Materials and Methods

The present study was part of a broader research study⁷ on the HAB, veterinary medicine, and veterinary education. The study was exploratory in nature and was designed to better understand veterinarians' perceptions of the HAB. Therefore, no attempts were made to define what the HAB is in the context of the present study, and few benchmarks were offered to study participants. Because the HAB is a conceptual construct, it cannot be measured directly. However, it is possible to determine levels of agreement with and levels of support for this conceptual construct, even if there are somewhat different understandings of what the construct entails. In particular, we were interested in determining whether and how the HAB had an impact on private veterinary practice, regardless of how participating individuals defined that bond. This research project was based on the fact that experts in veterinary medicine agree that the HAB is so important that veterinarians who support and facilitate the HAB will be more successful than those who do not.² Veterinarians who support the concept of the HAB—regardless of how they define it—can be expected to translate that support into specific actions (eg, communication and education efforts or offering HAB materials to clients) somewhat in proportion to the degree to which they endorse the HAB.

Survey development—An online survey^a was created by the College of Veterinary Medicine's People-Pet Partnership Program in collaboration with the Social and Economic Sciences Research Center at Washington State University. The survey was developed on the basis of data derived from preliminary interviews with private practitioners and was field-tested first by faculty members from the Washington State University College of Veterinary Medicine and then by several private practitioners unknown to the researchers. The Washington State University Human Subject Review Board approved the questionnaire and study protocol.

The questionnaire was designed to elicit information on demographics, education regarding the HAB during and after veterinary school, the importance that respondents placed on the HAB in their practices, and how respondents integrated the HAB into their practices. Only results pertaining to the perceived importance and integration of the HAB in private veterinary practice (22 questions) are included in the present report. Responses to each question were voluntary, and respondents could choose not to answer any question. Responses to most questions consisted of a 4-point Likert-type scale; all but one of the remaining questions were multiple-choice questions. For the final survey question, participants were asked to quantify the importance of 10 nontechnical skills associated with private veterinary practice (ie, communication skills, ethical reasoning, business management, interpersonal relationships, HAB, leadership skills, self-management, conflict resolution, technologic ability [computer skills], and legal knowledge). Participants were asked to assign a point score to each of these skills according to their perception of each skill's importance to private veterinary practice (higher scores indicated a greater importance), with the restriction that point scores had to total 100.

Participants—Veterinarians in private veterinary practice in the state of Washington were invited to participate in the study. A list of all veterinarians, practicing and retired, who worked in Washington was obtained from the Washington Department of Health. The 2003 membership lists from the American Veterinary Medical Association and the Washington State Veterinary Medical Association were then merged with this list, and veterinarians who were deceased or known to not be in private practice were removed.

Potential participants were contacted by mail, by e-mail, and via a booth at the Washington State University Annual Veterinary Conference. All potential participants were contacted a minimum of 2 times and a maximum of 5 times during the 9-week field period (March 22 to May 25, 2004). Each time an individual was contacted, he or she was provided with a personal access code and the link to the survey Web site. Participants could also request a printed version of the survey.

Data analysis—Surveys returned by respondents who did not complete at least 50% of the survey questions were not included in data analyses.⁸ Six surveys were removed for this reason. Potential participants for whom mailed materials were returned as undeliverable were also removed from the study.

To determine whether distribution of practice type for survey respondents was representative of practice type distribution for veterinarians in private practice in the state of Washington as a whole, information on practice type distribution was obtained from the 2003 AVMA Membership Directory for Washington veterinarians who indicated they were in private practice. To determine whether distribution of college of graduation for survey respondents was representative of the distribution for veterinarians in Washington as a whole, a list containing information on the proportions of Washington veterinarians who graduated from each college or school of veterinary medicine in the United States or Canada was obtained.⁹ To determine whether proportions of survey respondents who indicated that they were owners or associates were representative of the population of veterinarians in Washington, numbers of owners and associates in the state were obtained from the Washington State Veterinary Medical Association. Finally, the gender ratio for respondents was compared with the gender ratio for the initial list of 1,602 veterinarians in private practice in the state of Washington.

Nonrespondents—In an effort to determine the extent of any nonresponse bias, 50 randomly selected nonrespondents were contacted twice via telephone. Individuals who agreed to participate were asked 4 questions from the survey, and demographic information was obtained.

