On-site communication skills education increases client-centered

ommunication is recognized by veterinary or-

ganizations,

1,2

veterinary medical education,

3,4

and veterinary professionals

5–8

as a key pillar of suc-

cess for veterinarians and a core competency by the

AVMA Council on Education.

Nonetheless, there is

evidence of a communication disconnect between

veterinarians and their clients across North America.

2,9

Generations of practicing veterinarians did not re-

ceive communication skills training, contributing

to the gap between communication skills currently

taught in veterinary colleges and what occurs in

practice. Further, many veterinary graduates do not

On-site communication skills education

increases client-centered communication

in four companion animal practices

Natasha Janke, PhD

*; Jane R. Shaw, DVM, PhD

; Jason B. Coe, DVM, PhD

Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO

Department of Population Medicine, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada

*Corresponding author: Dr. Janke (njanke@uoguelph.ca)

Received February 17, 2023

Accepted April 6, 2023

doi.org/10.2460/javma.23.02.0101

feel condent in their communication skills upon

entering the profession and expressed interest in

postgraduate communication training.

7,10,11

Results from client focus group studies suggest

client preferences for client-centered communica-

tion.

12–16

A client-centered approach is a “collabo-

ration between the veterinarian and the client to

provide optimum care for the animal”

and involves

a greater focus on eliciting the client’s agenda and

needs for the visit, oering partnership and relation-

ship building. Clients want their veterinarian to lis-

ten to their concerns and respect their contribution

OBJECTIVE

To evaluate veterinarian-client communication before and after a 15-month on-site communication skills training

intervention.

PROCEDURES

Multipractice, pretest-posttest intervention study.

SAMPLE

A convenience sample of 4 companion animal practices owned by a single practice group in Austin, Texas (n = 9

veterinarians; 170 audio recordings).

RESULTS

After intervention, visits were 8 minutes longer (P = .005), and veterinarians’ client-centered scores increased sig-

nicantly (2.30 vs 2.72; P = .006). Veterinarians’ biomedical questions decreased by nearly a third (P = .0007), while

veterinarians’ facilitation (ie, partnership-building) statements were 1.15 times as great (P = .04) after intervention

due to an increase in asking for the client’s opinion (P = .03) and use of back-channel statements (P = .01). Agenda-

setting skills, including agenda-setting questions (P = .009), summary of the client’s agenda (P = < .0001), and a

check for remaining concerns (P = .013), increased signicantly after intervention. Clients asked 1.9 times as many

lifestyle-social related questions (P = .02) and provided 1.3 times as much lifestyle-social information (P = .0004)

after the intervention. Additionally, clients oered 1.4 times as many emotion-handling statements (P = .0001),

including showing concern (P = .03) and optimism, reassurance, or encouragement (P < .0001), after intervention.

Paraverbally, clients presented as more anxious/nervous (P = .03) and emotionally distressed/upset (P = .02) after

the intervention.

CLINICAL RELEVANCE

Results suggest that client-centered communication skills increased after intervention. This study builds upon previ-

ous case-based studies examining practice-based communication training, emphasizing that long-term interven-

tions positively enhance veterinarian-client communication, which is likely to have a positive impact on client and

patient care.

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to the appointment, including their observations

and knowledge about their pet.

12,13

These ndings

emphasize the importance of veterinarians utiliz-

ing communication approaches that align with the

evolving expectations of clients.

Eective use of client-centered communication

is associated with improved client visit satisfaction,

veterinarian visit satisfaction,

and client adherence

to veterinarians’ recommendations.

Noncompliance

can result from a lack of exploration of factors associ-

ated with a client’s home or work situation in relation

to drug dosages when prescribing treatments.

Giv-

en the inuence of communication on veterinarians,

clients, and patients, there is merit in understanding

the eect of communication skills training on veteri-

narians’ use of a client-centered approach.

Three previous studies

21–23

examined the impact

of communication-skills training on practicing vet-

erinarians’ utilization of communication skills using

a pretest-posttest intervention study design and the

Roter Interaction Analysis System (RIAS). RIAS is the

most commonly used quantitative assessment tool

for investigating clinical communication and breaks

down medical dialogue into discrete communication

variables.

McArthur and Fitzgerald

measured the

eects of a 1-time, 6.5-hour continuing education

workshop on communication and found no signicant

changes In the 13 participating veterinarians’ use of

communication skills after intervention. In a case-

based study of a 3-doctor practice, after a 6-month

communication intervention, Shaw et al

found that

veterinarians increased their use of facilitative (ie,

partnership-building) and emotional rapport com-

munication and signicantly increased client educa-

tion regarding biomedical topics. In response, clients

engaged in twice as much social talk and provided

signicantly more biomedical information.

In a case-

based study of a 4-doctor practice after a year-long

communication curriculum, veterinarians signicantly

improved their use of partnership building and posi-

tive rapport–building statements.

In return, partici-

pating clients expressed signicantly more lifestyle-

social information and emotional statements.

These

3 studies utilized experiential learning techniques

with numerous contextual dierences. Best practices

in teaching communication skills involve a stepwise

approach: skills knowledge, observation, descriptive

feedback, and reection, starting with in-the-moment

reviews, followed by review of video or audio record-

ings and, nally, repeated opportunities for practice,

including simulation, small-group activities, or one-

on-one coaching.

This study builds upon previous work by expand-

ing the study sample to multiple practices, veteri-

narians, and clients, increasing the number of video

recordings, and observing a 15-month intervention

period. The current study is part of a larger multi-

part study and previous publications reported on

veterinary professional involvement in shared deci-

sion-making

and the impact of the intervention on

client visit satisfaction.

The objective of the current

study was to evaluate the impact of the intervention

by measuring veterinarian-client communication

dynamics, content, emotional tone, and agenda-setting

prociencies before and after intervention.

Materials and Methods

Study design

A pretest-posttest intervention study was con-

ducted at 4 multidoctor companion animal veterinary

practices owned by a single group practice surround-

ing Austin, Texas. In-practice communication training

was conducted between April 2018 and June 2019.

Survey data and video recordings were collected 3

months before and after the intervention period. The

Human Subjects Research Committee of the Colorado

State University Research Integrity and Compliance

Review Oce approved the research protocol. This

study was also approved by the University of Guelph

Research Ethics Board (REB#16-12-606).

Recruitment

Recruitment for this study was previously de-

scribed.

A convenience sample of all practices

owned by a single practice group known to the prin-

cipal investigator (JRS) at the time of pretest data

collection were enrolled in the study.

Veterinarian participants were recruited at the level

of the 4 practices and were invited to participate in the

study. All veterinary team members provided online con-

sent at the beginning of the study period. Veterinarians

who were not present for the full study were excluded.

Demographic data

The following demographic data were collected

using an electronic survey completed during the pre-

and postintervention data collection periods:

Veterinary practices—Data included type and

location of practice, number of veterinarians, and

number of veterinary team members employed.

Veterinarian—Data encompassed gender, age, job

title, years in current position, years since graduation from

veterinary school, and previous communication training.

Clients—Data comprised gender, age, high-

est level of education achieved, household income,

number of veterinary visits per year, and length of

veterinarian-client relationship (years).

