Financial discussions can be very emotive. How often do we hear phrases like “What! How much?”, “Why does it cost so much to spay my dog when it’s routine?” and “Why have prices gone up? The papers say vets cost too much!”? These questions represent the tip of the iceberg and can lead to clients contesting their bills or using non-payment as leverage to ensure they have been heard and taken seriously.
When challenging questions are posed, it is tempting to explain procedures or options more fully in an attempt to justify fees. Superficially, this would be reasonable, especially if veterinary professionals become increasingly conversant about the costs of providing veterinary care. However, it may not allay more complex concerns surrounding the client’s motivations for discussing cost.
An example of vets and clients on parallel journeys that never come together during a discussion is covered in a series of studies by Coe et al. (2007, 2008, 2009). Here, clients wanted to focus on how costs related to the future health or function of their pets, but this occurred in only 10 out of 58 appointments. Instead, when cues about costs were raised, the vet made assumptions and focused primarily on how they related to their veterinary time and service, thus not tackling the underlying wishes of their clients. This miscommunication can, however, be tackled.
This article will look at how vet and client agendas regarding costs can be brought closer together to achieve shared decision making (SDM). To attain this, we must consider how we communicate to ensure the salient points are understood by our clients (Table 1).
| Skill | What is it? | What does it involve? |
|---|---|---|
| Content skills | What we as professionals communicate | The substance of the information we use in terms of: – What we gather and give to the client – Our questions and responses – What we discuss as the way forward |
| Process skills | How we communicate | How we: – Discover or provide information – Use and interpret verbal and non-verbal behaviour – Develop relationships with clients – Organise and structure interactions |
| Perception skills | What we are thinking and feeling | Our thought processes for: – Internal decision making – Clinical reasoning – Problem solving – Attitudes – Capacity for compassion – Mindfulness – Integrity – Awareness of own self-concept and confidence – Awareness of our biases and distractions |
Using SDM skills to open cost-related discussions
A strong beginning – ascertaining ideas, concerns and expectations
Conversations must start with a strong base, so it is essential to ascertain the client’s “starting point”. This might seem counterintuitive when discussing options, procedures, treatment and costs, but in order to reach a mutual understanding about costs and a way forward, it is important to discover what your clients know about the condition or procedure. A client’s baselines are often influenced by previous visits, experiences with previous pets, “Dr Google”, talking with friends or their own healthcare experiences. It is equally important to understand the client’s views, concerns and expectations; this will help determine the level at which you pitch information.
During this initial conversation, clients may reveal their thoughts about areas they would like to address – we might “strike lucky” as the client may raise the subject of pricing, which provides a springboard for discussing cost. Even if they don’t, it is still important to summarise all the areas the client wants to talk about as well as our own. This is necessary for the process known as “setting the agenda”: otherwise the consultation is not “relationship centred”.
At this early stage, we may organically acquire insight into the client’s perspective, as well as their ideas, concerns and expectations (ICE). You can use more direct questions to provide an opportunity for your clients to raise financial (or other) concerns if this information is not given freely during open questions at the start of a consultation. For example, ask: “Before we talk about the results and a way forward, do you have any thoughts/concerns/expectations?”
When things go awry – communication breakdown
Human consultations go awry when there is incongruity between the patient and the physician’s explanatory framework (Tuckett et al., 1985); it is the same in veterinary practice (Coe et al., 2008). For example, a client presenting with a puppy that has an ear infection might be worried about ongoing costs due to the experience of a friend whose cat has expensive chronic ear problems. Alternatively, clients may have read that vet bills are “extortionate”. Unless you ascertain the client’s ideas and concerns and explain the information in a manner that takes these ideas into account, the client may be unconvinced that you really understand their situation.
Human consultations go awry when there is incongruity between the patient and the physician’s explanatory framework; it is the same in veterinary practice
Coe et al. (2008) cite the two most common reasons for a breakdown in client–vet communication:
- Clients not feeling adequately informed of the procedure, cost or possible outcomes, including the long-term implications for owner and pet
- Clients feeling that their concerns were not heard
The authors also found that clients expect to discuss the cost of veterinary care but expect the vet to initiate this. Yet such conversations are uncommon in practice. Even if a client’s ICE is not cost-orientated, it is still important to ascertain their opinion. This makes your clients feel more supported and understood. Eliciting ICE when taking a history can also ensure a more accurate diagnosis and efficient consultation.
Perhaps the most important benefit of discovering the client’s perspective is its effect on explanation and planning. Recall, understanding, satisfaction and adherence are all likely to improve when an explanation addresses the client’s ICE.
Understanding non-verbal cues
Another means of discovering a client’s ICE is to pick up verbal and non-verbal cues. These cues are given throughout the consultation, and when a cue is missed, half are raised a second or even a third time (Levinson et al., 2000). Despite this, additional opportunities may also be missed.
