Contextualised care and communication

Sally Everitt

Welcome to this RCVS Knowledge podcast, in which we’ll look at the importance of communication to the delivery of contextualised care in veterinary practice. I’m Sally Everitt and have been the clinical lead for the RCVS Knowledge work on contextualised care. Just before we start, I would like to thank SPVS Educational Trust for supporting this podcast. We all know that communication skills are essential in veterinary practice. However, communication is not always easy.

Especially if we’re meeting someone for the first time and we have to make decisions quickly, either because of the urgency of the situation, pressure of a full weighty room, or because we have to have difficult conversations around quality of life or finances. Delivering contextualised care is not just about offering a range of evidence based treatment options, but having the skills to work with pet owners in potentially emotionally charged situations to find the most appropriate option.

I’m therefore delighted to be joined today by Ruth Serlin and Hamish Morrin, who have both thought deeply about these issues and have joined us today to share their knowledge and experience. Perhaps I could both ask you both in turn to briefly introduce yourselves and explain why you think communication skills are so important. Ruth, perhaps I can come to you first.

Ruth Serlin

I’m a vet and I’ve worked mostly in charity in university, so I’ve done some teaching. I’m a small animal vet.

But I’m really, really interested in communication because, you know, even from prior to being a vet, it’s it’s it’s the way that we create the world around us. It’s it’s fundamental to our existence. I think we can be you know, we can think, it’s just transfer of information, but it’s it’s actually the interactions that we have, we we build a world, we build space.

And so communication for me is all about really just creating a world that I want to be in and I want to live in. and how do we do that? How do we create that? Probably we’ll come on to some of the topics, but that world in which we can really hold no judgment and create space for people to share, to be curious, to talk and to just develop ideas.

So as well as being a vet, I ended up doing a masters in applied linguistics, which is all about how we communicate and the power of communication and the impact of communication. So that’s informed my teaching and my understanding of communication, but it also led me into getting involved with a veterinary humanities group because it was an English Masters, and in the veterinary humanities group, we talk about the issues in veterinary medicine that can’t be solved by science alone.

So bringing in elements of humanities and social sciences. So that was where the idea about just calling the thing that we’re going to talk about contextualised care, and I’m sure we’ll dig into why that is. so yeah, it it’s been sort of a fundamental piece of thinking around veterinary medicine.

And finally, you know, my I’m dyslexic and I have ADHD and I always say this because I think people can’t we we need to to own these things and we need to to be visible. And I’m currently working in small animal practice and building my own communication consultancy to help vet professionals communicate in challenging situations, particularly around neurodiversity.

Sally

Thank you very much. Hamish, would you to introduce yourself?

Hamish Morrin

Not after that, no. That was too big or too too. No. Such a great statement of how important it all is. I mean, I probably came from so I came from a vet nursing background and in fact I was a zookeeper before I was a vet nurse. So years of animal welfare, and I did my masters in welfare ethics and law. And as I looked at all the problems I was seeing, it just came back over and over again to communication, that actually poor communication was causing poor animal welfare.

And I felt like we knew, we knew what we needed to do. It was our ability to work together to make it happen was the biggest problem. And I I came to the feeling that actually more than the practical skills I developed, actually it was the communication skills would make more of a difference to how much I could improve animal welfare.

And that inevitably led to a lot more reading and me moving into teaching and wanting to teach that. so I am now a senior lecturer in veterinary clinical applications and which is essentially simulation. So I teach communications, interprofessionalism, simulated activities, trying to make it real as possible, teach people how to do this. And I know we’ll get on to that later.

And I’m currently completing my professional doctorate in education. I have about a year to go. but all my research within that has been on topics related to communication and things like shame and psychological safety within education to see how we can actually improve the way we teach communication and prepare people for the industry.

Sally 

Fantastic. This is gonna be great. Perhaps we can start with a discussion about the importance of communication skills for specifically around contextualised care, which is something that perhaps some of us think is the way we’ve always done it, but is also a new term and brings in a lot of things that perhaps haven’t always been made explicit in the way we’ve done our work in the past. So Ruth, you just said you’ve you’ve recently gone back into clinical practice, so perhaps I can come to you first.

How have you found thinking about contextualised care as interacted with your views on communication?

Ruth

This has been a really, really interesting move back into practice because I think when I went into education and I was teaching communication skills, I was drawing back on the past of how I communicated in the past and thinking about that and thinking, yeah, no, I didn’t miss do it that way. That’s kind of interesting. So going back into private practice, it’s been it’s been such an interesting move because the it within within a couple of weeks I had a client say to me, mo one’s ever put it like that before or no one has asked me what I think before.

And that’s no disrespect to anyone else. It may be they haven’t been in they haven’t been at a vet for a little while or that it just wasn’t obvious to them that maybe somebody was. But and there was another client that just didn’t want me to prescribe the things that have been prescribed before, and so came in quite with with a sort of slightly combative stance. And I was able to just say, I’m curious. Why? Just please talk to me so that we can find a way that you know respects that. And I just saw her face just go, I’m not gonna have a fight.