Pets (client reported)—Data included age, spe-

cies, and sex.

Intervention

The communication skills intervention was previ-

ously described.

The entire veterinary team participat-

ed in the intervention. In brief, 7 training sessions were

conducted at each practice over the 15-month interven-

tion period. Each training session was conducted over a

4- or 8-hour in-person visit, based on practice size. The

curriculum progressed through the clinical interview

structure (ie, initiating the interview, history gathering,

building relationship, explaining and planning, provid-

ing structure, and closing the interview) and featured 20

key communication skills from the Calgary-Cambridge

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Guide communication framework.

27,28

Using a ipped

classroom design,

a 1.5-hour workshop focused

on implementation and application of the commu-

nication skills was held each training session. The

interactive workshops were oered in the form of a

lunch-and-learn, and included role-play, small group

discussions, and brief communication skill drills. Fol-

lowing each workshop, an author (JRS) led one-on-

one communication skills coaching with veterinar-

ians and team members while they interacted with

clients during a scheduled appointment. Each team

member was observed at least once during each visit,

as they interacted with clients during scheduled ap-

pointments. Throughout the 15-month intervention

period, hospital managers led 30-minute communica-

tion rounds, biweekly, with the entire team between

training sessions.

Video-recorded appointments

Eight appointments (4 preventative care and 4

health-problem visits) per veterinarian, before and

after intervention (n = 16), were video recorded us-

ing a standard tripod-mounted digital video camera

in the examination room. Written in-person informed

consent was obtained from clients by trained vet-

erinary team members. Each appointment was con-

ducted by a veterinarian alongside a veterinary tech-

nician who remained in the examination room for the

full length of the recording.

Appointment type

Appointment type was assigned by the partici-

pating veterinarian at the time of the appointment

and categorized as preventative care or initial health

problem. Preventative care appointments were en-

counters with a presumably healthy pet presenting

for a routine examination and prophylaxis. Initial

health problem appointments were with a patient

presenting with a health-related problem.

Roter Interaction Analysis System

The audio from recorded appointments was

coded using RIAS by 1 trained coder.

Coding al-

gorithms were previously adapted for veterinary

communication.

The directions of talk coded in the

present study were as follows: veterinarian to client,

veterinary technician to client, and client to veteri-

nary professional. The coders could not distinguish

between who the client was speaking to (ie, veteri-

nary technician vs veterinarian). Audio recordings

were randomized, and the coder was blinded to the

intervention status to reduce detection bias. Intra-

coder reliability was evaluated based on a subsample

of video recordings that were double coded by the

same coder at a second time point.

Measures of communication dynamics

Three measures were used to assess veterinari-

an-client dynamics and the power relationship during

each visit: proportion of talk, verbal dominance, and

client-centered scores. Communication dynamics

included veterinarian, veterinary technician, and cli-

ent statements. Proportion of talk was calculated by

dividing the total number of veterinarian, veterinary

technician, or client statements by the total number

of statements. A verbal dominance score was com-

puted by dividing the total count of veterinarian and

veterinary technician statements by the total count

of the client statements.

31,32

A score of 1 meant that

the dialogue was shared equally, while a score of <

1 signied that the client dominated the discussion

and a score of > 1 reected that the veterinarian and

veterinary technician dominated the conversation.

A client-centered score was estimated using the

patient-centeredness ratio in previous medical com-

munication studies using RIAS.

32–35

It is the sum of

lifestyle-social, facilitative, and rapport-building be-

haviors used by the veterinarian, veterinary techni-

cian, and client (ie, dialogue representing the client’s

priorities) to the sum of biomedical questions, closed-

ended questions, and information giving (ie, dialogue

reecting the veterinarian’s or veterinary technician’s

priorities). A score of 1 meant that the dialogue in-

cluded the veterinary professionals’ and client’s pri-

orities equally, while a score of < 1 signied the veteri-

nary professionals’ priorities dominated, and a score

of > 1 reected that client’s priorities was emphasized.

Content of veterinarian and client dialogue

The visit communication content was cataloged

into 3 categories: biomedical content, lifestyle-social

interactions, and anticipatory guidance topics.

Biomedical content included the medical condition,

diagnosis, treatment, and prognosis. Lifestyle-social

discussions comprised the pet’s environment, diet,

sleeping habits, and exercise routine and incorporat-

ed the pet’s behavior, temperament, or personality

as well as human-animal and animal-animal interac-

tions. Anticipatory guidance conversations entailed

expectations for normal development of the pet dur-

ing juvenile, adult, and geriatric life stages.

Communication variables and composites

Components of veterinarian-client-patient com-

munication including variables and composites have

been previously described.

24,30

In the present study,

communication variables were examined for veterinar-

ian and client communication only. Communication

variables were coded as a count of statements. Com-

posites are sums of individual variables that make up

appointment tasks (ie, data gathering, building rela-

tionship, client education, or establishing partnership).

Emotional tone of visits

Coders assessed the overall emotional tone of each

visit with respect to positive (ie, interest, friendliness,

responsiveness, sympathy, respectfulness, or interac-

tivity) and negative (ie, anger, anxiety, dominance, or

hurriedness) emotions on a 5-point Likert scale (1 =

low, 5 = high). Emotional tone ratings were provided

independently for the veterinarian and client.

Agenda-setting prociencies

Prociencies are communication skills that were

of interest to the researchers but are not standard to

RIAS coding. Three communication agenda-setting

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skills were coded. The rst was agenda-setting ques-

tions (eg, What brings you in today? What concerns

do you have for today’s appointment? What are you

hoping to accomplish during our time together?).

A second was coded for a summary of the client’s

agenda (eg, So, today you are here for …), and a third

prociency was developed for a check for remaining

concerns (eg, What else can I help you with today?)

during agenda setting.

Statistical analysis

Descriptive statistics included frequency for

categorical variables and mean, median, range,

and SD for continuous variables. The distribution of

continuous variables was tested for normality using

the Shapiro-Wilk test and visual inspection of a his-

togram. Pre- and posttest client and appointment

demographics were assessed for dierences using a

test for categorical variables and a t test for con-

tinuous variables with a normal distribution or Mann-

Whitney U test for continuous variables that were

not normally distributed.

RIAS variables for the clients and veterinarians

were measured as counts of events before and after

the intervention. The impact of the intervention was

assessed with a negative binomial mixed regression

model with random eects accounting for veterinary

clinics and veterinarians and xed eects for the inter-

vention (before or after) and visit type (preventative

care/wellness or health problem). Previous research

found communication patterns to dier based on

appointment type (ie, preventative care vs health

problem visits). While this study is not intended to as-

certain dierences in communication skills based on

type of appointment, the visit type was controlled for

when examining the impact of the intervention due to

earlier ndings. The mean length of the veterinarian-

client relationship diered signicantly between pre-

and postintervention groups. Therefore, length of

relationship (ie, years known vet) was tested in each

model; however, it was ultimately removed from all

models due to a lack of signicance.