Cues may relate to many issues, including long-term care, medication administration, surgical risks and, most importantly, costs. Research shows that if these cues are missed or vets assume their meaning, we may embark upon completely different discussions from those our clients actually need. Therefore, these cues need to be acknowledged and explored extensively (Table 2).
Non-verbal cues are often more difficult to explore and may require statements such as “Would I be right in thinking that the cost has come as a shock?” This “checking in” is useful with non-verbal cues, determining whether you and the client are on the same page.
| When to use | Example response phrases |
|---|---|
| To non-verbal cues | “I can hear from your voice that you are upset.” “I sense by your expression that the cost is worrying for you. Am I correct?” |
| When a comment needs clarification | “You mentioned it is all too much; can you say a bit more about that?” “What do you actually mean by too difficult?” |
| To cues that require a reflective response | “A bit difficult” “Unhappy” |
| Where the cue is unclear and requires an educated guess | “Would I be right in thinking that the cost is a concern for you? Or have I got that wrong?” “Am I correct to assume that you don’t want [pet’s name] to have surgery because of the cost, or have I misunderstood your thoughts on this?” |
| When it is an emotional cue | “I can see that [pet name]’s deterioration is very difficult for you to cope with.” “From what you’ve said, I can see that the news is very upsetting for you.” |
| When there are several comments that need summarising | “You mentioned that you had mixed feelings about [pet name]’s leg amputation. You are happy that you won’t lose her but you are also worried she won’t cope with three legs.” “You said you were scared about the side effects of chemotherapy. You appreciate that it is different in dogs, but you still have very sad memories of what your wife went through, and you find that upsetting as you can’t get that out of your mind.” |
Next steps – signposting
After ascertaining your client’s perspective and tailoring your explanations to suit, what else can we do to impart information and ensure the discussion involves costs? This is where signposting comes into play.
Signposting is a technique that forewarns the client about the categories of information that will be provided, allowing the vet to present the information category by category and, therefore, enhance recall (Ley, 1988). For example: “There are three important things I want to explain. Firstly, I want to tell you what the problem is; secondly, what tests we could do; and thirdly, what the treatment might be. Is that OK with you?”
Explicit categorisation is a useful way to initiate conversations about essential topics and flag that costs need to be discussed. For example: “There are three treatment options. Would you like me to discuss the cost at the end, or would you like me to go through them as we cover each option?”
When covering specific categories there are certain useful skills to consider:
- Less is more – a small amount of information is more understandable. If more information is needed, it can be addressed when we “check-in” with the client
- Repetition and summarising – these have been shown to assist recall. Summarise the medical aspect, the client’s perspective and costs, if discussed
- Use concise, easily understood language – jargon can be a problem for clients who are reluctant to seek clarification, so lay terms may be preferable. Words such as “chronic” or “parameters” may not be jargon to us but could be interpreted differently by clients
- Visual methods – diagrams can aid understanding
- Scan for cues when delivering information to the client – non-verbal cues may be the only indication clients are unhappy or do not understand
- Ensure risks and benefits are given for each option – either during the discussion of each, or at the end of delivering them all. It is important that these are related to cost and relayed in an unbiased way. Words such as “gold standard” may lead clients to feel guilty for not being able to afford something
Encouraging client contribution and checking understanding
Once something has been relayed to the client, encourage them to contribute their ideas, suggestions and concerns before moving to the next piece of information. You may be tempted to ask your client if they have any questions at this stage, but many may say “no” for fear of being considered “stupid”, or “uncaring” if cost is a concern. Instead, try using phrases like: “I’ve given you a lot of information, and I’m not sure I’ve made myself clear. What are your thoughts so far before we move to the next option?” Once they have stated their thoughts, it is important to listen attentively and show you have done so by repeating what your clients say back to them.
Once something has been relayed to the client, encourage them to contribute their ideas, suggestions and concerns before moving to the next piece of information
Finally, it is important to check the client’s understanding. Research shows that the best way to do this is by getting the client to repeat what has been discussed. Avoid appearing patronising by putting the onus on yourself and getting the client to recap a small section so they do not feel overwhelmed. It needs to be in your own words, but phrases like the following may be helpful: “I’ve covered a lot of information. To make sure I’ve not missed anything, do you want to run through what you need to do with the bandage between now and when I see you next week?”
Conclusion
However they are broached, discussions relating to cost may seem unnecessarily time-consuming when you are given the normal 10- to 15-minute first-opinion consultation. Despite this, discussing costs with your clients and assuaging their fears is crucial, especially given the current Competition and Markets Authority review of the veterinary sector.
Missing this essential step will, at worst, risk complaints and, possibly, claims down the line. At best, you are simply leaving your receptionists to cope with disgruntled clients. Not only does this burden your already busy front-of-house team, but you can guarantee disgruntled clients will be sure to inform all their friends just how expensive their vets are!
Research tells us that using the above skills to ascertain, acknowledge and address a client’s ICE leads to a more efficient consultation. But this article has only scratched the surface of the skills you can use to improve your approach to difficult conversations. If it has stimulated your interest and you would like to learn more, please explore the references below.
