What can veterinarians learn from studies of physician-patient communication about veterinarian-client-patient communication?

Transcription

1 Reference Point What can veterinarians learn from studies of physician-patient communication about veterinarian-client-patient communication? Jane R. Shaw, DVM; Cindy L. Adams, MSW, PhD; Brenda N. Bonnett, DVM, PhD There is limited information in the veterinary literature on veterinarian-client-patient communication, and what is available is predominantly based on expert opinion and anecdotal information, not peer-reviewed scientific studies. In contrast, the human medical communication literature contains a large number of empirical studies. Thus, a review of research of physician-patient interactions is a logical starting place to determine what steps veterinary researchers, educators, and practitioners could take to investigate and address veterinarianclient-patient interactions. The purposes of this report were to summarize recent advances in human medical communication research and education, link findings in human medical communication research to veterinary medicine, and provide a rationale for development of communication research and education programs in veterinary medical schools. The importance of communication skills in veterinary medicine is an emerging topic. For instance, 1 of the 6 critical issues identified during focus-group sessions of the KPMG study 1 was that while the scientific, technical, and clinical skills of the veterinary profession remain high, there is evidence that veterinarians lack management and communication skills necessary for success in private practice. These are general findings and may not be reflective of the skills of all veterinarians. However, many veterinarians participating in that study reported that they did not receive sufficient training in communication skills. When the researchers asked pet owners to rate the most important factors in choosing a veterinarian, the 2 factors most commonly listed were that the veterinarian is kind and gentle and that the veterinarian is respectful and informative. It is apparent, therefore, that pet owners value the interpersonal skills of their veterinarians but that many veterinarians perceive that they are lacking these valuable skills. Over the past decade, veterinarians have witnessed substantial changes in the profession. One of the major changes is the increasing recognition of From the Department of Population Medicine, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada N1G 2W1. Supported by Novartis Animal Health and the Ontario Veterinary College Pet Trust Fund. Address correspondence to Dr. Shaw. the relationships that people may have with their companion animals. 2 When asked about their relationship with their pets, 85% of pet owners reported that they viewed their pets as family members. 1 In conjunction with this, there is a growing recognition that provision of veterinary services in a manner that acknowledges the human-animal bond will lead to better outcomes for veterinary practices and their patients. 1 Appreciating the impact of animal companionship on the health and well-being of humans creates a new dimension for veterinarians in public health. Veterinarians responsibilities have expanded to include the mental health and well-being of their clients, as well as their clients pets. 2 In a recent address, Blackwell 2 stated that today s veterinarians are faced with educated clients armed with questions and greater expectations. Veterinarians responsibilities for addressing questions and providing client education are increased. In an increasingly litigious society, consumers are not forgiving of unprofessional services. 2 Most complaints to regulatory bodies are related to poor communication and deficient interpersonal skills, 3 with breakdowns in communication being a major cause of client dissatisfaction. In addition, it has been predicted that by the year 2005, women will become the majority in the veterinary profession, 4 and in a recent essay, Rucker 5 stated that women judge job satisfaction by different criteria than men do, placing greater emphasis on relationships with employers, staff, and clients. Interpersonal skills are integral to a positive and adaptive response to these societal and professional changes. There is limited information in the veterinary literature on veterinarian-client-patient communication, and what is available is predominantly based on expert opinion and anecdotal information, not peer-reviewed scientific studies. In contrast, the human medical communication literature contains a large number of empirical studies, and as a result, evidence-based recommendations inform physicians with respect to physician-patient interactions. Thus, a review of research on physician-patient interactions is a logical starting place to determine what steps veterinary researchers, educators, and practitioners could take to investigate and address veterinarian-client-patient interactions. 676 Vet Med Today: Reference Point JAVMA, Vol 224, No. 5, March 1, 2004

2 The purposes of the present report were to summarize recent advances in human medical communication research and education, link findings in human medical communication research to veterinary medicine, and provide a rationale for development of communication research and education programs in veterinary medical schools. The human medical communication literature was chosen for review because both physicians and veterinarians are health care professionals and service providers who use their talents and resources to care for living beings. Physicians and veterinarians share the common goals of improving patient health, promoting adherence to medical recommendations, and ensuring satisfaction with care. In both professions, the success of the medical encounter is dependent on human-human interactions and satisfaction is derived from those interactions. Beyond this, the structure and content of the medical interview are similar in human medical and veterinary medical practice, and the tasks that make up the clinical interview in human medicine (ie, initiating the session, gathering information, building the relationship, explaining and planning, and closing the session 6 ) are also used in veterinary clinical medicine. Finally, the methods used to evaluate the dialogue between a physician and patient are applicable to evaluating the dialogue between a veterinarian, client, and pet. Communication Skills Communication skills are a vital component of interpersonal interactions. Three broad types of communication skills have been identified: content skills, process skills, and perceptual skills. 