The distributions of the communication dynam-

ics variables were assessed for normality using the

Shapiro-Wilk test and visual inspection of a his-

togram. Nonnormal distributions were log-trans-

formed and checked for normality. The eect of the

intervention on visit length, proportion of talk (vet-

erinarian and client), verbal dominance, and client-

centered scores was evaluated with a mixed linear

regression model that included veterinary clinics

and veterinarians as random eects and the inter-

vention and visit type as xed eects.

The impact of the intervention on emotional tone of

appointments was examined using the Mann-Whitney

U test for client variables and Wilcoxon signed rank

test for veterinarian variables that exhibited sucient

variation. Client and veterinarian variables with mini-

mal or no variation were not assessed statistically.

Agenda-setting prociencies were dichotomized

(present or absent) for each visit. Visits were treated

independently as each visit included a unique com-

bination of veterinarian, veterinary technician, and

client, from whom prociencies were coded. The ef-

fect of the intervention on agenda setting was ana-

lyzed using a χ

test.

Intracoder reliability was calculated using a

random sample (10%; 17/170) of total audio re-

cordings collected for the study by calculating the

Pearson correlation coecient or Spearman rank

correlation coecient. All statistics were conducted

using standard statistical software (SAS OnDemand

for Academics; SAS Institute Inc), and a signicance

level of P < .05 was used for all analyses.

Results

Veterinary practice demographic data

Four companion animal practices in 3 suburban

and 1 rural location in Texas participated. Two small-

er practices employed 2 veterinarians and 9 to 12

veterinary team members, while 2 larger practices

employed 3 or 4 veterinarians and 12 to 19 veteri-

nary team members, at the start of the study.

Veterinarian demographic data

Three out of 12 veterinarians (25%) who did not

complete the full intervention were excluded from

the study. Two veterinarians departed the group

practice before the posttest data collection period,

and 1 veterinarian joined the practice after the pre-

test data collection period. The nal analyses includ-

ed 9 veterinarians, including 7 females (78%) and 2

males (22%), most of whom were associate veteri-

narians (55%; 5/9), followed by 3 (33%) medical di-

rectors/DVM and 1 (11%) practice owner/partner.

The mean for years since graduating from veterinary

school was 8.12 ± 3.64 (median, 7.50 years; range,

4.0 to 14.0 years), and mean age was 35.8 ± 4.29

(median, 35.0; range, 31.0 to 44.0) years old. Partici-

pating veterinarians held their current positions for a

mean of 2.90 ± 3.29 (median, 1.0; range, 0.2 to 10.0)

years, at the start of the study. Three veterinarians

(33%) completed continuing education communica-

tion training before the start of the present study.

Appointment, client, and patient

demographic data

Appointment, client, and patient demographic

characteristics were summarized (Table 1). The

number of years that clients knew the participating

veterinarian was signicantly higher in the postinter-

vention group (P = .02). There was no dierence in

the frequency of preventative care visits and initial

health problem visits before compared with after the

intervention (P = .44).

Quality of coding and audio recordings

Intracoder reliability of the 17 (10%) double-cod-

ed appointments was found to be good (average of

all client variables = 0.89; average of all veterinarian

variables = 0.85). Of the 85 audio recordings cap-

tured before intervention, 62 (73%) were rated as

having good quality, 22 (26%) were fair, and 1 (1%)

had inaudible sections. After intervention, 57 (67%)

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audio recordings were rated as having good quality,

28 (33%) were fair, and none had inaudible sections.

Communication dynamics

The mean visit length increased signicantly

from 37.4 ± 13.27 minutes before the interven-

tion to 45.4 ± 14.24 minutes after the intervention

(P = .005), controlling for visit type, which did not

dier signicantly in length (P = .58). Veterinary

technicians contributed 22%, while veterinarians and

clients each contributed 39% of the conversation be-

fore the intervention. After intervention, proportion

of talk did not vary signicantly, as veterinary techni-

cians, veterinarians, and clients contributed 21% (P

= .8), 36% (P = .23), and 43% (P = .06) of talk, re-

spectively. The verbal dominance scores (ie, ratio of

veterinarian to client dialogue) decreased from 1.61

± 0.35 (before) to 1.36 ± 0.48 (after), reecting in-

creased client contributions, though the dierence

was not statistically signicant (P = .07). Client-cen-

tered scores (ie, balance of veterinarian/veterinary

technician or client priorities) increased signicantly

from 2.30 ± 0.74 before the intervention to 2.72 ±

1.06 after the intervention (P = .006) with more focus

on the client’s priorities, oering partnership, and re-

lationship building (Table 2).

Content of veterinarian and client dialogue

and communication variables

The mean number of biomedical questions asked

by veterinarians per 30-minute interaction decreased

from 4.64 to 3.32 after intervention (P = .0007). Spe-

cically, the mean number of closed-ended questions

regarding medical treatment (before, 0.88; after, 0.63;

P = .035), and both closed (before, 0.77; after, 0.45;

P = .01) and open-ended questions (before, 0.68;

after, 0.45; P = .04) regarding therapeutic regimen

decreased signicantly. Facilitation (ie, partnership-

building statements) increased signicantly after

intervention (before, 30.69; after, 35.17; P = .04).

The increase in partnership-building statements was

driven by an increase in asking for the client’s opinion

(before, 1.71; after, 2.21; P = .03) and back-channel

statements such as “go on, um-hmm, or uh-huh” (be-

fore, 13.63; after, 17.31; P = .01; Table 3).

The mean number of lifestyle-social questions

asked by clients per 30-minute interaction in-

creased from 0.59 to 1.14 (P = .02) after interven-

tion. Clients provided signicantly more lifestyle-

social information after the intervention (before,

22.90; after, 31.01; P = .0004). The mean number

of emotion-handling statements spoken by clients

increased from 18.65 statements/30-min interac-

tion to 25.29 statements/30-min interaction, after

Preintervention mean ± SD Postintervention mean ± SD

(median; range) (median; range)

Variable Level or frequency (%) or frequency (%) P value

Client

Years known vet 1.81 ± 2.88 (1.0; 0–14) 2.84 ± 2.7 (2.0; 0–34) .02

Visits/y 3.70 ± 3.87 (3.0; 1–25) 3.77 ± 5.94 (2.0; 0–50) .64

Age 44.40 ± 14.23 (42.0; 20–80) 44.71 ± 12.22 (42.0; 21–74) .89

Gender Female 53 (72) 51 (73) .87

Male 21 (28) 19 (27)

Education High school or equivalent 8 (10) 5 (6) .92

Associate 6 (8) 6 (8)

Some college 12 (16) 12 (15)

Bachelor 34 (44) 33 (42)

Graduate 13 (17) 16 (21)

Professional 4 (5) 6 (8)

Income (USD) < $20,000 2 (3) 1 (1) .78

$20,000–$34,999 6 (8) 4 (6)

$35,000–$49,999 3 (4) 5 (7)

$50,000–$74,999 6 (8) 11 (16)

$75,000–$99,999 13 (17) 8 (11)

$100,000–$149,999 17 (23) 15 (21)

$150,000–$199,999 8 (11) 8 (11)

≥ $200,000 19 (26) 19 (27)

Patient

Age 5.78 ± 4.69 (4.0; < 1–19) 5.39 ± 4.53 (4.0; < 1–18) .58

Sex Female 40 (51) 43 (53) .76

Male 39 (49) 38 (47)

Species Canine 66 (85) 68 (84) .99

Feline 11 (14) 12 (15)

Other 1 (1) 1 (1)

Appointment

Visit type Preventative care 45 (53) 40 (47) .44

Initial health problem 40 (47) 45 (53)

P < .05.

