Thanks. Thank you for that kind introduction. We'll try not to argue too much while we're delivering the presentation.
Yes, yes, I just wanted to say that I've been running the communications training programme now for about 1314 years, and this was introduced because there was a problem with communication and the development of claims and complaints, but we now offer this service to practises as a, as a whole. And I think what we need to consider when we are communicating with our clients is that what are we really seeking to achieve. I think there's a great tendency to believe that just because we We speak, we speak English, we speak the language, some of us better than others, that, that is all part of communicating, but there's a difference between, you know, being a good communicator down in the pub versus somebody who's a good communicator on the yard or in the consulting room or in the in the stable block or or whatever.
So I think the first thing to do is to consider what it is we're seeking to achieve by being, being better communicators. And we know that there is a more effective interaction with clients. There's research to to back this up and we can end up with much healthier animals and improved levels of compliance and concordance which hopefully we're going to talk about a little bit more detail as the presentation goes on.
And I think, I think as you said, Christine, the whole lot, the whole lot started really VDS's impact or our interest in this really was in trying to mitigate complaints and claims and we know that from looking at what comes across the desk at at VDS and I think that possibly Royal College, we can't speak for them, but they would also agree is that when we analyse complaints and claims, is that 80% of complaints have a An element of poor communication and, and of those 54% are due to a breakdown in in practise procedures. I don't know about you, Christine, but when we talk to groups of people, it's, it's often the, the most senior members in a practise who who need their knuckles wrapped in terms of not sticking to practise procedures. It can be and I think when we actually look at our claims, the senior members of practise, tend to have a slightly higher blip with regards to numbers of complaints against them, and there's nothing like a, a complaint to, you know, set the tone for the day.
It's very upsetting and it certainly has a laxative and emetic effect. There's no doubt at all, it can be very upsetting indeed. So I think when we, when it's, if you actually sit down and actually ask yourself, is in which circumstances do we, do we listen best?
And if you put yourself in the, in the, in the sort of position of being a client or a receiver of a good product or a good service, we tend, we tend still, I think, to buy from people that we like, you know, and if you're in the selling mode of selling a service, selling a product. You have to sell yourself and then you sell what you're selling. And I know there are quite a number of equine practitioners out there this evening listening.
And we all know that when it comes to goodwill in inverted commas, that is very much attributed to the individual, as much as the practise. And so it's very, very important as part of our, of our communication and we look at this the model a bit later, is that it's very, very important. And to use those communication skills to develop a rapport with the other person.
And part of that is when, when, as a listener, when we're relaxed, if we're interested, and above all, if we feel we're going to benefit from the process, people often say that. Everything, whether it's a service or a product, it has features, functions and benefits. The fact is that when we buy a service or a product, we, we are buying it for the benefit.
What can it do, what can it do for us? What can it do for our horse? What can it do for our, our cat and dog?
And so if we are selling anything, whether it's a service or a product, we must make sure we get the message across about, about the benefit. Christine, did you want to say something about when, when we, when we understand what is being said in terms of coming in using appropriate language? I think we might just tackle that a little bit later on because it's very important.
That we do use appropriate language, but also that we check our clients understanding and hopefully we're going to give some tips further along in the presentation on phrases that we can actually use. OK, I think if you look at the last line on this particular slide it. If you analyse what you do say in a conversation, the majority of what is said is either to gain or impart information, and that's what communication is, is all about.
I slipped the slide in here from a personal point of view, and as much as I now have, this is a personal sort of, not a personal mission, but I, I now have 6 grandchildren and 3 on the way, and it struck it struck me that it's probably about 2 or 3 years before children actually say anything intelligent. And I think we could learn a huge amount from our children in as much as that we as practitioners, we must listen carefully before we can talk to those who understand us. So to understand where the client is coming from, you have to listen.
We, we, we are born with, two ears and one mouth, but my experience is that we often use them in the inverse ratio. We, we, we talk too much and don't listen. And a lot of the time when we are supposedly listening, we're actually waiting for an opportunity to come in and say what we want to say.
OK, so communication is certainly part of everything we do. And one thing we tend to think of communication very much as an art, but it actually is part of clinical competence and it's part of clinical competence along with knowledge, the physical examination, and problem solving. And so it can affect everything we do.
So there's no sense in being a very good communicator if we don't have the background excellence and knowledge to back up those skills. The other thing is that we tend to, we tend to think that we can communicate, and we all have a certain level of communication. But there is no ceiling to communication skills, and it is a series of learned skills.
And I think the best way that I like to think about it is that we wouldn't watch Roger Federer out and play some tennis and think that we can then go out and do exactly the same unless we analyse what those skills are, look at our own level and try to put those skills back in place. We're not going to actually improve, which is why we're trying to look at some of these skills today because it's that which will help to move our communication skills up to a certain level. I don't know how many people, Christine would be familiar with this particular model, but maybe you'd like to talk us through this because I know that probably if there are some recent graduates out there.
That they will have seen this, this model maybe as the Nuva model or whatever other title it might be given, but I think once you put a structure on something, then you can start to believe that it is a skill rather than an art. And actually, if you subdivide this model, there are, believe it or not, about 50 skills, and we obviously don't have time today to go into all 50. We will pick out only a few of them, but part of this model and also gives some latitude for style and personality.
So it's not meant to be followed slavishly. But if we find ourselves in a situation where we're not getting the outcome that we would like, if we start to think about the skills that belong to each of these headings, this can hopefully lead to a far better, far better outcome. And we break the whole consultation into preparation, initiating the consultation and gathering this whole area of explanation and planning and closing the consultation, while we have two threads down each side that run through the whole of the consultation.
