Secrets of Exam Room Superstars

1.  What pet owners most wanted from their veterinarian in an AAHA survey:

 More explanation time from doctor or the nurse, who use smaller words

 Supplemental written information so it can be explained to others at home

 Demonstration of medication administration was #1

 Follow-up calls for progress and reminders

2.  My first client after not practicing for over a decade

3.  Dr. Harris and Drake the Lab - Story

4.  The exam room is the high temple of veterinary medicine. Before surgery, we scrub, dress in special clothes, use special tools, etc. Why don't we have the same level of preparation before we go into the exam room to see clients? For example, studies have shown that a white lab coat and a stethoscope increase the client's perception of value by over 17%! - Spray yourself with Adaptil and Feliway; dab yourself with Gerber Graduate meat sticks.

5.  Secrets of exam room superstars:

 An appointment is a social contract; respect that.

 Clients are watching our facial gestures, body language, and voice tone when you first greet them. Does your face look relaxed and warm? Does your posture and stride convey calm or urgency? Is your voice tone welcoming and relaxed? These are all things that are hard to be aware of during a busy day. I recommend looking at yourself quickly in a mirror before seeing each patient - not because you're vain or need to adjust your hair. Rather, you can make sure your face reflects the warm, relaxed greeting you want to give. Take a deep breath and let it out slowly, releasing tension. This also makes your voice tone relax. Do this every patient, every time; make it personal protocol.

 If you're late for an appointment, say "I'm terribly sorry I kept you waiting so long. I had _____________ (explanation)." People don't mind waiting for exceptional service.

 Stand up straight. Confident posture conveys authority. Train yourself to lift your head and drop your shoulders every time you enter the exam room, and soon it will be a habit.

 Speak first and look clients in the eye about 70% of the time. It's scientifically proven that this strategy makes you more credible and likeable.

 Create a bond in the first 15–20 seconds of the visit by demonstrating friendliness with: smile, eyebrow flash, nod.

 Smile! Smiling is good. Evolutionarily, we want to smile. It helps us to be accepted. Researchers say that an openmouthed, sincere smile is visible from farther away than a frown; when you're smiling, you'll be recognized as having a smile at a great distance, even in a crowd. We feel better when we see it. And we feel better when we do it. But smiling is hard. Although it's one of the most intuitive things we do (babies smile, blind people who have never seen a smile, smile) it's difficult to do on command. Someone wants to take your picture, or you're introduced to a stranger, or your neighbor sticks a baby picture in your face. You try to slap one on, maybe show some tooth. It looks either fake, lame, or scary.
First a little anatomy. Any time you smile, you contract the zygomatic major, the muscle that runs from the corner of the mouth to the top of your jaw. A smile using the zygomatic major is easy. It's what we do to deliver a fake smile. The customer service rep smiles like that. You're smiling like that in your driver's license photo. Ryan Seacrest is smiling like that right now. It's a manufactured smile. You're not lighting up the room. Then there's "the smile," the kind of smile you appreciate in your wife, boyfriend, or a particularly kind-looking stranger. Because it's hard to do without meaning it. The "Duchenne smile" (after a French neurologist who studied the muscles of the face in the mid-nineteenth century) involves both the zygomatic major and the orbicularis oculi, the muscles surrounding the eyes, the ones that the makers of Botox target for crow's feet. It's not just adding a squint to a smile - a squint involves the inner parts of the eye muscles and is easy to do. It's the outer parts of these muscles you want, and you have to be happy to activate them. When the orbicularis oculi get involved, the smile becomes forceful. You light up. The room lights up. The client smiles. The dog's tail wags. The cat purrs. It's easiest to just be happy, delighted with what you do and with who is in front of you in the exam room. But you can fake it if necessary (just had a patient die, payroll is due, preceding client difficult, etc.). For photos, you can force it easy enough; just smile about 20% more than you think you should. Get it right up there between "glad to be here" and "rapturous to be here." And show your teeth. The top row. The key is smiling wide. Look in the mirror and make a smile so that you're showing the middle six teeth on the top row. Now really smile - wide enough so that your side teeth show. Now, smile even wider than that. You will feel ridiculous, but you will end up looking happy. That's the other thing. Think happy. Simply put, happy works. If you need something to smile about, think of puppy breath, a kinetic mass of kittens, a pet that should have died but didn't, a pet whose name ends with II or III. Source: Esquire magazine, Oct 2009.