6 Content skills are what doctors communicate the content of their questions and the information they give. Process skills relate to how doctors communicate through verbal and nonverbal methods of communication. Verbal communication is composed of what is said and how it is said. It includes not only word choice but also other verbal indicators such as voice tone, volume, and pitch and the pace of speech. 7 Nonverbal communication is the message that is communicated without the use of words and is conveyed through facial expression, eye contact, proximity, posture, and gestures. 7 Nonverbal communication bridges the gap between what is said and what is interpreted. Perceptual skills include cognitive skills (ie, problem solving and critical reasoning) and relationship skills (ie, awareness of others, self-awareness, and personal attitudes and biases). Content, process, and perceptual skills all contribute to the overall efficacy of communication. Interpersonal communication skills are vital clinical tools in general and specialty veterinary medical practice and for veterinarians working with companion animals, exotic pets, horses, and food animals. 8 Such skills are not limited to private practitioners and are essential for veterinarians working in academia, public health, industry, and government. 9 In addition, effective communication is important not only in the veterinarian-client-patient relationship but also when communicating with staff and colleagues. Finally, communication skills are transferable from the professional environment to community and personal settings and can be used when interacting with others in volunteer organizations or dinner clubs or on sports teams and with spouses, friends, and children. Measurement of Physician-Patient Interactions Measuring physician-patient interactions presents unique challenges. Researchers have used participant observation and audiotaping or videotaping to capture conversations between physicians and patients during clinical encounters. The difficulty lies in how to evaluate the content, process, and meaning of these conversations. 10 Although a large variety of qualitative and quantitative methods have been developed, many have not been validated 11 and have been used in only a single study. Few publications provide a meaningful rationale for the choice of instrument or indicate the relative advantages and disadvantages of 1 instrument versus another. 12 Beyond this, there is a lack of agreement on basic definitions for communication variables, 12 and the level of detail, description, and number of communication variables measured vary greatly. As a result, it is difficult to compare differing methodologies. Determining the Ideal Physician-Patient Relationship A gold standard does not exist for assessing physician-patient interactions, nor is there an accepted definition of the ideal physician-patient relationship. In fact, under different clinical circumstances, different models may be appropriate and effective. 13 In addition, the choice of communication style should be tailored to the individual patient. 14 In human medical practice, the most common model for the physician-patient relationship is still paternalism. 15 In this model, the physician dominates the medical encounter, setting the agenda and goals for the visit, and the patient s voice is diminished. The content of the discussion is predominantly biomedical, and the physician plays the role of guardian of the patient and acts in the patient s best interest. In contrast, it has been proposed that the optimal model for physician-patient relationships is relationship-centered care, which reflects a balance between physician paternalism and patient autonomy. 15 Relationship-centered care is characterized as a partnership, in which negotiation and shared decisionmaking are used to take the patient s perspective into consideration. The role of the physician is as an advisor or counselor. In veterinary medicine, relationship-centered care represents a joint venture between the veterinarian and client to provide optimal care for the animal. Respect for the client s perspective and interests and recognition of the role the animal plays in the life of the client are incorporated into all aspects of care. In a recent essay, Rucker 5 stated that veterinary medicine is a relationship profession that includes the veterinarianclient-pet relationship, the relationship between the client and his or her pet, and the relationships between the veterinarian and his or her staff members. On the basis of her personal experience, the author 5 suggested that practices that foster relationships can expect to be more successful, both personally and financially. JAVMA, Vol 224, No. 5, March 1, 2004 Vet Med Today: Reference Point 677

