It May Be a Dog’s Life But the
Relationship with Her Owners Is Also
Key to Her Health and Well Being:
Communication in Veterinary Medicine
Cindy L. Adams, MSW, PhDa,*, Richard M. Frankel, PhDb
aVeterinary Medicine-Clinical Communication, Faculty of Veterinary Medicine,
University of Calgary, G380, 3330 Hospital Drive, NW Calgary, Alberta T2N 4N1, Canada
bRegenstrief Institute, Indiana University School of Medicine, RG-6, 1050 Wishard Boulevard,
Indianapolis, IN 46202, USA
I am writing to you, to describe the situation I had to deal with, because I
took my dog to Random Animal Hospital. Never have I seen such incompe-
tence. My dog did not receive proper care. It was obvious that this veteri-
narian wanted nothing more from me than my money and he charged me
as much as he could. But, my dog was in worse condition after Dr. X was
finished with him that afternoon. And I felt like I was part of a three ring
circus, due to the numerous people I didn’t even know but had to deal
with when I was at the Hospital with Toby. ....This was probably the worst
experience I’ve had in my life.
communication that clients experience with veterinary professionals. A recent
issue of Update, a newsletter published by the CVO, reported that 60% to
67% of complaints from 2002 to 2004 contained some concern regarding com-
munication . A list too extensive to include in this article was published item-
izing the most prevalent types of communication problems found in the
complaint letters. These included failure to ask for the pet’s name, return
phone calls, obtain consent, provide postoperative instructions, or demonstrate
empathy at the end of a pet’s life. Poor communication in human medicine has
been associated with higher rates of medication errors, patient dissatisfaction,
he excerpt above comes from a review of letters of complaint to the Col-
lege of Veterinarians of Ontario (CVO). It illustrates one of the most per-
vasive problems in veterinary practice today: a lack of trust and poor
Parts of this article are identical to that published in a previous communication; Frankel RM. Pets, vets and
frets: what relationship-centered care research has to offer veterinary medicine. JVME 2006;33(1):20–7; and
are reproduced with permission of the copyright owners of this work.
*Corresponding author. E-mail address: email@example.com (C.L. Adams).
0195-5616/07/$ – see front matter
ª 2007 Elsevier Inc. All rights reserved.
Vet Clin Small Anim 37 (2007) 1–17
SMALL ANIMAL PRACTICE
nonadherence, suboptimal biomedical and psychosocial outcomes, and claims
for medical malpractice .
An emerging line of research in veterinary medicine has begun to investigate
the impact of communication on small animal veterinarian–client–patient con-
sultations . Despite obvious differences between human and veterinary med-
icine, it is clear that there is substantial overlap in the kinds of communication
mishaps found in both. Over-reliance on technology, a disease-based approach
to training and practice, and pressing economic considerations may result in re-
lationships that fail to meet client expectations.
Problems in communication have been recognized in the practice commu-
nity and more recently in schools of veterinary medicine. As a result, significant
gaps in communication and management skills training for veterinary students
have been identified [4,5]. In response to the issues raised by these studies,
a consortium of veterinary schools has attempted to define the competencies
needed for practice success in veterinary medicine. With the assistance of the
organizational consulting firm Personnel Decision International a list of non-
technical competencies deemed necessary for practice success was generated.
Communication was especially featured .
to prepare entry-level graduates for success in practice. In a recent survey by
Lloyd and King , 23 of the 27 participating veterinary schools in the United
changesfell into thecategoriesof admissions,orientation, curriculum,cocurricu-
lar, and other. The other category included administrative changes, the develop-
ment of a combined degree program (such as the DVM-MBA), and training in
fessionalism and interpersonal skills, law/ethics, personal finances, communica-
tion, entrepreneurship, and life skills. Although Lloyd and King  concluded
schools and colleges’’ it is not clear exactly what these schools are doing differ-
or only a select group.
