Introduction 

Just over 50 years ago, the Canadian Veterinary Journal carried an article, presenting an outline of all that was known at that time about feline medicine 1. It ran to ten pages in total. Feline medicine has grown steadily in popularity since then; the first cat-only practices were established in the U.S. in the 1970’s. Veterinarians can now pursue specialty certification in feline medicine and surgery in many countries, and benefit from specific continuing education opportunities, including journals and textbooks devoted to feline medicine. However, a disconnect exists between the advances in feline medicine and what is happening in day-to-day veterinary practice. Although cats have now surpassed dogs as the most popular companion animal in many countries, most veterinary clinics are designed primarily with canine patients in mind. In addition, some alarming statistics about feline veterinary care have been published recently, further highlighting the discrepancy in care for cat patients compared to dog patients. For example, in 2011, feline veterinary visits in the U.S. had decreased 4.4% from 2006, while canine visits increased by over 9% in the same period 2, and it is estimated that fewer than half of the 74 million pet cats in that country receive regular veterinary care. In 2011 in Canada, only 46% of cat owners had taken their cat to the veterinarian in the previous year, compared with 77% of dog owners 3. While these statistics are disappointing, they can be taken as an opportunity to improve feline health and to increase veterinary business.

The reasons for the decline in feline veterinary care are multiple and complex 4. They include issues such as:

• Difficulty getting the cat to the veterinary clinic
• Low levels of owner awareness regarding basic feline medical needs 
• Owner difficulty in recognizing subtle signs of illness in cats
• The perception that cats are able to take care of themselves
• The belief that indoor cats are protected from most illnesses
• The low perceived value of cats, since many cats are acquired accidentally or for free
• Owner discomfort and stress associated with experiences at the veterinary clinic

Why have a cat-friendly clinic?

All veterinarians who treat cats can benefit from an understanding of the unique nature of cats as well as the physiologic and behavioral responses to stress experienced by this species. Cats are bonded to their home environment and seldom leave it by choice. Being forced into a strange environment makes a cat uncertain about its safety, and causes anxiety and distress. Cats prefer to avoid danger and confrontation by running away or hiding, strategies that are not easy to employ during clinic visits. It is important to make a visit to the clinic as pleasant as possible for both cat and owner, and if possible this should start when a kitten or young cat attends the clinic for the first time. This age group is less likely to experience anxiety during a veterinary consultation, which offers an opportunity to bond both client and pet to the clinic by making the visit a positive experience. This is important, as some cat owners will feel that a traumatic experience at the clinic is more detrimental to the cat than a lack of veterinary care. Implementation of approaches to create a feline-friendly practice environment and use of respectful handling techniques will improve welfare and veterinary care for cats; it will also make working with cats safer and more rewarding for the veterinary team. In addition, a focus on health care tailored to feline life stages improves early recognition and treatment of problems, thereby improving pet health and welfare, and preserving the human-animal bond.

Stress reduction 

It is in the best interest of feline patients, and in the best interest of the business of veterinary medicine, for veterinarians to adapt hospital policies and procedures with the cat in mind. This starts with educating owners about cat carriers and travel to the veterinary clinic. In one study, 58% of cat owners said that just thinking about taking their pet to the veterinary clinic was stressful (compared with 38% of dog owners), and 38% said their cat hated going to the veterinary clinic (compared with 26% of dog owners) 5.

Reducing the stress associated with veterinary visits starts at home; habituation to the carrier and travel should start early in the cat’s life. Each cat should travel to the veterinary clinic in a carrier; it is unsafe to allow a cat to move freely inside an automobile. Placing more than one cat in a carrier is unwise, as redirected aggression and injuries can occur in fearful situations. Solid sturdy carriers with wide openings at the front and top, or with easily removable tops, are preferred (Figure 1).

The carrier should provide the cat with an enclosed, safe feeling; carriers without solid sides can be covered with a towel or blanket to provide privacy. Feline facial pheromone can be sprayed on a towel and placed in the carrier about 15 minutes before the cat is put inside (to allow time for the alcohol in the spray to evaporate). Various other tips can help desensitize cats to carriers, such as leaving the carrier out in the home so that it is familiar, feeding the cat in or near the carrier, placing catnip or toys in the carrier, training the cat to enter the carrier on command for a reward, and acclimating the cat to the car and carrier with occasional short trips that are not to the veterinary clinic. Travel to the veterinary clinic should be on an empty stomach; this helps prevent motion sickness and makes the cat more interested in treats while at the clinic. In some cases, medications such as maropitant may be useful to prevent motion sickness. 

