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Abstract

As veterinarians, we support not only our patients but also the millions of humans who share their lives with animals. Veterinarians and their colleagues are accustomed to being reminded that the veterinary profession is built on human connections with animals, and we recognize that the human-animal bond is important in all settings. In terms of academic theory and practical application, however, the human-animal bond approach is most advanced in the area of companion animals. The benefits of promoting the human-animal bond in companion animal practice are, by now, quite clear. It has, for example, been shown that the bond between owners and their pets has an important influence on the care those pets receive, that owners who have the strongest bonds with their pets are more likely to accept health-care recommendations from their veterinarian, and that highly bonded owners visit their veterinarian more often and are more likely to seek preventive care. For veterinarians in companion animal practice, however, it can sometimes be unclear how the human-animal bond can be incorporated into everyday practice activities. For those veterinarians, focusing on client communication and animal handling provides practical methods for emphasizing the human-animal bond.
42 JAVMA • Vol 249 • No. 1 • July 1, 2016
As veterinarians, we support not only our
patients but also the millions of humans who
share their lives with animals. Veterinarians and
their colleagues are accustomed to being reminded
that the veterinary profession is built on human
connections with animals, and we recognize that the
human-animal bond is important in all settings.1,2 In
terms of academic theory and practical application,
however, the human-animal bond approach is most
advanced in the area of companion animals.
The benefits of promoting the human-animal
bond in companion animal practice are, by now,
quite clear.3 It has, for example, been shown that the
bond between owners and their pets has an impor-
tant influence on the care those pets receive, that
owners who have the strongest bonds with their
pets are more likely to accept health-care recom-
mendations from their veterinarian, and that highly
bonded owners visit their veterinarian more often
and are more likely to seek preventive care.4
For veterinarians in companion animal prac-
tice, however, it can sometimes be unclear how
the human-animal bond can be incorporated into
everyday practice activities. For those veterinarians,
focusing on client communication and animal han-
dling provides practical methods for emphasizing
the human-animal bond.
Client Communication
Empathic client communication is essential to
supporting and advancing the human-animal bond
in companion animal practice. Empathic communi-
cation emphasizes the ability to listen for underly-
ing messages and implies, in essence, that the vet-
erinarian attempts to understand the prevailing
problem from the client’s perspective. Empathic
communication allows the veterinarian to effective-
ly propose solutions while also gaining the support
Opportunities for incorporating the human-animal
bond in companion animal practice
and commitment of the client, resulting in a higher
likelihood of adherence to the treatment protocol.
Two other vital aspects of effective client com-
munication are engagement and education.5,6 En-
gagement involves listening to the client’s concerns
and is reinforced through the use of reflective lis-
tening, whereby the veterinarian summarizes the
conversation, allowing the client to correct miscon-
ceptions. Education is vital in achieving good treat-
ment outcomes, as it not only allows clients to un-
derstand what is going on with their pets but also
enables clients to make sensible adjustments in the
treatment plan while still ensuring an overall good
outcome.
These three aspects of communication—empa-
thy, engagement, and education—are vital to good
client communication at any time, but particularly
when dealing with owners of elderly pets and pets
with terminal conditions. In general, it is advisable
to avoid asking clients to make important decisions
when they are under emotional stress or during a
crisis. When possible, therefore, veterinarians should
have discussions about emergency treatment, end-
of-life care, and invasive or expensive procedures
with clients before a critical situation develops and
should record the clients’ wishes in the medical re-
cords. These so-called advance directives will keep
hospital staff informed as to the wishes of the cli-
ent when impending events threaten the life of a
patient.
An important consideration regarding client
communication is apparent gender-based differenc-
es in veterinarian-client interactions.7 Women veter-
inarians are reportedly more relationship-centered
during appointments, seem to have more rapport-
building perspective with clients, talk to pets more,
and are seen by clients to be less hurried. These
communication styles may encourage clients to
provide lifestyle and social information that could
Commentary
From Zoetis Inc, 100 Campus Dr, PO Box 651, Florham Park, NJ 07869 (Knesl); the Department of
Anatomy, Physiology and Cell Biology, School of Veterinary Medicine, University of California-Davis,
Davis, CA 95616 (Hart); the College of Education and Integrative Studies, California State Polytechnic
University, Pomona, CA 91768 (Fine); and 1304 Pacific Dr, Davis, CA 95616 (Cooper).
