Sticks and Stones May Break Your Bones, But Words Can Cost Your License
A 10-year-old Yorkie died unexpectedly after receiving the third mitotane (Lysodren, drugs.com/pro/lysodren.html) tablet you dispensed to treat her Cushing’s disease. You know that either you or your room technician told the client about the possible risks and complications of this treatment because “someone always does.”
Now you are being investigated by the state veterinary medical board, your license is at stake, and Ms. Loveherpet is threatening a lawsuit for $100,000 in damages for emotional distress for the loss of her best friend “Gigi.”
Even worse, she’s threatening to trash your practice by starting a website to determine how many other pets you have “killed.” You couldn’t sleep last night because all you could think about were the 14 years of your life you’ve spent building a practice that is now at risk because of a simple breakdown in communication.
According to Laura Downes, executive director of the Maryland State Board of Veterinary Medicine, unprofessional conduct lawsuits often boil down to charges of negligence or issues with communication. She says, “It is not uncommon for investigations to indicate that the standards of medical care have been met but documentation of the communications by the veterinary team was inadequate. If the pet’s condition deteriorates or the pet dies while under veterinary care, clients often assume that substandard care was provided. Excellent communication at the beginning and throughout treatment can assuage misunderstandings later should the pet not respond favorably to treatment.” Complaints from clients can result in hefty fines, mandatory continuing education, and even license suspension.
Facing the Facts
Many veterinarians will face situations like this at some point in their careers. Downes estimates that 75% to 80% of client complaints to state boards are the result of breakdowns in communication. Poor listening skills are cited in a large percentage of medical negligence cases as one of the main reasons why individuals take legal action against health care professionals.1
One of the main issues in these cases stems from obtaining educated owner consents. Without discussing diseases in lay person’s terms and documenting communications in patients’ records, clients can easily come back and say, “I didn’t realize this procedure required so many follow-up visits and care or had so many possible adverse effects, or I never would have agreed to it.” For this reason, the use of clear communications as well as written, signed consent forms that educate clients about the course of treatment and risks associated with various procedures helps minimize communication errors and omissions.
What’s worse is that these facts may not change any time soon. Only 6 of the 26 veterinary schools researched for this article list a specific communications course in their curriculum, either as a required class or an elective.2 Some schools, like Washington State, Wisconsin, and Minnesota, require multiple courses that are specifically focused on communications throughout the 4-year program.2 Many others have some coverage of this important skill scattered throughout the curriculum.2 Still, the community of veterinary schools as a whole is not doing enough to provide veterinary students with sufficient client communications training.3,4
Typical communication mistakes veterinarians make include the following:
1. Assuming that other team members provide accurate and relevant information to clients without providing them with detailed scripts, question lists, educational consent forms, and/or operational instructions to use for key client interactions.
2. Assuming that clients understand what is being explained just because they are nodding along or saying “yes” or “uh-huh.”
3. Using closed and/or leading questions that suggest certain answers without allowing clients to expand on them.1 While closed questions make it easier to control the discussion, they can make clients feel intimidated or threatened; open-ended questions allow clients to describe their experiences, feelings, and understanding of the subject under discussion.1
4. Assuming that clients do not have the resources or are not willing to pay for what’s best for the patient and failing to explain why that course is the best option.5
5. Failing to use legal consent forms and discuss the issues they contain.6
There are many things you can do to ensure that you or your associates never face state board complaints, investigations, and/or disciplinary actions as a result of simple communication errors.
Use the term “medical care plan” instead of “estimate” to focus on courses of action for patient care. This semantically different term emphasizes the diagnostic and treatment part of the plan and diminishes the focus on money.
When possible, stand side-by-side with clients as you educate them, using “show and tell” models, images, or handouts. Encourage them to stop you for clarification and ask questions as you are explaining procedures or as they read the consent forms they are signing. When clients hesitate to sign consents, say, “Please be sure to tell me about any concerns you may have.” The side-by-side posture decreases the image that you are using confrontational communication techniques and, instead, illustrates rapport-building communication.
As much as is practicable, document all forms of communication in the medical record, including in-person educational discussions, phone conversations, and emails. Recording modestly detailed notes during and after these conversations allows you to refer back to them later, when time has faded your accurate recall of events. Detailed records ensure that you and your staff look and are “smart”; incomplete records make all of you appear careless. Remember that documenting courses of action that were recommended and deferred or refused is just as important as documenting the risks and adverse effects of procedures that may have been accepted.
Learn to use personality assessments such as Myers-Briggs (myersbriggs.org) or DISC (discprofile.com) to help staff understand their communication styles. Practice communicating with clients and staff who have different personality types to better understand how to be more effective.
Do your best to assure that someone on your team can speak Spanish or at least communicate in this language using medical terminology. According to the 2009 U.S. Census Bureau, 12% of the population is Spanish-speaking—and that number is only expected to increase.7 Keep an English/Spanish medical dictionary in your clinic and hang posters in or around the exam rooms with translations for common phrases and terms used in veterinary exams. Don’t let language be a barrier between you and your clients!
Invest in books that teach communication skills. Handbook of Veterinary Communication Skills by Carol Gray and Jenny Moffett, Getting Past No by William Ury, and Legal Consents for Veterinary Practices, ed 4, by James F. Wilson are good resources.
Communication regarding medical subject matter is a skill that is developed over a lifetime of effort and experience. You can educate yourself and your team regarding the most common mistakes and how to avoid them. Fundamentally, if we communicate well, then our clients will be happier, our patients will get well quicker, and we will all enjoy our jobs more.1 | EVT
1. Handbook of Veterinary Communication Skills. Gray C, Moffet J.—Ames, IA: Blackwell Publishing, 2010; pp 15-26.
2. Research performed by Christina Moore referencing web-based course content for all U.S. veterinary school curricula, 2011.
3. The KPMG study: The current and future market for veterinarians and veterinary medical services in the United States. Brown J, Silverman J. JAVMA 2:161-183. 1999.
4. NAVMEC Report, final draft. aavmc.org/veterinary-educators/navmec.aspx.
5. Law and Ethics of the Veterinary Profession. Wilson JF, et al—Yardley, PA: Priority Press, 1989, p 112.
6. Legal Consents for Veterinary Practices, 4th ed. Wilson JF—Yardley, PA: Priority Press, 2006, pp 4-7.
7. Language spoken at home: 2005–2009 American community survey. U.S. Census Bureau; factfinder.census.gov.