I found it absolutely fascinating with that idea about contextualised care of the shared decision making making that’s fundamental to it. But man, it is not easy. It is not easy. even writing the stuff that we wrote prior to me going into practice, I think I was a little bit more like, yeah, you know, we can do this, we can that. It in the amount of time available in an appointment, with the amount of information that’s going backwards and forwards with all of the things that you need to do an appointment having the having the honed communication skills to create an environment where a good contextualised care plan can happen, that’s a skill. That’s a real skill.

And I’m happy to I’m putting my hand up here, but I’m happy to say I’m still learning that. You know, yeah. I think we all are all the time. And I think you know really interesting things there are in communication, we’re used to talking about the science side of it and seeing our role as as finding out those sort of clinical things and communicating, but communication is about listening as much as it is about speaking. And listening to our clients, if we’ve got any resistance, what is that resistance to? Because it may actually not be to what we assume it is if we, as you did, sort of are curious and try to find out what’s behind that attitude.

Sally

Hamish, have you got any views that?

Hamish

Yeah, ’cause I think I mean obviously after Ruth everything Ruth said and I think the challenge is that in contextualised care we’re trying to understand the client’s context. But that’s a complicated issue for many people in their context, what their bond is with their pet, what their home situation is, what their financial situation is, what they want out of this. And we have there are tools for learning how to draw all these things out of someone to have these conversations. But as Ruth says, the real challenge is that you’ve got to do that in quite constrained environment in quite a constrained amount of time where you’ve got to do a lot of other stuff. And that’s what makes it hard.

And I think often when we talk about contextualised care, people say, but that’s obvious and it’s, you know, we’ve been doing it. So yes, but we struggle to do it because our environment is not always optimal for doing it. And we might be able to do it, but we’re not always able to do it in the time we have and we can’t often dig down to the level we want to effectively.

And I think that’s what makes it hard. And that’s why there’s such a requirement for more sort of skills development. Because I think most vets or vet nurses can do this. They’re often in a situation where it’s very difficult to do it well. And so we need to both increase people’s skills and improve the environment to make it more achievable. One of the things I’ve noticed is certainly when the term contextualized care came out, the the resistance that there was to the term seemed to some extent to come from those of us who’ve been around for a lot longer, going that, you well, this is what we’ve always done.

And I think there’s an element of truth in that. But I also think the problem is we’re doing it implicitly and we can’t explain to anybody else that we’re doing it. So the younger vets come along or nurses come along and they don’t we’re not making it explicit. So they can’t quite work out what it is that we’re doing differently and why the client wants to see this vet rather than that vet, because clinically there’s not necessarily a huge difference.

So I think one of the things I’ve really been pushing for is that perhaps we just think about it a bit more and try and be a bit more explicit about what we’re trying to do. It won’t be an exact science because communication skills and humanities and things are not exact sciences in the biology isn’t a very exact science as well, if we are honest about it. But we have got a tendency to think, you know, there is a right answer to something and moving away from that, I think’s quite a helpful starting point.

I think we we had a lot of pushback at the very beginning from people saying this, yeah, this is how it’s always been done. And I think one of the the big things is yes, but we haven’t defined it. Yes, we we do.

And it isn’t just about the client’s context as well, it’s about our own context. So it’s about reflecting on self. What is it that’s driving me to push this above that? Or what is it that’s really making me feel uncomfortable about that client and their choices or their beliefs or or the situation that I’m in, whether I’m working in a corporate or an independent practice or a charity, and whether or not client in front of me is a a real person or a member of the sort of society, you know, when we’re dealing with with unowned animals and things like that. So people have said, yes, I’ve taken the clients into consideration. So that’s relationship-centered care or client-centered care, maybe. But this is wider, much, much wider than that. And if we’re trying to teach something, we need to define it and we need conversations when it’s a…

Sally 

The actual idea isn’t a new concept at all, but the the bringing it into something that’s actually overt, as you said, being able to define it, being able to test the boundaries of it, be able to have conversations in which we’re kind of talking about the same thing and developing it at the same time. And we needed something that wasn’t that that had a name. and we chose the name of contextualised care because you can’t put judgment into the word context.

And there’s been pushback in various areas. And I love it. I love the pushback because like that develops our thinking, doesn’t it? Yeah. You know, the challenges actually it’s the conversation that helps you define where we’re going and what’s important and those sorts of things. Yeah. So we know communication is important, but the veterinary consultation has the limitations of time, but there are also things that are going on in that consultation that seem to provide some difficulties when we’re communicating. I think even if we start with you know the best will in the world that everyone in there is thinking about the welfare of the animal, there are some hurdles we have to overcome because there are some emotions involved in that.

We also in most cases are having to discuss finances with them and there is always this quality of life brings in this thing at what point do we decide the quality of life is not good enough and therefore we have to consider euthanasia, which one side or the other may have already got to thinking of that, but not all parties in the room may be on the same page. So how do we deal with these these difficult areas of communication?

