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A framework for the

veterinary consultation
2 Alan Radford

Introduction
I am guessing that if you are reading this, you are an adult and you work in some part of
the veterinary health care profession. That means you are at least 16 years old (and probably
a lot older). However old you are, you will have had about the same number of years of
developing your own communication skills. So with this wealth of experience, why should
you read any further? Surely we know all there is to learn about communication, in both
our private and professional lives? I suspect that the people who truly believe this statement
will never actually read this chapter. For me there are two main reasons to carry on reading.
Firstly, if we are honest, we all make mistakes in communication in our day-to-day lives. We
even have an expression for some of these mistakes: it is that ‘foot in the mouth’ experience,
when we realize we should not have said what we just did. More often, perhaps, it is that
gut feeling when we realize that an interaction with someone has gone horribly wrong, but
we cannot quite figure out why. And if we make mistakes in our personal communication,
we surely do in our professional communication.
The second and main reason to keep reading is that not only are we imperfect commu-
nicators, but we can all improve. That is good news. As with all learning, we really have to
want to learn, otherwise we are unlikely to get very far. But once we are motivated, we can
then learn through experience. But how can we learn about our communication skills? In
particular, how can we identify the good skills we use, and, just as importantly, how can we
identify the things we could improve? At one level, you know if you get a thank-you card or
a present that you must have done something right – but what? Conversely, we may get the
occasional complaint, and nearly always that means there has been a breakdown in commu-
nication between our veterinary practice and clients – but where? The interaction between
ourselves and our clients is highly complex and multi-faceted. Where can we start to learn

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26 Handbook of Veterinary Communication Skills

about this process? The way we can learn most efficiently is by breaking such complex tasks
down into their component parts.
For those of you who have ever been for a golf lesson, I suspect the following scenario will
ring true. After first watching you hit a few balls, the golf professional systematically decon-
structs your swing into its many component parts: the stance, the grip, the back swing, strik-
ing the ball and the follow-through. For those less impressed by a golfing analogy, imagine
you went out for a meal one evening to a restaurant, and the next day a friend or colleague
asks you what it was like. What we tend to do again is break the experience down into its
parts. For this example that might be the venue, the starter, the main course, the pudding
(my Yorkshire background peeking through there), the value for money and the quality of
the service.
And what does this compartmentalization do? It puts things in order and it helps us not
to miss things out. It helps us understand what was good about an experience or a task, and
what could be improved upon. It allows for constructive criticism and promotes the learning
experience.
So, how does this relate to the art of communication? Can a process as natural as com-
munication be similarly deconstructed when you get to adulthood? Well, I guess you may
not be surprised to hear that it can. Otherwise, this would be a very short chapter. What
we will do in the rest of this chapter is learn about one framework or model that has been
used to break down communication, in this context the medical consultation, into its com-
ponent parts. Such models were originally developed by medical educationalists and are
now widely used to train doctors and other professionals allied to medicine at all stages of
their careers, from undergraduate to consultant, in the clinical skill that is the consultation
process. More recently, these have been adapted and are being introduced into veterinary
schools as a basis for teaching veterinary students. In this chapter we will learn about one of
these models. It has a name, even though not a very catchy one: ‘A guide to the veterinary
consultation based on the Calgary–Cambridge observation guide’. The Calgary–Cambridge
guide is one of the models that are widely used in medical education (Silverman et al. 2006).
As we will see, the model breaks the consultation down into seven key parts: preparation,
the opening, gathering information, giving information, providing structure, building a re-
lationship and, finally, closing the consultation.
And who am I to take you through this process? Well, I was part of a group that developed
the use of this model for veterinary training (Radford et al. 2006), and I have had the privilege
to use it for almost 10 years, mostly with undergraduates. But none of that is important here.
What is important is that I am someone who passionately believes that good communication
is at the heart of best clinical practice. The learning experiences I remember, almost above
all others from my time in veterinary school, relate to communications skills. How, when I
watched a consultation by a now retired dermatologist, he always started by asking us what
we thought about the clients and their reactions, rather than by asking about their animals’
skin. And when I was ‘seeing practice’, how struck I was by the privileged position we have
in the animal health business, and how, through communication, we can have either a very
positive or a very negative impact on our clients. Seeing practice as a veterinary student is a
wonderful thing; you rarely get to see other people consulting once you leave the veterinary
school. Fundamentally, if we communicate well, then our clients will be happier, our patients
will get well quicker and we will all enjoy our jobs more. So, let us take this wonderful and
complex thing, the veterinary consultation, break it down into its component parts, and look
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Chapter 2 A framework for the veterinary consultation 27

