Introduction
Following up with clients fulfills a number of functions in veterinary medicine: to check on the pet’s progress; to relay test results; to ensure the client understands their role in fulfilling the treatment plan; and to schedule additional appointments. It can range from a veterinarian calling the client—an appointment in miniature—to rote, automated emails and mailed reminders to schedule vaccinations. Personalizing follow-up means rooting communication in the facts of that particular case. It means creating a communication plan that meets the needs of a pet and their owner.
In order to understand how and why Nuzzle approaches follow-up as it does, let’s go over the big-picture significance. First and foremost, follow-up should help to build rapport between the veterinary team at the clinic and the client and their pet. This partnership is the backbone of successful veterinary care. A client who feels that their concerns are understood is more likely to make the best-fit choice in diagnostic and treatment options, to perform necessary at-home treatment, and to feel good about their appointment and its outcome, which assures future business for the clinic. By tailoring follow-ups to the needs of a pet and their most recent visit, a client can be made to feel that they are participating in an ongoing process of care.
To that end, personalized follow-up fills in the communication gaps that can occur during and especially after an appointment. It ensures that whatever takes place during a visit gets converted into a treatment plan that the client and clinic can follow together. Clients cannot be expected to remember everything they are told during a visit, especially a stressful one. Personalized follow-up therefore reduces the cognitive burden that comes with having to understand a new health concern while also learning how best to manage it. At its best, personalized follow-up can even shore up deficiencies in a vet’s communication style.
Create an action plan
Personalized follow-up begins with an action plan that reflects the pet’s health needs, the client’s values and concerns, and the veterinarian’s recommendations. The action plan establishes all that is to come after an appointment: what the client needs to do and why, further appointments to schedule, and more options from which to choose in the event of disease progression or ineffective treatment.
Make it goal-oriented
An appointment should determine goals for a pet’s health along with a clear understanding of how those goals are to be pursued. Thus, the client should find these goals listed at the top of the plan. Goals in turn motivate next steps: e.g. to ameliorate symptoms, to rectify a health problem, or to rule out underlying diseases.
Translate biomedical knowledge into explicit actions
Veterinarians provide their clients with a lot of specialized information in a short amount of time. They moreover need to tailor their explanation to respect the client’s current knowledge as well as their priorities for the health of their pet. As clients voice their concerns, respond to the vet’s questions, and ask their own, it becomes easy to lose a sense of direction for what ought to be done after an appointment. An action plan converts the vet’s knowledge, suggestions, and implicit expectations for what the client should do into explicit instructions complete with rationale, cost, priorities, and reminders. A vet saying, “I would be worried if your pet starts vomiting more,” becomes in the action plan: “Track how often your pet vomits. If it continues at two to three times weekly or increases, contact us so we can adjust treatment and schedule a follow-up examination.”
Providing “an effective recommendation”
Presenting the client with a plan to aid their decision making addresses a major contributor to poor compliance: ineffective communication of recommendations. According to Clayton MacKay, DVM, who measured compliance using data from 240 practices and 1400 dogs and cats, “the [second] most common reason for poor compliance is the client never receives an effective recommendation from the practice team. All too often the client is faced with information overload plus distractions in the exam room or reception area.” Another study analyzing adherence to dentistry recommendations (19 companion-animal veterinarians and 83 clients) backs this up: “The odds for adherence were 7 times as great for clients who received a clear recommendation, compared with clients who received an ambiguous recommendation from their veterinarian” (Kanji N, et al., 2012). Given their significance, recommendations, and medical explanations more broadly, should be relayed in multiple modalities: verbal, visual, and written.
Personalized follow-up reiterates visually and in writing what the doctor explained verbally during the appointment. Options and next steps should be arranged in visual blocks ordered according to priority and category. The pet owner may therefore have their understanding of new information and instructions both reinforced as well as helpfully organized.
For instance, a client may need to decide on scheduling a dental cleaning and an abdominal ultrasound for their pet who has been having GI-related symptoms. They cannot quite recall how those two procedures were connected and whether one ought to precede the other. Looking to the doctor’s recommendations on an action plan would clear up the confusion. They would see that the ultrasound has a high priority in order to investigate underlying illnesses such as GI lymphoma and IBD. They would also see that a dental cleaning and exam is important due to the state of their pet’s teeth, but that some pet owners opt to wait on diagnostic procedures before scheduling a dental appointment due to financial constraints. Should the client elect to do both procedures at the same time, then both could be done under the same general anesthesia. This pet would tolerate an ultrasound without sedation, but it would be made easier with it, and a dental cleaning definitely requires sedation. All of this was discussed at the appointment, and it should be made readily available in this easy-to-reference, actionable format.
Aside: Clinic Protocols
Since that addresses the second most common reason for poor compliance, you may be wondering what the most common reason is. According to Mackay’s study, compliance suffers the most when a clinic lacks consistent protocols. Since this obstacle pertains to intra-clinical communications, it lies beyond the remit of this article. However, ensuring that the vet provides the client with an effective recommendation in an actionable format should have a knock-on effect of clarifying for the clinic what its responsibility is in a treatment plan. When a client confirms their choice of treatment, the clinic ought to be prompted to take the appropriate action. If, for example, a client elects to schedule chest x-rays to check for possible spread of Mast cell tumors, then the clinic should take whatever steps it has in place to schedule the x-ray appointment.
