Transcript
Speaker: Welcome back to another episode of the North American Veterinary Anesthesia Society podcast. I'm your host, Dr. Bonnie Gatton, and this is the show where we dive deep into all things veterinary anesthesia, breaking down complex topics and providing practical insights to help veterinary professionals improve patient care.
Speaker: Our goal with this podcast is to advance and improve the safe administration of anesthesia and analgesia to all animals. Today, we're tackling a topic that every veterinarian and veterinary technician has faced at some point, communicating with pet owners about anesthesia.
Speaker: While anesthesia is an essential part of veterinary medicine, allowing pets to receive life-saving or life-altering care, it's also a huge source of concern for pet owners.
Speaker: Whether it's addressing general anxieties, managing cost discussions, or navigating the difficult conversations that come with unexpected adverse outcomes, clear and compassionate communication is key.
Speaker: But before we get started, we need to thank our sponsor of this podcast, DECRA. Not only do they help us at the NavVest podcast to provide continuing education to all you gas passers with these monthly episodes, but they also provide a range of high quality anesthesia related products.
Speaker: To check them out, please visit www.decra-us.com. Also, if you're not yet a member of the North American Veterinary Anesthesia Society, make it your personal goal to join this year.
Speaker: Navis membership comes with a range of benefits, including access to continuing education events, focus on anesthesia and pain management, informative blog posts, fireside chats with board certified anesthesiologists and specialty technicians, and so much more.
Speaker: Also, registration for the Navas Springs Symposium is now open. This is a free virtual event featuring a range of speakers and panel discussions, and it's happening on May 3rd and May 4th of this year.
Speaker: If any of this sounds interesting to you visit www.mynavas.org to take your anesthesia expertise to the next level. Back to our episode, I'm reminded of a particularly tough conversation I had with a pet owner recently about their elderly dog, Bentley, who really needed a dental procedure.
Speaker: Bentley had never had an anesthetic procedure after being neutered at a young age, mostly over owner anxiety over anesthesia. However, Bentley was now exhibiting signs of oral pain and he had horrible halitosis.
Speaker: Multiple teeth had root exposure and were actively trying to fall out during the examination. It was clear that Bentley would feel better after receiving extensive oral care.
Speaker: However, Bentley had a recently diagnosed heart murmur and his owner was terrified that he wouldn't wake up from anesthesia. No matter how much I explained the safety protocols we had in place, the advanced monitoring we used, and the anesthetic plan that would be tailored specifically for Bentley, his owner just kept saying, I don't know if I could take that risk.
Speaker: It was a conversation filled with fear of uncertainty, and it reminded me of how challenging, but also how important it is to help pet owners feel informed and supported when making these decisions.
Speaker: To help us explore this topic, I'm thrilled to welcome back a returning guest, Dr. Eric Hoffmeister. Dr. Hoffmeister is a board-certified veterinary anesthesiologist and a professor of veterinary anesthesia at Auburn University College of Veterinary Medicine.
Speaker: His research interests include scholarship of teaching and learning, as well as evidence-based decision-making, and he's conducted some fascinating research into evidence-based methods of effectively communicating regarding anesthesia with pet owners.
Speaker: Together, we'll discuss how to nimbly handle conversations with pet owners who are risk adverse, what the evidence tells us about effectively communicating to pet owners about anesthetic risk, and how to handle difficult conversations when adverse events occur under anesthesia.
Speaker: So stay tuned for another exciting episode of the Navas podcast.
Speaker: Thank you so much for coming back on the podcast. You are our first repeated guest oh wow on the podcast ever. So what I would like for you to do is just remind our listeners, you know, who you are.
Speaker: Tell us a little bit about your background and your experience with veterinary anesthesia and maybe also your experience specifically with client communications, since that's going to be our topic for today.
Speaker: Yeah, for sure. Well, I'm Eric Hoffmeister. I grew up in Los Angeles and went to undergrad vet school at Washington State University. did an internship in private practice back in Southern California.
Speaker: Did my residency in anesthesia at the University of Georgia. Stayed on faculty there for a while. Then I went out to Midwestern University in Phoenix and was a department chair there. And then I moved out here to Auburn, where I've been on faculty for about six years now.
Speaker: So I'm a Board-certified anesthesiologist, mostly academician, but I've had a fair amount of experience in private practice, partly from my internship, partly i did ER moonlighting when I was a resident and early faculty. So I had a lot of conversations with clients that I'm sure you all would would recognize.
Speaker: My experience with communication largely started at Midwestern University. There's a pretty robust communication curriculum there each semester of the preclinical content.
Speaker: So they do the simulated patients with actors and, you know, use all the the lingo like signposting and reflective listening and pause for you know questions.
Speaker: So I learned all the proper communication techniques there and then here at Auburn have been involved in the communication course, specifically talking about medical error and patient safety culture, how to talk to people about medical errors, both in your team and with your clients.
Speaker: And then I've been talking about communicating two clients about anesthesia for a while. It's something that I always make sure to talk to the students on rotation with me about, because I feel like it's one of those things that that we never talk about, that it doesn't get discussed a lot. And, you know, I think that it's something that we need to spend more time thinking about.
Speaker: Yeah, I have two comments on this myself. So the first one is that the very first experience I had specifically with communication had to do with when I was already like a faculty at academia.
Speaker: I graduated vet school a long time ago, and it was definitely not emphasized in my curriculum really hardly at all. No, not at all. Yeah, we we didn't learn this stuff.
Speaker: And it was definitely not spoken about in my anesthesia residency in particular, because quite frankly, all the anesthesia residencies are currently, at least from my understanding, are in academia.
Speaker: And the anesthesia team gets very like shaded from everybody else. Like you don't really have ah an open front or an open communication with clients really ah hardly at all. Your function is really the anesthesia department is to just like make the hospital function and serve the needs of the hospital as opposed to serving the needs of like the clients that you're interfacing.
