We started with one interesting finding from the Workshop for Veterinary College Administrators, Educators, and Practice Management Consultants, sponsored by the National Commission on Veterinary Economic Issues, which was, "It is not the scientific nor the technical which make successful veterinarians, it is their leadership and life skills that are the defining success factors."

Successful veterinarians was not a defined term, but it was suspected to mean successful in the practice of veterinary medicine, including supporting their families and lifestyles, as well as compensating the staff fairly.

Fairly was not a defined term, and in most cases, the evaluation of "fair" is in the eye of the beholder. Equitable has not been used in this context, except by our consulting firm, which believes that doctors and staff should be provided a "suitable living wage" if they want to make veterinary medicine a career.

Life skills were often equated to communication skills, rather than being able to balance a checkbook, although this later aspect is considered essential if you are successful in developing adequate practice liquidity. Life skills included an expectation for a well-balanced life, balanced between the veterinary profession and the personal quest(s) outside the profession.

Effective communication has not been taught in veterinary schools, but that is changing. One veterinary school is now presenting only "provisional grades" until the student passes the oral presentation of the material. Stanford University research has shown that effective verbal communication between adults is only seven percent words and thirty-eight percent tonal. The balance, fifty-five percent, is from non-verbal communications.

There is a new break-through text, Crucial Conversations: Tools for Talking When Stakes are High, by Patterson, et. al., published by McGraw-Hill in 2002, which resonates with applications to practice staff, associates, clients, family, friends, and community activities. Crucial conversations were defined as situations between two or more people where:

 Opinions vary.

 Stakes are high.

 Emotions run strong.

This sure sounds like an "ethical dilemma" in the making. The authors propose that when you are faced with a crucial conversation environment, people can do one of three things:

 Avoid them.

 Face them and handle them poorly.

 Face them and handle them well.

In Crucial Conversations, the basic premise is, as discussions move from causal to crucial, most people shift to their worst behavior, because we were designed wrong.

The generations of instinctive behavior tends toward flying fists or fleet feet, not intelligent persuasion, gentle attentiveness, or win-win behavior.

 Someone disagrees with one of your personal values, and the hairs on your neck stand up. You can handle your hairs, but unfortunately, those two tiny organs atop your kidneys have caused it, from the adrenaline being pumped into your blood stream. This is the involuntary body response you cannot control, your adrenal glands do, and you must learn to live with it.

 When the adrenals start the adrenaline flowing, your brain diverts blood from nonessential activities to high-priority tasks, such as hitting or fleeing. The bad news is that while arms and legs get greater blood, the brain is getting less, so the higher-reasoning parts of your brain have less air and nutrients to work with, so you revert to reptilian response rates.

 When you are under pressure, response become spontaneous, and more often than not, they come out of nowhere, and startle the listener, as well as yourself, when thought about in retrospect. Words spoken cannot be taken back and set the tone for fight or flight in the other person or people.

 So, what makes perfect sense in the heat of the moment become "dumb", when you watch the reactions of others. In truth, you were real-time multi-tasking with a brain that was working on another job. You are lucky you did not "stroke out" instead of debating from your gut.

 In our doped-up, dumbed-down, state of fight or flight, we react in self-defeating ways. The strategies selected are reactive and not proactive. Win-lose survival actions replace the win-win harmony. We are our own worst enemies in most all these cases.

 Crucial conversations require practice, preparing, and controlling the adrenaline-pumped reactions. This is not the time to "wing it" and make it up as you go along. You need to plan the crucial conversations, using the theories, principles, and virtues discussed earlier in the bio-ethics evolution descriptions.

The power of open dialogue is amazing. It has been said: "The pool of shared meaning is the birthplace of synergy." Dialogue skills can be learned, that is the good news. The bad news is a quote from Woody Allen, "More than any time in history mankind faces a crossroads. One path leads to despair and utter hopelessness, the other to total extinction. Let us pray that we have the wisdom to choose correctly."