P < .01.

P < .001.

Table 1—A comparison of demographic characteristics of clients and patients who attended a preventative care or

initial health problem appointment with 1 of 9 participating veterinarians, pre- (n = 85) and postintervention (85).

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intervention (P = .0001). The rise in emotion-han-

dling statements was caused by an increase in cli-

ents showing concern (before, 9.13; after, 11.52;

P = .03) and showing optimism, reassurance, or

encouragement (before, 9.54; after, 14.77; P <

.0001; Table 4).

Emotional tone of visits

There were no signicant dierences between

the emotional tone of veterinarians before or after

the intervention. After intervention, clients appeared

more anxious and nervous (mean Likert scale, 1.93

before intervention vs 2.12 after; P = .03). Clients

expressed more emotional distress and upset after

intervention (mean Likert scale, 1.06 before inter-

vention vs 1.20 after; P = .02). Several global aect

ratings could not be tested statistically due to the

minimal variation observed. Descriptive statistics for

all veterinarian and client global aect ratings are

summarized (Table 5).

Table 2—A comparison of visit length, proportion of talk, verbal dominance, and client-centered scores pre- (n = 85)

and postintervention (85; 9 veterinarians).

Preintervention mean ± SD Postintervention mean ± SD Intervention Visit type

Variable (median; minimum-maximum) (median; minimum-maximum) P value P value

Visit length (min) 37.40 ± 13.27 (35.17; 9.23–67.85) 45.41 ± 14.24 (43.72; 21.7–81.0) .005

.58

All veterinarian-to-client talk 295.35 ± 142.66 (272; 98–747) 364.82 ± 170.83 (328; 149–1020) – –

All veterinary technician-to-client talk 157.57 ± 80.61 (143.5; 2–477) 207.95 ± 125.38 (178; 3–631) – –

All client-to-veterinarian/veterinary 307.93 ± 153.05 (274; 79–746) 442 ± 195.89 (418; 181–1447) – –

technician talk

Proportion of all talk, veterinarian 0.39 ± 0.09 (0.38; 0.24–0.64) 0.36 ± 0.09 (0.35; 0.15–0.59) .23 .007

to client

Proportion of all talk, veterinary 0.22 ± 0.09 (0.22; 0.002–0.47) 0.21 ± 0.09 (0.21; 0.003–0.45) .80 .0001

technician to client

Proportion of all talk, client to 0.39 ± 0.06 (0.40; 0.22–0.50) 0.43 ± 0.06 (0.44; 0.28–0.59) .06 .06

veterinarian/veterinary technician

Verbal dominance score 1.61 ± 0.35 (1.47; 1.01–3.51) 1.36 ± 0.48 (1.29; 0.70–2.51) .07 .07

Client-centered score 2.30 ± 0.74 (2.12; 0.92–4.48) 2.72 ± 1.06 (2.41; 1.07–7.74) .006

< .0001

P < .05.

P < .01.

P < .001.

Table 3—Results from negative binomial mixed models comparing RIAS veterinarian-speaking-to-client variables

before (n = 85) and after (85) the intervention, controlling for appointment type (9 veterinarians).

P value for

Preintervention rate Postintervention rate Eect dierence eect dierence

(No. of statements/ (No. of statements/ Intervention between problem between problem

Variable 30-min interaction) 30-min interaction) Change (%) P value and wellness

†

visits and wellness visits

Data gathering

Biomedical 4.64 3.32 –28% .0007

+0.58 .13

Closed questions

Medical 0.88 0.63 –28% .035

+0.34 .005

Therapeutic 0.77 0.45 –42% .01

+0.19 .10

Other 0.01 0.04 +300% .18 –0.01 .36

Anticipatory guidance 0.03 0.01 –67% .33 –0.01 .43

Open questions

Medical 1.85 1.41 –24% .07 +0.14 .55

Therapeutic 0.68 0.45 –34% .04

+0.04 .71

Other 0 0 0 — — —

Anticipatory guidance 0.02 0.08 +300% .17 –0.09 .08

Bid for repetition 0.04 0.06 +50% .38 +0.02 .33

Lifestyle-social 1.82 1.52 –16% .30 –0.03 .90

Closed questions

Lifestyle-social 0.58 0.61 +5% .77 –0.01 .95

interactions

Anticipatory guidance 0.01 0.02 +100% .74 –0.03 .20

Open questions

Lifestyle-social 1.10 0.76 –31% .09 +0.13 .52

interactions

Anticipatory guidance 0 0 0 — — —

Client education

Biomedical 58.82 52.02 –12% .09 +17.86 < .0001

Lifestyle-social 6.99 7.95 +14% .51 –3.63 .01

Building a relationship

Emotion handling 13.90 15.46 +11% .21 +1.69 .17

Positive talk 64.04 59.04 –8% .21 –2.04 .61

Negative talk 0.04 0.02 –50% .30 +0.05 .07

Social talk 13.01 12.46 –4% .83 –3.87 .14

Establishing partnership

Facilitation 30.69 35.17 +15% .04

+4.99 .02

Procedural 19.05 18.44 –3% .66 +4.67 .0009

P < .05.

P < .01.

P < .001.

†

Referent category.

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Agenda-setting prociencies

The proportion of appointments that incorporat-

ed agenda-setting skills increased signicantly after

intervention, comprising agenda-setting questions

(before, 38% [32/85]; after, 58% [49/85]; P = .009),

summary of the client’s agenda (before, 33% [28/85];

post, 80% [68/85]; P = < .0001), and a check for re-

maining concerns (before, 49% [42/85]; post, 68%

[58/85]; P = .013) during agenda setting.

Discussion

The present study was a multipractice pretest-

posttest intervention to evaluate the impact of a

15-month communication skills training on communi-

cation dynamics, content of veterinarian-client dialogue,

communication variables, emotional tone, and agenda-

setting skills. Overall, ndings suggest that veterinar-

ians promoted a more client-centered interaction, as

Table 4—Results from negative binomial mixed models comparing RIAS client-speaking-to-veterinarian/veterinary

technician variables before (n = 85) and after (85) the intervention, controlling for appointment type (9 veterinarians).

Preintervention rate Postintervention rate Eect dierence P value for eect

(No. of statements/ (No. of statements/ Intervention between problem dierence between problem

Variable 30-min interaction) 30-min interaction) Change (%) P value and wellness

†

visits and wellness visits

Question asking

Biomedical 3.84 4.13 +7% .57 +0.53 .29

Lifestyle-social 0.59 1.14 +93% .02

–0.26 .25

Providing information

Biomedical 42.71 44.85 +5% .51 +12.77 .0001

Lifestyle-social 22.90 31.01 +35% .0004

–4.45 .046

Building a relationship

Emotion handling 18.65 25.29 +36% .0001

+2.84 .09

Positive talk 94.57 104.45 +10% .12 +0.79 .90

Negative talk 0.69 0.83 +20% .48 –0.07 .74

Social talk 15.96 20.34 +27% .22 –5.85 .33

Establishing partnership

Facilitation 7.41 8.53 15% .21 +0.43 .64

Procedural 19.90 23.53 18% .054 +3.65 .051

P < 0.05.