Until recently, communication skills were part of the informal curriculum,
learned through practical experience, and without a formal assessment or
brace communication skills training in a spectrum of settings from core curricula
at veterinary schools to continuing education, efforts should be made to under-
plication of communication skills to small and large animal practice settings.
Serious initiatives are underway to provide continuing education on
communication topics and skill building for practicing veterinarians. Mega-con-
ferences, including the North American Veterinary Conference, offer a yearly
full-day interactive workshop on communication skills for practice. The
2 ADAMS & FRANKEL
American Animal Hospital Association offers a 3-day intensive program for all
members of the veterinary team. The emphasis of this program is on team-based
communication. Likewise, pharmaceutical and pet food companies recognize
the importance of good communication skills and have provided funding for
communication research and larger practice initiatives. More recently the
National Board of Veterinary Medical Examiners has included assessment
of clinical communication skills as part of its examination process for foreign-
In this short article, we offer a framework for communicating with clients
and colleagues that links elements of communication with processes and out-
comes of care. Using excerpts from letters of complaint, we also provide prac-
tical examples of how clinical communication skills can lead to more effective
client relationships in practice. We also offer our ideas about how to develop an
individual communication skills repertoire in practice. Our goal is to add mo-
mentum and empiric support for recognizing the importance of practice-level
communication skills in achieving successful clinical outcomes.
EVIDENCE-BASED MODEL FOR COMMUNICATING
The Four Habits Approach
The Four Habits approach was originally developed to synthesize the literature
on patient- and relationship-centered interviewing effectiveness in human
medicine.Thismodelisbasedonwhat physiciansactually doinpracticeplusad-
ditional strategies that they find practical and useful for practice. Relationship-
centered care is founded on four principles: (1) relationships should encompass
the entire personhood of the participants, (2) emotions are an important part of
these relationships, (3) providers and patients can and do influence one another,
and (4) forming genuine relationships in health care is morally valuable .
The original model, published as a monograph in 1996 and updated in 2003,
was designed for educational and research purposes [10,11]. In the time that it
has been in use, more than 10,000 physicians have been trained using the ap-
proach. The model has been shown to be valid and reliable . Further, there
is support to show that physicians trained in the model score higher in patient
satisfaction scores for a period of at least 6 months posttraining compared with
physicians not trained in this model .
It was Aristotle (384 BC–322 BC) who said, ‘‘We are what we repeatedly do.
Excellence then, is not an act, but a habit.’’ We use the term habit to denote an
organized pattern of thinking and acting during the clinical encounter. Much as
clinicians use pattern recognition to think about and diagnose disease, the Four
Habits—invest in the beginning, elicit the patient’s perspective, demonstrate em-
pathy, and invest in the end—provide the background for clinicians to recognize
and embody effective communication strategies. The goals of the Four Habits
are to establish rapport and build trust rapidly, facilitate the effective exchange
of information, demonstrate caring and concern, and increase the likelihood of
adherence and positive health outcomes, respectively. In addition to the
3 EFFECTIVE OWNER COMMUNICATION
relevance of the model in human medicine, the Four Habits model has high
applicability to veterinary practice.
A growing evidence base suggests that patients and physicians derive consid-
erable satisfaction from interpersonal aspects of care . It also documents
that certain clinician behaviors affect the likelihood of achieving desired out-
comes or avoiding negative outcomes, such as medical malpractice [15,16].
From an educational perspective there is ample evidence that clinical commu-
nication skills can be taught, learned, and practiced . It is our contention
that the same increase in satisfaction and successful outcomes with effective
communication also holds for veterinary medicine.
Overview of the Approach
The communication tasks that make up the Four Habits are organized into cat-
egories of skills, techniques, and payoffs (Table 1). In addition, the habits and
associated skills are seen as nested and interrelated. For example, asking an an-
imal owner or agent to share all their concerns at the beginning of a visit, ex-
ploring their perspective, and showing appropriate empathy all set the stage for
successfully engaging in joint decision making and education.