The common discussion technique used in veterinary practice is directive case management. To that end, the patient's welfare and provider's knowledge and judgment are central to the exchange. In life, learning how to dialogue is critical, but no one teaches it, so most think like Woody Allen did in the above quote. This is because the bio-ethical and moral values discussed at the beginning of this section are not usually appreciated. Crucial conversations fall into the fight-or-flight response before we can establish a dialogue. The first and most important principle of dialogue is start with your own heart!

When conversations become crucial, do not revert to your life experiences of debate, power-based directives, silent treatment, manipulation, bluster, or similar traits so common in families and businesses. So let's look at what your brain needs to learn as "crucial conversation" habits:

 Focus on what you really want for yourself, for others, and for the relationship. Ask, "How would I behave if I really wanted these results?"

 Refuse to take the sucker's choice. Ask, "What are at least three options available that are healthy, honest, and heart-felt?"

 Open yourself to change, search for the elusive, and what tends to be mutually beneficial. Ask, "What are my real concerns, and how can it be phased as a neutral question?"

 Step out, make it safe, then step back in. Ask, "What conditions are at risk, what is our mutual purpose, and how can I establish a mutual respect?"

 If mutual respect or mutual purpose is at risk, use three hard-hitting skills to regain dialogue: Apologize, Contrast, and CRIB.

 Apologize to break the downward cycle. If you have hurt someone, say that you are sorry, and ensure you have a true change of heart.

 Contrast (a do/don't statement) to fix misunderstanding. Address the others' concerns that you do not respect them or their ideas, and confirm your respect of the mutual purpose being addressed, clarifying your real purpose in wanting open dialogue.

 CRIB is used when we find different purposes on the table, and you need to establish a mutual purpose:

 Commit to seek mutual purpose.

 Recognize the purpose behind the strategy.

 Invent a mutual purpose.

 Brainstorm new strategies.

Emotions just don't happen. They do not roll in like a fog and blanket your entire being. Strangely, they are not foisted on you by others either. It has been proven time and again, others cannot make you mad. You make yourself mad, because only you can create your emotions. Once you have created your emotions, there are only two choices left. You can act on them, or be acted on by them. When it comes to strong emotions, which usually precede crucial conversations, you either find a way to master them, or you fall hostage to them.

Stories create perceptions, which create feelings. Every person in a dialogue has a story to tell, and then "path to action" requires a specific flow be established to get to the end point. William Shakespeare said it best, "Nothing in this world is good or bad, but thinking makes it so."

Stories explain what is going on, according to the storyteller's perceptions. The teller builds theories to explain the why, how, and what of the premise. These perceptions and premises are usually linked to judgments of right/wrong, good/bad, kind/selfish, fair/unfair, which yield meanings to the story that may or may not be what was even being discussed. Even if you do not realize it, you are telling yourself stories, and those stories are what drive the emotions, not the other person's actions.

Storytelling typically happens at light speed. We build a story so fast that we do not realize we have, and just sense the resulting emotions. Don't think this happens? Think back, when someone has laughed at you, have you always gotten angry? Think back, when someone has disagreed with you, have you always gotten defensive and protective? The thing to remember in any dialogue is that any set of "perceived facts" can be used to tell an infinite number of stories. If we take control of our stories, they won't control us. The above arrow shows the path to action, so retracing the steps, one element at a time, allows you to change any one or more of the elements, and thereby modify the emotions caused by the story:

 Act -- Notice your behavior. Ask, "Am I in some form of silence, violence, or retreat?"

 Feel -- Get in touch with your feelings. Ask, "What emotions are encouraging me to act this way?"

 Tell story -- Analyze your thoughts. Ask, "What story is creating these emotion?"

 See/hear -- Get back to the mutual facts. Ask, "What evidence do I have to support this story?"