Address correspondence to Dr. Knesl (oliver.knesl@zoetis.com).
Oliver Knesl bvsc, msc
Benjamin L. Hart dvm, phd
Aubrey H. Fine edd
Leslie Cooper dvm
JAVMA • Vol 249 • No. 1 • July 1, 2016 43
be relevant to their pets. There is reason to believe
that when men engage in the same relationship-
centered communication, freely talk to the pet, do
not act hurried, and focus on rapport building, they
are as effective as women in engendering client sat-
isfaction and the best clinical outcomes for patients.
Traditionally, client communication involved the
veterinarian making recommendations that the cli-
ent was obliged to follow. One major disadvantage
of this traditional approach is that decision-making
is not shared and responsibility for treatment out-
comes is similarly not shared. If the outcome of treat-
ment is unsatisfactory, the veterinarian will most
likely be held accountable, regardless of whether the
treatment was the best available option. Conversely,
if the veterinarian takes on the role of a teacher, re-
porting diagnostic outcomes and listing treatment
options but leaving the decision-making entirely to
the client, the client may become confused and the
outcome may be less than optimal.
By taking on the role of a collaborator, the
veterinarian not only provides information about
diagnostic outcomes and treatment options but
also seeks information about the client’s desires
and concerns, including concerns about costs. The
veterinarian and client can then discuss the pros
and cons of the various approaches and arrive at
a more-or-less joint decision. This collaborative ap-
proach generally results in higher rates of client
compliance with proposed treatment plans and the
highest levels of client satisfaction.
Animal Handling
Physical handling and restraint are necessary to
perform examinations and obtain diagnostic samples,
but the handling and restraint methods that are used
can have far-reaching effects. Veterinarians and their
staff may lose credibility if they do not compassion-
ately handle active, fractious, fearful, and distressed
animals. Clients may be disinclined to return if their
pet was fearful, if their pet threatened or injured staff,
or if the veterinarian was angry or uncomfortable.8
For these reasons, attention has recently turned
toward reducing stress and anxiety in animal pa-
tients during hospital visits. Establishment of safe
movement routes for reactive individuals, designa-
tion of quiet areas for clients to visit with hospital-
ized pets, and development of separate waiting and
examination areas for individual species are some
potential methods for reducing animal stress and
anxiety.9 In addition, all staff members, but especial-
ly animal caretakers, should be trained in identify-
ing behavioral signs of stress, anxiety, fear, and pain
in the animals with which they work. Because signs
in many species can be subtle, simply assuming that
stress, anxiety, fear, and pain don’t exist because
overt signs are not seen can be misleading.9–12
Veterinarians and staff should strive to con-
tinually learn new restraint and handling tech-
niques that reduce fear and agitation. Any situation
or handling that results in increased emotional
arousal, agitation, or fear can waste time and lead
to distress and injury for animals and handlers.
Many low-stress techniques take advantage of nat-
ural calming signals (eg, dark and quiet environ-
ments),9,13 and information on low-stress handling
techniques for companion animals in a clinic set-
ting is widely available.9 More recently, the Fear
Free Initiative14 brings together resources related
to low-stress handling, behavior, clinic design, and
protocols, with the goal of making clinic visits as
stress free as possible for veterinarians, staff, own-
ers, and animals.
Clients can be encouraged to desensitize their
pets to handling and procedures that are likely to
occur during a veterinary examination and to ac-
climate their pets to methods of transport early in
life. Dogs with a history of fear-related aggression at
the clinic can be conditioned to comfortably wear a
basket muzzle during visits, saving time and reduc-
ing danger to caregivers and veterinary staff. Clients
can also be advised on the use of products that may
help reduce stress in diverse situations, such as spe-
cialized clothinga and head halters.b
The development of faster-acting antianxiety
medications and safer sedatives has made chemical
restraint a reasonable alternative when other stress-
reduction techniques are not effective or practical.