Statistical analysis—Descriptive statistics were calculated for all survey questions. Comparisons were made between males and females, between owners and associates, and among groups for years since graduation. For analyses involving years since graduation, respondents were grouped on the basis of quartiles. Responses from retired veterinarians were included in calculations of descriptive statistics; however, the number of retired veterinarians who responded was too low to allow statistical comparisons with responses from owners and associates. Similarly, comparisons among practice types (eg, small animal, large animal, and mixed animal) were not possible because the number of responses from practice types other than small animal and mixed animal were insufficient for reliable statistical analysis.

Responses for the survey question in which respondents were asked to quantify the importance of 10 nontechnical skills were used to rank the skills on the basis of mean point score. The Jonckheere-Terpstra test was then performed to determine whether there were significant differences in rankings between males and females, between owners and associates, and among groups for years since graduation. This analysis tested whether a group's rankings differed from a specific sequence selected a priori at random from among the groups included in each analysis.

Two-tailed z tests were used to compare the demographics of respondents (ie, practice type, employment status [owner vs associate], gender, and school of graduation) with those of the Washington state population of private practitioners. Demographics and answers to the 4 survey questions were compared between respondents and nonrespondents by means of χ² analysis.

All analyses were performed with standard software.^b,c Values of P < 0.05 were considered significant.

Results

Response rate—The final population of potential participants consisted of 1,602 veterinarians in private practice in the state of Washington. Of these, 415 (26%) returned valid surveys. Most respondents completed the survey online (388); the remainder submitted printed copies of the survey (27). Given the response rate, maximum sampling error was less than ± 5% at the 95% confidence level.

Demographics—Of the 388 respondents who provided information on gender, 204 (53%) were female and 184 (47%) were male. Mean age was 46 years, and mean years in practice was 18 years.

Information on practice type was provided by 397 respondents. Three hundred (76%) respondents indicated they were in small animal practice, 54 (14%) indicated they were in mixed animal practice, 12 (3%) indicated they were in large animal practice, 12 (3%) indicated they were in equine practice, 3 (1%) indicated they were in exotic animal practice, and 16 (4%) indicated they were in some other practice type.

Two hundred fifteen of 394 (55%) respondents had graduated from Washington State University, but graduates from 28 schools or colleges of veterinary medicine in the United States and Canada were represented. Ten (3%) respondents indicated that they had graduated from schools outside these 2 countries.

Two hundred twelve of 392 (54%) respondents were owners of private practices, and 160 (41%) were associates. Twenty respondents (5%) were retired.

Nonrespondents—Calls were placed to all 50 randomly selected nonrespondents; contact was made with 31 individuals. The remainder did not return telephone calls. Of the 31 individuals who were contacted, 5 were considered ineligible to complete the survey because they were no longer with the practice or no longer in private practice, and 2 refused to participate. Of the remaining 24, 23 did not remember receiving information about the survey, and 1 indicated that he was too busy to answer the initial survey.

Nonrespondents contacted by telephone did not differ from survey respondents with regard to gender distribution (male vs female), practice type distribution, or employment status distribution (owner vs associate). Additionally, the distributions of responses to the questions “To what extent do you offer HAB resources to your clients?” and “As a defining feature of your personal practice, how important is facilitating the HAB?” were not significantly different between respondents and nonrespondents contacted by telephone.

A significantly (P = 0.047) higher proportion of nonrespondents contacted by telephone (21/24 [88%]) strongly agreed with the statement that veterinarians who recognize and facilitate the HAB in their practices will be more successful than those who do not, compared with respondents (237/404 [59%]). In addition, a significantly (P < 0.001) higher proportion of nonrespondents (8/23 [35%]) indicated that they provide a lot of training for their front office staff members, compared with respondents (28/337 [8%]).

Comparison of respondents with Washington state population—Gender (male vs female) and employment status (owner vs associate) distributions for respondents were not significantly different from distributions for the population of Washington state veterinarians in private practice. The proportions of respondents in small animal, equine, exotic animal, and other practices were not significantly different from proportions for Washington state veterinarians in general; however, the proportion of respondents in large animal practice was significantly (P = 0.005) lower and the proportion in mixed animal practice was significantly (P < 0.001) higher than proportions for Washington state veterinarians in general. The proportion of respondents who had graduated from The Ohio State University was significantly (P = 0.014) lower than the proportion among veterinarians in the state of Washington.

Importance and integration of the HAB in private practice—When respondents were asked to indicate which of 3 definitions of the HAB came closest to their own philosophy (the HAB is a mutually beneficial relationship between people and animals shaped by behavior essential to the health and well-being of both,¹⁰ the HAB is a dynamic relationship between people and their pets that may have positive and negative elements,¹¹ or the HAB represents the affection an owner has for his or her animals and the care that owner provides for those animals [definition developed by the authors]), 233 of 413 (56%) chose the first definition, and 130 (31%) chose the second. Only 44 (11%) chose the third definition, and 6 (1%) chose none of the above.

