Fearless columnist Natalie L. Marks is an educator, consultant and practicing Chicago veterinarian. Dr. Marks is a leader within the Fear Free movement, was a member of the original Fear Free advisory board and is Fear Free Certified Elite. She passionately believes that all veterinarians should be committed to the physical and emotional health of their patients.Read Articles Written by Natalie Marks
The heartbeat of every general veterinary practice is the exam room. This is where worried new clients sit with their dogs and cats, and sadly, where end-of-life discussions take place and the hardest decisions have to be made. The exam room is where the human-animal bond can shine, trust is created, and veterinarians, clients and patients become part of one bigger family.
Unfortunately, the exam room is also where this beautiful process can falter because of the inadvertent development of fear, anxiety or stress in the patient or client. However, with a few specific and economically feasible changes, and with a veterinarian who embraces available tools, an exam room can instantly change into a positive place for all. Trust leads to compliance, better medicine and better revenues for a practice.
To reduce fear, anxiety and stress appropriately, we need to consider all the senses used by our patients when in the hospital setting and exam room. First, let’s understand what triggers a canine’s senses and, more importantly, how we can prevent developing the “fear cascade” in our patients.
A good friend of mine loves to say, “Failure to prepare is preparing to fail.” This applies to the new philosophy of bringing the diagnostics to the patient. Many veterinarians used to take a canine patient “to the back” to obtain samples, check blood pressure, or perform a quick ultrasound or grooming procedure. In this new age of reducing fear, anxiety and stress, make it a priority to have all these lab supplies, diagnostic tools and treatment needs inside the exam room so that movement through the hospital, where other new triggers may present themselves, are reduced.
Stand or Sit
The exam table, while historically a centerpiece of the exam room, is becoming less and less necessary. For patients that still do well on the exam table, consider offering a heated tabletop or topping it with a non-skid mat and warmed towel. Many veterinarians are shifting to a padded floor mat or having smaller dogs sit in the owner’s lap. In any of these situations, secured footing and traction are essential during the orthopedic and neurologic components of the physical exam in the interest of patient safety and exam accuracy.
Having a patient sit in the owner’s lap during an exam can be intimidating at first for a veterinarian who is not used to treating an animal in this manner. Start out by doing the exams on the dogs of clients who have a good relationship with the practice, or try it with team members and their pets. Develop a comfort level before you move on to other clients, and then start with those you have a great rapport with. All this is worth the effort because the comfort you create for the patient will help you practice better medicine and the bond you develop with your client will become stronger.
Neutralize the Air
Do dogs smell fear? While thought to be an exaggeration by some, it is true. A dog that is stressed or fearful will produce a fear pheromone that is excreted in urine and that other dogs will smell. If a fearful patient urinates in your exam room and appropriate disinfection isn’t used, the fear pheromones will be detected by other patients throughout the day, setting off warning triggers and escalating anxiety before the veterinarian even walks into the room. These chemical and other noxious stimuli, such as strong perfume, anal gland secretions and blood, need to be neutralized and removed using a hydrogen peroxide-based disinfectant.
While a dog’s sense of smell is superior, a canine also has a very strong acoustic range. In fact, according to Louisiana State University, the acoustic range is almost twice as wide as a human’s, and sounds in the upper frequencies can be irritating to dogs of all breeds and ages. The louder the sounds, the more a dog may whine or try to flee from the source. This is why newer philosophies call for avoiding high-pitched baby talk when working with a canine patient and adding a soft, lower frequency music source inside the exam room, such as with a portable music player.
I have touched on pheromone therapy before, but I cannot stress its importance more than I do now. Canine-specific pheromones can be used as diffusers in the exam room, be sprayed on the veterinarian and exam room assistants, and be impregnated on towels, stethoscopes, scales and other exam room accessories.
An important point to remember, however, is that calming pheromones should be diffused or sprayed on towels, clothing and tools at least an hour before the exam. A client service representative can ask clients to start the process at home by spraying a pheromone inside the car, on a dog’s bandana or in the carrier at least 30 to 45 minutes before arrival.
Who Wants a Treat?
Positive reinforcement is a key element in the reduction of fear, anxiety and stress. My hospital has created a protocol in which high-reward treats such as frozen cream cheese cups, cheese slices and squeeze cheese with pretzel sticks are placed in a small cooler in the exam room. Frozen peanut butter cups are kept in a freezer in a treatment area and brought into the exam room only upon request and after ensuring that the client and family members do not have a peanut allergy.
High-reward treats are essential during the introductory phase of the exam, both for rewarding appropriate behavior and for distraction. The client should be able to request and choose the treat and should be involved in its handout during the exam to promote a team approach. This partnership helps to create a ladder of rewards that is based on the level of patient anxiety and the animal’s need for restraint or diagnostics.
What is important to note is that some dogs prefer toys or being brushed rather than a high-reward treat. This is true with patients that are not motivated by food in a relaxed home setting. In patients that are food motivated, we ask the client to not feed them before the appointment so that they will be more excited about a high-value treat.
Separate the Species
If space and time allow, try to designate feline-only and canine-only exam rooms. Separate rooms not only help tailor what is specifically needed in the exam room, they also create a more personalized experience for the client.
Building a relationship with your patient and client that avoids fear, stress and anxiety involves so many aspects. The client preparing to take a pet to the clinic, the actual travel and the time spent in the waiting room all lead up to the invaluable time you spend with the patient in the exam room. It’s important that we do everything we can to make our time together as positive as possible so that we have many more visits in the future.