P < 0.01.

P < 0.001.

†

Referent category.

Table 5—Mean ± SD, median, and minimum-maximum scores for emotional tones of veterinarians and clients during

appointments before (n = 85) and after (85) the intervention.

Emotional tones

Client ratings

P value Emotion Preintervention Postintervention Mann-Whitney U test

Negative emotions Anger/irritation

†

1.00 ± 0, 1.0, 1–1 1.02 ± 0.15, 1.0, 1–2 —

Anxiety/nervousness

†

1.93 ± 0.55, 2.0, 1–3 2.12 ± 0.61, 2.0, 1–3 .03

Depression/sadness

†

1.08 ± 0.28, 1.0, 1–2 1.12 ± 0.32, 1.0, 1–2 .45

Emotional distress/upset

†

1.06 ± 0.24, 1.0, 1–2 1.20 ± 0.46, 1.0, 1–3 .02

Dominance/assertiveness

††

3.56 ± 0.52, 4.0, 3–5 3.60 ± 0.49, 4.0, 3–4 .60

Positive emotions Interest/attentiveness

††

4.00 ± 0, 4.0, 4–4 3.99 ± 0.11, 4.0, 3–4 —

Friendliness/warmth

††

3.98 ± 0.15, 4.0, 3–4 3.97 ± 0.24, 4.0, 3–5 .70

Responsiveness/engagement

††

4.00 ± 0, 4.0, 4–4 3.99 ± 0.10, 4.0, 3–4 —

Sympathetic/empathetic

††

3.99 ± 0.10, 4.0, 3–4 3.99 ± 0.10, 4.0, 3–4 —

Respectfulness

††

4.00 ± 0, 4.0, 4–4 4.00 ± 0.00, 4.0, 4–4 —

Interactivity

††

3.99 ± 0.11, 4.0, 3–4 4.00 ± 0.00, 4.0, 4–4 —

Veterinarian ratings

(n = 9) rank test

P value Emotion Preintervention Postintervention Wilcoxon signed

Negative emotions Anger/irritation

†

1.00 ± 0.00, 1.0, 1–1 1.00 ± 0.00, 1.0, 1–1 —

Anxiety/nervousness

†

1.07 ± 0.27, 1.0, 1–2 1.07 ± 0.27, 1.0, 1–2 .50

Dominance/assertiveness

††

4.00 ± 0.00, 4.0, 4–4 4.00 ± 0.00, 4.0, 4–4 —

Hurried/rushed

†

1.09 ± 0.29, 1.0, 1–2 1.12 ± 0.42, 1.0, 1–4 .81

Positive emotions Interest/attentiveness

††

4.00 ± 0.00, 4.0, 4–4 4.00 ± 0.00, 4.0, 4–4 —

Friendliness/warmth

††

4.00 ± 0.00, 4.0, 4–4 4.01 ± 0.11, 4.0, 4–5 —

Responsiveness/engagement

††

4.00 ± 0.00, 4.0, 4–4 4.00 ± 0.00, 4.0, 4–4 —

Sympathetic/empathetic

††

4.00 ± 0.00, 4.0, 4–4 4.00 ± 0.00, 4.0, 4–4 —

Respectfulness

††

4.00 ± 0.00, 4.0, 4–4 4.01 ± 0.11, 4.0, 4–5 —

Interactivity

††

4.00 ± 0.00, 4.0, 4–4 4.00 ± 0.00, 4.0, 4–4 —

†Interpretation of Likert scale: 1 = no sign of aect; 2 = low aect; 5 = high aect.

††Interpretation of Likert scale: 1 = low aect; 3 = average aect; 5 = high aect.

P < .05.

P < .01.

P < .001.

Unauthenticated | Downloaded 08/03/24 06:52 PM UTC

shown by the signicant increase in client-centered

scores, partnership-building statements, and elicit-

ing the client’s agenda, in addition to decreased ver-

bal dominance and biomedical question asking af-

ter intervention. Concomitantly, clients asked more

lifestyle-social questions, provided more lifestyle-

social information, and expressed more concerns

through verbal statements and paraverbally, as mea-

sured by clients’ emotional tone, after intervention.

Examination of a compilation of studies that

utilized a client-centered model to implement com-

munication training with practicing veterinary pro-

fessionals, including the present study, indicates

that long-term interventions make the greatest im-

pact on measurable outcomes.

21–23,37

Congruently, a

meta-analysis examining the impact of continuing

education training in human medicine found that

length of intervention and use of active learning

methods are positively associated with eect size of

the intervention.

The length of the intervention is

a critical factor and should be considered when de-

signing a communication intervention.

In a previous study published from the current

intervention,

clients had greater odds of being com-

pletely satised with their veterinary appointment af-

ter intervention. In contrast, after a 6-month interven-

tion, Shaw et al

found that overall satisfaction was

not impacted. However, the study did show that clients

participating in the study were more satised with their

involvement in the appointment and the veterinarian’s

interest in their opinion after intervention. Signicant

increases in client-centered scores were established af-

ter a 12-month intervention

and the 15-month train-

ing conducted in the present study. Short-term com-

munication interventions did not identify any changes

in client satisfaction

21,37

or client-centered scores.

Findings suggest that veterinary practices would ben-

et from investing in long-term, in-practice communi-

cation training in lieu of short-term solutions to achieve

the greatest impact on clinical outcomes.

In addition to the length of training, multiple fac-

tors were considered in the development of the inter-

vention and practice selection that may have contrib-

uted to the veterinary team members’ receptivity to

the training.

Briey, these include practice culture

and leadership that support a client-centered model,

experiential techniques used to teach communication

skills, participation of the full veterinary team, devel-

opment of common communication-skills language,

experiential learning methods, one-on-one coaching,

and communication rounds. The intervention was an

intensive and immersive experience for the veterinary

team with continuity of training between sessions.

Recommendations from a previous practice-level

communication training intervention included, rst,

video recording and review and, second, feedback

sessions for veterinary team members’ interactions

from an experienced facilitator and enhancing stan-

dardization of training protocol by using a consistent

facilitator at all practices

; both of these recommen-

dations were applied in the present study. Future

communication intervention studies could investigate

how practice-level factors impact training ecacy.

Veterinarians at the beginning of the study uti-

lized a client-centered approach, yet their scores

increased signicantly after intervention. Client-

centered care is derived from the concept of patient-

centered care

in human medicine. Patient-centered

care was fueled by a desire of patients to share in

an egalitarian relationship with their physician,

a client expectation also recognized in veterinary

medicine.

12,13

A client-centered approach encour-

ages veterinarians to expand the perception of dis-

ease beyond the biomedical components to include

lifestyle and social factors, form strong veterinarian-

client-patient relationships, and empower clients to

contribute to shared decision-making.

