Materials and Methods

Study design—The study consisted of a series of 6 pet owner focus groups, made up of individuals who had recently visited a veterinary clinic, and 4 veterinarian focus groups, made up of individuals actively engaged in companion animal practice. Focus group interviews were conducted during the summer and fall of 2004. For the purposes of the present study, client expectations were defined as value expectations, which represented what clients would like to have happen during veterinary care encounters.^14,15 The study protocol was approved by the University of Guelph Research Ethics Board.

Study participants—Participants in the pet owner focus groups were recruited from the clientele of a convenience sample of 5 small animal veterinary hospitals located within a 40-minute drive of the Ontario Veterinary College. Participants were recruited by the principal researcher (JBC) during multiple visits to each of the 5 veterinary hospitals. Recruitment visits were made at different times on different days of the week, with each recruitment visit lasting from 2 to 3 hours. During each visit, a conscious effort was made to approach every pet owner entering the hospital. Pet owners were informed of the purpose and format of the study and were offered a $20 honorarium for participating. Individuals who agreed to participate were asked to sign a consent form and were then permitted to choose to attend 1 of 6 focus groups sessions scheduled during various evenings from late July through early August. A confirmation letter was subsequently mailed to consenting participants, and a reminder telephone call was placed the evening before the scheduled session. To obtain perspective regarding the communities from which participating pet owners came, demographic information was collected from Statistics Canada^{16,17,18,19,20,21} on population and mean household income of communities in which participating pet owners lived at the time of the study.

Participants in the veterinarian focus groups consisted of 1 veterinarian from each of the 5 veterinary hospitals from which pet owner participants had been recruited. In addition, a list of small animal veterinarians practicing within the geographic area where the pet owner participants lived was assembled from a database of licenced veterinarians available from the College of Veterinarians of Ontario. The sampling frame was limited to veterinarians designated as practicing small animal medicine exclusively or > 50% of their time; veterinarians in mobile practice were excluded. Veterinarians in the sampling frame were randomly selected to participate in the study. The initial contact was made through a letter of introduction that outlined the study, described the veterinarian's involvement, and offered a $20 honorarium and dinner for participating. One to 2 weeks after letters of introduction were mailed, a follow-up telephone call was made to answer questions, obtain consent, and schedule attendance at 1 of 4 focus group sessions. Veterinarians received a reminder telephone call the day of the scheduled focus group session.

Focus group interview structure—Pet owner focus group sessions were held at the Ontario Veterinary College, were 2 hours long, and were conducted by a professional moderator and the principal researcher. A semistructured interview format that used a series of standardized open-ended questions and follow-up probes was followed (Appendix 1).

Veterinarian focus group sessions were held in a hotel conference room in Guelph, Ontario, were 1.5 hours long, and were conducted by the same moderators who conducted the pet owner focus group sessions. A semistructured interview format with a series of standardized open-ended questions and follow-up probes was used (Appendix 2).^a

All focus group discussions were recorded with a digital audio recorder and omnidirectional digital microphone. Discussions were subsequently transcribed verbatim from the audio recordings by a professional transcriptionist.

Data analysis—Audio recordings and transcripts of the focus group discussions were reviewed by the principal researcher to ensure the quality and accuracy of the transcriptions. Content analysis¹³ was then performed on transcripts of the focus group discussions. In brief, transcripts from the pet owner focus group discussions were examined to identify trends and patterns across focus groups that reflected major opinions and ideas common to several groups or participants. Following several passes through each transcript, identi-fied trends and patterns were organized into categories and subcategories and described in a codebook. Subsequently, the veterinarian focus group discussions were analyzed with the coding framework developed through the analysis of the pet owner focus group discussions, with the addition of categories that captured new areas of discussion, such as veterinarians' challenges and changing client expectations. To establish the reliability of the coding scheme, a pet owner was chosen to independently review and code all of the transcripts on the basis of the established codebook descriptions. This process determined how well 2 coders, a veternarian and a pet owner, working independently agreed on how blocks of the transcribed data should be coded.²²

The purpose of the present study was to explore viewpoints. The study was not designed to establish statistical generalizability. Therefore, categories and subcategories of viewpoints are presented as descriptive summaries, rather than in a numerical fashion, with trends and majority agreements indicated.

