Communicating with the Client Enhancing Compliance by sofiaie

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									Communicating with the
Client: Enhancing Compliance
                DETERMINANTS FOR CLIENT COMPLIANCE:
                ■ Time spent by veterinarian during examination room visit
                ■ Collaborative planning of treatment regimen
  KEY POINTS:




                ■ Specific verbal and written instructions
                ■ Timely encouragement


                CLIENT ADHERENCE TO INSTRUCTIONS:
                ■ Improves health of pet
                ■ Improves client confidence
                ■ Benefits the veterinarian
                ■ Benefits the veterinary practice




                       How many times in a day or week do you find yourself asking the question, “Why don’t
                       these clients do what we want them to do?” The answer lies somewhere between your abil-
                       ity to listen and your ability to persuade. By enhancing several key communication skills,
                       you really can influence the behaviors of your clients. For 30 years, medical researchers
                       have been studying physician–patient interactions1 and the results, although not easy to
                       analyze, have been surprisingly straightforward. Effective communication has been
                       found to significantly improve medical outcomes, including patient health and satisfac-
Kathleen Bonvicini,
MPH
                       tion, adherence to medical recommendations, and doctor satisfaction.
Institute for Health        Approximately half of all medical patients in the U.S. are not following their
   Care                doctor’s advice.2 A review of 63 studies assessing patient compliance showed that
   Communication       close to 40% of patients take prescribed medication incorrectly or not at all. Almost
New Haven,
   Connecticut         twice that number fail to adhere to dietary restrictions and prescribed exercise or
                       continue to engage in compromising habits such as smoking and abusing alcohol.3
Sarah K. Abood,        This nonadherence and partial adherence by patients results in increased frustration
DVM, PhD               for both the doctor and the patient and can lead to incorrect diagnoses and unnec-
Michigan State
   University
                       essary or prolonged treatment.
College of Veterinary       In veterinary medicine, a recent study conducted by the American Animal
   Medicine            Hospital Association revealed that client compliance is much lower than veterinari-
East Lansing, Michigan
                       ans had predicted.4 The study looked at estimated levels of compliance in small ani-
                       mal practice and was limited to six key areas: heartworm testing and prevention, den-
tal prophylaxis, therapeutic foods, senior screenings, canine and feline core vaccines (DHLPP and
FVRCP), and preanesthetic testing. In general, the study concluded that the majority of practitioners sur-
veyed believed their client adherence levels were as high as 75% when in reality the average rate was found
to be 50%.4 This means that only half of the clients seen in those practices followed through on the treat-
ments their veterinarians recommended. The study also found that veterinarians estimated that client com-
pliance in regard to therapeutic foods was 59%, but the actual rate was 21%. Estimates for dental pro-



                                                                                                             35
                    phylaxis were 54%, but the compliance rate was 35%, and the gap for heartworm preventive
                    was even greater. Therefore, low adherence to recommendations presents complex challenges
                    for all members of the health-care team. Improving compliance relies heavily on the quality of
                    the interaction between the client and veterinarian and other members of the health-care team.
                        A 1999 review5 identified four distinct dimensions of physician-patient communication
                    that were associated with increased compliance: health-care education, negotiation, an active
                    role for the patient, and expressions of empathy and encouragement by the physician. A sep-
                    arate study6 found that patients were more likely to be compliant when their doctors offered
                    additional information, used more positive (less negative) language, and asked fewer ques-
                    tions. The less time spent asking questions meant more time for providing information.
                        Studies examining owner compliance in the veterinary literature7,8 have documented
                    short-term use of antimicrobials; an important determinant for compliance was that owners
                    felt the veterinarian spent enough time during the examination room visit. Other determi-
                    nants of compliance were collaborative planning of the treatment regimen, provision of spe-
                    cific verbal and written instructions, and timely encouragement.9 Unmistakably, patient care
                    is influenced by client adherence and satisfaction with the quality of communication between
Improving           veterinarian and client. One 2006 study10 highlighted specific types of communication that
compliance relies   are essential for patient health including ensuring that clients understand correct administra-
                    tion of medications, instructions for providing pet home and after care, and the importance
heavily on the      of appropriate follow-up visits.
quality of the
                    BENEFITS
interaction         Client adherence has many benefits for the animal, client, veterinarian, and the veterinary
                    practice. When clients adhere to recommendations for their animal, it can result in improved
between the
                    pet health, which minimizes the need for urgent visits. It also means that if their animal is
client and          healthier, clients and others who interact with the animal will benefit. Adherence also
                    improves client confidence, because the client feels good about taking action and carrying out
veterinarian and    recommendations. The veterinarian benefits because it is rewarding to see treatment plans
other members       followed all the way to completion and confidence gained improves his/her ability to com-
                    municate with clients, staff, and colleagues. Finally, the veterinary practice benefits when
of the health-      clients adhere to recommendations because they make scheduled wellness and preventive care
care team.          visits more regularly.