And this guide has been used for some time within each of the veterinary schools within the UK and in Ireland as early as 2001. So it's been used for quite some time and hopefully we can start with initiating the consultation and gathering information. I think before we leave this, I think I'd like to draw people's attention to the right, the right hand vertical bar linking back to what we said before, that every, every time we meet with a client or if you happen to be a practise owner, every time your, your receptionist or one of your assistants has an interaction, communication with the client, it's an opportunity to build that relationship with the, with the client.
So there's there's a lot going on there, interestingly enough, Christian, I think I'm right in saying that when the doctors The medics, human medics developed this in the first place. They didn't have preparation there as part of their communication skills model, but they do now. That's certainly, certainly correct because this model is based on a model called the Calgary Cambridge guide, and it was with the blessing of the medics in conjunction with each of the schools and the Royal College that we developed our own meal model and they certainly I have preparation in place, very, very important key area that can often be overlooked.
I think the go ahead, Christine, sorry. No, I was just going to say that if we look at the very start of the consultation, this initiating the consultation and gathering information, these two areas can be very blurred. And, and that moves me on to introductions.
And this is an area that I think appears very straightforward and it's interesting to know what our audience think about this, because I just like to ask the following question how many vets do not introduce themselves? Is it 23%, 30%, 49%, 72%, or 80%? OK, I've just launched that poll for everybody, so you can cast your votes just by selecting the answer that you need.
If you're on a tablet, iPad, Android device, you should be able to select by just touching on the screen. If that won't let you do, just pop your answer into the question box, and we'll have a look. Nearly everybody's, .
Voted we shall give everybody 3 more seconds. I'm gonna be very harsh and close the poll. OK, and I shall share the results and I shall read them out because I don't think you guys can see those results, can you, Jeff?
So I can't see them. I can. So that you'd like to talk to Christian and I chip in because I, I I can't see them.
OK, well, 23% 3% of our audience thought that the answer was 23%, 11% of the audience thought it was 30%, 27% of the audience thought it was 49%. The largest contingency at 32% thought the answer was 72% and 28% of the audience thought it was 80%, and the actual answer is 80%, which is very, very interesting indeed. It's one of the most overlooked areas, that we tend to see in practise and both Jeff and I have watched many consultations now, and it, it really doesn't happen.
And we're not just talking about saying hello and greeting the client it's actually seeing who you are, but also your role in the practise. And I think Jeff, you've got quite an interesting story about when you were in practise and some confusion. It's in my 2nd practise and I was in a mixed practise in Somerset and my boss was quite chuffed one day when he came back into the office.
And said these are, well, the receptionist came into the office and said whoever clients they were wanted to see Mr. Bridges. So my boss put on his white coat or wore white coats in those days and tottled down to see the clients, quite chuffed that he'd never seen them before, and they were my regular clients, and they, they just took one look at him and they said, Well, we've we've come in to see Mr.
Bridges, and he said, I am Mr. Bridges, and the client said, You're not. We we always see Mr.
Bridges and you're not Mr. Bridges. And I've been working in that practise for 4 years, but because I've never introduced myself to the clients at that stage, they just put two and two together, saw the name above the door in the brass plaque which said Mr.
Bridges and assumed that I, I was he, but that was my fault, and that was a, you know, a lesson that I learned. And so I think now as Christine said, it's very, very important to introduce something. The other thing it can do is that it, it forces in a nice way for The person you're dealing with to introduce themselves, give you, give you their name, and with a bit of luck, if you're, if you're working in equine practise, they might tell you their particular role on the yard if they're not the, if they're not the owner.
So I think it works, it works both ways and it's it serves to dispel any any confusion. OK, so we can move on to the side. OK, I think that what it's always good if you find so many people will go in with with sort of a very closed attitude and we know that if we actually get a better consultation, a better history, and believe it or not, a faster history, if we ask a nice open question sort of well, what seems With the problem today.
What can we do for you today rather than going in with a very, very closed question such as which which leg is he lame on or, you know, I hear he's coughing, is it an exercise. So closed I think would be familiar with the difference between, you know, an open and a closed question. So starting with this open question and then and then listening, I think we'll come to the listening bit a bit further on, Christine, won't we?
Yes, if we move to the next slide, I think it may be worthwhile just looking at that at this point in time because listening is a very key skill and something everybody seems to appreciate, but the reality is, you know, it can be, it could be a little bit different. And I'd like to move to our next polling question, which is how long before we interrupt the client's opening comments? Is it 18 seconds, 23 seconds, 42 seconds, or 64 seconds?
OK, so I've launched that poll for everyone to select their answer. Thanks, Wendy. It will be interesting to see the result of this because this is a question that we posed to our recent graduates when we run our recent graduate reunion seminars, and I'd be very interesting to try and compare how the polling pans out.
And this Christian, I think is after we asked that first question, whether it's hopefully an open question and the client is then starting to give us some history. It is indeed, it is indeed. It applies to that first, that first opening question, although it listening is very important throughout the whole of the consultation.
OK, so I'll just give everybody 2 more seconds to vote before I close the poll. There we go and share the results and I will mute myself. So Christine, you should be able to see and read those results out for us.
Yes, I will do. 40% of everybody, watching the screen voted for 18 seconds. 33% voted for.
