Practicing a spectrum of care

The phrase “spectrum of care” has grown in popularity over the past several years and is part of the broader conversation of improving access to veterinary care. It refers to “a continuum of acceptable care that considers available evidence-based medicine while remaining responsive to client expectations and financial limitations.”¹

Ultimately, spectrum of care medicine ensures patients receive care that improves their quality of life within the individual constraints of the pet family while allowing veterinary professionals to uphold their moral, ethical, and legal obligations. This approach to medicine is most successful when the entire veterinary team shares the mindset and participates in client communication.

Identifying barriers to care

Client financial limitations are the most common barrier to veterinary care experienced in small animal practice.² Over half of small animal veterinarians report cases affected by finances on a daily basis in 2017.³ Since the COVID pandemic, financial limitations have increased and are considered the most challenging ethical conflict faced by many veterinarians.⁴

While finances are the most common barrier, they are not the only consideration. Other barriers to care can include client factors, patient factors, and veterinarian factors (See “Barriers to veterinary care”). It is essential veterinarians and team members recognize the large number of barriers that must be considered when approaching a case with a spectrum of care mindset.

Mental health benefits of spectrum of care

In a survey of veterinarians by the Access to Veterinary Care Coalition, the vast majority of respondents agreed with the following statements:²

• “All pets deserve some level of veterinary care.”
• “Owned pets are a member of the family in which they live.”
• “Not being able to obtain needed veterinary care impacts pet owner’s mental and emotional health.”

These sentiments are likely shared by veterinary team members, as well. When client factors create barriers that prevent pets from receiving care, veterinary professionals suffer, along with the clients and patients.

Moral distress, or “the experience of knowing the right thing to do while being in a situation in which it is nearly impossible to do it,” is experienced commonly by veterinarians and their team members.6 Nearly 80 percent of veterinarians have experienced moderate to severe stress when not able to “do the right thing” for a patient, and 73 percent feel their staff had the same experience.6 In extreme cases, financial limitations can lead to euthanasia for purely economic reasons. This can be particularly stressful for veterinary team members and contributes to professional burnout.7

In fact, compassion fatigue is considered a top concern by credentialed veterinary technicians in both the 2016 and 2022 National Association of Veterinary Technicians in America (NAVTA) demographics surveys.8

Patients and clients clearly benefit when veterinary teams partner with them to find ways to overcome barriers and provide some level of care. However, the mental health of veterinary team members can benefit, as well. In the short term, this is good for team morale. In the long term, this may keep caring professionals in the clinic instead of moving into non-clinical positions or leaving the profession altogether.

The importance of a team approach

Successfully practicing a spectrum of care requires veterinary professionals to think critically about their cases within the context of any barriers they have identified in talking with clients. They must also be able to educate pet families on available options while communicating clearly and with empathy. The way options are presented affects how a client feels about the options and ultimately the decision they make for their pet. This includes the order in which options are presented and the nonverbal cues that come with the conversation.

While the veterinarian determines which options might be appropriate for a given patient, they are not the only member of the team to communicate with the client. Clients often interact with multiple team members before and after the veterinarian. These interactions can have just as strong of an impact on the client’s perception of the visit and services received as the time spent with the veterinarian.

This is especially true when a client elects a treatment option that may be deemed “substandard” by team members. Even if the veterinarian on the case is empathetic and presents the options without judgment, if the communication from team members—whether verbal or nonverbal—contradicts this, it can leave clients feeling guilty for their decision. This can alienate the client and compromise future care for the pet.

Many times, veterinarians have a detailed conversation with clients about their limitations and options and work together with the client to determine what will fit their situation the best. Veterinary technicians and other team members may only be given the final decision and may be frustrated by the choice a client makes when they lack the greater context. It is essential team members remember that the choice a client makes is never a reflection of the strength of their bond with their pet. One client does not “care less” about their pet because they are not able to afford all the recommended diagnostics or travel to the local referral clinic for orthopedic surgery.

Veterinarians can reduce frustration for the team by discussing the client’s limitations and establishing the context. While this may not always be feasible in the moment due to time constraints in the clinic, create opportunities to debrief about difficult cases and discuss them later in the day. Additionally, involving veterinary team members more in the appointments and client communication can ensure that they have opportunities to connect with clients to better understand their individual situations.

Essential communication skills for team members

All team members should receive communication skills training to enhance their interactions with clients. Three skills of particular importance in spectrum of care medicine include open- ended questions, listening, and nonverbal communication.

Veterinary team members are vital in identifying potential barriers clients may be experiencing. While some clients will openly share their concerns about finances or their ability to treat a pet, others are embarrassed to share this information outright or may not know how important it is for the veterinary team to have the information. Using open-ended questions, veterinary team members can elicit client opinions and concerns about treatment.