Speaker: So it wasn't until I was a faculty where I got an opportunity to go take a specific veterinary communication course that I even got any kind of communication training, upon which I realized I was woefully untrained
Speaker: in communicating in general. And I remember the first time i was asked to communicate with an actor. And it was a it was like a very I don't know how to put it I don't want to say life altering, but it was definitely an experience that I will not forget.
Speaker: So it's really great that you are involved with helping students like learn this particular skill, because I think I agree with you. It's really not a skill that is well taught in general.
Speaker: Yeah, you're totally right. In academic settings, that there's a big big disconnect between us and the client's And I've tried to bridge that here. I actually proposed a plan where the anesthesia students would call the clients the night before because they get assigned their case the night before.
Speaker: Call them the night before and say, hey, I'm Josh. I'm going to be helping with anesthesia on your pet tomorrow. What can I talk to you about with anesthesia? And obviously we would, you know, coach them about what to say. And if they had problems, then, you know, they could escalate it to talking to the resident or anesthesiologist.
Speaker: And the surgeons put a hard no on that. Wow. but Why? do you have any idea why? They do not want anyone talking to the clients, but them. all right.
Speaker: Well, in your opinion, why is effective communication about anesthesia so critical in veterinary medicine? You know, why were you pushing these students to be contacting these owners the night before?
Speaker: I mean, I think that it's it's self-evident that clients are interested in this and care about it. We did a survey recently where we asked veterinarians about different things that they thought that new graduates needed to know and be able to do.
Speaker: And something like 99% of respondents said that new graduates need to be able to communicate about anesthesia. And in that same study, we asked faculty members, what do you teach in your curriculum? What topics do you teach, et cetera?
Speaker: And what do you let the students do? And not very many curricula teach communication about anesthesia. And very few curricula, again, let students communicate to clients about anesthesia when they're in clinics.
Speaker: So it's like we expect them to be able to do this thing, but we never teach them how to do it. And I think it's definitely something that clients, you know, they're anxious, they're nervous, they want to know what's going on.
Speaker: And obviously, you know, it's also part of the team. We're mostly talking about communicating to clients, but you also need to communicate to your team that's delivering anesthesia, you know, usually the technicians.
Speaker: about how to talk to the clients about these things because the clients are going to ask the tech. You walk out of the room as the doctor and now the tech is doing the wrap up or getting the consent or whatnot. They're going to be talking to the technicians about what to expect.
Speaker: So what do you think are some of the most common concerns or fears that pet owners have when it comes to anesthesia? So we did, this is a different study where we asked clients what they're concerned about.
Speaker: And so we had some some kind of common problems and, you know, had them rank not at all concerned to extremely concerned. And generally, it's what you would expect. They're they're worried about pain. They worry about never recovery. They're worried about death.
Speaker: Those are probably the top ones. But they're also worried about all sorts of other things. So behavior change after anesthesia, stress or anxiety while in the hospital, nausea and vomiting, waking up during the procedure, having the wrong procedure performed, um having the cost of care increased.
Speaker: So there's all sorts of things that they have mentioned that they are worried about. But at least from this study, it looks like death is the top as well as pain. So knowing that owners have these types of concerns, because I guess in my experience, the majority of the communication about anesthesia is coming either from the veterinarian or in my case, maybe the surgeon or the specialist who is working with that particular pet owner.
Speaker: What do you think are like kind of the highlights of things that should be communicated properly? you know, about when you're talking about anesthesia with a pet owner, given like what their primary fears and concerns are?
Speaker: Well, I think that that there's a wide range of approaches to take. And I don't know that there's necessarily a best one. Like one approach is to just not talk about it and give them like an information pamphlet or direct them to a website to be like, hey, here's how we run anesthesia if you want to know.
Speaker: And I think that works fine for some people that might work fine in some practices. There are some clients when we did this study where we surveyed the clients that said that they just don't want to know, frankly.
Speaker: So there there are those people out there. And if you encounter them trying to take all this time to explain everything, like they just might be like, I don't care. don't care.
Speaker: So there there are those clients. And then there are the clients, on the other hand, They'll talk you to you for an hour, you know, and your time is valuable. You can't be camped out in the exam room going over every possible thing that might go wrong with anesthesia.
Speaker: So those are kind of the two extremes that that I think of. And it is, you know, how your practice functions, what kind of clientele you have, what kind of procedure you have, what kind of patient you have.
Speaker: You know, I think that it's reasonable if you're having a patient that's going to be going under anesthesia, you know, giving a brief explanation. Like, look, you know, we're going to put your patient under anesthesia for this procedure and a basic outline of what that entails and what you're going to do to try to maximize safety for them.
Speaker: I don't know that every single case you need to tell the client, look, your you know healthy dog has a one in 2000 chance of dying. You know, I don't know if everybody wants to know that information. And if you have the time then to explain, you know, what you're going to do to make that patient be safe.
Speaker: but at least i think mentioning that there is risk is relevant because I think a lot of people have no idea. And I find this, especially when we talk to patients with brachycephalic dogs, that that these clients have no idea that their dog is at a higher risk.
Speaker: And so that degree of ignorance is sometimes shocking to me. And so just mentioning to them, like, look, anesthesia is risky. And if maybe that'll allow the opportunity for them then to say how concerned they are. And then you have more of a dialogue.
Speaker: So speaking of like broaching the topic of anesthesia with pet owners and like explaining the process to clients, is there a approach that you recommend to make sure that it's like as easy as possible for the clients to understand exactly what is going on in that process?
Speaker: Yeah. So I think there's there's two approaches that you can take. One would be for the veterinarian to go through this and the other would be for the technician to go through this. I personally like the idea of the technician kind of debriefing the client when they're getting consent or when they're checking them out or whatnot.
Speaker: One, because that empowers your technician. Two, technician is often the one doing anesthesia, and hopefully it'll and educate the technician you know in this process. And two, you know, as the veterinarian, your time is a little bit more restricted and valuable. So if you can pop in to do another case or see another appointment, that may be a more efficient use of resources.