Present options
When appropriate, providing multiple options for treatment can be conducive to client satisfaction and to increased compliance with treatment. In a small but in-depth study of five pet-owner focus groups (27 owners) and three vet focus groups (24 vets), the researchers noted a couple of benefits to providing options and disadvantages when not doing so (Janke N, et al. 2021). Many participating pet owners felt that without options, they were being pressured or not listened to, or even that the vet had financial motivations. Some felt that being presented with only one option can be “uncomfortable” and “awkward” (Janke N, et al. p.11). Instead, by presenting a client with options, the client can be made to feel invested in the ongoing medical process. Selecting a treatment is the first step in complying with a treatment.
Veterinarians should not be so worried about how the cost of various treatments and procedures may impact pet owners that they adjust their recommendations. From Clayton MacKay’s aforementioned study: “At times practices believe the client is overly concerned about costs and therefore does not offer all of the services available (sticker shock). This has been refuted by many other studies as well. Clients wish to receive all of your advice and recommendations” (emphasis added). To be sure, it is good for veterinarians to be conscientious of how clients’ finances may unfortunately impact their ability to get the care they want for their pet. This awareness ought to affect not what the vet says but only how they say it. There is nothing to be gained by negatively judging a pet owner or pressuring them to go into debt, and neither is anything to be gained from an incomplete medical assessment.
Nuzzle’s action plan is a decision aid
Nuzzle’s action plan serves as a comprehensive decision aid. Decision aids in medicine “make the decision being considered explicit, providing a detailed, specific, and personalized focus on options and outcomes for the purpose of preparing people for decision making” (Stacey D, et al. 2017). A meta-analysis of 105 studies involving 31,043 participants showed that decision aids in human medicine increased patient knowledge, the proportion of people actively involved in making a decision, and the proportion of patients whose decisions ended up being consistent with their own values. Based on the efficacy of decision aids in human medicine, researchers investigating the psychology of vet-client communications expect decision aids to be similarly worthwhile in veterinary settings (Seiss, et al, 2015, p.3). So do we.
Motivate with benefits, not negative consequences
Human behavior is better conditioned when framed in terms of the benefits of certain actions rather than in terms of negative consequences for failing to do something. This contradicts the dogma that loss aversion is a stronger motivator of human behavior than aspirations for positive outcomes. (Here is a paper that presents the evidence against the notion that loss aversion is a stronger cognitive bias than its counterpart. The paper also explains the inertia by which that notion persisted despite countervailing evidence. Here is a summary article by co-author and professor of marketing David Gal.)
There is already evidence for this in veterinary medicine: “when prevention practices are framed in terms of the benefits of engaging in a behavior, ‘if you give heart worm medication to your dog regularly you can ensure the health of your pet,’ they are more likely to be heeded than if they are framed in terms of the consequences of not engaging in a behavior” (Seiss, et al. p.2; Gallagher and Updegraff 2012).
Just about every recommendation from a vet can go either way. Consider the following scheduling recommendation for a dog named Lucky who had surgery one week before. It first reads: “Schedule an appointment for one week from today to remove Lucky’s stitches.” And then either: “Removing sutures on time will help ensure the surgical site heals well.” Or: “Failing to remove sutures on time could prevent proper healing and lead to infection.”
The first, positive motivator aligns with the pet owner’s and veterinarian’s goals for Lucky. It assumes that the pet owner is invested in Lucky’s recovery because it explains the good that will come about from following through with the treatment plan. It builds on the rapport that exists between vet and pet owner. By contrast, the second, negative motivator begins with the assumption that the pet owner is aloof, inattentive, and perhaps unconcerned about Lucky’s well-being. At worst, it comes off as infantilizing and punitive. Framing recommendations in terms of the benefits to compliance reinforces the gold standard of vet-client communications: partnership in caring for the pet.
Don’t leave it at that: or, why the phone call isn’t always best
Follow-up starts with the appointment, and it should carry through to the next. Consider, in contrast to how Nuzzle approaches personalized follow-ups, that the state of the art in follow-ups is currently to make a phone call, often the next day after an appointment. Prescribed a new medication? Call the client the next day. Told the client to start their pet on a new diet? Call the client the next day. Sent a pet home with an e-collar? Call the client the next day. Established care with a new pet or client? Call the client the next day. It starts to feel like a rote practice intended to bookend the appointment by tying off loose ends rather than an act of care meant to bridge communication between a sequence of appointments.
The next-day phone call is not a one-size-fits-all solution to follow-ups. To be sure, phone calls do have their place, especially for relaying test results and conferring with clients regarding sensitive, high-priority health concerns. Phone calls should be considered brief telehealth appointments in their own right. However, there are better ways to answer some questions, clarify instructions, and monitor symptoms.
