreau
Trust is the foundation for collaborative decision making toward a common goal. The veterinary-client-patient relationship is based on that one shared goal: the well-being of the pet.
The client may bring a dog into the emergency room at 2:00 a.m. after seeing a tapeworm in the feces while being completely oblivious to the swollen lymph nodes and coughing that has “just recently started, but I'm not too worried about it.” Treatment of the tapeworm, or at least some dedicated time discussing the plan for treatment, is essential to establish trust with this client before an in-depth discussion on oncology ensues. Otherwise, the client will feel like you did not treat the most immediate and pressing issue (what the client sees with his/her own eyes) and instead chose a more expensive and deadly route.In the example above, both the client and the veterinarian are “right.” Both have the pet's best interests at heart. But the important thing is to get on the same page first to maximize a positive outcome. The satisfaction of both parties with the outcome is pliable, mendable, and will change over time based on the knowledge at hand, but without establishing trust and rapport first, the client may not trust an expensive oncology workup after the original concern was simply a tapeworm.
Under the right circumstances, significant rapport can be built in a short amount of time. Experts estimate that it takes anywhere from a few seconds to 2-3 minutes for an immediate “good gut feeling” about someone to be established. In the author's opinion, it takes 1-2 seconds for clients (especially a stressed pet parent) to decide if they “like you” or not, 1-2 minutes for clients to decide if they trust you, and about 15 minutes for significant rapport to be established, even if you don't have all the answers.
Simple things such as eye contact, smiling, open-ended questions, facing the patient, and even physically touching the person will leave the client feeling like the appointment lasted twice as long as it actually did.Box 1.2
Physicians that had never been sued (noclaims) were compared with ones that had been sued two or more times. No-claims primary care physicians used more statements of orientation (educating patients about what to expect and the flow of a visit), laughed and used humor more, and tended to use more facilitation (soliciting patients' opinions, checking understanding, and encouraging feedback). Additionally, noclaims primary care physicians spent an average of 3.3 minutes longer in routine visits (Levinson et al. 1997).
Setting the stage for this type of trusting relationship to be established and to use the tools discussed later in this chapter starts with the veterinarian even before entering the exam room. When dealing with clients, particularly in a stressful or sad situation, such as chronic disease management, there are three rules that should always be followed:
1) Maintain self-control by actively listening and controlling your reactions.
2) Detach from the outcome; expect that you will not “win” every discussion.
3) Identify the shared value system between you and the client; remain focused on the common goal(s).
Self-Control
It is the veterinarian's role to be and appear to be in complete control when those around him/her are not. Control indicates confidence, and confidence earns trust. When setting the stage for good, constructive, collaborative decision making, self-control is the most important and powerful tool the veterinarian has. This is, of course, much easier said than done. The basis of this rule is to remain in compassionate control of the appointment flow, allowing the client to feel secure and well guided throughout the interaction with the veterinarian. It also requires active listening with little to no negative emotional reaction to the client's words.
It requires you to put yourself in the position of the client and listen to his/her story from that viewpoint, not yours.Imagine that a client is having the worst day of his/her life. Perhaps a spouse was just diagnosed with a terminal illness or the client lost his/her job. The client may need to focus this discontent and, quite naturally, you may become the target. To mitigate against this, first build a constant stream of empathy for the situation. Still, the client may begin to complain about a mistake he/ she felt you made. Instantly reacting in an emotional, hostile, or defensive manner will scar the relationship immediately. Instead, continue to actively listen: let the client vent his/her frustration. Often such hostility is simply grief over a condition the client wishes to be different. Instead, remain poised and concerned but confident. Focus on a solution or on better explaining the proposed course of care. If it's appropriate, there will always be time to share your side of the story later. It is far better to be kind than to be right.
Tips for maintaining self-control in the exam room:
1) Remember it's not about your feelings.
2) Remember the outcome is not happening to you.
3) Control fear and anger.
4) Use “emotional labeling” (“I can tell you are upset/angry/hurt”).
Detaching from the Outcome
Detaching from the outcome is simply about understanding that you will not always “win” a disagreement with a client. Some clients are too entangled in their grief to fully listen or understand your suggestions. They may appear to be “picking a fight” with you from the very beginning. Being attached to the outcome of the disagreement (e.g., pushing the client to approve your treatment plan) too early may set the stage for resentment, particularly in clients with personalities that need time to establish a relationship with you and process information. Actively listening and requesting clarification and feedback from these clients will help them feel that you are not pushing an agenda on them but rather that you are there to support their pet in the same way that they are.
Shared Value Systems
Remaining focused on the shared value systems that both the veterinarian and the client have reminds both parties of the purpose of the interaction. Phrases like “we are both in this for the same reason, we both want Max to feel better” will remind them that everyone wants the same thing. Particularly when emotions rise or there is a moment of impasse, this is an important tool to use.
Maintaining self-control, detaching from the outcome, and focusing on shared value systems will leave the client feeling nonjudg- mentally validated. People do not want to be judged in any thought or opinion that they have or in any action that they take. It doesn't mean you agree with someone. Validation is taking the time to listen to what their needs, wants, dreams, and aspirations are. You may not always understand, but simply by your listening, the client will feel validated and the stage for collaborative decision making will be set.