Speaker: But regardless, who does it? I do think that it's worthwhile to say, you know, hey, so Fluffy has to have anesthesia for this, you know, say dental procedure There is some risk associated with anesthesia. The concerns that a lot of people have, of course, is if they never recover or if they don't make it through anesthesia, what we're going to do to minimize that is we are going to make sure that they are sedated with a good, sensitive drugs. They have good pain medication on board.
Speaker: We are going to monitor their vitals, including heart rate and blood pressure and respiration. And we are going to monitor them in recovery. Again, make sure that they're comfortable, quiet and warm.
Speaker: There's going to be a dedicated technician who's going to supervise Fluffy throughout the procedure. So that whole spiel took, i don't know, maybe a minute. And I think that that is opening the door to further questions if the client has them.
Speaker: But at least they they have a basic idea now of what's happening in that big black box that is the veterinary clinic. Yeah, I really like how you explain that. And i I think the important things, in my opinion, are one, most people do not have a medical background or really a good science background. And I think like some kind of tidbit that I've heard out in the ether that always stuck with me is that people's science education like maxes out at like middle school level.
Speaker: So if you just like explain things to people as though they were like a middle schooler, most of the time that's about the level ah of understanding that that people have as far as science is concerned or you know medical dialogue is concerned.
Speaker: So that's like the first thing I always keep in mind. I think the only thing I would add to that is at the end of that spiel, which I did like that spiel a lot that you gave, maybe just saying like, okay, I've said this to you. Do you have any questions about that?
Speaker: And also allowing people to maybe even have some reflective listening. Like, is there any part of anything anything I just said that you have any questions about?
Speaker: If you don't, that's okay. You can think about it and let me know later. But directly asking people is really important. And then the only other thing I would say is the biggest communication problems I have in my current practice have to do with like,
Speaker: preoperative medications that patients are on. And so now if we give instructions to owners, so for example, if an animal has heart disease and we want that patient to have its cardiac medications beforehand, I usually advise people who are giving these instructions to tell the instructions to the client and then ask them to physically repeat it back to them to make sure that they heard. Nice.
Speaker: So important. Yeah. Yeah. People will be like, yeah, yeah, yeah. Just like you said, but they like are not actually listening or they're just overwhelmed. so mean, I'm not, there's so much information.
Speaker: Yeah. And so asking people to like repeat the important things back to you, you know, not everything is really important. And I know it does sound patronizing to do that to clients, but like, I just frankly don't care.
Speaker: yeah Yeah. And yeah you're absolutely soliciting questions, I think, is is really prudent. There again, you know, you might need to read the the room and the clients and the situation a little bit. Like if it's a client that you know is high maintenance and you've talked to them about this before and you know they're going to talk their ear off.
Speaker: Like I can imagine a situation where I might not want to invite that because I don't have a whole half hour you know, to spend on them. But yeah, generally, yeah, asking people what they're worried about is is probably the best way to go.
Speaker: You know, speaking, I guess, of that high maintenance clients, there are many pet owners who are very hesitant to put their pet under general anesthesia for like a bunch of reasons. Maybe they had a bad experience in the past themselves or like with a with their own pet or maybe, you know, classically, they think their pet's too old to have anesthesia.
Speaker: Maybe they're just like a generally risk adverse person. But regardless, how do you think veterinary teams can approach these clients to address their concerns without minimizing or dismissing their fears?
Speaker: Yeah, it's a really tough thing. um My approach whenever I have a conflict or disagreement is always to seek understanding. Right. Because that person has a rationale in their head for why they're making the decision. It might not make sense to you, but it makes sense to them. So I would just want to say, you know, to tell me what you're worried about. Like, what are your concerns?
Speaker: Because you can't manage them if you don't know what they are. And that will hopefully help to to narrow down. And I mean, sometimes they might just be like, i don't know, I'm just kind of worried, you know, but they might tell you, oh, yeah, well, Fluffy, my last pet died under anesthesia. You know, that's that's meaningful. Or I heard from my breeder that this dog is particularly sensitive to anesthesia.
Speaker: Or my neighbor said that they had their dog's dental done without anesthesia. You know, so each of these is going to be a different conversation. And so I think starting with understanding, ask them to explain and to help you understand and to have that open spirit yourself. So not in an accusatory way, but just really genuinely wanting to know, I think will help open them up.
Speaker: I do think that dismissing their fears or concerns or saying, oh, don't worry about it, we've got it handled, or there's nothing to to be concerned about, that is not good on so many levels. One, people don't feel heard and validated. Like, at the end of the day, we all of just want to be heard and validated.
Speaker: So that's not going to make them feel good. Two, what if that patient dies? Right. And you were like, oh, it'll be fine. And then that patient dies. That's not a good look for you.
Speaker: So I'm always wanting to hear what people have to say. What are you worried about? How do you think veterinary professionals should approach the cost discussion? Because I think you mentioned one of the client's concerns from your survey had to do with like increasing cost of care.
Speaker: And I know there are some veterinary clinics that who, you know, they want to offer that like multi-parametric monitoring and things like that, but maybe, you know, they're having a hard time justifying, you know, adding that cost or increasing the cost of anesthesia to compensate for maybe adding more drugs or adding more monitor equipment, things like that.
Speaker: So how do you think is the best way to approach that cost discussion while still emphasizing the value of care that's being provided?
Speaker: Yeah, that's that's a really good point. And I think the word that you said there that is what I always focus on, which is value, right? Because people will pay the money if they perceive that the value is there.
Speaker: So part of it is explaining what the value is. And I've got a whole like separate talk on how to decide, you know, to buy new monitors or buy new drugs or that sort of thing, because that's a practice, economic, philosophic discussion.
Speaker: h But I personally think that that once the patient gets behind the door for anesthesia, for most practices, that's it. Like we're going to treat all of them the same.
Speaker: And I take that philosophy here. Like, you know, we've had some high profile, you know, clients come in or some muckety muck. I'm like, I'm going to treat your dog the same way I treat every dog that comes in a high level of care.
Speaker: And so I think that that's a decision at the practice level. and And now, look, I think it's important to realize that if there are practices that that cater to lower income clients. And that's great.
