A Guide to Oral Communication in Veterinary Medicine

Ryane Englar

• Publisher: 5m Books
• Year: 2020
• eBook ISBN: 9781789181234
• Topic: Medicine
• Subtopic: Veterinary Medicine

Good communication skills provide better clinical outcomes and help avoid minor as well as major mistakes. Approximately 60-80% of negligence claims against vets are related to poor communication, with new graduates especially vulnerable. Communication skills are a growing part of the curriculum in veterinary schools, recognising how fundamental clear communication is to good practice.A Guide to Oral Communication in Veterinary Medicine covers why communication skills are important, the structure of typical communications and suggested approaches, veterinary specific communication pathways and sample scripts between vet and client. Scenarios covered include everyday communication, dealing with challenging situations, different species, different settings, and communication within the veterinary team. The aim is to instil confidence and competence, build professionalism and avoid problems.Most current teaching is based on a toolbox approach developed from the human medicine model. However, there is no set standard for teaching methodology which is why this is primarily a book for students but also includes a section for educators to provide guidance in this nascent subject.

Part I
Clinical Communication as an Integral Part of the Veterinary Profession

Chapter 1
What Do Our Clients Understand?

The Evolution of the Doctor–Patient Relationship, Patient Autonomy, and Health Literacy

The physician–patient relationship was conceptualized in the writings of Hippocrates, who was credited with authoring the Oath that to this day continues to be recited, in modified form, at commencement ceremonies for graduating doctors of innumerable disciplines.(1)

This Oath has undergone multiple transformations, yet the Oath in its original state set the stage for a tradition of paternalism in the practice of medicine.(2)

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art – if they desire to learn it – without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but to no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about.

If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

Translated from the Greek by Edelstein.(3)

The Oath has since been modernized. Those who recite it no longer pledge their allegiance to the ancient Greek gods, and the increasing emphasis on separation of church and state in modern times has removed spirituality from most renditions.(1) Assisted suicide and abortion continue to be hot-button topics in bioethics, and cases of each frequent the legal system, calling into question the rights of patients, including the rights of the unborn.(1, 2) Today’s surgeons are trained to “use the knife” to heal, contrary to the Oath in its original form, and patient confidentiality may need to be breached in certain circumstances, as when there is evidence of abuse or neglect.(1)

In spite of these alternations and regardless of its relevance to modern times, the tradition of the Oath has persevered along with its present day interpretation, Do not harm.(1)

1.1 The Development of Medical Paternalism

Do not harm gave birth to the concept of medical paternalism by ascribing the philosophy of doctor-knows-best to the physician and granting him the power to act upon this belief.(4–6) For instance, if sharing a diagnosis with a patient was thought to be detrimental to his health, then the physician had the right to withhold this information from the patient. Information withholding included terminal diagnoses, such as cancer. (5, 7, 8) A study by Donald Oken identified that nearly 90% of practitioners in the 1960s withheld this diagnosis.

Some physicians avoid even the slightest suggestion of neoplasia and quite specifically substitute another diagnosis. Almost everyone reported resorting to such falsification on at least a few occasions, most notably when the patient was in a far-advanced stage of illness at the time he was seen.(8)

It was believed that transparency in relaying a terminal diagnosis would extinguish hope and that lost hope might precipitate suicidal ideation.(9) It was thought to be kinder to allow patients to live with false hope rather than no hope at all. Physicians were, in a sense, privileged gatekeepers of information that could be withheld if doing so was deemed to be essential to the patient’s physical and/or mental wellbeing.(10)

In addition to withholding information about death and dying, physicians also failed to communicate risks about medical and surgical procedures out of fear that “many people would refuse to have anything done, and therefore would be much worse off.”(11) Patient autonomy was sacrificed for what was perceived to be clinical benefit.(4–6, 12)

Patient decision making was non-existent. Even guardians were not active participants in healthcare decisions of those under their care, including minors, such as newborns. Whether or not to initiate or continue life-saving measures was largely under the purview of doctors. Consider, for instance, early neonatal intensive care units and decision making about whether or not to resuscitate infants. Informed consent was rarely granted and physicians bore sole responsibility to make the call.

