Truly Listening

Are you listening to your clients?

I am proud of my listening skills with clients.  I feel that I ask open ended questions, listen to client’s stories, and craft appropriate differentials based on what I hear.  I strongly believe that the answer to many diagnostic dilemmas is in the history.

However, I had a memorable experience where bias got me off track.

The Story

On a busy Saturday evening shift, an 8-year-old lab presented for not moving and not eating.  The dog did not want to get up or move. He had not eaten in 24 hours but was not vomiting nor having diarrhea.  I asked the owner whether there was anything he could have gotten into.  She told me she hadn’t seen anything but that she had called a pet communicator who had spoken to her dog on the phone. According to the pet communicator, the dog had told her that the neighbor had thrown something over the fence which the dog had eaten and had made his stomach upset.

I do not know about you but as soon as someone says pet communicator or psychic, I become extremely skeptical.  I do believe that I know a lot about what my dog, Biscuit, wants in life and feel like he talks to me in facial expressions and actions.  However, I don’t believe he can send me brain waves or communicate over the phone.

I also get skeptical when people say their neighbors did something to their pet.  In 90% of emergency cases when someone says their neighbor did something to their pet, I instead diagnose an underlying metabolic or neoplastic condition.

Thus, I was extremely skeptical as I began my physical exam.  However, I felt like I was as thorough as normal.  The dog had a normal temperature, pulse and respiration.  Blood pressure was normal.  He was quite still in the room. His neurologic exam was normal but he just didn’t want to move much.  He grunted when I palpated his back and seemed uncomfortable. He did tense when I palpated his abdomen but allowed deep palpation without clear pain. I opted not to run full bloods but did check PCV/TS, BUN, glucose and electrolytes, which were all normal.  I told the owner I was most suspicious of a musculoskeletal problem, probably a slipped disc, and sent the dog home with pain medication.

The Punchline

I went home and when I returned the next afternoon, I found that the dog had been admitted to the hospital several hours after I saw him.  He had gone home, vomited and come back in.  On admit, full bloodwork and radiographs were performed.  He was diagnosed with pancreatitis, usually caused by eating something bad. Luckily, I had used a pain medication that was safe for GI conditions and the dog returned quickly before it got much worse.

Learning from diagnostic errors

This case had lots of lessons for me.  It was a good reminder to not get cocky about your skills. In this case, the pet communicator was the better diagnostician!

It taught me that owners may tell you important pieces of information in oblique ways.  Did the owner know the dog ate something rotten and didn’t want to tell me how he got it?  Maybe the neighbor really did throw something over the fence?  Or possibly, there are people who really can understand and communicate with animals in a different less explainable way.

Identifying bias

Everyone has bias that impacts what they do.  Wikipedia defines bias as, “disproportionate weight in favor of or against one thing, person, or group compared with another, usually in a way to be unfair.  Bias can exist in different areas including gender, politics, culture, region, class, geography, and education.  If you are consciously aware of your likelihood to be unfair, this is an explicit bias.   Bias can also be implicit, driven by your subconscious and influencing decisions in ways in which you are not aware.

My bias

I think many of us in science are skeptical of pet communicators and psychics.

In this case, my bias was that anyone who believes a pet communicator should not be believed.  Subconsciously, I interpreted and maybe even performed by exam in a way that confirmed this bias.

The problem with bias

I am not alone in having a diagnostic error due to bias.  In an interesting study, physicians were shown videos of people of different genders, ages, ethnicities, and insurance coverage but with the same presenting complaint and clinical signs.  Recommendations for diagnostics and treatment varied not just based on medical differential lists but also on the non-medical factors.  In another study, physicians with implicit racial bias made different recommendations for thromboprophylaxis in cardiac patients  based on the patient’s race.  Luckily, other healthcare studies looking at implicit bias have shown less association with recommendations and outcomes.  This is a hard area to study due to the number of variables (no one has looked at pet communicator bias. . .)

It is important to identify your possible biases.  When you name your biases, you can push them aside to provide the care all clients and their pets need.

Listening with an open mind

At the end of the day, this diagnostic error made me a better veterinarian.  I am more cognizant that statements people make can elicit bias that can impact my diagnostic skills.  I try to do every exam with an open mind.  I now start from the idea that all owners know their pets better than I do.  Even when they can’t put a name to it, they can have a “spidey-sense” about what is going on. Thus, we should be extra cautious when we think an owner is wrong.

For more information on unconscious or implicit bias in healthcare, click here.