at the skills that we use in each phase. Time does not permit much recourse to the scientific
literature available in the medical field that underpins this and other models. Instead, I shall
be appealing to your heart rather than your head. I will use some experiences from my
personal time in practice to illustrate key points, but better still, I hope that you will come
up with examples from your own practice.

A GUIDE TO THE VETERINARY CONSULTATION BASED ON

THE CALGARY–CAMBRIDGE OBSERVATION GUIDE
The summarized version of the consultation guide is shown in Figure 2.1. Not the most
beautiful of things on paper, is it? But let us briefly look at its structure, before we delve more
deeply into its individual sections. The central spine of the model is simple and applies to all
types of communication. We should prepare. We must open the communication (otherwise
we would never talk to anyone), we must close the communication (otherwise we would
be talking forever – I am sure we can all think of people who are good at doing that). In
between, we give information and receive it. Communication is always a two-way process.
The sidebars are where things get professionally more interesting, and they are arranged
down the sides to reflect the fact they are happening throughout the consultation. We should
build a professional relationship with our clients and we should structure the consultation.
The clinical examination is represented as the jam in the consultation process. This model
can be used for all types of veterinary consultation, whether our clients own one Yorkshire
terrier, a horse or a herd of dairy cows. And it works for all staff involved in the work of
the veterinary practice, whether you are a veterinarian, a nurse or one of the other people
involved in client care. As often happens in chapters such as this, I will include some phrases
in quotes to illustrate points. There are no prescriptive scripts. It is really important you
always use phrases that you are comfortable with and suit your own communication style.
Models such as this are not meant to turn us all into professional clones. They are tools that
allow us to explore and improve our own consultation style, in a fashion that must be very
personal to who we are as individuals.

PREPARATION
It is nice to feel special that you are important for who you are and not just the next in a long
line of clients (Figure 2.2). And that is what preparation should allow us to do – to ensure
that when we first meet our client, we are focused on them and their animals, and not on
anything else, whether it is personal or professional.

Create a professional, safe and effective environment

Clearly, there are very practical issues here to do with the safe and secure handling of our
patients. I speak as someone who had a patient escape me in my first job. The owner hunted
the streets for several days, eventually finding his dog – he knew it would be with children.
But what does our client need and expect? In small animal surgeries, the classic environment
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28 Handbook of Veterinary Communication Skills

Preparation
• Establish context
• Create a professional, safe and effective
environment
Initiating the consultation

• Establish initial rapport with clients and

animals
• Identifying the reasons for the
consultation
Building the Providing
relationship Gathering information structure to
with the client the consultation
• Exploration of the client’s presenting
complaints to discover
• The clinical perspective (disease – short-
• Non-verbal behaviour term history) • Making oganization
• Developing rapport • The client’s perspective (include animal’s overt
• Involving the client purpose) • Attending to flow
• Involving the animal • Essential background information (long-
term history)

Physical examination

Exploration and planning

• Providing the appropriate amount and type

of information
• Aiding accurate understanding and recall
• Achieving a shared understanding:
incorporate the client’s perspective
• Planning: appropriate shared decision
making
Closing the consultation

• Summarize
• Forward planning

Figure 2.1 A guide to the veterinary consultation based on the Calgary–Cambridge observation
guide.

