Abstract
ABSTRACT
Client communication skills and professional ethics are areas that have received much attention in veterinary education in recent years. The objectives of this study were to: i) establish the confidence level of faculty teaching in three veterinary schools with regard to their client communication skills, ii) establish a baseline of professional ethics indicators in the same faculty, and iii) compare veterinary students of all levels to faculty in both areas. Students and faculty received identical questionnaires, including statements addressing client communication skills and professional ethics. The results indicate that students are generally comfortable with their communication skills, except in the areas of visual and/or audio aid use, handling emotional clients, and discussing costs of care and payment. Faculty were more comfortable than students in all areas of client communication, although they also had low confidence when dealing with costs of care and payment. Ethically, students and faculty answered similarly. Faculty showed a stronger belief that people are basically honest and ethical, but both cohorts responded similarly when asked about reporting an ethical violation admitted to them by their best friend. Further research is needed to determine whether students are communicating as effectively as they believe they are, with particular attention paid to improving communications with emotional clients and the business aspects of veterinary medicine. Additional work is needed to ensure that veterinary students are learning how to cope with ethical issues objectively. This may begin by ensuring that faculty are teaching and, more importantly, modeling these behaviors during the clinical year(s).
The accreditation policies and procedures of the American Veterinary Medical Association (AVMA) Council on Education include, under Standard 9, a requirement that veterinary curricula provide opportunities for “students to gain an understanding of professional ethics, delivery of professional services to the public, … and management skills” and “opportunities … to learn how … to communicate effectively with clients and colleagues.”1 This standard also requires that “fair and equitable assessment of student progress” be made by veterinary schools and colleges. Furthermore, Standard 11 of the accreditation policies and procedures requires institutions of professional veterinary education to provide outcomes assessment measures demonstrating that their graduates have the necessary client communication skills and ethical values needed to practice veterinary medicine in an independent manner.1 These accreditation standards pose a number of questions for veterinary academics. For example, consideration might be given to whether communication skills or ethics can be taught during a four-year curriculum, what instructional strategies are best suited for achieving this outcome, and how to “fairly and equitably” assess these skills. Certainly, these are questions that require scholarly attention if accreditation standards are to be reliably enforced.
While the full scope of the preceding questions is beyond the scope of this study, the following objectives were set: i) to establish the confidence level of faculty teaching in three different veterinary schools with regard to their client communication skills, ii) to establish a baseline of professional ethics as practiced by the population noted above, and iii) to compare veterinary students of all levels to faculty in both areas.
Medical schools already believe that communication is a core clinical skill, on par with medical knowledge, performing physical examinations, and problem solving.2,3 Outcomes-based research in the field of human medicine supports this premise, and indicates that communication skills impact patient health, satisfaction, and compliance, as well as physician satisfaction.2 Although there are numerous reports about the importance of client communication skills in veterinary medicine, relatively few have directly addressed the integration of communications courses into curricula or provided evidenced-based research clearly indicating that communication skills are lacking in practicing veterinarians.
Within the realm of professional ethics, there is also a lack of evidence-based research to support the need for ethics courses. There are many opinions about the value of teaching ethics in a professional curriculum, and those in favor of doing so probably subscribe to the philosophy that “People are not born possessing moral skills; moral skills must be cultivated and developed, much like skills of other kinds.”4 This statement is as strong as any other in arguing that professional medical ethics need to be taught, not just assumed. And attending a professional school (e.g., medical, dental, law) exposes students to many situations that may be unfamiliar. Encouraging students to think about potentially unethical situations is imperative in helping them to make good decisions when such problems arise.
It is hoped that this study will encourage veterinary schools to more closely evaluate their professional skills curricula and, ultimately, improve them so that new graduates are better able to communicate effectively and so that they understand and practice good professional ethics upon entering their chosen field. Additionally, veterinary faculty and administrations need to follow the lead of human medicine in realizing that communication is a core skill, not something to be “picked up” during the clinical year(s) of veterinary medical training.5 Finally, it is important to recognize that ethics needs to be taught using a method that is experientially based, so that when people are faced with ethical situations as medical professionals, they are equipped with the tools and insight to consider the ethics of a situation before making a final decision.