3 Communication as a Core Clinical Skill In human medicine, communication is considered a core clinical skill, alongside knowledge, physical examination, and problem solving. 6 Dr. Peter Eyre, then dean of the Virginia-Maryland Regional College of Veterinary Medicine, stated that there is a skills gap between the content of the veterinary school curriculum and the actual skills required to be a successful veterinarian. 16 Likewise, Dr. Lonnie King, then dean of the Michigan State University College of Veterinary Medicine, emphasized that veterinarians require a skill set that will allow them to serve the needs of society. 17 Such veterinarians would not only have strong grounding in the traditional areas of medical knowledge and technical skills but would also have training in life skills such as interpersonal competence, the ability to work in teams, and selfconfidence. One subgroup of the National Council on Veterinary Economic Issues, which was established in response to the KPMG study, is currently studying the skills, knowledge, aptitudes, and attitudes of successful veterinarians. 18 The consensus of the group members is that scientific and technical skills alone are not sufficient for veterinarians to be successful and that business expertise, interpersonal and communication skills, and the ability to work well in a team and understand cultural differences and values are important skills. Practitioners recognize the importance of interpersonal communication. In a survey, 19 veterinary alumni of North Carolina State University stated that communication skills were 1 of the topics that should have been addressed during their veterinary education but were not. In addition, communication skills and dealing with clients were listed as the most important skills for success in veterinary practice. 19 Likewise, 1994 and 1995 graduates of Australian veterinary schools, when asked what criteria they used to select new graduates, identified interpersonal skills as the main selection criterion. 20 Similarly, when alumni enrolled in the Queensland Veterinary Surgeons board were asked what skills veterinarians should possess on graduation, 95% of respondents indicated that the most important were communication skills, including the ability to communicate with clients and gain clients confidence. 21 Surveys 22,23 of fourth-year veterinary students in the United States indicated that veterinary students understood the importance of addressing the humananimal bond and the need to provide pet loss support in interacting with clients. Similar research in Canada found that students and alumni of the Ontario Veterinary College would like to receive more training in human relations. 24 Taken together, the results of these surveys demonstrate that veterinary educators, practitioners, and students have a strong interest in incorporating communication skills training into the veterinary curriculum. Effects of Physician-Patient Communication on Quality of Health Care For 30 years, medical researchers have been studying physician-patient interactions, and a wealth of information has been gathered on physician-patient communication and its relationship to important medical outcomes. 10 Effective communication can significantly improve medical outcomes, including patient health and satisfaction, adherence to medical recommendations, and physician satisfaction. Patient health A review 25 of 21 studies (10 analytic studies and 11 randomized, controlled trials) concerned with physician-patient communication and health outcomes concluded that physician-patient communication has an important and demonstrable influence on many patient health outcomes, including emotional health, symptom resolution, functional status, physiologic measures (eg, blood pressure and blood glucose concentration), and pain control. For example, in a cohort study 26 of patients with a new complaint of a headache, patients who perceived that their headache symptoms were fully discussed with their physician were 3.4 times as likely to experience resolution of their headaches as were patients who did not have the opportunity to fully discuss their headache problems. In randomized, controlled trials 27,28 of patients with chronic disease (eg, breast cancer, diabetes, hypertension, or peptic ulcer), patients who expressed themselves fully, including their feelings and opinions, had better health and functional status. The following elements of communication appeared to be most influential to improving health outcomes: allowing the patient to fully share his or her story, providing empathy and support, providing clear information, sharing decision-making, and achieving agreement. 29 Although empirical evidence linking communication with patient health outcomes is lacking in veterinary medicine, the authors hypothesize that effective communication between veterinarians and clients would also be strongly associated with better patient health outcomes. Certainly miscommunication could adversely affect patient care, as proper communication is needed to ensure correct administration of medications (eg, route, dose, and frequency), proper home care (eg, special diets, exercise restrictions, and bandage or wound care), and appropriate follow-up examinations (eg, recheck visits and repeated diagnostic testing). Patient satisfaction Patient satisfaction has been the most frequently studied outcome of patient-physician communication. 30 A meta-analysis 31 of 41 studies of patient satisfaction identified a number of determinants of patient satisfaction. The strongest predictor of patient satisfaction was how much information was provided to the patient, with patients who received more information being more satisfied. Social climate was also a major factor in patient satisfaction, with partnership-building, social conversation, positive talk, and positive nonverbal behavior associated with greater satisfaction. A warm and friendly emotional climate was more satisfying. A separate meta-analysis 32 investigating patient satisfaction with 11 aspects of care in 107 studies found that humaneness was ranked first after overall quality of care, followed by technical competence. Patients are most satisfied when physicians ask about psychosocial issues (eg, problems of daily living, social relations, and emotions) and do not focus solely on biomedical topics, such as the medical condition or therapeutic regimen. 33,34 An affiliative 678 Vet Med Today: Reference Point JAVMA, Vol 224, No. 5, March 1, 2004

