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Core Communication Skills for Remote Consulting

Christine Magrath chats about the chat from the VDS monthly webinar ‘Core Communication Skills for Effective Remote Consulting'

Several viewers mentioned:

The vet John Fuller was using closed questions which was hindering in getting an effective history

Indeed, using closed questions too early in the dialogue can shut down the client’s responses. Also, the vet has to work extremely hard as they need to generate subsequent closed questions. This can elicit a full history but only if the vet alights on the right questions. All too often essential information both in clinical terms and thoughts from the client’s perspective are missed if we don’t keep the dialogue open long enough. Having watched consultations both remotely and in the consulting room and during experiential sessions I’ve noticed that as a profession we start off with appropriate open questions but close the dialogue down too quickly. Using open questioning techniques encourages the client to tell the whole story in their own words.

McArthur and Fitzgerald (2013) reported that small animal vets used no open questioning techniques in 15% of consultations. Jansen (2010) found that 6 out of 10 vets in her study used no open –ended questions during herd health conversations that varied in length from 54 to 166 minutes. Dysart et al. (2011) showed that even when open questioning techniques are used small animal vets interrupted clients’ responses midstream with a closed question 55% of the time.

It is important to note that this does not mean we should not use closed questions at all. Both types of questioning techniques are essential but achieve very different ends and their use throughout the consultation should be chosen with care. In intentionally deciding which questioning technique to use I suggest using an ‘open-to-closed cone’ (Goldberg et al. 1983).

However closed questions early in the dialogue can sometimes be effective with both talkative and reticent clients and those clients who would prefer a vet centred approach rather than a shared one. Nonetheless it is worth noting that 73% of clients prefer a shared approach but their preference can change throughout the dialogue.

John Fuller used multiple questions:

Again, this is a very common occurrence. For example:

“Is he stiff through the whole day, or is it in the evening or do you find he is worse after exercise or is he also uncomfortable when he is lying down”

“Is he eating or not happy”

Research shows that when this happens clients tend to respond to only one question and more often than not it is the last one. As a profession we often don’t ask the first questions in the list again and important information may be missed both from a clinical and client’s perspective. Alternatively, we ask the questions again which can waste valuable time. When this happens, it can appear to the client that the consultation is losing focus and this becomes particularly relevant in a remote consultation as it is even more important to keep a structure in mind.

It would help if the vet could see or hear the dog

It is important to do a thorough examination of the patient and the physical examination is an important part of a consultation. However, in face to face consultations in an attempt to keep to time veterinary professionals will often take a history while examining the patient. Examining the animal while taking a history can lead to cutting corners in terms of using the appropriate skills needed to achieve an effective history. There is a wealth of research in the medical world and some in the veterinary profession which shows that by initially focusing on our communication skills for taking a history before the patient is examined can speed up the consultation. Therefore, it may be an ideal time to hone in on those skills when we initially don’t have a live animal in front of us. By using effective communication skills it should put those taking a history in a better position to decide if a patient needs to be seen or not.

The client doesn’t know what we’ve done to come up with diagnosis of Kennel Cough which was made the day before

Although this may be the case, until we ascertain what the client knows already it will be difficult to fill in the gaps. As professionals we could end up repeating information the client already knows or alternatively miss out important or relevant information which could have a bearing on how we move this consultation forward. This is known as ascertaining the starting point which often needs addressing on two levels:

  • The client’s understanding of what has been done for the animal already in terms of care and management of the problem. This is particularly important if the patient has been seen by a different professional and you are taking over. It is even more important during the Covid-19 outbreak when practices have had to move to remote consulting quickly and the handing over of clinical history may be less efficient than previously.
  • Furthermore, the client’s understanding of the patient’s illness/condition is also important in terms of starting point. Your client may be a health professional with a wealth of knowledge, a doctor but not a medical one, a farmer or equine owner who is very knowledgeable or there may be someone in the family who has a similar condition i.e. the family member may be diabetic as is the dog. Equally we may think the client has a basic understanding but by getting the starting point we may find the client doesn’t have a clue.