Hamish

I mean, that’s a lot. Yeah, you don’t have to talk about all of them. I think one of the things is people don’t really like being asked point blank, like, have you got insurance? What can you afford? etc. So maybe using structures like laying out the options and the costs, and then say, Is there anything you would like to talk about regarding the money side of this, the cost of this, anything you would like to explain?

Techniques like that of just trying to give that person space to bring in what they’re concerned about rather than putting them on the spot and making you feel like they’re judging them. So I think that’s and again, hard because making space takes more time out of your consult than just asking a blunt question.

Sally

And it came out really strongly in our context-based care ro research that owners do not want to be asked how much they can afford or whether they’ve got insurance, even though that’s useful contextualized information. Asking that question shuts it down, doesn’t open things up.

Hamish

Yeah. So I think giving them that space where you can say, is there anything about those costs that you want to talk about? If they do, great. If they wanna keep that to themselves, that’s probably getting a bit beyond our res level of responsibility anyway. Obviously it’s there’s challenges around if people decide to go for something and can’t pay, but that I think is a separate, slightly separate issue. I also think Ruth brought this up before. The shared decision making, I think the animal welfare and the question of youth and age are things you raise quite early on. The five domains model.

It’s not that complicated. You can explain a simplified version of that and some ideas of how to measure welfare to anybody. And that is where you start having those conversations about what is a good life. And that’s how you establish what they think a good life is for their pet and whether it’s very different to what you think. By having those conversations, and you find out without being judgmental, you just start asking, like, what is it?

Your animals life that you think they enjoy that matters to them, etcetera, what matters to you. And you start establishing that discussion. And I think I think giving people permission to think about euthanasia as part of that, you kind of raise it as it is an option.

You know, it’s something we can discuss. That’s you know, that is you know, it’s let’s face it, it’s the outcome we’re always going to end up with sooner or later, almost always. So I think giving people raising it neutrally is just here’s a list of options, this is one of the options. People can respond to that or not. So I think again it’s it’s everything that Ruth said, it’s all these models of giving someone that opportunity to take that conversation, to bring up what matters to them.

And then you can run with that rather than you having to try and I guess put them on the spot. I think that’s great. I think the problem sometimes is we have these things and there is an implicit in that that yes, you have euthanasia as an option, but when it’s appropriate, you don’t want to put it in a vaccination appointment with a young colleague. so there is a context around where that is an appropriate thing to make certain but it  isn’t just in the this animal now needs to be put to sleep consultation. This it needs to be in so that people are expecting to have that conversation.

Sally

Yeah, Ruth.

Ruth

I think that comes into one of my students did a a little a little project. For her it was a big project. but it was, you know, a small project for her part of her degree. about actually I think that’s a quality of life conversation that you can bring up on day one.

So if you’re having conversations around an animal’s quality of life and their what they like to do, you know, I think the nurses, the the you know, the abilities model, you know, are they that that’s a clinical quality of life element, but there’s there’s asking clients, you know, just let’s keep a diary, let’s keep a a a concept of your animal’s quality of life and introducing it early on.

Over time, so incidents happen in that animal’s life, you know. So it might be hospitalised for some reason, it might be operated on, it might be neutered, it might have a cut pad, it might need to come into hospital for vomiting and diarrhoea. If they and if a client have a really good concept of the animal’s quality of life, then we can start making decisions around that animal that are not just clinical, but are contextualised into that animal’s welfare and quality of life as well.

So the discussion when you get closer to the end of life is less tricky, is less sort of.. it’s less unexpected. And I often just coming back into how do you introduce that euthanasia topic, I will say to the client, so I’m gonna say something that might be tricky or difficult, but I’m just gonna say the doors open here for this conversation.

You know, we as a clinic or we as people that are caring for you and the animal, we are open to this conversation because I think you know the research says that clients don’t want to bring it up because they don’t want to be judged. We don’t want to bring it up because we’re scared of the client’s reaction. That there’s sometimes just a place of where you can slow it up slightly and say, it might not be now that we want to have this conversation, but this conversation can be had.

We’re not making any judgment about the reasons why you don’t or do have that conversation with us. And we want to approach it openly with you and maybe objectively. and I say to people, I have advocated for euthanasia with an animal, and I’ve also said to clients, This doesn’t sit quite rightly with me, and that’s not, you know, that’s not a decision that I feel comfortable making with you at the moment. So I think just opening that space in a very careful and thoughtful way. And people will just go, okay, I’m not ready for that. All right, we’re good. It’s there. And then I’ll make notes that it’s there. We’ve opened the door.

Sally

Yeah, I think that’s really important. One of the things we’ve done at RCVS Knowledge is to produce some conversation guides. And one of those is of preparing for the consultation. Now not every client’s going to have one, but for those who are interested, the idea of that is really to just let them think about some of those things before they get to the veterinary practice, before they’re in the consulting room. Because I’ve certainly had clients when you’ve started that, they look a bit sort of shocked and a bit sort of rabbit in the headlights, I’m not ready to talk about that. And one of the questions we’ve got on that consultation guide is, do you want to have a conversation around euthanasia or end of life care even?

