Using a Standardized Client Encounter in the Veterinary Curriculum to Practice Veterinarian–Employer Discussions about Animal Cruelty Reporting

There is no universal definition of animal cruelty.⁴ How animals are treated is in large part influenced by societal and cultural norms.⁵ The North American and European perspectives overlap in their consideration of animal cruelty as “socially unacceptable behavior that intentionally causes unnecessary pain, suffering or distress to and/or death of a non-human animal.”^6(p.51),7 Under the umbrella term of animal cruelty are several different subtypes that are recognized by law, including, but not limited to, neglect, intentional abuse, animal hoarding, and organized abuse.⁸ In the United States, all subtypes are ultimately defined by the legal system. Statutory language varies between states and even by jurisdiction not only in how cruelty, neglect, and abuse are defined, but also in what constitutes an animal.

The incidence of cruel acts against animals is difficult to determine because no federally mandated, national reporting systems are in place to track cases.^9,10

Violent acts against animals are particularly concerning because this behavior has been linked to subsequent violence against people.^9,11–16 For example, of the 11 perpetrators who participated in nine school shootings in the United States from 1996 to 1999, 45% were alleged to have abused animals earlier in life.¹¹ In addition to murder, violent acts such as arson, sexual predation, and other forms of interpersonal assault, including domestic violence, have been linked to animal cruelty.^7,17–25 Although it is important to note that engagement in acts of cruelty alone does not predestine one to a lifetime of violence, abusing animals is considered a warning sign.²⁶

Every graduate of a college of veterinary medicine accredited by the American Veterinary Medical Association (AVMA) takes an oath to protect animal health and welfare and alleviate animal suffering.¹ When animal welfare is in jeopardy, as through acts of animal cruelty, the AVMA “considers it the responsibility of every veterinarian to report animal abuse to appropriate authorities, even when such reporting is not mandated by law or local ordinance.”²⁷

Although animal cruelty is considered to be a felony in all 50 US states and in the District of Columbia, only 11 states have legislation at the state level that mandates veterinarians to report suspicions of animal cruelty.^2,28,29 Veterinarians are responsible for familiarizing themselves with the statutory language of the state in which they practice as well as with city and county ordinances, which may vary widely within the same state.^30,31 Should a veterinarian in a mandatory reporting state fail to report, she or he will be subject to disciplinary action that may include a warning letter, license suspension, or even license revocation.³⁰

In addition to state law regarding mandatory reporting, state-specific veterinary practice laws may also require reporting.³⁰ In addition, other states provide infrastructure for voluntary reporting and may even encourage it.³¹

Reporting veterinarians must abide by the state-specific process for reporting,³¹ which may require the reporting veterinarian to provide the date of examination and a description of the animal in question, in addition to the owner's name and residence.³⁰ The agency with the authority to take reports varies between states, but case investigations may involve cooperation among animal control, humane societies, agricultural departments, and law enforcement officers.³¹ Reporting veterinarians are not required to provide a guarantee that abuse took place; they are merely responsible for conveying their suspicions.^3,29

Reporting veterinarians may or may not be provided immunity from civil and criminal liability for good-faith reporting.³⁰ In states that include provisions for immunity, the court will assume that the reporting veterinarian used “the proper degree of care and skill and [acted] under the honest belief that [this action] will benefit the animal.”^30(p.686)

Veterinarians may be professionally or legally obligated to report, but they may also be handicapped by their perceived lack of training or resources.^32,33 Veterinarians have expressed discomfort with identifying animal abuse because of the lack of standardization of definitions and the lack of uniform guidelines by which to critique an animal's condition.^30,33–35 Veterinarians may also be conflicted as to how to juggle mandatory reporting with their obligation to maintain client confidentiality.³⁰ In most cases, there is no actual legal conflict: For instance, the State of Arizona has mandatory reporting, but it does not have a confidentiality statute in place to protect veterinarian–client communication.³⁰ Despite this, veterinarians may still feel torn about breaching their clients' trust. They may also feel pressured not to report the suspicions of colleagues who may fear that reporting will have an adverse impact on the practice's bottom line.³⁰

Veterinarians are not alone with regard to their concerns about reporting. A 2013 study by Creevy et al.²⁴ found that, although more than 86% of veterinary students agree that they have an ethical obligation to report animal cruelty, their perceived lack of training in this content area impedes their understanding of how to initiate and follow through with reporting. To enhance student comfort with the subject and to practice having difficult conversations with colleagues about reporting, Midwestern University's College of Veterinary Medicine (MWU CVM) developed a standardized client (SC) encounter titled “Grizabella's Final Fight.”