 Ask them to describe why they're in to see you, and then listen without interruption (about 1 minute).

 Don't discourage clients from gathering information before they come into the veterinary hospital, but not to over-search. Too many statistics and case histories can be overwhelming, and all that information is useful only to a point: each case is different, and each patient is different.

 To make the most of each visit, veterinarians should first focus a pet owner's concerns and then focus on just one or two of their pet's most pressing medical problems, saving others for later visits. - NPWM (twice yearly wellness visits)

 Get ready to set an agenda. This involves stating what you already know about the visit, then learning the client's priority. Open-ended questions help solicit a client's reasons for seeking care. "I know that you made the appointment because Rusty has been having diarrhea and is not using her litter box. Is there something else we should focus on today?" According to studies, doctors often redirect patients' initial descriptions of their concerns. Once redirected, the descriptions are rarely completed. Clients, if given the opportunity, have an average of three concerns per office visit, so there is a chance of ignoring important issues and creating less efficient visits unless you hear them out.

 Look for clues indicating a client's clear understanding: why you are performing the exam - nodding, smiling.

 Ask the client, "What were you hoping I could do for _________?" Accurate diagnosis, alleviation of pain, cure?

 Up to three expressions of empathy. For example, you could say, "I can only imagine how worried you must be for Sparky, but I'll do all I can to help him...and you."

 Face the person you're talking to. You may not realize it, but when you discuss something that makes you uncomfortable (such as the cost of a diagnostic procedure), your feet and body will start pointing toward the door. Counteract this tendency by turning your whole body toward your client, because it occupies your hands.

 Slightly direct your voice to the person's right ear. Why? Nearly three-quarters (72%) of people turn their right ears toward a person speaking. The reason? The left side of the brain (and right ear) specializes in language processing skills, while the right side of the brain (and left ear) excels at picking up emotional cues. The researchers found that requests spoken into right ears generated more positive responses than those uttered into left ears.

 Limit the fidget. Scratching an imaginary itch, fiddling with your hair, or covering your mouth with your hand makes it seem like you're lying. Not a good thing when you're telling a client her cat needs a $200 test. Can't go wrong with stroking the pet!

 Match a client's mood. Is she sad because her dog might have a tumor? Thrilled because his liver values are stabilized? Match this emotion with a supportive comment, vocal tone, and facial expression and you communicate, "We're on the same team here."

 Exude confidence and the fact that you'll take care of the problem, take away the worry. - How about when your own pet gets sick?

 Don't try to "fix" the emotion when bad news upsets a pet owner. Rather, empathize and align with the client and say something like: "I can see you weren't expecting this news. I understand that you're upset by it. I'm disappointed too that we didn't get a better response to the treatment." "I'm also sad the results of the tests were worse than we we'd hoped for."

 There's a world of difference between "if" and "when" when discussing the chance a disease like cancer will reoccur, or a condition like kidney failure will persist. The word "when" is a prediction of doom that can make it difficult or impossible for pet owners to find hope that their pet will be okay. In contrast, a prognosis preceded by "if" introduces uncertainty. This hint of possibility encourages pet owners to strive for a balance of hope and acceptance that helps them continue to work and play, laugh and love in the face of a fragile future for The Bond. For pet owners to be free to find the balance that helps them live, or eventually let go, the door must be left open for them to find hope.

 Rather than focus solely on the expected outcome when a prognosis is dismal, share both your expectations and your hope with patients. Pet owners can "expect one thing" and "hope for another." Health professionals are obligated to never extinguish hope. - Brain spay.

 Personalized pet health protocols - based on breed, age, current health status, lifestyle, emerging risks.

 Dr. Mehmet Oz told me he was programmed to believe that cold data solved health problems, but then he had an epiphany: People are motivated to change their behavior through appeals to emotion, rather than reason. Metaphorically, philosophically, but also naturally, the heart is where a lot of the game is played.

 Ask, "Have I answered all of your questions?"

 Encourage patients to be honest and forthright. Too often, pet owners withhold critical information or lie because the truth is embarrassing or because they don't want to disappoint the veterinarian by admitting they did not follow the advice or precise treatment plan - giving prescriptions, treating ears, or bathing.