                    ESSENTIAL SKILLS TO ENHANCING CLIENT ADHERENCE
                    • Introduction—Even in urgent care, introductions set a tone for the encounter.
                    • Greetings—With returning clients, it is important to acknowledge the patient and the
                      person in the room.
                    • Open-ended Inquiry—Invite the story from clients in a manner that allows them to tell
                      you in their words what is wrong, why they have brought their animal in, what they have
                      noticed, their concerns and expectations, etc. Sometimes the story will be fairly straight-
                      forward: “Ingrid is here for her vaccinations and I want to be sure she is healthy.” At other times
                      the story may take more prodding to understand the medical issues as well as the meaning
                      and anticipated concerns that lie beneath the surface: “I noticed that Max seems to be vom-
                      iting more often and seems to be losing weight.” Clients may or may not voice additional con-
                      cerns unless asked to share their story, which may or may not include their own ideas about
                      what they think might be wrong. One example of how to invite the story is: “Tell me more
                      about what you’ve noticed and what your thoughts are about these changes in Max.”


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• Reflective Listening—Simplest form of reflective listening is a short summary. With a ris-
  ing tone of voice it is both a statement and a question: “So Max threw up twice last night.”
      The second form offers an interpretation, changing the words that clients use so the cli-
  nician is sure that he/she understands what is being said: “Glad that you brought him in
  today. It sounds like you’re really concerned.”
      The third kind of reflective listening tests the hypothesis that clients are not saying out-
  right what they are thinking or feeling: “Given your recent loss of Snowball, I’m wondering
  if that’s what you’re worried about with Max.”
• Express Empathy—The communication of empathy lets clients know that the clinician
  has heard them at a deep level. The clinician not only understands what the experience
  was like for the client, but he/she also appreciates the meaning of the experience: “I think
  anyone who cares about their cat the way you do would have reacted that way.”
• Body Language—It is important to be aware of clues that clients provide indicating they
  need clarification, are anxious, or experiencing other emotions. These may be apparent in
  facial expressions, a shift in eye contact, or nervous gestures. Your own nonverbal cues may       Be aware of
  enhance or inhibit the interaction with clients. Are you aware of your facial expressions,
                                                                                                     clues that
  tone of voice, and overall presence when you communicate with clients?
• Literacy Sensitive—Do not make any assumptions about the level of the clients’ health
                                                                                                     clients provide
  literacy. It has been estimated that less than half of the information clients are given dur-      indicating
  ing each visit is retained.11
     Limit the amount of information given, use clear, simple language, and keep a slow pace         they need
  to allow clients the time to absorb information. If discussing risk, avoid using too many          clarification,
  numbers that may overwhelm the client.
                                                                                                     such as:
• Assess Client Understanding—Providing information (ie, teaching) is only one aspect of
  client education. You should also assess clients’ understanding of the cause of the problem,       • facial
  why it is important to act, and what needs to be done. Be sure that clients have asked all
                                                                                                       expressions
  their questions: “We talked about a few things now. I’m wondering what questions you have
  for me?” “What will you tell your family about this when you get home?”                            • a shift in eye
• Assess Conviction and Confidence—Assess conviction by asking, “How important do                      contact
  you feel this endoscopy procedure is to identify Jake’s intestinal problems?” To quantify, you     • nervous
  might ask, “On a scale from 0 to 10, with 0 not important at all to 10 being of utmost impor-
                                                                                                       gestures
  tance, how important do you feel this surgery is to help Keke’s paw?”
     Assess confidence by asking, “How confident are you that you can carry out this plan?” or
  “On a scale from 0 to 10, how likely is it that you will be able to remember to give Rocket this
  medication twice a day?”
• Provide Options—Whenever possible, offer clients options: “Would you like the medica-
  tion in pill form or liquid?”
• Clarify Details—Whenever possible, include pictures and clear, specific, written instruc-
  tions (ie, how often treatment must be given, meal requirements, etc.). Discuss positive
  reasons for following recommendations, including anticipated benefits, and discuss suc-
  cessful techniques that will help clients remember to give medication or help them to keep
  a schedule. Prepare in advance with the client for weekends, holidays, vacations, and other
  disruptions to daily routines. Discuss potential side effects clients should report.
• Provide Written Action Plan—Written instructions (and supplemental materials) that
  are knowledge sensitive can help clients remember what was said during an office visit.