Habit 1: Invest in the Beginning
Three key skills come into play at the beginning of the client encounter with
the practitioner. These are: creating rapport quickly, eliciting the full spectrum
of concerns, and planning the visit.
Creating rapport quickly
The first few moments of the veterinary encounter are often treated as small
talk and irrelevant to the clinical business at hand. Although this may be
true in a narrow technical sense, the opening moments are a gateway for estab-
lishing trust and creating a lasting impression of the encounter from a commu-
in this study was closed ended. This form of inquiry limits a client’s ability to re-
spond with additional concerns as the example provided in Box 1 illustrates.
Notice in this example that there is no attempt on the veterinarian’s part to
join with the client. Instead a series of closed-ended questions has been used to
elicit biomedical information. The pattern of questioning limits the owner/client
to a series of yes or no replies from which it is difficult to discern if there are
any additional concerns. This type of interviewing style is characteristic of a vet-
erinarian-centered approach. In human medicine, this approach is associated
with poor adherence, satisfaction, and trust [18,19].
The example in Box 2 illustrates a veterinarian using several Habit 1 skills to
elicit the full spectrum of client concerns about the pet. Notice how this line of
questioning focuses first on the relationship by inquiring about something
4 ADAMS & FRANKEL
shared in the last visit before entering into the business of the current encoun-
ter. Addressing the relationship first sets the tone for opening the clinical
inquiry about the reason for the pet’s visit.
In addition, the veterinarian uses open-ended questions that elicit factual and
affective information from the client. The veterinarian also uses a linguistic de-
vice known as a re-completer to facilitate the relationship and elicit high-quality
clinical information. After the client says ‘‘She’s just sort of been listless lately,’’
the veterinarian simply repeats a key word, listless, with an upwardly rising in-
tonation. This functions as an invitation to tell the story that is the context for
her statement about the pet’s condition.
After the patient introduces the story with ‘‘Yes, it started about 3 days ago’’
the veterinarian uses another linguistic device known as a continuer. These are
vocalizations, such as ‘‘mmh hmh,’’ ‘‘go on,’’ ‘‘I see,’’ that encourage the
speaker to elaborate on the content and emotional impact of what she is saying.
In this case, the veterinarian’s open-ended continuer produces a statement of
concern on the owner/client’s part. The veterinarian’s silence at this point pro-
duces strong affect, as the owner/client asserts: ‘‘I’m scared to death that she
might have gotten rabies.’’ In developing an approach to the owner/client,
this is potentially important information because it provides a convincing ratio-
nale for why the owner/client is seeking care for her pet.
There is little time difference between these approaches. In human medicine it
takes about 1 minute longer to invest in the relationship and encourage the full ex-
pression of concerns than to remain exclusively problem- or disease-focused .
about inquiring about and noting something personal in each owner/client’s chart
after each visit and using it as an opening inquiry in the next visit.
a framework and organization for the visit that is clear and explicit. The value of
this habit in human medicine has been demonstrated in research conducted by
the Headache Study Group at the University of Western Ontario . They
found that the strongest predictor of resolution of chronic headache symptoms
at 1 year follow-up was the perception on the patient’s part that the clinician
had listened completely to all of their concerns in the first visit. Investing in the
beginning sets the stage and tone and provides the plan for the rest of the visit.
Habit 2: Elicit the Owner’s/Client’s Perspective
In human medicine, the current climate of consumer demand for high-quality
care and information, ethical and legal standards requiring that patients be fully
ical errors all point to the importance of eliciting the patient’s perspective. As re-
critical importance of a paradigm shift from doctor-centered to patient- and rela-
tionship-centered communication stating that ‘‘one of the most effective ways to
reducemedicationerrors istomovetowardamodelofhealth carewherethere is
more of a partnership between the patients and the health care providers’’ .