Because that’s like not quite as final. so that they can just think, is that something they want to talk about yet or not? And you can do that. So it’s great and we’ll come on to that in a minute about you know, we can train ourselves and our staff and everyone working in the clinic, but it as you say, if the clients aren’t expecting to have these conversations because that’s not been their experience in the past, that can make the whole communication a bit more difficult.

Ruth

Yeah, really. I was just thinking, can I come back into the finances element of it?  Because I think you know, I’ve been intrigued by how we talk about money and why we get so upset about money and why we get so judgmental about money. And I’m talking about we as a group of people in the world, but also we as a group of professionals that work together. And it’s it’s really, really interesting. And I think there’s some models that may or may not work so well where money’s off the table.

And I had conversation with a with somebody who was creating something where money was off the table. It was a subscription only model, but there’s always going to be a limiting factor. And I think money’s often a cipher for other limiting factors. And I think w it’s easy to fall into money’s a pro and for a lot of people money is, and I can get on to thinking about how we how we deal with that.

When we take money off the table, we now get into the gnarly nitty-gritty of beliefs and welfare and ethics. And sometimes money’s the thing that people put in front of it. My fifteen-year-old dog isn’t gonna have this because it costs too much. Well, is your two-year-old dog gonna have it? I don’t know. You know, there’s there’s a lot around it, and we can be very out in ourselves very judgmental about what people spend on things, handbags, cars, holidays and it it’s destructive to us as a group of professionals, I think, to hold that to hold all of that. It’s destructive to our relationships with our clients, but also our relationships with what we’re doing, because then we end up with that you have to you know, pets are a luxury thing.

Well you know, I don’t know if we want to get into that, but you know, if we thought about the human animal bond as being the thing that we’re treating, maybe some of the things that we would we would then think about change. And just getting down into the nitty-gritty of how we present financial choices. And I think Hamish used the word cost, and again and again I’ve heard people talk about in an ideal world, in the textbook, if money was no object, the gold standard. And if you present that first to people, you everybody gets disappointed because it’s unobtainium. It’s in the unicorn space. We’re we’re upset because we can’t do it. Clients are upset because they can’t do it and they think that they don’t care. So framing that into there are are some options. Here are the pros and cons, here are the costs, given what you’ve told me about what matters to you. I wonder if this option fits and not using the word expensive and cheap, because again they hold value. So I loved Hamish talking about here are the costs of that, here’s the financial cost of that, but also here’s the physical cost, the emotional cost. Yeah.

Hamish

And the quality of life to the animal. I mean, sometimes doing something highly invasive is not appropriate for that animal, even if it can be afforded, because of the quality of the impact it would have on the quality of life of that animal.

And the benefit to the animal of this treatment, the benefit to the animal is the one that we get lost in, well, drips cost a lot of money and putting in IV lines cost a lot of money and then the equipment costs a lot of money. It’s like, what’s the benefit to the animal of what you’re doing? You know, if we’re putting in a drip, the the cat isn’t going to be dehydrated anymore. So he’s going to feel better and want to eat.

And we forget some of that and we say, well, you know, drips cost IV pumps monitoring and all of that. And the clients aren’t interested in that. They’re interested in what’s the benefit to my animal that your research brought up so nicely, Sally. Because I come from a weird background, right? It’s mostly zoos and where there’s no clients generally. And yet we had all these issues and all these conversations just around different considerations, you know, when you’re looking I mean, okay, zoos have their own sort of ethical concerns, but often then you’re looking at, well, what can we realistically do with this animal that is basically wild and hates being handled and being touched compared to, you know, it’s easier to pill a a pet cat than a tiger, and also a lot often it’s like the value of the social group and the value and also all the people have value for animals, the keepers who work with them. So you’re still having those same conversations. So it’s interesting, I think that’s Ruth’s point about obsessing about money. Actually there’s always going to be one or two things that some people think are the most important characteristic. And we’ve got to be willing to listen.

In I think in zoos is often a very much as like, is it all about the species or is it about the individual? It’s an ongoing challenge. Wildlife, what’s acceptable to do to a wild animal, is an ongoing fight. And usually volunteers and rescuers tend towards the do everything. The clinical staff tend to not. That causes massive conflict. So it is we’ve got to acknowledge that this is it’s not just about the issues we see within perhaps first opinion or referral.

There are very similar sets of contextual issues across every area of veterinary work.

Sally

Yeah, everyone’s dealing with these things. So moving on from that, how can we teach and support our the members of the veterinary care? And I’m going when we did the research, we were looking specifically at undergraduate and postgraduate vets and vet nurses, but I think when we’re talking about this, we’ve also got to talk about all members of the practice team and long after they’ve lost left university, because people like me never got any communication skills training when we graduated. So perhaps we could just start with just what’s what is currently being taught and then perhaps look at what things are also needed to sort of enable everyone to support the delivery of contextualized care. Hamish, perhaps can I come to you first on this? Because you’re doing it.