Feline-friendly clinics

Once at the clinic, the owner should be welcomed with visible signs that emphasize the staff care about cats; e.g., posters, photos of staff and clients’ cats, products for cats, and cat-specific information. Veterinary staff interacting with cats and their owners should be knowledgeable about general cat care, behavior, handling, medical and surgical needs, and cat breeds. The clinic can hold special educational events or “clinics” for diabetes education, obesity prevention and treatment, “kitten kindergarten”, etc. A separate cat-friendly waiting area that is not available to canine patients could be created by partitioning part of the reception area. Tables or shelves should be provided so that carriers can be placed off the floor (Figure 2). Ideally, owner and cat should be placed into an examination room as soon as possible to provide a quieter, less stressful location. Minimizing waiting times helps reduce stress for both cat and owner. In addition, some clinics have found success in reserving certain appointment times (e.g., one afternoon per week or one Saturday per month) exclusively for feline patients.

The examination room should be stocked with all the supplies and equipment necessary for working with feline patients (Figure 3); it is best to avoid leaving the room to retrieve items. Ensure that all equipment (e.g., stethoscope, thermometer, etc.) is cleaned between patients, not only to reduce disease transmission but also to avoid lingering odors from other patients. If possible, one examination room can be designated specifically for feline patients. Once in the examination room, the clinician should spend time taking a history and talking with the owner while allowing the cat to adjust and venture out of the carrier, on its own if possible. Cats are very sensitive to sights (e.g., other cats, other pets), sounds (e.g.,voices, equipment, door bells), and smells (e.g., perfumes, disinfectants, alcohol); attention should be paid to these details to reduce anxiety. The examination room should be a calm, quiet environment.

No rule says all cats must be examined on a stainless steel table; many cats are more comfortable remaining in the carrier (with the top removed), or being examined on a lap, on the floor, on a shelf or window ledge, in a box or basket, or even on the scale after being weighed. Exam table surfaces can be covered with non-slip washable materials such as rubber bath mats. Non-traditional exam tables are often desirable for cats such as smaller tables from home furniture stores, or custom-made tables in different shapes. When possible, allow the cat to remain on the towel or bedding that came with the carrier. A feline facial pheromone plug-in diffuser should be placed in waiting areas, examination rooms, and all areas of the clinic where cats will be housed. Security is important; ensure that any loose cat cannot escape via open doors or windows, or become trapped in an inaccessible area.

When simple procedures such as nail trims, blood pressure assessment, blood sampling, or urine collection are required, consider performing them in the exam room rather than moving the cat to another part of the clinic. It is better for staff to come to the cat than to have the cat move to another area of the clinic where it will have to acclimatize to a new environment. If the owner is uncomfortable witnessing a procedure, consider having the owner wait in the reception area until the procedure is completed. 

Handling cats

Respectful feline handling is a critical component of successful feline practice 6. Owners are more likely to return for regular visits if they feel the veterinarian and clinic staff are skilled and careful when handling cats. In addition, many veterinary team members dislike working with cats if they lack the skills and equipment. They are concerned about potential injuries and zoonotic diseases, and they dislike the disruption and inefficiency that can result when a difficult feline patient must be cared for. In the worst circumstances, performing a complete physical examination, collecting laboratory samples, or undertaking diagnostic testing such as radiographs may be difficult or impossible. Fear and stress can also affect diagnostic test results (Table 1).

Gone are the days when fearful and defensive cats should routinely be handled with large gloves or “scruffed”. The key to successful handling is an understanding of feline behavior. Most of the undesirable behaviors exhibited by cats in veterinary clinics are induced by fear or pain. Physical confrontation is the last resort for most cats; their efforts are first focused on avoidance and escape. The more control the cat has during the visit, the less forceful and aggressive the handling, and the more tolerant the approach, the better the outcome. Many anxious cats can successfully be examined with the use of a towel to cover the head; reducing sight of unfamiliar people and places can reduce fear. Cats should be approached calmly and talked to quietly. Avoid direct eye contact, as “staring” is considered confrontational. Minimal restraint is the best approach for cat handling; various techniques using towel wraps for restraint have been published, but always start with the least invasive procedures and progress to those more likely to be stressful later in the appointment if necessary. Reinforce the cat’s positive behavior with toys or treats (Figure 4) – getting the owner’s permission first – and ignore negative behavior rather than trying to correct it. 

Always document in the medical record which handling technique worked best for a given patient, and which approaches should be avoided. Cats that are anxious or fearful during veterinary visits may benefit from longer appointment times to avoid having to rush the consultation. If all else fails, sedation should be considered, rather than escalating forceful handling and risking an adverse outcome for all involved. 