5 EFFECTIVE OWNER COMMUNICATION
The Four Habits Model adapted for veterinary medicine
Habit Skills Techniques and examplesPayoff
Invest in the beginningCreate rapport quickly
Elicit client’s concerns
Plan the visit with the
Convey knowledge of patient’s history
by commenting on prior visit or problem
Attend to patient/client comfort
Make a social comment or ask a nonmedical
question to put client at ease
Adapt own language, pace, and posture
in response to client
Start with open-ended questions:
‘‘What would you like help with today?’’
‘‘I understand that you’re here for ... Could
you tell me more about that ?’’
Speak directly with client when using
Repeat concerns back to check understanding
Let client know what to expect: ‘‘How about if
we start with talking more about..., then I’ll
do an exam, and then we’ll go over
possible tests/ways to treat this? Sound
Prioritize when necessary: ‘‘Let’s make sure
we talk about X and Y. It sounds like you
also want to make sure we cover Z. If we
can’t get to the other concerns, let’s...’’
Establishes a welcoming atmosphere
Allows faster access to real reason for
Increases diagnostic accuracy
Requires less work
Minimizes’’Oh, by the way...’’ at
the end of visit
Facilitates negotiating an agenda
Decreases potential for conflict
ADAMS & FRANKEL
Elicit the patient’s
Ask for client’s ideas
Elicit specific requests
Explore the impact on
the patient/client’s life
Assess client’s point of view:
‘‘What do you think is causing your
‘‘What worries you most about this
Ask about ideas from significant others
Determine client’s goal in seeking care:
‘‘When you’ve been thinking about this
visit, how were you hoping I could help?’’
Check context: ‘‘How has the illness affected
Allows client to provide important
Uncovers hidden concerns
Reveals use of alternative treatments or
requests for tests
Improves diagnosis of depression and
Demonstrate empathy Be open to client’s
Make at least one
Be aware of your own
Assess changes in body language and voice
Look for opportunities to use brief empathic
comments or gestures
Name a likely emotion: ‘‘That sounds really
Compliment patient on efforts to address
Use a pause, touch, or facial expression
Use own emotional response as a clue to
what client might be feeling
Take a brief break if necessary
Adds depth and meaning to the visit
Builds trust, leading to better diagnostic
information, adherence, and outcomes
Makes limit-setting or saying ‘‘no’’ easier
(continued on next page)
EFFECTIVE OWNER COMMUNICATION
HabitSkillsTechniques and examplesPayoff
Invest in the end Deliver diagnostic
Involve client in making
Complete the visit
Frame diagnosis in terms of client’s original
Test client’s comprehension
Explain rationale for tests and treatments
Review possible side effects and expected
course of recovery
Recommend lifestyle changes
Provide written materials and refer to other
Discuss treatment goals
Explore options, listening for the client’s
Set limits respectfully: ‘‘I can understand how
getting that test makes sense to you. From
my point of view, since the results won’t
help us diagnose or treat the symptoms, I
suggest we consider this instead.’’
Assess client’s ability and motivation to carry
Ask for additional questions: ‘‘What
questions do you have?’’
Assess satisfaction: ‘‘Did you get what you
Reassure client of ongoing care
Increases potential for collaboration
Influences health outcomes
Reduces return calls and visits
Encourages self care
Adapted from Frankel RM, Stein T, Krupat E. The four habits approach to effective clinical communication. Oakland, CA: Kaiser Permanente; 2003. p. 17; with permission.
ADAMS & FRANKEL
Although acknowledged as important to the care process, many physicians,
and veterinarians do not avail themselves of the opportunity to build partner-
ships during the interview. Such missed opportunities relate to increased non-
adherence and medication errors. A study by Braddock and coworkers 
found that only one in five primary care physicians and surgeons inquired
about the perspectives of their patients. According to the authors the rationale
for exploring patient perspectives is that ‘‘Physicians may assume that patients
will speak up if they disagree with a decision, but patients often need to be
Box 1: Opening the visit: closed questioning
Vet: Hello Ms. Jones. What problems is Fluffy having?