The concept that SCs could be incorporated into the veterinary communications curriculum to enhance experiential learning was borrowed from human medical educators. As medical educators' perception of communication evolved and they began to view it as a teachable skill,^36–48 they recognized the utility of having standardized patients (SPs) in medical teaching.^37,49–60 These so-called SPs allowed students to learn through practice and repetition in a safe, constructive environment.^61–64 Initially, SPs were used to portray various disease states.^37,49,50,52 However, their role has subsequently expanded to include sensitivity training,^37,53–58 particularly when it comes to the delivery of bad news.^59,60

Student role-plays preceded the use of SCs in veterinary education.^65–68 Not until the late 1990s and early 2000s did SCs formally became a part of the veterinary curriculum, beginning with Ontario Veterinary College.^62,69,70 This innovative approach to veterinary education paved the way for US-based colleges of veterinary medicine to follow suit, including Colorado State University,⁷¹ Michigan State University,⁷² Washington State University,⁷³ Ross University,⁷⁴ and Western University of Health Sciences' College of Veterinary Medicine.⁷⁵ The data published in the current veterinary medical literature are limited with regard to the thematic content of these encounters. What has been published has emphasized basic aspects of clinical communication in the examination room such as note taking, history taking, and agenda setting.⁷⁵ Few programs advertise that they make use of simulation-based education to work through the delivery of bad news and ethical dilemmas.⁷⁶ To my knowledge, the use of animal cruelty cases as the backdrop for pre-clinical exercises in US-based colleges of veterinary medicine is infrequent.

“Grizabella's Final Fight” is one of 27 SC encounters that MWU CVM students participate in over eight consecutive pre-clinical quarters. Each quarter (fall, winter, spring) spans 10 consecutive weeks, and each class year contains roughly 100 students. All encounters are conducted in mock examination rooms equipped with microphones and audiovisual recording devices, with the capacity for long-term data storage of audiovisual data and SC feedback through health care–based Learning Space software (CAE Healthcare, Sarasota, FL).⁷⁷

The breadth and depth of simulation-based education at MWU CVM promotes student exposure to cases that progress in intensity.⁷⁷ The primary objectives of these encounters are to provide students with the opportunity to (a) experience veterinary clinical scenarios in a safe and supportive learning environment and (b) practice Calgary–Cambridge guide communication skills.^48,78–82

Students are also routinely grouped so that they benefit not only from directly participating in encounters but also from witnessing classmates experience similar case scenarios. A common set-up for simulation-based education at MWU CVM involves five concurrent cases. Each student in a group of five is randomly assigned to lead one case as the sole interviewer and observes his or her classmates in the other four.

“Grizabella's Final Fight” debuted in December 2016, during the final (eighth) pre-clinical quarter, as one of five encounters that emphasized difficult conversations. “Grizabella's Final Fight” was preceded by VMED 1605, a required course that introduced the topic of animal cruelty, and was supported by concurrent enrollment in VMED 1709, a required course that discussed state-specific statutes for Arizona and mandatory reporting. Students were taught that Arizona has mandatory reporting written into law for practicing veterinarians.³⁰ Specifically, Arizona Statute 32–2239 stipulates that

Veterinary colleagues who may not have examined the patient but have reason to believe that the patient has been abused are equally responsible for filing a report. Reporting veterinarians are subsequently immune from civil liability provided that the report was made in good faith.⁸³

“Grizabella's Final Fight” was designed to test students' understanding of Arizona-specific legislation by tasking them with convincing the SC—in this case, their employer—that they were bound by law to report their suspicion that a deceased patient of theirs was a victim of animal cruelty. “Grizabella's Final Fight” is scripted. The script includes an opening statement, pertinent background information, key phrases, “triggers” (student statements that would amplify the emotional intensity of the case), and “defusers” (student statements that would de-escalate the situation). Scripts were distributed to SCs, but not to the students, two weeks before the encounter (Table 1).

Table 1: Script for “Grizabella's Final Fight”

Third-year veterinary students were randomly assigned to groups of five. Each student within a group of five was randomly assigned to be the sole interviewer or student clinician for one of five cases. Of 93 students, 19 were assigned to the role of interviewer for “Grizabella's Final Fight.” Students received a synopsis of the case 2 weeks before the event (Table 2). The synopsis was intended to provide them with a backstory so that they could initiate a dialogue with the SC. Students were instructed that the SC would be playing the role of the employer rather than the client. Therefore, the interaction for which they were prepping was solely student doctor:employer rather than the more typical arrangement of student doctor:client.