Results

Number of participants in the 6 pet owner focus groups ranged from 4 to 7, with a total of 32 pet owners participating in the study. Pet owner participants ranged from 21 to 68 years old (median, 43 years); 21 (66%) were female. Participants owned between 1 and 5 pets each (median, 2), and all had at least 1 dog or cat, with the exception of a single participant, who owned a ferret. Of the 32 participating pet owners, 16 were from communities with populations > 100,000, 8 were from communities with populations between 10,000 and 100,000, and 8 were from communities with populations < 10,000. With the exception of 1 pet owner, the mean 2001 household incomes for the communities in which the participating pet owners lived were all above the mean household income in Canada (mean household income in 2001 was $58,360 in Canadian dollars).

Number of participants in the 4 veterinarian focus groups ranged from 5 to 7, with a total of 24 veterinarians participating in the study. Each participating veterinarian came from a different practice. Veterinarians had from 1 to 26 years (median, 17 years) of clinical experience. Seventeen of the 24 (71%) were practice owners or partners, 22 (92%) practiced small animal medicine exclusively, and 15 (63%) were female. Participating veterinarians worked in practices employing between 1 and 13 veterinarians (mean, 2.6; median, 2). At the time of the study, mean base cost of an office visit for participating veterinarians was $50.45 (median, $52.00; range, $40.00 to $58.00; all values in Canadian dollars).

Intercoder reliability for the 2 independent coders of the transcripts was 0.95. Content analysis revealed 8 distinct themes relating to clients' expectations in regard to veterinary care, including the veterinarian-client relationship, the veterinarian-pet relationship, the client-pet relationship, veterinarian-client communication, veterinarian confidence and competence, the monetary aspects of veterinary care, the role of the support staff, and physical aspects of the veterinary hospital. The present report describes results related to the monetary aspects of veterinary care, including relationships between the monetary aspects of veterinary care and the 7 other themes that were identified.

Six areas relating to the monetary aspects of veterinary care were consistently addressed by study participants. These related to the ideas that care of the animal should take precedence over monetary aspects, discussions of costs should be initiated upfront, the costs of veterinary care should be placed in a meaningful context, client suspicion should be addressed, the financial limitations of clients should be considered, and veterinarians feel their services are undervalued.

Care of the animal should take precedence over monetary aspects—An expectation discussed during several of the pet owner focus groups was that veterinary medicine should be a profession where animal care comes first and monetary aspects come second. For example, one pet owner stated that the veterinary profession should be about “care first, compensation second; about treating from the perspective that the cash component of the business is secondary.” Importantly, whether pet owners perceived their veterinarian as having an interest in the care and well-being of the pet versus making a profit appeared to have an influence on the pet owners' experiences.

As a corollary, there was an expectation among some participants that out of a shared interest for the pet, the veterinarian would work with the client to find a solution if the client could not immediately afford veterinary care. As stated by one pet owner, “I would like to think that in a pickle, where care was needed and it was expensive, there could be some accommodation around payment plans, or whatever, in the interests of the animal.”

During all of the pet owner focus group discussions, the idea emerged that pet owners view those working in the veterinary profession as being there out of genuine love for and interest in animals, rather than for strict monetary gain. In addition, it was apparent that for participating pet owners, the perception that their veterinarian had a genuine interest in their pet beyond the veterinarian's monetary gain had a positive influence on the pet owner's relationship with his or her veterinarian. Participating pet owners consistently discussed compassion and caring in terms of the veterinarian going beyond their expectations, stating that “It makes you feel good because it's not the money issue. It's like ‘I'm concerned about you and I'm concerned about your animal.'”