At the end it is usually the doctor who has to decide the issue. It is … cruel to ask the parents whether they want their child to live or die …(13)

This attitude of paternalism was reinforced by the belief that “the healer has always been possessed of a body of knowledge and skills unavailable to his patient.”(14) Because the physician was assumed to know more than the patient, he or she was expected to act on the patient’s behalf to maximize wellbeing.(6, 9)

Case outcomes were therefore doctor-driven. The good doctor was one who orchestrated patient care behind-the-scenes to minimize physical harm or emotional trauma.(9) The good doctor made choices to protect the patient, in the way that he or she saw fit.(9)

This philosophical approach to medicine placed a heavy burden on the physician and his or her capacity to make life and death determinations about the welfare of the patient, without eliciting the patient’s perspective on the matter.(9)

Physicians were expected to make decisions based upon sound evidence; yet decisions were often made based upon fear of how a patient might react: “I would be afraid to tell [a diagnosis that carried a poor prognosis] and have the patient in a room with a window.”(8)

So, it was that, historically, clinical decisions and case outcomes were physician-driven. Patients were told what physicians felt they needed to know. In exchange, patients were expected to submit to physicians’ orders and comply with the diagnostic and treatment plans that were prescribed.

Patient perspective was neither expressed nor welcomed. Patients did not have a say in their own care. Their experiences and insight took a backseat to the doctor-is-always-right attitude, and patients were frequently interrupted when the physician felt that it was time to move on.(15, 16)

Patients were pawns in the chess game of healthcare. They were trained to follow instructions, not to question them.(17) As a result, interpersonal communication was lacking to non-existent. The physician initiated dialogue that mirrored the sport of shot put: conversation was one-sided. The physician spoke, and the patient was expected to absorb, like a sponge, what limited information was provided.

1.2 The Limitations of Medical Paternalism

Paternalism was intended to benefit the patient. As a result, this model dominated human healthcare through the 1960s.(2) Physicians were authorized to make unilateral decisions about patient health based upon their own perceptions of what was best.(10, 18) However, research confirms that medical paternalism has the potential to adversely impact the physician–patient relationship. The following consequences have been highlighted in the medical literature as the direct result of paternalistic care.

• Patients are discouraged from sharing their story.(19)
• Many patient concerns are not voiced.(20)
• If patient concerns are voiced, they are rarely acknowledged and often dismissed.(21)
• Patients feel misunderstood.(15)
• Patients are frustrated by what they perceive to be their physicians’ lack of empathy.(15)
• Consultations gather information that is inaccurate or incomplete.(22)
• The majority of presenting complaints are missed by physicians.(23)
• The majority of physicians and patients disagree on the primary problem.(24)
• Patients do not receive insight into that which they value most: information about what caused their condition and the prognosis for what ails them.(25)
• Patients are dissatisfied when they are dismissed from the examination room without being adequately informed.(26)
• Patients may feel uncertain about the diagnostic or treatment plan that has been prescribed; uncertainty is distracting and may detract from case outcomes.(27)
• Patients want more control over decision-making, but are prevented from doing so.(28)
• Patients end the consultation desiring more information than what was given.(29–31)
• Patients do not always understand or recall what has been shared after the fact.(32, 33)
• Patient compliance and adherence to medical recommendations is poor.(34, 35)
• The healthcare system is burdened by the cost of noncompliance.(36)
• Malpractice is a likely outcome when there is a breakdown in communication between physicians and patients.(37–41)

A primary downfall of medical paternalism is its assumption that the doctor knows best.(17) Medical paternalism assumes that the ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• About the Author
• Preface
• Dedication
• Acknowledgments
• About the companion website
• List of Acronyms
• PART I CLINICAL COMMUNICATION AS AN INTEGRAL PART OF THE VETERINARY PROFESSION
• PART II DEFINING ORAL COMMUNICATION SKILLS AS THEY RELATE TO THE VETERINARY CONSULTATION
• PART III APPLYING COMMUNICATION SKILLS TO EVERYDAY CONVERSATIONS IN CLINICAL PRACTICE
• PART IV TESTING YOUR UNDERSTANDING OF ORAL COMMUNICATION SKILLS IN VETERINARY MEDICINE
• Index