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Category: Opinion

  • Learn to teach (to learn)

    Learn to teach (to learn)

    It has been proven that you learn better and recall more information when you are expected to teach someone, compared to when you are expecting to be examined on it.

    So, how can you take advantage of this, and what are the benefits?

    1. The benefit of sharing knowledge is twofold – you benefit, but so do others. There is no point holding on to what you know if your colleagues, community and patients can benefit from it.
    2. Teaching not only benefits others, but also makes sure you understand what you are talking about.
    3. The questions you get asked highlight the common aspects you should know and highlight areas you need to learn in more depth.

    Practical application

    I use this by thinking of something I want to know more about, or be better at – and I pre-organise having to teach it to others.

    I recently used this with ECG interpretation at our hospital, which we are competent at, but not great.

    We were limited as we were all teaching each other little bits and pieces here and there, but no one was really 100% clear about the topic. So I decided it had been on my bucket list for long enough and booked a tutorial one month in advance. I then scheduled in reading and time to prepare, then deliver, a presentation.

    As I was learning it, I made sure I knew it well enough so I could pass on that knowledge and train others to do the same. I have now delivered the presentation twice.

    I guarantee you, this is a very effective method of learning and has benefited not only myself, but the whole team.

  • Trust, part 3: communication

    Trust, part 3: communication

    Most complaints you’ll face in your career will not be about something you did, but about something you said. Or didn’t say, or because of how you said it, or how it was heard, perceived or interpreted.

    Ah yes, communication – the final of the three Cs that will help you build trust.

    Excellent communication is the cornerstone of trust in any relationship. Get it wrong and the entire thing can come tumbling down. In fact, the entire CTR-C framework is built on good communication.

    But here are a few communication hacks that directly relate to building trust.

    Listen

    When we think of communication, we usually think of what to say and how to say it, but tend to forget about that thing that makes up – or should make up – at least half of every exchange we have: shutting up and listening.

    And I mean really listening – without formulating your response in your head, or going through your differential diagnosis list while the client is speaking.

    Listen carefully to exactly what the client is saying, and what he or she is not saying. Ask questions to get him or her to speak more, not less, so you can listen more.

    This is a skill that takes time to develop and will take more time to delve into than this article permits, but suffice to say a large portion of the complaints I have dealt with in my leadership role stemmed from clients not feeling listened to.

    Are you listening? Good. Let’s move on.

    Speak

    Speak the truth (also known as the no BS rule)

    The good old white lie, the half-truth, the confident statement of “fact” based on nothing but personal opinion and a desire to just get home. I have witnessed masters of BS in action in many a vet clinic – and I got fairly good at it myself.

    The scary thing is that many clients love a confident BSer – and even worse, you’ll eventually fool yourself.

    But it is toxic to your team, erodes your professionalism, will reduce your enjoyment of your job over time, and, one day, your perfectly packaged parcel of poo will be revealed for what it is and is likely to explode in your face.

    Keep your promises

    We make promises to our clients all the time – from the implied big promises that come with your degree and our values as a profession, such as care, empathy, prevention of suffering and speaking
    for those who can’t speak; to the explicitly stated small daily promises, such as “we’ll call you tomorrow with the blood results” or “you can pick her up at 5pm”.

    Broken promises damage relationships. The latter group of promises may seem trivial, but neglecting these leads to death by a thousand cuts when it comes to any trust that you’ve managed to build.

    Look, no one’s perfect – sometimes I promise my children I’ll watch a movie with them on a Friday night, only to be called out to work (or to the pub…). Stuff happens.

    They key is to acknowledge the slip, apologise, and promise to do better. For example: “I promised we’d phone you with an update this morning and we didn’t – I’m sorry. I’m sure you were very worried. I’m blocking off time now for tomorrow’s telephone call.”

    If done right, this can sometimes even strengthen the bond.

    This also means you need to be very wary about making promises you can’t deliver. Most of us are people-pleasers, so we tell people what we think they want to hear. Setting unrealistic expectations sets us up to disappoint our clients, and puts us and our teams at risk of burnout.

