Patient compliance can limit care. Fear, anxiety, or stress may hinder safe medication, exams, or treatment, while the stress of treatment can strain the pet-family bond. Photo courtesy Dr. Kate Boatright In fall 2022, my cat, Gambit, was diagnosed with intermediate cell lymphoma. After meeting with an oncologist to discuss treatment options, my first instinct was to pursue the most aggressive chemotherapy protocol offered, but my husband and I had to consider many factors. Gambit and I were very closely bonded, which meant he would tolerate a lot from me—but only me. I could administer oral medications and put him in a carrier with minor struggles, but no one else could. With my travel schedule, weekly visits to the oncologist would be difficult; administering daily medication would be impossible. Additionally, the specialty hospital was an hour away, which meant a huge time commitment to travel to appointments. Plus, Gambit did not enjoy travel, even with a heavy dose of gabapentin. Gambit’s temperament, the location of the specialty hospital, and my travel schedule posed a potential barrier to care for us. This story is not unique to my family. While we often discuss the barriers keeping pet owners away from the veterinary clinic during access-to-care conversations, it is important we also consider the numerous barriers preventing clients in the clinic from following the veterinary team’s recommendations. While finances are the most common factor, there are many other client, patient, and practice factors impacting patient care, client satisfaction, and veterinary team morale. Veterinary teams must learn to communicate compassionately with clients to identify potential barriers. Once identified, veterinary teams can partner with clients to identify solutions using a spectrum of care approach. How to effectively identify and overcome barriers Practicing a spectrum of care allows veterinary teams to identify these barriers and work with individual pet families to find a solution. This allows more patients to receive care, improves client satisfaction, and reduces stress for veterinary team members. In fact, the most recent update to the Principles of Veterinary Medical Ethics (PVME) now includes contextual care as part of a veterinarian’s code of conduct.1 It now states: “A veterinarian should be prepared to offer a range of diagnostic, treatment, and when deemed appropriate, referral options that meet the needs of both the patient and the client.”1 Veterinary teams must learn to ask clients questions in an empathetic and nonjudgmental way to help identify and solve potential barriers. Once identified, veterinary teams and pet owners can work together to come up with a solution using a spectrum of care approach. Photo courtesy Dr. Kate Boatright When a client declines a recommendation or returns for a recheck and has been noncompliant with the original plan, veterinary teams should get curious. Ask the client to share why they are declining the recommendation in the moment, were not able to administer a medication, or did not come for the originally scheduled follow-up. By getting curious, veterinary team members can start to identify barriers that may be solvable. When asking these questions, it is essential to phrase them in an empathetic and nonjudgemental way. One of the most important communication tools veterinary teams can use is open-ended questions. These questions invite the owner to engage in conversation and answer with more than a yes or no (See “Get curious”) and can be used throughout the visit—from check-in to history taking and when reviewing treatment plans and discharge instructions. Get curious Here are sample questions your team can ask clients to help identify individual barriers: “What is your budget today?” “What concerns do you have?” “What are your goals for today’s visit?” “How has your pet handled medications in the past?” “What does your typical schedule look like?” “How are you feeling about the treatment plan we’ve discussed?” “What questions do you have about what we’ve discussed?” However, for these questions to have the most impact, we must stop talking and allow the client time to respond fully. In one study of veterinary communication, researchers found while most of the appointments observed included open-ended questions intended to solicit client concerns, over half of the clients were interrupted during their response.2 On average, these interruptions occurred within 15.3 seconds of the client beginning to speak.2 Team members should utilize reflective listening to ensure they fully understand the client’s concerns and identify potential barriers. When discussing diagnostic and treatment options with a client, the veterinary team must maintain empathy and withhold judgment. The way options are presented to a client can influence both their decision and their feelings about it. Clients have a bias toward assuming the first option presented is the best option, so if options are always presented with the most invasive/expensive/intensive option first, even when the team knows this is not feasible for a client, we can inadvertently make the client feel guilty for not choosing the first option presented.3 Instead, start by presenting the option that seems to be the best fit for the individual circumstances, followed by other options—ranging from traditional “best practice” to less invasive or intensive options. Addressing patient compliance Sometimes, as in Gambit’s case, patient compliance is a major limiting factor to care. Some pets, no matter how hard we try, are nearly impossible to medicate safely. Other times, the pet’s fear, anxiety, and stress during transport or in the clinic limits the team’s ability to examine or perform diagnostics and treatments. Additionally, the stress of treatment can negatively impact the bond between pet and family, creating a further barrier to continued care. When looking at possible solutions for patient compliance barriers, it is essential to consider not only patient, client, and staff safety but also patient stress, pain levels, and the potential impact on the bond between client and pet. Potential treatment plans should consider patient comfort and quality of life, which includes prioritizing pain management and minimizing