23 seconds, 15% voted for 42 seconds, and 12% voted for 64 seconds. So I think this is a little bit lower than our recent grads. The correct answer is 18 seconds.
These days are newer graduates tend to, know that it's 18 seconds. Very interesting. Extremely, though there was a pilot also done at Nottingham University and it was coming in at 12 seconds.
Also, the medics, if you look at their statistics, they were coming in at 18 seconds before we actually interrupt as well. But with communication skills training, that was moving back to about 23 seconds. I just think that it's I'm not too sure how to interpret the results that we've got.
If 40% of people listening to us this evening know it's 18 seconds or thought it was 18 seconds. I, I hope that it's, it's, it's not them that interrupts after 18 seconds. I'm not too sure how to, how to interpret that.
I find that quite interesting because if we talk to a group of delegates in some of our seminars which we run. Everybody seems to think that interruption is a very important area. And when we actually watch individuals and carrying out a consultation skill with stimulated clients, it's one of the key areas that tends to come up all the time and we do see individuals interrupting quite dramatically.
But if we also look at completing the opening statements, 23% of clients complete the opening statement. And if you ask 100 vets if they're going to return to that initial statement, only 9% actually do. So the result is that many bits of information, including clinical information, as well as clients, thoughts and feelings and may actually get missed and the jigsaw then doesn't get put together and we can't often reach the right diagnosis because we haven't got the right amount of information there right at the right at the start.
I think this. I think the tendency, I think the tendency to interrupt is probably because, you know, clients come in with their particular agenda and we feel that we have our particular agenda. We feel that our time is probably important and we, we tend to hijack the consultation and try and take it in the direction that we want to take it in.
I think the I think the interesting thing is that when we tend to interrupt again it's we we can see this with research we tend to interrupt with a closed question and the problem is once we start to go down the road of closed questions too early in the consultation, it means we have to follow each closed question with another closed question. And the bind is forced away from the contribution from the client and often we're forced down a route, you know, prematurely and into diagnostic reasoning, you know, too, too, too early. I think, I think when it comes to comes to listening, we, we talk about this attentive or active listening, it's not just sufficient to actually hear what a client is saying.
You have to demonstrate that you are, that you are listening and you're taking it, taking it on board. And, and some of that really is, is sort of is, is a use of silent repetition, echoing what the client says is indicating that you're listening to what they're saying, paraphrasing, picking up on keywords, picking up on cues. I think there's there's a tendency as perhaps you become more confident in your, in your clinical life and your practise to share your thoughts because I, I don't suppose we have all the answers to all the questions that we were given and it will depend on the client you're dealing with, but Sharing your thoughts with, with, with the client, you know what I'm thinking at the moment is that this lameness could be due to this or whatever.
What I'm thinking is we may need to do a nerve block, we may need to take some radiographs. What I'm thinking is this cough could be X, Y, Y, and Z is all is all very important to show that you're actively Listening to a client and Christine body language, things like nodding, you know, it's very important. Very important, and that can actually overshadow and some of the verbal communication and being able to pick up on those cues can be quite difficult.
And if we pick up on a queue, the client doesn't necessarily know that we've done that. Unless we actually managed to reflect that back to the client. So as we've noticed something, we can actually say I've noticed that you've, that you've done this or I've, you know, you've mentioned that you're concerned about the the tail end and how this horse might be itching the tail area and to let the client know that you've picked up in these cues, particularly something somebody's mentioning things over and over again.
One of the key things we talk about, we use a few of these sort of acronyms is ICE, and ICE in communication parlance stands for ideas, concerns, expectations, and Just like the iceberg, I think probably about 10% of it is above the surface and 9/10 of it is hidden underneath the surface. Clients don't always show you exactly what their ideas, concerns, expectations are, unless you use other skills which we'll talk about tonight. But You know, it's very, very important that we elicit what the people's ideas and particularly their concerns are.
I often talk about my mother who was diagnosed with lymphoma, and because she'd known somebody else who'd been successfully treated with lymphoma. She wasn't particularly worried about the chemotherapy, as it happens, she should have been, but what she was worried about was was hair loss, and so the consultant, I think initially looked quite baffled, but until he actually addressed that particular issue and firstly said to her, look, Mrs. Little.
Unfortunately, you're probably going to lose all your hair. She couldn't then move on to accept the information she was being given about the chemotherapy. She kept on going back to this, this sort of problem with with hair loss, and I could see the consultant probably inwardly thinking, well, this is, this is totally irrational, but, but you have to address people's ideas, concerns, expectations before, before people can move on.
If we move a little bit further on as well, this whole area of trying to gather information, the traditional methods of taking history, we now teach our students to look at the disease, which is the biomedical perspective and also the client unease, which is ideas, concerns, their thoughts and their And their feelings. And because we're asking lots of open questions at the start, this information may come out in a in a fashion that's not particularly coordinated, and it's down to us as the professional to try and signpost and work through the information that we're actually getting. And you may say why do we need to look at both perspectives.
We, the answer is we may have a client, for example, who's presenting sign with the patient is joint problems, and our role is to diagnose and treat any underlying disease. However, the client's main concern may be the possibility of having that animal put down. There for the client's agenda may therefore concern putting more emphasis on the prognosis rather than the actual diagnosis.
So very important that we managed to weave both of these, both of these strands together. I think particularly in equine practise, Christine, where, where animals are meant to perform and and go to gym Carner's hunting, etc. Is that That may be quite high up on the client's agenda in terms of their unease versus the disease.