One challenge for veterinarians that received attention during the veterinarian focus group discussions and that appeared to be closely related to pet owners' expectation that animal care would come first and monetary aspects second was a general unease about discussing the costs of veterinary care with clients. For many, this unease was rooted in experiences where the veterinarian had felt guilty or undervalued after discussing such costs. For example, one veterinarian stated that “They will make you feel guilty about the bill too, because sometimes it is sort of like, ‘Well, I'm going to have to put my animal down if that is what you are going to charge me' and it does happen that we'll lower the cost out of guilt.” Another suggested that “It's very easy to feel devalued as a veterinarian when going over the money issues.”

Although this topic received considerable attention from participating veterinarians, there was agreement that situations where veterinarians felt guilty or undervalued were the exceptions rather than the rule, but such situations left a strong impression when they did occur. As indicated by one veterinarian, “It is probably more the exception that they are going to be questioning the money aspect as opposed to the general, but you feel more assaulted when you come up against a case like that, so those stand out in your mind.”

In contrast, some veterinarians indicated that discussing the costs of veterinary care with clients was not a source of unease because they felt clients “have a responsibility to their pets” and as long as “you're having an open discussion, the challenges just go away.”

Discussion of costs should be initiated upfront—Across the pet owner focus groups, participants expressed the idea that they expected veterinarians to discuss the costs of veterinary care upfront. However, 2 different perspectives on this issue emerged. The first reflected the opinions of experienced veterinary clients who were comfortable not discussing the costs associated with routine care because they were familiar with them and knew what to expect on the basis of their previous experiences. Nevertheless, these pet owners still expected upfront discussions of any new costs. The second perspective reflected the feelings of clients who were relatively new to pet ownership and who, as a result, had less experience with veterinary care. Their expectation was that veterinarians would be upfront with respect to all costs, including the costs of basic items. For many new pet owners, it was important to have the costs of even these basic items addressed so that they could properly budget for veterinary care, saying that “Some people can be surprised by how much it costs. You wouldn't think it would be that expensive and then you find out it's that expensive, so upfront.”

A number of participating pet owners expressed their concern that failure to discuss costs upfront was a barrier that could lead clients into getting overextended financially. One pet owner, for instance, was concerned that “People do not know what they're getting into in a lot of cases before it is past what they can afford.” Similarly, participating pet owners worried that they could be vulnerable when making decisions related to their pet's health and that they could quickly get in “over their head” if costs were not discussed upfront. As one pet owner put it, “When you're emotionally upset like that, it's easy to get pulled into things.” Another said, “I think people get caught in that emotional side of it and they get into financial situations that they can't handle because it wasn't really explained to them well enough.”

Although veterinarians did not explicitly talk about their clients' expectations in relation to discussing the costs of veterinary care upfront, several veterinarians were of the opinion that clients who say that “cost doesn't matter” can often be a challenge when it comes time to pay the bill. As one veterinarian put it, “The worst thing is somebody says to you, ‘I don't care what it costs.' They're the ones that do.”

A recent graduate indicated that another challenge to discussing costs was prejudging clients, stating that “I find it difficult with different clients not to prejudge and think, ‘Well, they would never be able to afford that.'” Although several of the more experienced veterinarians indicated that they have learned not to judge what people will spend on care for their pets, many veterinarians shared experiences where they have been caught prejudging a client. For example, one of the veterinarians recalled an incident when “I did not even give them a cost because it looked like that was what they wanted to do, and then cost became an issue later on.”

Thus, avoiding discussions of the costs of veterinary care not only was a concern for clients but also raised a number of potential challenges for veterinarians. Importantly, it was evident during the pet owner focus groups that failure to discuss costs upfront contributed to clients' suspicion and mistrust of the veterinary profession.

Costs of veterinary care should be placed in a meaningful context—Apart from the issue of discussing costs upfront, several participating pet owners indicated that costs should be discussed within the context of their pet's health and prognosis, stating, for instance, that “I want the information about cost in the context of what's a reasonable prognosis.” Included in this was a concern that the client's personal beliefs and values be taken into consideration. One pet owner, for instance, indicated that “For my wife and I, we've got to be realistic. Like, we can't re-mortgage the house, can't do this, can't take out all the RRSP [registered retirement savings plan] just for a cat.”