is a fairly bare room with an examination table that divides the room into the client’s half
and the vet’s half. This separation has been used for years to reinforce the professional status
of the veterinarian. But what about chairs? Some less able people may well need to sit. One
place where I used to locum had a low, broad window ledge and a chair, which allowed
both me and the client to sit and talk, rather than having me towering over them. Even for
the able-bodied, sitting creates an impression of dedicated time for communication, and may
be appropriate, particularly where there is no need for a lengthy physical examination.
We also need to think here about how we appear. Whether we realize we do it or not, we
often use a person’s appearance to form our initial impression of them. This is not the place
to be prescriptive, suffice to say we should have a professional appearance, appropriate to
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Chapter 2 A framework for the veterinary consultation 29

Figure 2.2 The busy veterinarian.

the animals we are seeing and in the environment in which we are going to be examining
them (for more information on professional appearance, see Chapter 3).

Establish context
Whether it is in between clients in a busy small animal surgery, or during the trip out to
visit a farm or a stable, there is always some time to prepare for the consultation. We should
familiarize ourselves with the owner, the animal, the stated reason for the consult and any
appropriate history. We can then start the medical process in our minds even before we meet
the client. Another lecturer I remember, this time in equine studies, used to say when driving
to the stable, ‘switch Radio Two off and think about case’.

INITIATING THE CONSULTATION

This part of the consultation takes you from first meeting your client and patient to finding
out why they have come to see you. There is a really important distinction to be made here.
If you want your clients to be happy, then one of the most important things to discover is
why they have come, not necessarily why you think they have come.

Establish initial rapport with clients and animals

How do you feel when you go and see the doctor or dentist? Are you at your relaxed and
eloquent self? Almost definitely not. If you are anything like me, you are frequently nervous,
and are concerned about the visit and what may be wrong with you or about to happen to
you. This can make me inarticulate, often stumbling over my words. This whole feeling is
reinforced by the fact that we rarely see the same professional these days. And the same is
often true in veterinary practices. That is what many of our clients will be feeling like as
they wait to see us – stressed, apprehensive and nervous – and this can create a barrier to
efficient communication with you. And if you do not communicate well, you will diagnose
less efficiently and your patient care will suffer.
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30 Handbook of Veterinary Communication Skills

There are many ways we can start to break down this barrier. Clearly, it is polite to have
a round of introductions: who you are, and who the person is that you are consulting with.
This may not always be the owner, and this is important to find out, especially in relation to
assessing the quality of the information you gather later in the consultation, and in obtaining
permission to treat. Some people shake hands at this stage, but this is a personal decision. It
is nearly always appropriate to acknowledge the patient. After all, we do work in an animal
welfare business.
Providing it is not an emergency consultation, we can then engage in a bit of idle ‘chit
chat’. We all have our own way of doing this – it is whatever we are most comfortable with.
The English are said to love talking about the weather. I used to enquire whether people
had been kept waiting for long. If you already know the client, you are in a great position
to build on previous consultations by, for example, enquiring about the client’s holiday. If
you are lucky enough to be on a visit, then you can talk about the environment you are in.
This is not wasted time. We might gather some useful information and will be starting to
relax the client. It is also important to understand that people learn how to behave with each
other right at the very beginning of a relationship, and this learnt behaviour is very hard to
change. If you have an open and relaxed style with your clients from the beginning, then
your client will quickly learn to be open and relaxed with you. Conversely, if you are closed
at the beginning, you are likely to only get answers to the questions you ask.