Almost all respondents strongly agreed (237/404 [59%]) or somewhat agreed (153 [38%]) with the suggestion that veterinarians who recognize and facilitate the HAB in their practices will be more successful than those who do not. In addition, most respondents reported that facilitating the HAB was a very important (285/413 [69%]) or somewhat important (108 [26%]) defining feature of their personal philosophy of veterinary practice. Females were significantly (P = 0.028) more likely to report that the HAB was a very important feature of their personal philosophy (154/268 [57%]) than were males (114/268 [43%]). Most respondents said that the degree of bonding between a client and his or her companion animal affects the way they practice veterinary medicine a lot (291/414 [70%]) or somewhat (94 [23%]). Similarly, most veterinarians indicated that when treating an animal, they would always (138/410 [34%]) or most of the time (234 [57%]) actively evaluate the degree of bonding between the client and his or her companion animal.

When asked who was the best person at the practice to evaluate the bond between a client and his or her companion animal, 240 of 407 (59%) respondents indicated that it was the veterinarian, 31 (8%) indicated that it was the nonclinical (ie, front office) staff members, and 28 (7%) indicated it was the veterinary technician. One hundred eight respondents (27%) indicated that they did not know who was the best person in their practice to evaluate the bond between a client and his or her animal.

More than half the respondents indicated that they offered very little (128/410 [31%]) or no (82 [20%]) HAB resources to their clients. However, owners were twice as likely to say that they offered a lot of resources to their clients than were associates (28/210 [13%] vs 10/160 [6%]; P = 0.009).

Overall, 318 of 414 (77%) respondents indicated that they had 1 or more veterinary technicians in their practices, and 340 of 405 (84%) indicated that they had 1 or more front office staff members in their practices. Most respondents indicated that veterinary technicians in their practices always (21/315 [7%]) or most of the time (187 [59%]) actively evaluated the degree of the bond between clients and their companion animals. Similarly, most respondents indicated that front office staff members in their practices always (20/335 [6%]) or most of the time (182 [54%]) actively evaluated the degree of the bond between clients and their companion animals.

Less than half of the respondents reported that they train veterinary technicians in their practices a lot (37/313 [12%]) or somewhat (111 [36%]) in regard to the HAB. Individuals in the highest quartile for years since graduation (ie, the longest time since graduation) were five times as likely (4/71 [6%] vs 22/84 [26%]; P = 0.006) to indicate that they did not train veterinary technicians at all in this area than were individuals in the lowest quartile (ie, the shortest time since graduation). Owners were twice as likely as associates (24/145 [17%] vs 10/140 [7%]; P = 0.001) to indicate that they trained veterinary technicians a lot in this area.

Similar results were found with regard to front office staff members, with 28 of 337 (8%) respondents reporting that they trained front office staff members in their practices a lot and 109 (32%) reporting that they trained front office staff members somewhat. Individuals in the highest quartile for years since graduation were three times (28/86 [33%] vs 8/78 [10%]; P = 0.003) as likely to indicate that they did not train front office staff members at all in this area than were individuals in the lowest quartile. Owners were six times (21/174 [12%] vs 3/142 [2%]; P < 0.001) as likely as associates to indicate that they trained front office staff members a lot in this area.

Sixty-four of 311 (21%) respondents indicated that they had once or twice in the preceding 12 months actively encouraged veterinary technicians in their practices to learn about the HAB. Thirty-three (11%) indicated that they had done so 2 to 4 times in the preceding 12 months, and 37 (12%) indicated that they had done so > 4 times. However, 177 (57%) indicated that they had not actively encouraged veterinary technicians in their practices to learn about the HAB in the preceding 12 months. Owners were twice as likely (44/145 [30%] vs 23/142 [16%]; P = 0.038) as associates to indicate that they had encouraged veterinary technicians to learn about the HAB 2 to 4 times or > 4 times in the preceding 12 months.

Similarly, 97 of 334 (29%) respondents indicated that they had once or twice in the preceding 12 months actively encouraged front office staff members in their practices to learn about the HAB. Twenty-nine (9%) indicated that they had done so 2 to 4 times in the preceding 12 months, and 35 (10%) indicated that they had done so > 4 times. However, 173 (52%) indicated that they had not actively encouraged front office staff members in their practices to learn about the HAB in the preceding 12 months. Owners were over twice as likely (23/173 [13%] vs 7/141 [5%]; P = 0.001) as associates to indicate that they had encouraged veterinary technicians to learn about the HAB > 4 times in the preceding 12 months.