    Instead of “we’ll be done with surgery by 4pm and I’ll telephone you immediately after” when you know the day is likely to go crazy, try: “I’m aiming to be done by 4pm, but if we get emergencies it may be pushed back a bit. I’ll call you as soon as I’m done, but if you don’t hear from me you can presume it’s all good news. Feel free to telephone to check in any time, and once I’m happy that Fluff-nuts is stable and comfortable, I’ll sit down with a coffee and we’ll have a long chat. Does that sound good to you?”

    Remember – the goal of our series is to have problem-free, complaint-free consult. It is very unlikely that a client will hold on to any serious feelings of anger, or allocate blame or complain about someone they like and trust. The client who is on your side may complain to you when a fissure arises in the trust, but the intention will generally be to restore trust, not to hurt you.

    You want your clients to trust you. Trust me.

  • Trust, part 2: competence

    Trust, part 2: competence

    The previous post wrapped up with tips to help you build confidence, keeping in mind that we’re not focusing on confidence just for our own sake – we’re using confidence as a building block towards building trust with our clients.

    Remember, why would your clients trust you if you don’t trust yourself?

    The next trust-building tool is Competence. If you want someone to trust you with his or her pet, he or she needs to know that you know what you’re doing, right?

    But more exists to competence than simply showing that you know your stuff – it’s also about knowing that you know your stuff, which, of course, leads back to last week’s topic of confidence.

    Competence breeds confidence, which will make it easier for you to try new things and learn new skills, which, in turn, will lead to even more competence. More feedback loops…

    Here are some practical ways to use competence as a tool for perfect consults.

    Show competence

    Your clients want to know you are good at your job before fully trusting you.

    The problem is, they don’t get to see you shine once you leave the consult room, so you need to make sure you demonstrate competence in your dealings with them.

    This means making sure you know how the practice software works, know the vaccination protocols, how to confidently examine their pet, how to give an injection… the basics we mostly take for granted.

    If you appear to be a bumbling buffoon with the simple things, clients will presume you’ll be the same where it really matters.

    Talk about how competent you are

    Don’t be afraid to talk yourself up a bit. You can sell yourself – whether it’s your own skills, or your clinic’s – without being arrogant. For example:

    • “I have a special interest in skin cases, so I’m confident we can make a big difference here.”
    • “We see a lot of these cases, and we have high success rates.”
    • “Dr X, who will be doing the surgery, is one of the best in the business.”

    Develop competence

    It’s much easier to feel like your good at something when you are actually good at something.

    Resist the default of the aimless drift towards mediocrity – “Jack of all trades, but master of none.” Pick something – anything – and spend a bit of time polishing your skills in it. The manky ear, in-house cytology, behaviour, treating seizures, reading radiographs, dealing with angry clients, fixing canaries… anything.

    Distinguish yourself by becoming a “mini-specialist” in something, so that the next time one of those situations arises you absolutely smash it.

    Others will see this. Your clients will see it. People will acknowledge your skill and, maybe, praise you. Someone less skilled may start deferring to you the next time they have a similar case.

    These things will light up all those feel-good social centres that our minds have evolved for, which will give you a massive confidence boost. Which, as we just said… have I mentioned feedback loops?

    • The next part look at the final C needed to establish trust with your clients.
  • Trust: the second key feeling

    Trust: the second key feeling

    Welcome back to the series on the CTR-C method for complaint-free consults.

    My previous post covered the first essential step in perfect consults – establishing a connection. Now, let’s look at the next essential thing our clients want to feel in their dealings with us – trust.

    Think about your own dealings with other professionals – whether you’re buying your morning coffee, having new down lights installed by the local electrician or booking your spinal surgery. Somewhere in your head the following questions are probably floating around:

    • Do you know what you’re doing?
    • Will you do your best work for me?
    • Are you telling me the truth?
    • Are you going to try to screw me over?

    Well, your clients are asking the same questions. So how do we address their unspoken concerns?

    The great news is that because you’ve already established a connection with them, they desperately want to trust you. They like you, and they want you to be the vet to fix their problem. Now, let’s cement that connection by establishing trust.

    In keeping with our theme of acronyms, let’s look at the three Cs of establishing trust – Confidence, Competence and Communication.

    Confidence. Image © Jacob Lund / Adobe Stock
    Image © Jacob Lund / Adobe Stock

    Confidence

    How do you expect your clients to trust you if you don’t trust yourself?

