On November 19, 2019 the Merck Veterinary Manual held a live Twitter chat with Dr. Karen Overall, DVM, PhD, DACVB. The topic covered was how to incorporate behavioral medicine into a general veterinary practice. For those who weren’t able to log in to participate in the live chat, we’ve transcribed the questions and Dr. Overall’s responses so that you can see what she had to say on the topic.
Merck Vet Manual: How can you incorporate behavioral appointments into a general veterinary practice?
Dr. Karen Overall: To do this successfully requires true, conscious thought. I realize that most veterinarians did not have training in veterinary behavioral medicine while in veterinary school, but this need not be a crippling handicap. There is now sufficient and widespread CE so that motivated vets can fill in the gaps.
The advice I usually give people is to first decide what you are interested in. Do you want to focus on minimizing fear and distress during vet visits? Do you want to focus on preventive care for puppies and kittens? For rescue dogs? Do you want to focus on lifetime care that minimizes anxiety and distress? Do you want to learn to assess the mental health of every patient who comes into your practice? Do you wish to learn to actually diagnose and treat behavioral conditions that are common in your practice? (And if so—I recommend starting with one at a time. Get good at feline elimination complaints or housetraining problems or dogs who cannot be left alone, et cetera.) Once you know what you are interested in you can start by finding out what the most up-to-date info in the field is and just start. Reach out to specialists for advice as needed but start somewhere and tell your clients what you are doing and why you are doing it.
Because all of this involves a change in the way you practice medicine, you need to make a concerted effort to educate your complete staff—from the cleaning staff to the managers. You are going to be implementing change and they are all going to have roles to play. These are sea-changes. Everyone needs to be on board, and for that you need excellent communication.
Merck Vet Manual: What are your top tips for reducing animal stress during veterinary visits?
Dr. Karen Overall: First, you and the clients need to be stressed as little as possible. Ensure that there are comfortable seats in the exam room for the clients. Ensure that the patient is comfortable and has firm footing (either their own crate or a yoga or other non-slip mat). Make sure you are sitting down. Dogs and cats are less reactive if you are sitting. Look at and listen to the client. Studies show that vets interrupt after 8 to 11 seconds. Don’t do that. Instead, listen and guide the conversation in a useful manner for the sake of efficiency, but ensure that you ask the client about their concerns.
You can help yourself by having every single client—no matter whether they have never done this or have done it a dozen times—complete a brief, one-page, objective tick sheet about behaviors the patient is exhibiting. These are freely available (AAHA has some online) and ask for objective responses about specific behaviors that correlate with problems. If you ask at every visit you will catch these early, you will see patterns of response that matter in your own practice, and you will not have to struggle for words or formats. Let the experts help you do this more easily. If your practice has a policy that everyone completes this form at each visit, when you are sitting talking with the client you can review the form and have the client elaborate. You are now well on your way to understanding both the patient and the client’s concerns and you have not touched the patient yet.
Examine patients where they are comfortable: in crates, for some cats, on the floor on a mat for most dogs, on the table on a mat for tiny dogs, or in the client’s lap. Talk to the patient first. Studies have shown that petting dogs on the chest provokes less anxiety than touching them on the head or the back of the neck. Offer dogs a treat. Stressed dogs cannot take a treat, and those who take it may not be able to consume it if stressed. Studies have shown that behaviors offered volitionally by patients are good indicators of stress. If the dog does not approach you or take a treat and becomes more fearful or withdrawn when you start examining him or her after doing the above, ask yourself if this can be deferred—with medication on board and possibly practice exposures.
Merck Vet Manual: How do you balance early socialization needs with the need to protect puppies and kittens from infectious diseases?
Dr. Karen Overall: For me this is simple. I know that some vaccine experts want puppies and kittens kept isolated until they are fully immune competent. If you do that, however, you put them at risk for profound behavioral problems because they miss all the sensitive periods for exposure. This is like recommending that our kids do not experience the world until they are 12. How well is that going to work? More dogs and cats die in developed countries because of their behavior problems than from infectious disease... we must allow patients actively engaged in competent immunization programs to learn about their physical and social worlds. Precautions are all common-sense ones: only attend classes, events, and get-togethers with groups that practice good biosecurity, do not expose puppies and kittens to actively ill or shedding individuals, do not expose puppies and kittens to urine and feces that is more than incidental. Remind clients to seek help at the first sign they are concerned. Encourage them to put their choices on the side of minimizing risk, such as seeking help sometimes when it isn’t needed. If you are willing to always ask, you are unlikely to miss anything.
Merck Vet Manual: What are the top 3 things you would tell someone adopting a pet from an animal shelter?
Dr. Karen Overall: 1) Love is not enough. 2) You need patience—they will reveal their story and their damage (and there is damage). 3) Love is not enough, but it can help you get through the rough times. Get help early and often if you are concerned, and don’t try to fix these dogs and cats or make up for anything that you think happened. Instead, protect these dogs and cats for the first few weeks of their time with you so that they have the space, security, and trust to tell you who they are.
Merck Vet Manual: How do you find a dog trainer who uses appropriate methods for clients to work with?
Dr. Karen Overall: This is work. You need to have the vocabulary to ask the right questions and to evaluate the answers. You cannot ask about positive techniques unless you know what these are and which techniques meet the definition and which do not. Ask about specific methods: do you use shock, do you use prong collars, do you use choke chains, do you hit dogs? The UN does not let the providers or handlers of their dogs do this, so why would anyone else allow it? And, you must go and watch the trainer. Ensure that they are insured and belong to an organization that requires continuing education as part of certification. Yes, there are certification organizations for dog trainers, and they are largely voluntary… but modern, motivated trainers partake. Finally, ask if this is a person you would entrust with YOUR puppy’s brain. If you cannot scream YES while you are rushing out the door with your pup and gear to go to class... don’t go.
Merck Vet Manual: What do you do with clients who want an "instant fix" for their pet's problem?
Dr. Karen Overall: Life is complex. They have a choice. They can meet their dog’s or cat’s needs or they cannot, and there is no in between. Understanding the problem is 9/10ths+ of the battle and all of that work—all of it—is theirs, but it is intellectual. They have to discuss the concern with their vet and/or a specialist and decide how it can be best managed in their lives and worlds. Every day I tell people I lack magic.
Merck Vet Manual: How do you decide when to refer behavioral cases to a specialist?
Dr. Karen Overall: Refer whenever you feel you cannot do the best job possible and you know you are missing something. All specialists are happy to get what’s a less complicated case for them, and their referral letter and discharges will help with your education.
Merck Vet Manual: What sort of qualifications do you look for if there isn't a board-certified specialist nearby?
Dr. Karen Overall: Find someone who cares, who seeks education and who can admit that there are things they do not know. Many practitioners have special interests. If they go to meetings, belong to some of the behavioral organizations, and have an active way to work with like-minded colleagues and or specialists (e.g., list serves)—these people are priceless. We are not all interested in the same thing and we do not all have the same gifts.
Here are some additional resources recommended by Dr. Overall to help you successfully incorporate behavioral approaches in a general veterinary medical practice:
Read more about the behavior of dogs, cats, horses, and other species in the Merck Veterinary Manual.