Open-ended questions are those that invite clients to share their opinions and experiences. They require more than a yes or no answer. Some questions that can be particularly helpful in spectrum of care conversations include:

• What are your goals for today’s visit?
• What is your budget today?
• What concerns do you have about your pet’s treatment?
• What other questions do you have today?

Once a question is asked, it is essential for veterinary professionals to stop and listen to clients without interruption. There are two types of listening we can employ: Active listening demonstrates engagement with what the speaker is saying by using nonverbal cues such as nodding and maintaining eye contact to demonstrate the act of listening. Reflective listening allows the listener to clarify their understanding of what was said by summarizing what they heard and asking follow-up questions after the speaker finishes talking. In both cases, the listener waits until the speaker finishes before continuing the dialogue. This ensures the speaker, in this case the client, feels what they have to say is valued.

Finally, nonverbal communication skills are critical to compassionate communication with clients. Tone of voice, posture, and facial expressions can easily convey judgment or disapproval of a client’s choice no matter what words are being said. Veterinary team members should maintain awareness of their nonverbal cues to ensure they maintain empathy for the client throughout their discussions.

Additionally, when speaking with clients about an estimate or treatment plan, it is important to pay attention to their nonverbal cues. This can be an important clue as to how they are feeling about their options and if they are fully understanding what is being discussed.

Mentoring a spectrum of care

Many new graduate veterinarians report being stressed when faced with cases where clients are unable to pursue the gold standard diagnostic and treatment plan they are familiar with.5

This stress often arises because veterinary students’ time is often focused on traditional gold standard approaches to disease. With the technological and scientific advances that have come to veterinary medicine over the past several decades, the amount of information taught to veterinary students has increased exponentially. Yet, veterinary school remains a four-year program.

While it is certainly important to understand the gold standard approach to cases, it is essential to learn how to critically evaluate a case and develop alternative plans that fit the individual needs of the pet family. Veterinary education continues to evolve, and more schools are incorporating opportunities to discuss spectrum of care in the curriculum. This shift will take time but is supported by the American Association of Veterinary Medical College (AAVMC)’s Spectrum of Care Initiative.

Veterinary clinics that employ new graduates should be prepared to offer mentorship and support to early career veterinarians in developing a spectrum of care mindset. They can do this by demonstrating this approach through their own case management and modeling compassionate client communication. Additionally, mentors can encourage their mentees to consider the range of available options when having case discussions or rounds.

Create a team culture that supports spectrum of care

Practicing a spectrum of care benefits patients, clients, and veterinary team members. When spectrum of care medicine is practiced most effectively, all team members will work with the client to find a treatment option that fits the limitations of their individual situation—whether that is financial or another barrier.

Veterinary teams can enhance their commitment to spectrum of care by discussing the scientific evidence for a range of treatment options during team meetings, debriefing after difficult cases, and celebrating cases with positive outcomes when a spectrum of care was offered to the pet family.

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Kate Boatright, VMD, is a small animal general practice and emergency veterinarian, speaker, and author in Western Pennsylvania. Dr. Boatright enjoys discussing mentorship, the spectrum of care, well-being, communication, and professional collaboration. In March 2023, Boatright published the Veterinary Mentorship Manual, a resource for practices to help guide them in developing solid mentorship programs to support new graduates.

References

1. Fingland RB, Stone LR, Read EK, Moore RM. Preparing veterinary students for excellence in general practice: building confidence and competence by focusing on spectrum of care. JAVMA 2021;259(5):463-470.
2. Access to Veterinary Care Coalition. Access to Veterinary Care: Barriers, Current Practices, and Public Policy. Available at http://avcc.utk.edu/study.htm. Accessed October 25, 2023.
3. Kipperman BS, Kass PH and Rishniw M (2017). Factors that influence small animal veterinarians’ opinions and actions regarding cost of care and effects of economic limitations on patient care and outcome and professional career satisfaction and burnout. JAVMA 250:785-94.
4. Quain A, Mullan S, McGreevy PD, Ward MP. Frequency, stressfulness, and type of ethically challenging situations encountered by veterinary team members during the covid-19 pandemic, Frontiers 2021;8: https://doi.org/10.3389/fvets.2021.647108.
5. Reinhard AR, Hains KD, Hains BJ, et al. Are they ready? Trials, tribulations, and professional skills vital for new veterinary graduate success. Frontiers 2021;8: https://doi.org/10.3389/fvets.2021.785844
6. Moses L, Malowney MJ, and Boyd JW (2018). Ethical conflict and moral distress in veterinary practice: A survey of North American veterinarians. J Vet Int Med 32:2115-2122. DOI: 10.1111/jvim.15315.
7. NAVTA. NAVTA 2022 Demographics Survey Results: Pay and Education Have Increased; Burnout and Debt are Still Issues. https://drive.google.com/file/d/11pmYzIouybfL55YsduRbaZ1TtMD1i2DB/view. Accessed December 1, 2023.