Photo courtesy Dr. Karen Becker It’s a bustling Monday in the veterinary hospital. With an elaborate conglomeration of previously scheduled appointments and same-day sick appointments, you know you are destined for sensory overload. With enthusiasm, you dive into patient records to see what you are up against. The first nine appointments look straightforward, but the 10th elicits a guttural response. Your allotted 20-minute, 2 p.m. appointment is with Sir Nips-A-Lot, owned by Ms. Flutter. Blazing in red, the alerts on his chart read, he “does best when taken to the back room.” Well-known for his aggressive displays of communication, Sir Nips-A-Lot will need a physical exam, blood work, a rabies vaccine, nail trim, and, of course, a tooth evaluation for possible infection. Understanding that his aggressive behaviors are likely a manifestation of fear, stress, or anxiety, and that the veterinary clinic is pretty good at inducing these emotions, you gingerly tiptoe into the room to evaluate the relevant collective tensions. After quickly assessing Sir Nips-A-Lot’s stress to determine how best to support him, you unlock the vault of your wisdom. Science-based, modern medicine has provided us with many resources to understand behavioral and psychological aspects of stress. Tools, such as the Canine Behavioral Assessment & Research Questionnaire (C-BARQ), enable us to evaluate behavioral changes, while psychological changes can be gauged through measurements of blood cortisol levels, heart rates, body temperatures, frequency of lip-licking, and more. However, the quickest measurement is observing the patient’s body language. With dilated pupils and adhering to his owner, Sir Nips-A-Lot is yawning, whining, and trembling. Revisiting the alert, the big question is, “Why the back room?” Unless there is something miraculously comfortable there, it seems counterintuitive to remove him from his owner and the room. You, the patient, and the owner Only after I began doing house calls did I truly appreciate the stark contrast in how my patients reacted to routine veterinary procedures in a hospital versus in the comfort of their own home. No doubt, there are obvious variables accounting for these differences. Avoiding car travel, sights, sounds, and smells associated with the hospital indisputably attenuates the stress response, making other aspects of the veterinary visit more tolerable. However, even with these factors eliminated, I continued to observe the fearful expressions, tense postures, and anxious demeanor of my patients, that almost invariably sought refuge in the presence of their human caregivers. My fearful and anxious patients consistently showed reduced signs of stress and anxiety when handled with gentle care and when their owners were actively present, whether at home or in the hospital exam room, and research supports this observation. There are physiological and psychological advantages to both allowing owners to remain present with their pets and allowing them to interact with their pets during the exam.1 Author Anastasia Stellato, PhD, found that when owners are present and permitted to actively participate in their dog’s exam, by comforting in the form of petting and talking to their pet, their dogs have reductions in heart rates, lower body temperatures, vocalize less, and yawn less frequently.2 Gentle, low-stress handling of our patients in the exam room and with their owners present reduces patient stress, improves animal welfare, builds client trust, and positively impacts production. Photo courtesy Dr. Karen Becker With clinically significant information suggesting common treatment areas spike stress levels, it is in the animal’s best interest to perform exams and procedures with the owner present.3 So, why do we continue to bring patients away from their owners to the “back room”? Throughout my 22 years in practice, the most frequent reasons I have observed for staff moving patients to the back include concerns about the pet reacting poorly to restraint, needles, or procedures; apprehension an owner may be distressed by the restraint method; fears of potential injury to staff or the owner; and the pressures of a demanding work environment that push employees to prioritize efficiency. Of most concern is that the leading reason for relocating patients away from their owners was not medical necessity, but rather the pressure employees feel due to limited time. They worry keeping both the pet and owner together will significantly extend the duration of the exam. Let’s face it, veterinary professionals feel pressured to produce a certain level of revenue and to meet production targets, but does gentle, low-stress handling of our patients in the room with