When respondents were asked how often they inform veterinary technicians about the degree of bonding between a client and his or her companion animal, only 36 of 311 (12%) responded that they always do; 174 (56%) responded that they do most of the time, 98 (32%) responded that they rarely do, and 3 (1%) indicated that they never do. When respondents were asked how often they inform front office staff members about the degree of bonding between a client and his or her companion animal, only 25 of 334 (7%) responded that they always do; 142 (43%) responded that they do most of the time, 152 (46%) responded that they rarely do, and 15 (4%) indicated that they never do. Owners were over three times as likely (19/172 [11%] vs 4/142 [3%]; P = 0.003) as associates to report that they always inform front office staff members of the degree of bonding.

Similarly, only 19 of 306 (6%) respondents indicated that veterinary technicians in their practices always informed them of the degree of bonding between clients and their companion animals, whereas 184 (60%) indicated that veterinary technicians did so most of the time, 98 (32%) indicated that they rarely did, and 5 (2%) indicated that they never did. Sixteen of 334 (5%) respondents indicated that front office staff members in their practices always informed them of the degree of bonding between clients and their companion animals, whereas 151 (45%) indicated that front office staff members did so most of the time, 157 (47%) indicated that they rarely did, and 10 (3%) indicated that they never did. Owners were three times as likely (10/171 [6%] vs 3/142 [2%]; P = 0.027) as associates to indicate that front office staff members always informed them of the degree of bonding between clients and their companion animals.

When asked how well-prepared veterinary technicians in their practices were to recognize and facilitate the HAB, 59 of 315 (19%) indicated that veterinary technicians were very prepared, 183 (58%) indicated that veterinary technicians were somewhat prepared, 48 (15%) indicated that veterinary technicians were somewhat unprepared, and 9 (3%) indicated that veterinary technicians were very unprepared; 16 (5%) respondents indicated that they didn't know. Owners were almost three times as likely (40/146 [27%] vs 14/143 [10%]; P < 0.001) as associates to say that veterinary technicians were very prepared. When asked how well prepared front office staff members in their practices were to recognize and facilitate the HAB, 49 of 335 (15%) indicated that front office staff members were very prepared, 172 (51%) indicated that front office staff members were somewhat prepared, 70 (21%) indicated that front office staff members were somewhat unprepared, and 24 (7%) indicated that front office staff members were very unprepared; 20 (6%) respondents indicated that they didn't know. Males were twice as likely (31/156 [20%] vs 15/168 [9%]; P = 0.043) as females to indicate that front office staff members were very prepared. Individuals in the lowest quartile for years since graduation were twice as likely (16/78 [21%] vs 31/248 [12%]; P = 0.007) to report that front office staff members were very prepared, compared with all other quartiles. Owners were almost three times (33/172 [19%] vs 10/142 [7%]; P < 0.001) as likely as associates to indicate that front office staff members were very prepared.

When responses for all respondents were analyzed, rankings for the 10 nontechnical skills, in order of importance to private veterinary practice, were as follows: communication skills (mean point score, 18.2), ethical reasoning (13.7), business management (12.0), interpersonal relationships (11.0), HAB (10.8), leadership skills (8.5), self-management (7.7), conflict resolution (7.7), technologic ability (5.7), and legal knowledge (4.9). No significant differences in rankings were detected between males and females or between owners and associates or among groups when respondents were grouped on the basis of years since graduation.

Discussion

Any conclusions drawn from the present study must be evaluated in light of the fact that the size and nature of the sample of individuals who responded may prohibit extensive generalization. Social desirability and self-selection bias may have played a role, further limiting the extent to which results can be generalized. However, because of the methods used, the similarities between respondents and nonrespondents, and the similarities between respondents and the population of Washington state veterinarians in private practice, we believe that our observations are reliable.

One theme that we identified in our results was that for private practitioners in Washington, there was an imbalance between the perceived importance of the HAB in private veterinary practice and the extent to which procedures to facilitate the HAB were incorporated. Results for the first part of the survey, which asked general questions about the HAB concept, suggested that respondents considered the HAB to be important and that respondents believed they integrated the HAB into their practices. For example, almost all veterinarians who responded agreed that facilitating the HAB was a defining feature of their philosophy of private practice, and most veterinarians reported that, most of the time, they take an active role in evaluating the bond between a client and his or her companion animal.