 Make the dog's tail wag or the cat purr.

6.  More businesses are using behavioral economics to appeal to customers, seeking to capitalize on the notion that people don't always act in their economic self-interest. Since April 2008, the Sacramento Municipal Utilities District (SMUD) has told 35,000 customers in their monthly bills how their energy use compares with neighbors' and with the district's most-efficient customers. Customers who received the additional information cut their energy use by 2%, compared with a similar group of users who didn't get the data. These preliminary findings match up with research from Arizona State University showing that people are more likely to reduce energy use to keep up with peers than to save money. "Taking a behavioral approach completely changes the way you view the consumer," says Richard Thaler, a behavioral science and economics professor at the University of Chicago's Booth School of Business. Behavioral economics aren't new to business, as marketers have long tried to appeal to non-economic motivations, such as class status or prestige. Dan Ariely, a professor of behavioral economics at Duke University, says businesses now approach the subject more rigorously, and use behavioral experiments to influence product designs, among other things. Vitality Inc., a Cambridge, Massachusetts, startup, wants to apply behavioral economics to prompt people to take prescriptions. Vitality's GlowCaps uses lights and sounds as reminders. The caps also contain a radio transmitter that sends email to doctors, relatives, and others about how often the cap is opened. Mr. Ariely says people are more likely to take medications as prescribed if they believe others are watching - an idea not addressed in typical economic theory. "Why should you care about what other people do? It's irrelevant," to a classical economist, Mr. Ariely says. But not to a behavioral economist.

7.  Touch before you teach, teach before you reach, reach before you treat.

8.  Make exam room a mixture of classroom and theatre.

 Not just a spay. Perhaps the only major surgery your pet will ever have!

 "I don't think she'd have made it."

 "One of the worst fractures I've ever seen."

 "She was in a lot of pain; it's a good thing you brought her in."

9.  Learn how to do the "two yes" option sequence for responding to requests. Take, for example, a client who asks to change an appointment:

 Tuesday or Wednesday?

 Wednesday is doable, morning or afternoon?

 Morning is doable, which is better for you, 9:15 or 9:55 a.m.?

 We now have you and Smokey scheduled at 9:55 Wednesday with Dr. Becker; would you like the reminder by phone or email?

10.  When a client purchases a new product or service, the team member responds with, "That is a great product/service. Many of our clients have reported they appreciated getting it and that their pet has benefited from it." In addition, the team member can give a personal testimonial about how they use the product on their own pets. This is called comforting the buying decision. I tell people about Reconcile, Novifit, Atopica, daily oral care.

11.  Make an assumptive close - "Mrs. Smith, based on what you've told me and my physical exam, here is what we're going to do." Then you outline the personalized pet healthcare protocol and end with silence. If the client says "Yes!" give her an estimate or quote and get started. If the client says "maybe" or "no," don't immediately acquiesce and offer an inferior plan B. Instead, fight for plan A. Say something like, "I must not have communicated to you clearly enough how important these tests are if I am to know what's wrong with Sparky and be able to make her well." If the client still says no to some or most of your recommendations, you can say, "I know that you care deeply for Sparky but that your budget is a concern today." Let me prioritize my recommendations, and let's see what we can postpone until a later visit that will cause the least pain or risk to Sparky. In this way, you haven't backed away from your professional recommendations but have only deferred them to a future date. - Again, NPWM.

12.  Understand that what you are selling is peace of mind. Those clients opting for "no" or "later" should feel comfortable with their decisions, not guilty. The consequences of deferred or waived care are explained, and a "next visit" expectation is communicated to clients and put into the records before they leave the hospital. In a nutshell, you foreshadow future healthcare protocols. - "Frugality is the new reality." NPWM.

13.  Comfort the buying decision - MDs are terrible at this, DVMs are better, but neither is good enough. Every time somebody buys a product or service, they want to know that they made the right choice, that it was a sound decision, that they received value. There are several ways to do this: Have the team tell clients the same message: "It's a good thing you brought Sparky in. She was in a lot of pain, but she'll be feeling better in no time!"