their owners take too much time? Should generated revenue and production numbers supersede animal welfare? Looking at ethical and welfare issues Let’s delve into the ethical and welfare issues embedded in these questions by exploring the benefits of keeping our patients in the room with their owners. Ms. Flutter has expressed a range of emotions, from worry to embarrassment, over bringing Sir Nips-A-Lot into the hospital. She feels a lack of control over the pet’s distress, is worried it may injure someone or itself, anticipates cleaning up its urine and stool, and questions the long-term psychological impacts of the exam on the pet. Ms. Flutter’s fears are valid because even just one particularly stressful vet exam can lead to potential long-term neurochemical changes.4 For veterinarians and technicians, the veterinary visit becomes an art of navigating the patient’s needs aside from maneuvering the emotions of their owner. The 2011 Bayer study on veterinary care usage reported that “cat owners found taking their animal to the veterinarian highly stressful for the animal and themselves.”5 In the exam room, certified veterinary technician, Laura Sestito Maloney, uses gentle handling to trim her patient’s nails while allowing the owner to help. PHOTO COURTESY LAURA SESTITO MALONEY, CVT, CPDT-KA Issues, such as their cats resisting the carrier, vocalizing during transport, stress in the waiting room with other animals, stress during the exam, and unfavorable lingering behaviors after returning home, cause owners to want to circumvent future visits. It was found many owners felt stressed bringing their dog to the hospital and reported that “their dog “hates” going to the veterinarian.”5 An owner’s perception of their animal’s stress does indeed directly impact animal health and welfare. According to Edwards et al., “addressing fear at the veterinary clinic and promoting pet-friendly practice is integral to the continual improvement of companion animal welfare.”6 Allowing guardians to remain involved in the treatment and care of their pet opens the doors of communication, builds trust with that client, and influences client choice of veterinarian and how frequently they bring their pets in for treatment.6 According to Fitzgerald et al., owners “want to see their veterinarian interact compassionately with their dog,”7 especially when handling of that pet becomes challenging for humans and stressful for patients.8 Owners want confidence in their pet’s safety with the staff and peace of mind that their pet won’t cause harm. The Guide for Practitioners in Veterinary Clinics of North America reports that fearful pets pose a risk for injuring themselves, staff, and owners, and may become injured from restraint;9 When an owner is petting and talking to their dog, that dog will be less likely to jump off the table and succumb to injury.1 Feline patient, Otis, is receiving food rewards and comfort from his owner during an ear exam by Dr. Becker. Photo courtesy Dr. Karen Becker Keeping Sir Nips-A-Lot and Ms. Flutter in the room creates the perfect opportunity to teach her about her pet’s body language. It also builds client confidence, which translates to better healthcare and patient welfare outcomes. According to the 2015 AAHA Behavior Guidelines, Ms. Flutter will be more likely to bring Sir Nips-A-Lot into the hospital for non-urgent appointments when she sees her pet is handled in a gentle, low-stress way by staff trained in behavior modification. Client trust increases client retention, which in turn is a win for hospital revenue and profitability.10 Ethically speaking, upon graduation, veterinarians and technicians take a pledge to advocate for the health and welfare of animals. Veterinarians are expected to adhere to a comprehensive code of medical ethics, which, according to the American Veterinary Medical Association (AVMA), includes fundamental principles of stewardship, integrity, and respect. In recent years, a new language emphasizing animal welfare was added to the Veterinarian’s Oath. According to J. Bruce Nixon, DVM, chairman-elect of the Animal Welfare Commission (AWC): “From today forward, every graduate entering our profession will swear an oath not only to protect animal health but also welfare; to not only relieve animal suffering but to prevent it. That’s a powerful statement defining ourselves and our responsibilities, not a vague symbol.”11 Putting into practice By keeping Sir-Nips-A-Lot and Ms. Flutter in the exam room, this appointment I have stepped into will be profitable. As I enter, I am greeted with a warm smile, somewhat veiled with apprehensive tones. Sir-Nips-A-Lot has been given his anxiolytic medication and was properly basket muzzled by