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THIS article was very purposefully entitled dealing with the difficult clinical encounter, rather than deal-ing with difficult clients, because labelling an individu-al as ‘difficult’ is limiting; we tend to attribute problems to that individual. Anyone can be ‘difficult’ given the right (or wrong) conditions – including veterinarians. Being able to appreciate the factors contributing to the perceived difficulty or conflict within a consultation can allow us to turn it around and neutralise the trou-ble – or even turn it into a positive encounter.

Successful negotiation of the difficult clinical encounter is as much of a clinical triumph as a medi-cal or surgical cure, and should be celebrated as such (Kroenke 2009). Appreciating our own role in predis-posing, initiating or perpetuating difficult interactions can enable us to navigate such encounters successfully, improving clinical outcomes and reducing work-relat-ed stress in the process.

Nature of difficult encounters

It is estimated that, in human medicine, the average clinician will have three to four difficult encounters per day (Kroenke 2009). Similarly, most consultations fall into the ‘comfort zone’, but around 30 per cent of consultations fall into the ‘challenge zone’ – that is, they require a focused effort to create or maintain a good working relationship with the client (Morrisey and Voiland 2007). A much smaller proportion of consultations fall into the ‘get help zone’, in which the relationship cannot be repaired or restored without seeking assistance from a third party.

Difficult clinical encounters arise from three core problems:■■ Success is frustrated (eg, we don’t get the outcome

we want);■■ Expectations are misaligned (eg, vet and client

might have different ideas about what is wrong or what standard of care should be provided);

■■ Flexibility is insufficient (usually because of a lack of empathy) (Morrisey and Voiland 2007).

As in human medicine, the veterinary clinical context brings unique pressures that might predis-pose situations to become difficult encounters: a high workload, long working hours, juggling multiple cases (Rowe and Kidd 2009). It can be difficult for veteri-narians and support staff to uphold a caring approach to all clients, especially those perceived to be challeng-ing, all of the time. During busy times it is all too easy to treat a client as an interruption.

All people, including vets, are apt to become defen-sive in response to criticism, difficult relationships or patient resistance (Morrisey and Voiland 2007). Furthermore, because veterinarians as a group have limited experience with failure, we might not always be as good as we think we are at examining the situ-ation from a neutral perspective and changing our behaviour accordingly (Morrisey and Voiland 2007). Some of us might recognise that we have an unpro-ductive response in a particular type of situation (eg, when a client loses their temper or challenges a diag-nosis). Being able to identify these patterns allows us to then reflect on the way we react in those situations and improve our response.

However, the circumstances surrounding a vet-

Dealing with difficult clinical encounters

Anne Fawcett

Anne Fawcett qualified from the University of Sydney in 2005 and obtained a masters in veterinary studies in small animal practice from Murdoch University. She currently works as a general practitioner and as a lecturer at the University of Sydney.

Training may prepare veterinarians for working up difficult cases but, for most practising vets, the toughest situations don’t involve medical conundrums but instead relate to people. Anne Fawcett considers what makes these kinds of encounters particularly difficult, the impact they can have on everyday practice, and outlines ways to manage and even prevent them in the future.

doi:10.1136/inp.f5574Provenance: Commissioned

The stress of having an unwell pet can amplify clients’ personality traits, which might be a source of difficulty in the clinical setting

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erinary visit place unique pressures on clients, such as emotional stress. Factors such as battling to get a cat into a carrier, long waiting times and ‘bill shock’ compound that stress. As skilled, clinical decision makers, we often don’t appreciate how powerless cli-ents can feel in the face of diagnostic and therapeutic options that they might feel unqualified to weigh up. Reminding ourselves of a client’s circumstances and challenges is helpful in taking an empathic approach.

It’s not uncommon for vets to express frustration with clients, yet clients can also be a major source of our job satisfaction. The possibility of complaints and litigation, along with unexpected clinical outcomes and after-hours on-call duties, are usually reported as the most common causes of clinician stress; however, the top five sources of job satisfaction are often good clinical outcomes, relationships with colleagues; intellectual challenge, client satisfaction and rela-tionships with clients (Viner 2010).