Stories are common, everyone has one or more about any event. As we begin to piece together the steps causing action, why we are doing what we are doing, time and experience will allow us to become quite comfortable at coming up with explanations that will defuse the "crisis" and allow dialogue to be re-established. There are many kinds of stories, but three are the most common:

 Victim stories -- "It's not my fault!"

 Villain stories -- "It's all your fault!"

 Helpless stories -- "There's nothing else I can do."

So why do we tell ourselves these clever stories that destroy the opportunity for dialogue during crucial times?

 They match our reality, and sometimes they are even accurate. The other person may really be trying to harm you!

 They get us off the hook. There is a need to excuse ourselves from responsibility, and they allow us to feel better about ourselves.

 The clever stories keep us from acknowledging our own sellouts. Some stories cause us problems in relationships, especially if they explain away an ethical or morale breech in our own behavior. Self-justification allows us to negate our own mistakes and obsess on another's perceived faults, concurrent with validating our innocence. Self-image becomes more important than the mutual respect or mutual purpose of the relationship or dialogue.

So, you want to change and have meaningful dialogue, you want to reestablish mutual respect, and achieve a mutual purpose for continuing. As Paul Harvey has said for years, learn to "tell the rest of the story".

 Turn victims into actors. Accept that you have a role in the dialogue, and then pretend that you did something to cause the rift.

 Turn villains into humans. A reasonable, rational, and decent person wouldn't do that, so why am I making them be something they are not?

 Turn the helpless into the able. Assess your initial motive, what do you really want, for yourself, for others, and for the relationship.

 Ask yourself, "What would I do right now if I really wanted these results?" Then, as Nike says, Just do it!

So far, so good. But how can you speak persuasively, not abrasively? When sharing a risky meaning, something delicate, unattractive, or controversial, learn to be very clear, frank, and respectful. If you find yourself understating the facts, so the other person will feel comfortable in establishing a dialogue, ensure you become clear, frank, and respectful early in the dialogue exchange. Also, maintain safety, which is done by maintaining the highest respect for the other person(s). The information is shared with confidence and humility, and they are skilled enough not to engage in story conflicts, but rather, establishing the mutual purpose, while retaining the mutual respect.

Those that work to develop their dialogue skills understand they must start from the heart, thinking about what you really want and how the dialogue can help you get there. There are five distinct skills (acronym state) to accomplish this:

 Share your facts. Facts are the least controversial, so remember to differentiate between evaluative premises and factual premises, since the facts are more persuasive than subjective/evaluative conclusions.

 Tell your story. This is the tricky part for most people. It takes confidence to get the perceived facts out in the open, without piling it on. You must watch for any deterioration of "safety", and if you see any defensiveness, revert to contrasting to rebuild the safety.

 Ask for other's path. To establish meaningful dialogue, your goal needs to be to learn, rather than to be right. Being open and attentive to listening further demonstrates your humility. As more information, facts, and feelings are shared, the other person will reshape the respective stories, and the result will be a better pool of shared meaning, mutual respect, and you will be closer to agreeing on the mutual purpose.

 Talk tentatively. This means downplay the facts, when telling your story, speaking in personal opinions and personal beliefs, rather than inviolate statements of logic. This allows perceptions to see "uncertain views", which reduces defensiveness, but doesn't come across as forceful or wimpy. Use the Goldilocks test if you are unsure:

 Too soft: "This is probably stupid, but..."

 Too hard: "How come you ripped us off?"

 Just right: "It's starting to look like you're taking this home for your own use. Is that right?"

  OR

 Too soft: "It's probably my fault, but..."

 Too hard: "You wouldn't trust your own mother to boil water."

 Just right: "I'm starting to feel like you don't trust me. Is that what's going on here? IF so, I would like to know what I did to lose your trust?"

 Encourage testing. This is essential, when the other person is moving toward silence or flight. Invite opposing views, and mean it when you say it. Even playing the devil's advocate sometimes can break the ice, when you perceive the other person is hesitant to open up and share. Model the disagreement by disagreeing with your own view: "Maybe I am wrong here. What if the opposite is true? What if the real reason client return has dropped is because of..."