To assess how veterinary school professors—both clinical and non-clinical—perceive their skills in these areas, a survey was delivered online. Survey statements were based upon the situational experiences of one of the authors as well as ethical decision-making seminars that first-year students at Texas A&M University (TAMU) are required to attend. Students in the TAMU veterinary program received a paper version of the survey, and an identical version of the survey was administered online to the two additional veterinary schools that agreed to participate on condition of anonymity. All responses were tallied and compared among groups consisting of faculty and all four years of veterinary students. Institutional Review Board approval was obtained, and all answers received were anonymous and voluntary.
TAMU veterinary students were surveyed at or near the beginning of their academic years, with the exception of fourth-year students, who were surveyed one week prior to entering their clinical year as this was the only time available to administer the survey to the entire class and ensure the highest participation possible. Students and faculty from the other participating universities were asked to take the survey online starting in early May 2007 and early January 2008.
Fifty-four faculty and 557 students responses were received from the three different schools. The student numbers represent approximately 45% of the total number of students available for surveying (1,222 total students enrolled across three programs, 557 total respondents), with the majority of student responses from TAMU (79% of 440 students). An unknown number of faculty were included in the e-mail survey due to an inability to send individual e-mails, and also because the authors were not responsible for the e-mails to faculty at the other two participating schools. However, of the responses received, it should be noted that the numbers do largely represent TAMU (85%, 46/54 faculty).
The survey asked students and faculty to evaluate themselves through 10 statements (see Table 1) related to client communication skills on a Likert scale, with 1 indicating “strongly agree,” 3 being “neutral,” and 5 being “strongly disagree.” Students and faculty were also asked to rate their feelings about seven broad ethics statements on a Likert scale identical to that used for communication skills.
At least 50% (range 51–79%) of the first-year students responded with “strongly agree” or “agree” in each statement regarding communication skills, except for three statements: “I routinely use visual and/or audio aids in addition to verbal communication with my clients” (37%, 66/179 students), “I am fully capable of handling clients who are emotional when discussing their pet(s)” (50%, 89/179 students), and “Discussing payment and costs of care with clients is easy for me” (28%, 50/179 students). Second-year students followed suit, with some mild variations in numbers (36%, 30/84 students; 36%, 30/84 students; and 30%, 25/84 students, respectively). The third-year students showed a shift, with only two of 10 statements showing at least 50% of students being confident in their client communication skills (range 19–45%). Three of the four lowest-percentage statements remained the same as in the first and second years, with “When discussing treatment options with clients, I feel I am capable of clearly explaining reasons, plans, and expected results” rounding out the lowest scores for this cohort (34%, 50/145 students). Fourth-year students mirrored the other students, with only slight variances in percentages (31%, 46/149 students; 44%, 65/149 students; and 29%, 43/149 students, respectively).
Faculty results indicated that they have the same insecurities as students in the area of discussing payment and costs of client care, where only 38% (20/53 responding faculty) strongly agreed or agreed with the statement. Most felt fully capable of handling all other situations presented by the survey (range 63–76%).
The AVMA publishes and periodically revises its “Principles of Veterinary Medical Ethics,” most recently approved in July 1999 and revised in November 2003.6 The basic premise of these principles is the “Golden Rule,” an ethical principle that essentially tells us to treat others as we would like to be treated. While the AVMA Web site does not explicitly use this definition of the “Golden Rule,” the authors have inferred that this is the intended meaning from the context of the Web site's information.
The results from the ethics section of the survey indicate that there are certain areas where it is quite obvious that students and faculty have a clear-cut belief as to the ethical basis of certain situations. This is demonstrated by the overwhelming “strongly agree” or “agree” responses to the statement: “I understand that referring cases I am not comfortable with is an important part of practicing ethical veterinary medicine.” Seventy-nine percent (66/84) of responding second-year students strongly agreed or agreed with this statement, with first-, third-, and fourth-year students and faculty at 89% (159/178), 92% (133/145), 90% (135/149), and 85% (46/54) agreement, respectively.
Statements such as “I believe there are situations in medicine where it is okay not to tell the complete truth” showed first- through third-year students fairly evenly distributed between agree, neutral, and disagree, generally hovering around the 25–30% range for each category. Forty-four percent (65/149) of fourth-year students answered either strongly agree or agree, 22% (33/149) were neutral, and 34% (50/149) disagreed or strongly disagreed. This closely matches the results for faculty, where 41% (22/54) agreed (no faculty strongly agreed), 17% (9/54) were neutral, and 39% (21/54) disagreed or strongly disagreed.