4 style, characterized as a positive relationship between the physician and patient that includes behaviors reflective of interest, friendliness, empathy, warmth, and compassion, has been positively related to patient satisfaction, whereas a control style, which includes behaviors that maintain the physician s power, status, authority, and professional distance, has been negatively associated with patient satisfaction. 14 Finally, patients of physicians who demonstrate a patient-centered approach are significantly more satisfied. 35 Few scientific studies on client satisfaction in veterinary medicine have been published. However, there is some anecdotal evidence that client dissatisfaction has a substantial negative impact on practice income. In particular, it has been suggested that each dissatisfied client tells 26 other people 36 ; therefore, improving client relations has the potential to increase practice satisfaction and economic health. Results of a limited study 37 of client expectations in 3 small animal clinics suggested that clients seek out a veterinarian who provides good medical care for their pets and expresses concerns for them. Specifically, clients expected veterinarians to treat them with respect, to provide medical information about their pets, and to listen to what they had to say. Characteristics of a good veterinarian-client interaction include respect, courtesy, full disclosure, true sincerity, listening, and high-tech medicine. 38 The foundation of a sound veterinarian-client-patient relationship is fulfilling the client s expectations. Patients expectations of their physician appear to be similar to clients expectations of their veterinarian. Adherence to medical recommendations Medical recommendations range from prescribing medications to requesting return for follow-up appointments to suggesting lifestyle changes. In human medicine, it is estimated that the rate of patient noncompliance with treatment plans ranges from 30% to 60% 30 and most researchers agree that only 50% of patients are taking their medications as prescribed. 30 A review 29 identified 4 dimensions of physician-patient communication that are associated with patient compliance: patient education, negotiation, an active role for the patient in the interaction, and physician expression of empathy and encouragement. In addition, a separate study 31 found that patients were more likely to be compliant when their physician offered more information, used more positive talk and less negative talk, and asked fewer questions overall. Question asking was inversely related to information giving, in that the more time physicians spent asking questions, the less time they spent providing information. A study 39 of the patient s perception of the emotional versus informational components of care on the patient s compliance decisions found that the informational component was more influential. Finally, a study 40 of patients for which a new antidepressant medication was prescribed found that use of a collaborative communication style by the physician positively changed client knowledge and initial beliefs about the medication, client satisfaction with the medication, and client medication use. Studies 41,42 involving owner compliance in veterinary medicine have investigated short-term use of antimicrobials and suggested that compliance is a problem. An important determinant for adherence was that animal owners felt that the veterinarians spent enough time during the consultation. 41 Other factors that were suggested to improve client compliance include establishing 2-way communication and trusting relationships, a compassionate health care team, collaborative planning of the treatment regimen, provision of specific verbal and written instructions about medications, and timely encouragement. 43 Physician satisfaction Physician-patient communication has been shown to have a positive impact on physician satisfaction. A cross-sectional study 44 of the degree of satisfaction of general internists and their patients identified a positive association between physician and patient satisfaction, although whether satisfied patients resulted in satisfied physicians or satisfied physicians produced satisfied patients could not be determined. In a separate study, 45 physicians were less satisfied with encounters in which they were responsible for taking the initiative for the encounter, felt pressured by other medical commitments, or were on call and had high satisfaction with encounters that included nonverbal encouragement, compliant patients, and humor. Four distinct factors that relate to physician satisfaction include the quality of the physician-patient relationship, the adequacy of data collection during a visit, the appropriate use of time during the visit, and a nondemanding, cooperative patient, but the physician-patient relationship is the most important determinant of physician satisfaction. 46 Various authors have postulated that the veterinarian-client-patient relationship is important to veterinarian satisfaction, suggesting that talking to clients contributes to the pleasure and satisfaction of practice 47 and that measures of success and worth in veterinary medicine include the care provided to clients and patients. 48 Veterinarians derive happiness as a by-product of helping others, 48,49 and 30% of alumni of the College of Veterinary Medicine at North Carolina State University responding to a survey on satisfying aspects of veterinary medicine stated that working with clients and building relationships were the most satisfying aspects of being a veterinarian. 19 Problems with Communication in Human and Veterinary Medicine A cross-sectional study 50 assessing the physician s knowledge of patients problems during a clinical encounter reported that physicians did not elicit 54% of patient complaints and 45% of patient concerns. Similarly, a cross-sectional study 51 of physician-patient agreement on the problem list found that the physician and patient did not agree on the main presenting problem after 50% of visits. A separate study 52 found that during 69% of visits, the physician interrupted the patient s opening statement, and as a result, the patient failed to disclose all of his or her concerns. When the latter study was repeated, 53 similar results were found, in that physicians solicited the patients complete set of reasons for the visit in only 28% of visits and physicians interrupted patients within 23 seconds of the beginning of the clinical interview. In 65% of visits, JAVMA, Vol 224, No. 5, March 1, 2004 Vet Med Today: Reference Point 679