Hamish

Yeah, I mean I can’t speak for all the vet schools and and vetnurse training institutions. it is very, but from obviously, this is what I do for a job. So I have largely written our communication skills program at University of Lancashire. and I’ve gone from the principle that it’s a clinical skill. So we should teach like every clinical skill, it should be introduced early.

You should do it in very simple kind of individual context and then build in the complexity and challenge. And that it should not be taught separately because you never do communication skills apart. So they start off, our students start off with like doing basic consults, history taking, just doing com skills on their own, but then it starts being brought into doing like case-based learning where they’re doing their consult and then doing their case-based analysis and then wrapping up with a consult.

So it’s much more realistic that you’re actually communicating with people. And of course all the other things communicating with your team effectively. So I think for undergraduate education, it seems like having talked to a lot of people, there are a lot of people in your position, Sally, who’s like it just wasn’t taught. People assumed you learned it on the job.

And then it moved to being something that maybe was taught a little bit separate and not a huge amount of it. We talked to a lot of people who’ve had that. And I think now it’s moving toward this more kind of embedded. And I think that’s the way to go because you just when you think about your day in a in any clinical environment, how much time you spend and how critical it is that you have good communication with almost everyone you talk to, it needs to be taught alongside every other clinical skill, combined with those skills just the way it will be in real life.

And I think that’s for me absolutely the way to go. And I guess the other thing is simulation. There are a lot of things that basically every all of us probably learned by doing it. It’s the the client who absolutely breaks down you know, the the the euthanasia that is we feel is too soon or too late. So it’s like, you know, or the angry client, mostly you learn about that by having it happen to you. Quite frightening at the time if you’re not if you don’t feel prepared for it, it’s difficult.

Simulation gives you that opportunity to get in some actors, to try this out, to actually do those things in an environment where there’s no consequences if you screw it up. If it all goes really badly wrong, it doesn’t matter. You just then go out into a debrief and talk about why it all went wrong, what you did right, what you did wrong.

And I think that’s another huge opportunity to try these things. I ran one last year that was just for vet and vet nursing students, and they were doing a mock surgery, and we just faked an internal bleed, and they had to by communication as to what was happening, pick up what was happening, find it. It wasn’t a hugely complicated scenario, but it just set that basis of this is where your communication and clinical works together and that feeling of this is how it really works in a real life situation. But there’s no patient actually bleeding.

So I think there’s a lot to be said.

Sally

I’ve talked a lot about this, and I’m sure Ruth’s got some actually from her educational experience got quite a bit to add to this as well.

Ruth

I wrote down for this, I’m sure Hamish is going to fill in this because like I I’m not teaching undergraduates anymore.

And the one word I wrote really was integration between clinical and communication and other professional. I think if we try and teach them separately, they become separate in people’s minds. And actually applying all of this  in a clinic is really complex integration of skills. So I second everything that Hamish has said. I can’t add to it really, I think. It’s great. And I think, one of the things that I feel sad about is when people say that you don’t they don’t teach you this in vet school, like Hamish is actually teaching this in vet school, I used to teach this in vet school. We’re doing that people are doing amazing things. People are doing amazing things and the value of it, some students feel the value, some colleagues feel the value, but not all of them. And I think that’s one of those really tricky things is changing a culture, changing an a the way that we think about this stuff. And there was a lovely paper by a medical communications expert where I didn’t get chance to really integrate this into my teaching at university and I’ve done quite a bit of postgraduate work, but it’s actually asking clinicians or team members about maybe a particular clinical topic, what’s the most common conversation you have in this topic?

So it might and what’s the most complex conversation you have in this topic? And then basing your teaching and thinking around those things. So for heart it might be, you know, that the most common conversation you’re having is mitral valve disease. But the most complex one is how to manage a kitten with a heart murmur. What what are we going to do and what does that mean?

And actually integrating that into the teaching hopefully is more interesting to students or mean more interesting to other educational clinicians. I don’t know. I think that’s really, really important when it comes to postgraduate training as well, because we know when people are out doing CPD, there’s a there’s a feeling that the more clinical CPD, if you get more knowledge, it will all be fine.

And actually getting people to do non clinical CPD is quite hard, but I think getting people I think you could encourage people who are giving clinical CPD to talk about the common and the complex communication. I think that would be a really lovely way of getting just a little bit of it built into any CPD because that just feels something that clinicians could feel they could do without having to do sort of communication skills within their CPD, but I think that’d be a really lovely thing to take forward.

Hamish

Yeah. I I strongly agree because it’s amazing because almost everybody, if you ask them, will say that common skills are important. But if you look at who goes to lectures at conferences and who pays for CPD, it’s almost all clinical. So we put it together. Yeah. Exactly what I just described. We have simulation, we we combine and I think that’s more realistic for someone who’s actually in practice.