If possible, the decision to use chemical restraint
should be made before the animal becomes emo-
tionally aroused, as waiting can decrease the effec-
tiveness of the drug and allow fear of the situation
to be reinforced.13
Conclusions
The strengthening of the bond between humans
and their pets has changed the landscape for veteri-
nary medicine, with highly bonded owners showing
an increasing willingness to do whatever it takes to
maintain the health of their animals. Understanding
how to incorporate the human-animal bond in com-
panion animal practice by enhancing client commu-
nication and improving animal handling techniques
will allow veterinarians to improve the care that they
provide not just to the animals they see but also to
their owners. As stated by Dr. Rick Timmins in a recent
interview, “only when I began to understand [the pet
was meaningful to the human in some specific and
important fashion] could I be effective in my work.15
Acknowledgments
Dr. Hart’s contribution was partially funded by the Center for
Companion Health, School of Veterinary Medicine, University of
California, Davis (2009-54-F/M).
This manuscript represents work the authors completed in
their role as members of the AVMA Steering Committee on Human-
Animal Interactions (SCHAI).
The authors thank Drs. Lynette Hart and Emily Patterson-Kane
for assistance in drafting and reviewing the manuscript.
44 JAVMA • Vol 249 • No. 1 • July 1, 2016
Footnotes
a. Thundershirt, ThunderWorks, Durham, NC.
b. Gentle Leader, PetSafe, Knoxville, Tenn.
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For all commentaries, views expressed are those of the authors
and do not necessarily reflect the official policy of the AVMA.
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Professional service providers have been particularly vexed after the provision of their service with both billing and collecting from their clients. There are whole consulting industries whose sole purpose is to provide professional service providers with the skills and support to actually charge a “full” price without providing discounts, and buoy the self‐worth of the provider. The goal of a sound patient payment discount program should be to: reward for expected good behavior on the part of compliance, reward the client for achieving strategic financial benchmarks, and reward intended patient intangibles such as marketing the practice to other potential clients. Some pet owners may prey on the humanistic trait of most veterinary hospitals to emphasize patient care over finances. 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In fact, the caregiver placebo effect may be evident around 30–40% of the time regarding subjective evaluations, such as for lameness in dogs and cats. Another manifestation of caregiver placebo effect can be seen as a feature of being enrolled in a study, or receiving an intervention perceived as new and potentially exciting – known as the Hawthorne effect. One very interesting aspect of placebo studies is that sometimes they can still provide benefits even if the patient/client knows they are administering placebos. This is known as the honest placebo effect. The nocebo effect is an interesting phenomenon in which people have negative expectations about something and that alone is enough to make them perceive an ill effect. The human–animal bond (HAB) is the glue that keeps companion animals in families. Veterinary clinics and the wider community benefit from strong HABs. The HAB may affect owner decisions as to the choice of pet and where it is acquired, how the pet lives with them and owner lifestyle such as where they live, work, and take holidays. When veterinary clinic staff are aware of the HAB in general and, more specifically, the nature of their personal bond with their pets, it can help them support owners and accept different approaches to pet care. Compassion fatigue can occur when staff are interacting with clients whose attachment levels are very different from their own beliefs and attitudes about the HAB. Education of staff about the HAB and how it varies with different people can help staff accept owner decisions and minimize staff stress. Veterinary professionals should play an active role in promoting the human–animal bond among their clients. Education should be taken beyond the typical exam room discussions to include alternative methods that are easily absorbed by pet owners. The human–animal bond is a mutually beneficial relationship between people and animals. In addition to traditional exam room conversations, some opportunities are considered to educate veterinarians' clients. These include: enhanced exam room communication, custom literature, practice blog and social media, educational open house, and community event. The entire veterinary healthcare team should contribute to educating clients on important topics that impact the human–animal bond. To promote the human–animal bond, veterinary professionals should educate clients on the importance of preventive care, fear, and stress in animals, positive reinforcement training, enrichment, exercise and nutrition, pain in pets, and pet health insurance. The very good news is that pain management is now a central, and increasingly sophisticated, feature of small animal medicine and surgery, with an increasingly wide array of tools at the disposal of all members of the veterinary team. Underrecognized and undermanaged pain inflicts very real physiological and medical consequences, resulting in significant patient morbidity and in the extreme can contribute to mortality. Evidence‐based industry guidelines and consensus statements are available to direct veterinary clinicians to the highest, wisest, safest multimodal strategies for acute and chronic pain. Several clinical metrology instruments are validated for both dogs and cats to assign scores for acute postsurgical pain. Disasters, man‐made or natural, can be