Impact

Though the cases that fall within the ‘challenge’ and ‘get help’ zones discussed earlier constitute only a small proportion of a vet’s caseload, their impact on practitioners is intense and disproportionate. They tend to be the consults that stick in one’s mind and, unfortunately, colour one’s perception of the working day or even week. Occasionally, a difficult clinical encounter even has the power to trigger existential questions about whether one is in the right profes-sion.

One study found that physicians who perceived high numbers of difficult patients were younger and more likely to be female than those who perceived that they saw fewer difficult patients (Perry and others 2009). It might be because older, more expe-rienced practitioners had developed coping mecha-

nisms or, equally, it could be that patients were less likely to challenge older practitioners. In the same study, physicians who perceived more difficult encounters were more likely to be stressed, burned out and dissatisfied with their jobs (Perry and others 2009). It becomes a chicken or egg question: is it the difficult encounters that cause the burnout or does burnout mean we are more vulnerable to taking these difficult encounters to heart? Is it possible (though not proven) that the ability to successfully negotiate these kinds of challenging interactions might reduce the risk of burnout?

Empathy

One thing repeated in the literature on ‘difficult clini-cal encounters’ is the major role of perception. As Morrisey and Voiland (2007) put it, ‘. . . the prob-lem is the perception of the interaction and [it] is not necessarily related to any dysfunction of the parties involved. In essence, interactions present as difficult when there is a gap between what is expected to occur and what actually occurs.

This approach recognises that interactions are flex-ible. By considering the difficulty as a function of a particular interaction, rather than a property of the client per se, we recognise that a shift in perspective could yield a positive outcome. Such an approach requires the ability to enter an interaction with an open mind, a willingness to understand and the ability to empathise. Box 1 lists a number of common reasons why clients might be upset.

Sir William Osler, considered by many to have been ‘the founder of modern medicine’, put it this

Box 1: Mind reading: why might clients be upset?

There are many potential reasons for why a client might be upset. So don’t take it personally, but keep the situation in perspective and remembered that the stress of having an unwell pet will often amplify personality traits (Powell and others 2011). Identifying and acknowledging client concerns is essential to achieving both client satisfaction and a good clinical outcome.

Some common reasons for clients to be upset might be:

■■ The fact that their animal’s health status has failed to improve (or deteriorated) despite treatment;

■■ A perception that their concerns have not been addressed;■■ A perception of over-charging or over-servicing by the practice;■■ Disagreement with the diagnosis or treatment plan;■■ Dissatisfaction with customer service;■■ A perception that the veterinarian and/or support staff do not care for

clients or their animals;■■ Concerns about how they will manage or medicate an animal once at

home (for example, some clients are too embarrassed to admit that they struggle to give oral medication to their pet and might not be aware alternatives are available);

■■ Factors that exacerbate stress in the present situation (transporting an ill or distressed animal to the vet, the logistics of organising payment, or running late for an appointment);

■■ Factors that have nothing to do with the present situation (eg, personal relationships or work stress).

A client who feels that Elizabethan collars are ‘cruel’ might remove one as soon as their pet is discharged and consider the vet uncaring. Explaining its need, potential complications and coping strategies can foster empathy and is likely to facilitate trust and compliance

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way: ‘The consultation requires the art of equanim-ity which is a detachment of personal feelings and distractions; the virtue of using a systematic method for organised work; the quality of thoroughness in assessing symptoms, signs and opinions; the grace of humility; and a reverence for responsibility’ (Rowe and Kidd 2009).

Certainly, the predominant school of thought is that the relationship between professional and client is asymmetrical, ‘wherein the healer carries a greater responsibility for empathy and for “turning the other cheek,’’’ (Kroenke 2009). If we take something per-sonally we are likely to become hurt, angry, irate or otherwise emotional ourselves – and want to defend ourselves, often escalating the situation.

Diffusing difficult situations

When an interaction becomes difficult, for example the client becomes upset or angry, the first step is to stay calm and reflect on the interaction from a neu-tral perspective. It is important to go back to the three original reasons and figure out whether the interac-tion is difficult because: the outcome was not the desired outcome, expectations were misaligned, or one party was being inflexible. Once that is answered it is possible to develop a plan to discuss and address these concerns. Quite often, simply taking time to listen to the client – by saying, for example, ‘I sense that you are upset, can you tell me what is concerning you?’, can defuse the situation. Asking questions such as ‘What can we do to help support you?’ can help the client feel a little more in control of the situation.