They’re always doing communications skills in the context of a clinical environment and in context of cases, whether it’s with clients or colleagues or whatever. So making perhaps more CPD that works like that would be perhaps a bit more appealing, bring people in and be a bit more realistic. Cause one of my things is teaching communication. I’m very aware that no one’s going to learn communication from me standing at the front of the room talking at them.

Like that is an absolutely rubbish way of doing it. And I do the bare minimum of that when I just have to share something. so you know, people are not gonna want to go to a CPD and have someone like me stand up and tell them all about contextualised care and trauma-informed practice and shame competence and stuff. It needs to be it needs to be practical. So I think that’s where the simulation stuff does the the chance to do stuff that you really are terrified of doing in practice and you wanna do it in a situation where it’s safe, that’s I think the the way ahead for teaching people in practice.

Because it’s… again, we’re teaching people in practice, it’s more of a conversation. Because people have learned how to deal with some of these situations but still probably struggling with others and they’re wanting to fill in those gaps. It’s not like teaching someone from scratch. So you need a slightly different model to teach them from.

Sally

Yeah. Brilliant. Another area that’s getting a lot of attention at the moment is neurodiversity. And that obviously affects our communication skills. I know it’s something you’re both interested in. So I wondered if you could just say a little bit about how you think neurodiversity affects the communication skills we need, both within our teams for ourselves and with our clients. I think one of the really big things is we all or often.

Ruth

People make assumptions that about the other person through the filtering of the information that is coming into them about them. And one of the things, and so people communicate in different ways, and we all do, but there are certain groups maybe, there’s cultural groups, there’s neurodivergent groups, there are other, you know, when we talk about different people in our teams.

We all think about the world in a different way because of experiences, upbringing, belief systems, whatever, or you know, neurodiversity in particular. And neurodiversity in itself is about, you know, the spectrum of how people are on that. it’s like a biodiversity. A neurodivergent people have maybe a a specified I hate to use it use the word condition because I don’t see this as a a condition or an illness, it’s a societal issue where variation. A variation, thank you very much.

Where this way of communicating feels like it’s the norm, and other people not everybody communicates in that way. So I’m gonna have a a little a a small side rant, because I have ADHD, I’m often having small side rants. but about things like about eye contact. So, you know.

If we always are expecting or teaching eye contact, you know, make good eye contact. Well, for some people, that is just the most tricky, awful thing for them to have to do or to receive. So it’s okay, eye contact might be something in some places that is very, very useful, but if that’s not something that culturally fits with you or the other person, or on a neurodivergent level fits with you or the other person.

There are ways around it, you know, people who can’t see still communicate. People who’ve got sunglasses on still communicate, you know, so we have these very, very quite narrow and specific norms that we often expect people to communicate in. And actually that norm is a bit of a fallacy. And if we’re curious about other people and the way that they communicate, or the way that they’re thinking or what’s going on for them, then we start to break down those barriers that we we as a society, we as a group of people have created.

Hamish

Yeah, I don’t know that if that that’s probably the introduction to that bit. But just I think when we’re trying to communicate with people who are different from us, and I’m not going to go into lists of you know autistic people, you know, people with ADHD, dyspraxic people, dyslexic people, but just when we’re trying to communicate with people who are different from us, we can get quite entrenched in the way that we communicate and actually just asking how did that land or how does that feel or am I right in thinking that this is what you’re thinking or what you’re trying to say and actually having that curiosity and also a little bit of vulnerability to I’m not sure what you’re saying so I really want to understand on both sides of that norm, not norm, I’m putting that inverted commas, is really I think a fundamental way of managing it.

And if you’re part of the norm and you’re dealing with somebody who’s in a minority, it’s actually just trying to find out from them what works for them. This overlaps with lots of ideas about in medicine they often talk about cultural competence, which is this idea of understanding other people’s backgrounds. but the problem with that is the idea of intersectionality. It’s not just that people I mean you can’t just divide people up into you are from this culture, you’re from that. People overlap with all kinds of things there, gender and none of us are just one thing. Yeah. So better is the idea of cultural humility, which is more where you question your own assumptions. Why do I expect someone to make eye contact with me? Does it matter? Is it actually important to what I’m trying to do? And I think it’s that willingness to just ask yourself, Well, why does this person’s communication style bug me.

And is it a real problem that actually limiting our communication? Or is it just I find something I find frustrating because it’s not my background, my culture? Because some things you can just rule out and go, it doesn’t matter. I usually do this with my students. The very first lecture we have on communication skills, I put up a list of all kinds of different characteristics. So have a think for yourselves about where you might fit. And don’t share it. Just have a think about where you might fit.

And I then gently introduce the idea of intersectionality and then I say, Right, can I teach you one way to talk to everyone if every connection on there from you where you are? No. Right. So all communication is a toolkit. So and I try to have that from the beginning so my neurodiverse students immediately say, Right, eye contact. Eye contact is a tool, which you may or may not use. It might be in your toolkit, it might not be, but it doesn’t have to be.