14.  Don't hesitate to give something away for free. Free! When consultants from Diamond Perspective worked with an auto insurer that was struggling to sell extra services, such as roadside assistance, they suggested the company offer policy holders one free extra. Of those who accepted, 64% purchased one or more additional extras. Paul Blasé who heads Diamond Perspective says they took advantage of consumers' tendency to over-value things that are free. Too often, Blasé says, businesses only target the empirical, left side of the brain, while the quirkier right side is just as influential in decision-making. Mr. Ariely, the Duke professor, agrees that "free" is an important element of behavioral economics. In his book, Predictably Irrational, Mr. Ariely says Amazon.com Inc. boosted sales by offering free shipping for orders over $25, as consumers frequently bought more to quality for free shipping.

15.  What if you don't find anything wrong with the pet? Celebrate normal results and good health! And make the clients feel good about their actions. You might say, "Even though we didn't find anything wrong with Sparky, it's a good thing you brought him in. I saw a similar case a month ago that turned out to be very serious. So we're lucky. Plus, we have the results of laboratory tests that will serve as a good baseline in the future if something does go wrong."

16.  Two reasons why people don't come back (perceived indifference or hurting their pet). If the pet cries out, trembles, pulls back, winces...don't continue with exam; rather, tell the owner "It's obvious that this is uncomfortable for _________, and I don't want to cause her any unnecessary discomfort or pain. So I'll wait and examine that area carefully under sedation or anesthesia." A great tip is to have clients spritz the carriers with pheromones (like Feliway or D.A.P.) before they bring them into the hospital.

17.  Monday morning "cages are empty" medicine vs. Saturday morning "cages are full." In veterinary school, would you have picked up the phone for $100.00? Of course! Then why does it change once we start practicing as veteran veterinarians?

18.  Amp up the importance when taking a call by saying something (always the truth) like, "I was just getting ready to go into surgery/go into the exam room/go to lunch, but I wanted to take your call." This makes them feel extra special and lets them know you don't have a lot of time to talk.

19.  Make a client feel like they're the most important appointment you have that day, and same for the next one, and the next one.

20.  The value of the physical exam:

 The quickest way to improve overall practice quality is to improve the physical examination process. Heads you win...tails you win. Tip of nose to tippy toes.

 Seek more detail while investigating the patient's history. GMA executive with Bernese Mountain Dog - lameness after exercise, vacationed in CT.

 Stethoscope, ophthalmoscope, and otoscope have wow factor.

 Additional information will often lead to a more detailed physical examination (intraocular pressure, eye stain).

 A more complete physical will produce a higher level of diagnostic procedures (swollen joints...joint tap...C&S).

 The greatest opportunity to increase practice quality is through the use of diagnostic tests. Laboratory tests often uncover hidden conditions that would otherwise go undetected by even the most talented clinician at the top veterinary hospital in the world. Example would be feline cardiomyopathy, which is dramatically under-diagnosed (only way to tell is by ultrasound). When these conditions are found, early treatment and preventive measures can be provided. Speaking of breaking patterns:

21.  Seeing is believing! So is feeling, smelling, hearing. Flip the lip, flip the flap, rub the ribs, fluff the fur, etc.

22.  Use props: people learn much better by seeing what you're talking about. So use visual props such as arthritic hip model, bladder stones, heartworms.

23.  Communicate in words people understand. Doctor jargon is great for school, or talk between colleagues; but clients want, no, make that need to understand what is being said. Most clients don't know -itis from -osis, -ectomy from -otomy, or even benign from malignant.

24.  Young veterinarian said to owner who had stepped on dog's leg, "The radiographs show that the leg isn't broken. The dog is limping because of soft tissue damage." The owner was confused so I explained it as a severe sprain. Another owner came in because their Shih-Tzu was gasping for air (collapsing trachea or inhaling the soft palate). She was in her late 40s, and this, her first pet, was her child and she thought it was dying. She had already talked to other pet owners, breeders, and had looked on the Internet for answers. Medically, this wasn't a big deal for the young dog...but for the concerned pet owner...this was a really big deal! What she was buying wasn't a cure, it was a definitive diagnosis and peace of mind knowing a) her dog wasn't going to di.e., and b) it wasn't in pain.

25.  Become a pet advocate for the best quality of care. Can be a client advocate before and after the exam room.

 Eliminate any biases or preconceived impressions with clients (address up the Yak River). - Dog that had chewed off its own leg.

 Every single case, every single animal that enters your exam room warrants an objective, non-prejudging approach.