17,39

Given the

benets of a client-centered approach for veterinar-

ians, clients, and patients, it is important for veteri-

nary practices to explore opportunities to support

their teams in delivering client-centered care.

The increase in client-centeredness after inter-

vention was exhibited by a shift in communication

content reected in veterinarians’ signicant reduc-

tion in their biomedical data gathering, paralleled by

an expansion of lifestyle-social discussions; clients

posed more lifestyle-social questions and oered

more lifestyle-social information. Lifestyle-social his-

tory includes information about the human-animal

bond and interactions, the animals’ environment, be-

havior, exercise regimen, or enrichment and wellbe-

ing.

Understanding the context of a client’s lifestyle

impacts client adherence to recommendations.

20,40

After a year-long curriculum, Shaw et al

found an

increase in veterinarians’ data gathering and cli-

ents’ information giving in relation to lifestyle-social

topics. In the present study, veterinarians’ lifestyle-

social question asking decreased by 16%, while cli-

ents’ lifestyle-social question asking increased by

93%. Veterinarians and clients provided 14% and 35%

more lifestyle-social information, respectively, after

intervention. It is possible that participating veteri-

narians in the present study fostered an open atmo-

sphere in which clients initiated greater lifestyle-so-

cial discussions after intervention.

There was further evidence of client-centered

communication after intervention. Veterinarians pro-

moted an active role for clients through increased use

of facilitative (ie, partnership-building) statements af-

ter the intervention. Veterinarians elicited clients’ per-

spectives more frequently by asking their opinions and

indicated sustained interest using back-channel state-

ments, such as “um-hmm” and “go on.” It is advanta-

geous for veterinarians to understand the client’s per-

spective, including but not limited to their ideas and

beliefs, expectations, and concerns; the human-animal

bond; and the eect of the animal’s diagnosis or treat-

ment on their life. Nogueira et al

found that veterinar-

ians signicantly overestimated their use of client-cen-

tered communication; specically, they overestimated

their discussion of family or personal issues aecting

the pet’s health and manageability of treatment. It is

anticipated that the elicitation of a client’s perspec-

tive leads to a more honest, accurate, and complete

information exchange, leading to more collaboration,

which contributes to greater acceptance of diagnoses

Unauthenticated | Downloaded 08/03/24 06:52 PM UTC

and recommendations.

In human medicine, exploring

the patient’s perspective can uncover concerns that

may not be otherwise revealed, prompt higher satis-

faction with rst-time patients, and increase the pa-

tient’s perception of time spent with their physician.

Clients’ perspectives and attitudes regarding their pets

impact the provision of veterinary care,

42,43

and explor-

ing these areas early during a consultation ensures that

veterinarians tailor the remainder of the appointment

to the needs and expectations of each client.

Importantly, a client-centered environment was

reected in client comfort in sharing emotions para-

verbally and verbally. Paraverbally, clients conveyed

more anxiety/nervousness and presented higher

emotional distress/upset after intervention. Verbally,

there was an increase in client statements showing

concern and of optimism, reassurance, or encourage-

ment, indicating veterinarians possibly eased client

worries over the course of the visit. It is hypothesized

that the increase in client-centeredness promoted a

safe and supportive environment for clients to ex-

press their feelings. It is also plausible that there were

simply more clients after intervention experiencing

stressful circumstances with their pet, resulting in a

higher demonstration of negative emotions. Further

research exploring the impact of client-centered com-

munication on clients’ comfort expressing paraverbal

and verbal concerns is needed.

While client-centered scores increased after in-

tervention, participating veterinary professionals still

did most of the talking during appointments as mea-

sured by proportion of talk and verbal dominance.

This nding is not unexpected given the nominal use

of open-ended questions and the high number of cli-

ent education statements before and after the inter-

vention. One study

found that medical residents re-

duced their verbal dominance alongside an increase

in use of open-ended questions after a brief teaching

intervention. Nevertheless, veterinary profession-

als would benet from using what has been coined

the Frisbee approach

when engaging veterinary

clients. The Frisbee approach symbolizes interactive

and collaborative dialogue.

Rather than delivering

a soliloquy, veterinarians can engage the client in the

discussion. For example, when sharing information,

begin by assessing the client’s knowledge to de-

termine an appropriate starting point, then provide

small and discrete chunks of information, then check

in for client understanding (ie, chunk-and-check) to

support accurate recall and promote shared under-

standing.

This approach helps engage clients and

encourages a more balanced conversation.

Agenda-setting communication skills were pri-

oritized throughout the intervention, a key compo-

nent of the client-centered approach taught as a best

practice.

Veterinary team members in the present

study were trained to elicit the client’s reasons for

the visit as well as their concerns, goals, priorities,

and expectations, then to summarize the agenda

items back to the client and check for remaining

concerns using open-ended questions. In many in-

stances, practicing veterinarians do not fully explore

the client’s agenda.

Previous research

shows that

when the client’s agenda is solicited, communica-

tion best practices are rarely employed. The success-

ful implementation of the agenda-setting skills (ie,

agenda-setting questions, summary of the client’s

agenda, and a check for remaining concerns) after

intervention resulted in increased client statements

of concerns. Eliciting clients’ concerns up front re-

duces the likelihood of “oh, by the way moments” at

the end of the visit, decreasing veterinarians’ need to

prolong appointment time, disregard the concern, or

address it in a future visit.

While it is often perceived that client-centered

appointments take more time, ndings are mixed.

In this study, appointments were signicantly lon-

ger after intervention, and appointment length did

not dier based on visit type. After a 6-month in-

tervention, Shaw et al

also found that appointment

length increased; however, in another study,

after

a 1-year communication-skills intervention, there

was no dierence in appointment length after in-

tervention. In a cross-sectional study

of euthana-

sia discussions, appointment length was positively

associated with client-centeredness. Conversely, a

cross-sectional study

of wellness and health prob-

lem appointments found that appointments with a

predominantly biolifestyle-social communication

pattern, reecting a client-centered approach, took

signicantly less time than those with a biomedical

or veterinarian-centered communication pattern.

Stewart et al

concluded that physicians spend more

time with patients when learning new communica-

tion skills; however, once the patient-centered ap-

proach was “mastered,” little extra time was needed.

It is conceivable that the veterinarians in this study

were still “mastering” the skills, and the increase in

appointment length could be attributed to learning

new communication skills.

One of the limitations of the present study was

the turnover of veterinarians, as 3 individuals (25%) did

not complete the full study. In addition, the high turn-

over of veterinary technicians restricted assessment

of the impact of the intervention on veterinary techni-

cians’ communication skills. With increasing calls to

advance the role of veterinary technicians,

the vet-

erinary profession would benet from future research

examining veterinary technician communication skills.

Practice-based communication-skills training is time

and resource intensive and requires committed prac-

tice leadership to engage in a long-term intervention

and foster continuity of learning after training. Given

the client-centered culture of the practice group in-

volved in the present study, the results may not be

generalizable to a larger population of veterinary clin-

ics. With the long duration of the study, it is feasible

that practice-level changes occurred during the study

period, potentially impacting the ndings. Based on

a previous assessment of client satisfaction in video-

recorded appointments compared with unrecorded

appointments, video recording was not thought to

have a major impact on the participants’ behaviors

(ie, the Hawthorne eect).