    Clients can sense uncertainty like a Labrador retriever senses treats in a pocket. They may still smile and be nice, but they’re probably thinking “I think I need to look for a real vet…” Does this mean you’ll only be able to have perfect consults once you’re a few years into practice and know everything?

    The truth is that experience does indeed do a lot for your confidence, but it’s also true that it’s entirely possible for a recent graduate to be confident, just like it’s possible to be five years qualified and still struggle with a serious lack of confidence.

    I’ve had to work quite hard on my confidence, so here are my favourite confidence boosting tricks.

    Appear confident

    This one is close to “fake it till you make it”, but I’ve learned about a much better way of looking at it: “Be it till you see it.”

    If you consciously adopt the posture of a confident person – standing straight, shoulders back, chest out; like your gran told you – not only will others perceive you as confident (and, therefore, trustworthy), but you’ll also convince yourself.

    An upright confident posture plays around with your serotonin levels to make you feel more confident; you’re tricking your brain into thinking: “We’re standing up straight – we must be feeling confident.”

    And when others perceive you as confident and start treating you like someone worth respecting, you’re subconscious will notice this, which sets a lovely little hormonal feedback loop into motion.

    Be confident about your intentions, skills and training

    A confidence grows from being clear with yourself and others about your intentions, even when you don’t have all the answers and skills.

    And let’s be clear – you will never get to a point in your career where you know everything. Ask any specialist and he or she will tell you the more he or she learns, the more he or she realises so much exists that he or she doesn’t know.

    So, when you’re faced with that conundrum in the consult room and feel like a total fraud, you’re not alone. But be confident about what you do know, and be clear about your Intention to help and figure it out, no matter what it takes.

    Be confident about your plan (sometimes this may mean, for example, finding an excuse to leave the room to sit somewhere quiet and scribble down a plan on a notebook). For example:

    “Wow, this is a tricky one. I’m not 100% sure what’s going on here, but we’ll get to the bottom of it. Here’s what we’re going to do… And if I still haven’t figured it out I’m going to phone Dr X, who is the guru on this.”

    Remember, you’re not an idiot. You’ve graduated from one of the toughest university courses, and you’ve proven you have problem-solving skills and grit, which is an unbeatable combination. So back yourself a little bit.

    There’s one more important confidence builder, but it deserves its own heading as the second C of trust. So, the next part look at how to leverage Competence as a confidence and trust building tool.

  • The problem-free consult

    The problem-free consult

    Earlier this month, I closed a big chapter of my career when I sold my shares in the emergency clinic I started almost a decade ago.

    Any big change lends itself to a period of reflection, and I’m enjoying looking back at what I’ve learned from the experience as an emergency veterinarian and team leader.

    Clinical challenges

    One lesson I was taught and retaught – and taught again until I finally understood – is that the biggest challenges we face in clinical practice do not come from the animals.

    Clinical error or poor patient outcomes will happen, of course, but these account for a fraction of the stresses and misery we deal with. We’re pretty well equipped to deal with those.

    Miscommunications and complaints, on the other hand – that’s what will keep you up at night.

    Communication challenges

    The nature of the work in emergency practice tends to amplify many of the challenges we face in general practice: unpredictability, potentially life and death cases, long shifts, and, of course, highly emotional people.

    The majority of clients who present to you in an emergency setting are first-time clients. You don’t have pre-existing relationships and established trust to build on. Add to this the fact people who come to you at night are usually not there because they planned to be, but because something bad has happened. This means they are often frazzled, scared, worried, angry and tired. It’s a recipe for conflict.

    So, you learn the skills needed to deal with it, or you don’t last. What follows is what I’ve learned.

    Acronyms

    Doctors love acronyms – and nowhere do we love them more than in emergency practice: GDV, MVA, MLK, CPR, the ABC (or CAB) of resuscitation…

    When the shit is hitting the fan, you need all the brain space you can get.

    I love any tool that makes it easier to remember what you need to be doing. With this in mind, I’ve made an acronym to help me remember what I need to do for problem-free client interactions.

