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Fear Free™VeterinaryVisits Alaska cruise
As a 33-year-old budding practice management speaker, I was in Kansas City at the first CVC--- 26-years-ago. I shared a hotel room and an adjoining lecture room with colleague, mentor and friend, Dr. Ross Clark. Day and night we passionately talked about the importance of leadership, management, marketing, sales skills and customer service to be bookends with great medicine in successful practices.
And while I still know the tremendous importance of competent, confident medicine to be one of the bookends in successful veterinary practices, the other bookend of critical importance has changed. I believe it has now become the “emotional care of” and “compassion for” pets during their visits to veterinary hospitals. To survive, let alone thrive, it’s what veterinarians and team members must focus on and it’s what we must deliver to every pet, every day, forever. 26-years-ago I was passionate. This cruise, I’m nothing short of evangelical!
Everything changed for me the day I heard famed veterinary behaviorist, Dr. Karen Overall, in a lecture say, “Fear is the worst thing a social species can experience and it causes permanent damage to the brain.” I found out later that when Karen was a beginning undergraduate at Penn, she was lucky enough to be involved with a hands-on epidemiology project on pediatric cancer at Children’s Hospital of Philadelphia. Karen, like myself and many others in this room, had been raised in the health care or should we say “hell-care” for kids environment of the 1950s and 60s where kids endured, were fearful, were hurt, were manhandled, were threatened and were told that their feelings or opinions didn’t matter. Basically, put up with it and shut up about it.
When she got to Children’s Hospital of Philadelphia, no one forced those kids to do anything; they had to have their meds, but they get to say when. They didn’t have to sit still for a two hour IV infusion because they built a better IV splint and a very stable, lightweight IV stand and the kids could go anywhere, even play and take their meds with them. For the first time Dr. Overall saw patient care of dependent beings in a way that gave the patient some control and it took away the fear and the abuse. After the experience at the children’s hospital, Karen was stunned and saddened to see how pets, the dependent beings in vet med, were being treated and abused.
Back to fear is the worst thing a social species can experience. Basically, fear in responsive to something painful or disturbing---and whether it’s adaptive or beneficial fear--- can condition the pet to experience more fear in response to those circumstances --- like repeat visits to the veterinarian --- and become maladaptive. Dr. Overall is an evolutionary biologist so adaptive and maladaptive behaviors make a lot of sense in discussing fear and true pathology is easily understood through it. What became apparent during her first decade or so of practice was that many people did things to their pets because they thought they should be able to do it. The dog or cat had no say. The pervasive view was that dogs and cats should endure whatever humans do to them and the ones that fought back should be
killed and the ones that suffered in silence…well…no one thought about them and we just let them suffer repeat, severe physical and psychological damage. At a low point like this we want, no, need a success story and when Dr. Overall takes the microphone over she will tell you a story of understanding, redemption, victory and mission because of her Australian Shepherd, Flash.
In that lecture five years ago, Dr. Overall went on further to talk about signs of anxiety and fear in dogs and I realized that I only recognized about 50 percent of them.
Worse, while I recognized some of the signs of anxiety and fear in my patients, seeing them hadn’t caused me to change the way I was performing veterinary procedures, nor the way I was behaving or acting towards frightened pets or their owners for the 30 years I’d already been in practice. Pets that were frightened had been suffering repeated physiological damage in the practices I owned, worked at or visited. Worse than doing nothing, I and my veterinary team had been causing the damage or making it worse. So before I left Dr. Overall’s lecture room that day, my heart, mind, focus, commitment and mission were changed.
As doctors, we know that we must, “first do no harm.” Or think about the quote “Cure sometimes. Treat Often. Comfort always.” that has been attributed to Hippocrates. Perhaps most importantly, our veterinary oath requires us to “protect animal health and welfare, and prevent and relieve animal suffering.” We’ve been concentrating on getting pets into the veterinary hospital and focusing on their physical wellbeing while their emotional wellbeing has been overlooked. As such, we may have subjected many pets to serious, repeat, destructive emotional damage. I think it’s been like a disease that we just haven’t noticed all around us, and didn’t know all the signs of so it’s been underdiagnosed. Or maybe we brushed it off---giving it the medical weight of the common cold---something to just “get over.”
If pets’ anxiety and fear in going to the veterinary clinic were a disease, I think this would be the worst pandemic to ever hit the animals under our care. It affects most of the pets in most of the clinics in the world. While we haven’t seemed to take note, somebody has. That somebody is pet owners.
In 2011, the Bayer Veterinary Healthcare Usage Study showed us that 38% of dog owners and 58% of cat owners say their beloved pets hate going to the vet. And 26% of dog owners and 38% of cat owners said that just thinking about going to the vet was stressful. Did they keep coming to their trusted local veterinarian when their pets had medical problems? Too
many of them didn’t, and many of them started getting information, products and services in other places so that they and their pets didn’t need to suffer any unnecessary stress. Yes, the economic downturn caused some pet owners to eliminate or delay veterinary visits, but I believe an even bigger reason was that a trip to the local vet just wasn’t worth the “hurt” to the pet or the “hassle” to the owner.