Communicating with the Client: Enhancing Compliance                                           37
                      Learning ways to influence client adherence requires an understanding of the importance
                   of client and veterinary practice characteristics, cognitions, values, and communication
                   behaviors. In addition, improving client adherence requires the willingness to evaluate one’s
                   own behavioral contributions to relationship-building with clients. Learning and practicing
                   many of the above skills are the first steps to enhancing client relationships, increasing client
Written            satisfaction, increasing client adherence, and improving patient health.
instructions and
                   REFERENCES
supplemental        1. Silverman J, Kurtz SA, Draper J. In: Skills for communicating with patients. Arbingdon, Oxon, UK: Radcliffe
                       Medical Press, 2005.
materials that      2. Roter DL, Hall JA. In: Doctors talking with patients/patients talking with doctors: Improving communication in
                       medical visits. Westport, Connecticut: Auburn House, 1992.
are knowledge       3. DiMatteo RM, Giordani PJ, Lepper HS, Croghan TW. Patient adherence and medical treatment outcomes: A
                       meta-analysis. Med Care 2002;40:794–811.
sensitive can       4. The path to high quality care: Practical tips for improving compliance. In: Rees AM, ed. Lakewood, Colorado:
                       American Animal Hospital Association, 2003;46:4–25.
help clients        5. Stewart M, Brown JB, Boon H, et al. Evidence on patient-doctor communication. Cancer Prev Control
                       1999;3:25–30.
remember what       6. Hall JA, Roter DL, Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Med Care
                       1988;26:657–675.
was said during     7. Grave K, Tanem H. Compliance with short-term oral antibacterial drug treatments in dogs. J Small Anim Pract
                       1999;40:158–162.
an office visit.    8. Bomzon L. Short-term antimicrobial therapy – a pilot compliance study using ampicillin in dogs. J Small
                       Anim Pract 1978;19:697–700.
                    9. Sudo SZ, Osborne CA. Enhancing compliance with treatment recommendations. In: Kirk RW, ed. Current
                       veterinary therapy: Small animal practice. Philadelphia: WB Saunders Co, 2000.
                   10. Shaw JR, Bonnett BN, Adams CL, Roter DL. Veterinarian-client patient communication patterns used dur-
                       ing clinical appointments in companion animal practice. J Vet Med Assoc 2006;228:714–721.
                   11. Kessels RPC. Patients’ memory for medical information. J R Soc Med 2003;96:219–222.



                                     References for this article as well as further information on the topic are
                                       available on the Web at www.HillsVet.com/ConferenceProceedings.




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