Getting the starting point will help how we tailor the rest of the consultation and will also dictate how we pitch any explanation and planning or how we approach a shared decision

Tuckett et al (1985) talked about two experts in the room; the doctor who knows all things medical and the patient who knows about themselves. Patient and Doctor can easily be substituted for client and vet.

Assessing the client’s prior knowledge in this way was highlighted by Lue et al (2008) who found that one in eight pet owners had little or no previous experience caring for a pet. These people will have information needs that are different from those who have substantial previous experience. Also it is worth remembering that a client’s preference and need for information may change over time and from situation to situation.

Several comments were made such as we don’t know the frequency of the cough, is the cough productive, what the nasal discharge is like or the background history with regards to lungworm/heartworm.

These are all extremely important points. However, if the consultation is kept open for longer at the start many of these points will come out in the owner’s narrative. Also using the ‘anything else’ question (screening) can also contribute to providing a fuller and more complete picture. Any gaps can then be addressed with direct and specific questions which is more efficient than using this type of questioning technique throughout the greater part of getting a history. Again, at this stage it is important to not close things down too much and use more directive questions but still open.

Examples:

Open question about the cough when we are narrowing down a symptom: “Tell me about the cough?”

More directive but open: “What seems to make it better or worse?”

Closed: “Have you noticed if it is a hacking cough” or “Is it worse after exercise?”

John fuller demonstrated that he was listening

I agree that there was attentive listening which was backed up by Mrs Jackson’s comments. This allowed the client to complete statements without interruption and left space for the client to think before answering or to go on after pausing. This is even more important during remote consulting as there is also a technical delay and the temptation is to jump in and talk as we think the client is not responding.

Coe et al (2008) found that pet owners identified that vets who took time to listen was a key factor in a positive experience for the client. We have also known for a long time from Byrne and Long’s work in human primary care (1976) that many dysfunctional consultations arise because the physician has not listened and as a result do not uncover why the patient has come. Medical research has highlighted that patients attend a consultation with an average of 2.3 concerns and we have every reason to believe that this could be the case in the veterinary world. Interrupting instead of listening can prevent some of these concerns being elicited and result in the client being dissatisfied.

John’s listening techniques included:

  • Genuine wait time and silence. Wait time is different from silence as it infers we are not thinking about the next question in our head which can lead to us not fully listening to the client or observing them;
  • Encouragement/facilitative responses: uh-huh”, “um”. These can be very effective but as we often see in our experiential learning if the tone is not right or slang phrases such as OK are used or if the phrases are used excessively they can be seen as interrupters in the early stages of the consultation;
  • Non-verbal skills such as nodding and looking interested. These can be difficult for a vet to see in a remote consultation if the client is not in an adequately lit environment or seated in a good position in front of the camera. In these situations signposting, exploring the clients thoughts and sharing our own thinking can help to compensate;
  • The client confirmed that John was listening. However, Mrs Jackson felt that he had not heard her. This is why ‘internal summarising’ is helpful at this juncture. This type of summarising also has its place as the consultation continues and as a final ‘wrap up’ but here it verifies the vet’s own understanding of what the client has said; invites the client to correct the vet’s interpretation and provide further information in addition to demonstrating to the client that the vet has heard the client’s narrative.
Murphy is not himself and the vet needed to explore this further

This phrase was repeated in several ways i.e. “there’s a lot going on with Murphy”, “I’m worried about Murphy”.

