An interview with Dr. Jen Brandt, AVMA Director of Wellbeing and Diversity Initiatives
One of the most challenging parts of communicating with
clients is delivering bad news. Whether it’s admitting to making a mistake,
sharing a negative prognosis, explaining concerning lab results, or
recommending palliative care. What are your three main tips for sharing
information that will likely upset or disappoint a client?
It’s important to remember that there is no
one-size-fits-all formula for every conversation. Variations in context,
communication needs and preferences, the amount of social capital that may or
may not exist between the two parties, whether the news is anticipated, and
many other factors play a role in how we might engage. That said, I tend to
keep in mind three general components when delivering unexpected or difficult
news.
The first is preparation. If you were not the person
directly involved in the case, this stage requires gathering the information
that is available at the time. (Sometimes, this needs to happen quickly.) Additional
steps include deciding where the conversation will take place (e.g., if by
phone, verify that the listener is in a safe place to receive the news). For in-person
discussions, consider using a sensory-sensitive, non-clinical space, if
feasible, and advise your team to limit interruptions and excessive noise. Be
sure you and your clothing do not have visible signs of blood or fluids. Mute
your phone ringer. Take a few deep breaths, plan your next words carefully, and
prepare to give the client your full attention.
The second component is informing the client. Throughout
this process, be mindful of your nonverbal communication and take cues from the
client by watching their responses. Deliver the news clearly, succinctly, and
compassionately. “Hi, Ms. Smith, I have difficult news to share with you.”
Pause—allow a moment for the listener to activate their coping mechanisms. “We have
Hammie’s bloodwork and, unfortunately, the test results confirm that his kidney
disease has progressed and is now considered to be in the final stage.” (Pause)
“I know that’s not the news we were hoping for.” (Pause) “I want to reassure
you that no major decisions need to be made right now. For today, we can talk
through options for care as well as help Hammie feel better by providing fluids
and addressing his nausea and lack of appetite.” (Pause) “That’s a lot to take
in. What would be most helpful for you right now?”
Be prepared for a range of reactions—disbelief, guilt,
anger, sadness, acceptance. Throughout the process of breaking the news, allow
periods of silence to give space for the client to process information or interject.
Some may have questions. Others may sit in silence and have difficulty
articulating thoughts. Avoid medical jargon and avoid sharing too much
unsolicited detail initially. Look for signs that the client is ready and able
to hear more (e.g., they begin asking questions). Consider providing
information in a variety of formats (e.g., verbally and in writing).
The third stage involves providing support and necessary
medical information tailored to the specific needs and preferences of the
patient and client.
Let’s say a veterinarian has just delivered negative news
to a client, and now that client is extremely angry—responding in a raised
voice, sending nasty emails, making threats to leave bad reviews or reporting you
to the state licensing board. What should happen next, from the veterinarian’s
end?
In these moments, the best thing a veterinary professional
can do is avoid becoming reactive. It’s not helpful to have two people fueling
the emotional intensity. Listen for cues about what the client might be needing,
even if they aren’t able to articulate their underlying needs directly. The
next best step is context and situation-dependent. For example, is the client
threatening to take these actions, or have they already done so? If the former,
it is possible that the client is highly reactive for now, yet still seeking
some kind of connection with the veterinary professional (e.g., reassurance,
information, compassion, acknowledgment etc.) As humans, feelings such as
sadness, guilt, despair, fear, etc., can manifest as anger. It’s not personal despite
how it may feel to be on the receiving end. Rather, it’s an attempt to manage
pain or gain a sense of control and counter feelings of helplessness. Let the
client know you see they are hurting and very much want to help. Be clear about
what you can and cannot offer. Be aware of your nonverbal
communication—expressions, body position, tone of voice, rate of speech. Convey
calmness, compassion, and competence.
If the latter, it’s good to have a general plan for
difficult encounters in place ahead of time so you’re not trying to create a
solution on the spot. For example, have
boundary statements at the ready that every member of the team is trained and
empowered to use: “If you continue to raise your voice and threaten me, I will end
the conversation and ask you to leave.” Notify your insurance carrier of the
situation. Seek guidance from a reputation management consultant to help
mitigate fallout and avoid adding fuel to the fire. AVMA’s reputation management toolkit offers resources to help veterinary professionals
protect online reputations, prevent and combat cyberbullying, respond
effectively in the midst of a crisis, and support team wellbeing.
What would you say is the most challenging part of
utilizing good de-escalation techniques? And what’s the best way to handle this
challenge?
For many of us, the most challenging part of navigating difficult
encounters is keeping our own reactivity in check. We can’t control how others
behave and we can’t always predict how someone will respond. What we can do, or
can learn to do more effectively, is manage our own response. When we
become reactive, we behave in ways that aren’t consistent with our own values
and beliefs. We become more impulsive, and our perceptions of the situation
become skewed. Emotions and defenses drive our behaviors, rather than reason
and logic.
There are several skills we can practice and apply to manage
our own reactivity more effectively. Some examples include slowing down, taking
a deep breath, focusing on active listening, and utilizing reflective listening
statements. These skills can help us thoughtfully respond to the
underlying needs rather than react defensively to the messaging. In the
aftermath of challenging interactions, connect with your team to deconstruct
and learn from the encounter. For example, ask yourself what worked well in the
situation to help de-escalate the conflict. What could have been done even
better yet? If a similar situation occurs in the future, what might you do
differently? What are some systemic factors that may have contributed to this
or similar incidents (e.g., policies, procedures, unclear expectations, etc.) What
systemic changes can be implemented to help prevent future incidents?