 If you could give away veterinary services, what recommendations would you make for every patient? This specific patient?

 Sometimes we justify our position as empathy. What makes veterinarians feel we have special insights regarding client's desires? Clairvoyance 101 wasn't taught as part of my veterinary school curriculum; was it yours?

 The difference between "okay care" and "the best care" is just tens-of-dollars, not hundreds or thousands of dollars.

 The one thing you can't be accused of is ____________? You can be accused of charging too much, having a client wait too long, or missing a diagnosis. But the one thing you can never be accused of is doing anything that isn't in the pet's best interests.

26.  Examples of great scripts:

 "I'd like to give your pet a $50 disease, but that's just not possible with this case. It is much more serious than that and warrants this level of diagnostic workup and care."

 Tell a client who is in a hurry for a diagnosis - "Mrs. Beck, this is a very complicated puzzle. I have several parts of the puzzle put together, but I still need a few critical pieces. I hope to get these from some additional tests, from consultations with my colleagues, etc."

 "You'll never have the same amount of money as Bill Gates, but you can feed your dog exactly the same food he feeds his dog."

 Call Prescription Diet t/d "edible toothbrushes."

 Call Reconcile "chemical crutches" or like "taking a tea kettle off of the stove."

 Call loose teeth "piano keys."

 "Routine blood tests are like a 'picture-window on the body' allowing us an expansive view of your pet's current health status."

 "Bring in a stool sample the size of a Milk Dud. Don't clean up the whole yard and bring it in."

 "Because pets cannot talk or communicate their needs, we must use advanced diagnostic methods to determine their state of health."

 "Many pets mask or hide their illness from their owner and the veterinarian, so these tests can help us identify disease signs early, while there is still a good chance for a cure."

 Nutrition - "Nutrition affects your pet's life more than any other single factor."

 Chronic medications - "We recommend blood tests, radiographs, and ultrasounds on a routine basis to make sure the medications are effective and given at the proper dose."

27.  When a client seems distant or disturbed, the team member will ask, "You don't seem as comfortable right now; is there something I can do to help?"

28.  When a client shares disappointment with any service, product, or communication, the team member will ask, "We really want you to be pleased with our service. What can we do to make it right for you?"

29.  Mistakes happen and, unfortunately, the consequences of our mistakes can be significant, resulting in additional suffering or even the death of a patient. How we handle ourselves in these situations can determine the ultimate outcome. Self-preservation is a natural instinct that may tempt us to conceal an error when discussing an adverse outcome with a client. In the past, both the human and veterinary medical community have been resistant to making apologies, assuming it will create lawsuits by implying an admission of guilt. Interestingly, it appears the exact opposite is true. The majority (80%) of client concerns that elevate to a serious complaint (threats of media attention, lawsuit or formal complaint to the veterinary medical board) occur because of communication failure and missed opportunities; 15 percent occur as the result of grief; 5 percent occur due to perceived medical care issues; and less than 1 percent occur due to actual medical care or client service issues. Evidence shows that a sincere apology following a mistake has a significant impact on decreasing malpractice claims and lawsuits. When errors occur:

 Care for the patient (the health and safety of our patients are always our priority).

 Compose yourself and investigate the details of the event (make sure to document what went wrong).

 Disclose to the client what occurred in general terms, unless the client requests specifics (life-threatening complications must be communicated immediately to the client while attempting to stabilize the pet).

 Apologize for your errors.

 Discuss with the client the care plan for the pet.

 Be accountable and discuss reparation. Monetary compensation is never an appropriate substitute for an apology, although it may be part of the resolution.

 Show how you plan to prevent the situation from happening in the future.

30.  Two critically important things we need to do: One, make twice-yearly wellness visits sacrosanct. Two, make the next appointment before the pet owner leaves the current one.

31.  Make the visit a positive memory. Don't just say something mundane or knee-jerk things like "Have a nice day" or "Thanks for coming in." Jolt the consciousness with something personalized and unique like, "You're a loving, responsible pet owner and someone it's an honor and joy to serve. Sparky's so lucky to have a mom like you!"

32.  Using the phrases "My pleasure" or "Here to help" or "Thank you for choosing our practice" needs to be in a cheerful, sincere, non-parrot fashion in a wanting-to-help tone.

33.  Never trust a live pet to somebody who has dead plants.