“Could you repeat that one more time for my husband?” I was too new to get exasperated. Only in my second year of clinical practice, I was not yet jaded. Sure, I had just spent 10 minutes laying out the range of options for Tom, a 14-year-old male neutered black Labrador. He presented for a decubital ulcer on his left hock, and the plan was fairly straightforward: basic wound care, bandaging, antibiotics, and recheck in a couple of days. Tom was a sweetheart, and even though he staggered into the clinic like his joints were filled with frozen hydraulic fluid, he did great for his treatment. I was optimistic we could get the wound healed within a few weeks. The client, a warm and intelligent woman in her early 70s, listened patiently. I had never met her before, but honestly, the communication had been going really well. We set an agenda early, agreed upon the estimated cost of care, contracted for next steps, and listened to each other like excellent collaborators. It was textbook relationship-centered care.1 However, the warm, pleasant feeling I would almost describe as feeling like a competent medical professional was about to vanish like a steaming turd in front of a coprophagic Labradoodle. Tom’s owner asked me if I wouldn’t mind going over all of that again for her husband, who was waiting in the lobby. She explained he had recently been diagnosed with Parkinson’s and had difficulty walking. The slight incline of the hallway and the tight exam room were too much for him. I was confused at first, because our rooms didn’t seem particularly cramped, but as I walked up front with an eager beaver jaunt in my step, it suddenly made sense. I’m not short, but I was physically struck by his stature. Half expecting a withered old septuagenarian, I nearly walked right into the imposing 6’8” hulk of a man in the lobby. With broad shoulders and a blank face, he loomed over me. Probably–in retrospect–panicking a little, I quickly introduced myself and then hurriedly launched into explosive verbal diarrhea. Reading absolutely no expression on his face, I breathlessly reiterated the same explanation of Tom’s wound I had given his wife. The man simply stood motionless, towering and looming, and staring at me with his sharp gray eyes. By the time I had run out of air, his wife walked up with the dog. The man’s lips curled slowly at the edges into a slight smile. Then a tiny, barely perceptible nod of his head in my direction acknowledged he had heard my spiel, and the three of them headed to their car. Before leaving, the wife came back and thanked me. She loved Tom, but even more importantly, the dog was the entire world to her husband, who was slowly losing his ability to communicate. Tom kept his spirit strong. Hmm, I thought, not sure I needed that extra pressure, but oh well, how hard could this little wound be? GETTYIMAGES/DENGUY How do I put this? Two days later, Tom returned for his bandage change. The wound looked worse. It was larger, deeper, wider–moving in exactly the wrong direction. While the nurses cleaned the wound, I took a deep breath and went into the exam room. The wife listened politely, thanked me, and once again reminded me how important Tom was to her husband. She would do whatever was necessary. We submitted a culture, and Tom returned the next day. It didn’t look any better. This time, the husband came, waiting in the lobby for his dog. Walking up to the imposing figure with the stern face, I started babbling again. Resistance, antibiotics, susceptibility, blah! Blah! Blah! I probably threw in a few words I heard in veterinary school just because they sounded impressive. His expression didn’t change at all, even when I stopped in exhaustion, but he did speak, slowly and deliberately. “Okay, Doc.” For the next three days (an interminable eon), the wound made no progress. Each day, we replaced the dressings, and I updated Tom’s owners we weren’t on track yet. My conversations with the wife were calm and measured, but I kept blurting out in-depth lectures on fibroblast physiology to the gigantic, implacable husband in the lobby. Finally, microbial susceptibility results came back. It was a mixed bag, multiple isolates with clearly no superior antibiotic option. Not to mention problematic trade-offs every way I looked. I called an internist, checked in with colleagues, and scratched my head until I hit dura mater, and made some frantic adjustments. Nothing appeared to be helping. We tried fancy wound dressings. We tried low-level laser therapy. I offered a referral to a specialist, but Tom’s owners insisted they had faith in me. They never flinched at the mounting costs. For days, and then weeks, Tom’s owners waited in the lobby while the aging dog got his treatments “in the back.” I would come up front and do my best to sound optimistic, but I could not hide my disappointment in the nonhealing wound from the husband’s piercing gray eyes. Once, to my horror, a scalpel-happy colleague took Tom to surgery and excised the wound when I was out of town for a week. It dehisced a few days later. The elderly dog would walk in and out of the hospital, with a different color of bandaging, the only sign anything had changed. Every time I talked to the husband, I was unsettled by his lack of facial expression, and I pitched into wobbly and rushed explanations of the situation. Years later, I would learn communication research has consistently shown something I was accidentally demonstrating: clients do not simply respond to whether we’re competent. They respond to whether we appear rushed.2,3,4 Veterinarians perceived as hurried lose client trust, even when the medical care itself is unchanged At the time, ignoramus of veterinary communications science that I was, I simply suffered through it–until I couldn’t anymore. Ground to a halt One day, after months of fighting the Decubital Ulcer from Hell, I gave up. Dropping the pretense of clinical authority, I admitted to the wife I wasn’t sure what to do. The weight of fixing this unfixable problem, of rescuing this decrepit dog from the universe’s inexorable entropy, and of saving the old man’s dwindling dendritic connections, was too much for me (I didn’t say all that, I just said I wasn’t sure what to do). A pained look appeared on her face, but within moments was replaced by a wise and subtle smile. She and her husband still trusted me, she told me, and they were willing to try whatever I thought best. Briefly contemplating a request for $20k and a foreign visa, I instead groped for a new treatment plan. Let’s manage this fragile tissue as an open wound, I said. Let’s throw some ciprofloxacin at it, even with its pesky bioavailability data, and let’s submit to the mercy of the gods of veterinary medicine. As always, she warmly agreed, but I flinched when she asked me to explain the plan to her husband. He was too weak to come into the lobby and was waiting outside in the car. Humbled by my failure, I slowly walked out to the parking lot and approached the car. Seated in the passenger seat, the man wasn’t quite as striking, but his head turned toward me with the same familiar gaze. This time, I didn’t rush. With eyes downcast, I simply talked. We were almost out of options, but we weren’t giving up. I didn’t sugarcoat or shoehorn in any optimism. We’d give this a try, but if it didn’t work, I was at a loss as to the next steps. When I looked up, the man’s gray eyes had a slight glisten. They broke contact with mine and pointed toward the ground. Something resembling a slight quaver just barely touched the edges of his lips, and he nodded imperceptibly. His wife came out to the car with the new prescription in hand, and I helped Tom into the backseat, hoping his fibroblasts would finally read their physiology textbooks. Resistance and susceptibility Miraculously, within two days, granulation tissue started to appear. I couldn’t believe it at first, but slowly the gap filled in. A week or so later (which turned out to be the last time I saw Tom), his wound had finally healed. Buoyed by the recent improvement in his beloved dog, the husband had managed to make it into the lobby with his wife for the final visit. As I walked up, she smiled, and I beamed like a kid. I told them Tom was fully healed. The husband’s face gradually warmed into a faint smile. I’d spent so long rushing through and overcomplicating communication with him that I barely noticed I was allowing myself to simply let him go at his own pace. Very slowly, his right hand rose from his side. He extended it toward me and said, “Thank you,” with a slight catch in his voice. I reached out and gave it the world’s most delicate shake. Greg Bishop, DVM, is a small animal veterinarian and a part-time veterinary technology instructor in Portland, Ore. Dr. Bishop also creates the monthly cartoon series, “The Lighter Side.” The author’s opinions do not necessarily reflect those of Veterinary Practice News.