devastating. Lives can be disrupted or lost, property damaged or destroyed. It is vitally important that veterinary practices have a written disaster plan to cover emergency relocation of animals, back‐up of medical records, continuity of operations, security, fire prevention, and insurance and legal issues. For practices affected by a disaster, first and foremost there needs to be an evacuation plan for people and animals. Veterinarians should be included in the larger local or state government's disaster planning, and veterinarian should have a role in the incident command system. Disaster planning needs to include preparation for continuity of operations. Sometimes clients will have to go to an emergency shelter that also allows pets. Having medical records, medications, food, and water ready to go will make the evacuation less stressful. Sterilization surgery is considered the norm in North American dogs and cats, and is increasingly performed at young ages to prevent breeding of adopted dogs, and potentially reduce behaviors that may lead to relinquishment. The primary purpose of gonadectomy is to manage canine and feline populations. The majority of American veterinarians advocate for elective sterilization surgery. Most American dogs and cats undergo elective ovariohysterectomy (OVH) or castration within their first year of life. Neutering curbs unfavorable behaviors: castrated male dogs roam, mount, and urine‐mark less frequently, and male cats are less likely to spray. OVH is the standard sterilization surgery for bitches and queens in the US. Ovariectomy (OVE) may be performed as a minimally invasive technique using laparoscopy. The desire for less invasive procedures has led to the successful adoption of OVE in other countries. Pet overpopulation is a global, multifaceted, animal welfare issue. The veterinary healthcare team (VHT) is on the front line of the intersection of animals and the people in their lives, and the One Health concept recognizes the interconnection between people, animals, and the environment they share. The VHT should be knowledgeable about how their actions fit into the larger picture of the human/animal environment. Zoonotic diseases are those that can pass between people and animals. Connection between human and animal health is the use and misuse of antibiotics. Antibiotic use should be restricted for appropriate bacterial diseases and education by the VHT will help clients understand this use. A distrust of commercial pet foods has led some clients to make their own pet food or sometimes veterinarians recommend homemade diets for pets with specific medical conditions. Clients with a love for exotic pets pose a unique challenge for VHTs. Wildlife poses a unique threat to pets and people. Cancer is a disease of dysregulated genes. Personalized cancer medicine (Pmed) is a therapeutic approach to pet‐specific care that most often analyzes the molecular features of a patient's cancer, and uses this information to design treatment plans that target critical genetic alterations in that patient's tumor. Pmed can also be used to form the scientific rationale for new drug development that starts with the cancer patient rather than cancer cells in tissue culture. It is clear that cancer is a disease of dysregulated genomics. New genomic characterizations of cancer has fueled the field of precision medicine as a therapeutic approach, delivered recent drug approvals in human oncology, and is increasingly available to all species of cancer patients. Precision cancer medicine can be utilized to improve the understanding of a patient's cancer.
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When considering the unique aspects of health‐related welfare of small breed dogs, dental disease prevention and treatment is key to ensuring wellness. By ensuring our clients understand what it means to provide a healthy environment, appropriate behavioral expression opportunities, optimal nutrition, excellent health, and positive mental experiences, we can positively guide the way our clients care for their animals, and potentially choose breeding stock free from heritable dental conditions. Animal welfare, in comparison, chooses to focus on the subjective needs and experience of the animal itself, i.e. what impacts on that patient's daily quality of life is the severe periodontal disease having, and what can be done to alleviate them. When assessing patients with dental disease using the FAWN system, the majority of focus is placed on the need to be protected from pain, suffering, injury, and disease, as well as the need to be able to exhibit normal behavior patterns.
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The 2015 AAHA Canine and Feline Behavior Management Guidelines were developed to provide practitioners and staff with concise, evidence-based information to ensure that the basic behavioral needs of feline and canine patients are understood and met in every practice. Some facility in veterinary behavioral and veterinary behavioral medicine is essential in modern veterinary practice. More cats and dogs are affected by behavioral problems than any other condition. Behavioral problems result in patient suffering and relinquishment and adversely affect staff morale. These guidelines use a fully inclusive team approach to integrate basic behavioral management into everyday patient care using standardized behavioral assessments; create a low-fear and low-stress environment for patients, staff and owners; and create a cooperative relationship with owners and patients so that the best care can be delivered. The guidelines' practical, systematic approach allows veterinary staff to understand normal behavior and recognize and intervene in common behavioral problems early in development. The guidelines emphasize that behavioral management is a core competency of any modern practice.
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