    Rather than relegate these as secondary “soft skills” with vague guidelines, I put these up there with those other critical acronyms. It should be part of our first principles of practice. I call it CTR-C.

    What is CTR-C?

    From dealing with client feedback and complaints during my time as team leader, I’ve realised most complaints are preventable if you tick a few boxes. CTR-C lists those boxes. It’s not so much the information we give to to our clients in our dealings with them, but more about how we make them feel.

    The vast majority of complaints I deal with arose from situations where the following client needs were not met:

    • connection
    • trust
    • reassurance
    • clarity

    The order of these four needs is important, as each builds on the one preceding it.

    When someone feels a connection with you, he or she is unlikely to criticise your decisions – even if your decisions turn out to be wrong.

    He or she will also be emotionally receptive to trusting you, despite the fact he or she hardly knows you. Without trust, your job of caring for his or her pet will be exponentially harder – and feelings of connectedness greatly facilitates feelings of trust.

    Many situations in veterinary practice bring with them a lot of uncertainty and some very powerful emotions. It is vital clients feel reassured that you have their best interests at heart, and that they made the right decision to trust you.

    Finally, clarity – I put clarity slightly separate from the others as it does not build on the other three, but, rather, circles back to re-enforce them.

    Series

    I can (and possibly will) write a book about each of these, but the next few posts will cover some tips on how to achieve each of these in a limited time period and under less than ideal circumstances.

     

    • This article was first published in 2020

  • Dog bite wounds – the tip of the iceberg

    Dog bite wounds – the tip of the iceberg

    Dog bite wounds are one of the most common presentations in both general and emergency practice, and can often be challenging cases.

    Once you have stabilised the patient, it is time to speak to the client. Here is when you need to address the most important point: the injuries they (and you) can see are just the tip of the iceberg.

    It can be helpful to draw pictures to let the owner know a small penetrative puncture wound can often be masking a horrific injury underneath. This is especially likely in cases where a big dog has attacked a small dog as the latter is often picked up and shaken around.

    Recommendations

    Here are some of my tips when managing a dog bite injury:

    • Ask the nurse to do a very large margin of clipping. When in doubt, clip a lot more than you think you’d need to.
    • Explore all wounds to their depths by dissecting the tissues until you are satisfied it does not lead any deeper or further.
    • “The solution to pollution is dilution.” Lavage as much as you can and remove all visible foreign material.
    • Perioperative antibiotics are always indicated.
    • Drains: try to reduce dead space with tacking sutures or by closing down the wound in layers. If unable to do so completely, drains may be used. Remember, the drain should exit next to the wound, not through it.
    • Pain control is very important for these patients. Poor pain control will affect healing and therefore overall outcome. Often multimodal pain control strategies are required – for example, a combined opioid and non-steroidal anti-inflammatory strategy.
    • Make sure you take proper photos before, during and after surgery – especially in cases where your patient’s owner might seek compensation from the owners of the aggressor dog.
  • Triage, pt 2: secondary survey

    Triage, pt 2: secondary survey

    Secondary survey refers to the detailed physical examination performed after the primary survey, and should only be performed once the patient has been adequately stabilised.

    It is always important to perform physical examinations systematically to avoid overlooking organ systems. This could be difficult in a stressful emergency situation, so one way to remind yourself is with the following acronym:

    A CRASH PLAN

    A – Airway

    • respiratory pattern
    • airway patency

    C – Cardiovascular

    • circulation
    • heart sounds
    • pulses
    • capillary refill time

    R – Respiratory

    • respiratory sounds
    • bruising
    • external wounds to chest

    A – Abdomen

    • palpation
    • bruising
    • external wounds
    • fast ultrasound:
      • abdomen:
        • free fluid (diaphragmatic-hepatic site, splenorenal site, cysto-colic site, hepatorenal site)
        • bladder integrity
      • thorax (do this at the same time as assessing the abdominal cavity):
        • ensure you do both left and right sides
        • chest tube site
        • pericardial site
        • wet/dry/third space

    S – Spine and tail

    • gait and posture
    • pain sensation
    • crepitus

    H – Head

    • mentation
    • cognitive function
    • cranial nerves
    • external wounds/bruising
    • eyes – including symmetry, third eyelids, eye position, haemorrhage and detailed ophthalmological examination
    • ears
    • nose
    CPR
    The secondary survey will help identify any concurrent problems not seen on the primary survey.