Owner: She’s just sort of been listless lately.
Vet: When did it begin?
Owner: It started about 3 days ago.
Vet: What was going on then?
Owner: She was out in the back yard chasing squirrels and when she came back
in she just went to her bed and laid down. She’s been sort of listless ever since.
Vet: Has she been eating okay?
Owner: I think so.
Vet: Any coughing or vomiting?
Vet: Going to the bathroom regularly?
Vet: Noticed any loose stool?
Box 2: Using open-ended questions to build relationships
Vet: Hi Ms. Jones. It’s good to see you again. How have you been since I saw you
last? I seem to remember that you were just leaving to go visit your daughter in
Holland. How was your visit with her?
Owner: Oh it was marvelous. Thanks for asking!
Vet: Sure, and how is Fluffy doing since she was here last?
Owner: She’s just sort of been listless lately.
Owner: Yes it started about 3 days ago.
Vet: Mmh hmh.
Owner: She was out in the back yard chasing squirrels and when she came back
in she just went to her bed and laid down. She’s been sort of listless ever since.
Vet: Mmh hmh.
Owner: You know it’s really concerning to me.
Owner: I’m just scared to death that she might have gotten rabies and might have
to be put down or something like that.
Vet: I can see that you’re concerned and I’ll come back to that in a moment.
Before I do is there anything else you’re concerned about?
9 EFFECTIVE OWNER COMMUNICATION
asked for their opinion. It should be clear to the patient [and the pet owner] that
it is appropriate to disagree or ask for more time’’ . For example, asking
‘‘Does that sound reasonable?’’ or ‘‘What do you think?’’ invites patients or
clients to share their views.
Habit 2 serves several important functions: showing respect for the client’s
experience and individuality, developing partnerships, and comparing similar-
ities and differences in understanding. Early work by Pantell and colleagues
 in pediatrics showed that children who have asthma have their own needs,
and addressing these can improve their satisfaction and adherence to treatment.
A similar finding was recently reported by Staiger and colleagues , who
studied low back pain in adults.
In everyday life, owner/clients frequently engage in a process similar to dif-
ferential diagnosis. That is, they exclude certain causes and explanations for
their observations and include others. Knowing specifically what meaning
they are giving to their animals’ symptoms allows the practitioner to frame
the rest of the dialog accordingly. For example, the owner in the second exam-
ple (Box 2), who was ‘‘scared to death,’’ may seem unusually worried about
symptoms that seem vague or minimal to the practitioner. Finding out the cli-
ent’s attribution or source of concern by eliciting the client’s perspective often
clarifies the situation and offers an opportunity to strengthen the relationship.
The following excerpts from letters of complaint serve to highlight the impact
of missed opportunities to determine the client’s perspective.
I am writing this letter to lodge a formal complaint against Dr. X. Our dog
was assessed by Dr. X for dental health. He advised us to get Peppy’s teeth
cleaned and possibly there would be some extractions of teeth due to bad
gums. Dr. X removed 12 teeth during the cleaning! Later on he removed
another 7 teeth. He did not have permission to take our dog’s teeth out.
Now we have to water down his food so he can eat and he has to eat
on one side of his mouth. Did our dog really need 19 teeth taken out?
Dr. X did renovations to his clinic about a year ago. Could there be any
—Yours sincerely, The client
‘‘On January 3rd, a week after Mitsy’s next heat had finished we noticed
she was drinking large amounts of water again. We called ABC Animal
Hospital on January 5 and I explained my concerns to Sue, the receptionist
(as well as Mitsy’s recent history at the Hospital). An appointment was
made to have her looked at. The blood tests from last May were sent to
the hospital as well. During the week Mitsy was eating on and off but still
energetic. Both my wife and I felt blood work and X-rays were needed
based on what we had learned at the previous hospital. After the examina-
tion we all agreed that Mitsy should be spayed and we booked an appoint-
ment. We were surprised that no baseline diagnostics were taken given our
10 ADAMS & FRANKEL
description of the symptoms that we reviewed with the Dr. We were told
instead that they like to do the tests the day of the operation. We left the
hospital intending to return the following week for the surgery. We were
given no indication that we needed to be concerned about infection or pyo-
metra, even though she had a recent heat. ... The ovariohysterectomy was
performed the following week. We went to see Mitsy that evening. We
were told that Mitsy’s uterus has been infected and there were concerns
about her condition. We mentioned to the person we were seeing that
she had an exam the previous week and even though we requested tests
at that time we were told to wait until today. Mitsy had to stay for the night.