So we, we've got to address both of those sides. I forget who it was, but coined that nice phrase of dealing with the patient disease and the, the client unease at the same time. Yes, indeed.
And moving on to other skills, summarising, we tend to summarise throughout the consultation what we call internal summarising as well as summarising at the end. And this skill links very, very closely to listening and screening. If we're not listening, then we can actually pick up all the information and summarise that back to the client and the process of sum summarising.
Shows the client that you're listening, Jeff, I think you talked at the start about building the relationship. If the client believes we're listening, they're more likely to bond into what you're suggesting. The other important thing about the summarising is that it gives the client an opportunity to add in additional information that you might not have actually picked up.
And it also provides the vet with a little bit more thinking time and allows them to organise his or her thoughts and it helps recall information at a later, at a later stage. But the skill that I tend to think it works really well with is screening and Jeff, did you want to talk a little bit about that? Yeah, I think, I think I didn't do a huge amount of work, but on the work side of things, there was nothing more frustrating than you, me as a vet had finished the consultation to put the patient back in the cat box or back the dog back on the floor for the client to say, oh, by the way, his anal pharynculosis is is returned, or by the way, he's scratching.
So the idea of screening is that it, it goes with the summarising really as a skill, and it basically it's a deliberate checking with the client that you discussed all they wish to discuss by further open-ended inquiry. So you say he's lame, is there anything else? So you say he's coughing at exercise.
Is there anything else that you've, you've noticed? So he's got diarrhoea, is there anything else that you've noticed. So you shouldn't really get to the end of a consultation and be heading back towards your car or putting the animal back on the floor or going to shake hands with the client to find they actually then give you something else which starts a whole new 1015 minute consultation.
OK, I think a key area, Christine, that we, we find, isn't it is this whole aspect of of discussing the fee, key skills. It certainly is, and it doesn't really matter what type of practise you're in, it can certainly act as the trigger factor. And, you know, once the whole thorny issue of the fee is there, other areas tend to come out of the out of the woodwork.
And Jeff, did you want to talk a little bit about estimate and quotes? I think it's very important that if you are going to sort of start on embark on a course of treatment or going to hospitalise an animal horse or dog or cat, is the clients understand that if you're going to give them a price, they understand what it's for, that it is an estimate for the initial treatment, or if you're going to be quoting for a, say, a castration, that it's a definite quote because a quote is a is a binding figure, whereas an estimate is only as the words suggests, an estimate. Again, I think that one of the issues we, we find a lot of Christine, I think you'd agree, is that where the cost escalates, say, for a hospitalised equine or hospitalised dog or cat, and I think one of the nice things that we learned from somebody in one of our courses was that when they hospitalised a patient, they went through a whole lot of paperwork and they sort of promises to the client and and part of that promise was that they would keep the client informed on a Daily basis as to the ongoing cost.
So it seemed natural then to say, oh, and by the way, you know, Percy's doing very, very well indeed, and you know, we promised to keep you up to date with the cost. Well, the cost to date is, you know, 460 pounds and we're going to take some more scans tomorrow, so we're going to add an extra amount. Is that OK?
The other thing I've learned recently as well from people doing these courses is that If you, if you're going to embark on a course of treatment and you know yourself that once we get over the initial fire brigade treatment, that there's going to be a significant cost involved. I think you owe it to your client to tell them that that the 500 pounds or 400 pounds initial estimate for the first aid treatment and the first day's treatment. If, if we get over that, then we could be looking at another 2000 pounds.
I think, I think clients will understandably get quite upset if they feel they've been lured into a course of treatment, and they're suddenly faced with a large bill. This is when it comes, comes back on you. Yes, indeed.
Yeah, and talking about talking about consent, Christine, we have a, we have a question here, haven't we in terms of of of of of consent. Yes, another polling question. You must always have a consent form signed before putting an animal to sleep.
Yes, no, or depends. We should have put the odds on, shouldn't we? I'm watching a race.
OK, you've got 3 seconds. There we go, closing the poll, and I will share the results for you to read out again, Christine. Oh, very interesting indeed.
49% say yes, 13% say no, and 39% say Depends, very high proportion say yes, and I can understand why people say yes, but actually if we tend to look at the whole area of informed consent, Jeff, if you pass that on to the next slide, we can sort of have a look at this. I I was just gonna say that spots a deliberate mistake on this one as a prize for you must always have a consent from from science. It's how you can read something 3 or 4 times and get it wrong all part of communication.
So that might not have a question on the whole area is it it depends because what we're looking at is this magical word here that says informed consent. Certainly in an equine situation, we may find ourselves with an equine hospital very similar to small animal situation and it's more than likely consent forms will be signed, not just for euthanasia, but also for surgical procedures. But in ambulatory equine practise, I think this is less likely to happen and may even be nonexistent.
However, I think we would certainly BDS urge practitioners to think about carrying a ward of consent forms, certainly for such things as castration and euthanasia. However, if it is verbal consent, it's the informed that's the important issue. And I think all the more important that this information is recorded in the clinical notes.
We also see a situation in small animal practise where if we've got an animal on the table or it's a much loved pet, it's very difficult to you know, put out that and that consent form in front of the client under those situations and the key issue is shared decision making. This is really very, very important indeed the whole shared decision making. I think sometimes, Christine going back up what you said, you know, putting a consent form in front of a client who's already upset about losing a much loved horse or a much loved pet.