Speaker: Right. I think that it is important that. that people of all socioeconomic status have access to veterinary care. And so that practice, you know, you might not have a dedicated technician monitoring anesthesia the whole time. You might just have a Doppler. You might not have lot of the other stuff.
Speaker: And that's fine because that's what that practice has decided. High quality spay, high volume spay neuter settings are often like this where it's, you know, pretty minimal monitoring and just get it done. And then there are the practices. I have a friend of mine who does a bespoke anesthetic protocol for every one of her cases that comes in the door. And she has a technician monitoring anesthesia and they have all these multi-parameter monitors. And that's how that practice operates. So I think that the economic question really is a practice level philosophical decision.
Speaker: Once that patient is decided to get it under anesthesia, I think the care for the most part, should be the same. The exception being if they're willing to pay the premium for a board certified veterinary anesthesiologist or potentially a certified ah VTS um technician to monitor that case.
Speaker: I can see them paying a premium for that. But generally, I would say you walk in the door, we're going to give you the best care we do here at this clinic. I think that's a good way of communicating about costs for sure.
Speaker: i think that the only reason I'm asking this is sometimes people will ask me to consult about adding new medications to their practice, or maybe they wanna buy like a cabinet graph and they know it's like the best care they can provide for anesthesia, but they're concerned about you know the additional cost of adding that particular monitor and how do you like, you're gonna raise the cost of anesthesia how are you gonna communicate that to your clients?
Speaker: And I think really the, you nailed it, which is that you just have to inform people that the increased cost is to increase safety and provide the the highest standard of care that you have decided as a practice to provide to patients. And people are going to have to pay for that. And I guess if they are not willing to pay, you have to decide as a practice what that means. Like if that just means you lose that clientele or whatever that means, but that I agree with you. It's like a philosophical decision you make as a practice. Exactly. And on this ah client survey that we did, we asked them how much they would be willing to pay for a board-certified anesthesiologist to supervise their case.
Speaker: And the range was from zero to $5,000. Some people said, it doesn't matter how much it costs. I want the best for my pet. But the median was about $200. So realize that people realize that a board anesthesiologist brings value to their experience if that's a thing that your practice has access to, which is not very many.
Speaker: So let's move on to talking a little bit about risk with pet owners. As you mentioned earlier, for example, with brachycephalics and how those animals do have an increased risk of anesthesia.
Speaker: And lot of people just are not aware of that. So are there any specific strategies you would advise for discussing risks with owners of high risk patients?
Speaker: Yeah, so I kind of had my standard spiel that I give before. And then if you have high-risk patient, so this is going to be ah ASA status, three, four, or five patients. that This is going to be a patient with you know some kind of systemic illness, kidney disease, liver disease, heart disease are kind of the classic ones. Emergency cases, you know the hemoabdomins, the GDBs.
Speaker: brachycephalics, for sure, we have evidence that their their risk factors are higher. So a patient that that i think is going to have a higher risk associated with anesthesia, I kind of give my standard spiel.
Speaker: Then before asking if they have any questions, give my, your patient is a high risk spiel, which is something like, you know, just so you're aware that Fluffy is ah English Bulldog because of their breeding, they are at a higher risk for having anesthesia problems.
Speaker: We will do what we can to minimize those risks, but realize that that the risk of something happening to Fluffy is something like 10 times higher than another dog.
Speaker: And we'll certainly keep you informed and let you know if those any of those sorts of things happen. But you know, that I am more concerned about this patient than the average patient and then kind of open it up to questions.
Speaker: And I think, ah you know, sharing that I am more concerned, um hopefully we'll we'll do a few things. One, it'll invite the client to participate more of the discussion, right? They might want more details like, oh, what are you concerned about?
Speaker: And then you can talk a little bit about more about, you know, what that comorbidity is. it's a brachiosphalic, I'm like, I'm really concerned when we take the tube out that's delivering oxygen at the end of anesthesia, that they won't be able to to keep their airway open and move air but from out in the air into their lungs, and that we may need to re-anesthetize them to maintain that airway. so So then that allows you to kind of go into more specifics about what exactly the the concern is that you have for that patient.
Speaker: Yeah, you know, so I think that that you do need to be honest. I think you do need to be clear. um Because again, for me, the worst case scenario is saying, oh, it'll be fine and it not being fine.
Speaker: Interestingly enough, I heard this going around the pipeline not too long ago, which was that for for clients who had pets but that were high risk, so either like comorbidities or you know breed related increased risk,
Speaker: that as kind of like a CYA type of thing. And for those who, I'm not going to say the acronym, but basically to cover your butt, there was this thing going around where there's a recommendation that clients need to sign kind of line on their anesthesia consent form. And so like, I understand that my patient is a high risk patient and they sign it.
Speaker: I didn't know how you felt about that or if you have any opinions about doing something like that ah for people. I'm a big fan of informed consent and documenting things. i Like I said, I grew up in Los Angeles. So what I tell the students how I practice veterinary medicine is i ask, how will this sound in court?
Speaker: Because if you ask yourself that question, you'll always do the best thing for the patient. But along those lines, yeah, I think it's perfectly reasonable to have that. i think that would be good in terms of making sure the client reflects on and realizes that.
Speaker: I would certainly add it to the communication log, you know, that like talk to a client about anesthesia, you know, told them that this patient was high risk.
Speaker: You know, I think that would cover you from a legal standpoint, but from a making sure the client gets its standpoint, having them initial or sign an additional ah consent form. I think that's that's ah kind of like that.
Speaker: So when communicating about risk One of the things that I think is challenging, especially for clients to understand, is that you inform clients that you are going to do everything in your power to make sure that their animal experiences as safe of anesthesia as possible. But some of that risk comes from uncertainty or unknown, right? Like I cannot predict how every single animal is going to respond to a drug that I give because it's not uniform.