Identifying the reason(s) for the consultation

A slight apparent tangent is coming up here. If I were to tell you I had just come back from
a special holiday with my family and to ask you to find out about it, how would you do it?
Stop and have a think for yourselves before you read on. Okay, most people start by asking
really obvious questions. ‘Where and when did you go?’ is a good start. ‘For how long did
you go?’ ‘Did you stay in a hotel or was it self-catering?’ ‘Whom did you go with?’ All
these are examples of very sensible closed questions. But a far better way is to ask one open
question, such as, ‘Tell me about your holiday’. And this is a great way to start the clinical
phase of the consultation. We all have our own phrases and it is important to use one you are
comfortable with. ‘What can we do for Buster today?’, or ‘What seems to be the problem?’ If
we do take this more open route of questioning then this next bit is really important. If we
ask the open question, then we should shut up and listen. There is good evidence that whilst
many medical professionals start with an open question, they interrupt after approximately
18 seconds and start focusing on their agenda (Beckman & Frankel 1984). What this does
is educate the client to move into a closed mode, and only respond to questions they are
directly asked. It is much better to let them finish. Again, the evidence is clear. Very few
people talk for more than 30 seconds in response to this first open question. And if we listen,
we will gather a large part of the clinical history, and probably a lot more than if we had just
asked closed questions.
So, you have asked your open question and you have shut up and listened. The client
will likely tell you about their major concern. But what about all their other concerns? Most
people are worried about more than one thing. One easy way to address these other concerns
is to acknowledge the owner’s initial (or major) presenting complaint and then to repeat the
open question. So, for example, ‘apart from Bonnie’s vomiting, is there anything else you
are worried about?’ And again, we shut up and listen. Essentially, we can repeat this loop
until the owner says that that is everything. This is known as summarizing and is a useful
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Chapter 2 A framework for the veterinary consultation 31

technique at each stage of the consultation. There should then be no nasty surprises at the
end of the consultation. A good example of this is a pyometra in a bitch. The owner may
respond to our initial open question by telling us that Bonnie is off colour and vomiting. This
might initially lead us to have a gastroenteric diagnosis at the top of our list. If, however, we
do ask, ‘Is there anything else?’, then they may tell us that Bonnie is also drinking a lot.
This is a very rapid and efficient way of setting the scene for the rest of the consultation,
and critically allows the owner to share all their concerns. And remember, owners’ concerns
need not necessarily just relate directly to their animal’s medical condition. An equally valid
concern is the farmer who is desperately worried about the financial implications of your
visit, and such concerns also need to be addressed during the consultation. All we have
to do is listen. Using this method, even our first year students can collect good histories for
fairly complicated conditions, without ever having heard of the actual condition in question.

GATHERING INFORMATION
Having already established all the owners’ concerns through this repetitive loop of open
questioning and listening, we can now use our clinical knowledge to finish collecting the
history.
The order in which this is done is not really important, but this is one time when it is nice
to explain to the owners how we would like to proceed with the consultation, by making the
structure of the consultation overt. For example, ‘I am going to start by asking some general
questions about your farm and your herd, and then I will come back to your concern about
the number of lame cows you have . . . is that okay?’

The clinical perspective (disease – short-term history)

This is where we drill down on the specifics of the presenting complaint. It is the duration,
severity, frequency, progression and response to any treatments given. And it needs to be
done for all presenting complaints. It need not (and should not) be a big, long list of closed
questions. We can still start with an open question style and fill in the critical gaps with more
closed questions.

Essential background information (long-term history)

Much of this may be available to you through your previous experience of the client or from
the records. However, these are not always correct. Important information includes signal-
ment (age, sex, breed), how long the animal has been in the owner’s possession, management
(housing, feeding, use), routine procedures (vaccinations, worming, surgery), past medical
and surgical history including medications, and where appropriate, the health status of in-
contact animals including the owner and their family. To avoid the possibility of asking a
lot of questions that some owners may feel you should know the answer to, it is sometimes
useful to impress them with the knowledge you have gleaned from their records during the
preparation phase, and then ask them if this is correct. For example, ‘I have not met you be-
fore, but according to my records, Rover is 6 months old, you bought him as a puppy from
the breeder, he has not been castrated, but we did vaccinate him here when he was 3 months
old – is that correct?’ This can inspire confidence in you and your practice (unless, of course,
the owner comes back and says, ‘No, this is Bonnie, she is 12 years old, was neutered when
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32 Handbook of Veterinary Communication Skills

she was 1 year old and has never been vaccinated’). The only way it could be any worse is if
Rover was euthanized in the practice last year, something you had clearly overlooked. There
is no substitute for good records; we just need to make the time to read them.