The following day the Dr. contacted us and told us she had septicemia and
we should come right over. We stayed to comfort her for 3 hours and until
she passed away. All the vets were out of the clinic for lunch when she died.
A Dr. had to be called back to the clinic to pronounce her dead. He told us
it was a closed pyometra that induced the sepsis and loss of life. We are still
in shock over her loss and feel that if proper tests were done and action
taken, she would still be alive today. She did not deserve to die this way.
In human medicine Tuckett and coworkers  found that patients who were
able to fully explain their illnesses to their physician recalled more information
and were more committed to treatment. In addition to better adherence to
treatment recommendations, another payoff for Habit 2 is learning about
how owner/clients view the health, illness, and disease of their pets. This infor-
mation is valuable in considering how best to communicate prognostic and
treatment information to owner/clients and family members. In the case above,
had the veterinarian attempted to build a partnership with the owner by ex-
plaining that there was a relatively low likelihood of a serious underlying prob-
lem requiring immediate testing, the decision not to test would have been
shared rather than perceived as unilateral. Although the outcome would not
have changed, the owner’s perception of neglect on the part of the veterinarian
might have been different.
Habit 3: Demonstrate Empathy
Caring and compassion have characterized the relationship of human and an-
imal healers to their clients for centuries. In the modern era, great technological
advances and economic pressures have led to a relative de-emphasis on the
therapeutic benefits of caring and compassion in training and practice. Re-
search in human and veterinary medicine has found low levels of empathy ex-
pressed during visits. For instance, Shaw and colleagues  found empathy
expressed in only 7% of the 300 companion animal appointments they studied.
Suchman and colleagues  found an even lower level of empathy in their
qualitative study of empathy in human medicine. Researchers have linked
the presence or absence of caring to a range of outcomes, including satisfaction,
adherence to medical recommendations, and propensity to sue .
ship, empathy is the core skill for enacting it (see Table 1). Although understood
11 EFFECTIVE OWNER COMMUNICATION
barrier to its use is the perception of limited time availability to do anything but
the most instrumental clinical tasks in the visit. Many clinicians assume that it is
not possible to demonstrate empathy under such time-limited circumstances.
Contrary to this belief, researchers studying an elite group of outstanding clini-
cians observed that they invariably found a way to respond to patient emotion
to the clinician and adds meaning and depth to the relationship .
Accurately identifying emotions depends on observing nonverbal behavior,
such as facial expression and body posture, and listening closely to the patient
or client’s tone of voice as he or she describes the experience. In human med-
icine, physicians who are sensitive to nonverbal expression of emotion have
more satisfied patients . Likewise, physicians who use eye contact appropri-
ately are more likely to detect and treat emotional distress . There is also
evidence, based on content-filtered speech, that voice tone is a reliable predictor
of follow up to treatment recommendations .
In a study of referrals for treatment of alcohol abuse, a warm accepting tone
of voice on the provider’s part was highly associated with follow-up from the
referral . In a recent study using specialized analysis of content-filtered
speech, Ambady and colleagues  were successfully able to distinguish be-
tween surgeons who had never been sued and those who had been sued for
malpractice at least twice.
