The psychology of concordance and compliance - Veterinary Practice
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The psychology of concordance and compliance

discusses the psychological processes that connect how people think, feel and behave and how an understanding of these can help us produce the behaviour we are aiming for

FOLLOWING on from last month’s
article by Geoff Little, the aim of
this article is to explore the
psychology of how vets and clients
make decisions within the
consulting room and how an
awareness of some basic
psychology can be adopted to
improve concordance and
compliance within veterinary

The more we understand the
psychological processes that connect
how people think, feel and behave, the
more likely we are able to produce the
behaviour we
are aiming

behaviour results from
how we
interpret the
world in
relation to the
ideas, the beliefs and concerns we hold
about how it works and the “way
things should be”. The ICEBERG
model (Figure 1) is a useful way to
think about the factors in place when
people decide upon a course of action,
either consciously or unconsciously.

Like the proverbial iceberg, 90% of
what goes on happens below the
surface, at a subconscious level. Often
without realising it, when we make
choices we are guided by our internal
compass and these subconscious
influences lead us to make our minds
up before considering alternative
courses of action. Let’s have a look at

Ideas and hypotheses

Human beings have the unique ability
to conceptualise and analyse the world
in abstract terms. Our ability to
develop ideas about possible outcomes
or events, as well as come up with
theories and hypotheses about why
they occurred and then choose our
behaviour in response to them, is a
major reason why we have become the
dominant species.

These so-called cognitive abilities
enable us to run scenarios and adapt to
the problems we encounter where a
“problem” is defined as a difference between an actual and a desired state of
affairs. Our cognitive abilities don’t just
stop with our powers of imagination;
they also include our ability to analyse
and evaluate the evidence that is
offered in support of hypotheses,
theories, explanations or


Possibly the most universally held
abstract mental model which all human
beings hold is the concept of time. We
are unique in our ability to think about
the past, the present and the future.

Birds migrate based on instinct:
they don’t choose Africa one year and
the Caribbean the next. Squirrels hoard
nuts based upon the melatonin levels in
their brains, they don’t appear to have
considered the relative merits of
canned goods! The human ability to
conceptualise time in this way sets up
all sorts of expectations and
anticipated future states.

Beliefs and evaluations

Humans spend a lot of time thinking
about cause-and-effect and possible or
probable outcomes. This is because we
feel uncomfortable when we are
“uncertain” about what is happening
and this leads to anxiety. In order to
make sense of the “chaos” and
unpredictability of the world around
us, we create “systems” of beliefs in
our mind about how the world works.

These belief systems give our
experiences a sense of meaning and
predictability which in turn helps us
manage our anxiety. It is important to
realise, though, that whilst we can
consciously think about our beliefs,
most of the time they operate at a
subconscious level and inform our
decision-making without us even
realising it.

Values, rights and being right

Values are subjectively held beliefs
about “good” and “bad” outcomes as
well as “right” and “wrong” ways of
behaving. In veterinary practice, values
manifest as desirable future states as
well as ethical codes of conduct.

Rights are man-made rules (i.e. laws
and codes of conduct) which societies
have invented to protect against harm.
“Being right” and “having rights” is
not the same thing.

We can hold beliefs with a high degree of conviction that
we are “right”. When we are in
agreement with someone else about
which values and beliefs represent
“true, good and right”, we are said to
be in consensus with each other.

Consensus can develop over a long
period of time without us ever realising
that we are adopting certain beliefs or
it can occur more rapidly and
consciously when we discuss and
deliberate an issue with another person.

This rapid and deliberate process of
reaching consensus with a client is
called concordance: the shared
decision-making process between the
veterinary practice team and the client.
In other words, “consensus” is the
psychological outcome of the process
of “concordance”, which is much
more likely to result in compliance.


Emotion is the difference between
expectation and reality. Client
satisfaction is an emotion that occurs
when a client perceives that a practice’s
products and services have met or
surpassed their expectations, when they
and their pets have been treated “in the
right way” and been charged a “fair”
price – although this is subjective.

Clients’ beliefs about “right” and
“fair” come from a variety of sources
such as their previous veterinary
experiences or what the breeder has
told them to expect. If as vets, we
operate without considering the client’s
concerns, we are unlikely to achieve the
emotional state of consensus. Client
concerns often relate to four Ps: pain,
prognosis, price and practicalities. It is
important that we address them all
when making decisions.


The G in the ICEBERG model stands
for “ground”: the common ground we
need to find to reach a consensus. We
need to check that our
recommendations “make sense” and
connect with our client’s expectations
about how things “should be”. This
can be achieved by paying attention to
the clients’ emotional and verbal cues
as we interact with them.

Ultimately, if we don’t recognise
when our views of “right” and “fair”
are not in sync with the client’s views,
we are heading for a negative
emotional outcome. Recognising these
signs as early as possible allows us to
explore the reasons why, adapt and
work towards achieving the emotional
state of consensus.

To recommend or not

An emerging debate within the
profession is whether vets should be

making a clear recommendation at all
or whether they should simply present
clients with the options and allow them
to choose. Both strategies have risks
and benefits. Some vets say that
allowing clients to choose their
preferred option exonerates them from
being accused of a “hard sell”.

On the other hand, studies like
AAHA’s* demonstrate that many
clients expect their vet to take the lead
in helping them formulate a plan to
resolve their issue. Failing to offer a
clear recommendation when a client
expects one will also result in a
negative emotional outcome –

The AAHA study showed that
poor compliance was often due to the
lack of vet recommendations. It found
that only 23% of owners of pets with
dental disease got a recommendation
or what they perceived as a
recommendation and that veterinary
practices could double the number of
dental procedures just by making a
recommendation 100% of the time.

AAHA demonstrated that by
offering the client all the options as
well as making a clear recommendation
significantly improved compliance rates
across all areas investigated.

Interestingly, even though a client
may feel satisfied with the consultation,
it still does not guarantee that they will
follow-through on any
recommendations made. In other
words, although achieving consensus
during the veterinary consultation via
the concordance process significantly
improved compliance rates, it still did
not ensure that all or even the majority
of clients consistently followed through
to completion on the vet’s advice.

It would be easy to conclude at this
juncture that compliance is now
entirely in the hands of the client.
However, this is not correct. The
AAHA study showed that practices
with higher-than-average compliance
achieved these results by working as a
team – a topic to be addressed in next
month’s issue.

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