During the focus group discussions, participating veterinarians frequently referred to their reliance on estimates as a way to present the costs of veterinary care to their clients, with one veterinarian indicating that “I work in a clinic where there is nothing done without an estimate.” Although estimates provided a basis for discussing the costs of veterinary care, they still needed to be put into the necessary context. One pet owner, for instance, related that “We moved from that veterinarian to another veterinarian because every time we left, we walked out with an estimate for some procedure and it wasn't in the budget for us, and so, we needed to work with someone else that maybe recognized that.”

Although a number of the participating veterinarians provided estimates for their clients, a few indicated that providing estimates was a challenge. For one veterinarian, the challenge was arriving at a reasonably accurate estimate before the problem was defined and the required diagnostic testing was understood. For others, the perceived challenge was that “[Veterinarians] view them as estimates and clients view them as quotes, and a quote tends to be, if you said it was $662, it should be $662, not $685.”

In examining the manner in which pet owners and veterinarians referred to the discussion of costs, it became apparent that the 2 groups often approached these discussions from different contexts. The veterinarians tended to focus on the value of their services in terms of tangibles such as their time and service. One veterinarian, for instance, indicated, “I think a lot of the problems come when they don't understand what's involved, the material, the time, expertise, that kind of thing.” In contrast, pet owners focused on what their money was providing in terms of outcome and wellbeing for their pet.

Client suspicion should be addressed—Among several of the pet owner focus group discussions, an atmosphere of suspicion existed about the motivations behind recommendations. The most consistent suspicion arose from the conflict between the idea of veterinary medicine as a health-care profession versus a business. As one pet owner put it, “[Veterinarians] shouldn't go necessarily into all these heroics, you know, ends of the line to try to treat these animals when it's not the best thing and I think it's sometimes hard to do in that kind of industry when it's fee for service.” Although such concerns could be expected to pose a barrier to the individual veterinarian-client relationship, these suspicions were generally raised in reference to the profession as a whole, rather than in reference to any individual veterinarian. Many pet owners expressed high praise for their own veterinarian but still expressed suspicion of the profession, saying, for example, that “Veterinarians have to be very careful that they don't give people the impression that they're keeping you coming back.”

One pet owner stated that “I wish that veterinarians would … say ‘do as I do, not as I say,’ because I feel that veterinarians are taught to do certain things, but then, [when you] ask the veterinarian, ‘what do you do?’ they don't do that!” During the follow-up discussion on this comment, a few participants raised concerns about vaccination and heartworm testing protocols in particular, with these concerns appearing to arise from differences in protocols among veterinarians. One veterinarian also discussed experiences with clients who appeared suspicious, stating that “Some clients seem to be paranoid. They think that you lie to them to get them to do a procedure.”

The issues arising from the conflict between the idea of veterinary medicine as a health-care profession versus a business were complicated because pet owners often expressed conflicting expectations of veterinarians depending on the context of the discussion. For instance, when pet owners were considering the health and well-being of their own pets, emotions often appeared to drive their decisions, with monetary considerations put on hold. In contrast, when the emotional concern for their own pet's health and well-being was not at the forefront, participating pet owners appeared to approach their decisions in a manner similar to their approach to other consumer purchases, taking into consideration the financial aspects of their decisions. As stated by one pet owner, “There should be more comparison shopping available for people.” These conflicting expectations may contribute to veterinarians' feelings that their services are undervalued.

Financial limitations of clients should be considered—A number of participating pet owners indicated that they expected veterinarians to provide some type of payment plan for expensive procedures. This idea was expressed both by pet owners who had experienced difficulties affording veterinary care and by those who had not. However, one pet owner acknowledged that it may not be feasible for veterinary practices to offer this service to every client because as small businesses, they would have limited financial resources of their own. The idea of payment plans was not raised at all by the veterinarians during their discussions.

Many participating pet owners also indicated that they had received little information about pet insurance in terms of a possible solution to the costs of veterinary care, although they were curious about the topic. However, opinions about how this information should be presented to clients varied considerably, with some participants expecting their veterinarian to address it with them and others expecting the information to come in a form that they could access if they felt it necessary.