5 doctors underestimate their patient s desire for information and overestimate the amount of time they spend informing their patients. 54 Similar studies of veterinarian-client communication have not been performed; however, communication is a challenging issue for veterinarians. 1 Client relations and noncompliance are considered some of the biggest professional problems facing practitioners, 19 and an association between interpersonal communication and faltering practice incomes in veterinary medicine has been proposed. 55 A cross-sectional study 55 of the business behaviors of small animal practitioners reported that many veterinarians are not earning up to their potential and suggested that a limiting behavior was the failure to use management practices proven to improve business performance. The 3 management practices that demonstrated the largest potential to increase income were related to employee longevity, employee satisfaction, and client satisfaction. A primary component of these practices involves staff and client communication. In the same study, 55 self-esteem was identified as an important personal characteristic related to income potential. Those veterinarians in the study with the highest level of self-esteem also earned the most money. It is unknown whether those veterinarians with high self-esteem earned larger incomes or veterinarians with large incomes had greater self-esteem. Self-esteem is a complex construct and a reflection of interactions and relationships with individuals in day-to-day activities. These results suggest that interpersonal interactions play an important role in the personal and financial success of veterinarians. Various studies have suggested that communication deficiencies are evident during veterinary school. A survey 56 of the deans of the schools and colleges of veterinary medicine in the United States and Canada indicated that 63% of deans felt that students did not read, write, or speak as well as they should. Communication problems that were identified included participation in rounds, laboratory discussions, and classroom discussions; education of clients; and formal presentations. A survey 57 of Australian employers of new graduates reported that the area where new graduates needed the most support was interpersonal interactions, especially in difficult situations. Specific areas where new graduates were lacking necessary skills included working in a team environment, communicating with clients and employers, listening to clients needs, and taking responsibility when communication became a problem. A survey 58 of California veterinarians suggested that communication skills related to building and maintaining relationships with clients was a major deficiency of graduates; problems that were identified included difficulties with providing compassionate, courteous, and effective communication with clients; showing respect for clients; understanding the relationship between communication and successful functioning of a veterinarian; and establishing rapport with clients, colleagues, and staff. Two studies 59,60 indicated that difficult situations, such as discussing finances, dealing with a confrontational client, or supporting a client through the death of their pet, were more demanding of veterinarians interpersonal skills. Australian graduates reported that their most common deficiency was communicating with employers and clients, especially under difficult conditions. 59 Students and graduates of Ontario Veterinary College felt that they did not receive adequate instruction in professional skills. 60 In particular, participants did not feel competent delivering bad news, discussing euthanasia, interacting with demanding clients, and delivering quality care under time and financial constraints. Malpractice Patient complaints in human medicine are usually a result of communication problems and not related to technical competency or quality-ofcare issues, 61 and a breakdown in communication and resultant patient dissatisfaction is the most common reason underlying a complaint or malpractice claim. 29 A study 62 of physicians against which claims were filed, compared with physicians against which claims were not filed, found that physicians against which claims were not filed conducted longer visits, used more orientating statements (ie, statements that guide patients in terms of what to expect) and facilitating statements (ie, statements that encourage patients to talk and share their opinions), and expressed humor during visits. In-depth interviews with obstetrical patients revealed that physicians with prior malpractice claims were more likely to be perceived by patients as hurried, uninterested, and unwilling to listen and answer questions than were physicians without prior claims. 63 Patients of physicians with prior claims were less satisfied and offered twice as many complaints as did patients of physicians with no prior claims. A review 29 found that the most frequently identified communication problems were inadequate explanation of the diagnosis or treatment plan and a feeling by the patient that he or she was ignored. Qualitative analysis of plaintiff depositions found that problems related to the physician-patient relationship were identified in 71% of malpractice claims. 