The client’s perspective (including animal’s purpose)

This is a really important part of the consultation and reflects the wide diversity of our
clients, their previous experiences and their relationship to our patient. There is the clear
stereotype of farmers being motivated by money rather than welfare, and small animal own-
ers being motivated by length of life and less about money. But what about the pet goat and
the racing greyhound? Whilst some people do not worry much, others may be very worried.
Consider the owner whose horse probably has mild spasmodic colic, but whose previous
horse died of torsion of the large colon, or the owner of the dog with lymphoma, whose
partner recently died of leukaemia. This is sometimes referred to as ‘emotional baggage’.
Understanding these concerns is critical to the treatment of our patients. Whilst we may feel
our concerns are for the animal, the animal is treated via its owner, and our job in the veteri-
nary profession is to help our owners make informed decisions about the treatment of their
animals. For some of us, this can be extremely scary stuff because it exposes us to things that
are personal. It may uncover emotions, and we are likely to need to show a good deal of
empathy. (For more information on dealing with clients’ emotions, please see Chapter 4).

GIVING INFORMATION – EXPLANATION AND PLANNING

You have taken your history and finished the physical examination, and come to your pro-
fessional conclusion. It is now time to explain everything to the owner. Sometimes this may
be very simple, but more often than not, we need to impart a lot of complicated information.
And it is not sufficient just to tell our owners. It is also our duty to help them to understand
and recall, so that they can make not just a decision, but a truly informed decision. In times
gone by, receivers of medical care were told what to do, the advice of the medical profes-
sional being gospel. However, those days have now gone, and decision making is generally
much more of a partnership between you and your clients that necessitates imparting all
the necessary information to allow the client to balance the advantages and disadvantages
of each treatment option. In those cases where clients truly want you to make decisions for
them, it is still necessary to carefully explain the reasoning for choosing a preferred option,
and the reasons for ignoring other options.

Providing the appropriate amount and type of information

It may be necessary before undertaking complex explanations to find out what a client’s
current knowledge base is. I am sure we have all had to give information to medical doctors
about their animals. When I go to the doctor I usually tell them I am a vet. For me this
means I can have a more meaningful discussion about my reason for visiting. It may also be
that some of our clients have had experience of a particular condition before. It is certainly
increasingly true that many clients have ‘Googled’ and ‘wiki’d’ before they get to you, so are
variably informed or misinformed. Deciding how much information to tell someone requires
careful judgment, and is best decided in consultation with the owner. A simple place to start
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Chapter 2 A framework for the veterinary consultation 33

can be by asking the owner, ‘Have you any experience of this condition?’ This allows the
owner to say no, without feeling foolish.

Aiding accurate understanding and recall

There is no point telling a client anything if they cannot use the information or remember
it. That is a waste of your time, belittles the client and has a negative impact on the rela-
tionship between the client and the practice. Suppose a car driver pulls up next to you and
says they are running out of petrol and could you tell them the way to the nearest petrol
station. How do you do it? Not only must you tell them the directions, you must help them
remember. Common skills you can use are to break the information down into bits and ex-
plain this to them. ‘First I’ll tell you how to get to the cathedral, and then I will explain how
to get from there to the garage.’ You could also ask them if they know how to get to a well-
known landmark closer to the petrol station. If they do, then there is no need to explain the
whole thing to them, leaving them free to concentrate on the bit they really need to remem-
ber. You could ask them to go over the route afterwards to see if they got it right. This is
actually something a lot of people do for themselves. ‘Okay. Can I just check I have got this
right . . .’. All these skills apply to complex medical information. We should break the in-
formation down into small chunks, we should prioritize it, we should use repetition and
summaries to reinforce the information, and avoid using overly complicated words if they
are unnecessary. Of course, we may not need to rely only on verbal communication: they
say pictures paint a thousand words, so we should make use of them when we can. There is
now also an increasing number of models, professional artwork and owner leaflets that can
all be used to aid understanding.