Veterinarians also expressed that not having control over the finances for an animal's care was a challenge because they were dependent on the pet owners in terms of what the owners were willing and able to spend on their pets, limiting veterinarians in terms of the health care they could provide. One veterinarian indicated that pet insurance offered a viable solution to this problem. However, this was received with reservation from the rest of the group out of apprehension that insurance companies could change coverage and, in turn, dictate the veterinary care they could provide. As one veterinarian said, “You worry a little bit about that too, because if you've now got a practice that is really highly loaded on pet insurance people and the pet insurance decides they want to make some changes, that starts to influence how you practice.”

Veterinarians feel their services are under-valued—Feeling undervalued was a challenge expressed by many of the veterinarians participating in the study. There were a number of reasons mentioned for this. Several veterinarians believed clients had a poor understanding of health-care costs because a large portion of their clients' own health-care costs were not paid out-of-pocket, thus giving clients a naive perspective on the cost of health care. One stated, “It is easy to forget how much we pay for our medical service, just because we don't actually have to open up our wallet and give them money.”

Veterinarians also suggested that feelings of being undervalued were a result of having trained clients over time to expect inexpensive services. “Our vaccine visits are undercharged, our spays and neuters are grossly undercharged, and then we've trained them that they don't need pet health insurance because veterinary medicine is so cheap.”

Some veterinarians were of the opinion that “the value that people place on their pets” was a contributing factor, in that “for some people, pets are a disposable commodity” with a result that they place a low value on the services veterinarians have to offer. Finally, many veterinarians also felt undervalued because they believed clients held expectations of them that were greater than the expectations they had of other health-care professionals. As one veterinarian put it, “It sort of irks me, because you guys expect so much from me; look at the service you get on the human side.”

Discussion

The focus group approach used in the present study offered an interactive forum for participants to share and discuss their experiences, feelings, and views on clients' expectations regarding veterinary care. By soliciting the participation of pet owners, we were able to obtain insights into the attitudes, beliefs, and opinions of veterinary clients.⁶ Including veterinarians added further depth and balance to the study by taking into consideration veterinarians' perspectives. By including both groups, we were able to explore possible challenges and barriers affecting veterinarian-client-patient interactions.

In the present paper, we elected to focus on client expectations in relation to the monetary aspects of veterinary care for several reasons. First, the monetary aspects of veterinary care were important topics of discussion during the pet owner and veterinarian focus groups. Second, the monetary aspects of veterinary care were identified as a clearly defined theme during content analysis. Third, this issue represented an area where there were clear differences between pet owners' and veterinarians' perceptions.

During the focus group discussions, concerns with the actual cost of veterinary care were occasionally raised. More often, however, the discussion concentrated on how costs were communicated, the context within which pet owners and veterinarians considered the monetary aspects of care, and the challenges that the monetary aspects of care posed to the veterinarian-client interaction. Pet owners expressed concerns about inadequate discussions of cost during veterinarian-client interactions and their expectation that veterinary medicine not be a profession where the monetary aspects of care take precedence over concern about the animals. These feelings, in turn, appeared to drive some of the challenges veterinarians expressed, such as feeling their services were undervalued and a general unease discussing the costs of veterinary care. Although several studies^2,4,23,24 have found that price is not the primary concern when clients are choosing a veterinary practice, results of the present study suggest that the discussion of costs may be an area of contention for clients and veterinarians.

In Canada and the United States, the proportion of pet owners with health insurance for their pets is low,^2,24 with the result that most pet owners pay for veterinary services out-of-pocket. In contrast, Canada has a govern-ment-funded, universal health-care system that provides necessary medical services for its residents.²⁵ Because of this, pet owners in the present study were likely to have little knowledge of the costs associated with their own health care. In the United States, it is estimated that only about 20% of health-care costs are paid for out-of-pock-et.²⁶ It is likely, therefore, that pet owners in the United States would also have limited knowledge of health-care costs. For this reason, it should not be surprising that pet owners, as uninformed consumers, expect veterinarians to discuss the costs of veterinary care upfront. The findings of this study also indicate that this discussion should include explaining the costs in the context of the pet's health and well-being and taking into consideration the unique beliefs and values of individual clients.