Speaker: So what is the best way, in your opinion, to communicate uncertainty to clients? Because I always have clients say like they just like don't understand necessarily when you say like it's risky and they're like, well, I'm paying for your expertise and i'm paying for all these like drugs and i'm paying for all this modern equipment. Like what, why, where is this risk coming from?
Speaker: So what in your opinion is the best way to communicate uncertainty, i guess, to clients in face of all of, of all of that, especially those clients who's like, just really like, just don't, they just like, don't get it.
Speaker: You know, that's a really good question. And it's tough because, you know, I teach patient safety culture and medical error to the vet students. And that's a whole long presentation about like philosophically, why do we make errors as humans? What are complex systems?
Speaker: How is this like aviation and nuclear engineering? And so you don't really have the time to explain all of that to client and they don't have the educational background often to understand it.
Speaker: So I think that using statistics is maybe helpful and explain to them, you know, like regardless of the the quality of care, you know, at at university hospitals where they had boarded specialists taking care of patients, you know, something like You know, for high risk patients, it's about one in 100 dogs have a ah fatality.
Speaker: And for healthy dogs, it's about one in 2000. So you you can never eliminate the risk because these are complex systems. They're biological organisms. We can't see perfectly inside them.
Speaker: We have all these tests, but I don't know what's happening in the little cell, you know, for that patient that might cause all sorts of downstream problems. So I think that I would, you know, rely on numbers, rely on statistics, try to to explain to them that, you know, the system is complex and uncertain.
Speaker: If I had someone who who was really pushing back, I think, again, I might try to go back to that questioning and be and seek understanding and be like, okay, like, tell me tell me where you're coming from i'm like tell me what you're you know worried about you know what's your understanding i might pull in analogies from you know nuclear safety or aviation or those sorts of things and explain that you know like in spite of everything that we do sometimes a lot of the stars align and you know we have a bad outcome yeah the reason i asked that question
Speaker: is that I think one of the more challenging ah communications I've had in my like past few years was I was at a specialty practice and I had um ah English bulldog, of course, that suddenly arrested under anesthesia. And it was very sudden, like dog was doing great.
Speaker: We were literally like put in the last stitch and then like, boom, like dog just like was fine and then not fine. and And i still like no idea what happened because the dog's final parameters were very, very stable.
Speaker: And so you know When we were talking to that owner about what was going on, I think it was, I mean, obviously there was a lot of grief associated with what was going on as well, but there was just this like, I don't understand.
Speaker: You're telling me like everything was fine, that it wasn't. you know I paid for all this stuff and including you know boarded anesthesiologists to be there and I had a bad outcome and i just like don't understand how it could just like not be okay.
Speaker: And so i think that scenario that I'm giving you is going to bleed into kind of like our next topic, which is how do you communicate with owners when things go wrong and how do you navigate kind of these adverse outcomes?
Speaker: So what do you think veterinarians should be keeping in mind when they're preparing to deliver difficult news about an adverse outcome? Yeah. Yeah, I've had those cases as well. I remember very distinctly, I had a horse that was just like healthy young horse going under for arthroscopy, induced it, put it on the table. A minute later, i was like, I think this horse is dying. And sure enough, that's what happened.
Speaker: And one of the old timer surgeons kind of walked through around this time. He's like, oh, yeah, we get one of these about every 10 years and walks out. like, oh, great. It happened on lot my watch. Thanks. You know, thanks. Yeah, there are, you know, when it's a medical error, it's maybe almost easier sometimes because you can identify the problem and make a plan for addressing it.
Speaker: These random things where the patient is doing fine and just happens to die and then on necropsy, nothing is revealed. Those can be really frustrating. But regardless, when you have a bad outcome, the acronym that we teach the students is TEAM, T-E-A-M.
Speaker: So be truthful, express empathy, apologize, and make a plan. So be truthful. You know, it has to be said because a lot of lawsuits happen when vets start lying.
Speaker: And they do that because maybe they're embarrassed, maybe they're they're afraid of the consequences of being truthful. I don't know. But that's how you get sued as a vet is when you start lying.
Speaker: So being truthful is step number one and is really essential to also, you know, your team, you're you're a role model for your team. And if they see you dodging the truth, that's not going to be a good culture for your practice.
Speaker: Express empathy. This happens to to especially human medical professionals all the time. Again, the ones who get sued are the ones who are standoffish, you know, like the the classic surgeon who is like, I'm above all of this.
Speaker: Those are the people who get sued. Like if you walk in the room and you're like, yeah oh, God, it' like it's terrible that Fluffy died. I know how important this, you know, your pet was to you. Like if you express empathy, that's going to go a long way.
Speaker: Offering an apology, even if it wasn't your fault. Right. Bulldog was doing fine. nothing happened you didn't do anything wrong i think it's still fine to offer an apology for that because at the end of the day you know you have responsibility for that patient and then make a plan this is most evident when there's an error that that happened a lot of the times clients are obviously they are emotionally distraught but a lot of the times they want to know how is this not going to happen to someone else's pet And that's where the make a plan part comes in.
Speaker: Once they've kind of moved through their their anger and their grief and all those emotions, a lot of times they're like, okay, well what are we going to do so that this doesn't happen to somebody else's fluffy? So the make a plan is really important. So T-E-A-M, truthful, empathy, apologize, make a plan.
Speaker: It's pretty simple acronym and and pretty much gets the job done. As part of that making a plan, for some veterinarians ah are very concerned about people being like suing them and things like that or becoming litigious because of the event that happened.
Speaker: And I've known vets who have given the advice that they should contact their like professional liability as well. Anytime something like this happens, even if the client is not automatically going to like create any ah lawsuit or anything like that. But I don't know if you agree with that. Like, should you be reaching out to your professional liability if there is an error, even if the client is not necessarily pressing a lawsuit?
Speaker: I don't have too much of an opinion on that, to be honest, because I never have done. Again, My understanding from the the literature and personal experience is that most of the time you're going to get sued because you're not truthful or you don't express empathy, etc. It's not because something bad actually happened.
Speaker: Now, every now and then you are going to get those people that no matter what you say, they're going to be upset and they're going to want to sue you. A lot of people will threaten lawsuits, but the follow through is pretty darn rare.