Achieving a shared understanding: incorporate the

client’s perspective
Although this part of the consultation is supposed to be about giving the client the infor-
mation, it should not be a one-way process. We must relate our explanation to the owner’s
presenting complaints, and make sure we have answered all their concerns. For example, in
the earlier example of the pyometra, we may say, ‘Does that help you to understand why
Bonnie is not only vomiting, but also drinking a lot?’ We should give our clients the op-
portunity to ask clarifying questions, and even if they do not, we should be alert to their
non-verbal communication for evidence that they do not understand. It is our professional
responsibility not just to give the right information but to make sure clients have understood
it, so that then, and only then, can they make an informed decision.
We must also realize that telling people a lot of information can have a profound emo-
tional impact on them and we should acknowledge this. It is all part of showing empathy:
‘I’m sorry to give you all this information. I realize it is a lot to take in. Is there anything you
want to ask me?’; ‘Listen, I can see this is very upsetting for you, just take your time’. By
using phrases such as these, we show we understand as well as provide a practical solution
to our client’s predicament.

Planning: appropriate shared decision making

We have to remember that, at the end of the day, we are aiming to give clients information so
that they can make an informed decision about what is best for the treatment of their animals.
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34 Handbook of Veterinary Communication Skills

Therefore, we must encourage the client to contribute their thoughts, ideas, suggestions and
preferences so that ultimately we can negotiate a mutually acceptable plan. Treatment plans
are about offering choices rather than giving directives. For more information on decision
making, please see Chapter 3.

PROVIDING STRUCTURE TO THE CONSULTATION

This is one of my favourite parts of the consultation model. It is such a simple thing, but it
can help all the parties in the consultation enormously. It ensures we do not miss things out,
which is especially important as clients do not know the order we are planning to do things
in, and it helps the client know where they are in the process.

Attending to flow and making organization overt

This is our professional responsibility. It is about making sure we stick to time whenever
possible. And it is also about structuring the consultation in a logical order, one that satisfies
the needs of both the client and the vet. But more than this, it is about explaining to owners
how the consultation will be structured. This is sometimes referred to as ‘signposting’. If you
structure the consultation well and explain that structure, it puts clients at ease and helps
everyone make best use of the limited time available. As an example, our family recently
made use of the UK’s NHS maternity services, and we were very impressed with the level of
care we received. But there was one strange day when we went for a routine check-up, one
of our first. We did not know how the system worked, nor did we really know what would
happen to us. We were passed from health care professional to health care professional,
from administrators, to care assistants, to nurses, to junior doctors and eventually to the
consultant. At no stage in the process did we know what or who was coming next. It was
quite unnerving and meant we probably asked all the right questions but at the wrong time
to the wrong person. If someone had simply explained the order of the process, it would
have put us much more at ease, and ultimately made the process more efficient both for us
and for the medical professionals we saw that day.
We have come across this signposting a little already. It is really good if we can explain to
owners the order in which we are going to take the history, and we can say to owners that we
are going to give them lots of information, but there will be plenty of time at the end to ask
any questions. Or we can even give them the ‘permission’ to interrupt at anytime. Someone
once told me that a good way to give a lecture is first, to tell them what you are going to
tell them, then to tell them, and finally, tell them you have told them. This same principle
probably also works in the consultation.

BUILDING A RELATIONSHIP
This is the part of the consultation process that can often be overlooked, yet it is probably one
of the most important. It uses a lot of those skills that we develop throughout our lives. With
some thought, however, we can modify our behaviour to ensure a better clinical outcome.
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Chapter 2 A framework for the veterinary consultation 35