Interestingly, veterinarians who participated in the present study attributed their feelings of being undervalued, in part, to their clients' poor understanding of the cost of human health care. However, a client's lack of understanding of the cost of human health care might have limited impact on veterinary medicine if veterinarians were adequately educating their own clients. Thus, it seems more likely that the difference in the way veterinarians and clients relate to the costs of veterinary care may contribute more to veterinarians feeling undervalued. That is, it may be that a difference in perceived value and a general failure to educate clients adequately about the cost of veterinary care, rather than a lack of client knowledge about their own health-care costs, contribute to veterinarians' feelings that their services are undervalued.

A number of veterinarians in the present study indicated that they use estimates to relay the cost of veterinary care to their clients. However, without adequate discussion of these costs in a way that is important to clients, such estimates may not convey important information. Estimates do provide an excellent catalyst to initiate discussions of cost. However, veterinarians must not only communicate the value of their services and time but also explain what those services mean to the individual client in terms of his or her pet's health and well-being and in terms of the client's own beliefs, values, and expectations. In addition, our results indicate that it is important for veterinarians to keep clients informed and involved as diagnostic and treatment plans evolve, resulting in changes to the overall cost to the client.

Research²⁶ in human medicine has found that although two thirds of surveyed patients wished to discuss out-of-pocket costs with their physician, only 15% of patients reported ever having these discussions. Similarly, although most pet owners participating in the present study expected to discuss the costs of veterinary care with their veterinarian, it was evident that these discussions were not commonplace. We also found that clients have an expectation that their veterinarian will be the one to initiate such discussions. However, veterinarians may hesitate to raise the discussion of costs during their interactions with clients because many of these interactions involve emotionally charged situations where the discussion of costs feels inappropriate.²⁷ This idea is reinforced by pet owners' expectation that care will come first, with monetary considerations coming second. With pet owners expecting veterinarians to discuss the costs of veterinary care but also expecting that veterinarians not appear to be concerned primarily with monetary compensation, the discussion of costs can be challenging for veterinarians. A client's perception that a veterinarian is “in it for the money” could be expected to inhibit development of or compromise the veterinar-ian-client relationship. However, studies^28,29 in human medicine have found that the existence of a trusting physician-patient relationship moderates cost-related barriers. Thus, the veterinarian's relationship with the client is likely to play an important role in the discussion of costs.

Veterinarians' relationships with their clients are important contributors to their overall career satisfac-^30,31 In the present study, however, we found an element of suspicion among pet owners in relation to the motivation driving recommendations, potentially putting these relationships in jeopardy. The suspicion appeared to arise from the potential conflict of interest associated with the fact that veterinarians often influence the care their patients receive, and they receive more compensation for providing more care. Recent commentaries^32,33,34 have tackled this subject, reminding veterinarians that although it is fair to be adequately compensated, maximizing income should not become the profession's primary goal. To counteract client concerns that recommendations might be driven by business rather than strictly health-care considerations, veterinarians should be proactive by discussing cost with clients and educating them as to the purpose and value of their recommendations in a manner that includes consideration of what is important and meaningful to each client.

The financial limits of clients pose issues for clients and their veterinarians. In a profession where a common reason for entering the field is an individual's desire to work with and care for animals,² conflicts can arise when the quality of care a veterinarian can provide is dictated by the financial limitations of the client. Presumably, both veterinarians and their clients are interested in the health and well-being of the animals they care for. However, the monetary aspects of veterinary care can create barriers to a constructive veterinarian-client-patient interaction. If those barriers are not appropriately addressed, the veterinarian-client relationship can be strained. Obviously, communication will not overcome the financial limitations of every client. In the present study, however, we found that a number of pet owners were interested in discussing solutions to their financial barriers with their veterinarian. Participating pet owners expressed an interest in learning more about payment plans and pet insurance, believing that these could be possible solutions to their financial limitations.