John tried to answer these comments with information that was technically acceptable but the warning bell for me was the fact that these statements were repeated several times albeit in a slightly different way. For me this says that there is a cue that needs exploring. I’ve noticed that during our training most of the group notice that the learner who is practising often does not pick up cues. However, the learner who is in the middle of the dialogue often struggles to notice this themselves until it is pointed out and they have an opportunity to rehearse again. In the medical professions 50% of patients will bring up a cue a second or third time if it is not acknowledged or explored the first time. This is likely to hold true for the veterinary profession. Phrase such as “You said Murphy is not himself. Tell me a bit more about that”. Alternatively repeating back the cue and waiting can also act as an enquiry. “You said you are worried about Murphy”……….. and wait …………..and wait………..and wait.

Levinson et al (2000) a study of patient cues and physician responses in primary care and surgical settings. JAVMA 284(8): 1021-7

Picking up cues and exploring them is one of the skills we can use to elicit a client’s ideas, concerns and expectations (ICE). Verbal cues become particularly important when working remotely since many verbal cues are less obvious. However it is worth emphasising that non-verbal cues will still appear such as body language and facial expressions. It is just important to pick up these cues even if they are less obvious than in a face to face consultation e.g. “You appear to be very upset about ……………..” or “ You don’t look very convinced with our plan – what are your thoughts”.

If we pick up the wrong emotion or non-verbal cue the client will invariably correct it i.e. “I’m not angry. I’m just very upset that Bess has to have an operation to get to the bottom of what’s wrong”. When this happens it is important to apologise and recognise the correct emotion.

It is also worth noting that if the client doesn’t drop any cues or we don’t hear them we can us specific question’s to elicit a client’s ICE.

Ideas:

  • What are your thoughts about why this bill has come as such a shock?
  • “Tell me what you are thinking”
  • “You’ve given some thought to this. Have you any theories as to why this bill is more than you were expecting?”

Concerns:

  • “Is there something in particular you are concerned about?” “Tell me what you are thinking”
  • “What is your biggest worry about the bill?”
  • “Is there anything you are particularly worried about?”

Expectations:

  • “What are you hoping we can achieve today?”
  • “What were you thinking would the best way of tackling the outstanding fee?”
  • “What would be helpful for you in terms of settling the bill?”

Signposting note taking

This is useful in both face to face consults and when working remotely:

  • Ask permission
  • Explain why by giving a benefit to the client i.e. “ I just want to be thorough” “ I want to get all your concerns down”
  • A description to the client of how this might look on the screen such as a delayed response or it may look as though you are not paying attention.

Concern that using communication skills will mean the consultation is longer

A vast amount of evidence around each skill in the medical arena and more recently in the veterinary profession shows that using communication skills:

  • Speeds up consultation time;
  • Improves accuracy;
  • Provides support and trust to our clients;
  • Improves adherence and follow through;
  • Leads to greater patient safety and fewer errors;
  • Reduces conflict and complaints.


References and further reading not already cited in the body of the text

Adams CA, Kurtz S (2017) Skills for Communicating in Veterinary Medicine. Otmoor Publishing, Oxford and Dewpoint publishing, New York

Adams CA and Kurtz SM (2006) Building on existing models from human medical education to develop a communication curriculum in veterinary medicine. Journal of Veterinary Medical Education 33, 28-37

Adams CA and Ladner LD (2004) Implementing a simulated client program: bridging the gap between theory and practice. Journal of Veterinary Medical Education 31, 138-145

Kurtz S, Silverman J and Draper J (1998) Teaching and learning Communication Skills in Medicine. 1st edn. Radcliffe Medical Press, Oxford

Latham CE and Morris A (2007) Effects of formal training in communication skills on the ability of veterinary students to communicate with clients. Veterinary Record, 160, 181-186

Magrath C and Little G (2015) Communication in: BSAVA Manual of Canine Practice, ed. T Hutchinson and K Robinson, pp 14-24. BSAVA Publications, Gloucester

Radford A, Stockley P, Silverman J et al (2006) Development, teaching and evaluation of a consultation structure model for use in veterinary education. Journal of Veterinary Medical Education 22, 38-44

Silverman J, Kurtz SA and Draper J (2013) Skills for Communicating with Patients. 3rd edn. CRC Press, New York


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