Speaker: And i guess I always look to what the premium is for liability insurance in veterinary medicine as compared to human medicine. Like the premiums that we pay are fractions of a penny on the dollar of what MDs pay, which means two things. One, our odds of being sued at all are pretty low.
Speaker: Two, the odds of a suit winning are vanishingly low. So I guess even though you it's funny, right? Cause I said, oh, I practice, you know, as if I think about how this sounds in court, even though, you know, I grew up in LA in a very litigious culture and, you know, think about that that way and write everything down and make sure that I am protected legally.
Speaker: I don't really worry too much about lawsuits because the odds are vanishingly rare. And frankly, our liability insurance coverage people are pretty good from what I hear. How do you recommend explaining what went wrong to clients in a way that's clear and compassionate?
Speaker: Like what kind of language are you using? What I tell the students is to go through the what, how and why of the issue.
Speaker: you know, what what happened? Right. That's that's the first thing is you had this bulldog. Everything was going fine. The vitals were all stable. We were closing up. And then I looked up and I noticed that the heart rate had stopped on the one of the monitors and I couldn't hear the pulse anymore.
Speaker: And then started to do resuscitation efforts. So describe what happened. Right. And then kind of describe how it happened. In this case, it wasn't ah a medical error, but a lot of times medical errors, you know the steps that led up to that, you you would describe.
Speaker: And then the why, i think, is also really important. Like on a fundamental level, This you may or may not disclose to the client and it may take some time to figure out the why. um but a lot of the times it's because there were too many things going on because someone was distracted ah because, you know, it's ah on a fundamental level. The why is because it's a complex system. The why is not because you're incompetent.
Speaker: The why is not. Because anyone's not doing a good job. The why is it's a complex system and medicine is is difficult. Trying to communicate that concept to clients is probably going to be pretty tough.
Speaker: um And then ah how do we prevent it from happening again? So that that's kind of what I think of when I break down talking to a client about a problem. You know, you talk about being truthful and let's say, you know, in this example, a dog passed away because it accidentally got like 10 times the dose of a medication that it shouldn't have had. Right.
Speaker: I guess based off of like that example, How much transparency or how much detail are really important? Like, are you going to say you know, Fluffy was supposed to get one milligram of this drug, but then was given 10 milligrams of this drug and it's.
Speaker: became a problem? Or you just going to be very simple? Like, despite our best efforts, you know, Fluffy just received this medication and, you know, its body had a bad reaction and it died. So, you know, how much transparency are you really going to be giving to clients when you're trying to explain to them about what what happened in an ah adverse way? Yeah, this this is a little bit like, I remember when I was in school,
Speaker: One of our clinicians telling us the scenario of, you know, you're hurtling down the freeway at 65 miles an hour. You got kids in the backseat and a dog runs across the freeway. Are you going to swerve and maybe into a car accident, get yourself hurt, get your kids hurt, et cetera.
Speaker: Or are you going to stay on and hit that dog that's running across the freeway? And there is no right answer to this question. It's one that you have to decide for yourself. And so I will lever that same analogy to this scenario, that this is something that you have to decide for yourself.
Speaker: I personally am really bad at lying or being deceptive at all. And so I'm always in my leadership style is authentic leadership. So I'm always full disclosure.
Speaker: Like, I'm going to tell you exactly what happened. I'm going to tell you everything that happened. If I know why it happened and you want to know, we can talk about that. um So I am a big fan of of being as transparent and clear as possible.
Speaker: because that's that's what happened you know and and that's the reality of the situation i so i would say uh yeah ah you know unfortunately we ended up giving fluffy 10 times the calculated dose this is why that happened i'm supposed to double check the math and i was distracted by a different case and i didn't get around to doing it and the person who giving it didn't recognize that the volume was abnormal for such and such reason, you know, just just kind of break it down. Like, how did that error happen?
Speaker: In my experience, when I've done that, I have not ad clients fixate on that sort of detail, I know that I've heard other vets do the, oh, it had a bad reaction to the drug deal, which I think is somewhat disingenuous.
Speaker: Yeah. Now, are you going to have the the one hundred one in 10,000 clients that does totally freak out about that? Yeah, sure. And you know what? That's why you get paid the big bucks.
Speaker: When errors happen, a lot of times there is a lot of emotions surrounding this. And, you know, we have an entire podcast episode on second victim syndrome. So if you are somebody who had an adverse event going on and you're having a lot of mental health issues regarding that, I would advise you to go ahead and listen to our episode on on second victim syndrome.
Speaker: But regardless, outside of that, it is very emotional person a medical error or something, you know, outside of our control happens that results in a bad outcome for for our patients.
Speaker: What do you recommend as far as how veterinarians can handle their own emotions when dealing with upset or grieving clients? yeah Yeah, absolutely. It is a huge problem. And this is one reason why I like to talk to the vet students about patient safety culture and how medical errors happen, because medical errors, like I said before, do not happen because you're bad.
Speaker: You're not a good person. Medical errors happen because you're a human being in a complex system and you're never going to eliminate them entirely. You're always going to have the potential for for errors. You can minimize them. You can never eliminate them. So the first is understanding that, understanding that this happened because you're a human being in a complex system.
Speaker: not because you're a bad person. h So I always start there. The second is, you know, when you have an error, like identify if there's a problem, because sometimes there's a problem. If you if you give twice the dose of ketamine, there is not a problem, right? Massive iss therapeutic index. It's not going to hurt patient. It's fine.
Speaker: So is there a problem? If there is, you know, do what you can to help the patient. and once that's done, you know, have your feelings. It is upsetting to to be involved in medical areas upsetting to commit a medical error.
Speaker: Anyone who's practiced medicine for more than probably six months, I would say, has has had a medical error that they've been involved in if not one that they've committed. So again, not to not to say, oh, whatever error is happening, we don't have to care about it, but trying to make sure that this is a part of the system Not because you're a bad person.