stress. The author, Dr. Kate Boatright, with her pet cat, Gambit. Photo courtesy Dr. Boatright For patients that are difficult to medicate, considering alternative routes of administration is often the first step. When possible, long-acting formulations may be used, as they eliminate both the concern for patient and client compliance. Sometimes, changing the medication frequency or switching the formulation from a pill to a liquid or a transdermal preparation (provided there is adequate absorption) can be helpful. In other cases, consideration should be given to treatment options that are nonoral (e.g. topical treatments for skin disease) or dietary changes (e.g. prescription diets for hyperthyroidism.) Pros and cons of each treatment option should be discussed with owners, as well as potential side effects and plan B if the first attempt is unsuccessful. Veterinary team members can also help by instructing clients on how to administer various medications and provide tips. In some cases, especially with short-term treatments, veterinary team members may be able to travel to the owner’s house or have the pet receive medication in the clinic. Minimizing travel- or clinic-related stress for patients can also be accomplished in many ways. In addition to using pre-visit pharmaceuticals, Fear Free handling techniques, and working with owners on strategies to minimize transport stress, veterinary teams should discuss the number of visits patients may need to manage certain conditions. Perhaps for a highly stressed patient like Gambit, a treatment option that requires fewer trips to the hospital for monitoring and in-hospital treatments may be the best option. Alternatively, relying on at-home monitoring options, such as continuous glucose monitors or at-home glucose curves for diabetic patients, or recommending a mobile veterinarian may help to decrease some of these stressors and improve quality of life for the patient. Navigating client-specific barriers There are several client factors beyond financial limitations that can create barriers. Clients may have work schedules or other obligations that make it difficult to travel to a referral hospital (especially if there is a large distance), bring their pet in for regular follow-up appointments, or administer medications on a rigid schedule multiple times a day. They may lack reliable transportation to and from appointments or have a physical limitation that prevents them from bending down to administer injections or other medications. Many of the options to navigate patient barriers—such as changing medication frequency or choosing a treatment plan that requires fewer visits to the hospital—can be applied in situations of client limitations. Other potential solutions for client-related barriers include: Offering outpatient care or a hybrid in-patient care (where patients are hospitalized during the day and sent home overnight) when transfer to a 24-hour hospital is not feasible. Phone or virtual consultation with a specialist to guide case management in the primary care hospital. Using telehealth for follow-up visits or providing support for managing chronic conditions such as diabetes, weight loss, osteoarthritis, or behavior cases. Developing a way to get a pet onto a higher surface, such as a table, to make it easier for clients with mobility concerns to give medication or injections. Medical boarding for a pet that needs frequent medications for a short period of time (i.e. intensive medical management of a melting ulcer). In each case, clients should be presented with options, including the traditional best practice. Veterinarians and their teams should document the options discussed and why certain options were declined or chosen. The art of the spectrum of care approach In Gambit’s case, we elected to pursue a middle-ground chemotherapy option that required less frequent trips to the oncologist. We combined monitoring bloodwork and treatment into a single visit. While this made individual visits longer, the trade-off of having fewer car trips minimized stress for everyone. We tried several formulations for his oral steroids and ultimately discovered that when I traveled, injectable steroids were the best option. We also accepted that there would be occasional missed doses of the oral chemotherapy. While not the gold-standard, by the book treatment of lymphoma, this worked for our family and gave us another 14 months of good quality time with Gambit. At every step of our treatment journey, no matter what new barrier we faced, the oncology team supported us. They laid out the options, discussed the pros and cons, and helped us navigate each decision without ever making us feel pressured to do more or judged for declining a certain test or treatment plan. This is the art of spectrum of care medicine—building a partnership with clients to identify potential barriers, determining solutions for each one, and presenting the options in a way that lets the client know you will support the decisions they make without judgment. Many veterinary teams do this regularly, whether they call it spectrum of care medicine or not. Starting to recognize this type of practice for what it is will allow us to continue to have important profession-wide discussions about how best to support our clients and provide more care for more pets. Kate Boatright, VMD, is a small animal general practice and emergency veterinarian, speaker, and author in Western Pennsylvania. Dr. Boatright enjoys discussing mentorship, the spectrum of care, well-being, communication, and professional collaboration. In March 2023, Boatright published the Veterinary Mentorship Manual, a resource for practices to help guide them in developing solid mentorship programs. References AVMA. Principles of veterinary medical ethics of the AVMA. Available at https://www.avma.org/resources-tools/avma-policies/principles-veterinary-medical-ethics-avma. Accessed Aug 28, 2024. Dysart LM, Coe JB, Adams CL. Analysis of solicitation of client concerns in companion animal practice. JAVMA 2011;238(12):1609-15. https://pubmed.ncbi.nlm.nih.gov/21671816/ Benson J and Tincher EM. Cost of care, access to care, and payment options in veterinary practice. Veterinary Clinics of North America: Small Animal Practice 2024;54(2):235-250.