Often patients or clients only hint at an emotion. Statements such as ‘‘Fluffy
seems listless,’’ or ‘‘What do you think about surgery for Fluffy’s cancer?’’ do
not express an emotion directly. Suchman and coworkers  defined these oc-
currences as potential empathic opportunities (PEOs) and suggested that they
are often used by patients to test whether it is safe to talk about the underlying
emotion. Clinicians who attend to emotional clues and cues improve the qual-
ity of communication and relationships with patients. Likewise, Suchman and
coworkers  noted that when emotional clues are ignored, patients will
repeat or escalate their concerns or surface them only at the end of the visit.
In the following excerpt from a letter of complaint to the CVO, a client’s
experience of lack of empathy is compounded by the more routine aspects of
handling animals following death and the business side of practice:
On Friday morning I received a phone call from the veterinary clinic telling
me that Sasha was not well and I should come to the clinic as soon as pos-
sible. She told me she might not make it. I had promised Sasha if she was
ever to leave this earth I would be with her to show my immense love for
her. I had just come from the shower to get the phone. I promptly threw
on my clothes and drove there. She had died before I arrived and was
brought to me in a box. Only minutes later both the Dr. and the technician
were both very interested in selling me a plot of land to bury her and to sell
me a gravestone to commemorate her. Before I left to bury my beloved
12 ADAMS & FRANKEL
Sasha, and I was crying profusely, the technician had the utter audacity,
gall and disrespect to ask me what I would like to do with my invoice!
Helping owners/clients move from hinting at an emotion to its full expres-
sion is part of the work of empathy. Cohen-Cole  identified five types of
verbal statements that convey empathy and suggested a generic format for
each. They are:
Reflection—‘‘It sounds like you’re concerned that Fluffy ...’’
Legitimization—‘‘Anyone would feel scared ...’’
Support—‘‘I will be there for you no matter what happens ...’’
Partnership—‘‘I think we can figure this out together ...’’
Respect—‘‘I have confidence that you’ll do the right thing ...’’
Inaddition,theuse ofnonverbalactions,suchassilence,touch,gaze, facialex-
emotional distress . Had the technician described in the letter above re-
sponded to the client’s strong emotion by demonstrating empathy the technician
would in all likelihood have found the client more than willing to settle her
account after a brief opportunity to adjust to her beloved pet’s death.
Empathy adds depth and meaning to the relationship and also builds trust.
When the time comes to make difficult or complex decisions, having explored
the emotionalterrain surroundingthe issue facilitates partnershipsand informed
colleagues  describe skills necessary for talking about cost with patients in-
cluding the use of ‘‘we’’ statements and ‘‘I wish ...’’ as a platform for shared de-
cision making and a search for alternative approaches or plans . Timing the
discussion of services and costs so that they occur after empathy has been dem-
will take place within a trustworthy affective partnership.
Habit 4: Invest in the End
Although the first three Habits are based on gathering information, Habit 4,
investing in the end, is primarily focused on information sharing. This is re-
flected in the tasks at the end of the encounter, namely, delivering diagnostic
information, encouraging participation in decision making, and checking for
understanding of recommended treatments. Communicating bad news and
its effects on family members can be a real challenge. Although it may be re-
quired in practice, many physicians receive no formal training in this area as
the following narrative from a senior physician recounting his training experi-
ence in delivering bad news attests:
I was a third year student on an ER rotation when a family (grandmother,
10-year-old girl, uncle of girl) came in badly burned in a house fire. The
girl was in arrest and despite all efforts died. The grandmother was alive
but critically burned. The smell of charred flesh was overpowering. I was
sent to ask the mother for an autopsy. Instead of beginning by informing
13 EFFECTIVE OWNER COMMUNICATION
her of the death I began with: ‘‘Sorry to bother you at this time but ...’’ and
then asked her my question. She screamed and collapsed, hysterical at my
feet. I was aghast, guilty, stunned, felt inadequate to make any appropriate
response. I still feel awful about it to this day.