I’ve been working the past five years on how to create Fear Free visits for pets and I’m here to tell you the results are nothing short of breathtaking. With our guidance, the pet owner’s role in taking a pet to the veterinarian has fundamentally changed. Both pets and pet owners arrive at the veterinary hospital in a calm state. Using specific tools and tactics we have removed or reduced the animals’ anxiety triggers and have plans in place to douse anxiety or fear should they flare up. And no, I’m not talking about just using pheromones (which may or may not work) or giving pets an occasional squirt of spray cheese. I’m talking about seeing pets that are hungry and ready for not just a treat, but the treat we know they love most. Or seeing pets that have been fed a calming diet or may be receiving chill
pills. Pets that have been given meds to prevent nausea. Pets that arrive in a new generation of carrier, placed on a flat surface and covered to reduce stimuli. Pets that are treated to silence in the car or special comforting music. Synthetic pheromones wafting out of electronic dispensers throughout the clinic and off of our smocks and scrubs giving the pet a magic carpet ride from carpet at home, to carrier, car and then exam room. You’ll see many pets fitted with compression garments borrowed from our lending wardrobe.
The exam rooms are slightly remodeled but we’ve dramatically changed our handling techniques and voices and we are using an icon of veterinary medicine much differently and much less frequently. I’m talking about the exam table. On any given day, I might do two-thirds of my exams on the floor or on a bench or chairs next to the pet and the owner. Knowing the pet is hungry, I use food rewards and other training tips I’ve learned from my daughter, Mikkel, to take the pet from “terror eyes” to “training eyes.” I
focus first on the emotional wellbeing of the pet ---and the pet owner--- before I turn my focus to the animal’s physical health. We need both bookends in veterinary medicine---competent medical care and compassionate emotional care, not either or.
As veterinary health care professionals, we would never come to work in the morning expecting and accepting sending pets home in worse physical condition that they came in. Yet, the vast majority of pets that visit the veterinary practice go home in worse emotional condition than when they arrived. Maladaptive fear. This is abuse. I know it sounds serious, jarring, and may make some people who entered this profession because of their deep love of animals really uncomfortable, but it’s true, and the sooner each practice and person accepts this the better off pets, people, practices and our profession will be.
So this cruise I’m going to delve deeper into what the pets are experiencing emotionally when they come under our care. More importantly, I am going
to give you tactics, tips and strategies on how you can start to create a
Fear Free practice.
From the living room to the exam room (15 minutes)
1. Making the carrier part of 'fun furniture' or at least getting it out a few days before the visit if possible.
2. Feed high value meals/treats in the carrier.
3. Start magic carpet ride of pheromones. These may or may not work and make some cats more aggressive.
4. Pet owner goes to the vet’s office and gets Cerenia (motion sickness dose) to calm the stomach and either Anxitane (green tea extract) or Zylkene (milk protein) to calm the mind.
5. No drama when leading up to the vet visit and especially during the day of and the ride in.
6. Prepare vehicle to take the pet in. Pheromones, species specific music such as Through A Dog’s Ear or Through A Cat’s Ear (or not baby talking at the very least). Make sure the carrier is flat (can use Anti-Slanty of just a rolled up towel), and covered to decrease visual stimuli.
7. Don't feed the pet after 6 p.m. the day before the visit or just a very small meal if you have a late afternoon visit so that they’re hungry and respond to food rewards.
8. Can use Calming Cap, Thundershirts or other tools as needed
9. For some pets that are so psychologically damaged (or may be feral) we start sedation before we even leave home. Dr. Overall will talk about all pharmacological solutions in her presentation including at home and in clinic. Just as we’d rather be a month too early than a day too late to euthanize a suffering pet, the practice should be an hour too early than a minute too late to start sedation.
10. When arrive at hospital, don't necessarily follow the same rut gathering the pet from the vehicle and walking into the clinic to check in and wait in reception. Explore options of going immediately into the exam room to be checked in; have owner go into the practice to
check in and then go back out and wait with the pet in their vehicle until texted, waived or helped directly into the exam room. Some pets are fine checking in and waiting in exam as before.
11. Bring multiple pets into the veterinary office as an emotional buffer.
12. Make sure the practice has removed or reduced as many anxiety/fear triggers as possible. This includes removing or muting the doorbell/buzzer, decreasing bright lights (or increasing natural light), keeping noise down and smells like bleach. Did you know that besides being an anxiety trigger, a 1% bleach solution is sufficient to kill olfactory neurons and they take 3-4 days to regenerate? So if dogs work for information and they cannot smell cues…this is not good. Also, as Dr. Overall has taught, nose-work is one of the most stress-busting, pleasurable things we can do with a dog; but it doesn’t work if they can’t smell.
13. Pet owners are less anxious for two reasons. One, their pet is noticeably less distressed. Two, because the pet is less nervous, they are much more likely to remain calm instead of barking or even showing fear-based aggression; as such, the owner feels less embarrassed of their pet’s behavior.