There continues to be a practicewide commit-

ment to client-centered communication and ongoing

Unauthenticated | Downloaded 08/03/24 06:52 PM UTC

utilization of communication skills taught during the

intervention. Since the study, the veterinary practice

group expanded, adding 2 more practices in Texas,

and experienced continued employee turnover. To

compensate, the leadership team teaches the 20

communication skills during onboarding, and all

employees attend virtual interactive workshops. Re-

cently, the leadership team (ie, medical directors and

hospital managers) participated in train-the-trainer

video review rounds to lead biweekly/monthly com-

munication rounds with the practice teams.

As exemplied by this and previous studies,

22,23

veterinary practices need to create a culture condu-

cive to learning for the implementation of commu-

nication skills training to be successful in practice.

Given the length of training required, commitment to

enhancing client and team communication by hospi-

tal leadership and all team members is essential to

impact clinical outcomes. It is important for veteri-

nary professionals to foster an organizational culture

that promotes learning within their practices.

In conclusion, this study provides additional con-

tributions to the current evidence of practice-based

communication skills training. The need for veterinar-

ians to develop communication skills that acknowl-

edge and emphasize the human-animal bond is well

established.

17,43,49

Exploring beyond the traditional

biomedical focus in veterinary medicine to under-

standing the client’s agenda, perspectives, and life-

style results in a better shared understanding, enhanc-

ing client-centered care,

28,39

client satisfaction,

18,27

veterinarian satisfaction,

and client adherence.

Acknowledgments

The funding for this study was a gift to the Colorado State

University College of Veterinary Medicine and Biomedical Sci-

ences from Zoetis. Zoetis did not have any involvement in

study design, data analysis and interpretation, or writing of

the manuscript.

The authors thank the participating practices’ leadership

teams and veterinary team members for collecting data and

participating in the intervention, Eddy Rogers for assistance

with data collection, and Michele Massa and Rachel Hundert

for training and conducting RIAS coding, respectively.

References

1. American Animal Hospital Association. Compliance: Tak-

ing Quality Care to the Next Level. American Animal Hos-

pital Association; 2009.

2. American Animal Hospital Association. The opportunity.

Accessed September 11, 2020. https://www.aaha.org/

practice-resources/running-your-practice/partners-for-

healthy-pets/

3. AVMA. COE accreditation policies and procedures: require-

ments. July 2021. Accessed October 1, 2020. https://

www.avma.org/education/accreditation/colleges/coe-

accreditation-policies-and-procedures-requirements

4. North American Veterinary Medical Education Consor-

tium Board of Directors. The North American Veterinary

Medical Education Consortium (NAVMEC) looks to veteri-

nary medical education for the future: “Roadmap for vet-

erinary medical education in the 21st century: responsive,

collaborative, exible.” J Vet Med Educ. 2011;38(4):320–

327. doi:10.3138/jvme.38.4.320

5. Mellanby RJ, Rhind SM, Bell C, et al. Perceptions of clients

and veterinarians on what attributes constitute “a good

vet.” Vet Rec. 2011;168(23):616. doi:10.1136/vr.d925

6. Rhind SM, Baillie S, Kinnison T, et al. The transition into

veterinary practice: opinions of recent graduates and

nal year students. BMC Med Educ. 2011;11(1):64.

doi:10.1186/1472-6920-11-64

7. Haldane S, Hinchcli K, Mansell P, Baik C. Expectations

of graduate communication skills in professional vet-

erinary practice. J Vet Med Educ. 2017;44(2):268–279.

doi:10.3138/jvme.1215-193R

8. Rauch M, Wissing S, Tipold A, Kleinsorgen C. Interprofes-

sional survey on communication skills in veterinary and

veterinary-related education in Germany. BMC Med Educ.

2021;21(1):516. doi:10.1186/s12909-021-02938-8

9. Nogueira Borden LJ, Adams CL, Bonnett BN, Ribble CS,

Shaw JR. Comparison of veterinarian and standardized

client perceptions of communication during euthanasia

discussions. J Am Vet Med Assoc. 2019;254(9):1073–

1085. doi:10.2460/javma.254.9.1073

10. Bachynsky EA, Dale VHM, Kinnison T, Gazzard J, Baillie S.

A survey of the opinions of recent veterinary graduates

and employers regarding early career business skills. Vet

Rec. 2013;172(23):604. doi:10.1136/vr.101376

11. McDermott MP, Tischler VA, Cobb MA, Robbé IJ, Dean RS.

Veterinarian-client communication skills: current state,

relevance, and opportunities for improvement. J Vet Med

Educ. 2015;42(4):305–314. doi:10.3138/jvme.0115-006R

12. Coe JB, Adams CL, Bonnet BN. A focus group study of

veterinarians’ and pet owners’ perceptions of veterinari-

an-client communication in companion animal practice. J

Am Vet Med Assoc. 2008;233(7):1072–1080.

13. Janke N, Coe JB, Bernardo TM, Dewey CE, Stone EA. Pet

owners’ and veterinarians’ perceptions of information ex-

change and clinical decision-making in companion animal

practice. PLoS One. 2021;16(2):e0245632. doi:10.1371/

journal.pone.0245632

14. Kanji N, Coe JB, Adams CL, Shaw JR. Eect of veterinari-

an-client-patient interactions on client adherence to den-

tistry and surgery recommendations in companion-ani-

mal practice. J Am Vet Med Assoc. 2012;240(4):427–436.

15. Stoewen DL, Coe JB, Macmartin C, Stone EA, Dewey CE.

Qualitative study of the communication expectations of

clients accessing oncology care at a tertiary referral cen-

ter for dogs with life-limiting cancer. J Am Vet Med Assoc.

2014;245(7):785–795.

16. Küper AM, Merle R. Being nice is not enough—exploring

relationship-centered veterinary care with structural equa-

tion modeling. A quantitative study on German pet own-

ers’ perception. Front Vet Sci. 2019;6:56. doi:10.3389/

fvets.2019.00056

17. Shaw JR, Adams CL, Bonnett BN. What can veterinar-

ians learn from studies of physician-patient communica-

tion about veterinarian-client-patient communication? J

Am Vet Med Assoc. 2004;224(5):676–684. doi:10.2460/

javma.2004.224.676

18. Coe JB. Communication During Veterinarian-Client-

Patient Interactions in Companion Animal Practice. Doc-

toral thesis. University of Guelph; 2008.

19. Shaw JR, Adams CL, Bonnett BN, Larson S, Roter DL.

Veterinarian satisfaction with companion animal visits. J

Am Vet Med Assoc. 2012;240(7):832–841. doi:10.2460/

javma.240.7.832

20. Adams VJ, Campbell JR, Waldner CL, Dowling PM,

Shmon CL. Evaluation of client compliance with short-

term administration of antimicrobials to dogs. J Am

Vet Med Assoc. 2005;226(4):567–574. doi:10.2460/

javma.2005.226.567

21. McArthur M, Fitzgerald J. Evaluation of a communication

skills training program for companion-animal veterinar-

ians: a pilot study using RIAS coding. J Vet Med Educ.