The costs of poor training in this area are most obvious on the patient side,
although the literature suggests that physicians who make mistakes of this sort
suffer also . Poor outcomes and emotional wounds are a prescription for
patient dissatisfaction and malpractice suits.
The following excerpt from a letter of complaint highlights the client’s expe-
rience of not having adequate information to make an informed decision about
how to proceed with the care and treatment of her pet:
In September our dog was taken to see Dr. Y because of a lump in the tummy
area. She had a mast cell tumor. Dr. Yadvised that the cytology report was
very good and that she could undergo the removal of this tumor with no com-
plications. Rumour came through the surgery with no complications and the
time of this operation under no circumstances did the Dr. discuss with us any
that Rumour was in good shape and could withstand another surgery. ...
when to bring her back to have her stitches removed and she was not given
antibiotics or pain medication. We did as we were told and my husband
bathed the dog ...
The importance of checking for client comprehension and coming to a mutu-
ally agreed-upon plan cannot be overemphasized. In addition to shared
decision making and increased adherence to follow-up, using this approach
provides an ideal opportunity to educate clients about their pet’s condition
and to correct any misunderstandings or misapprehensions. Grueninger and
coworkers  suggest several helpful questions for use in optimizing compre-
hension and agreement. These include:
After having discussed the various options with you is there anything that I’ve
missed or anything that we need to clarify?
Are you comfortable with the plan we’ve outlined?
The payoffs from using Habit 4 are increased collaboration in decision mak-
ing and a corresponding reduction in risk for error and nonadherence. Further,
focusing on comprehension of diagnostic news, instructions, and recommenda-
tions, and barriers to adherence improves alignment between the health care
14 ADAMS & FRANKEL
provider and desired outcomes of care. Finally, knowing how to sensitively de-
liver bad news can relieve unnecessary suffering on the client’s part and make
the practice of veterinary medicine more deeply satisfying.
We have reviewed more than four decades of research and evidence in human
medicine that has consistently demonstrated that communication and relation-
ship building impact the quality and outcomes of care. There is emerging evi-
dence in veterinary medicine that many of the same challenges exist in
providing clinical care for pets, who cannot speak for themselves, and their
owners, who can and do. It seems that improved communication with pet
owners is associated with fewer complaints, higher levels of satisfaction, and
reductions in medication and other types of errors.
Growing recognition of the benefits of communication skills training has led
veterinary medical educators to develop explicit curricula based on evidence of
best practices. In doing so they have acknowledged that these skills belong in
the formal curriculum and need to be taught just as doing accurate diagnosis
and treatment are. As a result, we can expect that the next generations of vet-
erinarians will possess outstanding skills in communicating with their clients.
What can veterinarians do to improve their communication skills in prac-
tice? Several options currently exist:
Attend a national meeting in which workshops on communication skills are
Attend an intensive training course on communication skills offered by regional
or national organizations. (In human medicine the American Academy on
Communication in Healthcare and the European Association for Communi-
cation in Healthcare offer 1-, 2.5-, and 5-day intensive courses on improving
communication skills. Veterinarians have been active in both organizations.)
Contact the Institute for Healthcare Communication and learn about continuing
education opportunities on communication.
Assess your own communication skills using the Four Habits or an equivalent
approach. This might include having a colleague observe you for a clinic
session and provide feedback on your communication skills. Self-assessment
is another possibility.
Use letters of complaint and also those that complement the practice to work on
ways to improve communication and relationships with clients and within the
health care team.
Partner with one or more colleagues to discuss challenging cases and innova-
tive approaches to communicating more effectively.
Improved communication skills are of demonstrated benefit to clients, but
the evidence is that practitioners benefit also. An emphasis on the bottom
line may leave veterinarians feeling stressed and demoralized. Investing in
habits of practice that result in improved relationships has the added benefit
of reminding us of why we went into our chosen fields in the first place and
restoring the sense of joy in serving others and alleviating suffering.
15 EFFECTIVE OWNER COMMUNICATION
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