Part of why Nuzzle’s personalized action plans are so helpful is that they force the information exchange that occurs during the appointment into explicit steps to follow and choices to make. Thus, clarifications are made without needing to prompt the client. They have a clearly laid out treatment plan explaining what to do, how to do it, and why to do it. Providing medical information in its treatment context—rationale, goals, steps, alternatives—can additionally lead clients to have more informed questions. Moreover, any questions that do repeatedly pop-up can be incorporated into their corresponding actions for all clients and their pets. Since personalized follow-up begins with an action plan, the client and their pet are put on a trajectory of continuous care. The client should know exactly what to do, and on any matter that they are unsure, they have something specific to reference when they contact the clinic. The post-visit phone call becomes a less needed, secondary tool in many cases because the client will have already followed up in accordance with the treatment plan they agreed to with the vet.
Keep more than an eye on it
Some cases require regular monitoring of symptoms. It may be for the first two weeks after surgery, or as mild arthritis develops in an older animal, or tracking behavior to gauge a medication’s efficacy. Asking the client to “keep an eye on it” is vague and leaves everything up to the client’s implementation. Calling once to ask for an update is not the best use of clinic personnel’s time, nor does it facilitate symptom tracking beyond perhaps a reminder—which, by the by, would be better served by a phone call made several days, not one day, after the appointment, once the pet owner has had an opportunity to forget and the pet has had time to recover or respond to treatment.
Instead, Nuzzle can set up an at-home support plan in line with client preferences. By prompting a client with text or email at an agreed-upon frequency to make an observation, symptoms are more likely to be tracked accurately as well as recorded in a reliable way. Depending on the results, the pet’s doctor may decide to adjust the dosage, prescribe something else, or have the pet return to the clinic sooner than intended.
For example, when a cat presents with constipation and vomiting, the examining vet might say, “If she were to lose weight steadily, or to vomit more frequently, or exhibit a change in attitude, then that would worry me.” These conditional statements should become proactive elements in ongoing diagnostic work with specific thresholds: track weight at least weekly, log vomiting and bowel movements, and log behavior. If weight continues to drop, or if constipation and vomiting do not improve after a week, call us so we can adjust medication and dietary supplements.
Integrating explicit monitoring instructions into the rest of the plan would likely have several added benefits: first and foremost, it changes what might feel like a disappointing, vague visit outcome into a proactive element in treatment and diagnostic work; it makes the client feel like a partner with the vet team; and it locks in potential next steps for making a follow-up appointment.
Partnership: the happy medium between paternalistic and informed
Let us conclude by reflecting on how the best practices for follow-up augment the communication between veterinarian and pet owner. As in human medicine, so in veterinary medicine: current recommendations based on quantitative and qualitative analysis of physician communication are for relationship-centered communication. When centering the relationship between vet and pet owner, it is easier “to establish rapport and build trust rapidly,” which in turn “facilitate[s] the effective exchange of information” and improves compliance and overall satisfaction (Adams and Frankel 2007, p.3; Kanji N, et al. 2012). The pet owner and their vet both should feel that they are working together to achieve the health goals for the pet. Shared decision making contrasts with less effective styles of communication like unilateral directions and the provision of mere information without recommendations (Janke N, et al. 2021).
Personalized follow-up endeavors to convert as many aspects of the communication that occurs between appointments into an opportunity for vet-client partnership. In particular, personalized follow-up extends the fourth habit associated with relationship-centered communication: “invest in the end.” Cindy L. Adams, MSW, PhD, and Richard M. Frankel, PhD, explain: “The importance of checking for client comprehension and coming to a mutually agreed-upon plan cannot be overemphasized. In addition to shared decision making and increased adherence to follow-up, using this approach provides an ideal opportunity to educate clients about their pet’s condition and to correct any misunderstandings or misapprehensions” (14). In other words, “the end” comprises the treatment plan, its actions, and its goals. A vet’s “investment” in that end means arriving at a pet’s treatment by collaborating with the pet owner. We view the action plan as a kind of mutual contract between vet and client. It is the plan they have agreed to, and when the client selects treatment options to pursue, they commit themselves to this partnership.
Many of the practices argued for in this article fulfill the communication requirements for relationship-centered care. The general principle is to leverage the unique roles that vet and client each play in the care for a pet: one is biomedical expert, the other is caretaker. The doctor’s recommendations are presented according to their level of urgency with supporting information and reasoning. Yet they are not unilaterally dictated to the client—in order for a vet’s recommendations to be effective, they must be conducive to the client’s compliance, and so they must be offered as options to which the client commits rather than merely follows. Nor is the client left with a mass of information through which to sift. The vet’s knowledge and experience cannot be flattened into information without recommendations. Veterinary expertise entails situating biomedical knowledge in the context of an individual animal’s health needs alongside the pet owner’s understanding and involvement.
Personalized symptom monitoring further advances how follow-up can partner vet and client. The client knows their pet better than anyone, and the vet has the training and experience to interpret that intimate knowledge—but only if they have access to it. By assisting a client with tracking their pet’s progress and with complying with the treatment plan, personalized follow-up can produce data to guide veterinary interventions. Vet and pet owner therefore help each other through the structures designed into personalized follow-up.
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