Ruth

I really think it’s very important to establish that there really is no right way. What you’re asking for is how effective is the communication with this person for this context? Like if you can come to a happy agreement on what you how you’re treating that client’s pair, does the rest of it matter that much? And I think one of the tools we have as vets which I find is really useful is talking to the animal.

And talking or talking through the animal, w through the owner, because that’s a focus we’re both interested in. If we’re both focused on the animal, we may take some of the pressure out of the direct vet to client communication that you can do it there. Yeah, Ruth, sorry. I love those papers. There’s some really, really lovely research. There’s that’s sort of my my master’s was on conversation analysis about how people talk, how

Veterinary professionals talk to the animals, but also talk to the clients through the animals. And those pieces of research were all about when topics are tricky, when things are are hard. There’s a lovely paper about emotions. that we haven’t talked about empathy yet, have we? But anyway, but just actually being empathic to the animal just grounds the conversation a little bit more. And I think there’s a lovely new paper out just surveying owners, Louise Cora owned it. Yeah. And and that’s that’s really an interesting perspective. I think what I wanted to say about the neurodivergence as well is we very easily make assumptions about people who are overwhelmed and are showing behaviours that we find tricky to manage.

So our client who is pacing up and down because their appointment was six o’clock and they’re ten minutes late and is now getting angry at the desk may well be somebody that’s angry for whatever reason, but it may well be somebody that is really anxious about their animal because that animal is their only mate in the whole world. Well, that’s how they see their world, has been sat under those awful strip lights and has sensory processing issues and can hear the strip lights, has been assaulted by a whole barrage of smells that they’ve got and a sensory processing issue that makes them smell more acutely. In and out, people just coming and going, people coming and going. and also find it difficult to manage unexpected things happening. Now for whatever reason, you know, we can classify that those some of those traits might be autistic traits.

Some of them might be someone who is overwhelmed by another element of their life. It might be someone who, you know, has caring, needs to to get home to care for somebody. But there’s lots and lots of reasons why somebody gets angry, I’m putting angry inverted commas, but that anger is overwhelm. So telling someone don’t be angry, take a seat, sit down, is much more likely to escalate a situation than I can and and under that anger are those fear, loss, grief, frustration.

So you can, you know, begin to have empathy of I can see that you’re, you know, you’re concerned about the time. Can I help you with that? What can I do to help you? And I think that’s a very underused phrase in our in our world is what do you need from me to help with that? And it really turns the conversation around when somebody’s asked.

Is there something that you need? Can I do it? It might be something that can’t you can’t do, but at least it’s there. It’s like I would like to I would like to have helped with that, given that I can’t. You know, maybe we can make another appointment, or maybe if you want to wait in a quiet room or wait in the car park, whatever it is, or shall we, you know, do a phone appointment or whatever it is. but I think we have our fixed ways that things have to happen, that normative way.

Things have to happen culturally, neurodivergently, whatever, or even within our system. and we meet that upset, distress, overwhelm with Yeah, but sit down. No, but you can’t do that. No, but we can’t help.

Sally

And I think that shows really well the importance of the fact that it’s not just about what goes on in the consulting room, it’s what goes on throughout all the interactions with the practice and the really important role that receptionists can play in all of this, because they’re probably going to pick up these things first, even on the phone or as soon as the person enters the consulting room and empowering them to intervene and show empathy or make the decision to.

Somebody or do whatever it is and listening to their input about the context of our consultation. Because if you’re busy in a consulting room dealing with another client, you may not be aware of all of these things that have gone on before. And if you just have that little bit of knowledge, it can really help with lubricating the the communications between everybody. So that’s fantastic. Thank you.

Hamish

Obviously I’ve had hundreds of students. I’ve had students with disassociative disorder, anxiety, ADHD, autism, et cetera. I think one of the things I think is very important for these students going out into the world is for people to understand and be a bit more considerate about overwhelm, and about things like autistic meltdowns, because I think those students are going to go out into a world that is quite judgmental of that, and yet I don’t see it as something that defines their ability to be successful.

You know, let’s face it, everyone’s had a meltdown at some point for for one reason or other. We all have. so I think it would be nice if I guess some of our attitudes about what professionalism is, could maybe do with a bit of tweaking so that we could be a bit more considered to the needs of our colleagues as well.

And people feeling that they can stand up and say, I’m really sorry, I just need to take ten minutes and take myself out of this. I mean, the contortions we sometimes have to do, particularly in small animal practice, where the clients are coming at you, you haven’t got that time in a car going from one consultation to another. You know, you’ve just put a dog down, perhaps one you’ve been treating for years, and then two minutes later you’re bright and breezy with someone with a new puppy. You know, this is this is difficult stuff and it’s unreasonable to expect people to be able to do that.

Forget neurodivergence, just for anybody to be able to do that day in, day out with that amount of of changing. And we need to be able to enable people to say, Okay, I’m really sorry, I need to step back. And as you say, that’s professional behaviour, that’s looking after everybody. It’s not being difficult.