It is hoped that by now, starting from bio-ethics and ending with crucial conversations, that you can see a common thread in the dialogue needs. Start with your heart, be sincere, be curious, be patient, and stay curious. The ABCs of dialogue are:

 Agree, whether it is with the other person's "path to action", or their "factual premises". If you see the logic, state it right up front. Agree when you agree. Never turn agreement into an argument, when only five to ten percent of the story has differences.

 Build. Agree with the factual premises, and if the evaluative premise is mostly right, start building on those aspects where there are agreements. Being right is good, yet in evaluative situations, those crucial conversations, being right is usually at the expense of others. Look for that small element that was left out of the story or path, and build from an empathy position, such as: "Absolutely. In addition, I noticed that..."

 Compare. When there is a disagreement of perspective, suggest that you differ, start with a tentative openness, such as: "I think I see things differently. Let me describe how." Work together to explore the differences, and then look for the common purpose below the existing debate

Dialogue is not decision making. Yet, for effective dialogue about bio-ethical situations, the evaluative conclusion should lend itself to better standards of care for the patient. For a family argument, with effective dialogue about situations with teenagers, the evaluative conclusion should lend itself to a pool of shared meaning. Responsibility for resolution needs to be a shared agreement, based on mutual respect and mutual family purpose. There are four basic methods of decision making:

 Command. Either outside forces have given no "wiggle room", or there is a health/safety issue. The decision here is "how to make it workable".

 Consult. The primary decision maker, who asks for others to share views to influence any decision to be made, uses a very effective way to establish protocols for healthcare delivery.

 Vote. Better in larger groups, when you find many good options, and do not want to talk an issue to death. Briefly discuss the options from a neutral perspective and then take a vote.

 Consensus. This is both a blessing and a frustrating curse. The "high I" behavior style wants to talk and talk, while the "High D" behavior wants immediate results. D-I-S-C behavior profiles are described in the text Veterinary Management in Transition: Preparing for the 21st Century. Try to reserve this method for either complex issues, or issues where everyone must absolutely support the final choice.

So how do you decide which choice is best for the dialogue that is reaching an end point? The four important questions are:

 Who cares? Do not involve people who don't care!

 Who knows? Do not involve people who are unwilling/unable to contribute new information.

 Who must agree? Involve those who will offer resistance, to establish the importance of their influence on the decision(s).

 How many people is it worth involving? Involve the fewest number of people, while ensuring the quality of the premises, decision(s), and support for the implementation.

A summary that takes five pages must have a conclusion that states clearly, "yes!" In bio-ethics, everything is case-specific, so the "yes" is a transient peace. In issues like pain management, which have moved from "bio-ethical" decisions at the practice level to "public policy" from AVMA and AAHA, the dialogue becomes "how to implement" rather than "should we implement". In issues like ear crops and tail docks, the bio-ethical decision may simply be, "Who does it?", so patient welfare is not in jeopardy. In cases of elective active euthanasia, after the bio-ethical decision guidelines are established for the practice, the dialogue may be on the alternatives left available for the owners of the unwanted animals.

We know that there are multiple influences on bio-ethical decisions. So, in summary, the only thing for sure is that change is normal, status quo is death, and smart leaders use all the brains around them to determine the best course of action. The failure to take action causes more problems than making a decision and then "tweaking" the process until it appears to support the mutual purpose. The "tweaking" discussions will cause the practice members to reinforce the practice vision, share practice philosophy, re-validate the inviolate core values, and better understand the consistency needed in the standards of care. The staff will also be practicing dialogue and interactive behavior, so future crucial conversations can yield mutual purpose outcomes, while reinforcing the mutual respect needed on a veterinary healthcare delivery team. Good luck, and may the force be with you.