Non-verbal behaviour
We tend to think of communication as what is said or perhaps written. But a lot is
also communicated from our perception of each other’s body language. There is a really
simple exercise you can do here. Ask a friend or colleague to listen to you for 2 minutes
while you talk about yourself. Then, swap round and listen to them doing the same. The
only rule is that the listener cannot talk. When you have finished, ask yourselves, what did
the listener do that made it easier for you to talk? And conversely, was there anything the
listener did that put the speaker off? If you do this simple exercise, you will learn a lot about
listening . . . and probably find out a few surprising things about the speaker too.
Eye contact is very important. It is probably okay for us to look away sometimes when
we are speaking. When we are listening, however, eye contact is critical. If a client seeks eye
contact with us whilst they are talking, but we are looking out of the window, the clear mes-
sage the client will get is that we are bored. It is almost impossible to look at a watch whilst
listening without at the same time conveying boredom. As well as eye contact during listen-
ing, we can support a speaker by nodding, and saying encouraging things, such as ‘I see’ or
‘that’s helpful’, or even those funny little words that we all use that are in no dictionary and
are really hard to spell such as ‘mmm’ and ‘aha’. Laughing at the appropriate time is really
supportive, but smiling at the wrong time can be really off-putting. Our posture is important
as well and will be affected by the room set-up. People often ask about the use of a computer
or taking notes. It is likely that these are best left to when the client has gone, but if we feel it
necessary, then all we have to do is ask the client’s permission.
This is probably the best time in this chapter to think about physical contact (Figure 2.3).
As veterinary professionals, should we touch our clients? We spoke earlier about shaking
hands, but what I am thinking about here is how to comfort an emotional client, and in
particular should you hug them or place a reassuring hand on their shoulder, arm, back,
hand or knee? Of all the sections in this book, if not this chapter, how you comfort upset
clients has to be matched to your own personality and governed by what you are comfort-
able with. There are no rules. However, some people do say you should never touch a client

Figure 2.3 Physical contact.

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36 Handbook of Veterinary Communication Skills

for fear of being sued. Whilst I see the logic, I do not like rules that are made up to try and
prevent what are extremely rare occurrences, being applied to everyday practice. Nor am I
going to say the converse – you must touch an upset client. That is clearly stupid. However,
you may feel with a particular client that some physical contact at a time of high emotion is
appropriate. Clearly, it can be easier to interact this way with a client you have known for
some time. But, even for someone you have met for the first time, a hand rested on the upper
forearm can be appropriate. Done well, not only will this help convey your empathy, but it
can help the client at a difficult time, when sometimes there are no words to be said. And
also, I firmly believe that for some people, and here I am thinking about you, the veterinary
professional, such emotional consultations can offer the greatest professional satisfaction.
Some of the most satisfying consultations can be those where we have been involved in the
life and death of an animal, sometimes over several years, have got to know the client, and
been able to, in some small way, help them through the death of their animal, especially if
this was a euthanasia. So, to summarize physical contact, there are no rules, and above all
stay true to yourself. It is clearly not compulsory, but equally I do not think it should be
banned, and where appropriate can have a positive impact on clients and vets alike.
When we communicate, we do so not just by our words but by our body language. What
is really amazing is that when, as listeners, we receive conflicting information (such as when
words say one thing, but body language says something else), we tend to pay more attention
to the body language. So, if we are listening to someone and saying all the right things, but
our body language says we are bored and disinterested, that is the impression our clients are
likely to go away with. This highlights the power of our body language. To summarize this
section, some people think of listening as a passive process. But it is not, or at least it should
not be. Active listening promotes the gathering of information, and that is what a large part
of a good consultation is about (see Chapter 1 for more information on active listening).

Developing rapport
Rapport means a harmonious relationship. It implies a connection between people, and
moves the consultation away from just the exchange of facts, to a true professional rela-
tionship. One definition for rapport is camaraderie. I like that. It suggests the vet and the
client are in this together. It puts us on the same side.
There are many ways to achieve this camaraderie but perhaps the most important is em-
pathy. In the medical consultation it has been described as ‘appreciation of the patient’s
emotions and expression of that awareness to the patient’ (Stepien & Baernstein 2006). Em-
pathy therefore implies not only a personal recognition of how a client may be feeling but
letting the client know of our awareness. This can be summarized by the simple phrase ‘I
can see you are very upset’. I suspect empathy is where many of the boxes of chocolates
and thank you cards come from. We can show empathy for lots of things. For the difficult
financial market our clients may be working in. For the difficult decision we have just asked
them to make. For the bad news we have just given them. For the size of the bill they have
just received. Even for the fact they are angry. If we show empathy, research in medical prac-
tice suggests that our clients will be more satisfied and more likely to adhere to treatments
(Haslam 2007). Unfortunately, other research in medicine suggests that for many physicians,
empathy becomes eroded over time. I guess this is something many of us can empathize
with. But it is something to be guarded against.
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Chapter 2 A framework for the veterinary consultation 37

