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The Tyranny of Choice in The Exam Room


I read a comment on a social media thread that gave me reason to write about the tyranny of choice. Here’s what was posted, “Clients are more questioning of the profession these days, more able to price-compare and the reticence about discussing money is long-gone. Our practice ethos is to involve the client with the range of treatment options for their pet…”

Which is management speak for “we offer our clients choice”. Which sounds like a great thing to do, but I respectfully disagree with and have seen more than enough evidence from the exam room that this approach is hurting your patients, your clinical development, and your veterinary practice.

The tyranny of choice

Before we go further (and the angry comments flow) let me state that I am a fan of having choices in general. I like to be able to choose my mode of transport to work. I like to be able to choose what to write and when. I like to be able to choose who I vote for. There are many people on planet earth who don’t have the luxury of such choices. So choice, or rather freedom of choice, is fantastic.

But when it comes to a complex topic like veterinary medicine choice is, at best, a double-edged sword. There, of course, are some that disagree. In fact, many of you reading this will be practice owners who are self-selecting as the more extroverted and gifted communicators. If this describes you and you successfully navigate the exam room demonstrating close adherence to your standards of care and equally good client compliance with those recommendations then this article is not for you.

But I’m willing to bet you have staff. And the group that is most let down by the philosophy of offering choice are your assistant veterinarians. So let’s begin with three exam room realities which act as the backdrop to this post.

1. Many veterinary hospitals operate with 10-20 minute veterinary appointments, which are often running late. 2. Few vets are trained communicators and fewer still are naturally gifted at this skill. 3. People (in this case pet owners) do not generally grasp complex subjects in a short single sitting.

Since when was third best good?

Offering choice is, in theory, good and inclusive. But in reality, it is being poorly executed. Frequently, vets are not offering choice in such a way that all options are fully discussed and clearly understood well enough to allow a truly informed decision.

This, in my opinion, is completely understandable. To aim for such an outcome is setting you and your patient up for failure. The notion that we can successfully describe a complex clinical situation and the actions required to deal with it in such a way that a client could possibly make the choice unaided in less than 20 minutes is a very sick joke.

The bad taste punch line is that a shocking number of animals leave our exam rooms with clear clinical needs poorly addressed or not addressed at all.

This goes a long way to explaining why is the uptake of simple, inexpensive yet highly effective treatment options like preventative dental cleanings are so poor when the disease prevalence is so high.

What is happening in our time-crunched world is that we are offering two or three options with little in the way of useful qualification for each. And that inevitably leads the client to make a decision on what they understand best – price.

If the price for option A is £2000, option B is £1000 and option C a mere £500, then, in the absence of a persuasive (clear, understood and compelling) reason to choose A or B, the client is probably going to opt for C.

But how many clinical situations (come to think of it any situations) are best resolved by the third best option?

Consider the example. A time pressured vet finds dental disease (a progressive condition which needs treatment) in a dog. Next, she offers the client three choices.

1. Review things in three months because they aren’t really bad just yet. 2. Try a course of antibiotics. 3. Undergo a comparatively expensive descaling procedure to correct the problem.

What the client hears is that things can wait, because if it really needed doing then wouldn’t the vet just tell me clearly to get on with it?

If this recommendation isn’t made clearly, the client may assume that things are OK and since that’s the case they will go for the easy, cheap or safe option of reviewing things in the future. Or in low cost/commitment scenarios (like choosing parasite treatments) the client will often choose the middle option simply because they don’t want to look cheap.

Neither of these options is effective in the dental example and the likely result is that on the next visit to the vet (probably triggered by a vaccine recall letter), the pet will have “sewer mouth” and have suffered avoidable pain and infection.

Choice as abdication of responsibility

Other vets (typically those short on confidence – new graduates are a good example) use choice to subtly force the client to decide, and hence move the responsibility for decision making from vet to owner. How many times do you see “client declined X-rays”, defensively written on the clinical notes. When in reality the client chose a different option based on a poor understanding of the situation because they weren’t given enough guidance. ‘Client declined on cost basis’ and ‘client declined because they didn’t understand’ are not the same thing.

An alternative viewpoint on choice

My viewpoint on choice changed after seeing so many consults where the best option for the pet was not the one delivered.

I now train vets to:

1. Think through the choices then select the one they feel is in the best interests of the pet’s health. 2. Make a single recommendation of this plan. 3. Use persuasive language that makes it clear what the plan is and just as importantly, why this action is necessary.

If, after some discussion, the client does not want to follow this option then that’s OK. You are not going to convince everyone. Some will always be unable or unwilling to follow your advice. In that case, you can respectfully move on to plan B or plan C.

Much of the time though, this step down isn’t required when you do a good job of presenting plan A.

Choice and the veterinary “police”

“But the college/board say we must offer options” you howl. Yes, they do, and I’m not advocating reducing those options, merely presenting them in a way that makes it clear which option you believe (in your highly qualified, professional opinion) is in their pet’s best interest.

That’s not limiting choice, merely reframing it. No-one one is going to leave your consult room without a plan. It’s just that more of them will have a good plan that helps their pet stay well or get better ASAP.

The win-win of persuasive communication

Vets are typically very honest, extremely hard working, committed to their patients and thoroughly altruistic. All of which are awesome characteristics to be admired and encouraged.

Further, we spend years honing our clinical skills but then lament the fact that clients never seem to do what we want. All the while blaming clients and getting in a funk about this repeating cycle.

My recommendation for you is to spend some of that time and energy on getting good at the softer skills. Take a class in presentation skills. Get a coach. Read books. Educate yourself on the skills of effective persuasion and negotiation. Do these things and watch three awesome things start to happen.

1. Your will form deeper more trusting bonds with your clients.

2. You will get busier and hence have the chance to accelerate your clinical development.

3. You will generate more income for you and your practice.

What’s not to like?

So, next time you get in the exam room, what’s it gonna be? Same old style, or something new? The choice is yours.

If you'd like some help with training or coaching your team in how to get more out of their time in the exam room please get in touch about how I can help. Have a great day.

Dr D.

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