64 The 4 common communication problems that were identified included deserting the patient, devaluing the patient s or family s views, poor information delivery, and failing to understand the patient s or family s perspective. Thus, malpractice suits often arise from patients who feel uncared for or inadequately informed. Published information on malpractice claims in veterinary medicine is difficult to find; however, 1 study 65 indicated that 80% of claims contained an element of communication breakdown. Simple frequency data obtained from the College of Veterinarians of Ontario indicated that at least 50% of client complaints between 1999 and 2001 resulted from a communication issue. a Some of the concerns expressed by clients included failure to provide appropriate information, a disrespectful approach to the client, and a lack of communication with staff or other veterinarians. Various educators have suggested that avoiding malpractice complaints is a major reason for communication skills training in veterinary medicine. 65, Vet Med Today: Reference Point JAVMA, Vol 224, No. 5, March 1, 2004

6 Teaching Communication Skills Measuring changes in behavior resulting from a communication skills training program has its own unique challenges. Nevertheless, there is evidence that communication skills can be taught and that communication skills training can lead to improvements in communication skills. For instance, a review 67 of 15 intervention studies reported that physicians could learn communication skills. An example is a randomized clinical trial 68 investigating the effect of communication skills training on patients emotional distress found that physicians who went through emotion-handling skills and problem-defining skills training courses used more of these specific skills than did the control physicians. In addition, trained physicians recognized more psychosocial problems in their patients and used more strategies to manage emotional problems, and patients of trained physicians, compared with untrained physicians, showed a greater reduction in emotional distress. Fourth-year medical students who served as standardized patients for examination by first- and second-year students consistently demonstrated superior scores in clinical examination when their own communication skills were tested, compared with their inexperienced peers. 69 Physicians who attended a course on patientcentered interviewing asked more open-ended questions, more frequently asked for patient opinions, and gave more biomedical information. 70 Studies of the effects of communication skills training in veterinary medicine have been less common. Nevertheless, in 1 study, 71 measurements of cognitive knowledge of interpersonal skills were significantly improved after students took an 8-week course on client relations and communication skills. Communication is a series of skills that can be learned through appropriate training. Methods for Teaching Communication Skills In 1995, the Liaison Committee on Medical Education, which accredits medical schools in the United States and Canada, stated that communication is integral to the education and effective function of physicians and that medical schools must provide specific instruction in these skills. 72 In the past decade, the amount of time dedicated to teaching communication skills in medical schools has increased substantially. Some of the challenges that remain are a lack of trained faculty and clinical role models, a lack of funding, problems with coordinating the teaching of communication skills throughout all the years of training, and making room in a curriculum that is already too crowded. 72 Research efforts in medical communication have focused on the development of communication curricula, teaching methods, and assessment techniques. 73 Surveys of communication skills training programs in medical schools describe great variability among schools. Medical educators state that experiential learning techniques have been favored over traditional didactic lectures, 73 and the use of small groups and videotaped or live patients or role-playing actors, together with observation and constructive feedback, has been shown to be far more successful than didactic teaching in terms of skill performance. Teaching methods include self- and peer assessment, provision of descriptive and nonjudgmental positive feedback and constructively phrased negative feedback, offering suggestions for alternative phrasing and behavior, and participant practice. The educational method should be based on the expected outcome. For instance, if the objective is to improve communication skills in a clinical interview, the training program should involve repeated practice with guidance and feedback in the professional context (ie, the examination room). 67 This repetitive process reinforces learning efforts and builds skills over time. Communication skills are best taught by providing safe and supportive opportunities to practice. 73 In the past 15 years, 2 influential studies 1,74 of the veterinary profession highlighted the need for communication skills training in the veterinary curriculum. The Pew National Veterinary Education Program initially called for training in communication skills in In 1999, the KPMG study 1 emphasized the need for interpersonal skills training in the veterinary profession. Client relations and communication skills training varies among the schools and colleges of veterinary medicine, although some schools were teaching communication skills as early as the 1970s. 75,76 Other schools have only recently developed and applied communication skills training in their veterinary curricula, 77 although most schools and colleges of veterinary medicine have now incorporated interpersonal and communication skills into their curricula. In 1996, the Ontario Veterinary College identified interpersonal communication skills as 1 of the 7 general competencies required of veterinarians, 78 and in 2001, the University of California School of Veterinary Medicine, in a comprehensive listing of the attributes expected of its graduates, included scientific, technical, and life skills, stating that veterinarians must be compassionate, altruistic, dutiful, knowledgeable, and skillful. 