    P – Pelvis

    • wounds
    • bruising
    • pain
    • cepitus
    • perineum
    • external genitalia

    L – Limbs

    • deformities
    • fractures
    • pain
    • bruising
    • wounds
    • weight bearing vs non-weight bearing

    A – Arteries

    • all accessible superficial arteries – pulses and pressure

    N – Nerves

    • mentation
    • cranial nerves
    • conscious proprioception
    • postural reflexes
    • peripheral spinal reflexes
    • withdrawal reflexes
    • deep pain
    • cutaneous trunci reflex
    • anal tone

    Stable patient

    By following the primary and secondary triage processes consistently, you should be able to quickly determine the order of criticalness of patients, institute appropriate resuscitative measures and manage life-threatening injuries. Then, with your thorough physical examination, identify any other concurrent problems not seen on the primary survey.

    Overall, you have a stable patient, and are able to formulate an appropriate diagnostic and treatment plan.

  • Triage, pt 1: primary survey

    Triage, pt 1: primary survey

    The art of triage takes time to master – particularly in emergency hospitals, where critical patients arrive in quick succession to the crash area.

    Patients need to be examined quickly and effectively to ensure the most critical issues are identified and stabilised. To do this, I break triage into two categories – primary survey and secondary survey.

    In part one I will discuss the primary survey process. The second part will go into the details of the secondary survey.

    ABCDE approach

    Primary survey refers to the initial stabilisation stage, where the aim is to preserve life, manage life-threatening injuries and re-establish tissue perfusion with oxygenated blood.

    The approach to all deteriorating or critical patients is the same: ABCDE – Airway, Breathing, Circulation, Disability and External.

    ABC – Airway, Breathing, Circulation

    Critically ill patients need to be examined quickly and effectively.
    Critically ill patients need to be examined quickly and effectively.

    Assess airway

    • Is it patent?
    • Does it require suctioning?
    • Does evidence exist of upper airway obstruction?
    • Intubate if you suspect the patient may need resuscitation.

    If you suspect cardiopulmonary arrest, begin basic life support immediately. This involves chest compressions, and intubation and ventilation in:

    • loss of consciousness
    • absence of spontaneous ventilation
    • absence of heart sounds on auscultation
    • absence of palpable pulses

    Assess breathing

    • Is the patient hyperventilating or hypoventilating?
    • How is the respiratory effort? Is it sustainable?
    • What is its oxygen saturation, or does the patient looks like it needs oxygen? If yes, provide supplemental oxygen therapy.
    • Does the patient need to be ventilated? Ventilation is required if any of these criteria are satisfied:
      • hypoxaemia (partial pressure of oxygen lower than 60mmHg or blood oxygen saturation level lower than 90%) and unresponsive to oxygen supplementation
      • hypercapnia or hypoventilation (partial pressure of carbon dioxiden greater than 60mmHg)
      • unsustainable respiratory effort?
    • Consider sedation. Reducing stress can make a dramatic difference in stabilising dyspnoeic patients. Butorphanol or low-dose acepromazine (try to rule out cardiac disease first) can be used in these situations.

    Assess cardiovascular system

    • Mucous membrane colour, capillary refill time, heart rate and rhythm, pulse pressure, and temperature.
    • If a heart murmur or arrhythmia is present, I try to rule out cardiogenic shock before resuscitation therapy.

    At the same time, draw enough blood to run baseline blood work and begin IV fluid resuscitation if signs of shock are present. Fluid boluses should be considered if any of these exist:

    • pale mucous membranes
    • slow capillary refill time
    • tachycardia
    • poor pulse pressures
    • hypothermia

    I generally start with 10ml/kg Hartmann’s Solution over five minutes and reassess.

    D – Disability assessment

    Any abnormalities in:

    • Mentation? Seizures?
    • Level of consciousness?
    • Altered pain sensation?