2016;43(2):111–125. doi:10.3138/jvme.0215-016R2

22. Shaw JR, Barley GE, Hill AE, Larson S, Roter DL. Communica-

tion skills education onsite in a veterinary practice. Patient Educ

Couns. 2010;80(3):337–344. doi:10.1016/j.pec.2010.06.012

Unauthenticated | Downloaded 08/03/24 06:52 PM UTC

23. Shaw JR, Barley GE, Broadfoot K, Hill AE, Roter DL. Out-

comes assessment of on-site communication skills educa-

tion in a companion animal practice. J Am Vet Med Assoc.

2016;249(4):419–432. doi:10.2460/javma.249.4.419

24. Roter D, Larson S. The Roter interaction analysis sys-

tem (RIAS): utility and exibility for analysis of medical

interactions. Patient Educ Couns. 2002;46(4):243–251.

doi:10.1016/s0738-3991(02)00012-5

25. Kurtz SM, Silverman J, Draper J. Teaching and Learning

Communication Skills in Medicine. 2nd ed. Radclie Medical

Press; 2005.

26. Janke N, Shaw JR, Coe JB. Veterinary technicians

contribute to shared decision-making during com-

panion animal veterinary appointments. J Am Vet

Med Assoc. 2022;260(15):1993–2000. doi:10.2460/

javma.22.08.0380

27. Janke N, Shaw JR, Coe JB. On-site communication skills

education increases appointment-specic client satisfac-

tion in four companion animal practices in Texas. J Am

Vet Med Assoc. 2022;260(13):1711–1720. doi:10.2460/

javma.22.06.0242

28. Adams CL, Kurtz S. Skills for Communicating in Veterinary

Medicine. Otmoor Publishing; 2016.

29. Kraut AS, Omron R, Caretta-Weyer H, et al. The ipped

classroom: a critical appraisal. West J Emerg Med.

2019;20(3):527–536. doi:10.5811/westjem.2019.2.40979

30. Shaw JR, Adams CL, Bonnett BN, Larson S, Roter DL. Use

of the roter interaction analysis system to analyze veter-

inarian-client-patient communication in companion ani-

mal practice. J Am Vet Med Assoc. 2004;225(2):222–229.

doi:10.2460/javma.2004.225.222

31. Shaw JR, Bonnett BN, Adams CL, Roter DL. Veterinari-

an-client-patient communication patterns used during

clinical appointments in companion animal practice. J

Am Vet Med Assoc. 2006;228(5):714–721. doi:10.2460/

javma.228.5.714

32. Roter DL, Stewart M, Putnam SM, Lipkin MJ, Stiles W,

Inui TS. Communication patterns of primary care phy-

sicians. JAMA. 1997;277(4):350–356. doi:10.1001/

jama.277.4.350

33. Johnson RL, Roter D, Powe NR, Cooper LA. Patient

race/ethnicity and quality of patient-physician com-

munication during medical visits. Am J Public Health.

2004;94(12):2084–2090. doi:10.2105/ajph.94.12.2084

34. Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs

DM, Powe NR. Patient-centered communication, ratings of

care, and concordance of patient and physician race. Ann

Intern Med. 2003;139(11):907–915. doi:10.7326/0003-

4819-139-11-200312020-00009

35. Wissow LS, Roter D, Larson SM, et al. Mechanisms behind

the failure of residents’ longitudinal primary care to pro-

mote disclosure and discussion of psychosocial issues.

Arch Pediatr Adolesc Med. 2002;156(7):685–692.

36. Shaw JR, Adams CL, Bonnett BN, Larson S, Roter DL. Vet-

erinarian-client-patient communication during wellness ap-

pointments versus appointments related to a health prob-

lem in companion animal practice. J Am Vet Med Assoc.

2008;233(10):1576–1586. doi:10.2460/javma.233.10.1576

37. Cornell KK, Coe JB, Shaw DH, Felsted KE, Bonvicini

KA. Investigation of the eects of a practice-level com-

munication training program on veterinary health-care

team members’ communication condence, client

satisfaction, and practice nancial metrics. J Am Vet

Med Assoc. 2019;255(12):1377–1388. doi:10.2460/

javma.255.12.1377

38. Mansouri M, Lockyer J. A meta-analysis of continuing

medical education eectiveness. J Contin Educ Health

Prof. 2007;27(1):6–15. doi:10.1002/chp.88

39. Stewart M, Brown JB, Weston WW, McWhinney IR,

McWilliam CL, Freeman TR. Patient-Centred Medicine:

Transforming the Clinical Method. 3rd ed. Taylor & Francis;

2014.

40. Sutherland KA, Coe JB, Janke N, O’Sullivan TL, Parr JM.

Pet owners’ and companion animal veterinarians’ per-

ceptions of weight-related veterinarian-client communi-

cation. J Am Vet Med Assoc. 2022;260(13):1697–1703.

doi:10.2460/javma.22.03.0101

41. Lang F, Floyd MR, Beine KLB, Buck P. Sequenced ques-

tioning to elicit the patient’s perspective on illness: eects

on information disclosure, patient satisfaction, and time

expenditure. Fam Med. 2002;34(5):325–330.

42. Adams CL, Bonnett BN, Meek AH. Predictors of owner re-

sponse to companion animal death in 177 clients from 14

practices in Ontario. J Am Vet Med Assoc. 2000;217(9):1303–

1309. doi:10.2460/javma.2000.217.1303

43. Lue TW, Pantenburg DP, Crawford PM. Impact of the own-

er-pet and client-veterinarian bond on the care that pets

receive. J Am Vet Med Assoc. 2008;232(4):531–540.

44. Roter DL, Larson S, Shinitzky H, et al. Use of an innova-

tive video feedback technique to enhance communi-

cation skills training. Med Educ. 2004;38(2):145–157.

doi:10.1111/j.1365-2923.2004.01754.x

45. Dysart LM, Coe JB, Adams CL. Analysis of solicitation of

client concerns in companion animal practice. J Am Vet

Med Assoc. 2011;238(12):1609–1615.

46. Noguiera Borden LJ, Adams CL, Bonnett BN, Shaw JR, Ribble

CS. Use of the measure of patient-centered communica-

tion to analyze euthanasia discussions in companion ani-

mal practice. J Am Vet Med Assoc. 2010;237(11):1275–

1287. doi:10.2460/javma.237.11.1275

47. Stewart M, Brown JB, Weston WW. Patient-centred in-

terviewing part III: ve provocative questions. Can Fam

Physician. 1989;35(January):159–161.

48. Fults MK, Yagi K, Kramer J, Maras M. Development of

advanced veterinary nursing degrees: rising interest

levels for careers as advanced practice registered vet-

erinary nurses. J Vet Med Educ. 2021;48(3):242–251.

doi:10.3138/jvme.2019-0041

49. Adams CL, Conlon PD, Long KC. Professional and veteri-

nary competencies: addressing human relations and the

human-animal bond in veterinary medicine. J Vet Med

Educ. 2004;31(1):66–71. doi:10.3138/jvme.31.1.66

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