Veterinary Practice Issues
November 2008 (Vol 30, No 11)

Are Clients Truly Informed? Communication Tools and Risk Reduction

  • by
  • Kathleen A. Bonvicini , MPH , EdD

This column presents an overview of communication and malpractice risk in small animal practice and offers tools to reduce risk, improve client education and informed consent, and enhance practice success. To introduce the topic of malpractice risk, we provide a snapshot of the current climate of health care in the United States, with an overview of research evidence linking communication with health outcomes. In addition, we introduce specific tools that can be used to increase informed consent in small animal practice.

Background on Health Care

The "landscape" of health care in the United States provides an influential backdrop for consumers of both human and veterinary medical care. Consumers need only to turn on the television, read the newspaper, or search the Internet to find headline stories that reflect an increasingly litigious climate, problems with health care access and affordability for many Americans, high consumer dissatisfaction, and heartbreaking outcomes due to preventable medical errors. While these problems require reform on a macro and systems level through legislation and policy changes, an important element underlying these problems is the relationship between health care practitioners and consumers.1 This interpersonal relationship is a critical factor, particularly in times of illness and suffering, in predicting health outcomes in medicine.2,3

In veterinary medicine, the importance placed on the quality of communication between veterinarians and clients has been underscored in several studies within the past 10 years.4 The following excerpt from a letter sent to a veterinary practice by a client about a fee dispute underscores the significance of this relationship. As you read this excerpt, consider the high stakes that are contingent on the quality of and communication within the client"veterinarian relationship.

Dr. [name withheld] asked me several times, "How aggressive do I want to get?" "I don't," was my answer. "I want to go slow and easy with him." She knew this about me and did not like it. I wanted [name of dog] dealt with on as minimal [a basis] as possible and [left] alone. Seven blood transfusions tells me they didn't leave him alone for a second. It was a critical point, and we did not connect. I knew the second I left, she would do what she wanted, disregarding how I wanted to deal with my overly sensitive bulldog. Maybe [it was done out of ] pride that she was the doctor and I wasn't.

While there are indeed at least two sides to every story, consider that perhaps the veterinarian did his or her best to communicate effectively with this client. For instance, the veterinarian in this case may have spent an inordinate amount of time explaining a recommended course of care. The veterinarian may have had good intentions, yet may have made a very common communication error. She may have neglected to ensure the client was interested in pursuing the recommended course of care or, at the very minimum, that the client understood the proposed treatment.

We might ask, "Was the client fully informed?" According to the letter, the client perceived her requests to be disregarded by her veterinarian. This may or may not have been apparent to her veterinarian at the time. Without taking the time to invest in ensuring that you and your client have a shared understanding of what will happen during the course of treatment, you risk a scenario like the one described in this letter.

In the health care field, consumer perception is often considered the gold standard for evaluating how effectively we have communicated. It is surely no surprise to learn that studies have confirmed that consumer perceptions of medical care depend highly on the quality of consumer interactions with health care providers.5 We are reminded of a common quote in the health care field: "People don't care how much you know until they know how much you care."

Research Evidence

Abundant research evidence in human medicine has informed us that the manner in which clinicians interact with patients has a significant effect on a number of health care outcomes, including malpractice risk, satisfaction, compliance with treatment recommendations, and diagnostic accuracy.6 Unfortunately, some health care professionals may minimize the importance of learning and practicing more effective ways to communicate with patients and clients. In fact, the critical task of communication training in clinical care has traditionally been overlooked or defined as a "soft skill" in medical education. Evidence has demonstrated otherwise. The impact of communication in the medical care setting is anything but soft. For instance, it has been estimated that 75% to 95% of the information needed by physicians to make a correct diagnosis comes from the medical history reported by the patient,7 which must be elicited through astute and thorough interviewing and communication skills. In his New York Times best seller How Doctors Think,8 Dr. Jerome Groopman reinforces the concept of listening as the foundation of diagnostic accuracy by recounting many instances in which he or colleagues failed to listen to patients' stories and mistakenly ventured down the wrong diagnostic path. Reliance on the client-reported history in veterinary medicine is equally important.

Of particular interest to clinicians, malpractice carriers, and risk managers is the research evidence linking poor communication with liability risk (BOX 1). For example, the often-cited research by Beckman et al9 indicates that the major reason behind a patient's decision to pursue litigation against a physician is a perceived lack of caring by the physician. This research included close examination of plaintiff depositions and found that 71% of malpractice claims were initiated as a result of a physician-patient relationship problem, with a common theme being the patient's perception that the physician was uncaring.9 Furthermore, 25% of plaintiffs in these cases reported poor delivery of medical information and poor listening by the physician.9



Other researchers10,11 have sought to pinpoint which behaviors, if any, set apart physicians who are sued from those who are not. The researchers found that patients were more likely to report that physicians appeared rushed, showed a lack of concern, and provided inadequate medical information when the physicians had been involved in a prior malpractice suit than when the physicians had not previously been sued. Malpractice claims are often initiated by consumers who feel deserted or ignored. Furthermore, for practitioners, being the target of a malpractice suit can lead to significant emotional distress, which has been shown to affect their future practice on a personal and professional level. For instance, experiences after malpractice suits include emotional burnout, defensive-medicine practices, and abandonment of practice.12

Malpractice Risk and Informed Consent

As in human medicine, there is evidence in veterinary medicine that client complaints to licensing agencies and veterinary boards are related to communication breakdowns between the client and veterinarian.13,a In addition, increasing sophistication in modalities in veterinary care has enhanced the ability to provide high-quality care, resulting in increased client expectations. Furthermore, noneconomic damages are coming under increasing consideration in litigation involving companion animals.14 Many communication breakdowns linked to malpractice risk in small animal practice point to the necessity of obtaining informed consent from clients.