The statement: “If my best friend admitted that (s)he had committed an ethical violation, I would report him/her to the appropriate authorities” showed 22% (12/54) of faculty members agreeing with this statement; 35% (19/54) were neutral and 31% (17/54) either disagreed or strongly disagreed. Student numbers indicate similar opinions: 32% (47/149) of fourth years would report their best friend, 38% (56/149) were neutral, and 29% (43/149) would not. First- through third-year students indicated that 20–24% would report and 26–36% would not report their best friend's ethical confession (Figure 1).
Although there are references in the literature indicating that students overall are generally not satisfied with their communication skills,5 the results of this study indicate the opposite: the majority of students, particularly those in the first, second, and fourth years of study, are relatively confident in their client communication skills. Results from this survey indicate that third-year students appear to be slightly less confident overall than the other cohorts; with no specific known reason for this outcome, it is something that could certainly be further studied.
It is generally supposed that students will learn effective communication skills during their clinical year(s) of training in the veterinary curriculum, either building on skills learned previously in veterinary-related jobs or somehow acquiring them through interactions with clients during the clinical year(s).5 Unfortunately, students are usually not involved with delivering bad news, talking about euthanasia versus treatment for a possibly terminal disease, or dealing with similarly difficult communications scenarios beyond the extent of being present in the room as the clinician discusses these situations with the client(s). This is an important aspect of veterinarian–client communications, and if students are not equipped to deal with these issues upon graduation then they are learning with “real” clients, which is stressful for the clients and more stressful for the new graduate involved.
According to the literature, the majority of complaints lodged against veterinarians are a result of poor communication.7,8 It seems clear, then, that to improve this number and to better avoid complaints and/or lawsuits, especially as young graduates enter the profession, the teaching of client communication skills in the curriculum is well-supported. This study gives additional support to this claim: although students and faculty appear to be comfortable with some aspects of client communication, some of the more difficult aspects continue to be a problem.
The Atlantic Veterinary College has introduced a successful one-week elective course focusing solely on client communications into its curriculum. The course was introduced in response to the KPMG and NCVEI studies,9 which documented concerns about the non-technical skills of new veterinary graduates. High receptivity to and a high level of satisfaction with the course have been reported, as evidenced by post-course surveys of students.3 It must be reiterated that this is an elective course, and the possibility that the course received such strong reviews because only interested students enrolled in it must be considered. Because it is a resource-intense course, it may not be the ideal way to integrate communication skills training into every veterinary school curriculum. However, the skills taught through this model did not just serve the students in the course; there was a general feeling of improved communication skills for the trained coaches and a high level of satisfaction from teaching the course itself.3
When looking at the skills of current practitioners, there is some evidence that we need to change what we are doing to educate our students in this non-technical skill. Shaw et al. studied the client communication skills of practicing clinicians through the use of the Roter interaction analysis system, and found a lack of use of open-ended questions, many missed empathetic opportunities, and a lack of encouraging client participation during appointments.2 The mean age of clinicians that participated in this study was 41 years (range 26–68 years), and there were 24 males and 26 females. This study thus indicates that communication skills may need improvement, deficiencies are not gender specific, and even in some of the most seasoned veterans of this profession there are difficulties. No statistical analysis of the age or gender of participants in the current study was performed as demographics were not addressed in the survey.
Deficits in communication skills were recognized well before the KPMG and NCVEI studies were released, as evidenced in two articles from the 1970s that deal with this issue.5,10 Michigan State University (MSU) implemented a client communications course into their first-year curriculum in 1970 in the form of simulated interviews using hired “clients.”5 While the course appeared to receive positive feedback from the students and there was discussion among the faculty at that time about providing similar experiences throughout the curriculum,5 there is currently no client communications course listed as a requirement on MSU's veterinary curriculum Web site.11 Current research still supports the need for this skill to be revisited, particularly in this day of ever-increasing litigation regarding animals, especially those that are serving as pets.
