Communication is a clinical skill (part 5)

Shot-put or Frisbee approach

All of our attempts to improve communication can be reduced to two basic perspectives: the Shot-put approach and the Frisbee approach (Figure 1). The shot-put defines communication simply as the well-conceived, well-delivered message or more affectionately referred to as the “Park and Bark”. Many of us have attended lectures over the years, some of which are not of the highest quality and some of the following have contributed to them being less desirable:

• The lecturer speaks solid for 50 minutes and is unwilling to take questions until the end
• The lecturer used jargon you cannot understand
• The lecturer looses you early on in his talk and you have trouble making sense of anything said thereafter
• You are given too much or too little information
• You are not sure what the key points are of the lecture
• You cannot recall much of anything that was said when you return to work and are asked to report on what you learned

In the practice of veterinary medicine and especially during times in the appointment when we are giving information we can apply our experience from the lecture described above to how our clients might be feeling. The impact of the lecture noted above is reminiscent of a shot-put approach to communicating. We can optimize information giving and move toward a “Frisbee” approach by using the following communication skills:

Effective communication is comprised of what you want to tell the client, the delivery of the content or information and persuasion – you prepare your message carefully, you heave it out there, and your job is done. “Telling” is central to this approach; feedback is nowhere in the picture. Part of the reason that this approach is so prevalent might have to do with the fact that communication training and/or modeling has focused on the shot-put for years. Only in the middle of the twentieth century did the focus begin to shift from one-way to interpersonal communication or more informally named the Frisbee approach 1.

There are two concepts central in the Frisbee approach. The first is confirmation defined as recognizing, acknowledging, and endorsing another. To be clear confirmation does not equate to agreement. You might disagree terribly with a client’s desire to re-home her cat but you can still confirm her request with a simple “I hear that you are frustrated with Molly’s inappropriate urination throughout the house and are considering finding her a new home (because you’ve tried everything that we’ve talked about so far)”.

The second concept that goes with the Frisbee approach is mutually understood common ground. This common understanding that both people in an interaction are aware they share is a necessary foundation for trust and accuracy of information exchanged. Veterinarians and clients reach this common ground by talking with each other about it. A veterinarian might arrive at her awareness of common ground when what seems like a very stubborn client indicates that in spite of the financial challenges she is having she does want to do what is best for the dog with due consideration of the costs. This provides a starting place for shared decision-making regarding the patient going forward. So, if confirmation and mutually understood common ground are important to effective communication, the shot-put approach’s reliance on the well-conceived well-delivered message is inadequate. In the Frisbee approach the message is still important but the emphasis is on a back and forth interaction, provision of feedback to one another and collaboration. If communication is actually an interactive process, the interaction is complete only if the sender received feedback about how the message is understood. Simply put, we must develop and maintain a relationship throughout the consultation.

A relationship-centered approach or what is referred to in the literature, as Relationship Centered Care is becoming an accepted standard for the veterinarian-client relationship. Relationship centered interactions are characterized as a partnership in which negotiation and shared decision making are used to take the client’s perspective into consideration for the purpose of being able to provide the best options for the patient. Elicitation of the client’s perspective and interests, needs and expectations, feelings and beliefs can be gathered using the Frisbee approach. You might be thinking – a relationship-centered approach will take up way too much time. Communication research reveals that relationship centered consultations (RCC) take less time than traditional appointments with RCC taking 10.43 minutes and traditional taking 11.98 2. Once the skills essential for RCC are mastered appointments are more efficient and satisfying for the client and the veterinarian 3.