Speaker: So have your feelings, you know, be upset about it, walk away and reflect on it. And I find the the root cause analysis where you're like a five year old child, you keep out asking why, why, why, why that you'll often get to the root causes in the system that led to that error happen.
Speaker: And it's rarely that one of the root causes is you're a bad person. that's That's almost never one of the root causes, actually, in complex systems like medicine. So understand why errors happen, have your feelings, and then reflect on it and try to learn from it and be better next time.
Speaker: What are some strategies you recommend for deescalating conflict if a client becomes angry or confrontational during one of these conversations about um adverse outcomes?
Speaker: Yeah, those are really tough. Again, i think that a lot of times clients want to make sure that they are heard. So When I see this being a big problem is someone saying, you know, oh don't like why are you getting upset or don't get upset or, you know, ah trying to quote unquote calm them down is likely to upset them even more because that's minimizing their feelings and not making them feel heard. So I think making sure that they feel heard. i like using reflective listening when I'm in a situation where there's a heightened state of arousal. you have So take the time and say,
Speaker: So I understand that you're upset that Fluffy died during anesthesia because of a problem that we made. You know, reflect back to that. Make sure that they are are feeling heard.
Speaker: Validate their feelings also so that, again, they they they feel like they're being understood and heard. And, you know, frankly, a lot of times people just need to, like, blow it out.
Speaker: that They need to be angry and they just need to but get that out of their system. And so I'll just kind of sit there and take it, you know, and just keep listening and hearing and reflecting and understanding. And and most of the time, you know, they're in a state of shock. Right. So they're not hearing anything that you're saying.
Speaker: So they're that that that kind of what happened, how it happened, why it happened thing. You're going to have to do that multiple times when they're that upset. And so you just kind of keep repeating yourself, listening And then you kind of get to to one of two outcomes in my experience. One is they calm down and they're like, okay, you know, like, let's figure this out. are we going to help this moving forward?
Speaker: Or they do not calm down. And so the do not calm down situation, um I'll usually do one of two things either, you know, give them, let them know, okay, i'm I'm not feeling heard right now. I don't know that we can have a productive conversation.
Speaker: I'm going to step out and I'll come back in 10 or 15 minutes and hopefully we can keep talking at that time. So, you know, creating a ah hopefully positive goal for the future,
Speaker: or potentially appealing to peer or a superior, like a hospital director, that you might say, you know, I understand you're you're you're not feeling that I am doing what you need to.
Speaker: Can i go ask the hospital director to come and talk to you and explain what was going on? so ah I also like generally asking permission of the clients. You know, you heard, you know can I go get the medical director that gives them some sense of power and some sense of autonomy.
Speaker: Sometimes you can't do that, right? Because they just what they want is to keep yelling at you for next two hours. So sometimes you need to just be like, I am leaving. But my experience is pretty rare. Yeah, I've had needed to in the past establish boundaries with clients when they're getting really that upset. And I find that that approach is really productive if you do it in a way that makes them feel heard, which is kind of along the lines of like, I hear that you are extremely upset about what is going on. I hear it in your voice. I hear it in your tone.
Speaker: And I get it because I'm just as upset, but we are not going to have a good conversation about, you know, what our next steps are to make sure that we resolve this issue while you are talking to me in the way you were talking to me. So, you know, I need for us...
Speaker: to have this conversation, I'm going to need you to find a way to like get and get a in touch with your emotions or get ahold of your emotions so that we can actually continue to have ah a conversation that is productive.
Speaker: Nice. like that. And I, Thank you. And I've used that before. And sometimes people respect that and sometimes people don't. And, you know, like you just said, sometimes people are just angry because it's it the emotion that they are like holding on to.
Speaker: And you just kind of have to accept that and move on, but just realize like you're not going to change that for them. And so at that point, I agree with you. At that point, i'm like, okay, we're just going to have to I've said what I need to say. You're upset. I don't want you to tell you. It's not good for me to have you yelling at me either. So we're going to have to stop here and walk away.
Speaker: and think that's okay. You know, um I think that sometimes people feel like there's a need that they need to like make that client just like not be mad at them anymore. And I would say like that might be a lost cause. Yeah. You're also not a trained therapist or social worker, right? Like your, your skills in this domain and at a certain point, because that's not your thing. So sometimes you need to kick that to somebody else.
Speaker: Absolutely. Or refer them to like a social worker, a grave counselor. I know that there are some specialty hospitals now that are hiring social workers.
Speaker: And I think that's amazing. Absolutely. Because it is like a huge emotional burden for veterinarians to have to like handle clients emotions all the time. Definitely.
Speaker: For sure. So let's wrap up this conversation now with a question that I have for you, which is what's the most challenging question ah pet owner has ever asked you about anesthesia and how did you handle it?
Speaker: So instead of a question, I think that the hardest ask I will give is we had a head owner who was like, I insist that you not use ketamine in my dog. ah guy And that's a classic one. And I was, i was a relatively junior year faculty member at the time. And I'm like,
Speaker: you don't know what you're talking about. That's my job. Like, I know what's best for your dog. But i I talked to this client and I did not know what I know now, right, about how to communicate.
Speaker: But ultimately, I was like, okay, fine, whatever. You're making this ask of us and so we'll do it. And then through a series of medical errors, that dog got ketamine and that led to a screaming experience in the exam room.
Speaker: So that that was difficult for me because I was like, I don't know... I don't know how to handle my my feelings about this, like being dictated to by a lay person about something that I am the expert in.
Speaker: I had a difficult time sort of relating with that feeling and emotion ah again as ah as a junior clinician. Nowadays, I'm like, oh, whatever. I don't care. We'll do whatever they want.
Speaker: That's fine. Yeah, I think. I agree with you. If clients are very insistent on like their pet not getting a specific medication for whatever reason, it doesn't really bother me because there's so many different ways that we can. But I guess a really important thing, I guess, to ask if that ever happened to me and I like really wanted to use that particular drug for this dog for a reason.