Table 2: Case synopsis for “Grizabella's Final Fight”

On the day of the encounter, each student group spent 40 minutes on “Grizabella's Final Fight.” The first 10 minutes preceded the actual encounter and were used for brainstorming: In the absence of the SC, the interviewing student presented the case to his or her classmates and coach and identified learning objectives for the encounter. Then the interviewing student interacted with the SC for up to 20 minutes. After the encounter, the interviewing student initiated a debrief by self-reflecting on his or her performance. Each participant (SC, classmates, and coach, in that order) was then responsible for providing one example of what worked well followed by an example of constructive criticism. Handwritten feedback was also provided to the interviewing student by the classmates and faculty coach. SCs were responsible for providing typed feedback that was stored in Learning Space for subsequent review by the interviewing student. Each interviewing student was also granted access to the audiovisual recording of the encounter via Learning Space to encourage self-reflection.

After receiving institutional review board approval by MWU, I prepared pre- and post-encounter surveys for all five cases, including “Grizabella's Final Fight.” Pre-encounter surveys were designed to capture students' anticipatory reactions to the upcoming event, whereas post-encounter surveys were designed to capture students' reactions to the encounter after the fact (Table 3).

Table 3: Student pre- and post-encounter survey questions for “Grizabella's Final Fight” and mean score based on 23/25 completed pre- and post-encounter surveys

Pre-encounter surveys were made available at the check-in desk in the reception area of the MWU CVM Clinical Skills Center, where students were required to report 15 minutes before their assigned encounter time. All completed pre-encounter surveys were turned in to an on-site senior administrative assistant (SAA) before the start time of the encounter. Immediately after the encounter, post-encounter surveys were distributed, collected, and forwarded to me by the SAA. Students were informed that there was no financial or grade incentive to complete either survey and that the SAA was not in any way responsible for grading student performance during the encounter or for inputting students' grades after the encounter.

All 19 “Grizabella's Final Fight” encounters (100%) concluded with the interviewing student telling the reluctant employer that she or he was going to proceed with making a report to the appropriate authorities.

Eighteen pre- and post-encounter surveys were collected for “Grizabella's Final Fight” (response rate = 94.7%; 18/19).

The mean responses for Likert scale questions on the pre- and post-encounter surveys are listed in Table 3. Comparing pre- and post-encounter responses, student mean responses demonstrated improved preparedness to discuss the medical and interpersonal aspects of the case, in addition to reduced anxiety after the encounter (see Table 3).

The majority of students (16/18; 88.9%) felt prepared to discuss the legal issues surrounding the case. The minority of students had residual concerns about legal ramifications, specifically with regard to whether they had immunity in a court of law and whether they could be protected from retribution if they did indeed go against their employer's wishes by reporting (Table 4).

Table 4: Student free-text responses to pre-and post-encounter surveys with insight into emerging themes pertaining to animal cruelty reporting as experienced in this encounter

Pre- and post-encounter anxiety scores were largely linked to concerns about having to engage in conflict: Dissent within the veterinary team was mentioned by 38.9% (7/18) of students as a source of anxiety (Table 4). In particular, students expressed concerns about how to handle a clinical case that involved a difference in opinion between team members in which one team member (the employer) held authority over the other. Students had to not only navigate the emotional dynamic of the situation but also maintain professionalism in spite of dissent. Eliciting their employer's perspective and creating opportunities for partnership appeared to defuse tension and reduce dissent (see Table 4).

Of 19 students, 16 (84.2%) pinpointed at least one statement or action that they would have altered if they had the opportunity to repeat the encounter. In particular, they wanted to appear more confident by increasing eye contact, taking control of the conversation, and clearly outlining the legal issues at hand: “I would have informed [my employer] that he is just as responsible for reporting these cases [as I am].”

Through written feedback to the students, SCs for “Grizabella's Final Fight” confirmed that 19 of 19 students successfully demonstrated transparency and unconditional positive regard. All 19 also effectively elicited the SC's perspective, used appropriate medical jargon, and contracted for the next steps (Table 5).

Table 5: Standardized client written feedback free-text responses in response to student performance in “Grizabella's Final Fight”

The majority of students effectively used body language, empathy, and partnership (see Table 5). When student interviewers mentioned finding employment elsewhere, SCs noted that it worked against partnership: “It made me question your commitment to my practice.” When a lack of eye contact occurred, SCs noted that it created a barrier to nonverbal communication: “I would have liked you to look up more and at me to demonstrate greater confidence in yourself.”

SCs also suggested that students be more forthright in addressing the legal issues relevant to the case. SCs noted that in roughly one-quarter of the encounters (21.1%; 4/19), students had a tendency to skirt around the uncomfortable issues surrounding animal cruelty reporting and dissent within the veterinary team. SCs felt that it would have been appropriate for students to display more confidence in upholding the law rather than hedging around their legal responsibilities as if hoping the employer would fill in the blanks:

Taking into account all of the communication skills that students used, SCs were asked at the conclusion of the encounter to assess, on a scale ranging from 1 to 5, how well the student ultimately defused the conflict surrounding the case. The mean was 3.63 out of 5 (1 = could benefit from significant improvement; 3 = adequate/acceptable; 5 = exceptional).