Is that it's some people would view it as almost signing that that animal's death warrant. I think that your point that you made is that, you know, to record it somewhere in the clinical notes, and I know there's some practises almost, will get, will get a consent from two people over the phone if they consents over the phone. I think, I think that's what we be, you know, belt and belt and braces.
I think this is happening more and more, is to have two individuals over the phone, but of course that's quite different when we're actually out in the field trying to deal with the patient. And before we actually look at explanation and planning, I just wanted to mention that it isn't just consent about the anaesthetic, but we do need to think about consent for surgical risk as well. I'm thinking particularly maybe in the small animal situation where you've got a collapsed, and py your patient with a pyometra and we need to discuss the risks that might be involved in that type of, in that type of surgery.
OK, you're happy to lead on the explanation and planning now that we've actually done the information gathering? Oh, yes. And on explanation and planning, very, very key.
This is the whole area where we do tend to get compliance from our, from our clients. And what I'd like to do is to start with one of the skills that's very, very important, and that is assess the client's starting point. Something we tend not to do in practise or think about.
I certainly, didn't when I was in practise because our clients will have a whole different area of knowledge and certainly, just because somebody's a doctor doesn't mean to say they're a doctor of medicine, they could be a doctor of philosophy and I think Jeff, you had quite an interesting story in practise where there was a fracture that was diagnosed. Yes, it could, it could, it could it could pertain to, but this happened to be a small animal, very small animal. It was a cat with a fractured femoral head, and the vet in question was a very keen orthopod, put the X-ray up on the viewer and explained to the client.
What a fracture looked like and this side was the normal side. This side you can see it isn't joined to that and that's what we call a fracture, and that we're going to have to operate and remove the femoral head, that's the top part of the bone, otherwise your cat's going to be permanently in discomfort or in pain. And the client took a few steps towards the X-ray viewer and said, and this symphocele separation will not heal of its own accord.
So the X-ray was, was swiftly whipped off the the viewer, and the client reassured that we had seen the, the symphocele separation, and the, the vet in question asked the client said, but you must have some medical knowledge spotting that, and he said, I, yes, I'm the orthopaedic consultant at Stepping Hill Hospital, but because he'd been a mister. The particular vet in question, you know, assumed that he had no medical knowledge. So, I think other other skills, Christine, that you often talk about diabetic patients and assessing the clients starting point.
Yes, I mean, just because somebody's not medically trained doesn't mean to say that they don't know a reasonable amount about their pet's condition. And certainly also in the large animal situation, we have some very knowledgeable farmers around. The other area is animals that have been hospitalised.
I'm thinking now of equine and small animal, and if a colleague is actually gone on holiday or is off. It's very nice to try and assess the starting point of that client. There's only so much information that can go down on the clinical notes and to say to somebody, you know, what is Mr.
Barclay told you so far? You know, where do you think we've got to at this particular point in time? Very, very key to know where to pitch the whole thing at.
And I think this starting point, something that struck me, Christine, after we put these slides together was that there can be, they can be. Quite a challenge for, say, a particularly maybe a young equine vet who hasn't come from an equine background who finds themselves in inverted commas isolated out on the yard somewhere, who may have fantastic clinical knowledge, but perhaps their, their, their whole concept of, of the equine world is, is very different, and I think it's no harm to So to bow to to clients superior knowledge when it comes to to breeding bloodstock, etc. And I think that you can, you can alienate people by trying to, trying to be the consummate professional who knows everything and no harm in in learning from the clients as well as we go along.
I think you never, you never stop learning about about any aspect of veterinary medicine. Moving on to chunking, chunking and checking. Yes, I mean, this is a phrase that we tend to use for delivering information in bite-size pieces, and there is a tendency for practitioners from whatever, area we practise in to deliver our information in huge chunks and clients can tend to glaze over a little bit.
And they tend not to take everything on board because they're overwhelmed with a vast amount of information. And I think this tends to come from the fact that most petitioners are very, very knowledgeable. We want to impart as much information as possible.
But unless we deliver it in bite size pieces, the client's not going to understand. And again, if we're delivering several bits of information. It's important to signpost that and say there are 3 pieces of information I want to discuss with you.
The first one is, and the second one is so that the client is aware that they're coming in and segmented pieces. Very important to check with the client, moving from one section to another section that they're happy to move on to the next bit of information. But Jeff, if you can just talk about the client's understanding because how do we actually check that that client is understood without necessarily being patronising.
OK, I seem to have gone away from do do do do. Whoops, OK. Something actually you mentioned there again, Christy, which I just looked ahead.
I don't think we've actually got a slide which talks about signposting, have we? But what you were doing there was doing a bit of signposting as well in terms of first I'm going to do this, first I'm going to do that. Another skill that perhaps we haven't got time to talk about tonight.
But going back to a particular question on In terms of how can we ensure the client's understood, because going back to one of the previous slides, what we are doing with all of our communication skills is trying to find out things from the client by asking them questions, which is part of the history taking and history gathering, and the other half really is giving information out to the clients. So we've already decided that some clients might be very experienced, equine owners. Some might not be.
Some might be the mother of a child who, who is very au fait with horses, but how, how can we understand the client's understood? And I suppose you could ask, you could ask the question, couldn't you, Christine? Do you, do you understand?
Which, which I guess could come across as being quite patronising. And I think the problem is, do you understand you're likely to get a yes or a no. And the majority of people these days are likely to say yes, but you can actually then see their faces completely glazing, glazing over the body language speaks for itself.