Practice different phrasing and responses in non-stressful
circumstances so that your brain can access them under duress. Working with a
mental health professional can provide additional support and guidance in managing
emotional reactivity.
Do you have any advice specifically for veterinary
practice owners on how to respond in the event that one of their employees
finds themselves in a tense situation with a client? (If the owner is present
for an in-person incident, should they intervene? If the exchange is occurring
via email or over the phone, should they take over communications?)
Although there is no one-size-fits-all approach, one of the best
strategies is to have these discussions as a team, well in advance of a
situation occurring. To the extent possible, you want to take real-time guess
work out of the equation. The best way to know how to support an employee in these
situations is to proactively ask them what would be most helpful. Some will
want you to automatically intervene. Others will only want you to intervene if
they specifically request your help or if the situation escalates beyond a designated
threshold. Needs will vary according to the employee and the situation at hand.
Proactively gathering as a team to discuss what behaviors are and are not
acceptable in a practice, determining what range of responses all members of
the team have the autonomy to employ, and empowering all members of the team to
set and maintain boundaries are all essential ingredients to a safe workplace.
Unfortunately, one of the most common inquiries I receive is
from employees who ask what to do when they have set a boundary with a client
only to have it undermined by the leader or owner. Being clear in advance about
how the team is empowered to manage challenging encounters promotes
psychological safety and benefits every member of the team. Avoid handling
these exchanges via email or text. Too much in the way of tone and nuance can
be lost in written exchanges. Instead, invite the person to connect by phone or
video call.
Do you recommend that angry exchanges or threats be
documented by the practice?
Documenting concerning behavior is advised—specifically,
documenting behaviors in descriptive, tangible terms and avoiding personal
opinion or commentary. For example, “On 1/11/24, during his pet’s examination, Mr.
Jones raised his voice at me, used profanity, and said ‘trust me, you’ll be
sorry if anything happens to my dog!’ while clenching his fist” vs. “Mr. Jones
was angry and rude.” This information can be documented in the medical record
or a “Client Communication” file or log that is separate from the patient’s
medical record.
Extremely upset clients are (hopefully) not a daily
occurrence at the average veterinary practice. How can practice owners and
their teams practice de-escalation on a day-to-day basis and hone their skills?
For example, imagine a scenario in which a client politely asks for a refund on
a treatment because it didn’t help their pet recover. What’s the best way to
handle situations where the tone of the interaction is courteous and
appropriate, but the DVM and the owner find themselves on opposite sides of a
request?
Working with the public, particularly in high-stakes
environments, comes with the knowledge that we will find ourselves occasionally
with differing expectations. The best approaches are the ones that have been
discussed in advance with the team and all team members are empowered to apply.
For example, every member of the team can be trained and supported to set and
maintain appropriate boundaries. Boundaries are limits and rules we set for
ourselves to protect our safety and wellbeing such as, “We require 50% payment
at the time of service and the remaining balance at pick-up. I can provide you
information on applying for financing through a third party. I’m also happy to
provide you a copy of the estimate for review, and a list of other providers in
the area if you’d like to explore other options.” When setting boundaries, we
are not attempting to change the other person’s mind, ask for their
permission, or obtain their approval. Rather, we are clarifying what we will
and will not do in each situation.
Do you have any final tips or resources for veterinarians
as they navigate the unpredictable world of client interactions?
As uncomfortable as it is, unpredictability is a natural and unavoidable part of our personal and professional lives.
Although we all have varying limits on how much uncertainty we can tolerate,
there are steps we can take to navigate unexpected and uncontrollable circumstances:
1. Acknowledge discomfort and unmet expectations without
catastrophizing them. For example, when a client interaction becomes
challenging, instead of telling yourself “This is the worst thing that could
ever happen! Now my whole day is ruined!” consider something like “This
conversation took an unexpected turn, and I’m feeling uncomfortable.” Denying
the emotions or judging ourselves for having them tends to increase stress and
anxiety and make us more vulnerable to burnout. Accepting that things aren’t
what we hoped and our feelings about that allows us to meet life where it is
and move forward from there.
2. Recognize when you are attempting to control the
uncertain (e.g., excessively seeking external reassurance and validation,
constantly ruminating about the future, micromanaging, etc.) Like all emotions,
feelings of fear and uncertainty eventually pass. Choose a mantra to help you
focus on what is happening right here and now (e.g., “I am here. I am enough.”
or “Be where my feet are.”) Knowing who you can ask for help and normalizing
help-seeking behaviors are elements of a psychologically safe team.
3. Have some phrasing at the ready to create time
and space in difficult interactions. For example, “I need to
think about this. I will get back to you tomorrow before 5:00 p.m.” or “I’m
going to step out of the room for a moment to confer with a colleague.” Not all
situations need to be resolved immediately, and many will benefit from you taking
a temporary step back.
For more information on this and related topics, AVMA offers
resources rooted in communication practices that can enhance connection,
mitigate reactivity, and de-escalate conflict. To learn more, check out AVMA’s
Language of Veterinary Care, Train
the Trainer Program, Journey
for Teams, and AXON, AVMA’s digital
education platform.