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It's all fun and games until the doctor comes in...

Why patients go from sweet to sour when the doctor comes in

Just today I had a very sweet pit bull mix in for  his annual wellness exam.  He was pretty happy to take rewards from the staff and not showing much  stress in the exam room.  When I came in he was not so happy to take rewards from me.  Taking off my white coat, sprit zing  a little Adaptil spray on him and me helped but he was still tense on the table for his exam.  No aggression; no growling, lip lifting.  Tail tucked and increased panting which would increase and decrease as we progressed through the exam.  After  I  was finished examining him,  he did take some rewards on the table,   but he definitely saw me as the least favorite person in the room.  This dog has always been a bit timid and today he was not  that much more anxious, but why would he focus on me as a source of his fear?

A little history - the last time I saw this dog, he sliced his foot open and had to come in for suturing the wound.  As soon as I saw him, I gave him pain relief and anesthetized him to suture up the wound.  He recovered  without much anxiety at the office,  but through the home care he kept licking  around the incision.   E- Collars, antibiotics, pain meds, and bandages eased some of the pain but he was very bothered by the wound.  He never aggressed during  the rechecks or suture removal  but he was  stressed and took a few minutes of Adaptil for him to be more relaxed.  We never had to heavily restrain him and he never struggled through an exam.  He always had that worried look especially when I had to unwrap the wound, examine it and apply local anesthetic cream to facilitate examination.  We did not have to resuture the wound or any other more intense procedures.  This dog would take rewards tossed from me by the end of the exam.  It was tough for me to stay in the exam room until he was happier.  I do have to follow a schedule like many of you too.   Using rewards as soon as he arrived  in the waiting area, room and on the table really helped him to "forget" what was to come.  What he remembers is that I am the one to actually touch, handle or give medications around the painful area.   

I am sure you have experienced this scenario too.  The techs and staff can pet and handle a dog or cat, give rewards, etc but when the doctor arrives the animal tenses and starts to react.  We DVM's are the administrators of pain.  Yes, we are.  No matter how much we love our patients  we are the ones  palpating painful joints and examining infected teeth. .  Animals remember not only the act, but also who did it.  They also   pick up on the  clues as to who is the doctor - white coats, scrub suits, or the matter of fact  tone of voice we tend to use.   Dogs, cats, and horses are very observant of everything in their environment.  They can  see, hear, smell and sense all the little things that say this is the person who makes "bad things" happen.  Bad things like injections, positioning for exams on painful areas,  or suddenly a bunch of hands holding them down.  

Exams and procedures have to happen.  We don't have all day to provide care to one patient.   No matter how much pain relief or less stressful handling you use, there may still be pain or stress in the exam.  I don't think it is possible to achieve zero stress, yet there are ways to minimize it.  Dr. Sophia Yin has written a book, lectures are available at on many meeting, I have developed a system to record what makes this exam positive for each particular patient.  These are just a few resources to help you get started.

No matter what happens during the exam, it is essential that the doctor rewards the pet and is associated with the least stressful handling.  Pain relief is also paramount before an exam begins. If the doctor does not toss rewards to the pet, how will the pet associate good with the doctor?  Taking 10 seconds to toss really yummy treats, talking jolly talk, or petting over the shoulders or where the pet likes will help this animal bond with the veterinarian despite the previous stress.  How the exam ends with each member of the care team is a part of what this pet learns about exams at the clinic.  If the dog or cat is immediately off the table and away from the doctor in a nervous state, they learn to  stay nervous and anxious around  the doctor.

So doctors, add these techniques to your exam room routine:

  1. Take a few seconds to greet the dog or cat how they like to be greeted! 
  2. Look on the record or ask your staff before you step in what rewards this animal?  What treat?
  3. Give your techs time to get an animal in the most comfortable position - work with your staff on timing for rewarding as injections are given.  Don't rush the exam!
  4. Spray your lab coat or shirt with Adaptil or Feliway as indicated.  Try  remove your lab coat or put a sweater over your scrub top to change your appearance.
  5. Start pain relief before the exam - oral buprenex or lidocaine cream can help tremendously.

Maybe some of these tactics seem unprofessional.   I am not aware of many veterinary curriculum teaching these techniques.   Yet   what is the purpose of clinical veterinary medicine?  We are all here to deliver care and  educate the client about how to do home care, not just make a diagnosis.  If our staff, including the doctors are adding  anxiety or stress to the patient, we are interfering with the delivery of care.  These techniques are creative and need to be adapted to your office, your staff and your patients.  This can be frustrating in some ways.  Veterinarians and technicians are taught in a logical - technical manner not an intuitive way.  Embrace the opportunity to know your clients and their pets by shaping  the way you deliver care.   This is where the art of medicine and behavior combine with the science of both.

Tell me how you help your patients like the doctor more.  I love to hear these stories of how doctors, techs and assistants work together to make the exam experience the best by putting the patient first. I will be presenting 2 talks - Feline Friendly exams and No Pain No maim at the Illinois State Veterinary Medical Association Meeting this November 2, in Lombard Illinois. 

Sally J Foote, DVM  CFBC-IAABC
Okaw Veterinary Clinic Tuscola IL

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