    E – External assessment

    • assessment for wounds or injuries
    • control any obvious bleeding, apply direct pressure – possibly tourniquets, but only for less than 30 minutes unless life-threatening bleeding
    • initial medications:
      • pain relief – generally opioids are safest with unstable patients
      • antiepileptics – diazepam
      • sedation for dyspnoeic patients – butorphanol or low-dose acepromazine IV

    Once you have finished your primary survey and performed the required intervention, you repeat your primary survey until the patient is appropriately stabilised.

  • The dangers of casts and bandages

    The dangers of casts and bandages

    Casts and bandages are frequently used to treat orthopaedic conditions, especially in situations where clients have financial constraints that rule out surgical treatment.

    Necrotic foot
    Necrotic foot: a complication after inappropriate monitoring of a Robert Jones bandage (zoom).

    However, these techniques have an extremely high probability of complications, including:

    • malunion, delayed or non-union
    • fracture disease – which refers to joint stiffness, muscle atrophy and disuse osteopenia associated with prolonged casting

    And, most commonly:

    • soft tissue injury – ranging in severity from mild dermatitis or pressure sores to sepsis and avascular necrosis of tissues

    Check and check again

    Although avoidance of using coaptation techniques is recommended, very stringent case selection may help to reduce the risk of complications occurring.

    If you do end up having to attempt external coaptation, the most important thing to do is to schedule very regular checks and re-application of the cast or bandage.

    Get clients to monitor for:

    • any unusual smells coming from the bandage
    • changes in the way the patient walks, e.g. increase in lameness
    • discolouration of the bandage
    • any signs of pain or irritation

    Always err on the side of caution and schedule the checks more frequently than you think you should, otherwise you could end up with a situation as seen in the image above.

  • Dealing with abusive clients

    Dealing with abusive clients

    I’ve written before about client complaints and how to deal with them, but what about truly abusive clients?

    We’ll differentiate between the two by classifying your standard “complaining client” as someone who has, at least in their eyes, a valid complaint that could potentially be resolved if handled correctly, while the “abusive client” will move far beyond the actual problem and start focusing on ways to hurt you – they will insult you, attack your values, and question your motives.

    These are the kind of interactions that can have you lying awake at night ruminating about what was said, what you should have said, and eventually questioning those very same values and motives that your attacker targeted.

    Mental armour

    Some practical considerations for protecting yourself and your business in these situations won’t be discussed here, but what I do want to talk about is how to protect your mental and emotional states when you are on the receiving end of a truly abusive client.

    Over the years I’ve cobbled together the following techniques as a makeshift kind of mental armour, based on wisdom gathered through reading and listening to people much wiser than me. This armour is far from impenetrable, but it does seem to help lessen the damage inflicted by those who wish to harm me. Perhaps it can do the same for you.

    1. Learn to identify where my thoughts go

    It’s so easy to slip into negative thought spirals without even realising it. For me, this means some form of mindfulness training and meditation.

    2. Recognise what my mind is trying to do

    When my mind pulls me into those play-by-play rumination sessions, it’s trying to protect future me by reviewing the situation so I can learn from it. Useful in moderation, toxic when done in excess.

    So, once I’ve given it a reasonable amount of thought and I’m happy that I’ve learned what I needed to learn, I’ll tell myself (out loud): “Thanks brain, I know you’re trying to help me, but I think we’ve got this covered. Now let’s move along.”

    3. Ask myself: “Is anything this person is saying true?”

    Am I/was I dishonest or wilfully trying to deceive? Am I a bad person? If the answer is yes then I need to grow, and I’ll shift my focus on to what I need to do to achieve that growth.

    If the answer is no…

    4. Ask myself: “Do I want to be this upset about this?”

    Because as much as the other person is the trigger for my emotions – my response and my emotions are 100% mine.

    Once I’ve established that “this is not how I want to feel today, nor where I want to spend my energy or what I want to allocate my attention to”, then it’s much easier to go: “You know what, f*** this, I’m moving on.”

    5. Ask myself: “Did I really think my life would be without problems?”

    I’m prone to indulging in pity-parties – “I don’t deserve this, why me…” – but the reality is that life is a series of problems that need to be solved, so when a biggie comes my way I need to distance myself from feeling that the world is out to get me, and see it as just another problem to solve.

    This approach should help, but it won’t make it go away entirely. The good news is that a week, month or a year from now, you’ll laugh at how upset it made you.