79 Effective and empathetic communication was included within the professional life theme in a list of attributes of Australian veterinary graduates. 80 Communication has been included as a component of veterinary practice management curricula. 81,82 The North Carolina State University College of Veterinary Medicine offers a career and life program workshop on life skills that includes information on self-awareness, managing change, communication, teamwork, problem solving, and making informed judgments in the face of risk and ambiguity. 83 Communication is included in the professional practice program at the Faculty of Veterinary Science at the University of Sydney. 84 A recent seminar indicated that for communication skills training programs in the veterinary medical schools and colleges to be successful, there was a need to identify a cohort of trained individuals who could run the program, to set aside the necessary time in the curriculum, and to locate adequate funding. 65 In addition, the educational team should be multi-disciplinary, including researchers to describe veterinarian-clientpatient interactions and evaluate and monitor the efficacy of the communication skills training programs. 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7 Future Directions Results of cross-sectional studies of veterinary educators, practitioners, and students reflect the importance of communication skills in veterinary medicine, identifying deficiencies in communication abilities and training, and emphasizing the need for communication skills training. Research in medical communication provides a solid foundation on which to build an educational and research program for veterinary medical communication. However, for any such program to be effective, it must incorporate methods for evaluating the program and determining whether the program is adequately preparing veterinarians for practice. Human and veterinary medicine share much in common, allowing extrapolation of medical communication research to veterinary medicine. However, there are several contextual differences that deserve special attention and are rich areas for future research. One large difference is that veterinarians care for nonhuman patients. As a result, it is possible that veterinary medicine attracts individuals with different characteristics than does human medicine. Another unique aspect of veterinary medicine is the human-animal bond. The veterinarian-client-patient relationship has been likened to the pediatrician-parent-child relationship; however, the client-pet relationship differs from the parent-child relationship. As more and more clients consider their pets to be members of the family, there may be more similarities than differences. Importantly, euthanasia is an accepted medical practice in veterinary medicine, and special communication and support skills are required when discussing an emotional issue such as euthanasia with clients. 85 The death of patients is a substantial cause of stress for veterinarians, 86 and it has been estimated that veterinarians experience the death of a patient 5 times as often as do their medical counterparts. Finally, financial issues play a role in the clients ability to afford veterinary care for their pets, and a lack of finances can necessitate euthanasia of a pet for economic reasons. Conclusions For 30 years, medical researchers have been studying physician-patient interactions, and the results of these studies have yielded 4 basic conclusions: physician-patient interactions have an impact on patient health, patient satisfaction, adherence to medical recommendations, and physician satisfaction 25 ; there are major deficiencies in communication between physicians and patients 29 ; communication is a core clinical skill and an essential component of clinical competence 87 ; and appropriate training programs can significantly change students communication knowledge, skills, and attitudes. As a result, communication skills training is incorporated into medical school curricula, and interpersonal skills are assessed throughout training and in licensing examinations. Research on veterinarian-client-patient communication is lacking in veterinary medicine despite the fact that the trust and rapport that result from a healthy veterinarian-client-patient relationship have the potential to motivate clients to make appointments, show up on time, consent to treatment, follow recommendations, pay their bills on time, and refer other people. 88 Good communication improves staff relations, results in a smoother-running practice, promotes an environment conducive to best practice, decreases conflict, increases motivation, and reduces staff turnover. 89 The end result is personal and professional success resulting from healthy long-term veterinarian-client-patient relationships, veterinarian-staff relationships, and veterinarian-veterinarian relationships. It is clear that a focus on interpersonal interactions in veterinary medicine is essential to the ongoing evolution of the profession. Addendum Since the submission of this paper, 2 publications 90,91 have been released that make important contributions to the field of veterinarian-client-patient communication. The first is the personnel decisions study, 90 which identified non-technical competencies for career success, including interpersonal competence, work and life balance, effective communication, leadership skills, and business acumen. The second 91 was the American Animal Hospital Association compliance study, 91 which investigated compliance with 6 basic healthcare recommendations: heartworm testing, heartworm preventative, dental prophylaxis, therapeutic diets, pre-anesthetic screening, and core vaccines. 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