In contrast, when asked specific questions about procedures that might facilitate the HAB in their practices, respondents generally reported little activity in regard to communication about the HAB with staff members, training of staff members in the HAB, and offering resource materials related to the HAB to clients. For example, more than half the respondents had not encouraged veterinary technicians in their practices or front office staff members to learn about the HAB, and more than half offered little or no training in the HAB to veterinary technicians or front office staff members. In addition, few respondents indicated that veterinary technicians and front office staff members were very prepared to recognize and facilitate the HAB, and more than a quarter of the respondents did not know who the best person was in their practice to evaluate the bond between a client and his or her companion animal.

In the present study, respondents listed communication skills as the most important of 10 nontechnical skills for private practitioners. However, communication specifically about the HAB appeared to be limited. For instance, about a third of respondents reported that they rarely or never communicated with veterinary technicians in their practice about the degree of the bond between a client and his or her companion animal, and about half the respondents reported that they rarely or never did so with front office staff members. In addition, more than half the respondents indicated that they offered few or no HAB resources to their clients. Taken together, these responses suggest an imbalance between veterinarians' reported support for the HAB and the actual methods they use to facilitate the HAB in their practices.

There were some significant differences between genders, among respondents grouped on the basis of years since graduation, and between owners and associates in the present study. Females were more likely to say the HAB was important to their personal philosophy of practice than were males, which corresponds with findings of previous studies^12–14 involving veterinary students. Compared with individuals who had graduated the most recently, respondents with the longest time since graduation were significantly more likely to report that they did not train veterinary technicians and front office staff members in the HAB. Individuals with the longest time since graduation were also more likely to have graduated from veterinary schools that did not offer any structured teaching (eg, classes or seminars) in the HAB.⁷ Recent graduates were also more likely to perceive front office staff members as being better prepared to recognize and facilitate the HAB than were individuals who had been out of school for a longer time. These differences may reflect a gradual integration of the HAB into the veterinary school curriculum over the past 25 years.

Compared with associates, owners reported offering more HAB resources to clients and more HAB training to veterinary technicians and front office staff members. Owners encouraged veterinary technicians and front office staff members to learn about the HAB more often than associates did and reported greater communication with front office staff members about the HAB. These differences in responses between owners and associates seem to emphasize the leadership role owners have in private practices.

Regardless of these differences between subgroups (eg, male vs female), the fact remains that in the present study there was a dichotomy between what veterinarians in Washington said about the importance of the HAB in their practices and how veterinarians incorporated the HAB into their practices. How do we explain this dichotomy? One might argue that the private practitioners and faculty members involved in developing and field testing the survey might have been too sympathetic to the HAB, resulting in the wrong questions being selected. However, we believe any such bias to have been limited because of the methods used. Alternatively, the dichotomy may, in part, be attributable to social desirability bias.¹⁵ Facilitating the HAB in one's private practice is desirable behavior, especially given the importance placed on the HAB by leading business experts (eg, the KPMG study²). Thus, respondents may have been biased to overestimate the importance of the HAB in their own practices. The present survey was designed to take social desirability into account by first asking general questions about the HAB (eg, How important is facilitating the HAB?) and then asking specific questions on how the HAB is facilitated in the practice (eg, Do you offer HAB resources to your clients?). Social desirability may have played a role in response to the first set of questions; thus, responses to the second set of questions may better represent the actual role the HAB plays in private practice.

Self-selection bias may have skewed our data to some extent, in that veterinarians who support the HAB may have been more likely to respond to the survey than were veterinarians who do not support or do not have strong opinions about the HAB. If this were the case, one might argue that the true impact of the HAB in private practice may be even less than results of the present study suggest. However, it must be noted that when significant differences were determined between answers from respondents and nonrespondents, nonrespondents were more supportive of the HAB than were respondents.

We argue that part of the reason for the dichotomy between how important veterinarians perceive the HAB to be and how extensively they incorporated it into their practices may lie in their perception of the HAB. There is evidence that some veterinarians believe the HAB is a topic that cannot be taught, but that it is an innate trait in people.⁷ Such perceptions may inhibit practitioners from taking measurable steps (eg, providing brochures and training practice staff) to facilitate the HAB in their practices. It is not our intention to suggest that actively promoting and facilitating the HAB should be the central focus of all veterinarians or all practices. However, our results suggest that veterinarians who believe that facilitating the HAB is important for their practice should make sure they take steps to facilitate the HAB in their work.

Furthermore, if the discrepancy between supporting the HAB and actually taking steps to facilitate that bond is common to many practitioners and if the HAB is as important to the practice of veterinary medicine as some experts say,^1–6 a paradigm shift about what the HAB is may be needed.⁷ Coordinated efforts from experts in the field may be necessary to better explain what the HAB is and what its actual implications are for practitioners and for client satisfaction.