And if you don't, I think what happens certainly in maybe not so much an equine side because you're, I guess you're out on your own on the in the yard, but if it's in small animal, what I found is that The clients then go out and ask the receptionist what the vet was talking about because he or she's gone off on one of their particular interest happens to be, say, cardiology or ophthalmology, something quite complicated from the client's point of view. I think that to, to ask the question to ask the question of the, the client, sort of that, you know, you appreciate you've actually given them lots of information. Say, say it's a horse with with laminitis and not an experienced owner and you want to talk about the feed, you want to talk about medication, you want to talk about the farrier, and you're just trying to make sure that Clients understood.
I think it's useful to put the blame back on ourselves as well, to say, just to ensure I have explained it thoroughly, would you like to recap for me what you need to do between now and when I see you both, say, in a week's time. So that then I think when we've tried this with, you know, with, in reality with clients, they don't mind repeating it, repeating it back. It does, it does ensure that you've actually given the information and if you haven't, then it happens to be your fault.
Yes, indeed, indeed. And if we move on to the next slide of assessing individual information needs, something we tend not to do in practise, but it is very, very important indeed. People tend to take information in at different levels and everybody's needs can be quite different, depending on their emotional.
8 and also on their knowledge as as well. This can become very important when we're dealing with two clients at the same time and just trying to gauge how much the client wants to know, and it requires a high level of skills and balancing essential information with which to make a decision and the finer the finer detail. Within the communication sectors, it's still debatable on how we actually do that.
Do we have a direct approach you know, if it turns out to be something serious, are you the type of person who would like to know exactly what's going on with flow, or do we work in you with euphemisms and it can be quite tricky and we have to try and balance that but to try and gauge it to what the client wants and very, very important indeed. And also relating to the client's original concerns, if we haven't gathered their ideas, concerns and expectations, which Jeff talked about early on in the presentation, and then we're not going to be able to meet the needs of the client unless we actually meet those needs. We're not going to be able to get any degree of compliance or or concordance.
And Jeff, do you want to talk about making assumptions as well? I think, I think it's just very, very dangerous to actually assume that you know what the clients want in terms of a of a course of treatment. And I think if you've done the rest of the skills we've talked about up until now and you've elicited people's ideas, concerns, expectations, you're in a much better, much, much, much better position to make, you know, an accurate sort of shared decision with those clients.
And I think some of the skills really we talked about Christine, in terms of the shared decision making and some clients will, will, will actually ask you, well, what, what, what do you think? Mhm. And I think it's fair to actually give some guidance.
There is a concern within the profession that because we now teach students, that this share decision making process is absolutely key. They tend to say, here are your, options, and then they absolve all responsibility. It's.
Actually OK to say I have a preference for this particular type of, of, of, of treatment. And the key area is that once that client has made the final decision, you know, we don't disapprove of what they've actually decided because it's the whole discussion process leading up to that. That's the important, the important element.
And one area of shared decision making and that's absolutely key is this whole area of compliance and and cordance. And if you want to talk about that, Jeff, that would be lovely. Just Yeah, just just to say that really what we've been talking about up up until now is this whole aspect of bringing clients along with you and in the old days, I think that when professions were held in Much higher esteem than they are today, that when you bring clients along with the skills we've talked about, I would probably put these things around it the other way, and I would talk about the concordances first, which is basically one word for shared decision making, bring the client with you.
And then if you, if you convinced the client, answered all their their questions, addressed their ideas. It concerns, expectations. We need to put in some steps and some support mechanism to make sure we get this, this compliance as well.
And then certainly in the small animal world and probably applies across the board, equine as well, that often people, children are very good at telling you whether their parents have managed to actually stick to giving the, giving the treatment, give The medication, you get a much better honest answer from the compliance point of view from from children than you than you do from adults. I think adults learn to sort of fudge it as they as they get a bit older, but this is quite a busy slide, which, which really talks about, I suppose, the, the bottom right hand segment, bottom right hand sort of oblong there. Means that if you have high levels of concordance, which means you get this shared decision making and the client sticks with the recommendation, is that you, you end up with this high optimum level of, of happier clients, healthier pets, and higher profits.
I think the one thing, Christine, that often is forgotten in this is that in this shared decision making, it is a contract, if you like, with the client and that I think because we expect clients to stick with what we've agreed on the yard in the consulting room, we must also stick with that too, and, and this comes back to this whole aspect of keeping clients fully up to date with the ongoing costs. So I think it's an agreement that works, works both ways, and you can see the opposite diagonal one there if you have low levels of concordance, low levels of compliance, well, You're going to, you're going to get this poor adherence to a sort of a designated or an advised treatment regime and or an undertaking of, of medicine. So it's all about this concordance and and compliance and optimising those, optimising those levels.
And certainly a key skill because financially, it can make a tremendous, a tremendous difference. Moving on to, negotiating an acceptable plan with the client, we do need to think about offering choices. We need to check that the client is happy with the way forward.
And we do need to check that the client is actually on, on board. So Jeff, did you want to just move that on with that slide just so that our audience can see those key areas that we need to think about before we actually move on with, with a plan. There are many other skills associated with explanation and planning, but I'd like to just cover this whole area of closing the consultation before we leave some of the some of the skills and safety netting and the final summary are absolutely key.
Safety netting by that we mean checking that the client knows what to do, should things actually go wrong, if there's a problem with the dressing or something they're unhappy with, what they should do practically, what they should do in terms of being able to contact somebody and should there be a problem out of out of hours. And we talked about these sort of constant threads. In other words, we've talked about these key skills, these open questions, closed questions, but this constant thread, and I think this is hugely important in terms of building the relationship.