Ms. Flutter, who encourages the pet to move out of the corner. She stands at Nip’s front, gently talks to him, pets his neck, and feeds him the turkey she lovingly brought to his visit. As the physical exam is underway, a sense of relief comes over Ms. Flutter’s face. She appreciates being allowed to help with her pet’s treatment and learns from the veterinary staff the proper way to manage Nip’s anxiety and aggressive displays in the hospital. She expresses relief and gratitude that her pet is being treated with dignity, respect, and kindness. Nips growls when his foot is touched, but Ms. Flutter has learned the art of redirection. Blood is drawn from his hind leg using little to no restraint while Ms. Flutter increases the value of his food rewards at his front. With a gentle touch, a tongue depressor loaded with cheese spread touches Nip’s mouth in a way that allows for a dental inspection. This exam, performed in a reasonable amount of time, has laid the foundation for cooperative advocacy, in which both client and doctor mutually desire to compassionately and responsibly advocate for Sir-Nips-A-Lot’s health and welfare. With continued trust of the owner and patient, we will see Sir-Nips-A-Lot for future well exams, and profitability most certainly will grow. Karen Becker, VMD, is a small animal veterinarian with training and special interests in Clinical Animal Behavioral Medicine. She offers comprehensive behavioral consultations for dogs and cats who struggle with a variety of behavioral issues, is committed to promoting behavioral wellness in companion animals, and to protecting the human-animal bond. Dr. Becker is passionate about educating owners on canine and feline communication and proper socialization and is a strong advocate for teaching behavioral modifications that incorporate solely positive reinforcement techniques. Following a two-year term as president elect, Dr. Becker now serves as president of the American Veterinary Society of Animal Behavior. She is Fear Free Certified, is licensed in Pa., and N.J., and is a long-standing member of the American Veterinary Medical Association (AVMA). References Csoltova, E., Martineau, M., Boissy, A., Gilbert, C. (2017), Behavioral and physiological reactions in dogs to a veterinary examination: Owner-dog interactions improve canine well-being. J Physiology & Behavior, 177:270-281. https://doi.org/10.1016/j.physbeh.2017.05.013 Stellato, A., Dewey, C., Widowski, T., Niel, L. (2020), Evaluation of associations between owner presence and indicators of fear in dogs during routine veterinary examinations. J Am Vet Med Assoc; 257:1031–1040. https://doi.org/10.2460/javma.2020.257.10.1031 Mandese, W.W., Griffin, F.C., Reynolds, P.S., Blew, A.C., Deriberprey, A.S. and Estrada, A.H. (2021), Stress in client-owned dogs related to clinical exam location: a randomised crossover trial. J Small Anim Pract, 62: 82-88. https://doi.org/10.1111/jsap.13248 Overall, K.L. Karen Overall on the Effects of Fear on Veterinary Patients. 2014. Available online: http://veterinarynews.dvm360.com/facing-fear-head-tips-veterinarians-create-more-behavior-centered-practice (accessed on 21 December 2016). Volk, J.O., Felsted, K.E., Thomas, J.G., Siren, C.W. ( 2011), Executive summary of the Bayer veterinary care usage study. J. Am. Vet. Med. Assoc. 238, 1275–1282. https://doi.org/10.2460/javma.238.10.1275 Edwards PT, Hazel SJ, Browne M, Serpell JA, McArthur ML, et al. (2019) Investigating risk factors that predict a dog’s fear during veterinary consultations. PLOS ONE 14(7): e0215416. https://doi.org/10.1371/journal.pone.0215416 McArthur M, Fitzgerald J. Companion animal veterinarians’ use of clinical communication skills. Australian Veterinary Journal. 2013;91(9):374–80. https://doi.org/10.1111/avj.12083 Moberg G. (2000), Biological response to stress: implications for animal welfare. USA 2000. p. 1–21. In: Moberg, G.P. and Mench, J.A., Eds., The Biology of Animal Stress: Basic Principles and Implications for Animal Welfare, CABI Publishing, New York, 1-21. https://doi.org/10.1079/9780851993591.0001 Frank D. (2014), Recognizing behavioral signs of pain and disease: a guide for practitioners. Veterinary Clinics of North America: Small Animal Practice, 4;44(3):507–24. https://doi.org/10.1016/j.cvsm.2014.01.002 Marcy Hammerle, Christine Horst, Emily Levine, Karen Overall, Lisa Radosta, Marcia Rafter-Ritchie, Sophia Yin; 2015 AAHA Canine and Feline Behavior Management Guidelines. J Am Anim Hosp Assoc 1 July 2015; 51 (4): 205–221. doi: https://doi.org/10.5326/JAAHA-MS-6527 AVMA delegates approve changes to veterinary medicine ethics policy. https://www.avma.org/javma-news/2011-01-01/veterinarians-oath-revised-emphasize-animal-welfare-commitment.