Ruth

Yeah, I think thinking about our emotions as context, you know, bringing it back into the context. Contextualised care is all about all the factors in play when we’re making a shared decision or a co-decision about an animal’s plan. And one element of it, and one huge element of it is the clinical information. But there’s a lot going on around that clinical information that is very human. And I think one of the things that I am aware of going but way back to a bit of the earlier conversation where haven’t we always done it like this? Yeah, but I don’t know that we’ve included ourselves in these decisions, in these reflections around the decision. So some of the work that’s been done on human factors and Hamish, I love the stuff on shame because I think shame drives so many decisions in a maybe in a wonky direction or just makes it hard to make good decisions. so if we strip back some of that and really have that reflective piece which I don’t know that we’ve done in the past and is very difficult to introduce to students and my work either side of that graduation line is also difficult to introduce to postgraduate people. But actually just that work that Hamish does on day one is who do you think who do you think you are?

Sounds rude. But you know, who who who do you think you are and what are you to other people? And how do you the way that you or all the elements of you show up in your interactions with others and knowing yourself? And having that perception and confidence of yourself, being able to go into practice and then questioning yourself sounds negative, but actually just feeling comfortable with you know how did that go? What about me influenced any of this? What about me and what what I think and how I’m perceiving this has impacted my communication in this contextualised care,you know, situation.

Sally

This has been the most amazing conversation and I know in your conversation various things have come up, but I just wonder if either if if you have got any sort of practical tips that you would want to share at this stage with people working in practice and trying to do these things.

Hamish

I think I’ll start with there’s a couple of things people could Google. They could Google cultural humility and nonviolent communication.

And maybe if they want trauma and form of practice. These are the kind of things you don’t need to know all about them. We’re not therapists, we’re not, you know, we’re not counsellors. But I have found each of those really, really useful in helping to think about how I communicate and how I might change it to be more considerate of, different people and different people’s attitudes, and just being able to draw in some of those ideas that other people have and think about how they apply to you is really, really useful. And some of it you’ll read and think, well that’s no good to me at all. Other bits might be really turnaround the way you think. So I think those, yeah. Shame as another one. there’s the shame in medicine website, which has a lot of research into and when I looked into this and I went to a conference and they listed off all the effects of shame and medicine.

I thought, ooh, we’ve got all of that. So again, these are things I don’t think any any of us are… I’m not an expert in them and I’ve been working on this for a while. But just to have an awareness of these things. An awareness can make a big difference to your ability to reflect on what you’re doing and to think about whether there’s things you might change to help you have better communication with others.

And I think that’s a really good starting point that anyone can do without a huge amount of of effort. Just a reasonable level of reflection.

Ruth

I love it, Hamish, I love the nonviolent communication because our behaviour is needs, you know, so communicating around our needs is a really, really important thing and knowing, having that understanding. I think I loved what you said and it, you know, even though I’ve used the words again and again, this is a toolkit, just listening to Hamish talk about the communication skills and the communication training as a toolkit, it it landed yet another another level for me just now. Thinking about all of the elements, I mean listening is so important, but you know, asking questions through curiosity, being able to you know, do things like the the summarising, the signposting, all of those sort of fundamental communication skills that help us navigate our way with the client around a consult. You know, going back and looking at those kind of just real nuts and bolts things. I’m using the word toolkit. So yeah, and our toolkit to help us. Think about that. We don’t have to use those things every day all the time, but they’re there if we need them. So thinking about a communication skills toolkit.

Sally

And the analogy is you don’t use the same tool for every job. It’s not everything needs a hammer, you know. It is a kit and different things will be appropriate in different situations.

Ruth

And the real sort of skill to that is being able to think critically around what’s going on. But the tips I think the tips around being able to do to be able to to create an environment in which you can communicate around all the different contexts that are in play when you’re making a decision is that open-mindedness and actually thinking, I am part of this decision, but am I driving it? Am I listening? You know, am I how am I guiding it? How am I moving through it with whoever else needs to make this decision with me?

And just not always putting ourselves at the center of everything. Just taking that step back, being reflective and thinking, I’m curious about these these different things that are happening. I’m curious about it, and how can I help weave this into a good welfare-based evidence-led? And we haven’t talked about the evidence, but evidence-led decision where it’s grounded in something, because I think a lot of people worry about contextualised care as being not evidence-based or not, you know, it but it it it is a way of using the evidence to make a decision in a situation. So curiosity, rigour, and I don’t know if we’d kind of talked about that, it’s not fluffy, it’s a real critical thinking element, and being kind to yourself and to the others around you. Not making assumptions about what’s happening.

Sally

Thank you very much. We’ve covered a huge amount of ground in this podcast. I think that’s an absolutely perfect place to stop. I’m sure there are several more hours of conversation we could very happily have. And I really want to thank you for sharing your time. I’ve thoroughly enjoyed this process, but we probably ought to bring it to an end now. So thank you all for listening. If you’d like to learn more about the RCVS knowledge work on contextualised care, we have a dedicated web page where you can find links to our research report, our roadmap, and the conversation guides I mentioned in this study. Thank you all very much for listening. I hope you have a good day. Thank you.