At the AVMA meeting in Chicago last July I was lucky enough to have dinner with Dr. Steve Ettinger, a colleague and friend I’ve known for over three decades. We started the normal small talk and Steve asked me what I was working on. I gave him my “Fear Free” mini-sermon and Dr. Ettinger got emotional. I immediately hit the rewind in my head to think of what I might have said that elicited that response. I couldn’t think of anything so I asked him, “What did I say that made you react that way?” Gathering himself, Dr. Ettinger said that for the last year he’d been working at both a traditional veterinary hospital and a veterinary rehabilitation facility. At the traditional veterinary hospital, a well dog’s heart rate at check in was in the 140-150 beats per minute range. At the veterinary rehabilitation facility, the heart rate for most dogs was only 90-100 beats per minute. What would cause the heart rate to be 50-60 percent higher at the traditional veterinary hospital? Anxiety and fear! He called the increased heart rate, “Fear you can hear!”
By looking after the emotional wellbeing of pets we also help the physical wellbeing of pets. How so? A calm pet has a more normal temperature, pulse, respiration rates and blood pressure levels. We’ll get more accurate blood chemistry results with fewer hemolyzed samples, and peaceful, placid pets don’t mask signs of pain and discomfort like they do when they’re supercharged with adrenaline. They also have decreased
immunosuppression, fewer digestive upsets, and new research shows calm pets can actually live longer.
New veterinary hospitals are being designed not with the primary focus on curb appeal, efficiency, safety and comfort of clients and the veterinary team…but for the emotional wellbeing of the patients. Exam rooms will be as quiet as recording studios, there will be standard emotional isolation wards and many will feature separate treatment areas for dogs and cats. The Fear Free exam table of the future will fold up to leave more room on the floor to do exams on non-slip rubber flooring or on a yoga mat. Walls will be devoid of pictures/photos of other pets and will be painted or papered in colors that dogs and cats prefer. The exam table will be heated stainless steel with clamps to rigidly hold a heated towel infused with pheromones. Pets will no longer be lifted off their feet, hearts pounding, to be put on an elevated, slippery surface but will walk up a ramp or stairs onto the warm, nonskid towel.
Veterinary hospitals will apply the same sense of urgency (and specific training and techniques) we respond with when a surgery alarm goes off to a pet who is experiencing anxiety or fear. Just like decreasing the anesthetic and/or increasing the fluid flow can save a surgery patient’s
life…decreasing fear and increasing comfort can ultimately save a pet’s life. Pet owners are much more likely to bring this pet into your hospital for accidents, sickness and health.
What has been outlined for you this morning takes minimal changes to the practice but maximum changes to your understanding of anxiety and the handling of pets. Pet owners too.
This needs to vitalize our profession in general and your practice specifically. Many pet owners are already not coming in as often or at all because of the stress to the pet and themselves. What if many more pet owners realize that even the four-legged family members they thought liked to go to visit the veterinarian were experiencing anxiety and fear? Simply put, they’ll either find a veterinary office that offers Fear Free visits or stay away in droves causing serious damage to one of the world’s most important and trusted professions.
Another medical profession looked to just survive and is now thriving. Dentistry. I have two older sisters and an older brother. I’m the baby of the Becker family. We all went to a friendly and skilled dentist, Dr. Stanley Kern, in Southern Idaho. I can still smell the clove-like antiseptic odor (not fragrance), I can still see the round porcelain bowel with the swirling water and can hear the whine of the dental drill with all of those belts whipping around the angle of the arms of the drill. Because of anxiety and fear, one older sister and one older brother didn’t seek dental care throughout their lives because of the early experiences. Dr. Kern and future dentists like him probably lost much of their clientele. But my family members had the option as adults of not going into the dentist’s office. We were no longer dependent beings. Similarly, if cats were birds they’d fly out of veterinary offices like bats out of hell. And if dogs had hooves, they’d spook and stampede. And in increasing numbers, pet owners can and are choosing not to bring pets into veterinarians as often or at all.
But dentists changed. Have you been to a dentist lately? Unless you were scared away as a child, of course you have. More importantly have you been to a pediatric dentist lately? It’s like walking into the lobby of a spa. My Granddaughter, almost five-year-old Reagan has a dentist that offers her a choice of music and videos as she nestles into her super-comfy chair. The odor in the dental exam room of my past has been replaced with a pleasing fragrance. She wears special glasses that eliminate the glare of the lights. And at the end she gets the choice of REALLY nice toys, not the rings and rubber balls of my past. Most likely Reagan will never have cavities, but she’ll visit often for preventive care, orthodontics and maybe tooth whitening, much of which will be performed by the dental team and NOT the dentist. Far from merely surviving, the dental profession’s income has soared with no sign that the good times will end.
The future of veterinary medicine is blindingly bright if we treat creating Fear Free visits as an urgent obligation and an unprecedented opportunity. All we have to do is focus equally on the emotional and physical wellbeing of pets. Taking the pet out of petrified….puts pets back into practices.
If we don't galvanize our profession around something as important and vital as a Fear Free Veterinary Visit then what should capture our attention, education, enthusiasm and actions? If it's not the veterinary profession that looks out for the physical and emotional well-being of pets and pet owners, who should, can or will?
I ask that this profession rise level to the greatness of its responsibilities and opportunities.