We all know the clients have a, have an option to use other vets, other practises, and they will stick with us because they, they, they like what we do. They like us as individuals. And I think that the way of building this relationship is going back to these key areas of Acknowledging the client's concerns.
And these, these may, you may be able to read it in the client's face or in some, some words they say, some cues when you're sort of closing the consultation. I can see that you're, you're not entirely happy with it. Can, can you share with me what's still worrying you?
And not to be judgmental. Christian, we haven't talked about empathy, but of all the skills I think that people could, could learn this evening, probably no harm in leaving it to last to leave people with this important thing about, about empathy and, and, and what, what empathy is. Well well, empathy actually is hearing, seeing, feeling what the client is going through and being able to reflect that, being able to reflect that back.
And it's key no matter of what we're dealing with, but it's particularly important if we're dealing with emotion, if we're dealing with, as you've highlighted here, anger, which you can actually see somebody who's angry, you can actually see somebody who's upset. Sometimes with guilty statements, we've got to rely on what we actually, on what we actually hear. But it's one thing understanding that unless we start to reflect that back to the client.
Indicating the correct emotion and reflecting it with the correct intensity and the client's not going to know that we have taken on board their particular emotions and using the right tone is absolutely key. And I think, Jeff, you actually gave some phrases there. I can see how upsetting this is for you.
We do need to be careful using the word I understand. Because you may be met with somebody saying, of course you can't understand. You don't know what I've been going through.
You don't know what I've got to deal with. But if we tend to qualify that by saying I understand that this can be quite a difficult decision for you, that is a much easier thing for the client to take on board. And if you notice then as well, the tone in the voice is quite different in that particular situation.
And I think some people struggle and worry about using the word understand in the right context, but as you quite rightly say, it's all about senses, so I hear, I feel, I see that you're upset. I hear that you're very angry. I, I, I can sense that, you know, there's something you're still worried about, but so using those sensors rather than understand is probably a it could be it could be a safer safer approach.
I forgot that we didn't have signposting. I did, I did. I forgot.
So we've op that in for everybody. Just, just basically if whether it's giving information, whether it's a plan that you're going to take a scan of a leg going do some maybe an investigation of a lameness and you want to trot the trot the horse up, you then want to do a nerve block, you want to take radiographs. I think to actually signpost to the client, the structure of the consultation and or treatment, I think that that the client then you're taking the client on a, on a, on a journey, and they understand why you're, why you're then progressing from one thing to the other.
They may not understand why with a small animal you're looking in its eye is because it's come in because it's got a heart problem. You, you know, you need to explain to a client you're doing a full thorough clinical examination. So walking the client through the through the structure of the consultation, history taking or explanation and planning seems to be like an excellent idea.
We have one last last slide, I think, to end on, Christian, anybody knows who this is, but this is George Bernard Shaw, who basically said the single biggest problem with communication is the illusion that it has taken place. And and how many times do we, do we find ourselves saying to, to a client or a family member or a member of the practise, look, I thought I'd, I thought I'd told you that. I thought we'd discussed that.
Hopefully we've given some tips this evening, in particular on that aspect of finding out whether you have have actually got your message across. And I don't know whether you want to say any closing words, Christine. I'm looking at the clock and it's just about 3 minutes to 9.
Yes, I'm just conscious that there may be some questions that some of our audience would like to ask. It has been quite a brief run through. As I said before, there are about 53 skills and when We work with practise teams, we, we do tend to take some of those skills and we watch individuals working with educational role players, because one thing about these skills is nothing like putting them into into practise and and working with those particular skills, but hopefully we've given you a bit of a flavour tonight.
Thank you both very much for that presentation. We have got a couple of questions coming in, but if anybody has any questions or comments, then feel free to type them into the question box. And I'm sure we will get through them if, if, if we have time.
So let me have a look. Mary has said, thank you very much, and the cartoons were brilliant. Is that the best part?
And, Becky has said thanks, a very enjoyable webinar. Good, thank you. And, a question here, bear with me while I make the question box a bit bigger.
Ellen has asked how can verbal consent be proofed? I think the best way for verbal consent to be to be proved is to make sure that you add it to your clinical notes to say that that consent has actually been discussed. But the process, part of the process involves checking the client's understanding.
So once you've discussed the way forward, it's using phrases such as Jeff mentioned earlier, you know, we've gone through quite a bit of information, just to make sure that I've explained myself adequately and did you want to recap and everything that we've gone through so if you've got a process that you tend to use and also the fact that you record that information is absolutely key. Jeff, did you want to add anything to that? No, I'm not too sure whether it's somebody who's an equine practise where you're out on your own in a yard on your own, but I know there's some practises that say are small animal where a client is phoning up, they will have a protocol where they'll say, well, look, I'd just like you to also, maybe just have a chat with my colleague who'd also like to hear your decision over the phone, and you have to, you have a witness.
I know some practises do that. Some people may find that a little bit, a little bit over the top, but, but I think that some practises will certainly do that, and they will get the verbal permission from two people. But as Christine said, vital that it's it's recorded on the, on the clinical, the clinical history.
And that can certainly be done afterwards when you're back from doing a yard visit or you're doing something out on the field. Yeah. Thank you.
Few more questions, and, Julie has said, a thought provoking webinar, lots to think about even after 30 years as a vet nurse. Thank you. Good.
