Solving the Case by Creating a History Together: Part 2

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The case just might be solved. From the description Ms. Foster provided, it seems like the source of Tanner’s weight loss may be dental disease—an easy fix in your mind. So why the worry lines across Ms. Foster’s forehead?

Are those tears in her eyes? Your pulse begins to quicken.

The investigation was going so well. You used open-ended questioning to invite Ms. Foster to relay the details of Tanner’s weight loss and deteriorating appetite. Furthermore, you resisted interrupting her story by employing attentive listening and pause, which allowed her to fully express herself.  Still, there seem to be some holes.

In this article, we will explore the two remaining skills used for gathering information:

1. Reflective listening
2. Eliciting the client's perspective

Chasing Down a Lead
A good detective checks the facts for accuracy. After all, what good is it to be “hot on the trail” if you are headed down the wrong path? Reflective listening checks the validity of the data you’ve gathered by taking the client’s message and reflecting it back in your own words. This lets the client know that you are listening.

What if what you reflect is wrong? No harm done; you provide the client a chance to correct, clarify, confirm, and complement the information you’ve gathered, enhancing the accuracy of your data. Verifying your understanding can be accomplished using a variety of tools. The most common are echoing, paraphrasing, and summarizing. 

Echoing involves repeating the last few words that a client said. Paraphrasing uses your own words to restate the content and/or feelings behind the client’s message. Summarizing involves presenting an explicit synopsis of the information gathered back to the client.¹ For example:

Ms. Foster: I love Tanner but I've reached my wit's end. You say he'll improve after a dental cleaning, but he hasn't eaten in days; he's lost so much weight.

You: Tanner hasn’t eaten in days and has lost a lot of weight [echoing]. It sounds like you’ve been through a lot. I’m wondering if you’re concerned about putting him under anesthesia for the cleaning [paraphrasing]. I’d like to check to make sure I have all the pieces here. Tanner hasn’t eaten in 3 days, his appetite has been diminishing for the past month, you’ve been feeding him a buffet of food items, and he’s lost 3 pounds since his last visit. Is that right [summarizing]?

The “What” of Gathering a History

1. Biomedical Data
2. Client Perspective — Eliciting the client’s perspective*
3. Background Information

The “How” of Gathering a History

1. Open the Investigation
2. Funnel the Investigation
3. Listen — Reflective listening (echoing, paraphrasing, summarizing)*

*Skills covered in this article

Interviewing the Witness
A key piece to the “what” of gathering a history is eliciting clients’ perspectives and exploring the full range of their concerns. Like an expert witness to your case, the owner has front-row tickets to the animal’s clinical signs and behaviors. Clients will often come in with their own hypotheses and proposed solutions to the case based on their knowledge of their pets.

Your ability to serve patients and clients depends on the accuracy of the history you create together. Reflective listening provides your clients the opportunity to:

• Correct
• Clarify
• Confirm and
• Complement

…the information that they provide you.

Expanding data gathering to explore the broader lifestyle of the client and pet enhances the understanding of the animal’s illness. Discussing unique details, such as financial resources, the role of the primary caregiver, feasibility of implementing the plan, and recent life events (ie, new birth, death, job, or move) promote compliance. With increased societal recognition of the human–animal bond (HAB), it is important to assess the level of attachment and the impact of the animal’s illness on the family.

Eliciting information on the client’s expectations, thoughts, feelings, and fears about the pet’s illness fosters client participation and satisfaction and promotes shared decision-making. 

 1. Allowing clients to express their ideas and beliefs surrounding their pets’ care is an important step in discovering perspective.

You: So, Ms. Foster, could you tell me what Tanner eats on a
daily basis?

Ms. Foster: I cook all of his meals; pet food isn’t a natural diet.

You: Wow, he’s one lucky cat—I wish I ate that well! I’m wondering if you could tell me about the recipe you use.

2. Encouraging the client to share her concerns minimizes hidden concerns at the end of the appointment.

You: What else is worrying you about Tanner?

Ms. Foster: My sister’s dog lost his appetite and he had cancer…could Tanner have cancer? 

3. Taking the time to discover what the client expects allows you to remain on the same page throughout the interview and sets a collaborative tone for your relationship.
  
You: What are you hoping for from Tanner’s visit today?

Ms. Foster: Well I sure hope that you can do whatever it takes to fix my kitty. [OR:] I’m not looking for heroics here; I just want to know my options. 

4. Having a respect for and an understanding of your client’s lifestyle will help you formulate treatment plans to which your client can readily adhere.

You: How do you find the time to cook for Tanner?

Ms. Foster: I’m retired, so I make his meals along with mine.

5. Searching for clues in your client’s nonverbal behaviors and verbal statements may assist you in identifying the client’s underlying feelings.

You: Ms. Foster, I’m sensing that you’re still very worried about Tanner’s condition. What are your concerns?

Clues to the Client’s Perspective

1. Ideas and beliefs
2. Concerns
3. Expectations
4. Effects on life
5. Feelings

Late-Arising Clues
Concerns that are not expressed by the client while gathering information often creep up during the closing moments of the appointment.

We often label them “hidden agendas,” when in all honesty clients are probably not scheming or deliberately withholding information. Oftentimes, they may be waiting for the “right time” or until they feel comfortable enough to share the information with you.

Paying close attention to verbal clues and nonverbal behaviors throughout the interview provides you with hints and prevents the disclosure of additional concerns during closing.

Don’t Antagonize the Witness
Developing a good relationship with your clients ensures that your patients receive the utmost care.

Still, there will undoubtedly be times when you do not see eye to eye. In these moments you can show your support by acknowledging the client’s point of view without necessarily having to agree with it.  This nonjudgmental stance allows you to disagree and be respectful at the same time. Acknowledgment simply lets the clients know that you hear them and respect their right to have their own thoughts and feelings. It legitimizes their views and creates common ground through shared understanding.

You: I can tell that it’s really important to you that Tanner has a good diet and I’m wondering if we can work together to ensure it’s balanced for all of his needs. I’m concerned that eating a soft home-cooked diet might be contributing to his dental disease.

Organizing Your Toolbox
Now you have a complete set of tools for the gathering information section of your tool box: open-ended questioning, attentive listening, reflective listening, and client perspective. It is important to keep these tools sharp to obtain accurate diagnostic information and explore the presenting problem(s) through the client’s eyes. 

Putting It into Practice
As the key elements to creating a history with the client fall into place, give yourself a quick litmus test after each appointment. You may even want to hone in on one question at a time.

1. How did you create a “mental image” of the medical problem as if you witnessed it yourself? (key skill: open-ended questioning)

2. How did you check in with the client to make sure that your information was correct and complete? (key skill: reflective listening)

3. How did you invite the client to express his or her views?  (key skill: eliciting the client’s perspective)

4. Place yourself in your client’s shoes. How did you ensure that the client felt listened to? (pause)

5. How was your approach, collaborative or interrogative? (key skill: funnel—start with open-ended questioning, then clarify details with closed questions)

6. How did you move forward with your agenda, the client’s agenda, or a mutual agenda? (key skill: eliciting the client’s perspective)

If your answers to any of these questions  indicate some “missing pieces” in your information gathering, it may be time to open the investigation up again and retrace your steps, as you may be overlooking crucial clues to the case. | EVT 

Opening the investigation was discussed in Part 1 of this article, Solving the Case by Creating a History Together, in the July/August issue of Exceptional Veterinary Team.

This article is the third in the Communication Toolbox series. Visit myEVT.com/clincialcommuncation for additional articles and training materials

See Aids & Resources for references and suggested reading.