Another way to tackle such an encounter is to use the ADOBE model (see Box 2). The Bayer Animal Health Communication Project uses the mnemonic ADOBE to cover strategies that can be used to turn a difficult situation into a neutral or positive situa-tion. The most accessible discussion of the applica-tion of this model is in Morrisey and Voiland’s article (2007).

Extreme cases

A very small proportion of interactions are extremely challenging. These tend to be situations in which one party (usually the client) is very upset, triggering a ‘fight or flight’ mode. Physiological changes such as increased heart rate, blood pressure and adrena-lin reduce one’s ability to absorb information. This often means that the veterinarian’s input is unlikely to effectively counter the client’s current emotional state.

It is important to recognise such situations early. If not, the risk is that the veterinarian will keep try-ing to placate the client (perhaps by explaining actions or repeating themselves) and could become frustrat-ed and reactive in the process, creating a potentially explosive situation. It might help to offer the client water, a cup of tea, or a comfortable spot to sit. Such gestures demonstrate care but also buy time to reflect on the situation more calmly. Ideally, an alternative time for consultation should be arranged, for exam-ple when an employer or other staff member could be present.

If the individual is raising their voice, using offen-sive language or making threats, it is acceptable to inform them that you cannot tolerate that behav-iour and ask them to leave the building politely. If they refuse, you are within your rights to contact the police.

Make contemporaneous, detailed, factual records (ie, don’t write ‘Mrs Smith screamed the place down’, instead write ‘Mrs Smith then raised her voice to the point where it became audible in the other rooms in the practice’. A good rule of thumb is not to write any-thing about a case or client in the medical record, or associated with the record, that you would not want the client to see (Powell and others 2011).

The Veterinary Benevolent Fund also runs a 24-hour help-line for veterinarians, which can be

Box 2: The ADOBE Model

■■ Acknowledge problems: Recognise that a problem exists and assess the nature of the problem. Are expectations misaligned? Is there a language barrier? Is there ethical conflict? Accept the challenge to fix the problem (this can be hard as it is often easier to ‘burn bridges’ in the short term – but doing so can leave all parties dissatisfied and the animal vulnerable.

■■ Discover meaning: Understand where the client is coming from, their perception of the situation and concerns. Try to find common ground.

■■ Opportunities for compassion: Use opportunities to show compassion, such as interest in the client’s previous experience, the animal’s illness and the bond between the client and animal. Legitimise or validate concerns and respect efforts on the part of the client to cope.

■■ Boundaries: Recognise boundaries and understand that these might need adjusting to correct a failing relationship. For example, both vet and client might need to invest more time into the discussion. The client’s expectations of the vet’s role and the vets expectations of the client’s role might need to be spelled out and adjusted. The parameters of the discussion, including terminology used and topics covered, might need to be adjusted.

■■ Extend the system: Involve other parties. This requires recognising when to reach out and determining what help is needed (eg, referral to a specialist, involvement of an employer or senior colleague, involvement of authorities). This step is reserved for the very small proportion of extremely difficult clinical encounters.

Most difficult clinical interactions stem from interactions between veterinarians and clients. These might not result in physical injury, as happened in this instance, but can be the source of significant stress

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a useful resource for getting advice when extremely challenging situations do crop up. For more informa-tion visit www.vetlife.org.uk/about-us/vet-helpline

Prevention

Many difficult interactions can be avoided through improving communication and aligning expecta-tions. Two very simple ways to improve communica-tion in the veterinary consultation are:■■ Pause for three seconds after a client or colleague

has finished talking, to ensure he or she is fin-ished;

■■ Summarise what someone has told you to confirm your understanding (Viner 2010).Making clinical reasoning explicit is also extreme-

ly helpful in avoiding later difficulties. For example, talking the client through a physical examination by giving a running commentary can be very reassuring and serves to demonstrate that the practitioner is rul-ing many potential problems out through this proce-dure alone (Viner 2010).