Speaker: a lot of times I'll ask like, well, what are your concerns about? see Seek that understanding. Yeah, I had a client I spoke to not too long ago that their dog was getting like a tail amputation and the dog had a bad anesthetic event in the past that survived. But the dog had like a very sudden drop in heart rate, which was caught quickly and treated. But it it obviously made the owner very anxious.
Speaker: And that referring veterinarian said like, oh, your dog just like can't have anesthesia again because of what happened, which is a classic move, by the way. Yeah, it is. Or I don't know.
Speaker: Like, I actually don't think veterinarians are saying this. I think that's like what the clients are hearing. Interesting. That would make a lot more sense. And so, you know, this person was like convinced that this animal like could not have anesthesia again because its heart rate drops on her anesthesia.
Speaker: And he was asking me like, okay, well, what medications are you going to use? And I was like, well, we're going to use a very powerful opioid because your dog's having like pretty significant orthopedic and soft tissue surgery.
Speaker: And we're going to be washing his heart rate very closely because of what, you you know, you told me. and he's like, can't that drug like make my dog's heart rate? drop And I was like, first of all, i was impressed he knew that. But second of all, i was like, yeah, I could.
Speaker: And he's like, well, I don't want my dog to have an opioid. Point blank. Like no opioids for my dog. And I said, sir, I feel very comfortable about the fact that we can both give your dog an opioid and make sure its heart rate is under control under anesthesia. I feel very confident that we can do that.
Speaker: And you're going to have to just trust my expertise in this. I think we can monitor your dog's pain and do both at the same time. And he was like, okay. But I think it was only upon asking, you know, what is your deal with the opioids? Like, why can't we give opioids? Like, where is this coming from?
Speaker: That we pull the information out of him. And then we were able to come to understanding about, you know, what we could do to make sure that his dog could have a safe experience. pain-free anesthesia. Yeah, for sure. and And it also makes me think of as ah specialist anesthesiologist, we have a little bit of a privileged position where it's like, yeah, okay, if you want me to do an opioid-free anesthesia, I can do that.
Speaker: You know, like we can make that dog comfortable still because we have that that specialized, you know, knowledge and expertise and everything. I think for the the general practice clinician, especially who, you know, a lot of them, a lot of clinics have just their cocktail of, you know, pre-med induction, whatever, and that's what they use.
Speaker: i would I would be anxious if that's your if that's what you use and that's your standard and that's what you've been doing for 20 years and then you have a client roll in and who's like, i don't want you to do that. That is exactly how you get a bad outcome.
Speaker: Like you change what your practice is for 10 years for a single case, that that's going to go badly. Yeah, 100%. I totally agree with you on that for sure. Like, I think the best way of communicating with that client then is just to say, like, this is the drug protocol we use.
Speaker: We have excellent success with this program at or this protocol. Everyone is very comfortable with these medications. Deviating from that could cause more problems. exactly.
Speaker: And so, you know, this is the protocol we're using. And if you client are not comfortable with that, like maybe this is not the place to do this particular procedure. I'll never forget this during my anesthesia boards. The first time I took it, they gave me a scenario of anesthetizing a bear.
Speaker: And they said the client will not let you use a needle to sedate it. And I was like, I wouldn't do it. And this board of three, you know, anesthesiologists just stared at me and I was in my head, I was like, that, that was the wrong answer, but that is the right answer.
Speaker: I like that. Are there any resources like books or courses or like websites, organizations that you recommend for improving communication skills in veterinary medicines that, that is like geared towards veterinarians or veterinary teams? Yeah, I think the Institute for Healthcare care Communication has some good resources out there that would help with general communication skills.
Speaker: And then honestly, your local anesthesiologist, you know, if there's one in practice that you know, but you can always call up the university where you are closest to I love talking to clients about these kinds of things or talking to vets about these kinds of things. So, um you know, call up and use those resources that are there.
Speaker: So in one or two sentences or like bullet points, what are the most important takeaways for veterinarians or veterinary teams when it comes to communicating with clients about anesthesia?
Speaker: I think I'd say ah have the conversation. Don't avoid it because ah fear of fear of having that conversation to talk to clients about anesthesia and then listen and make sure that they feel heard and validated and understood.
Speaker: Well, thank you so much for coming back again on the Navis podcast and chatting with me again. this has been great, Bonnie. Thanks so much. Yeah, of course.
Speaker: Thank you for joining us today. If you enjoyed this episode, we invite you to explore the North American Veterinary Anesthesia Society and consider becoming a member. Membership with Navas provides incredible benefits, including access to anesthesia and pain management CE events, informative blog posts, fireside chats with board certified anesthesiologists and specialty technicians, and much more.
Speaker: Registration for the Navas Springs Symposium is now open. This free virtual event will be held on May 3rd and May 4th and will provide insightful lectures and panel discussions on a range of topics pertaining to veterinary anesthesiology.
Speaker: If you're interested, visit www.mynavas.org to elevate your anesthesia journey today. If you've been enjoying our podcast, we'd love your support.
Speaker: Please consider liking, subscribing, writing a review or sharing the podcast with friends and colleagues. Every bit of listener support helps us to reach more veterinary professionals like you.
Speaker: For questions about this episode or the podcast in general, or to suggest topics for future episodes, feel free to reach out to us at education at mynavass.org. We'd love to hear from you.
Speaker: Special thanks to our sponsor, DECRA, for making this podcast possible. To learn more about their veterinary anesthesia products, visit www.decra-us.com. And of course, a big thank you to our esteemed guest, Dr. Eric Hoffmeister, for this insightful discussion on communication and veterinary anesthesia.
Speaker: This episode was produced by Maria Bridges, edited by Chris Webster of Chris Webster Productions, with technical support from Saul Jimenez. Finally, thank you to all our gas passers out there for spending time with us on the Navas podcast.
Speaker: Veterinary anesthesia is a lifelong journey of learning and growth, and we hope you'll join us next month as we continue exploring it together. I'm your host, Dr. Bonnie Gatson. Thanks for listening and stay tuned next month for another episode of the Navas podcast.