Looking at the results of the professional ethics section of this survey, one might begin to wonder: are faculty less ethical than students, or are faculty less idealistic? Or, perhaps, faculty understand through experience that there are times for telling the whole truth and times for not telling the whole truth. Herein lies the difficulty of “teaching” ethics—the sliding scale upon which we stand makes ethics a deep shade of gray, and veterinary students (and perhaps academics) often view the world of ethics as being black and white. Even among ethicists there are differing opinions as to what an “ethical person” is, with no norms of ethics existing that can apply to all people in all situations.4 However, it is still important to develop sensitivity to other people's concerns and understand the principles of ethics4 so that students can learn to recognize when they are at an ethical decision point and then make an informed decision that is in accordance with what has been learned.12
There seems to be no question that professional students across the board need—and generally want—to be ethical in their chosen medical field.12,13 Unfortunately, there is increasing evidence that in spite of the great trust and high regard the medical professions command, the ethics of medical professionals are often dismal. Note the following excerpt from a recent New York Times article:
… how many doctors are willing to look the other way when rules are broken. For instance, 93 percent of doctors agreed that physicians should report all serious medical errors they observe. And 96 percent said physicians who are significantly impaired or incompetent should be reported to the authorities. But when doctors were asked about their personal experiences witnessing medical errors and bad doctors, 46 percent said they had firsthand knowledge of medical mistakes but didn't report them. And 45 percent said they were aware of bad behavior by doctors that they didn't report.14
It seems that physicians are often loath to report colleagues' bad conduct and/or inadequacies. This same reluctance is reflected in veterinary medicine by the results of this survey.
The New York Times article goes on to point out—and rightly so—that the “system for reporting problems is often stacked against the whistle-blower.”14 This somewhat parallels the survey statement: “Being honest will just as easily get you in trouble as lying.” While the majority of faculty and students believed this not to be the case, a significant number strongly agreed or agreed with this statement (20–35%). With one third of survey respondents indicating concern about telling the truth, there is ample reason to start new generations of health professionals out on the ethical track. Being honest should be viewed as a positive experience, although not necessarily easy, with dishonesty viewed as being unethical.
There are arguments on both sides of the ethics debates as to whether professional ethics can be taught to adults, although the majority believe that teaching ethics during the curriculum can affect change in professional students.15–18 For those who do not believe that teaching ethics is effective, it is not because students are not capable of change, but rather because current curricula are incapable of affecting change through content and delivery.12
With the exception of third-year students, at least 50% of the student respondents in our study reported positively in assessing their overall communication skills. A better test of whether lack of client communication skills is a real or perceived problem might be a survey of the clients with whom these students have communicated, although the practicality of doing this is highly suspect. Perhaps a more practical measure, although less accurate than client surveys, would be to have students take this (or a similar survey) during a communications course as a pre-test. This would be followed by the student being recorded in consultation with either real clients or actors, followed by evaluation via the same survey. Raters would be peers, clinicians, and clients, rather than the students themselves. A comparison between the two evaluations would give the student a clearer picture of whether their communication skills are as good—or as poor—as they initially perceived. Follow-up studies using this model might be very enlightening for veterinarians and veterinary educators; to the authors' knowledge, no studies using client perceptions as a measure of communication skills in veterinary medicine exist.
While the full scope of an ethical curriculum and its subsequent outcomes is beyond this paper, further work to develop an effective curriculum encompassing relevant ethical issues might be of high value. No long-term studies tracking outcomes of ethical instruction in the professional curricula were found during the literature search for this study; the outcomes of such a study could prove useful in determining whether such a curriculum enhances new graduates' experiences in practice.
The results of this survey show that students believe themselves to be good communicators overall. They are generally comfortable with their skills in the arena of client communications, although they are consistently least comfortable with discussing costs of care and payments with clients. It is interesting that concerns about communication in this area do not appear to go away with experience, as the faculty response rate mirrors that of the students with regards to this subject.
Ethically, this survey seems to provide support for the idea that most students and faculty know what ethics are and generally believe that people are honest. However, it also indicates that, while students and faculty understand ethics, they are not always willing to step up and be ethical, in the purest sense, themselves.
The results of this survey can be interpreted as indicating that students and faculty are somewhat wary of adhering to the highest standards of ethics. It cannot be said that they do not want to adhere to these standards; indeed, many would probably like to, but find it extremely difficult. This does not mean, however, that the veterinary profession should ignore the issue. Ethics and communication skills are the two most important factors in both social perception of admiration and the ability to ensure success in the medical field,15,19,20 and there is still much work to be done in both these areas of veterinary medical education.
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Figure 1 Sample statement with results: “If my best friend admitted (s)he had committed an ethical violation, I would report him/her to the appropriate authorities”
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| Ethics |
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