Discussing the prognosis is very important to the client, even for what we consider minor conditions (remember minor conditions to us are things we see all of the time, but the client might only see this con-dition once in their animal and won’t have a reference point for its severity). Similarly, clients might not fully appreciate that individual animals have idiosyn-cratic responses to diagnostic tests and treatments, or that the clinical presentation of an underlying disease can vary significantly between animals – or even in the same animal over time (O’Connell and Bonvicini 2007). The veterinarian employs diagnostic modali-ties to rule in or out differentials before arriving at a probable or definitive diagnosis; to the client, such hypothesis testing can be confused with diagnos-tic and treatment errors if clinical reasoning is not made explicit. Taking steps to ensure that clients have realistic expectations and some comprehension of diagnostic and therapeutic uncertainty can reduce the risk of blaming the practitioner in the event of a disappointing outcome (O’Connell and Bonvicini 2007).

To reduce difficult interactions with clients we need to reach a point where the client is in a position to accept shared responsibility for diagnostic and treat-ment plans. This means we need to invest heavily in informing them as best we can. A client who feels they have been a partner in the decision making is less likely to become frustrated, disappointed or angry.

It is important to understand that many owners arrive with preconceived ideas and expectations about what they think is wrong with their pet, along with what they feel can be the most appropriate diagnostic and treatment plan. Being able to elicit these is very helpful, even if they don’t relate to the ultimate diag-nostic and treatment plan, to ensure that the client’s concerns are addressed. For example, an owner might present a one-year-old dog for being lethargic. If he or she has come to the conclusion, based on Internet research, that the animal is suffering from hypothy-roidism, it is essential to be able to address why this is likely or unlikely, and why a diagnostic test might

be helpful in this situation – even if the test is not ulti-mately run. In my experience, explaining the meaning of a positive or negative test result at the time of test-ing reduces frustration on the part of a client when the result is not the one they expected.

Finally, in order to reduce the number of difficult interactions it is vital for veterinarians to be aware of factors that influence their own decision making. Personal characteristics influence decision making in both positive and negative ways. In addition, deci-sions might be influenced by external factors such as a demanding regulatory environment, time constraints, financial constraints, personal pressures and over-work (Vandeweerd and others 2012). The quality of decisions can be improved by asking the following questions:■■ What can I do now to confirm or inform this deci-

sion (ie, what evidence is available to support or refute this decision)?

■■ If scant or no evidence is available, how can I make another or a better decision?

■■ How will I explain this decision to the owner?

Accepting and moving on

Like our patients, clinical encounters are heterogene-ous and it is impossible to achieve excellent outcomes in all cases. It is inevitable that a small number of cli-ents will be dissatisfied no matter how empathic and reflective we are. When this occurs, learning to accept that we have done our best and tolerate that some situ-ations are beyond our control are important coping skills to remember and develop.

ReferencesKROENKE, K. (2009) Unburdening the difficult clinical encounter. Archives of Internal Medicine 169, 333-334MORRISEY, J. K. & VOILAND, B. (2007) Difficult interactions with veterinary clients: working in the challenge zone. Veterinary Clinics of North America: Small Animal Practice 37, 65-77O’CONNELL, D. & BONVICINI, K. A. (2007) Addressing disappointment in veterinary practice. Veterinary Clinics of North America: Small Animal Practice 37, 135-149PERRY, G., RABATIN, J. S., MANWELL, L. B., LINZER, M., BROWN, R. L. & SCHWARTZ, M. D. (2009) Burden of difficult encounters in primary care: data from the minimising error, maximising outcomes study. Archives of Internal Medicine 169, 410-414POWELL, L., ROZANSKI, E., & RUSH, J. (2011) Small Animal Emergency and Critical Care: Case Studies in Client Communication, Morbidity and Mortality. Wiley-BlackwellROWE, L., & KIDD, M. (2009) First Do No Harm: Being a Resilient Doctor in the 21st Century. NorthRyde: McGraw Hill AustraliaVANDEWEERD, J., VANDEWEERD, S., GUSTIN, C., KEESEMAECKER, G., CAMBIER, C., CLEGG, P. & OTHERS (2012) Understanding veterinary practitioners’ decision making process: implications for veterinary medical education. Journal of Veterinary Medical Education 39, 142-151VINER, B. (2010) Success in Veterinary Practice: Maximising Clinical Outcomes and Personal Well-Being. Wiley-Blackwell

Further readingSHAW, J. R. & LAGONI, L. (2007) End-of-life communication in veterinary medicine: delivering bad news and euthanasia decision making. Veterinary Clinics of North America: Small Animal Practice 37, 95-108

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Dealing with difficult clinical encounters

Anne Fawcett

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