Recognizing these concerns and further developing communication skills to enhance the discussion of the monetary aspects of veterinary care within the challenging environment of the veterinarian-cli-ent-patient interaction is important for veterinarians. For example, empathy has been described as a key ingredient in the discussion of out-of-pocket costs,³⁵ and even though empathy has often been thought to be an innate ability, previous research has shown that empathy is a teachable and learnable skill.^36,37,38 Using empathy to discuss costs with clients requires a 2-step process. First, the veterinarian must develop an understanding and appreciation of the client's cost awareness, financial limitations, and general beliefs and values with respect to veterinary care. Second, the veterinarian must reflect back to the client an understanding and appreciation of the client's situation with respect to the care of the pet and the associated financial costs.^35,36 During their focus group discussions, veterinarians identified that clients who indicate that “cost does not matter” are often a challenge because cost becomes an issue for many of these clients after the care has been provided. In these situations, it seems likely that such clients initially make a decision driven by emotions, but that after the situation is resolved and the emotions have dissipated, they begin to make decisions on the basis of financial considerations. By using empathy upfront in these situations, veterinarians could provide a platform for meaningful discussion of anticipated costs that acknowledges the context of the situation and is sensitive to the client's emotional concern for the pet.

Developing partnerships with their clients may assist veterinarians in discussing costs, as the veterinarians will be better able to obtain information about each client's ideas, concerns, and expectations. This partnership would include exploring the effect that these costs will have on the client and patient. Veterinarians also need to explain the rationale for costs while taking into consideration the client's perspective.³⁶ Including a discussion of costs in the decision-making process allows both the veterinarian and the client to obtain information relevant to the situation and better appreciate each other's position and perspective.

The focus group approach used in the present study provided in-depth information on clients' needs and expectations in regard to the monetary aspects of veterinary care. However, because of the small number of participants, our findings do not represent the needs and expectations of every client or every veterinarian during every context or every veterinarian-client encounter. Nevertheless, findings from the present study do suggest that veterinarians should explore each client's individual beliefs, values, and expectations in relation to the monetary aspects of veterinary care on an interaction-by-interaction basis. By taking the time to understand a client's individual perspective, a veterinarian should be better positioned to recognize and address any differences that may exist between the client's and his or her own perceptions, views, and practices.

The analytic method used in the present study was not intended and does not lend itself to statistical inference. Instead, this approach was adopted to allow us to obtain a deeper understanding of client expectations by considering the meaning of various statements within the context of the entire discussion.¹³ With other research methods, obtaining counts of the number of times certain words or ideas were mentioned may be appropriate. However, to gain the level of understanding achieved in the present study, an approach was required that considered participants' intentions, not only their words. The benefit of this approach can be seen in the subtle difference revealed in how participating pet owners and veterinarians related to discussions of costs or the difference in perceived value that may be contributing to the feeling among some veterinarians that their services are undervalued. This level of understanding offers veterinarians a meaningful starting point from which to reflect on their own perceptions and ideas in dealing with the monetary aspects of veterinary care.

With all forms of research, accounting for and controlling bias is an important consideration. In fo-cus group research, a unique form of bias can occur when the opinions of 1 or 2 participants dominate the group's discussion. In the present study, we attempted to minimize this type of bias by conducting several pet owner and veterinarian focus group discussions, analyzing findings across groups, and clearly identifying findings that arose from a single individual or group. Another form of bias that can arise with focus group research occurs when a moderator, knowingly or unknowingly, provides cues to participants about desirable or undesirable responses. We attempted to minimize this type of bias through the use of a professional moderator and by omitting responses to leading questions from analyses.

In conclusion, results of the present study suggest that clients expect to have conversations with their veterinarians about the costs of veterinary care. Better communication between clients and veterinarians regarding the costs of veterinary care, including the impact on the outcome for clients' pets, will likely alleviate a number of concerns identified during the study. There will always be challenges to communicating the costs of veterinary care. But such challenges can be minimized by exploring the individual client's perspective, improving veterinarians' communication, educating clients, and making the discussions of cost more common.