Oh, that's good. Because on on that particular sub-subject, Wendy, there is this, as Christine alluded to, these 50 key skills and the Nuvas guide, and, and I think I'd challenge anybody, whether they're 30 years qualified, 20 years, 40 years qualified to read that and not actually ask yourself the question, you know, whether I closed the consultation adequately, whether I am empathic enough. There are always things, I think, and as Christine, you've often said, there's no ceiling, is there, to communication skills, we can keep on improving them certainly isn't and .
We all have something to learn. We've all got personality. We've all got a great deal of skills that we use out there.
And it's not trying to teach MD from scratch, but it's to build on the skills that people are already using and to to try and use them in slightly different ways. Thank you. Just a, question here from Giles, I think it is.
I said, do you have concerns about the length of some appointments in that there isn't much time for listening sometimes without interruption. Oh, that's very, very interesting. We've not done a great deal of research within the veterinary profession, certainly within the medical profession, but by using some of these skills and in particular listening, we can actually shorten the interaction.
And Jeff and I, do a lot of what we call simul interactions where we have a veterinary surgeon or a nurse working with a simulated client and often we will time that . Interaction and then we will redo it, and put in some of these skills that we've been talking about listening being one of them. And the very interesting thing is when you actually time it on the second occasion, we, we find we've got a much quicker interaction.
Because we're getting all the information out upfront, like a menu, and then we can signposts and say, what I'd like to do today is, is to look at the problem with this patient's eye and because that's obviously the thing that's concerning both of us. Most of all, and then we will come back and look at the skin towards the end of the consultation or maybe even on a separate, on a separate visit, but it's getting that menu out up front. It tends to be a much quicker way of, of addressing concerns.
I think it's quite scary to begin with Christianism if people have been used to going through almost like a list in their head about is he doing this, yes, no, is he doing that? Yes, no, of of switching it and almost handing over the stage to the client and allowing them to come back with with a free range. But as you say, by getting all the information up upfront, it makes for a shorter, more effective, more efficient consultation.
It does. It does indeed. Thank you both.
We've had a comment here. Your presentations are always brilliant. Thank you very much.
You mentioned that you can help individual practises. Can you tell us how you do this? This is somebody actually who's in Spain at the moment.
Right. Well, we do help individual practises. They tend to be.
Members of, of VDS, whether we would have any remit, to help practises abroad, but the best thing to do is to contact by email is M Baxter, B A X T E R at vet. Death.co.uk.
OK, I'll put that email address into the chat box for people in case they didn't write that down. Can I answer the question in a different way, Wendy? In, in that from a practical point of view, what, what we do, and it, it's often the case that people People who come say and listen to a webinar, the people who are very, very keen, and they go back into their practises and they're hopefully enthused about a clinical talk or whatever, and people think, oh, you know, they'll they'll calm down after a week or so and and we'll grind them back down again, but When we go into actually work with individual practises, what we can do is we can take in educational role players, we can get the whole practise working, we can, we can walk a client through the practise in terms of communicating with the receptionist, communicating with the vet.
Everybody's put through the training at the same time and It's, you, you can, you can only learn a certain amount by listening to somebody watching a webinar, but there's nothing like being put in front of a, of a role player and having to deal with an upset client, having to deal with an angry client, having to deal with somebody who's got certain issues, because that changes people's behaviour. So that that's how we actually work at at practise level if that answers the question in a different way. And can I just say it certainly does change behaviour because there's a wealth of research from the medical profession.
But there was some research carried out a few years ago by Christine Latham at Cambridge vet school and we had 3 cohorts, of, of students, one who had no communication skills training, one cohort who had it in lecture format, and one who who were going through this experiential learning where we work with actors. And there was actually a slight improvement between the second group and the first group, but very little difference, but a vast improvement with those who were actually doing the experiential learning and we were getting some changes in behaviour there. Brilliant.
Thank you both very much. I think we have actually gone through all the questions, excuse me, that have come through a moment. If anybody has any questions, type them in quickly, and we can get to them.
I'd just like to, thank both speakers for, what, as always, is a great presentation. Also to thank MSD Animal Health for sponsoring this webinar, and do remember this is a series of webinars. So the next webinar in the this equine series is the 29th of October 8 p.m.
Again. And that is scanning horizons for emerging infectious disease threats to UK horses. So make sure you signed up for that.
This webinar has been recorded as well, so the recording will be available to watch as soon as it's been edited and uploaded. So make sure that you check, keep an eye on your inbox to we should email you when the recordings available. So you will be able to go back, watch this again, and also, you'll be able to get your attendance certificates there.
So I'll just have a quick look to see if there's any more questions. Oh, yes, someone's been quick on, quick on my keyboard here before I let you go. .
Just a moment, the new vax guide was mentioned. Is this something that can be accessed by all? The There is the NAC website, and I'm not certain how easy it is to access that.
Jeff, are you aware of any place else? I think, I think if you go on to the Nuva website, which stands for the National Unit for the Advancement of Veterinary Communication Skills, the last time I went on the Nuvax website, I think it diverted you to another website where the guide was available for downloading. Isn't that right, Christine?
Yes, I think you're right. I think you are right, yes. So if you start off like.
I was going to say alternatively, there are booklets that have the new vex guide inside it which we have published and certainly possibly going through that email address that we gave out earlier. You should be able to access it via Marina Baxter. I think there is a small charge associated for the production of, those, and, but we can certainly, you know, possibly, get involved in, distributing the odd one of those.
Brilliant, thank you very much.