Owner considerations 

Cats are not alone in experiencing anxiety during a visit to the veterinary clinic. The cat owner who accompanies the patient into the exam room often feels some apprehension that may affect their own behavior. The following advice for owners will help reduce anxiety in the exam room:

• Ask owners to avoid human behaviors that, while intended to comfort the cat, may actually increase its anxiety. Examples include clutching the cat, talking or staring in its face, and disturbing or invading its personal space. Sounds intended to soothe or quieten the animal (such as “shhhh”) may mimic another cat hissing. 
• Physical correction such as tapping the cat’s head and delivering stern vocal corrections may startle the cat and provoke the fight-or-flight response. Cat owners and veterinary staff should remember that despite being family members, cats are not human and do not understand efforts to discipline them.
• It is often helpful to instruct the owner not to handle or remove the cat from its carrier until all preparations are in place and a member of the veterinary team makes the request.

Once the visit has been concluded, a veterinary team member can either complete the check out and payment process in the exam room, or the cat can remain in its carrier in the exam room while the owner completes check out in the reception area.

Hospitalizing cats

There are many ways to improve the experience of hospitalization for cats, whether they are healthy and undergoing an elective procedure, or ill and undergoing diagnostic investigation and treatment (Figure 5) 7. Caging for cats in the clinic should be in a ward separate from dogs whenever possible. Additionally, cages should be placed so that cats cannot see one another. Cage materials should help decrease sounds and maintain heat, and may include bedding or blankets from home. Hiding places can be provided with a box made from material that can be cleaned or disposable materials such as cardboard. If space allows, the cat’s own carrier can be placed in the cage with its door open or removed; the opening of any box or carrier should be directed away from the front of the cage for privacy. The cage should have enough room to site the food and water as far as possible from the litter box. Feline facial pheromone can be sprayed on towels or bedding 15 minutes before being placed in the cage; this helps improve appetite and normal behaviors 8. 

Since cats evolved in desert environments, ambient temperatures somewhat above the typical human comfort zone are desirable, and this may be achieved with bedding for insulation and burrowing. Many hospitalized cats do not eat well due to stress; improving the cage environment, especially providing hiding places, may help increase food intake, but it is also essential to identify and treat any nausea or pain. In addition, have the owner bring familiar foods from home rather than introducing a new diet during hospitalization. 

Further thoughts

Many resources are available to help veterinarians focus on felines in their practice. Programs from International Cat Care (www.icatcare.org) and the American Association of Feline Practitioners (www.catvets.com) are available in several countries to help clinics increase veterinary visits for cats and improve the level of health care that cats receive. By participating in these programs, practices have the opportunity to earn the “Cat Friendly Practice” or “Cat Friendly Clinic” designation. The programs also provide many resources for staff training, ongoing education, and support for participation in social media outlets (e.g., Facebook, Twitter, and Pinterest); cat owners engage well with such websites, and having a social media presence helps practices convey their knowledge of feline medicine and their dedication to improving the veterinary experience for cat and owner.

The ultimate in feline veterinary care

The ultimate customization for feline veterinary care is the cat-only practice. Hundreds of such clinics have been established in North America, and the idea is increasing in popularity throughout Europe and Asia. There are many benefits to a species-specific clinic, such as staff that are especially interested in feline care and skilled in feline handling. Cats are smaller than most dogs, so feline clinics are often smaller than traditional veterinary practices, which can be important in areas with high property costs. A more limited range of equipment is required as well as a smaller inventory of drugs and supplies. At the same time, cat-only clinics can often carry out more specialized care, as their budget is focused on only one species.

Another option for customized veterinary care for cats is to provide house call services. A veterinarian and nurse (or other trained team member) can provide most preventive care services in the home environment. Some simple medical care can also be provided, and blood and urine samples can often be collected if needed, and of course euthanasia services in the home environment are highly valued by owners. There are many benefits for both owner and cat in offering home visits, such as not having to leave a familiar environment and avoiding the stress of travel to the veterinary clinic. As well, some owners may have mobility or transportation issues, or may simply have little time to schedule an office visit, especially if it involves a long trip in heavy traffic. There are benefits to the veterinarian as well; home visits (if conducted properly) can be relaxed affairs with more time available for the medical history and physical examination. It also allows inspection of the home environment; this is particularly important for behavioral and house soiling problems. However, there are some potential drawbacks to the home visit, especially for sick cats; transportation to the veterinary clinic may still be required for diagnostic testing and specialized treatment. 

Regardless of the type of clinic, any veterinarian that treats cats is a feline veterinarian. By following the advice of the legendary feline veterinarian Dr Barbara Stein, who always emphasized that “cats are not small dogs”, and taking advantage of the abundance of resources available, all clinicians can take steps to improve feline care and enhance the experience for the cat, the owner, and the veterinary staff.