However, simply showing empathy is not enough. We must also, wherever possible, pro-
vide our clients with the support they need to get through what are often very difficult
situations. These can be very practical offers of help such as an advice leaflet, or a sugges-
tion they phone back later if they have any further questions. One of the scenarios we ask
our students to do is to tell an owner their kitten died under anaesthesia for routine neu-
tering. Clearly, this can raise a lot of emotions in the client. But what this particular client
is concerned about is how to tell his young daughter for whom the kitten was bought. This
scenario resolves best when the student recognizes and acknowledges how difficult this sit-
uation is for the owner, and then provides a practical solution by offering to speak to their
daughter with them. Empathy requires us to acknowledge our client’s predicament, to show
them that we understand and to provide practical solutions where possible.

Involving the client

The old way to practise medicine essentially centred on the health care professional. They
knew best. Patients simply answered what they were asked, listened to what they were told,
and followed instructions. There is now clear evidence that satisfaction and clinical outcome
improve when the consultation revolves around the client and patient rather than around the
health care professional (Abood 2007). We must aim to involve our clients in the decision-
making process, and show that they themselves, their animals and their concerns are central
to the consultation at all times.

Involving the animal

There is not an owner on the planet who does not appreciate it when a vet acknowledges
their animals appropriately. There is almost always something positive and truthful that can
be said. We should ignore the client’s animal at our peril. I guess, as workers in the animal
health industry, we tend to be quite good at this.

THE PHYSICAL EXAMINATION

In the model, the physical examination is sandwiched between gathering and giving infor-
mation. Clearly, as we become more efficient, then we will start to merge these two processes.
But we must never let the physical examination interfere with our communication. Clients
may feel they are not being listened to if we are also examining a leg. We just need to explain
to them what is happening. However, we should leave some time in the consultation for just
communicating with our client. It is part of making them feel special and important, and
will really help build up a good working relationship with them.

CLOSING THE CONSULTATION

The end of another consultation has arrived. Now is the time to make sure we are all singing
from the same song sheet. We can achieve this through careful summarizing. At this stage
we, as the professional, as well as our clients, need to be sure of our ongoing responsi-
bilities. This includes what to do if the agreed plan is not working, and when and how
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38 Handbook of Veterinary Communication Skills

our client should seek help. Just before we finish, we should check again that the client is
happy with the outcome and ask if everything has been covered. ‘Have I missed anything?’
is my favourite question. I know this may raise some concerns about clients saying, ‘Oh
yes, whilst I am here, I did notice that . . .’. But if we established all the owner’s concerns at
the beginning of the consult, this is very unlikely. And it can be very satisfying when they
say, ‘No, thank you, that is everything’. Finally, it only remains to thank the client and say
goodbye . . . and then it all starts again with the next one.

SUMMARY
Some people raise concerns that applying such a model as this will lead to impossibly long
consultations. However, the evidence from our medical colleagues is that good communica-
tion developed within such frameworks is more efficient and does not take any extra time
(Marvel et al. 1998). Other people are concerned that following such an apparently strict
methodology will remove their individuality as communicators. However, that really is not
what this is about. There is endless scope within the model to develop our own style, and
it is very important we do. We are not actors, and we cannot deliver a script. We can, how-
ever, talk from the heart. And if we use a model like this one, we can break the consultation
down into manageable chunks, allowing us to evaluate our own consultation style in a logi-
cal framework, and improve our own performance. The evidence is clear – we can all learn
to consult better. And if we do, we will enjoy our jobs more, have more satisfied clients, and
last, but not least, have healthier patients.

REFERENCES
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of Internal Medicine 101(5):692–696.
Haslam N (2007) Humanising medical practice: the role of empathy. Medical Journal of Australia
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Marvel MK, Doherty WJ, Weiner E (1998) Medical interviewing by exemplary family physicians.
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