What are the elements of informed consent? According to Braddock et al,15 true informed consent involves the following elements:

    • Discussion of clinical issues
    • Discussion of options, including pros and cons
    • Discussion of uncertainties of the decision, such as side effects and aftercare
    • Assessment of client understanding
    • Exploration of client preferences
  • While most clinical encounters require at least one patient (client) decision, studies of physician-client interactions indicated that approximately 15% of visits did not adhere to any of these elements of informed consent.15 Furthermore, more than 50% of visits included only one element, 24% included two elements, 6% included three, and 2% included four.15

    Informed consent implies an agreement by the client to a course of diagnostic procedures or treatment after receiving enough information to make an intelligent decision.16 Information about the risk involved is especially important in this process. Informed consent is considered authorization for the care provider to act. Signed consent provides written authorization. Informed consent addresses the ethical need to fully inform clients about the risks and benefits of treatments and to ensure that clients' values and preferences play a prominent role in the final decision. Informed consent is rooted in the concept of client autonomy. Why, then, are the elements of informed consent so frequently overlooked? What are some of the communication challenges to successfully obtaining informed consent in practice?

    There may be several reasons veterinarians are reluctant to use written informed consent in practice.17 For example, written informed consent may be viewed as time-consuming because of the perception that it requires lengthy discussions and explanations as well as additional paperwork and storage. Furthermore, veterinarians may fear that explaining complex procedures may overwhelm clients. Although these may be valid concerns, signing consent is a normal procedure in human medicine (although not without problems, of course), and clients have accepted this as essential to their receipt of medical care. Also, the goals of informed consent, outlined in BOX 2, are to ultimately benefit the veterinarian as well as the client by making sure that both sides understand and share each other's position and concerns. Bearing these goals in mind may make it easier to incorporate the elements of informed consent into your dialogue with clients. While implementing written informed consent in veterinary practice may seem daunting, over time, it can become routine and facilitate the delivery of professional services.



    Although written informed consent may be perceived as important by many people, there is less agreement about how to implement it. What specific behaviors facilitate the informed consent process? Most people agree that veterinarians must do more than just give their clients a consent form to sign. A signature on a document is insufficient—it does not complete the process. Informed consent requires a two-way conversation ≥ a dialogue.

    The Ask-Tell-Ask Technique

    One tool that has been useful in conceptualizing this dialogue is the ask-tell-ask technique. This approach is based on the notion that client education requires identifying what the client already knows and building on that knowledge. It also works as a way to build a relationship because it shows that you are willing to listen to and negotiate the client's agenda. A great deal of communication in small animal practice involves providing information, although this does not mean that communication should be largely one-way. One of the essential elements of informed consent is being sure that the client really understands the information provided. If estimates from human medicine (e.g., 50% of patients leave the office confused18) are applied to veterinary medicine, there is a significant gap in what information is sent and what information is received and understood. Using the ask-tell-ask technique provides information in a manner directed by the client and "closes the loop" to assess the client's comprehension of the information. A few examples highlighting the three steps of this technique are provided below.

    The first step of ask-tell-ask is to assess the client's current knowledge and understanding to tailor the information that you will provide. You can do this by asking an open-ended question:

    You mentioned your friend's dog had hip dysplasia. Can you tell me what you know about hip dysplasia?

    The goal of this first step is to ask your client to describe his or her current understanding of the issue. This will help you craft your message to account for the client's level of knowledge, emotional state, and degree of education. With this knowledge, you are in a better position to formulate the education needed to fill in the gaps of information about hip dysplasia and tailor it in literacy-sensitive language.

    You are then ready to move to the second step of the ask-tell-ask technique.

    I know you've heard about some difficult experiences with surgery from your neighbor. I'd like to go over some of the pros and cons of these procedures to be sure we are both on the same page in treating Chance.

    This statement begins the telling task of the ask-tell-ask technique (BOX 3). The goal is to tell the client in straightforward language what you need to communicate. Stop short of giving a long lecture or large amounts of detail. Information should be provided in short, digestible chunks. One helpful guideline is to give no more than three pieces of information at a time. In addition, avoid using technical terminology, also known as medical-ese. The use of visual information (e.g., diagrams, charts, software programs, drawings, other client-education tools) can help augment your verbal explanation in the telling step.



    The third step of the ask-tell-ask technique is to assess your client's understanding (BOX 4). This can be done by asking a question such as the following:



    We've covered a lot of ground, and I can see this is upsetting. Let's take a minute and review the information we've discussed so far to see if it makes sense. What's your understanding of this surgery?

    This offers you the opportunity to check your client's understanding and is especially useful in assessing whether the client heard what was said. Consider asking your client to restate what was said in his or her own words or what he or she will tell a husband, wife, or partner. This provides the client with an opportunity to ask additional questions and can help you identify information gaps, details that need elaboration, and concepts that should be repeated. An excellent example of this is, "To make sure I did a good job of explaining this to you, can you tell me what you will tell your family?"19

    Depending on the complexity of the information being discussed, a full conversation often requires a series of multiple ask-tell-ask steps.

    Finally, ask the following:

    What else do you need to know at this time?

    Written informed consent is a necessary component of the informed consent process but is insufficient by itself. Written informed consent needs to be signed and dated and should represent the result of the conversation that took place. In addition, other requirements in the medical record should document not only that the informed consent conversation occurred but also what was discussed, who was present, and when and where it took place. This recordkeeping step is essential regardless of whether it is electronic or handwritten.


    There is a wealth of evidence demonstrating how improving communication skills can increase health outcomes for veterinary practice success. The ask-tell-ask technique is one of many communication skills used to enhance informed consent with clients and encourage true dialogue. Effective communication is the primary tool to retain clients, reduce complaints, and decrease malpractice risk.

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